Approaches to treatment of type 2 diabetes.

Abstract

Perspectives on the News commentaries are part of a free monthly CME activity. The Mount Sinai School of Medicine, New York, New York, designates this activity for 2.0 AMA PRA Category 1 credits. If you wish to participate, review this article and visit www.diabetes.procampus.net to complete a posttest and receive a certificate. The Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This article is based on presentations at the Metropolitan Diabetes Society on 11 December 2007 in New York, New York, and at the American Diabetes Association's 55th Annual Advanced Postgraduate Course, held 1–3 February 2008 in San Francisco, California (these lectures are available online at http://professional.diabetes.org), summarizing a number of somewhat divergent views recently expressed by different speakers on aspects type 2 diabetes treatment. At the American Diabetes Association (ADA) Postgraduate Course, Ralph DeFronzo (San Antonio, TX) reviewed the mechanisms of action and utility of various antidiabetic drugs, suggesting that sulfonylureas “are very unlikely to create a durable decline in A1C,” based on understanding of the physiology. Studies with glimepiride (1) and glipizide (2) show falls in fasting glucose of 40–50 mg/dl and in A1C by 1.5%—with monotherapy controlling 25–30% of patients—which he characterized as “a very good effect, initially.” However, DeFronzo said that “after the first 6–12 months the A1C starts to rise progressively.” Sulfonylurea-induced insulin secretion increases portal insulin levels, suppressing hepatic glucose production and lowering fasting glucose to a greater extent than postprandial glucose. In the UK Prospective Diabetes Study (UKPDS), sulfonylureas and insulin reduced microvascular risk by 37%, but myocardial infarction, stroke, and congestive health failure decreased by 14, 12, and 16% (none of the latter decreases reaching statistical significance) (3), leading DeFronzo to contend that “there is no evidence …