Diabetes medication - Revision history

Fire at 07:44, 13 April 2024

2024-04-13T07:44:56Z

← Older revision		Revision as of 16:44, 13 April 2024
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	{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}		{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}
	{{Drug List/ja}}		{{Drug List/ja}}
	{{PathNav\|Medication~~/ja~~}}		{{PathNav\|Medication}}
	'''Drugs used in diabetes''' treat [[diabetes mellitus]] by decreasing the [[blood sugar level\|glucose level in the blood]]. With the exception of [[Insulin (medication)\|insulin]], most [[GLP receptor agonists]] ([[liraglutide]], [[exenatide]], and others), and [[pramlintide]], all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.		'''Drugs used in diabetes''' treat [[diabetes mellitus]] by decreasing the [[blood sugar level\|glucose level in the blood]]. With the exception of [[Insulin (medication)\|insulin]], most [[GLP receptor agonists]] ([[liraglutide]], [[exenatide]], and others), and [[pramlintide]], all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.

Fire: Marked this version for translation

2024-02-04T03:09:02Z

Marked this version for translation

Show changes

Fire at 03:08, 4 February 2024

2024-02-04T03:08:49Z

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			<languages />
			<translate>
	{{Short description\|Drugs that lower blood glucose levels to treat diabetes}}		{{Short description\|Drugs that lower blood glucose levels to treat diabetes}}
	{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}		{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}
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	{{DEFAULTSORT:Anti-Diabetic Drug}}		{{DEFAULTSORT:Anti-Diabetic Drug}}
	[[Category:Anti-diabetic drugs]]		[[Category:Anti-diabetic drugs]]
			</translate>

Fire at 03:06, 4 February 2024

2024-02-04T03:06:41Z

← Older revision		Revision as of 12:06, 4 February 2024
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	{{Short description\|Drugs that lower blood glucose levels to treat diabetes}}		{{Short description\|Drugs that lower blood glucose levels to treat diabetes}}
	{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}		{{About\|treatment of diabetes mellitus\|treatment of diabetes insipidus\|Diabetes insipidus}}
			{{Drug List/ja}}
			{{PathNav\|Medication/ja}}
	'''Drugs used in diabetes''' treat [[diabetes mellitus]] by decreasing the [[blood sugar level\|glucose level in the blood]]. With the exception of [[Insulin (medication)\|insulin]], most [[GLP receptor agonists]] ([[liraglutide]], [[exenatide]], and others), and [[pramlintide]], all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.		'''Drugs used in diabetes''' treat [[diabetes mellitus]] by decreasing the [[blood sugar level\|glucose level in the blood]]. With the exception of [[Insulin (medication)\|insulin]], most [[GLP receptor agonists]] ([[liraglutide]], [[exenatide]], and others), and [[pramlintide]], all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.

Fire: /* Alpha-glucosidase inhibitors */

2024-02-04T03:02:54Z

Alpha-glucosidase inhibitors

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	==Alpha-glucosidase inhibitors==		==Alpha-glucosidase inhibitors==
	~~{{unreferenced section\|date=January 2016}}~~
	{{Main\|Alpha-glucosidase inhibitor}}		{{Main\|Alpha-glucosidase inhibitor}}
	[[Alpha-glucosidase inhibitor]]s are "diabetes pills" but not technically hypoglycemic agents because they do not have a direct effect on insulin secretion or sensitivity. These agents slow the digestion of starch in the small intestine, so that glucose from the starch of a meal enters the bloodstream more slowly, and can be matched more effectively by an impaired insulin response or sensitivity. These agents are effective by themselves only in the earliest stages of [[impaired glucose tolerance]], but can be helpful in combination with other agents in [[type 2 diabetes]].		[[Alpha-glucosidase inhibitor]]s are "diabetes pills" but not technically hypoglycemic agents because they do not have a direct effect on insulin secretion or sensitivity. These agents slow the digestion of starch in the small intestine, so that glucose from the starch of a meal enters the bloodstream more slowly, and can be matched more effectively by an impaired insulin response or sensitivity. These agents are effective by themselves only in the earliest stages of [[impaired glucose tolerance]], but can be helpful in combination with other agents in [[type 2 diabetes]].

