Diabetes treatment

Diabetes treatment

The steps below outline my approach to treating type 2 diabetes. Detailed information on obtaining medications at reduced or no cost is provided along with resources that provide specific recommendations on insulin dosing.
Pricing for diabetes-related labs like a hemoglobin A1C, CMP, cholesterol, and urine protein are available here - lab pricing
If you have any questions about your diabetes treatment, please feel free to email me

Initial therapy choice (insulin vs stepped approach)
Stepped approach (starting with noninsulin therapy)
Insulin therapy
Insulin cost (details on insulin costs and savings opportunities)
Insulin dosing
SGLT2 inhibitor patient assistance program information
GLP-1 analog patient assistance program information
DPP-4 inhibitor patient assistance program information

Initial therapy choice (insulin vs stepped approach)

Treatment-naïve diabetics

A1C > 10%

Insulin should be considered as an initial therapy in new diabetics with an A1C > 10% and in those who are experiencing significant symptoms (e.g. weight loss and dehydration). Insulin should only be considered in patients who can administer it properly and are willing to perform frequent blood sugar monitoring. Some patients are apprehensive about injecting themselves with insulin and prefer to start with other therapies. Starting with other therapies is fine, but the patient should be aware that it will take longer to get their blood sugars under control.
See insulin therapy and stepped approach (starting with non-insulin therapies) below

A1C < 10%

Most new diabetics with an A1C < 10% will be able to get their blood sugars under control with a stepped approach (starting with non-insulin therapies)
See stepped approach below

Diabetics currently receiving therapy

For diabetics who are already being treated, the approach to therapy will depend on their current medications, current control, and satisfaction with current therapy. Noninsulin therapies may be appropriate in some patients while insulin can be added to any treatment regimen and is the only therapy that does not have a maximal effect.
See insulin therapy and stepped approach below

Stepped approach

The table below lists the medications available to treat type 2 diabetes along with factors to consider when choosing therapy. The ADA recommends metformin as first-line therapy in all diabetics who do not have a contraindication. After metformin, any other medication is considered suitable, although SGLT2 inhibitors are now preferred in patients with heart failure or kidney disease, and SGLT2 inhibitors and GLP-1 analogs are preferred in patients with CVD (or high risk for CVD). See ADA type 2 diabetes treatment recommendations for a complete review.
SGLT2 inhibitors and GLP-1 analogs do not have generics, and they are expensive. Other classes of diabetes drugs have been around for much longer and are generally very affordable. Some patients may qualify to get SGLT2 inhibitors and GLP-1 analogs for free (see SGLT2 inhibitor PAP and GLP-1 analog PAP below).

First-line in all diabetics
Metformin ADA recommendation First-line therapy in all diabetics who do not have a contraindication Cost: Very cheap and used for many years Effect: Average A1C reductions of 1% Hypoglycemia: Does not cause hypoglycemia by itself Side effects: Causes gastrointestinal side effects (up to 40%) that typically improve with time
Preferred second-line in diabetics with CVD (or high risk for CVD), heart failure, or chronic kidney disease
SGLT2 inhibitors ADA recommendation Preferred second-line therapy in patients with CVD (or high risk), heart failure, and/or chronic kidney disease Cost: Expensive. See SGLT2 inhibitor PAP for information on how qualified patients may obtain for free. Effect: Average A1C reductions around 0.7 - 1% Hypoglycemia: Does not cause hypoglycemia by itself Side effects: Yeast infections (1 - 12%), UTIs (4 - 10%), and diuresis
Preferred second-line in diabetics with CVD (or high risk for CVD)
GLP-1 analogs ADA recommendation Preferred second-line therapy in patients with CVD or multiple risk factors for CVD. GLP-1 analogs may be beneficial in overweight patients because they can promote weight loss. Cost: Expensive. See GLP-1 analog PAP for information on how qualified patients may obtain for free. Effect: Average A1C reductions around 0.7 - 1.6%. Can promote weight loss (semaglutide > liraglutide > dulaglutide > exenatide > lixisenatide) Hypoglycemia: Does not cause hypoglycemia by itself Side effects: Nausea (12 - 40%), diarrhea (8 - 15%), and vomiting (5 - 15%)
Other treatments
Sulfonylureas (e.g. glipizide, glyburide) ADA recommendation: Second-line therapy Cost: Very cheap and used for many years Effect: Average A1C reductions of 1 - 1.5% Hypoglycemia: May cause hypoglycemia Side effects: Minimal side effects besides hypoglycemia
Glitazones (Actos, Avandia) ADA recommendation: Second-line therapy Cost: Very cheap and used for many years Effect: Average A1C reductions around 0.7 - 0.9% Hypoglycemia: Does not cause hypoglycemia by itself Side effects: May cause weight gain and fluid retention. Should be avoided in heart failure. Other: May improve nonalcoholic steatohepatitis
Insulin therapy ADA recommendation: Second-line therapy. Insulin should be considered for first-line therapy in patients with ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C is > 10% or blood glucose levels > 300 mg/dL. Cost: Cheap options exist (see insulin costs) Effect: Has no maximum effect. Can be titrated to blood sugar goals. Hypoglycemia: Can cause hypoglycemia. Side effects: Typically none besides hypoglycemia Other: May require frequent blood sugar monitoring. Patient or caregiver must understand how to inject properly.
DPP-4 inhibitors ADA recommendation: Second-line therapy Cost: Expensive. See DPP-4 inhibitor PAP for information on how qualified patients may obtain for free. Effect: Average A1C reductions of 0.4 - 0.7% Hypoglycemia: Does not cause hypoglycemia by itself Side effects: Generally well tolerated
Other therapies (not generally recommended) These medications are also approved to treat diabetes but are not widely used for various reasons The ADA does not include these medications in their type 2 diabetes recommendations Alpha-glucosidase inhibitors Meglitinides Pramlintide (Symlin®) Cycloset®

