What’s next for overmedicated diabetic?

Dear Dr. Roach: About 15 years ago I was diagnosed with Type 2 diabetes, and began years of increasing numbers of medications and higher doses, until all but one is maxed out. The Jardiance, metformin and Rybelsus I take are at their max doses, and the Tresiba is close.

About six months ago, my doctor decided to find out how much insulin my body makes. It turns out I make adequate insulin but I’m insulin resistant. I can find little about this. My doctor is treating me the same with the same lack of results. My BMI is north of 40. Of course, I know I need to lose weight but have not been successful at it. — N.V.P.

Dear N.V.P.: Type 2 diabetes is a disease of insulin resistance. Most people with Type 2 diabetes, at least early on in the disease, are able to make normal amounts of insulin; in fact, insulin levels tend to be higher than normal, because of the resistance to insulin. However, people with Type 2 eventually are unable to make insulin fast enough to bring the blood sugar down, especially after a meal. This combination of insulin resistance and inability to quickly make large amounts of insulin causes the blood sugar to rise. The high blood sugars are the predominant, but not only, way that complications arise from diabetes.

Your doctor has you on four medicines to try to help bring your blood sugar down. Empagliflozin (Jardiance) works by preventing your kidneys from absorbing all the blood glucose, so you literally lose blood sugar into the urine. The increase in urine infections is smaller than one might expect: about 2% more infections. Metformin works predominantly by preventing the liver from making sugar. Both of these therapies reduce the amount of insulin your body needs to make.

Semaglutide (Rybelsus and others) blocks a protein called GLP-1.

This has several effects, including increasing insulin secretion, slowing stomach emptying (which slows sugar absorption and allows the body time to make more insulin), reducing the anti-insulin hormone glucagon, and promoting weight loss, largely through making people less hungry. Weight loss with the injection form of this medicine at higher doses (2.4 mg per week) can be impressive.

Degludec insulin (Tresiba) is an ultra-longacting insulin. I’m not sure what you mean about the dose being near the maximum. Insulin can be prescribed at very high levels if needed. I have had patients on greater than 200 units a day.

There is a class of drugs you are NOT taking. This class (the TZDs, such as pioglitazone) works primarily by reducing insulin resistance. They are not often prescribed due to concerns about heart failure, and because they may cause or worsen weight gain.

Honestly, I am not sure more medication is right for you. Even a moderate increase in your exercise combined with a little less food (especially less sugars/starch) will have a significant impact on your blood sugar. Working with a nutritionist and a diabetes educator can be very helpful. If you really can’t successfully make changes to your food intake or exercise, it would be worth considering bariatric surgery, which has powerful effects on blood sugar control, often bringing blood sugar down so much that no medicines are necessary to control

the diabetes.