Fire: /* Sulfonylureas */

2024-02-04T03:02:41Z

Sulfonylureas

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	===Sulfonylureas===		===Sulfonylureas===
	~~{{unreferenced section\|date=January 2016}}~~
	{{Main\|Sulfonylurea}}		{{Main\|Sulfonylurea}}
	[[Sulfonylurea]]s were the first widely used oral anti-hyperglycemic medications. They are ''insulin secretagogues'', triggering insulin release by inhibiting the [[ATP-sensitive potassium channel\|K<sub>ATP</sub>]] channel of the pancreatic [[beta cell]]s. Eight types of these pills have been marketed in North America, but not all remain available. The "second-generation" drugs are now more commonly used. They are more effective than first-generation drugs and have fewer side-effects. All may cause weight gain.		[[Sulfonylurea]]s were the first widely used oral anti-hyperglycemic medications. They are ''insulin secretagogues'', triggering insulin release by inhibiting the [[ATP-sensitive potassium channel\|K<sub>ATP</sub>]] channel of the pancreatic [[beta cell]]s. Eight types of these pills have been marketed in North America, but not all remain available. The "second-generation" drugs are now more commonly used. They are more effective than first-generation drugs and have fewer side-effects. All may cause weight gain.

Fire: Created page with "{{Short description|Drugs that lower blood glucose levels to treat diabetes}} {{About|treatment of diabetes mellitus|treatment of diabetes insipidus|Diabetes insipidus}} '''Drugs used in diabetes''' treat diabetes mellitus by decreasing the glucose level in the blood. With the exception of insulin, most GLP receptor agonists (liraglutide, exenatide, and others), and pramlintide, all are administered orall..."

2024-02-03T14:32:15Z

Created page with "{{Short description|Drugs that lower blood glucose levels to treat diabetes}} {{About|treatment of diabetes mellitus|treatment of diabetes insipidus|Diabetes insipidus}} '''Drugs used in diabetes''' treat diabetes mellitus by decreasing the glucose level in the blood. With the exception of insulin, most GLP receptor agonists (liraglutide, exenatide, and others), and pramlintide, all are administered orall..."

New page

{{Short description|Drugs that lower blood glucose levels to treat diabetes}}
{{About|treatment of diabetes mellitus|treatment of diabetes insipidus|Diabetes insipidus}}
'''Drugs used in diabetes''' treat [[diabetes mellitus]] by decreasing the [[blood sugar level|glucose level in the blood]]. With the exception of [[Insulin (medication)|insulin]], most [[GLP receptor agonists]] ([[liraglutide]], [[exenatide]], and others), and [[pramlintide]], all are administered orally and are thus also called oral hypoglycemic agents or oral antihyperglycemic agents. There are different classes of hypoglycemic drugs, and their selection depends on the nature of diabetes, age, and situation of the person, as well as other factors.

[[Diabetes mellitus type 1]] is a disease caused by the lack of insulin. Insulin must be used in type 1, which must be injected.

[[Diabetes mellitus type 2]] is a disease of insulin resistance by cells. Type 2 diabetes mellitus is the most common type of diabetes. Treatments include agents that (1) increase the amount of insulin secreted by the pancreas, (2) increase the sensitivity of target organs to insulin, (3) decrease the rate at which glucose is absorbed from the gastrointestinal tract, and (4) increase the loss of glucose through urination.

Several groups of drugs, mostly given by mouth, are effective in type 2 diabetes, often in combination. The therapeutic combination in type 2 may include several [[Insulin (medication)|insulin]] isoforms or oral antihyperglycemic agents. As of 2020, 23 unique antihyperglycemic drug combinations were approved by the [[Food and Drug Administration|FDA]]. [[Dapagliflozin/saxagliptin/metformin|The first triple combination]] of oral anti-diabetics was approved in 2019, consisting of [[metformin]], [[saxagliptin]], and [[dapagliflozin]]. [[Empagliflozin/linagliptin/metformin|Another triple combination]] approval for [[metformin]], [[linagliptin]], and [[empagliflozin]] followed in 2020.

