Diabetes. How to treat type 2 diabetes: standards and recommendations What sugar pills

Diabetes is now affecting more and more people. Both adults and children suffer from it. In most cases, this disease is incurable and requires lifelong use of special drugs. There are different medicines for diabetes, they work in different ways and often cause side effects. Therefore, it is necessary to take only those drugs prescribed by the doctor.

Types of diabetes

There are two types of the disease. They are both characterized by high blood sugar levels, which occurs different reasons. In type 1 diabetes, also called insulin-dependent, the body does not produce this important hormone on its own. This is due to the destruction of pancreatic cells. And the main medicine for patients with diabetes of this type is insulin.

If the functions of the pancreas are not impaired, but for some reason it produces little of the hormone, or the cells of the body cannot take it, type 2 diabetes develops. It is also called non-insulin dependent. In this case, the glucose level may rise due to the large intake of carbohydrates, metabolic disorders. Most people with type 2 diabetes are overweight. Therefore, it is recommended to limit the intake of carbohydrate foods, especially flour products, sweets and starch. But, in addition to diet, drug therapy is also important. There are different drugs for type 2 diabetes, they are prescribed by a doctor, depending on the individual characteristics of the disease.

Insulin-dependent diabetes mellitus: treatment

There is no cure for this disease. All you need is supportive therapy. Why don't drugs help? In a healthy person, the pancreas constantly produces the hormone insulin, which is needed for normal metabolism. It is released into the bloodstream as soon as a person eats, resulting in an increase in glucose levels. And insulin delivers it from the blood to cells and tissues. If there is too much glucose, this hormone is involved in the formation of its reserves in the liver, as well as in the deposition of excess in fat.

In insulin-dependent diabetes mellitus, the pancreas is impaired. Therefore, the level of sugar in the blood rises, which is very dangerous. This condition causes damage to nerve fibers, the development of kidney and heart failure, the formation of blood clots and other problems. Therefore, patients with such diabetes must constantly ensure the flow of insulin from the outside. This is the answer to the question of what medication is taken for type 1 diabetes. With proper insulin administration, additional drugs usually not required.

Features of the use of insulin

This hormone quickly breaks down in the stomach, so it cannot be taken in the only way to introduce insulin into the body - with a syringe or a special pump directly into the blood. The drug is absorbed most quickly if it is injected into the subcutaneous fold on the abdomen or into the upper part of the shoulder. The least effective injection site is the thigh or buttock. You should always inject the drug in the same place. In addition, there are other features of the treatment of patients with insulin-dependent diabetes. The assimilation of the hormone depends on how much the patient moves, what he eats, and also on his age. Depending on this, different types of the drug are prescribed and the dosage is selected. What types of this hormone are there?

• Long-acting insulin - processes glucose throughout the day. A striking example is the drug "Glargin". It maintains a constant blood sugar level and is administered twice a day.
• Short-acting insulin is produced from a human hormone with the help of special bacteria. These are the preparations "Humodar" and "Actrapid". Their action begins in half an hour, so it is recommended to administer them before meals.
• Rapid-acting insulin is administered after a meal. It begins to act in 5-10 minutes, but the effect lasts no more than an hour, so it is used together with other types of insulin. Such drugs have a quick action: "Humalog" and "Apidra".

Non-insulin-dependent diabetes mellitus: medications

What other medicines can a diabetic take?

Such a patient needs to monitor not only nutrition. It is important to carefully study the instructions for any medicine, even for colds or headaches. Most of them are contraindicated in diabetes. All drugs should not affect glucose levels and have a minimum of side effects.

• What can you drink? Valid "Indapamide", "Torasemide", "Mannitol", "Diacarb", "Amlodipine", "Verapramil", "Rasilez".
• Most painkillers and non-steroidal anti-inflammatory drugs are allowed for diabetes, as they do not affect blood glucose levels: Aspirin, Ibuprofen, Citramon and others.
• During a cold, sugar-based syrups and lozenges should be avoided. Sinupret and Bronchipret are allowed.

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Choosing the right medicine for type 2 diabetes is a very important and responsible step. At the moment, there are more than 40 chemical formulas of sugar-lowering agents and a huge number of their trade names on the pharmaceutical industry market.

But don't get upset. In fact, the number of really useful and high-quality medicines is not so large and will be discussed below.

What are the medicines for diabetes?

All drugs for type 2 diabetes are divided into:

1. Those that increase the sensitivity of cells to insulin (sensitizers).
2. Agents that stimulate the release of hormones from the pancreas (secretagogues). At the moment, many doctors actively attribute this group of pills to their patients, which is not worth doing. They exert their influence by pushing B-cells to the limit. Very soon their exhaustion develops, and the disease of the 2nd type passes into the 1st. There is an absolute deficiency of insulin.
3. Medicines that slow down the absorption of carbohydrates from the intestines (alpha-glucosidase inhibitors).
4. New drugs.

Best drug for type 2 diabetes

There are groups of drugs that are useful, more effective and safe for patients and those that adversely affect their health.

The best medicines for diabetes, which are almost always prescribed to patients, are biguanides. They are part of a group of medicines that increase the susceptibility of all tissues to the action of the hormone. The "gold" standard remains.

Its most popular trade names are:

• . Possesses fast, but short-term action;
• . It has a gradual and longer lasting effect.

The main advantages of these drugs are the following:

1. Excellent hypoglycemic effect.
2. Good tolerance by patients.
3. The almost complete absence of adverse reactions, with the exception of digestive disorders. Flatulence (gas formation in the intestines) often develops.
4. Reduce the risk of heart attacks and strokes, due to the effect on lipid metabolism.
5. Do not lead to an increase in human body weight.
6. Affordable price.

Available in tablets of 500 mg. The starting dose is 1 g in 2 doses twice a day for half an hour before meals.

Alpha-glucosidase inhibitors are a very interesting group of drugs that slow down the absorption of carbohydrates from the intestines. The main representative is Acarbose. Commercial name - Glucobay. In tablets of 50-100 mg for three meals a day before meals. Combines well with Metformin.

What drugs should be avoided?

