Diabetes Treatment (cont.)

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Medications that decrease the amount of glucose produced by the liver

A class of drugs called biguanides has been used for many years in Europe and Canada. In 1994, the FDA approved the use of the biguanide metformin (Glucophage) for the treatment of type 2 diabetes in the U.S. Glucophage is unique in its ability to decrease glucose production by the liver. Briefly, because metformin does not increase insulin levels, when used alone, it does not usually cause hypoglycemia. In addition, metformin has an effect whereby it tends to suppress appetite, which may be beneficial in diabetics who tend to be overweight. Metformin may be used by itself or together with other oral drugs or insulin. It should not be used in patients with kidney impairment and should be used with caution in those with liver impairment. The older biguanides that preceded metformin were associated with a serious condition called lactic acidosis, a dangerous acid build up in the blood resulting from accumulation of the drug and its breakdown products. While metformin is safer in this regard, it is recommended that the drug be discontinued for 24 hours before any procedure involving the intravenous injection of dyes (such as for some X-ray studies of the kidney) or surgery is performed. The dyes may impair kidney function and cause a build-up of the drug in the blood. Metformin can be restarted after these procedures once the patient is urinating normally.

Medications that increase glucose excretion by the kidney

In March 2013 the FDA approved canagliflozin (Invokana) tablets to improve glycemic control in adults with type 2 diabetes. It belongs to a class of drugs known as sodium-glucose co-transporter 2 (SGLT2) inhibitors. Invokana works by blocking reabsorption of glucose by the kidney, leading to increased glucose excretion and reduction of blood sugar levels. Clinical trials on over 10,000 patients showed improvement in both fasting glucose and hemoglobin A1c levels with canagliflozin. Side effects included vaginal yeast infection and urinary tract infection. Invokana has been used as a single therapy and in combination with other drugs such as metformin, sulfonylurea, pioglitazone, and insulin.

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