__TOC__
==Mechanisms of action==
Diabetes medications have four main mechanisms of action:
* [[#Sensitizers|Insulin sensitization]]: Increase sensitivity of insulin receptors on cells leads to decrease in [[insulin resistance]], and higher effects of insulin on blood glucose levels.
* [[#Secretagogues|Stimulation of beta cells]]: This stimulation increases insulin secretion from [[beta cell]]s of [[pancreas]].
* [[#Alpha-glucosidase inhibitors|Alpha-glucosidase inhibition]]: Inhibition of the [[alpha-glucosidase]] enzyme decreases the rate at which glucose is absorbed from the gastrointestinal tract.
* [[#SGLT2 inhibitors|SGLT2 inhibition]]: Inhibition of [[sodium-glucose linked transporter 2]] (SGLT2) proteins decreases glucose reabsorption into renal tubules of nephrons, thus increasing amount of glucose excreted in urine.

==Insulin==
{{Main|Insulin (medication)}}
Insulin is usually given [[Subcutaneous tissue|subcutaneously]], either by injections or by an [[insulin pump]]. In acute care settings, insulin may also be given intravenously. Insulins are typically characterized by the rate at which they are metabolized by the body, yielding different peak times and durations of action. Faster-acting insulins peak quickly and are subsequently metabolized while longer-acting insulins tend to have extended peak times and remain active in the body for more significant periods.

Examples of rapid-acting insulins (peak at ~1 hour) are:
* [[Insulin lispro]] (Humalog)
* [[Insulin aspart]] (Novolog)
* [[Insulin glulisine]] (Apidra)

Examples of short-acting insulins (peak 2–4 hours) are:
* Regular insulin (Humulin R, Novolin R)
* Prompt insulin zinc (Semilente)

Examples of intermediate-acting insulins (peak 4–10 hours) are:
* Isophane insulin, neutral protamine Hagedorn (NPH) (Humulin N, Novolin N)
* Insulin zinc (Lente)

Examples of long-acting insulins (duration 24 hours, often without peak) are:
* Extended insulin zinc insulin (Ultralente)
* Insulin glargine (Lantus)
* Insulin detemir (Levemir)
* Insulin degludec (Tresiba)

Insulin degludec is sometimes classed separately as an "ultra-long" acting insulin due to its duration of action of about 42 hours, compared with 24 hours for most other long-acting insulin preparations.

As a systematic review of studies comparing insulin detemir, insulin glargine, insulin degludec and NPH insulin did not show any clear benefits or serious [[Side effect|adverse effects]] for any particular form of insulin for nocturnal [[hypoglycemia]], severe hypoglycemia, [[glycated hemoglobin]] A1c, non-fatal [[myocardial infarction]]/[[stroke]], [[Quality of life (healthcare)|health-related quality of life]] or [[all-cause mortality]]. The same review did not find any differences in effects of using these insulin analogues between adults and children.

Most oral anti-diabetic agents are contraindicated in pregnancy, in which insulin is preferred.

Insulin is not administered by other routes, although this has been studied. An inhaled form was briefly licensed but was subsequently withdrawn.

==Sensitizers==
Insulin sensitizers address the core problem in type 2 diabetes – [[insulin resistance]].

===Biguanides===
{{Main|Biguanide}}
[[Biguanide]]s reduce [[liver|hepatic]] glucose output and increase uptake of glucose by the periphery, including skeletal muscle. Although it must be used with caution in patients with impaired liver or [[kidney]] function, [[metformin]], a biguanide, has become the most commonly used agent for type 2 diabetes in children and teenagers. Among common diabetic drugs, metformin is the only widely used oral drug that does not cause weight gain.

Typical reduction in [[glycated hemoglobin]] (A1C) values for metformin is 1.5–2.0%
* [[Metformin]] (Glucophage) may be the best choice for patients who also have heart failure, but it should be temporarily discontinued before any radiographic procedure involving intravenous [[iodine|iodinated]] [[radiocontrast|contrast]], as patients are at an increased risk of [[lactic acidosis]].
* [[Phenformin]] (DBI) was used from 1960s through 1980s, but was withdrawn due to lactic acidosis risk.
* [[Buformin]] also was withdrawn due to lactic acidosis risk.

Metformin is usually the first-line medication used for treatment of type 2 diabetes. In general, it is prescribed at initial diagnosis in conjunction with exercise and weight loss, as opposed to in the past, where it was prescribed after diet and exercise had failed. There is an immediate-release as well as an extended-release formulation, typically reserved for patients experiencing [[gastrointestinal]] side-effects. It is also available in combination with other oral diabetic medications.