Often doctors prescribe drugs for type 2 diabetes that stimulate the release of endogenous insulin from B cells. This approach harms the patient's health more than it helps him.

The reason is the fact that the pancreas is already working 2 times harder than usual due to tissue resistance to the action of the hormone. By increasing its activity, the doctor only accelerates the process of organ depletion and the development of complete insulin deficiency.

Sulfonylureas derivatives:

• Glibenclamide. 1 tab. twice a day after meals;
• Gliquidone. 1 pill once a day;
• Glipemiride. 1 tablet once a day.

They are allowed to be used as short-term therapy for the rapid reduction of glycemia. However, long-term use of these drugs should be avoided.

The situation is similar with meglitinides (Novonorm, Starlix). They quickly deplete the pancreas and do not bring anything good for the patient's body.

New drugs for diabetes

Every time, many are waiting with hope, but is there a new cure for diabetes? Treatment of diabetes with drugs forces scientists to look for fresh chemical compounds.

These are:

• Dipeptidyl peptidase-4 (DPP-4) inhibitors:
  • Januvia;
  • Galvus;
  • Onglise;
• Glucagon-like peptide-1 (GLP-1) agonists:
  • Byeta;
  • Victoza.

The first subgroup of medications increases the amount of specific incretin substances that activate the production of one's own insulin, but without depleting B-cells. Thus, a good hypoglycemic effect is achieved.

Sold in tablets of 25, 50, 100 mg. The daily dose is 100 mg in 1 dose, regardless of food. These medicines are increasingly used in everyday practice due to the ease of use and the absence of side effects.

GLP-1 agonists have a pronounced ability to regulate fat metabolism. They help the patient lose weight, thereby increasing the susceptibility of body tissues to the effects of the hormone insulin. Available as a syringe pen for hypodermic injections. The starting dose is 0.6 mg. After a week of such treatment, you can raise it to 1.2 mg under the supervision of a doctor.

The choice of the right medication should be carried out very carefully and taking into account all the individual characteristics of each patient. Sometimes it is even necessary to carry out additional insulin therapy for type 2 diabetes. In any case, a wide choice of drugs provides reliable glycemic control for any patient, which simply cannot but rejoice.

Drug treatment is carried out with insulin injections or tablets that normalize glycemia. The latter have a different mechanism of action and are selected individually for each patient.

Main types of drugs

There are 2 types - insulin-dependent (type I) and diabetes that does not require insulin (type II). Each of them develops for different reasons and needs a separate treatment regimen.

Type 1 diabetes can only be treated with insulin shots. Tablets in this case are useless. For type 2 diabetes, oral medications are prescribed. All of them are used to reduce glycemia, but differ in the mechanism of action and, depending on this, are classified into different groups.

1 type

Given the nature of the development of type 1 diabetes, the only way to combat it is the regular administration of artificial insulin. The synthetic hormone has several types that affect the body in different ways, with a certain peak of activity and absorption time.

This diversity allows each patient to choose their own drugs for diabetes, fully consistent with the rhythm of glycemia.

Insulin happens:

• ultra-short;
• simple;
• intermediate influence;
• prolonged.

The ultrashort hormone begins to act 10–12 minutes after administration, so it is more convenient to use it before or during meals.

These types of drugs include:

• Humalog.
• Apidra.
• Novorapid.

Simple insulin begins to work after 30-40 minutes, so it is recommended to postpone eating for this period. While eating, it is very important to monitor the amount of food consumed, since each dose of the hormone corresponds to a certain number of bread units.

Examples of simple insulin are:

• Insuman GT.
• Actrapid NM.
• Regular.
• Humulin.

Drugs with an intermediate duration of absorption are included in the regulation of insulin 2-3 hours after injection and retain their effect for 12 hours.

Among them are:

• Actrafan.
• Protafan.
• Insulong.
• Tape.

Long-acting drugs for the treatment of diabetes mellitus are enough to use 1-2 times a day. They maintain a normal level of hormones for a long time and are similar in effect to the work of the pancreas.

The best long acting insulin:

• Levemir.
• Lantus.

Treatment of type 1 diabetes should be carried out under the supervision of a specialist. Obese patients who are forced to inject large doses of the hormone can supplement injections with Glucophage or Siofor.

type 2

Type 2 diabetes is formed in people over 45 years of age with a hereditary predisposition to the disease and suffering from obesity or gastrointestinal pathologies.

The list of hypoglycemic drugs for type 2 diabetes is quite large. Some of them stimulate the activity of the pancreas, others increase the sensitivity of cells to insulin (sensitizers).

A number of new generation medicines do not affect the production of the hormone. They are designed to protect glucagon-like polypeptide 1, which is synthesized in the intestine and improves insulin synthesis.

In type 2 diabetes, sulfa drugs should be treated with great caution. They are forbidden to be used by pregnant and lactating mothers, regardless of the effect achieved. Another contraindication to their appointment is a diabetic coma.

Drugs that increase tissue sensitivity to insulin

The most famous pills for type 2 diabetes are still biguanides - metformin derivatives. Drugs of this type reduce the absorption of glucose from the intestinal tract and increase the body's susceptibility to insulin.

Modern pharmacology can offer big choice biguanides for diabetics:

• Siofor.
• Metformin-Acre.
• Metfogamma.
• Glucophage.
• Bahomet.
• Avandamet.

The advantages of metformin include associated weight loss, prevention of atherosclerosis, the ability to combine with insulin and other hypoglycemic agents.

In some patients, metformin can cause indigestion (nausea, bloating). Also, it is undesirable to take the medicine for diseases of the upper respiratory tract, liver, kidneys and heart. Prolonged use of biguanides often leads to vitamin B12 deficiency.

Thiazolidinediones also play the role of sensitizers. This group of drugs for type II diabetes can be called universal. They are used in monotherapy or included in the treatment regimen along with sulfa derivatives, insulin and metformin.

Thiazolidinediones include:

• Diaglitazone.
• Aktos.
• Pioglar.

These drugs are the most promising and safe in the fight against diabetes. They practically do not cause complications and are well tolerated by the body.

