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Are there any alternatives to insulin? (Type 2)
Many people who have been advised that they should start insulin ask this question. It is
understandable that when faced with the prospect of daily injections people with type 2 diabetes are
keen to explore all other options. This handout outlines what alternatives are available, and whether
they may be suitable for you as an insulin alternative.
What is diabetes?
Glucose is normally absorbed from the food we eat into the different cells of our bodies using insulin
and insulin receptors. Insulin is produced by the pancreas and helps glucose move from the blood
into the cells of the body. Insulin receptors are found on each cell and help move the glucose into the
cells.
Type 2 diabetes develops when there is a mismatch between how much insulin the body needs and
how much is available. This usually occurs because the cell’s insulin receptors have become resistant
to insulin. This generally happens as a gradual process. Initially, the pancreas can overcome this by
increasing the amount of insulin it produces. However, its ability to keep up with the increased work
load does not last forever. Eventually not enough insulin is made and glucose builds up in the blood
stream. Because high levels of glucose are toxic to blood vessels, one of the major goals of treatment
is to keep the blood sugar levels at normal, or near normal level, to help prevent some of the longterm complications of diabetes.
Any useful treatment must address these underlying problems. Insulin injections help by providing the
very substance which the body is lacking. In the early stages of diabetes other treatment may be
useful. Drugs such as metformin work by making the insulin receptors more sensitive, and make any
available insulin more effective.
Surgery
In recent years surgical weight loss methods (bariatric surgery) have been used to achieve weight loss.
It has been found that obese people with type 2 diabetes were much more likely to achieve remission
of their diabetes after surgery through a large weight loss.
Bariatric surgery can be successful in achieving a dramatic weight loss but there are also associated
high risks and it is not a decision to be taken lightly. The long-term implications on a person’s life are
significant. There are strict criteria for selecting those suitable and only very limited funding is
available in the public health system.
Other medications for diabetes
1) Alpha-glucosidase inhibitor tablets
When food is eaten the carbohydrate component is broken down by enzymes to small glucose
particles which are absorbed through the gut. One of the main enzymes is called alphaglucosidase. Blocking this enzyme results in a decrease in the efficiency of this process and delays
the glucose absorption. This helps to lower blood sugar levels but is not as effective as
HealthInfo reference: 37317
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Issued: 14 July 2014
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Are there any alternatives to insulin? (Type 2)
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sulphonylureas. Although it is generally well tolerated, people may experience bloating, wind
(flatulence), and diarrhoea, especially if it is taken at higher doses. The alpha-glucosidase inhibitor
funded for use in New Zealand is called acarbose. There is no weight gain associated with the use
of acarbose.
2) Incretin-based therapy
Various hormones are involved in insulin secretion. A group of hormones called the incretin
hormones are made in the gut and their major action is to stimulate insulin production. Incretin
hormones are rapidly broken down by an enzyme called DPP-4.
 Sitagliptin: This works by inhibiting the DPP-4 enzyme and slows the rate at which incretin
hormones are broken down. This means that incretins are able to work longer. Sitagliptin is
taken once a day in tablet form and has a number of side effects, most commonly, a stuffy
nose and upset stomach. Occasionally more serious side effects can occur and the drug needs
to be stopped. Sitagliptin is not currently funded by Pharmac so there is a cost of
approximately $100 a month.
 Exenatide: This is similar to one of the incretin hormones and therefore mimics its behaviour,
leading to increased levels of insulin. It is administered via an injection twice a day in a similar
way to insulin injections. It can lead to weight loss, although the main side effects from this
drug are gastrointestinal, especially nausea at higher doses. It is not funded by Pharmac and
costs approximately $260 a month.
There is no weight gain associated with the use of either sitagliptin or exenatide.
3) Thiazolidinediones or glitazones
These drugs work by attaching themselves to receptors in fat, muscle and liver cells, making them
more sensitive to insulin. This reduces the insulin resistance and reduces the overall insulin
requirements. Pioglitazone is the only drug of this family available in New Zealand, however it may
not be suitable for everybody. It has a number of significant and potentially serious side effects:
 It can cause water retention and swelling, and therefore should be avoided in anybody who has
heart failure.
 It doubles the risk of fracture in women suffering from osteoporosis and can also lead to
thinning of the bones in men.
 It may also result in weight gain (about 3.5 kg in six months) and may be associated with a
slight increased risk of bladder cancer.
Sulphonylureas (such as glipizide, gliclazide, and glibenclamide) boost the secretion of insulin
from the pancreas, but are often only effective for a limited time. The natural history of diabetes
means that as the insulin production falters, the resistance of the insulin receptors increases. This
is when insulin is often recommended. Unfortunately insulin cannot be taken by mouth and needs
to be given by injection so that there are adequate levels in the blood.
HealthInfo reference: 37317
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Issued: 14 July 2014
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Are there any alternatives to insulin? (Type 2)
www.healthinfo.co.nz
Weight loss
The relationship between increasing weight gain and the development of type 2 diabetes is well
known. An increase in weight by 5 to 7.9 kg over 14 years increases the risk of developing type 2
diabetes by two-fold, whereas a gain of 8 to 10.9 kg results in a three-fold increase in risk.
Obesity (where the BMI is more than 30) increases insulin resistance, and may also decrease the
sensitivity of the pancreatic cells to glucose. This can be reversed with weight loss, and losing even a
small amount (5 to 10% of body weight) can help the body produce and use insulin more effectively.
Each person’s weight relates to how much energy they consume compared to how much energy they
use.
Increasing activity levels or exercising (such as brisk walking for at least 30 minutes three or four
times a week), combined with eating fewer calories will lead to weight loss. Using exercise as the main
method of weight loss may require approximately 60 minutes of moderate exercise every day. This
will lead to improved blood sugar control and can also lower blood pressure and cholesterol levels.
But it is clear that weight loss is hard to achieve and even harder to maintain.
Compiled by diabetes registrar, Diabetes Services, Christchurch. Endorsed by HealthInfo clinical advisers.
Reviewed March 2014.
37317
HealthInfo reference: 37317

Issued: 14 July 2014
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