Medications that actually work for type 2 diabetes – T2D 40

//Medications that actually work for type 2 diabetes – T2D 40

As we saw in our previous post, standard medications such as insulin, sulphonylureas, metformin and DPP4’s can reduce blood glucose but do not reduce cardiovascular disease or death. Yes, your sugars will be lower, but no, you will not be healthier. Whether you take the medications or not, you will suffer the same risk of kidney disease, heart disease, stroke and death. So why take these medications at all? Well, that is a good question, for which I do not have a good answer.

But why don’t these drugs work? It gets back to understanding what, exactly, insulin resistance is. High insulin resistance leads to high blood glucose, which is called type 2 diabetes. But it can be most easily understand as overflow of sugar (both glucose and fructose) in the body. Not just the blood, mind you. The entire body.

Our body is like the barrel in the picture. As we eat glucose and fructose, it can hold a certain amount. Glucose may be stored as glycogen in the liver or turned into fat via de novo lipogenesis. However, if the amount coming in far exceeds the amount going out, soon, the storage capacity of the barrel and will spill out.

We have two compartments for the glucose. In our body, and in our blood. If our body is full, incoming glucose spills out into the blood, which is now detectable as high blood glucose.

So, what happens when your doctor prescribes insulin? Does it get rid of the sugar from the body? No, not at all. It merely takes the sugar in the blood, and shoves it into the body. Sure, the blood has less glucose, but there’s more in the body. And the next time you eat, the same thing happens. Glucose comes in, spills out into the blood.

If you consider the rain barrel analogy, then insulin neither reduces the incoming water, nor does it increase the drainage of it. It merely sloshes the water around in different parts of the barrel. In your body, insulin has moved glucose from your blood into your liver. But it has not eliminated it from the body. This is the reason all those classic medications like insulin, SU, metformin do not make us healthier.

This is exactly what we see clinically. As we doctors have given more insulin and more medications, people still continued to suffer the same number of problems – heart disease, strokes, foot ulcers, kidney disease, blindness etc.

So, what we need is a drug that get rid of the water (glucose) from the rain barrel (body) rather than simply move it around. Recently a new class of medication, called SGLT2 makes you urinate out the glucose. This  seems like it would be pretty beneficial in the case of type 2 diabetes. After all, if the body has too much sugar, then peeing some it out seems like a good idea. This idea was tested in the trial called EMPA-REG which tested for both cardiovascular outcomes and renal (kidney) outcomes. This was the gold standard of evidence – a randomized controlled trial.

This trial showed that the drug, empaglifozin only reduced the A1C by a paltry 0.54%. This really sucks. Insulin, metformin, sulphonylureas all lower blood glucose way better. But that’s not the question. The primary outcome, death, heart attacks or strokes was reduced in the EMPA patients by 14%. Death from heart disease was reduced by 38%.

Kidney outcomes were similarly beneficial – this being very important information for me as a kidney specialist. In fact, this was the first new drug since ACE inhibitors to really show some renal protection. In case you are keeping track, ACE inhibitors were introduced in 1981. That’s a whopping 36 years where we had no new discoveries to protect kidneys against harm.

If cell phones were like kidney medications, we would all be using big chunky cell phones right now that do nothing other than place a call. Who even talks on the phone anymore? Yes, that is the state of medical research. No wonder engineers only shake their heads at the state of nutritional/ medical research.

This result was confirmed in the recent CANVAS study with another  SGLT2 inhibitor. But the overwhelming question is why these drugs work. Once we understand the paradigm of insulin resistance, it’s pretty simple. Insulin resistance is about too much sugar in the body. SGLT2’s help get rid of that sugar so that it can’t stay inside the body to cause harm.

But there’s another potential solution to the problem. Why can’t you simply turn off the tap leading to the overflowing rain barrel? This was tested in the STOP-NIDDM trial in 2003. The drug acarbose blocks the absorption of carbohydrates (glucose) into the body. Hey, that’s great. If it’s like the rain barrel – it is similar to turning off the inflow. Thus, glucose can’t come into the body where it will do harm. 

Acarbose generally has pretty crappy blood glucose lowering but patients lost weight (1.1 kg on average) anyways. But once again, that’s not the question. Did acarbose reduce heart attacks? The answer is an emphatic yes. Heart attacks were reduced by an almost unbelievable 49%!