The latest medicines

Medicine does not stand still. Pharmacists are constantly creating new and better medicines that can alleviate the condition of diabetic patients. These drugs include DPP-4 inhibitors, created in 2006.

The drugs do not provoke hypoglycemia, because immediately after the correction of glucose levels they stop working. However, they can be combined with all tablet forms.

The best DPP-4 inhibitors;

• Galvus.
• Januvia.
• Onglis.

The listed drugs for type 2 diabetes of the new generation with long-term use can cause abdominal pain. It is not recommended to use them for diseases of the stomach, liver and kidneys.

GLP-1 receptor agonists can also be noted among the newest drugs. Since the hormone is destroyed immediately after eating, it is unable to fully protect insulin and repair damaged tissues. It can be replaced by medical analogues - Byeta and Victoza. They are produced in injectable form, while the last drug acts for a day, and Byetta - only 4-5 hours.

GLP-1 receptor agonists have a lot of advantages - they control appetite, fight overeating and bring satiety closer.

Unlike other antidiabetic drugs, the action of α-glucosidase inhibitors (acarbose) goes beyond the boundaries of hormonal regulation - they prevent the absorption of carbohydrates from the intestine and their conversion into glucose. As a result, there is a post-prandial decrease in glycemia.

α-glucosidase inhibitors can be used with any antidiabetic medication. A significant disadvantage of acarbose is indigestion, so the remedy is undesirable for use in diseases of the gastrointestinal tract.

In Russia, of the drugs of this class, only Glucobay is registered. After 5-6 months of therapy with the drug, a decrease in cholesterol levels and restoration of lipid metabolism are observed. Among the side effects are a decrease in the concentration of vitamin B6 and calcium, the possibility of developing jaundice.

Hormone stimulants

The antidiabetic effect of sulfamide derivatives was accidentally discovered during the Second World War. It turned out that, in addition to destroying the infection, drugs in this group successfully release insulin even at low blood sugar concentrations.

Among the sulfonylurea derivatives, there are:

• Maninil.
• Amaril.
• Glurenorm.
• Glidiab.
• Diabeton.

These medications should be treated with caution. They deplete the pancreas, increase body weight and can trigger the transition from type 2 diabetes to type 1.

Another diabetes medication that stimulates insulin production is meglitinides. Medicines of this class are recommended to be taken three times a day with the first sip of food. The most popular are Novonorm and Starlix.

There are plenty of drugs with antidiabetic activity today. Not all of them are effective and safe, therefore, only a specialist should select the optimal remedy and draw up a treatment regimen.

Useful video about diabetes and its treatment

Properly selected drugs for the treatment of type 2 diabetes help to optimize the amount of sugar and avoid dangerous complications.

Through the use medications it is possible to stimulate the production of insulin, slow down the entry of glucose into the bloodstream, and, if necessary, increase the synthesis of insulin.

Treatment regimen

Drugs for type 2 diabetes can solve a number of problems:

Treatment begins with one drug. Then you can switch to combined therapies. If they do not give the desired results, the doctor may recommend insulin therapy.

Main categories of medicines

For the therapy to be effective, it is very important to follow the lifestyle recommendations - adhere to a special diet and exercise.

However, not all people are able to follow such rules for a long time. Therefore, drug therapy for type 2 diabetes is used quite often.

According to the principle of action, tablets for diabetes are included in various categories:

Treatment of this disorder usually requires the use of such medications:

These diabetes pills aim to reduce the body's resistance to insulin. This result is achieved by the following methods:

Such drugs often provoke unwanted reactions. They are caused by damage to the digestive tract. After 2 weeks, side effects disappear, so you should be patient.

If adverse reactions are present for a very long time, you should contact a specialist who will make adjustments to the treatment.

These drugs for the treatment of diabetes cause the following side reactions:

Sulfonylurea

The list of tablets for type 2 diabetes includes drugs such as gliquidone, glurenorm, glibenclamide. The activity of the funds is based on binding to beta-cell receptors. This leads to an increase in insulin production.

Such drugs are started to be used with small dosages. During the week, increase the volume to the required amount.

The key negative reactions of such funds include the following:

Glinides

Thanks to their use, it is possible to increase the amount of insulin that enters the bloodstream. This effect is achieved by stimulating the entry of calcium into the pancreas. This allows you to control post-tranial glycemia, or the amount of glucose after a meal.

The list of diabetes pills includes pioglitazone and rosiglitazone. These substances contribute to the activation of receptors in muscle and fat cells. This increases insulin sensitivity, which helps to quickly assimilate glucose into adipose tissues, muscles and liver.

Despite the excellent effectiveness of such funds, they have a number of contraindications. Key limitations include the following:

This category includes the diabetes medicine exenatide. Thanks to its use, the production of insulin increases. This is achieved by increasing the entry of glucose into the blood. This process is accompanied by suppression of the production of fatty acids and glucagon.

In addition, the removal of food from the stomach is slower. This allows the patient to feel satiated for longer. Therefore, this category of drugs has a combined effect.

The main side effect is nausea. It may be present 1-2 weeks after the start of use.

β-glucosidase inhibitors

The main drug in this category is acarbose. The substance is not key in the treatment of diabetes. But it is highly effective, because it does not enter the bloodstream and does not affect the synthesis of insulin.

Such tablets for type 2 diabetes mellitus compete with carbohydrates that enter the body with food.

Medicines bind to special enzymes that are produced to break down carbohydrates. This reduces the rate of their assimilation and eliminates the threat of large fluctuations in sugar after a meal.

Combined funds

Such drugs for diabetes include Amaryl, Janumet, Glibomet. These substances reduce insulin resistance and activate insulin production.

Amaryl stimulates the secretion and release of insulin from the pancreas. With its help, it is possible to increase the sensitivity of fat and muscles to the effects of insulin.

Glibomet is used in case of ineffective adherence to dietary nutrition and therapy with hypoglycemic agents. Janumet helps to control hypoglycemia, which makes it possible to avoid an increase in sugar.

The medicine helps to enhance the effectiveness of diet and exercise.

