Inside diabetes treatments

Why are there so many different treatments for diabetes? Learn more about the main treatments and how they work

July, 2017


There are different ways of treating diabetes. Type 2 diabetes may be controlled by diet and lifestyle alone, tablets (either a single medication or a combination of different medications), or injectable treatments.


There are many different types of diabetes medication that can be taken in tablet form. Below are some of the most common types, together with a little explanation of how they work to control your blood glucose and/or other effects of your Type 2 diabetes.


If you’re on metformin, you’re far from being alone – at least 120 million people worldwide are prescribed it. It’s often the first medical treatment people get for their Type 2 diabetes, after or at the same time as advice on changing diet and doing more exercise. Metformin works in three main ways to help bring down your blood glucose levels:

  • It helps stop your liver producing extra glucose (a form of sugar)
  • It helps your body use the insulin you do have
  • It helps slow down the intake of glucose from the gut
How does metformin work?

Your liver stores glucose in the form of glycogen (essentially, clumps of glucose). When blood glucose levels are low, insulin levels are also low. Low levels of insulin trigger the liver to release the stored glucose back into the blood, in an effort to keep your blood glucose at a reasonably stable level.

When you have Type 2 diabetes, this process is derailed. In Type 2 diabetes, your body is normally still able to make insulin, but your body stops reacting to it in the way it should (it’s almost as if your body ignores the insulin, and it’s known as “insulin resistance”). This all means that your liver mistakenly thinks that insulin levels are low, and produces extra glucose, adding to the glucose that’s already in your blood.

You then have two sources of extra glucose: all the glucose your cells can’t use, plus the extra from the liver. Your blood glucose levels can then rise and rise, and some people even find that their blood glucose is higher in the morning than when they went to bed.

The diagrams below help to summarise all this:

Without diabetes

How metformin works without diabetes

With diabetes

How metformin works with diabetes

Metformin helps to put things right again. It acts at point [4] in the diagram above to make your body more sensitive to insulin, so the cells can unlock and start using the glucose in the bloodstream.

It also acts at points [4a] and [4b], helping to stop the liver producing extra glucose when it’s not needed. In addition, metformin reduces blood glucose by delaying glucose absorption in the gut (meaning that the glucose you get from your food is only taken into your body slowly).

By reducing the amount of extra glucose from the liver AND helping your body use the glucose that’s there, metformin helps your total blood glucose levels come down.

DPP-4 inhibitors

Also sometimes called a gliptin, DPP4, DPP-4i, or DPP-4 inhibitor. DPP-4 inhibitors are another type of diabetes medication that come in tablet form. They work in a different way to metformin to help bring down your blood glucose levels.

How do DPP-4 inhibitors work?

Your pancreas makes insulin, which the cells in your body need in order to use the glucose in your blood. The process of making insulin is switched on, in part, by hormones (chemical messengers) called incretins. Incretins help by getting the body both to produce more insulin and to reduce the amount of glucose being released by the liver.

Levels of these incretins are affected by an enzyme (a chemical machine) called dipeptidyl peptidase IV (DPP-4, for short) that goes around breaking incretins down and making them inactive. This means that the message, “make insulin” doesn’t get through, so the pancreas doesn’t make insulin.

The DPP-4 inhibitors work by inhibiting DPP-4, i.e. stopping it working properly, so the incretins can continue doing their job: increasing the release of insulin and reducing the amount of glucose released by the liver. Both of these effects lower the blood glucose level.


This is another group of medications for Type 2 diabetes. Like metformin and DPP-4 inhibitors, sulphonylureas work to bring down your overall blood glucose level, but in a different way.

How do sulphonylureas work?

Looking in more detail at your pancreas and the way it makes insulin, there are cells in your pancreas that release insulin – called beta cells. The release of the insulin is triggered by rising levels of calcium inside these beta cells.

Sulphonylureas trigger a rise in calcium within the beta cells, which then sets off the release of insulin. This helps your body to release extra insulin. Your body can then use this insulin to “unlock” cells so they can use the glucose in your bloodstream for energy.

Alpha glucosidase inhibitors (AGIs)

Taken with meals, alpha glucosidase inhibitor (AGI) tablets help to regulate blood glucose by targeting the digestive system, slowing down the rate at which your intestines absorb carbohydrates from starchy foods.

How do AGIs work?

In the gut, starches in your food are first broken down into smaller carbohydrates by enzymes (chemical machines) made by the pancreas. Different enzymes in the gut wall, called alpha-glucosidases, then take over and finish dismantling these carbohydrates into their building blocks – glucose and other simple sugars – which are then absorbed into the bloodstream.

