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INTRODUCTION

Therapeutic Approaches to Type 2 Diabetes

Charles M. Clark, Jr., MD

In December of 1997, an international panel of researchers in diabetes and cardiovascular disease met to discuss the relationship between the treatment of type 2 diabetes and cardiovascular disease. The impetus for this meeting was twofold. First, there is growing evidence that treatment of hyperglycemia per se in people with type 2 diabetes will produce reductions in the microvascular and neurological complications similar to those demonstrated in persons with type 1 diabetes. Second, there is disagreement in the broader practicing community as to what treatment strategies should be applied to this population. In particular, there is confusion about if or when insulin should be used in the type 2 diabetes. Thus, the conference examined the theoretical mechanisms of increased macrovascular disease in type 2 diabetes and explored their relationship to clinical treatment.

The conference was organized by topical themes into four general sessions. Two or three presentations were given on the topics in each general session. A chair led the discussion that followed each presentation. The major questions addressed by presentations were the following: What are the likely mechanisms for increased vascular disease in type 2 diabetes? What are the relative roles of hyperglycemia and other cardiovascular risk factors in the genesis of macrovascular disease in type 2 diabetes? What evidence exists that the treatment of hyperglycemia and other cardiovascular risk factors in type 2 diabetes will reduce subsequent macrovascular events? and What are the advantages and disadvantages of different treatment modalities to achieve metabolic control in type 2 diabetes, particularly the use of insulin?

Dr. Michael Stern opened the conference with a review of the natural history of macrovascular disease in type 2 diabetes. We then had presentations regarding the other cardiovascular risk factors in the genesis of macrovascular disease in type 2 diabetes. Dr. George Steiner discussed the role of the classical lipid abnormalities in the genesis of macrovascular disease in type 2 diabetes. Dr. John Brunzell then discussed the role of the dyslipidemia of central obesity and insulin resistance. The other classic cardiovascular risk factor, hypertension, was discussed by Dr. James Sowers. Dr. Robert Eckel chaired the session and summarized the subsequent discussion.

In the next session, Dr. John Yudkin summarized the genesis of the abnormalities in coagulation and fibrinolysis in type 2 diabetes and their putative role in macrovascular events. Dr. George King then presented a discussion of the theoretical mechanisms whereby hyperglycemia and insulin resistance could cause cardiovascular disease in diabetes. Dr. Jean-Pierre Depres chaired this session and wrote the discussion summary.

The topic turned next to the risks and benefits of treating type 2 diabetes and its concomitant risk factors. Dr. Harold Lebovitz began the third session by discussing the effects of various oral agents in modifying macrovascular risk factors in type 2 diabetes. Dr. Christopher Saudek then discussed the effect on macrovascular risk factors of using insulin to achieve glucose control in type 2 diabetes. Dr. Steve Haffner closed the session with a discussion of the epidemiological studies on the effects of hyperglycemia and improvement of glycemic control on macrovascular events in type 2 diabetes. The session was chaired by Dr. Michael Stern, who summarized the discussion.

In the fourth and final session, Dr. Mark Feinglos presented an overview of the therapeutic options in the treatment of type 2 diabetes and discussed how to define therapeutic failure of oral agents in the treatment in type 2 diabetes. Dr. John Buse followed with a discussion of the rationale of combining oral agents with insulin. Dr. Michael Berger closed the conference with an impassioned plea for using insulin aggressively as the sole therapeutic agent in type 2 diabetes. The discussion that followed was led by and is summarized by Dr. Matthew Riddle.

This supplement provides an overview of each presentation, authored by each presenter, and relevant points of discussion, summarized by the respective chair of each general session.

From the Regenstrief Institute, Indianapolis, Indiana.

Address correspondence and reprint requests to Charles M. Clark, Jr., MD, Diabetes Care Editorial Office, Regenstrief Institute, 6th Floor, 1001 W. 10th St., Indianapolis, IN 46202-2859.

Received for publication 28 December 1998 and accepted 5 January 1999.

C.M.C. has received honoraria from Eli Lilly.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

This article is based on presentations at a conference organized by the Indiana University Diabetes Research and Training Center. The conference and the publication of this article were made possible by an unrestricted educational grant from Eli Lilly and Company.

Copyright © 1999 American Diabetes Association
Last updated: 3/99
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