New generation medicines

Type 2 diabetes drugs of the new generation include DPP-4 inhibitors. Such substances do not affect the production of insulin by beta cells. They contribute to the protection of a specific glucan-like polypeptide from the destructive activity of the DPP-4 enzyme.

This polypeptide activates the pancreas. This contributes to a more active synthesis of insulin. In addition, this substance counteracts the appearance of glucagon, which negatively affects the activity of the hypoglycemic hormone.

New generation type 2 diabetes drugs have a number of advantages. These include the following:

1. The impossibility of developing hypoglycemia, since the drug stops working after optimizing the glucose content;
2. Elimination of the risk of weight gain due to the use of tablets;
3. The possibility of complex use with any drugs - the only exceptions are insulin and injectable agonists of the receptors of this polypeptide.

The main negative effect of such substances is a violation of the digestive process. It is usually accompanied by abdominal pain and nausea.

Such drugs should not be taken in case of impaired functioning of the kidneys or liver. This category includes agents such as sitagliptin, saxagliptin, vildagliptin.

GLP-1 receptor agonists are hormonal substances that activate insulin synthesis and normalize the structure of affected cells. This type of drug leads to a decrease excess weight in obese people.

Such substances cannot be bought in tablet form. They are made only in the form of solutions for injection. This category includes medicines such as Victoza and Byetta.

Herbal preparations

Sometimes specialists supplement monotherapy with a diet using dietary supplements, the activity of which is aimed at minimizing the amount of sugar. Some patients consider them medicines for diabetes. But this is not true, because there are no drugs that completely eliminate this pathology.

However, biologically active substances, which contain exclusively natural ingredients, help to achieve tangible results in the complex therapy of the disease. They improve the situation in the presence of prediabetes.

One of the main representatives of the category is insulate. This medicine for type 2 diabetes mellitus allows you to reduce the amount of glucose by reducing its absorption in the intestine.

The use of the drug activates the secretory activity of the pancreas, normalizes metabolism and reduces weight.

Insulate can be used in preventive purposes or be part of a complex therapy for diabetes. With prolonged use of the substance, it is possible to achieve a stable decrease in the glycemic level.

Subject to strict adherence to dietary recommendations and the scheme of application of the drug, you can get as close as possible to normal blood glucose parameters.

Features of insulin therapy

Most often, the presence of diabetes for 5-10 years requires not only dieting, but also the use of specific medications. In such a situation, there is a need for temporary or permanent insulin therapy.

The use of this substance may be needed earlier. This need arises if the sugar content cannot be adjusted by other means. Previously, the use of insulin in such a diagnosis was considered a last resort. Doctors today think otherwise.

Previously, many people who took drugs and followed the rules of nutrition had a fairly high glycemic level. By the time insulin was used, they had developed dangerous complications.

Today, this substance is one of the most effective hypoglycemic drugs. It differs from other drugs only more in a complicated way introduction and high cost.

Among all patients with type 2 diabetes, insulin therapy is required for approximately 30-40% of people. The decision to use this drug should be taken exclusively by the endocrinologist after a thorough analysis of all indications and possible restrictions.

Therefore, it is so important to consult a doctor at the first signs of diabetes and start treating diabetes. Very attentive should be those people who have a genetic tendency to pathology, are obese or have pancreatic diseases.

A key problem that hypoglycemic drugs can lead to in type 2 diabetes is the risk of hypoglycemia if glucose levels approach normal. Therefore, some people are prescribed to maintain the volume of sugar at a high level - 5-10 mmol / l.

Features of the treatment of elderly patients

When choosing pills for type 2 diabetes in the elderly, you should be very careful. Most often, such people are prescribed drugs containing metformin.

Therapy of the disease at this age is associated with serious difficulties:

1. Pathology is accompanied by other diseases that accumulate in old age;
2. The financial problems of pensioners impede full-fledged therapy;
3. Manifestations of diabetes are often mistaken for other diseases;
4. Often the disease is detected in advanced cases.

In order not to miss the beginning of the development of pathology, from the age of 45-55 it is necessary to systematically donate blood for sugar. This disease poses a serious health hazard, as it can lead to diseases of the heart, kidneys, and liver.

Diabetes mellitus has been defined by the World Health Organization as an epidemic non-communicable disease. The disease is rapidly spreading throughout the world, its progression causes a number of complications.

The basis of the treatment of diabetes is lifestyle changes - rational nutrition and increased physical activity. But weight loss is rarely enough to prevent complications. Medication is needed. Purpose medicines, lowering sugar in type 2 diabetes, depends on the initial indicator of glycated hemoglobin (indicates blood sugar for 3-4 months), determined at the time of diagnosis, as well as on the predominant clinical problem that caused diabetes in the patient.

Type 2 diabetes medication is tested every three months. If blood sugar does not normalize, after six months another, more effective drug is prescribed.

Features of the course of type 2 diabetes mellitus in the elderly

The course of type 2 diabetes in older people is different than in younger patients. The disease has the following features:

• proceeds without external signs characteristic of diabetes - there are no symptoms of frequent urination, thirst, dry mouth;
• there are general, non-specific symptoms of the disease - memory disorder, general weakness;
• structural changes in the walls of blood vessels are detected already at the time of diagnosis;
• a pathological disruption of the work of several organ systems develops;
• in many elderly patients, laboratory analysis does not show elevated fasting blood glucose.

Whether the treatment of older people will be effective depends on many factors:

• general condition of the patient;
• the presence or absence of deep cardiovascular pathologies;
• understanding by patients and the ability to perform the necessary daily activities for them - control of blood sugar levels, taking pills, dieting;
• the risk of hypoglycemia - a sharp decrease in blood sugar levels below the normal range;
• the degree of cognitive impairment in the patient - memory loss, preservation of reason, sobriety of mind.

Loneliness, low pension, forgetfulness, difficulties in learning the necessary measures for self-control of the disease in diabetes mellitus create certain difficulties in the treatment of elderly patients.

