One of the most challenging aspects of managing diabetes is staying on top of your medications. As a pharmacist who spends all day helping patients with diabetes adjust their medications, I can tell you better than anyone how exhausting this process is.
While healthcare providers like myself try to make your drug regimen as burden-free is possible, the amount of work that goes into medication management can contribute to “diabetic fatigue.” Thus, it is not surprising that patients with diabetes often want to know if they can ever come off their medications.
To better understand the answer to that question, you must first understand how diabetes naturally progresses. A very important (“landmark”) trial1 in the 1980s actually examined the natural progression of Type 2 diabetes by measuring “beta cell function.” Beta cells, of course, are the cells in your pancreas that make insulin. What they found was intriguing:
What you will notice if you look carefully is that the “Time from Diagnosis” starts in the middle. That’s because they found that on average, patients with type 2 diabetes only have half of their ability to make insulin left over when they were first diagnosed! This means that from the beginning of your diagnosis your body is only working with half the insulin it used to have. What’s more, the pancreas slowly loses its ability to make insulin.
Though everyone is different, an average patient with diabetes will require insulin to keep blood sugars well controlled about 10 years after their diagnosis. This is why we are able to use medications that are not insulin early on but eventually must add insulin.
It is so important that we as clinicians set good expectations. Since lifestyle change is foundational to diabetes control, we very often focus on talking about diet and exercise as a way to avoid more medications. This is true, but we also need to confront the fact that diabetes gets worse with time regardless of diet and exercise. When we do not set these expectations, patients often see starting insulin as a failure on their part, instead of a natural part of their disease.
“But my doctor said if I eat better and exercise, I would not need as many medications!” Don’t let me steer you wrong here: that is absolutely true. I explain to my patients that your blood sugars follow this equation:
Blood sugar = Carbs Eaten (diet) – Carbs Burned (exercise) – Medications
To explain that in words, your blood sugar equals the sugar you put in minus the sugar you burn off—and medications are used to make up the difference. Sometimes this is depicted as a scale:
So, in simple terms: if you eat less and/or exercise more, you will need fewer medications at lower doses. However, remember the graph I showed you earlier—how much insulin your pancreas is still naturally making complicates this relationship. As your own natural insulin-producing ability goes down, the same amount of carbohydrates will make the blood sugar go up further than it did before.
Another factor we have not discussed is your insulin resistance. Patients with type 2 diabetes have fat and muscle cells that don’t listen as well to the insulin they are still making. We don’t completely understand what causes this resistance, but we think that most of the insulin resistance in our patients is caused by inflammation brought on by obesity, especially that fat that hangs around our midsection. See how this complicates the scale we saw earlier:
This explains why we advise you to lose weight: it decreases your insulin resistance! If you have enough of your insulin-making ability left, losing weight can actually allow you to come off some or even all of your medications provided your diet and exercise continues.
An extreme example of this comes from the STAMPEDE trial2 published in the New England Journal of Medicine last year (2017). They found that patients who underwent bariatric surgery and lost 40-50 pounds had better A1C control with fewer medications. In fact, almost half of the gastric bypass group was able to put their diabetes into REMISSION, where they required no medications 5 years after the procedure.
But here’s the truth—even though they required fewer medicines, over half the patients in that same group still needed some medications. The patients in this trial had had diabetes for an average of 8 to 9 years, so many of them had already lost critical amounts of their insulin-making ability. Dramatic weight loss was able to reduce their insulin resistance, but they still had reduced insulin-making ability. In other words, they were doing more with less.
Unfortunately, we currently do not have a “cure” for type 2 diabetes, because we have not figured out how to grow back the beta cells that make insulin but researchers are hard at work and may eventually discover a practical way to do this.
In the meantime, we think some of our newer medications, for example, GLP-1 agonists (e.g. Victoza, Trulicity, Bydureon) may slow the death of those cells—but we haven’t found anything that grows them back yet. Another strategy some are using is starting intensive insulin when you are first diagnosed to give those beta cells a “break.” One study, the LIBRA trial3, found that after a month of intensive insulin treatment about half of the patients went into remission (no meds!) for at least a year.
One final note: That same “landmark” trial I showed you at the beginning of this article found that metformin prevented heart attacks and deaths from heart disease that went beyond what came from lowering the blood sugars. For this reason, I usually advise patients to continue their metformin4 even if they lose so much weight they no longer their other medications.
Short Answer: Losing weight, eating fewer carbohydrates, and burning carbohydrates through exercise can reduce the number of medications you need for your diabetes. However, if you are insulin deficient, it can be difficult to maintain good blood sugar control even with a healthy diet and exercise.
This column is written by a medical professional, but is not medical advice and may not apply to your specific circumstances. You should always consult your physician or another qualified health practitioner before making any changes to your specific treatment plan.