Another new class of medication is the GLP1 agonists. Liraglutide increases GLP1 which increases insulin temporarily, but also slows movement of the GI system and the resulting nausea causes weight loss. The LEADER trial a randomized controlled trial showed that these medications could reduce body weight. It reduces blood glucose, but only barely – an average of 0.4% – a pretty crappy effect according to conventional medical thinking.

Once again, the main question is what effect this has on heart attacks. Well, it was able to reduce heart disease and death by a respectable 13%. Deaths from CV disease was reduced by 22%. Yet another medication showed

In the appendix of the LEADER trial, it is significant that using Liraglutide meant you could avoid taking alot of insulin. New insulin added dropped from 43.2% of patients to 28.6%, meaning that using liraglutide could reduce insulin usage.

Hmm… weight loss is obviously a big part of reducing insulin resistance. If you use medications like insulin and SUs that reduce blood glucose but increase weight, well, it may not be good. Metformin and DPP4s don’t cause weight gain or weight loss, and they’re neither good nor bad.

When you start to used medications that empty the glucose from the body rather than simply moving it around, then you start to see some substantial benefits. If you ’empty the sugar bowl’ or ’empty the rain barrel’, then you get healthier. It’s like garbage. Your house does not get cleaner because you throw your garbage under the bed. You need to throw it outside the house. Insulin, metformin, SUs and DPP4s all do not rid the body of the excess glucose. Neither do they prevent more glucose from coming in. So the studies consistently prove them useless.

However, if you use medications that both lower the blood glucose and cause weight loss, well now you’re cooking with fire. All of the SGLT2, acarbose, and GLP1 lower blood glucose and lower body weight at the same time. And all of them are PROVEN with double blind randomized controlled trial to reduce heart disease and death. No coincidence.

But here’s the main point. If type 2 diabetes is simply the body filling up with too much sugar, then reversal only depends upon 2 things.

  1. Don’t put more sugar in – Acarbose, GLP1
  2. Get it out – SGLT2

But you don’t need drugs for this. You can do it with intensive dietary strategies. The rest is up to you.

  1. Don’t put more sugar in – Low Carb diets
  2. Burn if off – Intermittent fasting.

The key to reversal of type 2 diabetes is entirely within our grasp – as I’ve written before here.

2017-10-19T21:52:06+00:00 48 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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48 Comments on "Medications that actually work for type 2 diabetes – T2D 40"

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Isabela
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There is a third point:

3. Don’t make more sugar in your body (aka slow down gluconeogenesis) – Metformin

I don’t know about studies, but anecdotally, metformin does help weight loss and from how it works, diabetes.

Tina
Guest
yes – I was thinking about that 3rd point. I’m at a point now where diet isn’t working, IF isn’t working – my overnight numbers are often 20-40 points higher than my evening number. So if i go to bed at 140, after low-carbing – i can conceivably at 190 in the AM, and have been. By my 3rd day in ketosis, my sleep is so rough, i wake up feeling horrible and like i said – 190s. The only really good explanation is GNG, and probably high cortisol, as well as standard Dawn phenomenon. Metformin barely has any impact,… Read more »
sten bjorsell
Guest
If you do not near EMPTY your liver of glycogen and liver fat you will never get rid of high morning sugar. I had heart disease – angina – and I was prediabetic. On LCHF most of the angina was gone, but not all, and FBG was around 110, never below. Taking carbs at night helped definitely, but never touched the cause, as FBG went up as soon as I didn’t. Then, 15 months ago, I planned a 3-day water fast, but it went better, ending up lasting 5 days. Working as usual and more energy than usual after day… Read more »
Tina
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I have done 36 and 42 hour fasts in the past few months. i can’t recall how low my BS went but it did go lower while i was awake – still dumped in the morning though. I can smell when i am in Keto (like nail polish remover) – so I am aware when I am in it (at night anyway – i can’t really smell myself during the day. lol). I first started IF March 1st. I’ve lost about 10 lbs, so I know insulin is low enough for some time in the morning or at night, but… Read more »
Tina
Guest

Btw – the sleep issues during ketosis have been ongoing for the past year and half – they just haven’t gotten better adding IF to the mix.

Nary
Guest

Similar but this week I added controlled dose of 11-15 g extra carbs each day, and 2 1-g doses of cinnamon and dropped BG 30 points fasting and under 90 all day. Good luck

Lyn Thompson
Guest

Sten,did you take any diabetic meds while fasting? I feel I should try this, but need a bit of advice before I begin. Can I still have “fat bombs” in the morning? Can I drink just plain tea without milk, can I have bone broth? Lots of questions I know but I really do appreciate the help.
Thank-you!