Type 2 diabetes drugs that lower blood sugar

Drugs that lower sugar, according to the mechanism of action, are divided into several groups. The list of classes of drugs for diabetes is as follows:

• biguanides (metformin);
• sulfonylurea preparations;
• glinides (meglitinides);
• thiazolidinediones (glitazones);
• α-glucosidase inhibitors;
• agonists of glucagon-like peptide-1 receptors (aGLP-1);
• dipeptidyl peptidase-4 inhibitors (iDPP-4, gliptins);
• sodium-glucose cotransporter type 2 inhibitors (iSGLT-2, gliflozins);
• insulins.

Special requirements apply to tablets for the treatment of type 2 diabetes in the elderly:

• the risk of hypoglycemia, an acute sudden drop in sugar below normal, should be minimized;
• no toxicity to the liver, kidneys, heart;
• the drug should not interact with other drugs;
• taking pills should be comfortable.

For the treatment of type 2 diabetes in elderly patients, the safest drugs are dipeptidyl peptidase-4 inhibitors. With their use, the risk of hypoglycemia is minimized.

Metformin is prescribed to people of both young and old age, if the patient has no contraindications to taking it.
Caution should be taken in elderly patients with sulfonylurea preparations, as the risk of hypoglycemia increases with aging. After 61 years, it is not recommended to take gibenclamide - tablets belonging to this group of drugs.

With caution, inhibitors of the sodium-glucose cotransporter type 2 are prescribed. They should not be used with diuretics.
Thiazolidinediones are not prescribed as a remedy for diabetes in the elderly.

biguanides

Biguanides have been used to treat diabetes for over 50 years. The main representatives of this group of drugs are metformin and phenformin. However, phenformin was discontinued due to an increased risk of lactic acidosis in patients receiving it. Lactic acidosis (milk coma) is a dangerous complication associated with a violation of the acid-base balance of the body in the direction of increasing acidity. Metformin-induced lactic acidosis is extremely rare. Therefore, since 2005, according to the recommendations of the international diabetes associations, metformin is the first-line drug for the treatment of type 2 diabetes.

The original metformin preparations are drugs under the commercial names Siofor (Berlin-Chemie AG, Germany), Glucophage (Nycomed, Austria). Pills have many generics - reproduced drugs.

Metformin is an effective blood sugar lowering pill most commonly prescribed in many countries. The drug has been used to treat type 2 diabetes mellitus for a long time, so the mechanism of its antihyperglycemic action is well understood. It is established that the drug causes:

• decreased absorption of carbohydrates in the intestine;
• increased conversion of glucose to lactate in the gastrointestinal tract;
• increased binding of insulin to receptors;
• increased transport of glucose across the membrane in muscles;
• lowering blood sugar, triglycerides and low-density lipoprotein levels;
• increased levels of high density lipoproteins.

Metformin overcomes resistance, insensitivity (resistance) of peripheral tissues to insulin, primarily muscle and liver. As a result of the use of the drug:

• the production of glucose by the liver is inhibited;
• increased insulin sensitivity and glucose uptake by the muscles;
• fatty acids are oxidized

The decrease in peripheral insulin resistance under the action of metformin leads to an improvement in the processing of glucose in the liver, muscles and adipose tissue. Due to this, hyperglycemia does not develop, which is dangerous for the development of complications of the disease.

Among the side effects of metformin, diarrhea and other disorders of the stomach should be noted: a metallic taste in the mouth, nausea, which are observed in almost 20% of patients at the beginning of therapy, but disappear after a few days. These disorders are associated with a slowing down of glucose absorption in small intestine under the influence of metformin. Accumulating in the digestive tract, carbohydrates cause fermentation and flatulence. The gradual adaptation of the patient to Metformin is ensured by the appointment of minimal doses of the drug (500 mg) first at bedtime, and then together or after a meal with a glass of water. Metformin increases the content of lactate in the tissue of the small intestine and almost doubles its concentration in the blood, which increases the risk of developing lactic acidosis.

Studies have shown that metformin is an effective drug for the treatment of diabetes, lowering blood sugar with a lower risk of developing hypoglycemia compared to sulfonylureas and insulin. Siofor is effective drug, which reduces the production of glucose by the liver, and therefore affects the main mechanism for increasing fasting blood glucose levels.

Metformin is now the main drug for the treatment of type 2 diabetes. It cannot be called the latest medicine, the last generation remedy, but interest in the drug does not weaken. There is a lot of research going on with the drug. The drug is unique, as it opens up new possibilities for its use.
It has been established that in addition to antihyperglycemic, metformin has other effects. The drug affects the leading mechanisms of atherosclerosis progression:

• improves the functions of the endothelium - a layer of cells lining the inner surface of blood and lymphatic vessels, heart cavities;
• cures chronic inflammation;
• reduces the severity of oxidative stress - the process of cell damage as a result of oxidation;
• favorably affects fat metabolism and the process of dissolving blood clots.

Metformin is not only an effective treatment for type 2 diabetes, but also a drug that has a preventive effect against heart disease. The drug is able to inhibit the growth of tumor cells, as well as slow down the aging process. However, further studies are needed to confirm these effects.

Dipeptidyl peptidase-4 inhibitors (gliptins) - new drugs for diabetes

Dipeptidyl peptidase-4 inhibitors are new drugs that lower blood sugar. Medicines are developed taking into account the knowledge that appeared in the 21st century about the physiology of incretins - hormones that are produced after eating and stimulate the secretion of insulin. According to the mechanism of action of this group of drugs, when they are taken, the following occurs:

• glucose-dependent stimulation of insulin secretion;
• glucose-dependent suppression of the secretion of glucagon - a hormone of the pancreas;
• decreased production of glucose by the liver.

One of the main advantages of the new class of sugar-lowering pills is that there is no risk of hypoglycemia. In old age, hypoglycemic conditions can provoke the development of a hypertensive crisis, spasm of the coronary vessels with the development of acute myocardial infarction, and sudden loss of vision.
Gliptins can be prescribed:

• for the treatment of patients with newly diagnosed diabetes;
• with poor tolerance or contraindications to the appointment of biguanides;
• in combination with other pills that reduce blood sugar.