AGIs get in the way, keeping some of the alpha-glucosidase enzymes out of action. This slows the rate at which the carbohydrates are broken down into glucose, which in turn slows the entry of glucose into the blood.

In this way, taking an AGI tablet with your meal slows down the rise in your blood glucose after you’ve eaten, meaning that you shouldn’t get such a high glucose spike.

SGLT2 inhibitors

This is a group of medications that work on your kidneys to help lower your blood glucose.

How do SGLT2 inhibitors work?

Your kidneys filter waste from your blood. As they do so, they also filter out some of the glucose from your blood. The kidneys then capture and return this glucose to your blood, before it can pass out of your kidneys and into your bladder.

SGLT2s (sodium-glucose co-transporter-2s) are one of the ways the kidneys “catch” filtered glucose and return it to your blood.

SGLT2 inhibitors block these SGLT2s, slowing their action and reducing the amount of glucose your kidneys return to your blood. So instead of glucose being returned to your blood, it stays in the urine and is passed out of your body. The end result is that this loss of excess glucose in the urine helps lower your blood glucose.


People can be sensitive to insulin, or resistant to it (although it’s on a sliding scale from one extreme to the other – it’s not an either/or thing). If you’re sensitive to insulin, your body responds well to it, and your blood glucose stays at a normal level most of the time. If you’re resistant to it, your body doesn’t use the insulin that’s there very efficiently, so glucose stays stuck in the bloodstream – as shown above in the metformin section.

How do thiazolidinedione/glitazone work?

Thiazolidinedione/glitazone helps to lower your insulin resistance and improve your insulin sensitivity. On top of that, it can help to protect the beta cells in your pancreas: these are the ones that make insulin, so protecting them can help them carry on making insulin.


Alongside tablets, the other most commonly prescribed types of diabetes medications come in injection form. These include incretin mimetics, and several different types of insulin.

Incretin mimetics/GLP-1 agonists

A mimetic is something that acts like (mimics) something else. As the name suggests, incretin mimetics act like your body’s incretins, helping your pancreas to release insulin – see the section on DPP-4 inhibitors above for more information about incretins.

Glucagon-like peptide 1 (GLP-1) is a type of incretin made by your gut after you eat a meal. A GLP-1 agonist is a medicine that works in a similar and enhanced way to the naturally occurring incretins that your body produces.


People with Type 1 diabetes will have to inject insulin regularly. If you have Type 2 diabetes, you may go on to need insulin injections if your Type 2 diabetes gets worse. If you need to take insulin as part of your diabetes medication, you may be prescribed different types. These can be active in the body for varying lengths of time, helping you to manage your glucose at stable levels throughout the day. Injected insulin acts in your body the same way as insulin you make yourself. Insulin helps to “unlock” the cells in your body so that they can use the glucose in your blood as fuel.

Short or fast-acting insulins

These are fast insulins, and are useful to counteract the spike in blood glucose that follows a meal. They are most active 2 to 6 hours after the injection, and can last for up to 8 hours.

Intermediate-acting insulins

Intermediate-acting insulins are often referred to as ‘basal’ insulins. This group are commonly used to help control blood glucose throughout the day and overnight depending on the timing of administration and number of injections. Intermediate-acting insulins can be administered alone or in combination with short/fast-acting mealtime insulins.

Long-acting insulins

These insulins are also referred to as ‘basal’ insulins, but because they last longer than intermediate-acting insulins, they are generally administered once daily at bedtime, either alone or in combination with mealtime insulins. As their name suggests, this type of insulin provides a steady background supply of insulin to help control blood glucose levels, overnight and between meal times.

Mixed insulins

These insulins contain a combination of both a fast-acting and a long-acting insulin. This means that when they are injected, they control both the glucose spikes that occur after meals, as well as managing insulin requirements between meals and overnight.

Dietary changes: the biggest string to your bow

What you eat plays a huge role in gaining control of your Type 2 diabetes. When you have Type 2 diabetes, the amount of carbohydrate you eat directly affects your blood glucose levels.

The bad news

For people with Type 2 diabetes, high blood glucose is a major problem. Your pancreas doesn’t produce enough insulin (and/or your body may have become resistant to insulin, so it doesn’t use it effectively), so the cells in your body can’t use the glucose available, and it stays trapped in the blood. Medications and exercise help bring your blood glucose down. Food with carbohydrate in it raises your blood glucose. Obviously, you don’t want to go too long without eating any carbohydrate – then your blood glucose might drop too low (making you feel ill) OR you might find your blood glucose goes UP if you don’t eat, as your liver will step in to replace the glucose from food with its own supplies.