===Thiazolidinediones===
{{Main|Thiazolidinedione}}
[[Thiazolidinedione]]s ([[TZD]]s), also known as "glitazones," bind to [[Peroxisome proliferator-activated receptor gamma|PPARγ]], peroxisome proliferator activated receptor [[Peroxisome proliferator-activated receptor gamma|γ]], a type of nuclear regulatory protein involved in transcription of genes regulating glucose and fat metabolism. These PPARs act on peroxisome proliferator responsive elements (PPRE). The PPREs influence insulin-sensitive genes, which enhance production of mRNAs of insulin-dependent enzymes. The final result is better use of glucose by the cells. These drugs also enhance PPAR-α activity and hence lead to a rise in HDL and some larger components of LDL.

Typical reductions in [[glycated hemoglobin]] (A1C) values are 1.5–2.0%. Some examples are:
* [[Rosiglitazone]] (Avandia): the [[European Medicines Agency]] recommended in September 2010 that it be suspended from the EU market due to elevated cardiovascular risks.
* [[Pioglitazone]] (Actos): remains on the market but has also been associated with increased cardiovascular risks.
* [[Troglitazone]] (Rezulin): used in 1990s, withdrawn due to [[hepatitis]] and liver damage risk.

Multiple retrospective studies have resulted in a concern about rosiglitazone's safety, although it is established that the group, as a whole, has beneficial effects on diabetes. The greatest concern is an increase in the number of severe cardiac events in patients taking it. The ADOPT study showed that initial therapy with drugs of this type may prevent the progression of disease, The [[American Association of Clinical Endocrinologists]] (AACE), which provides clinical practice guidelines for management of diabetes, retains thiazolidinediones as recommended first, second, or third line agents for type 2 diabetes mellitus, as of their 2019 executive summary, over sulfonylureas and α-glucosidase inhibitors. However, they are less preferred than GLP-1 agonists or SGLT2 inhibitors, especially in patients with cardiovascular disease (which [[liraglutide]], [[empagliflozin]], and [[canagliflozin]] are all FDA approved to treat).

Concerns about the safety of rosiglitazone arose when a retrospective meta-analysis was published in [[the New England Journal of Medicine]]. There have been a significant number of publications since then, and a [[Food and Drug Administration]] panel voted, with some controversy, 20:3 that available studies "supported a signal of harm", but voted 22:1 to keep the drug on the market. The meta-analysis was not supported by an interim analysis of the trial designed to evaluate the issue, and several other reports have failed to conclude the controversy. This weak evidence for adverse effects has reduced the use of rosiglitazone, despite its important and sustained effects on [[glycemic control]]. Safety studies are continuing.

In contrast, at least one large prospective study, PROactive 05, has shown that [[pioglitazone]] may decrease the overall incidence of cardiac events in people with type 2 diabetes who have already had a heart attack.

===Lyn kinase activators===
The [[LYN]] kinase activator [[tolimidone]] has been reported to potentiate insulin signaling in a manner that is distinct from the glitazones. The compound has demonstrated positive results in a Phase 2a clinical study involving 130 diabetic subjects.

==Secretagogues==
[[Secretagogue]]s are drugs that increase output from a gland, in the case of insulin from the [[pancreas]].

===Sulfonylureas===
{{unreferenced section|date=January 2016}}
{{Main|Sulfonylurea}}
[[Sulfonylurea]]s were the first widely used oral anti-hyperglycemic medications. They are ''insulin secretagogues'', triggering insulin release by inhibiting the [[ATP-sensitive potassium channel|K<sub>ATP</sub>]] channel of the pancreatic [[beta cell]]s. Eight types of these pills have been marketed in North America, but not all remain available. The "second-generation" drugs are now more commonly used. They are more effective than first-generation drugs and have fewer side-effects. All may cause weight gain.

