Annals of Nursing and Practice

Update in Type 2 Diabetes Mellitus Medications: the Many Paths for Control

Review | Open Access | Volume 5 | Issue 2

  • 1. Department of Nursing, University of Southern Indiana, USA
+ Show More - Show Less
Corresponding Authors
Mellisa Hall, 8600 University Blvd., Evansville, Indiana, USA

Diabetes is a growing epidemic worldwide (CDC, 2017). Type 2 diabetes mellitus (T2DM) affects more than 90% of people with diabetes. Because bedside nurses administer and monitor potential side effects of antidiabetic agents, a review of the numerous categories of antidiabetic agents now on the market to treat T2DM is summarized. This discussion is targeted for bedside nurses who are caring for diabetics in acute and transitional care settings, as well as in patient homes. The underlying pathophysiology of T2DM diabetes is reviewed, along with basic mechanisms of action of each category of antidiabetic agent. Safety considerations and common side effects will be presented for each medication category. Discussion will focus on both oral and injectable antidiabetic categories, including concentrated insulin products new to the market.


• Type 2 Diabetes mellitus

• Medications

• Nursing care


 Hall MA (2018) Update in Type 2 Diabetes Mellitus Medications: the Many Paths for Control. Ann Nurs Pract 5(2): 1098.


T2DM: Type 2 Diabetes Mellitus; ADA: American Diabetes Association


The incidence of diabetes continues to increase across the U.S., with 100 million people now diagnosed with diabetes or pre-diabetes [1,2]. Because of the growing incidence, not only in the U.S. but worldwide, pharmaceutical companies continuously bring to market new products to improve glucose control. The availability of new antidiabetic products makes it challenging for nurses to stay up-to-date and confident in practice. Patients are challenged as well to understand how newer agents work, making patient education a key focus of nursing care.

Standards of care for treatment of diabetes are updated annually by the American Diabetes Association (ADA), and they currently recommend a Hemoglobin A1c level of <7% for nonpregnant patients. A more relaxed goal of <8% is recommended for patients who have experienced frequent episodes of hypoglycemia, have a limited life expectancy, or already have evidence of microvascular or macrovascular complications [3]. Recommendations during pregnancy are more stringent, and outside this discussion. With their most recent update in January 2018, the ADA stresses most persons with diabetes do not meet recommended goals for glucose, blood pressure, or cholesterol control, leaving ample room for improvements in care [4].

Currently there are four major types of diabetes recognized by the ADA: Type 1, Type 2, Gestational, and diabetes secondary to other causes (pancreatic disorders, drug-induced hyperglycemia) [4]. Because more than 90% of diabetes is Type 2, the focus of this article will discuss antidiabetic medications currently marketed to manage Type 2 Diabetes Mellitus (T2DM). The value of exercise and formal diabetic education cannot be overemphasized. While lifestyle recommendations including exercise, nutritional therapy, and caring for mental health needs are vital to holistic care, only pharmaceutical treatment to maintain recommended glucose targets will be addressed.

Pathophysiology of T2DM

Insulin is required to transport glucose into cells in order to effectively use glucose for energy. Insulin resistance develops after years of an obese state with excessive adipose tissue. Hyperglycemia, or T2DM, then develops after years of insulin resistance. Insulin resistance reduces the body’s ability to transport glucose inside cells, requiring much higher levels of insulin to effectively use glucose and maintain glucose homeostasis [5]. Newer antidiabetic agents target various pathophysiologic mechanisms of T2DM discussed below [6].

