ReviewPharmacological Management of Type 2 Diabetes Mellitus: Rationale for Rational Use of Insulin
Section snippets
PATHOPHYSIOLOGY AND NATURAL HISTORY OF TYPE 2 DIABETES MELLITUS
Type 2 diabetes is characterized by 2 major pathophysiologic defects: insulin resistance, which results in increased hepatic glucose production (HGP) and decreased glucose disposal, and impaired β-cell secretory function (both basal and glucose stimulated).11 Loss of the acute insulin response to a carbohydrate load, a prototypical defect that occurs early in the natural course of the disease, generally when fasting plasma glucose levels reach 115 mg/dL,12 leads to postprandial hyperglycemia.
TREATMENT OF TYPE 2 DIABETES MELLITUS
Type 2 diabetes has traditionally been treated in a stepwise manner, starting with lifestyle modifications (medical nutrition therapy and exercise), proceeding to the use of 1 oral antidiabetic agent, followed by a combination of 2 or more oral agents before insulin is considered.3
PRACTICAL APPROACHES TO THERAPY
Although the benefits of improved glycemic control have been well established, most patients with type 2 diabetes do not achieve optimal glycemic control.59 The current stepwise approach in the treatment of type 2 diabetes does not address the underlying pathophysiology in which defects of both insulin secretion and action occur early in the course of the disease. Treatment is often conservative and allows an oral agent to fail before another one is added and generally delays institution of
CONCLUSIONS
Hyperglycemia is an independent risk factor for both microvascular and macrovascular complications associated with diabetes, and improvement in metabolic control reduces the risk of the development or progression of these complications. Hence, the goal of treatment of patients with diabetes should be to achieve and maintain near-normal glycemic control, without increasing the risk of hypoglycemia. Medical nutrition therapy and exercise form the cornerstone of therapy for type 2 diabetes
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Cited by (0)
This study was supported by an unrestricted educational grant from Aventis Pharmaceuticals Inc.
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Dr Abrahamson is on the speaker's bureau for Aventis Pharmaceuticals Inc, Bristol-Myers Squibb, Glaxo-SmithKline, Eli Lilly and Co, Novo Nordisk, Novartis, and Pfizer Inc.