A new treatment paradigm proposed by a multidisciplinary panel of diabetes specialists suggests starting treatment earlier and using simultaneous rather than
sequential combination therapy to address the dual defects of insulin resistance
and impaired beta-cell function characteristic of type 2 diabetes.
At a consensus conference on Managing Type 2 Diabetes in New York, the participants developed a position statement based on evidence from controlled clinical trials. “Current treatment approaches often miss target levels recommended by the American Diabetes Association,” said James R. Gavin III, MD, PhD, who chaired the meeting. “By beginning treatment earlier and simultaneously tackling insulin resistance and deficiency, glycemic control can be established and sustained more rapidly, which significantly decreases the potential for serious long-term complications,” he continued. Dr. Gavin is senior scientific officer, Howard Hughes Medical Institute, Chevy Chase, Maryland.
The panel noted that using the fasting blood glucose level as the criterion for starting treatment, as is currently the practice, “the majority of patients in the United States with type 2 diabetes are not diagnosed early in the course of disease.” At the time of diagnosis, patients are already insulin resistant and have lost as much as 50% of beta-cell function and many have retinopathy and other complications. They recommend, therefore, that lifestyle changes should be initiated when fasting plasma glucose (FPG) is impaired (ie, > 110 mg/dL and < 126 mg/dL). Pharmacologic therapy should be started when FPG is ≥ 126 mg/dL and type 2 diabetes is diagnosed.
Instead of the traditional stepwise care approach, in which a new agent is added only after the previous regimen fails, the panel recommends using several agents
simultaneously as needed to keep blood glucose levels as close to normal as possible.
“Only when patients can quickly reach and maintain their target goals can we begin to
interrupt the pattern of clinical frustrations that tend to characterize traditional treatment,” Dr. Gavin said.