BobM
Guest

I’ve seen some people say higher carbs the day before cause lower morning blood sugar. That doesn’t seem to happen to me, but maybe it would help you. I do seem to have higher daily blood sugar if I eat more protein, but I haven’t had time to do a good test to figure out if that’s true .

Tina
Guest
Yeah this may be a fluke – i will have to see if i can reproduce. And it may be a matter of timing as well. I tried it on Monday night – I ate the world’s smallest piece of wheat toast with my eggs and bacon dinner and that was probably around 7:30pm too. Same tulsi tea, same acv. But by 10:30 pm my BS had shot up to 205 and I was unable to sleep well, got up in the middle of the night to pee, etc. I did wake up at 166 the next morning though, but… Read more »
Doug
Guest

If Metformin really causes weight loss then when I went off Metformin wouldn’t I have gained weight? I didn’t. Three months off with no weight gain.

Michael B
Guest

“The primary outcome, death, heart attacks or strokes was reduced in the EMPA patients by 14%. Death from heart disease was reduced by 38%.”

Is that relative risk or absolute risk?

Ken Stephens
Guest

Relative risk by definition. Since CVD is relatively high in diabetics, relatively lower is a good thing, although this number isn’t particularly meaningful. We need to be shooting for much better.

What’s funny and sad about studies is that they compare one drug to another, one punch to another, a punch to the stomach might hurt less, let’s punch them in the stomach instead 🙂 So for instance injected insulin does less damage than orals, let’s break out the syringes people 🙂

Ken Stephens
Guest
The question we should be asking is which drugs actually help the diabetes. SLGT-2 inhibitors sure don’t. Acarbose doesn’t either. What we need to do is address the disease itself, which is not high blood sugar, that’s just a symptom. So what we ned to do is identify the problem, which is glucose over-regulation, and when we just lower our blood sugar, peeing out more for example, the body will still fight back and make even more, and this is why this class of med produces higher levels of glucagon. Excess glucagon is at the heart of the problem of… Read more »
Yanny Ong
Guest

Actually, the whole reason diabetes is a ‘disease’ in the first place is because of its end-organ complications like heart disease, stroke, kidney failure, etc. If diabetes doesn’t cause these morbidity and mortality, than it is not an issue for the body and wouldn’t even be a ‘disease’ in the first place.

Therefore, studying the effects of those drugs on these end-organ complications is the right way to go, rather than studying their effectiveness in lowering blood glucose.

Ken Stephens
Guest
Actually this got me thinking, what if we could create a novel substance (drug) that actually helped treat diabetes, what would that look like? Well if we take things that conventional medicine tells us about the correct management of disease and do the exact opposite, well that gets us very close to the ideal, so why not do this with medications? So we can take medications that are used to treat diabetes and instead come up with something that does the opposite and that would be pretty good. For instance things that reduce insulin secretion when there’s too much insulin… Read more »
Tony
Guest

Sandostatin

Sammy Pepys
Guest

I think your earlier summary was spot on Ken. “Just eat less carbs, duh!”

I know… it’s not taught at med-school and it’s far too simple and no-one profits from it… except the patient:)

Jerome Kahn
Guest
A technical question: I have posted some of the journal articles relevant to this at http://healthfully.org/rt2d/ I have come across in the medical journals evidence that the issue isn’t glucose levels, but rather low tissue vitamin C. Certain tissues store very high levels of vitamin C (ascorbate). Along with normal serum glucose, another sign that glucose isn’t the problem is that most diabetic reduce carbs somewhat, thus their cells should be more stuffed with glucose than many non-diabetics. This is further indication that the issue isn’t glucose in the cell, but defective production of collagen due to a compromise in… Read more »
sten bjorsell
Guest
It is well known that glucose and ascorbate share the same cell receptors. So every time we eat high carb meals we get a little less Vitamin C into our tissues due to this “competition”. If BG in a non diabetic is 100 it could well rise to 200 for a short period after a meal, not to talk about diabetics-2. The body regulates ascorbate independent of BG to some “normal” blood levels, developed during our evolution. So when we eat the “paleo diet” or low carb, LCHF, ascorbate and glucose are in the same balance as it used to… Read more »
Drifter
Guest
Regarding the statement that ” the issue isn’t glucose levels, but rather low tissue vitamin C”, I don’t believe Dr. Fung has ever stated that the only issue is glucose levels, just that (to paraphrase) they are one of the largest and most easily controlled factors for most people. There is a very long list of things that appear to affect insulin sensitivity independent of diet such as timing of meals, sleep quantity and quality, microbiome status, various micronutrients (like chromium), exposure to mid-day sunlight, type and timing of exercise, and the list goes on. However the key point seems… Read more »
Richard
Guest
These last two posts, by you and Stan, are really interesting to me., and I think they should be to most readers. As noted above most of these factors are smaller (in effect) than excessive carb consumption and too frequent (or really continua) eating, but still, if someone can manage to fast, why not look into the other issues and see which ones are amenable to some improvement. Or, considering the aging process itself, which ones need to be improved? I am 72 and on a regular “IF” program and I take supplemental D3, C, and K2. For starters I… Read more »
Amy Mandelker
Guest