Because obesity is an underlying concern causing cells to become resistant to insulin, obesity is a leading risk factor for T2DM [5]. Additional mechanisms impairing the ability of insulin to be effectively used in tissues contribute to T2DM, including genetic and environmental factors [6]. One result is islet cells of the pancreas work harder to produce higher amounts of insulin to maintain glucose homeostasis. After years of increased demands to produce larger amounts of insulin, the islet cells of the pancreas can no longer can keep up with higher demands, resulting in hyperglycemia [7-10]. Approximately four years elapse from the time insulin resistance begins to the time hyperglycemia occurs [5,6]. Hyperglycemia may not be actually diagnosed for months or years later, until symptoms develop, or hyperglycemia is recognized incidentally [10,11]. High insulin levels are being used to diagnose pre-diabetes, and oral agents are being prescribed earlier to reduce the progression from prediabetes to T2DM [12,13].

Oral antidiabetic agents

Because patients are less fearful of oral medications versus insulin, oral products will be the focus of this discussion. Many products combining two oral antidiabetic agents are available, but this article will focus on the mechanisms of action, common side effects, and patient education appropriate for individual oral antidiabetic products and newer injectable products other than insulin. A table presenting the categories of oral antidiabetic agents, as well as injectable antidiabetic agents other than insulins, is presented in Table 1.

Table 1: Oral and Injectable Antidiabetic Agents Other Than Insulins.

Mechanism of Action Risk for Hypoglycemia Comments
Sulfonylureas (Secretagogue) Glipizide
Stimulate pancreas to 
produce more insulin
Definite risk, especially if used with rapid or intermediate-acting insulin. Used with long-acting 
insulins to improve glucose 
control. Low cost. Requires 
multiple daily dosing. 
Biguanides Metformin Increases glucose uptake 
in tissues
Small GI upset initially
DPP-4 Inhibitors Sitagliptin Saxagliptin Reduced glucagon 
Small Weight neutral
Thiazolidinedione (TZDs) Rosiglitazone Pipglitizone Increased insulin 
sensitivity in fat and 
Small Edema, wt. gain, worsening heart failure
Alpha-Glucosidase Inhibitors Acarbose Miglitol Reduce absorption of 
carbohydrates from the 
GI tract
None GI upset including flatus. Must be taken with meals.
Meglitinides Injectable Products Other Than Insulins Stimulates insulin 
secretion with meals
Yes Wt. gain and frequent dosing
Injectable Products Other Than Insulins        
GLP-1 Agonists (Incretin 
Reduces glucogon 
secretion, increases insulin 
Small Nausea. May improve wt. 
loss. Available in daily or 
weekly dosing.
Amylin Analogs Pramlintide Slows GI emptying and 
reduces glucogon secretion
Yes Hypoglycemia should be 
expected if previous insulin 
dose not reduced.
Original table developed from references: 9, 16. ]
Abbreviations: DPP-4: Dipeptidyl peptidase inhibitors; GLP-1Agonists:Glucagon-like, Peptide-1 (GLP-1) Agonists.


While not the original oral antidiabetic category, biguanides (metformin) is currently considered the first drug of choice for T2DM. Biguanides reduce glucose production in the liver, reduce glucose absorption in the gut, and help reduce insulin resistance by increasing insulin sensitivity in fat and muscle [14]. Metformin helps reduce the blood viscosity and platelet aggregation. Because metformin is primarily eliminated by the kidneys, metformin is used cautiously in patients with elevated serum creatinine levels (males 1.5 mg/dl or greater, females 1.4 mg/dl or greater). The ADA currently recommends metformin as long as glomerular filtration rate (GFR) remains above 30 ml/ min [4,15]. Because of the risk of worsening renal function in the presence of contrast dye, metformin should be held for 48 hours before and after imaging studies requiring contrast [14]. Another indication to hold metformin is pre-existing metabolic acidosis. Lactic acidosis is a rare complication of metformin, yet is associated with a 50% mortality rate. Preventing dehydration is important to reduce acidosis risk. Patients with hepatic and renal dysfunction are at higher risk of drug accumulation leading to lactic acidosis [9,14].

