The Changing Face of Diabetes Management

The treatment of type 2 diabetes has never been more satisfying, or more complex. New options make life better for the person with diabetes, but more challenging for the physician and the diabetes team to determine the best options for each individual.

First, the dogma that fitness, good nutrition, and weight loss are the cornerstones of diabetes management has never been truer. In addition, however, sleep deprivation is being increasingly recognized as an important lifestyle contributor to poor diabetes control. Lifestyle changes often are difficult and insufficient, so medication is typically needed for good control and should not be seen as a failure on anyone’s part.

Foremost in the treatment of type 2 diabetes is not glucose, but optimal control of blood pressure and lipids, such as LDL-cholesterol and triglycerides. The guideline for good blood pressure control is < 130/80 mm/Hg, for LDL-cholesterol < 100 mg/dl. Many practitioners recommend a blood pressure agent in the category of ACE-inhibitor or ARB even for those with normal blood pressure. Similarly, many recommend the same strategies used to prevent cardiovascular disease, like aspirin, fish oil, and even vitamin D. That discussion is beyond the scope of this article, which will focus on the approaches to controlling glucose.

The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) convened the Pre-Diabetes Consensus Conference in September 2008, in Washington, DC, bringing together the top thought leaders in this field from all over the world. It focused on the 54 million Americans with prediabetes, defined as a fasting glucose of 100-125 mg/dl (impaired fasting glucose or IFG) and/or a two-hour post challenge glucose of 141-199 mg/dl (impaired glucose tolerance or IGT). In individuals with IFG and/or IGT, lifestyle modification is the most important treatment along with control of blood pressure and lipids as if the person were already diabetic. If medication for glucose is indicated, metformin has excellent data for diabetes prevention, albeit not as good as adherence with lifestyle improvement. There is also evidence that the alpha-glucosidase inhibitors, which block carbohydrate absorption, and thiazolodendiones, which enhance insulin sensitivities, help prevent progression to diabetes. We hope that ongoing research will help define the place of therapies such as DPP-4 inhibitors (e.g., sitagliptin) and GLP-1 agents (e.g., exenatide) in which there is exciting preliminary data for preservation of the beta cells, which make insulin.

AACE/ACE also convened the Diabetes Algorithm Committee in February 2009 to offer guidance to clinicians and individuals on appropriate options to control glucose in type 2 diabetes. The target for optimal control is an average glucose measured by a test called A1c to be less than or equal to 6.5 percent. In individuals at risk of hypoglycemic reaction (low blood sugar) or in those with cardiovascular disease, a somewhat looser target of 7 percent or above should be considered. Essentially the goal is the best possible control with the least risk of side effect such as hypoglycemia.

There are many reasons to choose specific agents. Fortunately, agents which work by different mechanisms of action can be combined to get good control even when one or two agents cannot. The cornerstone of therapy today is the drug metformin. There are abundant safety data, including in childhood and pregnancy, and it is very inexpensive. To avoid stomach upset, the dose is built up slowly. The least expensive and oldest agents are the sulfonylureas, with names such as glimepiride (Amaryl) or glipizide (GITS). Their disadvantage is the potential to cause serious hypoglycemia and weight gain, especially the agent glyburide.