Interesting! Please could you elaborate about the sun and thr timing amd type of exercise?

Jerome Kahn
Guest
The point I was raising was that pharma got us looking under the wrong tree for the cause of the pathology. It isn’t the glucose level that causes it, but rather the production defective (inferior) collagen because of a compromised produces to which ascorbate and sorbitol have a major role. “Because the hydroxylase enzymes that perform these reactions require vitamin C as a cofactor, a long-term deficiency in this vitamin results in impaired collagen synthesis and scurvy.[29]” https://en.wikipedia.org/wiki/Collagen There are listed 28 types of collagen. As others have stated to use type 1 diabetes with its low insulin and the… Read more »
sten bjorsell
Guest
What I mean above is that instead of measuring blood levels of VitaminC, measure the relative concentration of Vitamin C and the other key nutrients that are absorbed from the blood by every cell during the “cell feeding time”, the postprandial state. A high BG reduces relative concentration of EVERYTHING else! We then find that glucose can be an early culprit in all kinds of disease through what Richard above poignant referred to as “carbs crowding out other nutrients”. Lowering the glycemic index can help, but the longer exposure time counters, providing a small net benefit, not good enough to… Read more »
Patricia Figueroa
Guest

Do you drink your coffee black? I love sweets but I do try very hard to stay away from sweets , i do cut out carb, but eat wheat..I am trying to find food , I eat veg and lots of fruits everyday.

sten bjorsell
Guest

Black coffee without sugar and sometimes “bullet coffee” which is with coconut oil and butter mixed up into a froth with a hand mixer. If I eat fruit I chop it up and take a small serving with heavy cream. Usually only vegetables or salad to meals, minimum potatoes, rice or pasta.

TimothyD
Guest

I find this “carbs crowding out other nutrients” such as ascorbate discussion quite interesting. I often joke that people are not built as sturdily now as young athletes constantly tear and strain ligaments, tendins, and muscles. In MLB ligament surgery for pitchers is commonplace, almost seen as a necessary part of their development. Now I am wondering if the problem lies in how these bodies form their collagen in a vitamin C deprived environment caused by the standard western diet.

Patricia Figueroa
Guest

Does anyone know what bare the best food to eat ..???

PegNP
Guest

Go to diet doctor.com for good advice on what to eat.

Stephen T
Guest
Patricia, as Peg says there’s plenty of advice out there and Diet Doctor is a good place to start. Everyone’s version of low carb will be different, within broad principles, but here’s mine. I eat meat, fish, eggs, cheese, butter, yoghurt, cream, coconut oil, olive oil, vegetables and salad. The full fat version of everything and nothing with added sugar. I don’t eat bread, rice or pasta, but I do eat a few potatoes. I don’t eat wheat or other grains. Not too much fruit, except for berries, which are lower in sugar. No fruit juice, which contains as much… Read more »
alejandro heredia
Guest

I would like to consult you about whether chromium picolinate has any incidence in the subra of glucose in sagre and if together with conjugated linoleic acid they perform a certain function?

Bill
Guest

As a diabetic (T2), I wouldn’t go right away to try this drug. I will wait few years to see more studies and more trials.
Metformin is very old now and its side effects are well known.
The best is to avoid all these drugs once and for all by fasting

soliman
Guest

hi Bill, at what point in your fasting did you stop taking metformin? How did you spot the timing of stopping taking the meds? thanks.

honeycomb
Guest

LOL .. They wait till the end of the article to admit what was really going on ..

https://www.indy100.com/article/weight-loss-dieting-healthier-eating-breakfast-7855486

Richard
Guest

Yes. Quite amusing, really.