Buguanides are affordable, with availability on lowcost pharmacy lists. Biguanides are rarely associated with hypoglycemia but patients may have gastrointestinal (GI) upset, especially when initiating [9,14]. They are also associated with lower B 12 levels necessitating monitoring of B 12 with prolonged use [14]. Metformin is considered safe in elderly due to low risk for hypoglycemia, but should be used with caution in patients with hepatic and significant renal impairments [3,14]. Because biguanides improve insulin sensitivity and reduce the work of the pancreas, they are used for patients with pre-diabetes as well [13]. 

Patient teaching should include metformin is not associated with concerns for hypoglycemia. Patients should be warned about the potential for GI upset, including diarrhea. Dosing metformin with the evening mealhelps patients appreciate the degree of GI upset they may need to deal with when away from home. Patients should also understand food will reduce the absorption/ effectiveness of metformin in the immediate release form [14- 16]. The rare side effect of lactic acidosis is more common in patients with worsening renal function, including those with recent dehydration. Signs of lactic acidosis include dizziness, muscle pain, and weakness. Patients with T2DM will often appreciate a positive aspect of metformin use is the potential for weight loss [9,14].


Sulfonylureas were the first class of oral antidiabetic agents. Because of their age, sulfonylureas have lower cost than other oral medications, making them preferred formulary drugs for insured patients. For patients paying out-of-pocket, sulfonylureas are offered on pharmacy low-cost drug lists. Sulfonylureas (insulin secretagogues) work by stimulating the pancreas to produce more insulin (Secretagogues) [17]. Sulfonylureas help binding between insulin and insulin receptors, but their usefulness over time diminishes as beta cell function diminishes [18]. Insulin resistance has already required islet cells of the pancreas to produce a greater amount of insulin, and sulfonylureas increase the productivity of the islet cells [18,19]. While they will lower Hemoglobin A1c levels approximately 1.5%. Sulfonylureas do place patients with diabetes at risk for hypoglycemia [16,19]. An example of a sulfonylurea is glipizide.

Patients should be aware all sulfonylureas may cause hypoglycemia [16,19]. Patient education should include the signs/symptoms of hypoglycemia, and appropriate actions to take. Verification of the understanding of hypoglycemia should be received verbally by asking the patient to explain how they may feel. Patients should also be able to state appropriate actions to raise their glucose levels.

A second category of secretagogue is a non-sulfonylurea, meglitinides. Meglitinides are an alternative to sulfonylurea for patients with irregular meal times or those who have late post-prandial hypoglycemia episodes with sulfonylureas [20]. Meglitinides also asks the pancreas to produce a greater amount of insulin, their peak effect occurring within an hour of administration, and should be taken just before meals. Meglitinides stimulate insulin production to lower post-prandial glucose levels to provide immediate assistance with glucose spikes due to meals [19]. Meglitinides are rapidly absorbed from the GI tract. They are most often prescribed in combination with other oral antidiabetic agents to achieve glucose goals. Like sulfonylureas, non-sulfonylureas may cause hypoglycemia, and should be held if the patient is not able to eat. Patients should recognize these products work best when taken 20 – 30 minutes before meals to best prevent post-prandial glucose spikes. Meglitinides require multiple daily dosing due to the preprandial dosing requirement. An example of a non-sulfonylurea is repaglinide (Prandin) [15,21].

Dipeptidyl peptidase-4 (DPP-4) inhibitors

Dipeptidyl peptidase inhibitors (DPP-4) help maintain the good work of incretin hormones which stimulate insulin secretion [22]. Incretins also help reduce hunger in many patients [23]. DPP-4 inhibitors target the pathophysiologic dysfunction in T2DM by reducing the rate of decline of beta cells and reducing appetite leading to weight loss [22,23]. DPP-4 inhibitors help lower both pre and post-prandial glucose levels. DPP-4 inhibitors are absorbed from the GI tract and may be taken with or without food. There is little risk of hypoglycemia with DPP-4 inhibitors, but there is some risk of pancreatitis [15,22,24]. An example of a DPP-4 inhibitor is Sitagliptin. Studies are currently targeting the relationship between DPP-4 inhibitors and cardiovascular outcomes [25-27]. DPP-4 inhibitors are not currently available on low-cost pharmacy lists. Patient teaching with DPP-4 inhibitors includes taking the medication daily, and if forgotten, the pill should be taken the same day when remembered. There is no concern for teaching about hypoglycemia with DPP-4 inhibitors when used alone [16, 24].

