Type 2 diabetes and blood sugar medicines
Type 2 diabetes is treated in steps, and the medicines used belong to groups that lower blood sugar in different ways. Metformin is usually the first of them, with an SGLT2 inhibitor such as Jardiance or a DPP-4 inhibitor such as Januvia added when blood sugar stays above the agreed target. All of them are prescription only in Malta. This page explains what each group does, which results a doctor reviews before continuing treatment and when an examination is needed instead.
How type 2 diabetes is treated
Treatment rests on two things at once: eating, activity and weight on one side, medicines on the other. Neither replaces the other, and the symptoms that usually lead to the diagnosis are described on /health-guide/type-2-diabetes-symptoms/.
Medicines are normally introduced in steps. One is started, the effect is measured, and a second from a different group is added when blood sugar stays above the target agreed with the doctor. Fixed combinations in a single tablet exist for exactly that reason.
Targets are individual. Age, how long the diabetes has lasted, kidney and heart disease and the risk of low blood sugar all shift what a sensible target is, so a figure that fits one person does not fit another.
Every medicine described below is prescription only in Malta. Which of them the public system provides is settled under the Government Formulary List and through the Pharmacy of Your Choice scheme, known as POYC, rather than by whoever writes the prescription.
Metformin: usually the first medicine
Metformin lowers the amount of glucose the liver releases and makes the body more sensitive to its own insulin. On its own it does not cause low blood sugar and it is broadly weight neutral, which is why it is the usual starting point. There is more on /medicines/metformin/.
The commonest side effects come from the digestive system: nausea, loose stools, abdominal discomfort and a metallic taste. Taking it with food and building the dose up slowly usually helps, and modified release forms exist for the same reason.
Kidney function matters. Metformin is cleared by the kidneys, so the dose depends on how well they work, and it is normally paused during acute illness with dehydration, around some scans using contrast and around surgery. Long treatment can also lower vitamin B12, which is why that is sometimes measured.
Metformin appears in fixed combinations with other groups, for instance with sitagliptin as Janumet or with empagliflozin as Synjardy. A combination is one prescription but still two medicines, and the cautions for both apply.
SGLT2 inhibitors: Jardiance and Forxiga
SGLT2 inhibitors make the kidneys pass more glucose out in the urine. Empagliflozin, the substance in Jardiance, and dapagliflozin, the substance in Forxiga, belong to this group, and they usually lower weight and blood pressure a little as well. There is more on /medicines/jardiance/.
Because sugar passes in the urine, fungal infection of the genitals and urinary infection are more common, so washing and drinking enough matter. Pain, swelling or redness of the genitals with fever needs urgent assessment rather than waiting to see whether it settles.
Dehydration and light-headedness on standing can occur, particularly alongside a diuretic. The medicine is usually paused during acute illness with vomiting, around surgery and when eating stops, because ketoacidosis can develop even when blood sugar is not high.
Members of this group are also used in heart failure and in chronic kidney disease, so the same tablet may have been prescribed for a reason other than blood sugar. That changes how stopping it would be judged, which is why the reason for starting belongs in the answers.
DPP-4 inhibitors: Januvia and Trajenta
DPP-4 inhibitors block the enzyme that breaks down the body's own incretin hormones, so more of them stay active after a meal. Sitagliptin, the substance in Januvia, and linagliptin, the substance in Trajenta, belong to this group. There is more on /medicines/januvia/.
They lower blood sugar modestly, are usually well tolerated, are weight neutral and rarely cause low blood sugar on their own. That makes them a common second choice when the digestive system does not tolerate other groups.
Reported side effects include infections of the upper airways, headache and joint pain; severe and persistent joint pain is a reason to review the medicine rather than to endure it. Pancreatitis has been reported, so severe persistent abdominal pain reaching through to the back needs urgent medical attention.
For some members of the group the dose depends on kidney function and for others it does not, which is one of the reasons the choice belongs to a doctor rather than to a comparison of prices.
GLP-1 medicines in type 2 diabetes
GLP-1 medicines imitate a hormone released by the gut and are given mostly as an injection under the skin. Ozempic, Victoza and Trulicity are authorised for type 2 diabetes, and semaglutide also exists as a tablet, marketed as Rybelsus. There is more on /medicines/ozempic/.
Wegovy and Saxenda contain the same active substances as Ozempic and Victoza respectively, but they are authorised for weight management rather than for diabetes. What differs is the authorised indication, not the molecule, and the difference is explained on /weight-loss-injections/.
In diabetes these medicines lower blood sugar and usually weight, and their commonest side effects come from the digestive system. Combining them with insulin or with a sulfonylurea raises the risk of low blood sugar, so the doses are adjusted together.
Starting a GLP-1 medicine is not a repeat and needs an examination. Continuing one that a doctor has already started can be assessed from a questionnaire, provided the details and the recent results are complete.
Which results a doctor reviews before a repeat
For a repeat the doctor needs to know which medicines you take, at which strength and on which schedule, who started them and when, and whether anything was recently changed, added or stopped.
The results that matter most are a recent HbA1c, kidney function and weight, together with blood pressure. Readings you take at home help as well, particularly when they show low values or wide swings during the day.
