Oral Meds for Type 2 Diabetes: Understanding the Risk of Low Blood Sugar

If you live with type 2 diabetes (T2D), you might be taking oral medications or using insulin to manage your blood sugar levels. Oral medications benefit people with T2D in many ways. 

Oral medications can help you:

• Increase insulin production
• Improve insulin sensitivity
• Reduce insulin resistance

Oral medications for T2D help you keep blood sugar levels in a healthy range. In rare cases, they can also increase your risk of experiencing low blood sugar (aka hypoglycemia). So it’s important to know how to treat lows and prepare for low blood sugar emergencies, especially if you take more than one medication or use insulin.

How to get ahead of lows: why they happen + what to watch for

If you’rre taking blood sugar-lowering medication, it’s important to take these three steps as soon as possible after you pick up your first prescription:

• Invest in emergency glucagon. Whenever you’re taking a blood-sugar-lowering medication, you should have glucagon and low blood sugar treatments like glucose tablets, gels or powders on hand. Emergency glucagon is used to treat severe lows (55 mg/dL/3.1mmol/L or lower) while glucose tablets, gels and powders are used to treat standard lows (70/3.9 mmol/L to 56 mg/dL/3.1 mmol/L).
• Teach your loved ones how to help you during a low-blood-sugar emergency. If you’re not sure how to teach them, ask your healthcare team for support—that’s what they’re there for!
• Consider wearing a continuous glucose monitor (CGM) if you aren’t already, which can help you get ahead of lows and see how your oral medications affect your blood sugar levels in real time.

When am I most at risk for lows?

Part of living with diabetes means dealing with lows. But with time, you get better at preventing and managing them. And while it’s good that your oral medications are lowering your blood sugar as intended, the risks of low blood sugar happen when:

• You take a higher dose of your medication or forget to take a dose, then double it.
• You don’t eat after taking your medication or eat less than you originally planned to after taking it.
• You increase your physical activity without adjusting your medication with your healthcare team.

If you find yourself in any of these situations and are unsure how to manage them, it’s always best to consult your healthcare team. You might need a medication adjustment or to explore different oral medication options.

What oral medications are most likely to cause lows?

Some medications are more likely to cause low blood sugar than others. As a rule of thumb, taking insulin with these drugs also generally increases the risk of low blood sugar.

• Sulfonylureas (Amaryl, Glucotrol, Micronase, Glynase, and Diabeta): Lower blood sugar by stimulating the release of insulin by the beta cells in the pancreas. Risk of low blood sugar is HIGH. 
• Meglitinides (Starlix, Prandin): Lower blood sugar by stimulating the release of insulin by the beta cells in the pancreas. Risk of low blood sugar is MEDIUM. 
• Biguanides (Metformin): Helps lower blood glucose levels by decreasing the amount of glucose produced by the liver and  by making muscle tissue more sensitive to insulin. Risk of low blood sugar is LOW. 
• Oral GLP-1s (Rybelsus, Wegovy, Orforglipron): Increase the release of insulin and reduce the release of glucose from the liver after meals. Risk of low blood sugar is LOW. 
• DPP-4 Inhibitors (Nesina, Januvia, Tradjenta and Onglyza): Work by preventing the breakdown of naturally occurring hormones in the body, GLP-1 and GIP. These hormones reduce blood glucose levels. Risk of low blood sugar is LOW. 
• SGLT-2 Inhibitors (Invokana, Farxiga and Jardiance, Brenzavvy) : Cause your kidneys to take in less glucose and move it out of the body through urine. Risk of low blood sugar is LOW. 
• Thiazolidinediones (Avandia, Actos): Help insulin work better in the muscle and fat and reduce the amount of glucose produced in the liver. Risk of low blood sugar is LOW. 

The risk of these oral medications causing low blood sugar increases when combined with each other and when also taking insulin.

Get proactive about low blood sugar episodes

Since so many factors can lead to low blood sugar, it can occur at any time. Sometimes, low blood sugar episodes are severe enough to require help. If untreated, they can lead to seizures, coma or loss of consciousness. 

Ways to be proactive with your blood sugar management and reduce low blood sugar events include:

• Learn the signs and symptoms of hypoglycemia.
• Don’t skip any meals.
• Keep track of the timing of your meals when taken with medication.
• Take your medicine as directed by your healthcare team.
• Have emergency treatment, such as nasal glucagon or another form of glucagon, available in case of a low blood sugar episode. 

If you were prescribed oral medications to manage your T2D, they’re designed to help. Don’t let the risk of low blood sugar scare you. With any blood-sugar-lowering medication, it’s important to be aware of the risks and signs of low blood sugar so you can act if needed.

Feel like no one in your life understands what it’s like to manage the highs and lows of type 2 diabetes? We’re happy to tell you that you’re wrong. There’s a community waiting for you! Join the Type 2 Community App.