Alpha-glucosidase inhibitors

Alpha-glucosidase inhibitors work by delaying carbohydrate absorption form the small intestine. They need to be dosed with meals. Alpha-glucosidase inhibitors are more effective the higher the post-prandial glucose level. They cause a change in carbohydrate digestion into a lower portion of the small intestine. Due to their mechanism of action, alpha-glucosidase inhibitors may cause GI upset including flatulence and abdominal bloating. They are effective in treating pre-diabetes. An example of an alpha-glucosidase inhibitor is miglitol. There is no concern for hypoglycemia with this category [28]. Patient teaching should include the risk of GI upset, including considerable flatus, and the need to dose the medication routinely as they begin eating. Patients should be given hope that the GI side effects will improve often within two weeks [28].

Sodium-glucose co-transporter 2 (SGLT2) inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors help control glucose by blocking reabsorption in the kidney and increasing excretion of glucose through the urine [29]. Glucose reabsorption takes place primarily in the proximal tubule via SGLT1, a high-affinity, low-capacity transporter, and SGLT2, a low-affinity high-capacity transporter. SGLT2 contributes to 90% of glucose reabsorption and SGLT1 contributes to 10% of reabsorption respectively [30]. Thus, SGLT2 inhibitors work in the proximal tubules to block up to 90% of glucose reabsorption. This action can lead to osmotic fluid loss and orthostasis, especially in patients already at risk for volume depletion. SGLT2 Inhibitors are contraindicated in patients with GFRs less than 30 ml/min, and dosage reductions are recommended in patients with GFRs of 45 ml/min or less [15,16,29]. Because of changes in fluid volume, renal function should be monitored when patients initially begin a SGLT2 Inhibitor, along with serum potassium levels [15,29]. Other potential concerns with these products include the risk for hypoglycemia if combined with insulin [29].

An example of a SGLT2 inhibitor is empagliflozin a “flozin.” Current recommendations suggest adding a “flozin” to the treatment regimen after metformin to improve outcomes for patients with arteriosclerotic heart disease [3]. Adverse effects associated with “flozins” include candidiasis in males and females, urinary tract infections (UTIs), a decrease in bone mineral densities, and amputation [16,29]. SGLT2 inhibitors are safest when used in patients with little or no renal impairments (GFR>60 ml/min). Hypoglycemia is rare, but dizziness can be an adverse effect as well. SGLT2 inhibitors are approximately $300.00 monthly [15,16,29]. Patient teaching should encourage patients to take their medication at the same time daily, preferably before the first meal. Patients should be warned to be cautious when going from supine to upright due to lower fluid volumes and risk for hypotension. Signs and symptoms of Candidiasis should be reviewed [29].

Thiazolidinediones (TZDs)

Thiazolidinediones (TZDs) reduce glucose by increasing insulin sensitivity in fat and muscle [15,16,31].TZDs target nuclear receptors to boost the level of proteins that improve insulin action on cells [31]. This improves insulin action in the liver, muscle, and adipose tissue [9]. TZDs do not ask the pancreas to produce more insulin, nor do they place patients at risk for hypoglycemia. Although TZDs work on the root cause of T2DM, they are associated with the adverse effects of weight gain, edema, worsening heart failure, and fracture risk [31]. TZDs are to be avoided in patients with symptomatic heart failure. TZDs may be recognized in the generic format with the suffix “zone.” This category offers more sustained glucose control than sulfonylureas or metformin [3].