Medicines have few side effects, do not cause weight gain, slow gastric emptying. The intake of gliptins is not accompanied by the development of edema. These type 2 diabetes drugs can be taken in all stages of chronic kidney disease. Metformin, glucagon-like peptide receptor agonists, and α-glucosidase inhibitors cause gastrointestinal disturbances, while gliptins are well tolerated by patients.
But the new drug for the treatment of diabetes has a serious drawback. The drug is expensive.
With caution, diabetes medications belonging to the group "dipeptidyl peptidase-4 inhibitors" are prescribed:

1. with severe liver failure (except saxagliptin, linagliptin);
2. with heart failure.

Tablets for type 2 diabetes of the gliptin class are contraindicated in ketoacidosis, a complication of diabetes that develops against the background of a lack of insulin; during pregnancy and lactation.
In clinical practice, dipeptidyl peptidase-4 inhibitors have been used since 2005. The list of drugs belonging to the DPP-4 group registered in Russia is presented in Table 1.
Table 1

Among themselves, gliptins differ in duration of action, interaction with other drugs, and the possibility of use in certain categories of patients. In terms of blood sugar lowering, safety and tolerability, these type 2 diabetes pills are identical.

These diabetes medications are given in combination with metformin. Vildagliptin and sitagliptin can be administered with insulin preparations, which opens up new possibilities for combination therapy in patients with a long course of the disease.

Since their appearance, dipeptidyl peptidase-4 inhibitors have managed to take a firm place among the drugs for the treatment of type 2 diabetes mellitus. Low risk of hypoglycemia, no effect on body weight, no side effects gastrointestinal tract distinguish this class of drugs from other drugs for the treatment of type 2 diabetes.

Sulfonylureas

According to the mechanism of action, sulfonylurea drugs are classified as insulin secretagogues (secretagogues). For many years, drugs in this class were the main among all blood sugar-lowering pills. The tablets stimulate the production of insulin in the blood and are effective tool control of blood glucose levels.

But the use of sulfonylurea drugs is associated with a moderate increase in body weight and the risk of hypoglycemia, to which the body's immunity quickly develops. Therefore, this group of drugs is biased towards an alternative drug that lowers blood sugar. But if there are contraindications to the use of metformin, sulfonylureas are prescribed as the main tablets.

In elderly patients, due to the increased risk of hypoglycemia, it is recommended to start taking sulfonylurea drugs at doses half that of younger patients and increase the dosage slowly.

The list of drugs belonging to this group is long. Medicines are divided into two generations. The most typical second-generation sulfonylurea derivatives are glimepiride, glibencamide, gliclazide, glipizide, gliquidone. First-generation drugs are not used in clinical practice.
The list of sulfonylurea drugs is presented in Table 2.
table 2

Certain difficulties may arise, which pills are best for a particular patient, which medicine from the list is more effective. The tablets differ from each other:

• blood glucose lowering activity;
• duration of action;
• dosing regimen;
• security.

Many studies have been conducted in which effective drugs for diabetes of the sulfonylurea class were tested for safety. However, only glibenclamide has been singled out by the World Health Organization and the Russian Ministry of Health as the best drug recommended for use in the treatment of diabetes among all representatives of this class of drugs.

Glibenclamide is an effective diabetes pill that has saved the lives of a huge number of patients around the world. The drug has a unique mechanism of action and is also the only sulfonylurea drug that has been tested for safety in pregnant women. The efficacy and safety of glibenclamide for the treatment of type 2 diabetes have been tested in long-term, high-quality evidence studies. An additional effect of the drug on the reduction of microvascular complications during its long-term use was noted. Treatment with only one glibenclamide for many decades was considered as a priority, sometimes the only effective treatment.

More than 10 years ago, a micronized form of glibenclamide was created, which has the best, almost one hundred percent bioavailability, the action of which begins much faster.

Long-acting sulfonylurea preparations are not recommended for elderly people due to their increased risk of developing hypoglycemia. Instead, it is better to take gliclazide, gliquidone.

Glinides (meglitinides)

Glinides stimulate pancreatic insulin secretion. In clinical practice, this class of type 2 diabetes pills is less commonly used, less effective than sulfonylurea drugs, and more expensive. Basically, glinides are prescribed when blood sugar rises after a meal (postprandial glycemia). Drugs stimulate predominantly the early phase of insulin secretion. After taking the tablets, they are rapidly absorbed, reaching the highest concentration in the blood plasma within one hour.
Characteristics of the drug, a list of advantages and disadvantages of the use of drugs of the glinide class are shown in Table 3.
Table 3

α-glucosidase inhibitors - new drugs

The mechanism of action of drugs of the α-glucosidase inhibitor class is based on slowing down the release of glucose from complex carbohydrates. This reduces postprandial hyperglycemia. By regulating the absorption of glucose from the intestines, alpha-glucosidase inhibitors reduce its daily fluctuations in blood plasma.

Drugs in this group do not stimulate insulin secretion, therefore, do not lead to hyperinsulinemia, do not cause hypoglycemia. Slowing down the absorption of glucose into the blood under the influence of drugs of the class of α-glucosidase inhibitors facilitates the functioning of the pancreas and protects it from overstrain and exhaustion.

The α-glucosidase inhibitors include acarbose, miglitol, and voglibose. A new drug from this group is voglibose. According to clinical studies, voglibose is especially effective in the treatment of patients with type 2 diabetes mellitus with moderately elevated fasting glucose levels (7.7 mmol/l) and high postprandial glycemia (over 11.1 mmol/l). The advantage of the drug is that there are no hypoglycemic reactions, which is especially important in elderly patients.
In Russia, of the drugs of this class, only acarbose is registered. The commercial name of the product with this active substance is Glucobay. Tablets are available in a dosage of 50 and 100 mg, they must be taken three times a day.

