Magazine article Drug Topics

Management of Type 2 Diabetes Takes More Aggressive Turn

Magazine article Drug Topics

Management of Type 2 Diabetes Takes More Aggressive Turn

Article excerpt

A recently drawn-up position statement on Type 2 diabetes (mellitus (DM) may lead to a bold transformation in the way the disease is treated.

Under today's treatment paradigm, diabetes patients who are not controlled with diet and exercise are typically started on pharmacologic monotherapy. As the treatment fails to maintain adequate glucose control over time, doses of the single agent are gradually increased to maximum levels. After exhausting monotherapy, a second drug is added to the regimen, and the pattern is repeated.

The authors of the statement, which came out of a Diabetes Summit-sponsored by the Postgraduate Institute for Medicine and held recently in New York-have identified several limitations to this therapeutic approach. One drawback is the reliance on treatment failure to occur before progressing to a different or more aggressive therapy Another problem is that many patients are not adequately monitored, which leads to prolonged monotherapy that does not properly control blood glucose levels. Another concern is that patients may be treated with an exceedingly long trial of diet and exercise.

The newly proposed approach calls for, essentially, more aggressive management of Type 2 DM. Criteria for instituting various treatments appear more clearly defined. For example, initiation of lifestyle changes is recommended in patients with impaired fasting plasma glucose (FPG greater than or equal to 110 mg/dl and less than 126 mg/dl). Once fasting glucose is elevated to 126 mg/dl or greater, pharmacologic treatment should be initiated.

In regard to drug therapy, the position statement calls for the initial use of combination treatment, as opposed to sequential therapy, to address the two primary defects in Type 2 DM-- insulin resistance and impaired beta-- cell function. Accord ing to Daniel S. Donovan Jr., M.D., C.D.E., one of the authors of the position statement, this new method is based on a recent study in which a new glyburide/metformin combination product (Glucovance, Bristol-- Myers Squibb) was compared with monotherapy with either agent as both first-line and second-line treatment. The results, presented at the 60th Scientific Sessions of the American Diabetes Association in San Antonio, indicate that the combo product produced greater decreases in HbA^sub 1c^ levels than did either drug alone.

"The combo also resulted in lower fasting BG and postprandial BG, compared with monotherapy," noted Donovan, an assistant clinical professor of medicine at Columbia University, College of Physicians & Surgeons and director of the diabetes management services at Columbia Presbyterian Medical Center. …

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