Current clinical practice guidelines from the [[American Association of Clinical Endocrinologists|AACE]] rate sulfonylureas (as well as glinides) below all other classes of antidiabetic drugs in terms of suggested use as first, second, or third line agents - this includes [[bromocriptine]], the bile acid sequestrant [[colesevelam]], [[Alpha-glucosidase inhibitor|α-glucosidase inhibitors]], [[Thiazolidinedione|TZDs]] (glitazones), and [[Dipeptidyl peptidase-4 inhibitor|DPP-4 inhibitors]] (gliptins). The low cost of most sulfonylureas, however, especially when considering their significant efficacy in blood glucose reduction, tends to keep them as a more feasible option in many patients - neither SGLT2 inhibitors nor GLP-1 agonists, the classes most favored by the AACE guidelines after metformin, are currently available as generics.

Sulfonylureas bind strongly to [[plasma protein]]s. Sulfonylureas are useful only in type 2 diabetes, as they work by stimulating endogenous release of insulin. They work best with patients over 40 years old who have had diabetes mellitus for under ten years. They cannot be used with type 1 diabetes, or diabetes of pregnancy. They can be safely used with metformin or glitazones. The primary side-effect is [[hypoglycemia]], which appears to happen more commonly with sulfonylureas than with other treatments.

A [[Cochrane (organisation)|Cochrane]] [[systematic review]] from 2011 showed that treatment with [[Sulfonylurea|Sulphonylurea]] did not improve control of glucose levels more than insulin at 3 nor 12 months of treatment. This same review actually found evidence that treatment with Sulphonylurea could lead to earlier insulin dependence, with 30% of cases requiring insulin at 2 years. When studies measured fasting [[C-peptide]], no intervention influenced its concentration, but insulin maintained concentration better compared to Sulphonylurea. Still, it is important to highlight that the studies available to be included in this review presented considerable flaws in quality and design.

Typical reductions in [[glycated hemoglobin]] (A1C) values for second-generation sulfonylureas are 1.0–2.0%.
* First-generation agents
** [[tolbutamide]]
** [[acetohexamide]]
** [[tolazamide]]
** [[chlorpropamide]]
* Second-generation agents
** [[glipizide]]
** glyburide or [[glibenclamide]]
** [[glimepiride]]
** [[gliclazide]]
** [[glyclopyramide]]
** [[gliquidone]]

===Meglitinides===
{{Main|Meglitinide}}
[[Meglitinide]]s help the pancreas produce insulin and are often called "short-acting secretagogues." They act on the same potassium channels as sulfonylureas, but at a different binding site. By closing the potassium channels of the pancreatic beta cells, they open the calcium channels, thereby enhancing insulin secretion.

They are taken with or shortly before meals to boost the insulin response to each meal. If a meal is skipped, the medication is also skipped.

Typical reductions in [[glycated hemoglobin]] (A1C) values are 0.5–1.0%.
* [[repaglinide]]
* [[nateglinide]]

Adverse reactions include weight gain and hypoglycemia.

==Alpha-glucosidase inhibitors==
{{unreferenced section|date=January 2016}}
{{Main|Alpha-glucosidase inhibitor}}
[[Alpha-glucosidase inhibitor]]s are "diabetes pills" but not technically hypoglycemic agents because they do not have a direct effect on insulin secretion or sensitivity. These agents slow the digestion of starch in the small intestine, so that glucose from the starch of a meal enters the bloodstream more slowly, and can be matched more effectively by an impaired insulin response or sensitivity. These agents are effective by themselves only in the earliest stages of [[impaired glucose tolerance]], but can be helpful in combination with other agents in [[type 2 diabetes]].

Typical reductions in [[glycated hemoglobin]] (A1C) values are 0.5–1.0%.
* [[miglitol]]
* [[acarbose]]
* [[voglibose]]
These medications are rarely used in the United States because of the severity of their side-effects (flatulence and bloating). They are more commonly prescribed in Europe. They do have the potential to cause weight loss by lowering the amount of sugar metabolized.

==Peptide analogs==
[[Image:Incretins and DPP 4 inhibitors.svg|thumb|300px|right|Overview of insulin secretion]]

===Injectable incretin mimetics===
[[Incretin]]s are also insulin [[secretagogue]]s. The two main candidate molecules that fulfill criteria for being an incretin are [[glucagon-like peptide-1]] (GLP-1) and [[gastric inhibitory peptide]] (glucose-dependent insulinotropic peptide, GIP). Both GLP-1 and GIP are rapidly inactivated by the enzyme [[dipeptidyl peptidase-4]] (DPP-4).