How often HbA1c is measured is a decision for the treating doctor rather than a fixed rule: more often after a change of treatment, less often once the result has been stable at target for a while. What matters for a repeat is that the last result is recent enough to describe the present situation rather than the situation last year.
Episodes of low blood sugar, problems with the feet, changes in vision, swelling of the ankles and shortness of breath all belong in the answers, because each of them can change what should be prescribed.
When a repeat is not enough
A first diagnosis and a first prescription need an examination, blood tests and a plan, so they sit outside this route.
Insulin sits outside it as well. Insulin needs the dose to be adjusted against measured values, teaching about low blood sugar and regular contact, and none of that can be done from a questionnaire.
Rapidly rising values, repeated low blood sugar, unexplained weight loss, vomiting, drowsiness or the smell of acetone on the breath need urgent care. Chest pain, breathlessness or sudden weakness are emergencies: call 112 or go to Accident and Emergency.
Pregnancy and planning a pregnancy change the treatment entirely, because several of these medicines are not used then. Regular review of the eyes, the feet and the kidneys stays with the Maltese health service.
What we offer and what we do not offer
We offer a medical questionnaire and a doctor's review of treatment that is already established. The route is /repeat-prescription/ and the review costs 24,90 €; priority handling is an extra 9,90 €, which means a place in the queue and not a promised date. Where a GLP-1 medicine is prescribed for weight rather than for diabetes, the route is /weight-loss/ at 29,90 €.
The document is a cross-border prescription in the format set out in the Annex to Directive 2012/52/EU, and you receive it as a PDF by email. It is not written into any Maltese state record and is not visible in myHealth, so there is no code at the pharmacy to call up.
It is issued by lek. Damian Wojno, registered with the Polish Medical Chamber, licence no. 3211301. He is not registered with the Medical Council of Malta and does not take over the role of your family doctor or of a diabetes clinic.
We do not offer video calls, telephone consultations or live chat. We do not start treatment, we do not prescribe insulin, we do not issue medical certificates and we do not handle mental health problems. The fee covers the doctor's review, not the issuing of a document and not the price of the medicine at the pharmacy. If the doctor decides on medical or legal grounds that a prescription is not justified, we refund the fee, and the same applies when the assessment cannot be completed. Dispensing is decided by the pharmacist, who may refuse. There is more about the fee on /blog/online-prescription-cost-malta/.
Which medicine is used first?
Metformin is usually the first medicine in type 2 diabetes. It lowers the glucose the liver releases, makes the body more sensitive to its own insulin, does not cause low blood sugar on its own and is broadly weight neutral. Where it cannot be tolerated or is not enough, a medicine from another group is added or used instead, and the choice belongs to the doctor.
How often is HbA1c checked?
There is no single figure that fits everyone. The interval is set by the treating doctor: more often after a change of treatment, less often once the result has been stable at target for a while. For a repeat what matters is that the last result is recent enough to describe the present situation, with the date attached, rather than a value remembered from a year ago.
Can these medicines be combined?
Yes, and they often are. Metformin is frequently combined with an SGLT2 inhibitor, a DPP-4 inhibitor or a GLP-1 medicine, and fixed combinations in a single tablet exist, for instance Janumet and Synjardy. A combination is one prescription but still two medicines, so the cautions for both apply. Combining with insulin or a sulfonylurea raises the risk of low blood sugar.
Which side effects are common?
With metformin, digestive effects: nausea, loose stools, abdominal discomfort and a metallic taste. With SGLT2 inhibitors, fungal infection of the genitals, urinary infection and dehydration. With DPP-4 inhibitors, infections of the upper airways, headache and joint pain. With GLP-1 medicines, nausea and other digestive effects. Full lists are in the leaflet in the box and in the product information published by the European Medicines Agency.
What does a doctor need before a repeat?
The names, strengths and schedules of the medicines you take, who started them and when, and anything recently changed or stopped. Then a recent HbA1c, kidney function, weight and blood pressure, with dates, plus readings taken at home if you have them. Episodes of low blood sugar, foot problems, changes in vision, ankle swelling and breathlessness belong in the answers too.
Is insulin part of this service?
No. Insulin needs the dose to be adjusted against measured values, teaching about low blood sugar and regular contact with a doctor, and none of that can be done from a questionnaire. A first diagnosis and a first prescription are outside this route as well. For insulin the right route is a doctor or a diabetes clinic in Malta.
Will a pharmacy dispense it?
That cannot be promised. Dispensing is a professional decision taken by the pharmacist, who checks identity and the completeness of the document and who may refuse where something is doubtful. The pharmacist may also offer an interchangeable product with the same substance, strength and form. Whether a medicine is provided by the public system is a separate question, settled under the Government Formulary List and the POYC scheme.
What does the fee cover?
The doctor's review of your questionnaire, not the issuing of a document and not the price of the medicine at the pharmacy. The review costs 24,90 € for treatment you already take, with priority handling for an extra 9,90 €. If the doctor decides on medical or legal grounds that a prescription is not justified, we refund the fee, and the same applies when the assessment cannot be completed.