Insulin therapy

It goes without saying that insulin is an important part of treating diabetes. Unlike other treatments that have a maximal effect, insulin can be increased until blood sugars are controlled. Most insulins are expensive, but there are some cheaper options available now, and patients without insurance who meet certain criteria can get certain insulins for free.
NPH or a long-acting insulin (see insulin chart) should be the initial insulin used in most patients with type 2 diabetes. Lantus, Semglee, Basaglar, and Tresiba are preferred. Toujeo is not as potent as these 3 and typically requires doses that are 27% higher to achieve the same effect. Levemir has a shorter duration of action (< 20 hours) at lower doses (< 0.4 units/kg) and may require twice daily dosing. NPH has to be dosed twice daily in most cases, and unlike the long-acting insulins, it has a peak effect which can increase the risk of hypoglycemia. Despite this, NPH is still one of the cheapest insulins available ($25/vial at Walmart) so it may be preferred in some patients.
Options for obtaining insulin at reduced or no cost are outlined in the table below. The free insulin programs from Lilly, Sanofi, and Novo Nordisk use 400% of the federal poverty level as a financial cutoff for eligibility (see federal poverty levels).
Dosing recommendations for insulin are detailed here - insulin dosing

See federal poverty levels
Insulin	Reduced cost programs	Free programs
Basaglar, Humalog, Humulin N, Humulin R, Humalog Mix 50/50, Humalog Mix 75/25	Lilly Insulin Value Program Insurance: with and without Cost: $35 for a month supply Eligibility requirements: none	Lilly Cares program Income < 400% of federal poverty level U.S. legal resident No insurance
Lantus, Toujeo, Admelog, Apidra	Sanofi Insulin Value Savings Program Insurance: without Cost: $99/month for up to 10 packs of pens and/or vials Eligibility requirements: none	Sanofi Patient Connection Income < 400% of federal poverty level U.S. legal resident No insurance
Levemir, Tresiba, Novolog, Fiasp Novolin N, Novolin R, Novolin 70/30, Novolog Mix 70/30	My$99Insulin Program Insurance: with and without Cost: $99/month for up to 3 vials or 2 packs of pens Eligibility requirements: none	NovoCare Patient Assistance Program Income < 400% of federal poverty level U.S. legal resident No insurance
NPH and Regular	Walmart Insurance: with and without Cost: Novolin N - $25/vial and $43 for 5 pens Novolin R - $25/vial Eligibility requirements: none	NovoCare Patient Assistance Program Products: Novolin N and R vials only Income < 400% of federal poverty level U.S. legal resident No insurance Lilly Cares program Products: Humulin N and R Income < 400% of federal poverty level U.S. legal resident No insurance