====Injectable glucagon-like peptide analogs and agonists====
Glucagon-like peptide (GLP) agonists bind to a membrane GLP receptor. As a consequence, insulin release from the pancreatic beta cells is increased. Endogenous GLP has a half-life of only a few minutes, thus an analogue of GLP would not be practical. As of 2019, the [[American Association of Clinical Endocrinologists|AACE]] lists GLP-1 agonists, along with SGLT2 inhibitors, as the most preferred anti-diabetic agents after metformin. [[Liraglutide]] in particular may be considered first-line in diabetic patients with cardiovascular disease, as it has received FDA approval for reduction of risk of major adverse cardiovascular events in patients with type 2 diabetes. In a 2011 [[Cochrane (organisation)|Cochrane]] [[Systematic review|review]], GLP-1 agonists showed approximately a 1% reduction in HbA1c when compared to placebo. GLP-1 agonists also show improvement of [[Beta cell|beta-cell]] function, but this effect does not last after treatment is stopped. Due to shorter duration of studies, this review did not allow for long-term positiver or negative effects to be assessed.
* [[Exenatide]] (also Exendin-4, marketed as Byetta) is the first [[glucagon-like peptide-1|GLP-1]] agonist approved for the treatment of [[type 2 diabetes]]. Exenatide is not an analogue of GLP but rather a GLP agonist. Exenatide has only 53% homology with GLP, which increases its resistance to degradation by DPP-4 and extends its half-life. A 2011 Cochrane review showed a HbA1c reduction of 0.20% more with Exenatide 2 mg compared to insulin glargine, exenatide 10 µg twice daily, sitagliptin and pioglitazone. Exenatide, together with liraglutide, led to greater weight loss than glucagon-like peptide analogues.
* [[Liraglutide]], a once-daily human analogue (97% homology), has been developed by [[Novo Nordisk]] under the brand name [[Victoza]]. The product was approved by the [[European Medicines Agency]] (EMEA) on July 3, 2009, and by the [[U.S. Food and Drug Administration]] (FDA) on January 25, 2010. A 2011 Cochrane review showed a HbA1c reduction of 0.24% more with liraglutide 1.8 mg compared to insulin glargine, 0.33% more than exenatide 10 µg twice daily, sitagliptin and rosiglitazone. Liraglutide, together with exenatide, led to greater weight loss than glucagon-like peptide analogues.
* [[Taspoglutide]] is presently in Phase III clinical trials with [[Hoffman-La Roche]].
* Lixisenatide (Lyxumia) Sanofi Aventis
* [[Semaglutide]] (Ozempic) (oral version is Rybelsus)
* [[Dulaglutide]] ([[Trulicity]]) - once weekly
* [[Albiglutide]] (Tanzeum) - once weekly

These agents may also cause a decrease in gastric motility, responsible for the common side-effect of nausea, which tends to subside with time.

====Gastric inhibitory peptide analogs====

====Dipeptidyl peptidase-4 inhibitors====
{{Main|Dipeptidyl peptidase-4 inhibitor}}
GLP-1 analogs resulted in weight loss and had more gastrointestinal side-effects, while in general [[dipeptidyl peptidase-4]] (DPP-4) inhibitors were weight-neutral and increased risk for infection and headache, but both classes appear to present an alternative to other antidiabetic drugs. However, weight gain and/or hypoglycemia have been observed when [[dipeptidyl peptidase-4 inhibitor]]s were used with sulfonylureas; effects on long-term health and morbidity rates are still unknown.

DPP-4 inhibitors increase blood concentration of the [[incretin]] GLP-1 by inhibiting its degradation by DPP-4.

Examples are:
* [[vildagliptin]] (Galvus) EU Approved 2008
* [[sitagliptin]] (Januvia) FDA approved Oct 2006
* [[saxagliptin]] (Onglyza) FDA Approved July 2009
* [[linagliptin]] (Tradjenta) FDA Approved May 2, 2011
* [[alogliptin]]
* [[septagliptin]]
* [[teneligliptin]]
* [[gemigliptin]] (Zemiglo)

DPP-4 inhibitors lowered hemoglobin [[Glycated hemoglobin|A1C]] values by 0.74%, comparable to other antidiabetic drugs.