Patient teaching important to include with TZDs should focus on remembering the medication daily in the morning. Side effects from TZDs are rare, including the risk for hypoglycemia. Because of the risk for fluid retention, patients should understand to report concerns with edema or shortness of breath [31].


While the foundation of treatment is focusing on lifestyle changes recommended with T2DM, glucose control is used as a decision point for when to initially begin insulin therapy. Insulin will be considered as first line therapy in patients presenting with a fasting glucose of 250 mg/dl or higher, a random level of > 300 mg/dl, a Hemoglobin A1c level of 9.5% or higher, or weight loss with ketonuria associated with uncontrolled diabetes [3,11]. Insulin will be considered as an add-on therapy to oral agents when the pancreas continues to tire, and glucose levels persist with Hemoglobin A1c levels of > 8.5% [32,33,34].

The disadvantages of insulin therapy include risk of hypoglycemia and weight gain, with hypoglycemia the most life-threatening risk for any age patient [32,34]. Patients should explain verbally how to recognize the signs of low glucose levels, and voice the activities placing them at higher risk for hypoglycemia (increased physical activity).

Oral antidiabetic agents may be continued with the addition of insulin. This decision is based on the mechanism of action of the oral agent, with agents helping to increase insulin sensitivity as priority. Continuing these oral agents helps minimize the amount of supplemental insulin required for adequate glucose control [3, 32, 34]. A table summarizing current insulins with newer highconcentration products is presented in Table 2.

Table 2: Insulins.

Rapid-Acting Insulins Example of Brand 
Onset of Action Peak Action Duration of Action Concentrations 
Insulin lispro Humalog 15 minutes 0.5 – 1.5 hours U 100: Up to 5 hours
U 200: Up to 6 hours 
U 100
U 200
Insulin aspart NovoLog 5 minutes 0.5-2 hours Up to 5 hours U 100
Insulin glulisine Apidra 15 minutes 0.5 – 2 hours Over 5 hours U 100
Short-Acting Insulins 
Regular ‘R’ Humulin R 30 minutes 2 – 3 hours U 100 up to 12 hours
U 500 up to 24 hours
U 100
U 200
Intermediate Acting 
Insulins (NPH)
Insulin isophane 
Suspension (NPH)
Humulin N 1-2 hours 4-10 hours Up to 24 hours U 100
Long-Acting Insulins          
Insulin glargine Lantus 1 hour None Up to 32 hours U 100
Insulin glargine Basaglar 1 hour None Up to 32 hours U 100
Insulin glargine Toujeo 6 hour None Up to 120 hours U 300
Insulin detemir Levemir 1 hour None 24 hours U 100
Ultra Long-Acting 
Insulin degludec Tresiba 1 hour None Up to 42 hours U 100 
U 200
Reference: 16, 38
Abbreviations: U: Unit, NPH: Insulin isophane Suspension

Additional parenteral therapies for glucose control

Amylin analogs: Amylin analogs are Injectable products that slow GI emptying and reduce glucogon secretion after meals [15,16,35]. Amylin analogs are injected twice a day prior to the largest meals. Amylin analogs may be used with metformin and a sulfonylurea. An example of an Amylin analogs includes pramlintide. Amylin analogs are associated with nausea, weight loss, and rare incidence of pancreatitis or thyroid tumors [35].

Glucagon-like, Peptide-1 (GLP-1) Agonists (Incretin Mimetic): GLP-1 agonists are daily or weekly injectable products that work by slowing GI emptying, decreasing glucogon secretion, and improving insulin production in response to glucose spikes [16,36]. An example of a GLP-1 agonist isexenatide or liraglutide. GLP-1 agonists are associated with nausea, and rarely pancreatitis or gall bladder dysfunction [15,36]. There is low risk for hypoglycemia with GLP-1 agonist and a rare risk of thyroid cancers. GLP-1 agonists may be combined with insulin for more effective glucose control [36]. Patients with atherosclerotic heart disease have been shown to benefit from the addition of liraglutide as an additional treatment following metformin [3].


