Improving glycaemic control with current therapies.

Abstract

A considerable proportion of Type 2 diabetic patients suffer from hyperglycaemic symptoms and therefore experience reduced quality of life. Furthermore, increasing evidence suggests that poor glycaemic control is associated with a risk that late complications will develop. The traditional stepped approach to therapy often results in a reluctance to escalate therapy to keep up with the progression of the disease, and therefore new strategies are needed to improve the results. Type 2 diabetes is a heterogeneous disorder, and hyperglycaemia is the result of deficient insulin secretion and insulin resistance; and the natural course of the disease is progression of hyperglycaemia. The therapy should be tailored to match the different needs of individual patients. Diet and exercise are essential to support all other therapies, but are often overlooked and may not be effective alone. The effectiveness of oral hypoglycaemic agents (OHAs) depends on the patients having sufficient insulin secretory capacity. These agents are therefore of little benefit to patients with profound beta-cell failure. The combination of oral agents from two different pharmaceutical groups can be more effective than monotherapy, but in many patients insulin deficiency ensues and hyperglycaemia progresses. In principle, insulin therapy should always be able to lower glucose levels; improved glycaemic control is achieved in most patients, followed by amelioration of hyperglycaemic symptoms and improvements in quality of life. However, near-normoglycaemia may be difficult to achieve with the pharmacological limitations imposed by the preparations available, the methods of administration, and the ability and motivation of the patients. Importantly, insulin therapy should be tailored to meet the individual needs of the patients, and patients should be taught self-adjustment of doses based on self-monitoring of blood glucose levels. A considerable proportion of Type 2 diabetic patients (primarily the young and lean) require multiple-dose regimens. Combination therapy with OHAs and insulin might offer an advantage to some patients, and a recent study from Finland suggests that the combination of bedtime insulin and daytime metformin may be superior to other bedtime insulin regimens. There is still some way to go to devise an optimal therapy for Type 2 diabetes.