Incretin Based Treatments
When you have type 2 diabetes, the blood sugar may be too high after a meal, even if you eat very little carbohydrate (CHO). This, in part, is due to glucagon levels staying too high after meals.
Medicines, called incretin based treatments, are now available to control post-meal glucagon, and help reduce the post meal blood sugars. These medicines also are blood sugar normalizing medications or euglycemics (drugs that help return the blood sugar to the normal range.)
Sitagliptin (Januvia®)
Sitagliptin is an oral medicine for people with type 2 diabetes that helps control blood sugar levels after eating. It is a medicine that slows the breakdown of your natural GLP-1 by slowing its breakdown by the enzyme DPP-4. It is called a DPP-4 inhibitor.
Sitagliptin is approved by the Food and Drug Administration (FDA) for combined use with metformin, insulin releasing pills and thiazolidinediones.
In short, sitagliptin lowers glucagon during a meal, and increases insulin release from the pancreas when the blood sugar is too high.
The most common side effects are:
- Sore throat
- Runny nose
- Upper respiratory infections
- Low blood sugar, when taken together with insulin releasing pills and insulin
Uncommon side effect:
- Hypersensitivity reactions including allergic reactions, mouth and throat swelling and skin rashes
- Sitagliptin, has been reported to rarely cause pancreatitis, a serious condition. If you experience nausea, vomiting, anorexia, and persistent severe abdominal pain (which may travel to your back), contact your medical provider right away.
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 sugars. Unlike exenatide, people do not typically lose weight with DPP-4 inhibitors, but fortunately they don’t cause weight gain.
Saxagliptin (Onglyza®)
Saxagliptin is an oral medicine for people with type 2 diabetes that helps control blood sugar levels, especially after eating. It is a medicine that slows the breakdown of a natural hormone called GLP-1, by slowing its breakdown by the enzyme DPP-4. Saxagliptin is the second medicine available from the family of medicines called DPP-4 inhibitors (as they inhibit the breakdown of gut hormones called GLP-1 and GIP).
Saxagliptin is approved by the Food and Drug Administration (FDA) for use in people with type 2 diabetes, along with diet and exercise. While it may be used as an initial choice for a medicine to help lower blood sugar levels, DPP-4 inhibitors are mainly being used as 2nd or 3rd line therapy (that is these medicines are added on when a person is already taking a medicine for sugar control, such as metformin), or possible already taking two medicines (such as metformin and an insulin releasing pill, such as a sulfonylurea).
In short, saxagliptin lowers glucagon levels after meals, which then reduces the amount of sugar released from the liver, and increases insulin release from the pancreas when the blood sugar becomes too high after meals. Unlike exenatide, people do no typically lose weight with DPP-4 inhibitors, but fortunately they don’t cause weight gain.
The most common side effects are:
- Upper respiratory tract infections
- Urinary tract infections (bladder infection)
- Headache
- If used with a thiazolidinedione (such as pioglitazone), swelling or fluid retention may occur or become worse.
- If used with an insulin secretor (such as a sulfonylurea), the chance for a low blood sugar (hypoglycemia) may become worse.
Uncommon, but serious side effects are:
- Allergic (hypersensitivity) reactions, such as rash, hives, and swelling of the face, lips, and throat
- Sitagliptin, another medicine in the family of DPP-4 inhibitors, has been reported to rarely cause pancreatitis, a serious condition. If you experience nausea, vomiting, anorexia, and persistent severe abdominal pain (which may travel to your back), contact your medical provider right away.
Contact your medical provider right away if you have side effects.
Saxagliptin may negatively interact with other medicines, such as certain antibiotics, medicines that treat fungus infections or HIV/AIDS. Be sure to alert your medical provider if you will be starting or stopping any of these types of medicines, as the dose of saxagliptin might need to be changed.
Ask your medical provider for specific medication and insulin dose adjustment recommendations to avoid low blood sugars.
Exenatide (Byetta®)
Exenatide is an injected medicine for people with type 2 diabetes that helps prevent the blood sugar from rising after eating. Exenatide acts 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 normally is broken down very quickly in the bloodstream by enzymes known as DPP-4. Exenatide was developed to resist breakdown by the enzyme DPP-4. This way exenatide lasts longer in the blood stream and the GLP-1-like action lasts longer. Exenatide is approved by the Food and Drug Administration (FDA) for use in combination with metformin, thiazolidinediones and insulin secretagogues.
In short, exenatide lowers glucagon during a meal, slows food emptying from the stomach, curbs appetite and increases insulin release from the pancreas when the blood sugar is too high.
The most common side effects when starting exenatide are:
- Nausea
- Vomiting
- Low blood sugars
Uncommon side effect:
- May cause pancreatitis
If you experience any side effects, contact your medical provider immediately.
Caution:
Give your body a chance to adjust to this new medicine slowly. The starting dose is 5 micrograms twice daily, taken at breakfast and dinner. After 1 month, if you are tolerating exenatide, the dose may be increased to 10 micrograms, twice daily. It is available in a disposable pen device.
If you are treated with insulin releasing pills and starting exenatide, it is important to remember:
- Reduce the insulin releasing pill dose by half. Ask your medical provider for exact recommendation.
- Inject exenatide up to 1 hour before eating; it is taken at breakfast and dinner.
- Exenatide is not yet approved by the FDA for use in insulin treated individuals. However, if you are taking exenatide in combination with insulin therapy, the insulin dose should be decreased. Ask your provider for specific recommendations regarding the insulin dose adjustment.
- Some people can lose a small amount of weight while taking exenatide.
For more information about incretin therapy formulations, initial and final doses, and side effects, see our Medications Table.
Self-assessment Quiz
Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about Treatment of Type 2 Diabetes, take our self assessment quiz when you have completed this section. The quiz is multiple choice. Please choose the single best answer to each question. At the end of the quiz, your score will display. If your score is over 70% correct, you are doing very well. If your score is less than 70%, you can return to this section and review the information.
next