Helping Patients Understand Their Diabetes Diagnosis and Medications

The ADA provides an interactive diabetes education website focusing on medication therapy [4]. Their website located at http://www.diabetes.org/living-with-diabetes/treatmentand-care/medication/ is comprehensive and includes up to date medication information, explaining the diagnosis and pharmacotherapeutics for T2DM. The site may be used to augment patient education and to verify patient comprehension about their medications, including safety teaching. Because T2DM is an ongoing chronic illness changes in therapy will be expected. The ADA updates their treatment recommendations annually based on current evidence. Nurses can anticipate changes in individual patient care based upon the ADA’s annual updates. Patients can anticipate changes through the ADA as well through Diabetes Forecast located at: http://www.diabetesforecast.org/2014/ apr/why-so-many-meds-for-type-2.html Encouraging patients to participate in face-to-face diabetic education sessions leads to improved patient outcomes [37,38]


Because there are numerous ways to approach glucose control in T2DM, it is challenging to remember each antidiabetic category. A mnemonic to assist in remembering categories of antidiabetic agents is presented below: Big Appetites Start Small And Grow Dangerous In Time

Big: Biguanides
Appetites: Alpha- Glucosidase Inhibitors
Start: Sulfonylureas
Small: Sodium Glucose Co-Transporter Inhibitors 
And: Amylin Agonists
Grow: Glucagon-Like Peptide Agonists 
Dangerous: Dipeptidyl Peptidase-4 Inhibitors 
In: Insulins 
Time: Thiazolidinediones 

Diabetes is often the primary reason nursing care is required, if not a frequently encountered co-morbidity during hospitalization. Feeling confident in understanding the mechanism or action of antidiabetics, and the benefits and concerns of high-concentrated insulin products lead to confident nursing care. Understanding antidiabetic agents can also lead to improved patient understanding and safer medication experiences during hospitalization and in the home.


References in the text should be in square brackets, e.g. [1- 3], for multiple references e.g., [1,2-5] and figures/tables are in parenthesis, e.g. (Figure 1) or (Table 1).


1. Center for Disease Control. National diabetes statistics report – 2017. Estimates of diabetes and its burden in the United States. 2017.

2. Center for Disease Control. New CDC report: More than 100 million Americans Have diabetes or pre-diabetes. 2017.

3. American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care, 41, S1 – S 155. 2048.

4. American Diabetes Association. Standards of medical care in diabetes – 2018. A bridged for health care providers. Clinical Diabetes. 2018; 36: 14 – 37.

5. McCulloch DK. Pathogenesis of type 2 diabetes mellitus. UpToDate. 2016.

6. Cypress M, Tomky D. Complete nurse’s guide to diabetes care. In B.P. Childs, M. 7. Cypress, & G.R. Spollett (Eds.) Arlington, VA: American Diabetes Association. 2017.

8. Carstensen M, Herder C, Kivimaki M, Kivimäki M, Jokela M, Roden M, et al. Accelerated increase in serum Interleukin-1 receptor antagonist starts 6 years before diagnosis of type 2 diabetes. Diabetes. 2010; 59: 1222-1227.

9. De Fronzo RA. From the triumvirate to the ominous octet: A new paradigm for the

10. treatment of type 2 diabetes mellitus. Diabetes. 2009; 58: 773-795. 11.

9. Prescriber’ Letter. Drugs for Type 2 Diabetes. Prescriber’s Letter. 2017; 31: 310601. 12.

10. Skyler JS, Bakris GL, Bonifacio E, Darsow T, Eckel RH, Groop L, et al. Differentiation of diabetes by 13.pathophysiology, natural progression, and prognosis. Diabetes. 2017; 66: 241-255.

