Introduction.
Diet and exercise are the cornerstones of diabetes treatment, but since these alone are often insufficient to control the disease, drug therapy becomes essential.
There are many types of drugs, each with different mechanisms of action, indications, and side effects.
This article will organize the latest use strategies, concomitant use concepts, and precautions, with a special focus on drug therapy.
1. timing of initiation of drug therapy and basic strategies
- Introduced when target blood glucose cannot be achieved by lifestyle modification alone
- If HbA1c remains above target (e.g., around 6.5-7.0%)
- Consider early induction if symptoms of hyperglycemia are present
Guidelines have reinforced the notion that early initiation of treatment and early multidrug use are effective in preventing complications.
2. types and characteristics of major diabetic drugs
Below is a summary of the major drug categories and the characteristics and use of each.
| drug class | mechanism of action | Key Benefits | Cautions/contraindications | Adaptation examples |
| Biguanides (e.g., metformin) | Inhibits gluconeogenesis in the liver, improves insulin sensitivity | Low cost, little weight gain | Cases of reduced renal function/chronic renal failure/severe hepatic impairment Caution | Many examples of first-line drugs |
| SGLT2 inhibitor | Promotes sugar elimination from the kidneys | Weight loss, blood pressure reduction, cardio-renal protective effect | Risk of dehydration, urinary tract infection, and ketoacidosis | Obese cases, cases with coexisting hypertension |
| DPP-4 inhibitor | Incretin hormone maintenance | Low risk of hypoglycemia, easy to use | Moderate effect | Elderly patients and cases with concomitant basic treatment |
| GLP-1 receptor agonist | Promotes postprandial insulin secretion and suppresses appetite | Weight loss and cardiovascular protection effects | Nausea and gastrointestinal symptoms caution | Cases of coexisting obesity and high risk of atherosclerosis |
| SU drugs/rapid-acting secretagogues | Accelerated insulin secretion | immediate effectivity | Risk of hypoglycemia | Example of postprandial hyperglycemia |
| insulin therapy | Exogenous insulin replacement | Strong blood sugar control | Hypoglycemia and weight gain | Cases of significantly decreased secretion, pre-coma diabetes mellitus |
3. specific selection and combination strategies
(1) Start with a single agent
First, use one drug and check its effects and side effects.
If the appropriate drug is selected, one drug may be sufficient to control the disease.
(2) Multiple drug use (two or more drugs)
When a single drug does not reach the target, a synergistic effect is aimed by combining drugs with different mechanisms of action.
E.g., metformin + SGLT2 inhibitor/metformin + DPP-4 inhibitor, etc.
(3) Early introduction strategy
Recent guidelines suggest a strategy of early introduction of two or three drugs or early introduction of GLP-1 or SGLT2.
(4) Insulin induction
In severe cases or those at high risk of complications, one strategy is to introduce insulin therapy early to rapidly stabilize blood glucose and then switch to other agents.
4. safety, side effects, and monitoring points
- Hypoglycemia: special attention to SU drugs and insulin. Need to adjust in conjunction with diet and exercise.
- Renal function: metformin and SGLT2 inhibitors are prudent in renal dysfunction
- Gastrointestinal symptoms: GLP-1 system is prone to nausea, etc.
- Dehydration and urinary tract infection Risk: Hydration is essential when using SGLT2
- Utilization of cardioprotective effects: emphasis on SGLT2/GLP-1 selection in high-risk cases
Once treatment is initiated, regular monitoring of blood glucose, HbA1c, renal function, electrolytes, and weight is essential.
5. our drug therapy policy
Ikejiri-Ohashi Sera Clinic has the following policy regarding diabetes drug therapy:
- Individualized: Drug selection based on age, renal function, cardiovascular risk, and comorbidities
- Early combination: look for early combination if indicated
- Complications Perspective: SGLT2/GLP-1 is a priority consideration with emphasis on cardioprotective effects
- Prescribed in combination with exercise and diet: not only drugs but also a set of lifestyle modifications.
