Incretin Based Treatments

When you have Type 2 Diabetes, the blood glucose may be too high after a meal, even if you eat very little carbohydrate. This, in part, is due to glucagon levels staying too high after meals. Medications, called incretin based treatments, are available to control post-meal glucagon, and help reduce the post meal blood glucose.  The incretin based medications are available in two families of medicines: DPP-4 Inhibitors and GLP-1 analogs. Sitagliptin, saxagliptin, linagliptin and alogliptin are DPP-4 inhibitors and are taken as pills. Exenatide, liraglutide, dulaglutide, semaglutide and lixisenatide are GLP-1 analogs and are taken by injection or oral form.  If you have kidney problems, the dose of the incretin based medicines may need to be adjusted. Please tell your doctor if you have kidney problems before starting these medicines.

DPP-4 Inhibitors

DPP-4 inhibitors are oral medications for people with Type 2 Diabetes that help control blood glucose levels, especially after eating. After eating, your gut naturally releases hormones—two important ones are GLP-1 and GIP. These hormones increase insulin release to help control blood glucose levels. GLP-1 also decreases glucagon release at meals, to further control blood glucose levels. However, these hormones are quickly broken down in the body by an enzyme called DPP-4.  DPP-4 inhibitors like sitagliptin and saxagliptin block DPP-4 from breaking down GLP-1 as quickly so that GLP-1 can have a longer effect in the body.  While DPP-4 inhibitors may be used as an initial choice for a medication to help lower blood sugar levels, they are mainly being used in combination with other diabetes medication.  This means that these DPP-4 inhibitors are usually added on when a person is already taking one or two medications for diabetes, but their glucose levels are still not well managed.  You may need to lower insulin or insulin releasing medications if a DPP-4 medication is added, this will need to be evaluated with your medical provider.  Unlike with GLP-1 agonists, people do not typically lose weight with DPP-4 inhibitors. Fortunately, these medicines do not cause weight gain.

GLP-1 Analogs

GLP- 1 analogs are medications for people with Type 2 Diabetes that helps prevent the blood glucose from rising after eating. GLP- 1 analogs act like a natural hormone, GLP-1, that is released in the gut when we eat. When you have Type 2 Diabetes, GLP-1 doesn't work on the pancreas properly and post-meal glucagon levels stay too high. GLP-1 also delays emptying of food from the stomach and promote a feeling of satiety (satisfaction of having eaten enough). The natural hormone GLP-1 is normally broken down very quickly in the bloodstream by enzymes known as DPP-4. GLP-1 analogs were developed to resist breakdown by the enzyme DPP-4, this way the medication lasts longer in the blood stream and the GLP-1-like action lasts longer.  These are now available in both oral and injection medication forms.  There is a GLP-1/GIP analog that works similarly to GLP-1, called Tirzepatide. 

In short, GLP-1 Analogs lower glucagon during a meal, slows food emptying from the stomach, curbs appetite and increases insulin release from the pancreas when the blood glucose is too high.

Be sure to discuss potential side effects, contraindications and drug-drug interactions of these medications  with your medical provider and pharmacist.  Contact your medical provider right away if you have side effects.  Ask your medical provider for specific medication and insulin dose adjustment recommendations to avoid low blood glucose.