The good news

Your diet is one of your main tools for getting and staying healthy. There is no such thing as a special “diabetic diet” – what’s healthy for everyone else is healthy for you too. A healthy diet full of vegetables and different, tasty ingredients can help:

  • Give you more energy
  • Keep your bowels healthy and regular
  • Protect against certain diseases
  • Get you trimmer, if you’re overweight
  • Hold off some of the bad health effects of diabetes

Exercise – the other big string on your bow

Almost everyone can benefit from doing a bit more exercise – it’s good for all of us. When you have Type 2 diabetes, though, it can feel like you are under the orders of a drill instructor – it seems as if you can’t turn around without someone else telling you about how important it is to exercise, as if you didn’t already know.

Actually doing the exercise, though – that’s where a lot of us fall down. It might be easier to get motivated if you think of exercise as a form of treatment for Type 2 diabetes, and think of all the benefits it can bring you.

What exercise can do for you when you have Type 2 diabetes

Bring your blood glucose downIn the short term, a bout of exercise uses glucose to fuel your muscles, so your blood glucose level can come down. Over time, keeping up an exercise routine can lower your HbA1c, which is the measure that healthcare professionals use to get a picture of your average blood glucose levels over the past few weeks or months.
NOTE OF CAUTION!Exercise can have a major impact on your blood glucose if you have Type 2 diabetes. It’s best to follow the advice of your doctor or nurse about how much you should be doing, how intense it should be, and how often you should be doing it.
Cheer you upThere have been some good scientific studies that show that getting moving can help you feel good about yourself, reduce stress, improve your mood and give you more energy. It’s even part of some treatments for depression.
Send you offExercise can tire you physically and also reduce mental stress, so that sleep comes easier and is of better quality.
Keep you goingPhysical activity can help dramatically reduce your chances of developing heart disease and some types of cancer. Looking after your heart is important when you have Type 2 diabetes. People who exercise regularly are also more likely to live longer, and to stay well into old age.
Whittle your waistWhen you’re eating healthily, adding exercise can also help burn fat and together they’re essential if you want to lose some weight.
Keep you uprightStaying active through life appears to have a strengthening effect on your bones. Activities like dancing and yoga can also have the effect of improving your balance. Together, these effects can help prevent falls.
Keep you “with it”Recent scientific research has shown that there appears to be a link between being active and having a reduced risk of dementia.
More…you know. The other.Not doing enough exercise is one of the (many) factors that can contribute to erectile dysfunction.

Lifestyle changes for people with Type 2 diabetes

When you’re diagnosed with Type 2 diabetes, as well as making changes to what you eat and doing some exercise, there are also some other things you can do to help yourself feel fitter and healthier.

Stub it out

No-one would say that smoking is good for you, but when you have Type 2 diabetes it can be even more of a problem. Smoking when you have Type 2 diabetes makes it more likely that you’ll get some of the complications of diabetes like heart disease, stroke and circulation problems (like slow wound healing, cracked skin, serious foot problems, erectile dysfunction). Finding ways to cut down and, ideally, quit smoking altogether, will be one of the biggest favours you can ever do for yourself – for your health, your bank balance, and your relationships.

Alcohol and Type 2 diabetes

If you have Type 2 diabetes, you don’t have to suddenly turn teetotal. For most people, a few alcoholic drinks, within the usual recommended limits, isn’t a definite no-no. It’s just that it pays to take a little more care with drinking, as it can have an effect on your blood glucose levels. A lot of people with Type 2 diabetes assume that drinking will push their blood glucose levels UP, as alcoholic drinks contain carbohydrates. Strangely, though, it more often has the opposite effect, and some people can find themselves having a hypo (short for a “hypoglycaemic event”) which can make you feel very ill very quickly. Take it steady, keep an eye on your blood glucose level if you can, and ideally have someone within easy reach who knows that you have diabetes.


Stress can have a huge effect on your health – particularly when you have diabetes, as it can alter your blood glucose levels. Stress can be physical, such as when you’re ill, pregnant or are doing something strenuous (putting up shelves, pushing a broken-down car, shifting the washing machine), or mental, such as pressure at work, relationship problems, money worries, anxiety and depression.

Taking time out to properly relax is getting harder and harder in our pedal-to-the-metal modern world, but it’s also becoming more and more important. You might not be the type to sit about in the lotus pose for hours on end, but things like mindfulness, meditation and yoga don’t have to be “weird”. It can be as simple as just taking a few minutes to unclench your muscles and breathe more deeply. There are loads of free websites and apps available with ideas and advice for managing stress and finding time to relax. Laughing is also good at relieving tension and stress – in some cases it really can be the best medicine.

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