Hypoglycemia does not develop during therapy with α-glucosidase inhibitors, however, if it has developed for another reason, then α-glucosidase inhibitors can significantly slow down the absorption of carbohydrates taken orally to correct hypoglycemia, that is, despite the intake of carbohydrates (sugar, flour products), hypoglycemia may worsen. In this case, drinks containing simple glucose (sweetened carbonated drinks) or glucose tablets should be used to correct hypoglycemia.
α-Glucosidase inhibitors are not as effective in lowering total glycemia as metformin or sulfonylurea derivatives. The content of glycated hemoglobin when they are taken is reduced by 0.5 - 0.8%.

The most common side effects with α-glucosidase inhibitors are bloating, flatulence and diarrhea, the severity of which depends on the dose of drugs and the amount of carbohydrates. These effects are not dangerous, but they are a common reason for discontinuation of drugs in this class. Side effects develop due to the large amount of carbohydrates entering the large intestine, which are fermented there. expressiveness unwanted effects can be reduced by starting treatment with small doses and increasing the dose gradually.

The main contraindication to the use of drugs of the α-glucosidase inhibitor class is diseases of the gastrointestinal tract.

Glucagon-like peptide-1 receptor agonists - the latest generation of type 2 diabetes drugs

Glucagon-like peptide-1 (GLP-1) receptor agonists (AG) are the latest drugs for the treatment of diabetes mellitus.
The main effect of this class of drugs is the stimulation of insulin secretion by pancreatic beta cells. Medications slow down the rate of gastric emptying. This reduces fluctuations in postprandial glycemia. Drugs of this class increase the feeling of fullness and reduce food intake, reduce the risk of developing cardiovascular diseases.
A list of glucagon-like peptide-1 receptor agonists is listed in Table 4.
Table 4

The listed GLP-1 ARs have different pharmacological effects. Some are classic prandial drugs - they control glucose levels after eating, others - non-prandial drugs - reduce fasting blood sugar.

The short-acting prandial GLP-1 ARs (exenatide and lixisenatide) suppress glucagon secretion and reduce peristalsis and gastric emptying. This leads to slower absorption of glucose in the small intestine and indirectly moderately reduces postprandial insulin secretion.

Non-prandial long-acting GLP-1 ARs act on the pancreas by activating insulin secretion and suppressing glucagon production. This contributes to a moderate decrease in postprandial glycemia and a significant decrease in fasting glycemia by suppressing glucagon secretion and reducing appetite.

Non-prandial GLP-1 ARs include slow-release exenatide, liraglutide, albiglutide, and semaglutide. Various mechanisms actions delay the absorption of substances from the subcutaneous tissue. As a result, the duration of action of the drugs increases.
The advantages and disadvantages of GLP-1 class of antigens are shown in Table 5.
Table 5

This new class of drugs is indicated for the treatment of type 2 diabetes as adjunctive therapy to metformin, sulfonylurea drugs, or a combination of the two to improve glycemic control.

GLP-1 class of antihypertensive drugs are not accompanied by hypoglycemia, but 30–45% of patients have mild gastrointestinal side effects, such as nausea, vomiting, or diarrhea, which decrease over time.

Sodium-glucose cotransporter type 2 inhibitors (gliflozins) are the newest drugs for type 2 diabetes

Sodium-glucose cotransporter type 2 inhibitors (IGLT-2) are the newest pills that lower blood sugar. As the latest generation of drugs, SGLT-2 works in a completely different way than any other type 2 diabetes drugs. The mechanism of action of this class of drugs is to inhibit the reabsorption of glucose in the kidneys. This removes glucose from the body in the urine. The result is a long-term, dose-dependent decrease in blood glucose levels with a simultaneous increase in insulin secretion and a decrease in insulin resistance.

The list of drugs of the gliflozin class registered in Russia and their commercial names is as follows:

• dapagliflozin (Forsiga);
• empagliflozin (Jardines);
• canagliflozin (Invokana).

Tablets of the gliflozin class stimulate the excretion of excess sugar in the urine. This makes the patient lose weight. In studies, patients taking dapagliflozin plus metformin for 24 weeks lost more body weight than those taking metformin alone. Body weight decreased not only due to water, but also due to fat. However, the new diabetes drug cannot serve as a diet pill. Weight loss slows down as blood sugar returns to levels close to normal.

Glyflozin class drugs are prescribed at any stage of the disease in combination with any other types of treatment. They are safe and effective.
However, patients taking dapagliflozin are at risk of developing genital infections, especially fungal infections. Also, drugs of this class increase the level of low-density lipoprotein, which is important to consider, since patients with diabetes are at an increased risk of cardiovascular disease.
Potential risks when taking tablets of the class of sodium-glucose cotransporter type 2 inhibitors are:

• hypoglycemia;
• impaired renal function;
• diuretic effect;
• decrease in the volume of circulating blood;
• lowering blood pressure;
• violation of mineral metabolism.

Medicines are prescribed with caution in the elderly, with chronic infections of the genitourinary tract, when taking diuretics.
The gliflozin class of drugs has a significant drawback. They are expensive.

Thiazolidinediones (glitazones) - new drugs for type 2 diabetes

Thiazolidinediones are a fundamentally new group of drugs. They were approved for use as drugs for the treatment of type 2 diabetes in 1996. The mechanism of their action is to increase insulin sensitivity, that is, the effect on one of the key components of the cause of diabetes - insulin resistance.

Eliminating the reduced sensitivity of cells to insulin, the tablets enhance the physiological effect of their own endogenous insulin and at the same time reduce its concentration in the blood. In addition, glitazones have the ability to preserve the functional activity of the pancreas, that is, the ability to prevent type 2 diabetes, which puts them one step above other tablets for the treatment of diabetes.

In Russia, two drugs from this group are registered - rosiglitazone and pioglitazone. Rosiglitazone has been taken by patients all over the world for many years. More often it is prescribed for diabetes mellitus in Russia. Previously reported cardiovascular insecurity of rosiglitazone: increased risk of myocardial infarction and cardiovascular mortality. However, the drug was later rehabilitated.

Studies have shown that when treated with only one drug of rosiglitazone for a long time, the need to add the next drug does not arise as quickly as it does when treated with other (glyburide or metformin) investigational drugs.

