Most of the nearly 30 million Americans who have type 2 diabetes are not even aware that cardiovascular problems pose a huge risk for them.

Even more troubling: Your doctor may be facing a knowledge gap, too—for different reasons. A new generation of prescription diabetes medications now is available, and these drugs are particularly effective at helping people with type 2 diabetes control their blood sugar while simultaneously reducing their risk for cardiovascular disease. (One botanical supplement may have similar benefits.) But the proper use of these medications can be so complicated that your doctor may not be making the right choice for you.

To learn more, Bottom Line Personal interviewed diabetes expert George L. King, MD.

New Heart-Friendly Diabetes Drugs

For many years, there were only three types of drugs—not counting ­insulin—to help people with type 2 diabetes control their blood glucose levels. Metformin typically was prescribed first (and still is)—it’s effective, safe and affordable. It has not been shown to increase or decrease cardiovascular risk.

When metformin wasn’t enough to control blood sugar, sulfonylureas often have been prescribed in addition. They are effective—sometimes too effective, leading to dangerous low-blood-sugar episodes. More disturbing, some studies have found that long-term use of sulfonylureas are associated with an increased risk for heart disease. Similarly, thiazolidinediones, introduced in the 1990s, have been shown to increase the risk for heart failure.

What’s new: In the past decade, and especially in just the past few years, a host of new, heart-friendly diabetes drugs have appeared. Most notable are the glucagon-like peptide-1 receptor agonists (GLP-1 agonists, for short) and sodium–glucose cotransporter 2 inhibitors (SGLT2 inhibitors). Both types have been shown in large studies to not just control blood glucose levels but also reduce the risk for heart failure—and reduce mortality in people with type 2 diabetes.

Other new diabetes drugs include ­dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors), which don’t increase cardiovascular risk, and colesevelam and ­bromocriptine, both of which may reduce cardiovascular risk but have significant side effects. Each of these is a different type of drug, and the complexity is leading to some not-so-smart prescriptions and danger for patients.

The Doctor Knowledge Gap

Metformin remains the “first-line” type 2 diabetes drug. But what should
be prescribed when, together with lifestyle changes, it’s not enough? Unfortunately, some doctors will not come up with the best answer to that question.

Type 2 diabetes typically is treated by primary care physicians, some of whom are not well-versed in the latest research…or who lack the time to figure out which of the drug options is best-suited to a particular patient. Don’t blame your doctor—selecting type 2 diabetes drugs has very quickly become very complicated. Doctors must not only sort through an ever-widening range of drug options with various (and different) side effects, but they also must consider each patient’s blood glucose levels, cardiovascular condition, other prescribed medications and, increasingly, financial situation.

Example: New joint guidelines from the American Diabetes Association and the European Association for the Study of Diabetes, to be presented in October 2018, recommend the use of GLP-1 ­agonists or SGLT2 inhibitors as the second drug after metformin for patients with type 2 diabetes who have cardiovascular disease. But while metformin and sulfonylureas can cost less than $10 for a 30-day supply, these newer drugs can run $400 or more per month for patients who must pay out of pocket…and might have hefty co-pays. There are many medical caveats, too—such as not using SGLT2 inhibitors in a patient with a certain degree of kidney failure…and how to ramp up the dosage of a GLP-1 agonist to decrease potential side effects.

What Diabetes Patients Should Do

Do not assume that the glucose-control drugs your doctor has prescribed are necessarily the best drugs for you. In particular…

  • If you take a drug other than metformin to control blood glucose—and especially if you take three or more ­glucose-control drugs—ask your doctor to explain why he/she selected each of these drugs.
  • If you have a history of heart attack or stroke and are taking multiple drugs to control your blood glucose—but are not taking a GLP-1 agonist or SGLT2 inhibitor—ask your doctor whether one of these might be appropriate for you.
  • If your doctor cannot explain why he chose the drugs you are taking in a way that you can understand and that sounds reasonable, ask for a referral to an endocrinologist who specializes in the treatment of diabetes.

The Growing Power of Lifestyle

The new diabetes medications give doctors new tools to tailor treatment to an individual’s most important risks, including cardiovascular risk. But it’s never a good idea to take an additional drug to control your blood sugar if you can do so through lifestyle changes instead, which are more powerful and healthier than any drugs. Fortunately, most of the lifestyle changes that help control blood sugar also protect your heart. Even small changes—such as getting up from your desk and walking around for five minutes every hour—can be very helpful. My recommendations…

  • Work up to walking 10,000 steps a day. You can track this on your phone or with a fitness watch or pedometer.
  • Get 60 minutes of more vigorous exercise every other day—evenly split between aerobics (such as treadmill jogging) and strength training. Good news: Those jogging “steps” count toward your 10,000.
  • At mealtime, follow the two-one-one formula—two portions nonstarchy vegetables (especially dark, leafy greens)…one portion whole grains, legumes or starchy vegetables…and one portion protein-rich food (fish, poultry, lean beef, tofu). For dessert, fruit is best.
  • Get seven or eight hours of sleep a night.

I know the power of these lifestyle changes from personal experience. About 25 years ago, when my father was age 72, he developed diabetes and was promptly placed on three medications. He took them, but at the same time he began walking an hour a day and eating as I describe above. A year and a half later, while he still technically “had” diabetes, he no longer needed any medication to control it. That’s why I have been following this lifestyle myself ever since.

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