CLINICAL
DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. Editorial For Better or for Worse Alan J. Garber, MD, PhD, Editor As we begin 1997, we can only look back in appreciation over the past two years, which have been accompanied by enormous improvements in our armamentarium of treatments for patients with diabetes, both type I and type II. The number of oral therapies has expanded from one to three classes of agents, which can be used either as monotherapy or in combination as dual or perhaps even triple therapy for patients with type II diabetes. Our traditional reliance on sulfonylureas for first-line management of type II diabetes is being challenged by some of these newer therapies, which have uniquely beneficial pharmacodynamic profiles perhaps better suited for mono-therapy in certain patient subpopulations. For example, biguanides are not associated with weight gain, as are some of the sulfonylureas. The biguanides, therefore, might be better for use in patients who are already substantially overweight, since additional weight gain would be deleterious to the progression of their diabetes and would worsen their cardiovascular risk profiles. Alpha-glucosidase inhibitors such as acarbose have efficacy with respect to postpran-dial hyperglycemia and minimal efficacy with regard to fasting hyperglycemia. They are useful in patients who have early or mild degrees of primarily carbohydrate intolerance. They are also useful in patients whose co-morbid medical conditions could be complicated by an exaggeration of an underlying tendency toward fasting hypoglycemia, which might worsen with sulfonylureas. New insulins are becoming available for patients with type I diabetes, and these can also be used in the treatment of type II disease. New insulin analogs are more convenient because they can be taken just before meals and also produce better postprandial glucose levels and even a reduction in the frequency of hypoglycemia. Thus, for knowledgeable clinicians, sophisticated decision-making now becomes a mandatory element of diabetes practice. Reflex prescriptions for one agent or another are no longer appropriate in an era of multiple pharmacotherapeutic choices. Careful profiling of patients to be treated and a characterization of their special needs will be required to make optimal use of multiple agents having different pharmaco-dynamic profiles of action and efficacy. This is both a blessing and a curse for physicians and patients. Thoughtful practitioners will realize that additional information, clinical trial data, and outcome evaluations are necessary in order to use these agents to their fullest advantage. Unfortunately, the plethora of new agents, particularly those that can be used in combination, appears to have resulted in an unwanted outcome, namely less, rather than more, emphasis on diet and exercise. Patients with type II diabetes inadequately controlled on one class of oral anti-diabetic agents are far more accepting of combination therapy than of intensive diet and exercise management. Frankly, it is far easier for physicians to prescribe the extra pill than to insist on and monitor aggressive diet management and exercise therapies for these patients. Finally, patients are perhaps the most culpable in their own neglect. There can be little doubt about the benefits of diet and exercise with regard to cardiovascular risk reduction, amelioration of underlying insulin resistance, and retardation of long-term diabetes deterioration. Still, patients seem unwilling or unable to implement diabetes management strategies that require self-care. They demand, and we all too often accede to their demands for, additional medications to solve their problems. For the most part, patients seek multiple strategies designed to avoid insulin injections and to minimize the need for self-management through diet, glucose monitoring, or exercise. But while it seems likely that most classes of oral therapies effectively lower blood glucose and possibly ameliorate diabetes complications, only insulin has been demonstrated to do this in prospective, long-term, clinical trials. This is unfortunate because patients are highly desirous of oral, rather than injectable, therapies. It seems likely that such oral therapies will prevent diabetes complications, although their efficacy is clearly tempered by patients’ commitment to diet and exercise as adjunctive, if not primary, therapy. Managed care organizations until recently generally have not espoused the commitment to patient education required to make diet and exercise a meaningful prescription. Physicians have all too willingly participated in the prescription-writing frenzy that is often necessary to control type II diabetes in overweight, sedentary, minimally compliant patients. Thus, the recent proliferation of effective oral therapies is both a blessing and a curse. It is a blessing for patients who are actively attempting to care for their diabetes and for the physicians who participate in such efforts. But it may be a curse for patients who can delude themselves and their physicians that such agents are effective even in the absence of diet and exercise, points which have not been demonstrated in prospective, randomized, clinical trials. A new class of oral therapy for both types of diabetes, the thiazolidinediones, will become available soon. It will present another level of temptation to bypass established, effective treatments, albeit treatments that require self-management and self-discipline. Whether any of these approaches produce the morbidity and mortality reductions demanded of agents in other arenas, such as cholesterol-lowering, is a matter of speculation. Reliable clinical trial data are unavailable. Yet such data should be available before one can dismiss out of hand the importance of both diet and exercise to the management of patients with diabetes, no matter how many new agents, better agents, or improved agents become available. Copyright © 1997 American Diabetes Association Last updated: 6/3/97 For Technical Issues
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