Therapy with glitazones has a number of advantages. But clinicians are in no hurry to introduce drugs of this class into widespread practice. The opinions of the medical community regarding the effectiveness and safety of the use of thiazolidinediones are divided. The most controversial point is the lack of data on the safety of long-term use of these drugs.
Numerous data on side effects in the treatment of glitazones attract attention:

• an increase in body weight (approximately 3 - 6 kg);
• fluid retention with the development of edematous syndrome and heart failure;
• decrease in bone mineral density.

Additional study requires data that the use of thiazolidinediones is associated with an increased risk of developing malignant neoplasms, in particular colon tumors, which is confirmed by experimental studies. An increased risk was found to a greater extent for rosiglitazone.
Before prescribing drugs of the thiazolidinedione class, it is important to assess the potential risk of developing heart failure. The main risk factors for its development are:

• heart failure;
• or ;
• arterial hypertension;
• left ventricular hypertrophy;
• clinically significant lesions of the heart valves;
• age over 70;
• duration of diabetes mellitus more than 10 years;
• edema or treatment with loop diuretics;
• development of edema or weight gain during treatment with glitazones;
• insulin therapy;
• the presence of chronic renal failure (creatinine more than 200 µmol / l).

Numerous clinical studies have been and continue to be conducted to study more precise mechanisms and possible applications of this group of drugs.

But to date, the newest drugs for type 2 diabetes of the thiazolidinedione class are not prescribed as the main drugs for the treatment of patients. Additional clinical studies are needed to test the safety of their long-term use.

Insulin therapy in the elderly

With a progressive course of diabetes mellitus, it is possible to prescribe insulin to the patient. Insulin should not be taken by mouth as a tablet, as the stomach acid will treat it like food and break it down faster than it can work. To get a dose of insulin, you need to give an injection. The scheme of treatment with insulin preparations in the elderly does not differ from the prescriptions for young patients.

Insulins are divided into short-acting and extended-acting preparations. The duration of action of insulin varies from person to person. Therefore, the selection of an insulin therapy regimen is carried out under the supervision of doctors. In the hospital, the level of glycemia is monitored, the dose of insulin is selected in accordance with the metabolic processes in the body, diet, physical activity.

Since the patient performs insulin administration independently, insulin therapy in elderly patients is possible only if the cognitive functions of the elderly patient are preserved, their adequate perception of the world around them, after learning the basic rules of insulin therapy and self-monitoring of glycemia levels.
The list of insulin preparations registered in Russia is presented in Table 6.
Table 6

Which diabetes medication is better: old or new

International experts on the rational use of medicines do not recommend rushing to include fundamentally new drugs in the lists for treatment. The exception is those cases where a new drug has "revolutionized" the treatment of a disease. The complete safety of a medicinal product is determined only 10 years after its widespread use in real medical practice.

by the most the best pills Only metformin and glibenclamide are recognized by the World Health Organization for type 2 diabetes. Because it is they who have the best evidence that the pills are effective and safe. These drugs are best correlated in terms of "efficacy - safety - cost of treatment."
The main conclusions and the most complete understanding of the possibilities of controlling the course of type 2 diabetes mellitus were obtained against the background of the use of metformin and glibenclamide tablets. A large-scale study that lasted 5 years, evaluating the efficacy and safety of metformin, glibenclamide and rosiglitazone in the treatment of patients with type 2 diabetes, also convincingly showed that the "old" drugs are more effective. They are safer than the "new" rosiglitazone.
Of particular importance in the choice of type 2 diabetes medication is the importance of achieving good glycemic control as the most proven way to prevent and slow the rate of progression of micro- and macrovascular complications.

However, the most important argument is emphasized: for "old" diabetes drugs, adverse reactions are well studied and almost all expected and predictable. Potential toxic effects from the "new" pills can be unforeseen and sudden. Therefore, long-term research and observation programs, especially for medicines with numerous potential target organs are very important.

For example, rosiglitazone, a representative of the thiazolidinedione group, which had many potential targets, had been in practical use for about 8 years, when a new side effect, osteoporosis, was detected for the first time in long-term clinical studies. Subsequently, it was found that this effect, which is also characteristic of pioglitazone, develops more often in women, is associated with an increase in the frequency of fractures. Subsequent studies have shown an increased risk of myocardial infarction in the treatment of rosiglitazone and the risk of cancer Bladder while taking pioglitazone.

Some of the side effects of diabetes medications can be particularly devastating in the most typical diabetic patients. Even such consequences as hypoglycemia, weight gain, not to mention the threat of edema, osteoporosis, chronic heart failure, are very unfavorable for patients with type 2 diabetes, who are extremely prone to comorbidity.

Understanding the above arguments, it is better to start treatment with the most studied drugs. They have not only a good safety profile, but also the highest hypoglycemic efficacy. "New" drugs did not have time to prove their safety in long-term use. In addition, they did not show a better hypoglycemic effect compared to traditional, “old” means. These conclusions are made after numerous studies.

What drug to prefer? What is the best medicine for type 2 diabetes. The European Association for the Study of Diabetes recommends choosing medicines that have a sufficient evidence (research) base supporting the benefits and safety of any class of diabetes medicines.

The latest generation drugs seem to be the most effective. But the prospect of their use will be determined only after confirmation by a wide and long practice. In Europe and the US, the vast majority of patients continue to be treated with proven and well-researched "old" drugs.
The most effective means for initial stage treatment of type 2 diabetes mellitus remains metformin, taking into account all its positive effects, and sulfonylurea derivatives as a priority class of diabetes drugs for more intensive treatment and transition to combination therapy.

The "old" classic, traditional drugs - metformin and sulfonylurea derivatives remain the international standard in the treatment of type 2 diabetes. The reasons for choosing them were the following:

• safety of treatment of patients;
• achieving better long-term results;
• impact on quality and life expectancy;
• economic expediency.

And these drugs will be the mainstay in the treatment of diabetes until more information about new drugs becomes available, until large studies show them to be more effective than traditional drugs.

The results of long-term clinical studies and the vast experience gained in routine practice are the most reliable and most reasonable arguments for the choice of drug therapy for the treatment of diabetes mellitus.