Insulin dosing

When initiating and titrating insulin, the greatest concern in most patients is the occurrence of hypoglycemia. Any patient on insulin therapy should be counseled on the symptoms and treatment of hypoglycemia (see hypoglycemia information for more)
Approaches to insulin therapy in different patient types are given below

Patient type and recommendation
New diabetic (see therapy approach) Long-acting insulins Starting dose: 10 units/day or 0.1 - 0.2 units/kg/day Dose titration: see three-day method for adjusting basal insulin NPH See twice-daily NPH dosing
Treated diabetic (adding insulin) Long-acting insulins Starting dose: 10 units/day or 0.1 - 0.2 units/kg/day Dose titration: see three-day method for adjusting basal insulin NPH A1C > 9%: see twice-daily NPH dosing A1C < 9%: Patients with A1C < 9% may respond to once-daily NPH. I start with 6 - 10 units. If the patient has normal fasting AM blood sugars, the NPH should be given in the morning, otherwise, it can be given at bedtime. Titration can then follow the three-day method.
Diabetics who would like to change their insulin See recommendations for converting between insulin brands and types

See federal poverty levels
SGLT2 inhibitor Patient Assistance Program Information
Canagliflozin (Invokana®, Invokamet®, Invokamet® XR) Manufacturer: Johnson and Johnson Eligibility criteria: Live in the U.S. \| Income < 300% of federal poverty level Program information Program application
Dapagliflozin (Farxiga®, Qtern®, Xigduo XR®) Manufacturer: AstraZeneca Eligibility criteria: U.S. resident \| Income < 300% of federal poverty level Program information Program application
Empagliflozin (Jardiance®, Glyxambi®,Synjardy®, Synjardy® XR) Manufacturer: Boehringer Ingelheim Eligibility criteria: U.S. resident \| Does not give details on income level Program information Program application
Ertugliflozin (Steglatro®) Manufacturer: Merck Eligibility criteria: Does not have program currently

See federal poverty levels
GLP-1 analog Patient Assistance Program Information
Albiglutide (Tanzeum™) Manufacturer: GlaxoSmithKline Eligibility criteria: Live in the U.S. \| Income < 250% of federal poverty level Program information Program application
Dulaglutide (Trulicity™) Manufacturer: Lilly Eligibility criteria: Permanent, legal U.S. resident \| Income < 400% of federal poverty level Program information Program application
Exenatide (Bydureon®, Byetta®) Manufacturer: AstraZeneca Eligibility criteria: U.S. resident \| Income < 300% of federal poverty level Program information Program application
Liraglutide (Victoza®) Manufacturer: Novo Nordisk Eligibility criteria: U.S. citizen or legal resident \| Income < 400% of federal poverty level Program information Program application
Liraglutide (Saxenda®) Manufacturer: Novo Nordisk Eligibility criteria: U.S. citizen or legal resident \| Income < 400% of federal poverty level Program information Program application
Lixisenatide (Adlyxin®) Manufacturer: Sanofi Eligibility criteria: U.S. resident \| Income < 400% of federal poverty level Program information Program application
Semaglutide (Ozempic®) Manufacturer: Novo Nordisk Eligibility criteria: U.S. citizen or legal resident \| Income < 400% of federal poverty level Program information Program application
Semaglutide (Rybelsus®) Manufacturer: Novo Nordisk Eligibility criteria: U.S. citizen or legal resident \| Income < 400% of federal poverty level Program information Program application

See federal poverty levels
DPP-4 inhibitor Patient Assistance Program Information
Alogliptin (Nesina®, Oseni®, Kazano®) Manufacturer: Takeda Eligibility criteria: U.S. resident \| Income < 500% of federal poverty level Program information Program application
Linagliptin (Tradjenta®, Glyxambi®,Jentadueto®,Jentadueto® XR) Manufacturer: Boehringer Ingelheim Eligibility criteria: U.S. resident \| Does not give details on income level Program information Program application
Saxagliptin (Onglyza®, Kombiglyze® XR, Qtern®) Manufacturer: AstraZeneca Eligibility criteria: U.S. resident \| Income < 300% of federal poverty level Program information Program application
Sitagliptin (Januvia®, Janumet®, Janumet® XR) Manufacturer: Merck Eligibility criteria: U.S. resident \| Income < 400% of federal poverty level Program information Program application