Emily
Guest

I’ve decided to start at the very beginning of the blog, and I’m embracing the concept, however can someone please link me to a post that talks about WHAT to eat between fasts? I’m doing alternate 24 hour fasts, with 500 calorie meals, but I feel like I’m sleeping into reduced calorie eating on top of fasting

Lori
Guest

Look into a low carb moderate protein high fat diet

No more than 20 grams of carbs, 1 gram of protein per kilo of lean body mass (so for the average non active woman 50-60 grams a day, more if you exercise strenously) and fat to satiety (avoid Poly unsaturated oils such as canola and corn. Olive, coconut and butter are great options).

Ketogenicforums.com or listen to the 2KetoDudes Podcasts

Richard
Guest
Yes, but: part of what I consider the benefit of having your body (not just blood) sugar under control is that (ultimately) you can eat what you want. My favorite is that when someone has a birthday you can eat the cake and do just fine. It’s not going to kill you. If your metabolism and pancreas are working properly your insulin levels will rise and deal with the sugar. So yes, most of the time the Low Carb, High Fat diet is the way to go. Fasting or not. And ultimately probably at most two meals per day, one… Read more »
Emily
Guest

All good points! I’m familiar with every diet program out there, and know first hand they do not work for me. HFLC makes sense, but I don’t want to be obsessive about it. I’m finding between my fasts, I’m craving nutritious foods! Which is awesome

Stephen T
Guest
Emily, if you scroll up, I answered a similar question from Patricia. We all start from a different place with different goals. Lori gives well-informed advice at the stricter (ketogenic) end of the spectrum. I eat low carb but I have never measured grams of this or that or calories in my life. I’m at the right weight and not taking any medications, so I can probably be a bit more relaxed. I also think it’s easier to stick to something healthy permanently if, once you’re on the right path, you’re not obsessing endlessly. I’ve now eaten this way for… Read more »
Scott
Guest

https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4354-8.pdf

As it relates to medications. These represent a new class not yet discussed. Would love to hear Dr. Fung’s feedback.

Emily
Guest

After the last meal, when the body releases hinger signals, is this a good sign that it has depleted sugars in the liver and moving towards burning fat?

DebbieC
Guest
SGLT2 = Invokana = https://www.endocrineweb.com/news/diabetes/57572-fda-orders-stronger-warning-about-canagliflozin-invokana-amputation-risk The U.S. Food and Drug Adminstration is calling attention to the risk of amputation if you’re on the drug canagliflozin (Invokana, Invokamet). It is requiring the drug to carry stronger warnings about the risk. The drug’s label will have the so-called ”black box” warning, designed to call attention to serious or life-threatening risks. In its statement, the FDA says that ”Based on new data from two large clinical trials, the FDA has concluded that the type 2 diabetes medicine canaglifozin (Invokana, Invokamet, Invokamet XR) causes an increased risk of leg and foot amputations. FDA is… Read more »
Jeffrey Baker
Guest
Thank you dr. Fung for the well-written article. Your insides have cause me to change my thinking about td2 and my approach to bringing my A1C and insulin resistance in control. I have been fasting for 5 or 6 days and taking 3 days off and then reinitiating a five or six day fast with three days off and then this fast will be my last five or six day fast this week. I don’t feel like my insulin resistance is coming around. I did check my blood sugar yesterday and an hour or so after eating it was still… Read more »
soliman
Guest

Hi Jeffrey, I am also experiencing the same… yes, hoe we are just both optimistic. While fasting are you still taking your regular diabetes meds? Thanks.

soliman
Guest

joining the discussion, please.

Lyn Thompson
Guest

I am T2 and was prescribed Invocana I was told that Imwould pee some of my sugar out.
After having some bowel issues my doctor took me off this drug. I take Januvia and gliclizide.
I really want to not take any meds and I am currently doing Keto and trying to not eat until 2 pm.
I notice I have the DP and even if my BS are low in the evening 6-7 in the morning they are 10.
I Need some help please?

Lyn Thompson
Guest

Frustrated, need advice! Doing very low carb but morning Blood sugars are between 9-10 very disappointingly! I know Ins
Have the “Dawn Phenomenon” so thinking I should take a gliclizide in the evening so my morning starts out good. What do you think?
I take Januvia too but have cut back on meds dud to low carb.
Thanks so much for your thoughts and advice!
Do you think I should join IDM?

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