Medication Selection Strategies for Obese Type 2 Diabetes: A Guide to Scientific Weight Loss and Medication Use

Drug Therapy:

If a type 2 diabetic patient cannot achieve satisfactory blood glucose control after 8-12 weeks of regular dietary therapy and exercise, drug therapy should be initiated. Obese diabetic patients often exhibit significant insulin resistance and hyperinsulinemia. Therefore, drugs that increase insulin sensitivity, such as metformin, acarbose, and troglitazone, should be the first choice. Sulfonylureas and insulin should be used sparingly, as they can cause hyperinsulinemia, exacerbate insulin resistance, and create a vicious cycle. For non-obese type 2 diabetic patients, if blood glucose control is poor after dietary control and appropriate exercise, sulfonylureas can be chosen. If symptoms are severe, insulin therapy should be initiated as early as possible.

(I) Biguanides

1. Pharmacological Actions
Biguanides lower blood glucose not by increasing insulin release, but by promoting glucose uptake in peripheral tissues, inhibiting gluconeogenesis, delaying glucose absorption in the intestine, and enhancing the post-receptor effects of glucose transporters and insulin receptors. This type of drug can lower blood glucose in diabetic patients without causing hypoglycemia, and has no significant hypoglycemic effect in normal individuals. In addition, it also has the effects of reducing weight and improving lipid metabolism. The main indication is obese or overweight NIDDM patients.

2. Drugs and Hypoglycemic Applications

(1) Metformin Metformin is the first-line drug for treating obese or overweight type 2 diabetes. The starting dose is 500 mg daily, and the usual daily dose is 500–1500 mg, divided into 2–3 doses. Metformin mainly lowers blood glucose by improving insulin sensitivity and is also suitable for treating IR patients. In first-degree relatives of type 2 diabetes, after taking metformin, blood glucose did not change significantly, but blood insulin solubility decreased and insulin sensitivity increased. In patients with impaired glucose tolerance, their oral glucose tolerance test returned to normal after taking the drug.

Metformin is mainly absorbed from the small intestine, and its solubility in the gastrointestinal wall is 10–100 times that in plasma. After administration, gastrointestinal reactions such as bitter taste, metallic taste, nausea, vomiting, and diarrhea may occur. This medication should be taken with or after meals. Metformin is contraindicated in cases of pregnancy or breastfeeding, liver or kidney dysfunction, severe cardiopulmonary disease, or severe infection.

(2) Phenformin (Glucose-Lowering Agent): Oral administration, 25 mg three times daily. In cases of hypoxia such as liver or kidney dysfunction, shock, or heart failure, lactic acidosis can be induced, which can be fatal in severe cases.