14.11. McCulloch DK, Nathan DM, Mulder JM. General principles of insulin therapy in type 2 diabetes. 15.

12. Knowler WC, Barrett-Conner E, Fowler SE. Reduction in the incidence of 16.type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine. 2002; 346: 393. 17.

13. Meigs JB. The metabolic syndrome (insulin resistance syndrome or syndrome X). 2017. 18.

14. Bristol-Myers Squibb. Glucophage. 2018. 19.15. Monthly Prescribing Reference (MPR). Diabetes Treatments. 2017.

20.16. Robinson M, Shaw K. Drugs affecting the endocrine system. In T. M. Woo & M.

21. Robinson (Eds.) Pharmacotherapeutics for advanced practice nurse prescribers. (4th ed.). Philadelphia, PA: F.A. Davis. 2016.

22.17. Proks P, Reimann, F, Green N, Gribble F, Ashcroft F. Sulfonylureas stimulation of insulin secretion. 23.Diabetes. 2002; 51: S368-S67. 24.

18. Matthews D, Wallace T. Sulphonylureas and the rise and fall of beta-cell function. 25.British Journal of Diabetes & Vascular Disease. 2005; 5: 192-196. 26.

19. Pfizer/Roerig. Glucotrol. 2018. 27.

20. Stein SA, Lamos EM, Davis SN. A review of the efficacy and safety of oral antidiabetic drugs. Expert 28.Opin Drug Saf. 2013;12: 153-175. 29.

21. Novo Nordisk. Prandin. 2017. 30.22. McCulloch DK. Overview of medical care of adults with diabetes. 2017. 31.

23. Diabetes Forecast. Incretins and Diabetic Medications. American Diabetes Association. 2018. 32.

24. Merck. Sitagliptin. 2018. 33.25. Chin HJ, Nam JH, Lee EK, Shin JY. Comparative safety for cardiovascular outcomes of DPP-4 inhibitors versus glimepiride in patients with type 2 diabetes: A retrospective cohort study. 2017; 96: e7213. 34.

26. Yousefzadeh P, Wang X. The effects of dipeptidyl peptidase-4 inhibitors on cardiovascular disease risks in type 2 diabetes mellitus. J Diabetes Res. 2013; 2013: 459821. 35.

27. Monami M, Dicembrini I, Antenore A, Mannucci E. Dipeptidyl peptidase-4 inhibitors and bone fractures: a meta-analysis of randomized clinical trials. Diabetes Care. 2016; 39: S196-204. 36.

28. Pfizer. Glyset. 2016. 37.

29. Boehringer-Ingelheim. Jardiance. 2017. 38

30. Poudel RR. Renal glucose handling in diabetes and sodium glucose co-transporter 2 inhibition. Indian J Endocrinol Metab. 2013; 17: 588- 593. 39.

31. GlaxoSmithKline. Avandia. 2016. 40.32. Dashora U, Castro E. Insulin U 100, 200, 300, or 500? British Journal of Diabetes. 2016; 16: 10–15 41.'

33. Prescriber’s Letter . Tips to improve insulin safety. Prescriber’s Letter. 2016; 23: 320709. 42.34. Prescriber’s Letter. (2016a). Insulin. Prescriber’s Letter. 2016; 23. 43.

35. AstraZeneka Pharmaceuticals. Symlin. 2015. 44.36. Novo Nordisc. Victoza. 2010. 45.37. Mitchell L, Ball L, Ross L, Barnes K, Williams L. Effectiveness of dietetic

46. consultations in primary health care: a systematic review of randomized control trials.

47. Journal of the Academy of Nutrition & Dietetics. 2017; 117: 1941- 1962.

48.38. American Diabetes Association. Living with diabetes: Treatment: Medication. 2018

Hall MA (2018) Update in Type 2 Diabetes Mellitus Medications: the Many Paths for Control. Ann Nurs Pract 5(2): 1098.

Received : 11 Sep 2018
Accepted : 26 Oct 2018
Published : 28 Oct 2018
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X