A result in one RCT comprising 206 patients aged 65 or older (mean baseline HgbA1c of 7.8%) receiving either 50 or 100 mg/d of [[sitagliptin]] was shown to reduce HbA1c by 0.7% (combined result of both doses). A combined result of 5 RCTs enlisting a total of 279 patients aged 65 or older (mean baseline HbA1c of 8%) receiving 5 mg/d of [[saxagliptin]] was shown to reduce HbA1c by 0.73%. A combined result of 5 RCTs enlisting a total of 238 patients aged 65 or older (mean baseline HbA1c of 8.6%) receiving 100 mg/d of [[vildagliptin]] was shown to reduce HbA1c by 1.2%. Another set of 6 combined RCTs involving [[alogliptin]] (approved by FDA in 2013) was shown to reduce HbA1c by 0.73% in 455 patients aged 65 or older who received 12.5 or 25 mg/d of the medication.

===Injectable amylin analogues===

[[Amylin]] agonist analogues slow gastric emptying and suppress [[glucagon]]. They have all the incretins actions except stimulation of insulin secretion. {{As of|2007}}, [[pramlintide]] is the only clinically available amylin analogue. Like insulin, it is administered by [[subcutaneous injection]]. The most frequent and severe adverse effect of pramlintide is [[nausea]], which occurs mostly at the beginning of treatment and gradually reduces. Typical reductions in A1C values are 0.5–1.0%.

==SGLT2 inhibitors==
{{Main|Gliflozin}}
[[SGLT2 inhibitor]]s block the sodium-glucose linked transporter 2 proteins in [[renal tubule]]s of [[nephron]]s in kidneys, reabsorption of glucose in into the renal tubules, promoting excretion of glucose in the urine. This causes both mild weight loss, and a mild reduction in blood sugar levels with little risk of hypoglycemia. Oral preparations may be available alone or in combination with other agents. Along with GLP-1 agonists, they are considered preferred second or third agents for type 2 diabetics sub-optimally controlled with metformin alone, according to most recent clinical practice guidelines. Because they are taken by mouth, rather than injected (like GLP-1 agonists), patients who are [[Fear of needles|injection-averse]] may prefer these agents over the former. They may be considered first line in diabetic patients with cardiovascular disease, especially [[heart failure]], as these medications have been shown to reduce the risk of hospitalization in patients with such comorbidities. Because they are not available as generic medications, however, cost may limit their feasibility for many patients. Furthermore, there has been growing evidence that the effectiveness and safety of this drug class could depend on genetic variability of the patients.

Examples include:
* [[Dapagliflozin]]
* [[Canagliflozin]]
* [[Empagliflozin]]
* [[Remogliflozin]]

The side effects of SGLT2 inhibitors are derived directly from their mechanism of action; these include an increased risk of: [[ketoacidosis]], [[urinary tract infection]]s, [[Vaginal yeast infection|candidal vulvovaginitis]], and [[hypoglycemia]].

==Comparison==
The following table compares some common anti-diabetic agents, generalizing classes, although there may be substantial variation in individual drugs of each class. When the table makes a comparison such as "lower risk" or "more convenient" the comparison is with the other drugs on the table.

{| class="wikitable sortable"
|-
! colspan="5" style="background-color: #CCEEEE;" | Comparison of anti-diabetic medication
|-
! Drug class
! Mechanism of action
! Advantages
! Disadvantages
|-
| [[Sulfonylurea]]s ([[glyburide]], [[glimepiride]], [[glipizide]])
| Stimulating insulin release by pancreatic [[beta cell]]s by inhibiting the [[ATP-sensitive potassium channel|K<sub>ATP</sub> channel]]
|
* Inexpensive
* Fast onset of action
* No effect on [[blood pressure]]
* No detrimental effect on [[low-density lipoprotein]]
* Lower risk of [[Human gastrointestinal tract|gastrointestinal]] side effects than metformin
* Convenient dosing
|
* Cause an average of 2–5 kg [[weight gain]]
* Increase the risk of hypoglycemia
* Glyburide increases risk of [[hypoglycemia]] slightly more compared to glimepiride and glipizide

