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Future challenges and therapeutic opportunities in type 2 diabetes: C hanging the paradigm of current therapy
Author(s) -
Owens David R.,
Monnier Louis,
Barnett Anthony H.
Publication year - 2017
Publication title -
diabetes, obesity and metabolism
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.445
H-Index - 128
eISSN - 1463-1326
pISSN - 1462-8902
DOI - 10.1111/dom.12977
Subject(s) - medicine , postprandial , insulin , type 2 diabetes , type 2 diabetes mellitus , diabetes mellitus , incretin , glycemic , regimen , basal (medicine) , endocrinology
Most algorithms for type 2 diabetes mellitus ( T2DM ) do not recommend treatment escalation until glycated haemoglobin ( HbA1c ) fails to reach the recommended target of 7% (53 mmol/mol) within approximately 3 months on any treatment regimen (“treat to failure”). Clinical inertia and/or poor adherence to therapy contribute to patients not reaching glycaemic targets when managed according to this paradigm. Clinical inertia exists across the entire spectrum of anti‐diabetes therapies, although it is most pronounced when initiating and optimizing insulin therapy. Possible reasons include needle aversion, fear of hypoglycaemia, excessive weight gain and/or the need for increased self‐monitoring of blood glucose. Studies have suggested, however, that early intensive insulin therapy in newly diagnosed, symptomatic patients with T2DM with HbA1c >9% (75 mmol/mol) can preserve beta‐cell function, thereby modulating the disease process. Furthermore, postprandial plasma glucose is a key component of residual dysglycaemia, evident especially when HbA1c remains above target despite fasting normoglycaemia. Therefore, to achieve near normoglycaemia, additional treatment with prandial insulin or a glucagon‐like peptide‐1 receptor agonist ( GLP ‐1 RA ) is often required. Long‐ or short‐acting GLP ‐1 RAs offer effective alternatives to basal or prandial insulin in patients inadequately controlled with other therapies or basal insulin alone, respectively. This review highlights the limitations of current algorithms, and proposes an alternative based on the early introduction of insulin therapy and the rationale for the sequential or fixed combination of GLP ‐1 RAs with insulin (“treat‐to‐success” paradigm).