- Follow-up and flexible adjustment: review the type and dosage of medications as appropriate while monitoring side effects/effects
summary
- Multiple medications and individualization are key to diabetes drug therapy.
- Metformin is first choice, SGLT2/GLP-1 is a focus drug with protective effects
- Monitoring is essential for both safety and effectiveness
- At Ikejiri-Ohashi Sera Clinic, we support treatment by appropriately designing drug therapy and combining it with lifestyle modification
References
- The Japan Diabetes Society. Diabetes Care Guide 2024-2025.
- American Diabetes Association. Standards of Care in Diabetes 2024.
- Davies MJ, et al. Management of hyperglycemia in type 2 diabetes, 2023. Diabetologia.
- Zelniker TA, et al. Cardiovascular, mortality, and kidney outcomes with SGLT2 inhibitors in patients with type 2 diabetes: a systematic review and meta- Lancet Diabetes Endocrinol.
Diabetes Series - Related Article List
1. Know the basics of diabetes
- What is Diabetes - Why does blood sugar rise? Causes and Mechanisms Explained
Introduces the root causes of diabetes, including "insulin resistance," "heredity," and "lifestyle," which are all related to the development of diabetes, in an easy-to-understand manner. - Early Symptoms of Diabetes - Don't Miss the Early Detection Signs
Early signs that are difficult to recognize, such as thirst, polyuria, and weight loss, are carefully explained. - Diagnostic criteria for diabetes - Difference between HbA1c, blood glucose and OGTT and latest criteria
It summarizes the numerical values used for diagnosis and the key points of the recently revised diagnostic criteria. - Diabetes Testing - Comprehensive evaluation of blood, urine, and even complications
Introduction to the comprehensive examination system available at the Ikejiri-Ohashi Sera Clinic, including fundus examination, ABI, and carotid artery echocardiography.
2. Treatment and lifestyle modification
- Diabetes Treatment - Protecting Blood Sugar and Blood Vessels with Diet, Exercise, and Medication
Explains treatment strategies to "prevent complications" rather than "lower the numbers. - Diabetes Diet - Control Blood Sugar Effortlessly with Locavore
A practical diet that emphasizes how to eat, not what not to eat. - Diabetes and Exercise - Muscle is Medicine! The Science of Aerobic x Muscle Training
The benefits of exercise to directly lower blood sugar and how to create an easy to follow exercise routine. - Drug Therapy for Diabetes Mellitus - Latest Treatment Policies and Multi-Drug Approaches
The characteristics of DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 agonists are compared, and the latest treatment trends are presented.
3. To prevent complications
- Complications of diabetes - Complication measures to remember with "shimeji" and "enoki" mushrooms
The six major complications of neuropathy, retinopathy, nephropathy, gangrene, stroke, and cardiac disease are explained together. - Neuropathy due to diabetes - Mechanisms and countermeasures for numbness and pain in hands and feet
Early signs of peripheral neuropathy and ways to improve life that should be done early. - Diabetes and Renal Dysfunction - Importance of Urine Albumin Testing and Habits to Protect
Practical approaches to reduce the burden on the kidneys and prevent dialysis. - Diabetes and Eye Disease - Causes of Blurred Vision and Early Detection of Retinopathy
Explains how fundus camera examinations work and the risks of neglect.
4. Prevention and early intervention
- Prevention of Diabetes - Reduce blood sugar waves and make your body less prone to diabetes.
Introduces diet, exercise, and sleep regimens to "get in shape before it happens," rather than "fix it after it happens. - Characteristics and constitution of people prone to diabetes - Self-check that you can do now
Early intervention is recommended by sorting out the risk of developing the disease, including heredity, fatty liver, and lack of exercise.
5. Our features and support system
- Lifestyle-related disease treatment at Ikejiri-Ohashi Sera Clinic - Cross-cutting management of diabetes, MASLD, hypertension and dyslipidemia
Includes a comprehensive evaluation system including physician supervised exercise therapy, locavore diet support, fundus, ABI, and carotid artery echocardiography.