|-
| [[Metformin]]
| Acts on the liver to reduce gluconeogenesis and causes a decrease in [[insulin resistance]] via increasing [[AMPK]] signalling.
|
* Associated with weight loss
* Lower risk of hypoglycemia compared to other antidiabetics
* Decreases [[low-density lipoprotein]]
* Decreases [[triglycerides]]
* No effect on blood pressure
* Lowered all-cause mortality in diabetics
* Inexpensive
|
* Higher risk of [[Human gastrointestinal tract|gastrointestinal]] side effects
* Due to the risk of potentially fatal [[lactic acidosis]], contraindicated in people with [[shock (circulatory)|shock]]; with acute or chronic, moderate or severe [[kidney disease]] or at risk for impaired kidney function from [[Radiocontrast agent|intravenous dye]]; and with acute or chronic [[metabolic acidosis]]
* Risk of lactic acidosis also is increased for people with unstable or acute [[heart failure]], [[liver disease]], or [[alcoholism]], or who are recovering from major [[surgery]]
* Increased risk of [[vitamin B12 deficiency]]
* [[Metallic taste]]
|-
| [[Alpha-glucosidase inhibitor]]s ([[acarbose]], [[miglitol]], [[voglibose]])
| Inhibit carbohydrate digestion in the small intestine by inhibiting enzymes that break down polysaccharides
|
* Slightly lower risk of hypoglycemia compared to sulfonylureas
* Associated with modest weight loss
* Decreases triglycerides
* No detrimental effect on cholesterol
|
* Less effective than most other diabetes pills in lowering [[glycated hemoglobin]]
* Increased risk of GI side effects than other diabetes pills except metformin
* Inconvenient dosing
|-
| [[Thiazolidinediones]] ([[Pioglitazone]], [[Rosiglitazone]])
| Reduce insulin resistance by activating [[Peroxisome proliferator-activated receptor gamma|PPAR-γ]] in fat and muscle
|
* Lower the risk of hypoglycemia
* May slightly increase [[high-density lipoprotein]]
* Rosiglitazone linked to decreased triglycerides
* Convenient dosing
|
* Increase the risk of [[heart failure]]
* Cause an average of 2–5 kg [[weight gain]]
* Are associated with a higher risk of edema, anemia and bone fractures
* Can increase low-density lipoprotein
* Rosiglitazone has been linked to increased triglycerides and an increased risk of a heart attack
* Pioglitazone has been linked to an increased risk of bladder cancer
* Have a slower onset of action
* Require monitoring for [[hepatotoxicity]]
* Expensive
|-
|[[SGLT2 inhibitors]]
|}

==Generic==
Many anti-diabetes drugs are available as generics. These include:
* [[Sulfonylureas]] – glimepiride, glipizide, glyburide
* [[Biguanides]] – metformin
* [[Thiazolidinediones]] (Tzd) – pioglitazone, Actos generic
* [[Alpha-glucosidase inhibitor]]s – Acarbose
* [[Meglitinide]]s – nateglinide
* Combination of sulfonylureas plus metformin – known by generic names of the two drugs
No generics are available for [[dipeptidyl peptidase-4 inhibitor]]s (Onglyza), the glifozins, the incretins and various combinations. Sitagliptin patent expired in July 2022, leading to launch of generic sitagliptin brands . This lowered the cost of therapy for type 2 diabetes using sitagliptin .

== Alternative Medicine ==
The effect of [[Ayurveda|Ayurvedic]] treatments has been researched, however due to methodological flaws of relevant studies and research, it has not been possible to draw conclusions regarding efficacy of these treatments and there is insufficient evidence to recommend them.

== Further reading ==
* {{cite book |author=Lebovitz, Harold E. |title=Therapy For Diabetes Mellitus and Related Disorders |publisher=[[American Diabetes Association]] |location=Alexandria, VA |year=2004 |edition=4th |isbn=978-1-58040-187-6 |url-access=registration |url=https://archive.org/details/therapyfordiabet0000unse_w1x1 }}
* {{cite book |author1=Adams, Michael Ian |author2=Holland, Norman Norwood |title=Core Concepts in Pharmacology |url=https://archive.org/details/coreconceptsinph0000holl |url-access=registration |publisher=Prentice Hall |location=Englewood Cliffs, NJ |year=2003 |isbn=978-0-13-089329-1 }}

{{Oral hypoglycemics}}
{{Major Drug Groups}}
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[[Category:Anti-diabetic drugs]]