Physiologic and Weight-Focused Treatment Strategies for Managing Type 2 Diabetes Mellitus: The Metformin, Glucagon-Like Peptide-1 Receptor Agonist, and Insulin (MGI) Approach
Diabetes and Endocrine Associates, York Hospital, York, ME. .Postgraduate Medicine (Impact Factor: 1.7). 05/2013; 125(3):112-26. DOI: 10.3810/pgm.2013.05.2666
The prevalence of type 2 diabetes mellitus (T2DM) is rising in association with an increase in obesity rates. Current treatment options for patients with T2DM include lifestyle modifications and numerous antidiabetic medications. Despite the availability of effective and well-tolerated treatments, many patients do not achieve recommended glycemic targets. Lack of efficacy is complicated by the wide range of available agents and little specificity in treatment guidelines, thus challenging clinicians to understand the relative benefits and risks of individual options for each patient. In this article, lifestyle intervention strategies and current antidiabetic agents are evaluated for their efficacy, safety, and weight-loss potential. Because of the heterogeneous and progressive nature of T2DM, physicians should advocate approaches that emphasize weight management, limit the risk of hypoglycemia and adverse events, and focus on the core pathophysiologic defects in patients with T2DM. A healthy, plant-based diet that is low in saturated fat and refined carbohydrates but high in whole grains, vegetables, legumes, and fruits, coupled with resistance and aerobic exercise regimens, are recommended for patients with T2DM. When necessary, drug intervention, described in this article as the MGI (metformin, glucagon-like peptide-1 receptor agonist, and insulin) approach, should begin with metformin and progress to the early addition of glucagon-like peptide-1 receptor agonists because of their weight loss potential and ability to target multiple pathophysiologic defects in patients with T2DM. For most patients, treatments that induce weight gain and hypoglycemia should be avoided. Long-acting insulin should be initiated if glycemic control is not achieved with metformin and glucagon-like peptide-1 receptor agonist combination therapy, focusing on long-acting insulin analogs that induce the least weight gain and have the lowest hypoglycemic risk. Ultimately, a patient-centered treatment approach that addresses the core pathologies of T2DM and obesity will not only increase overall efficacy and the likelihood that a patient adheres to treatment, but may also improve a patient's mental well-being and quality of life.
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ABSTRACT: Diet plays an integral role in the treatment of type 2 diabetes mellitus (T2DM). Unfortunately, many patients with T2DM do not have access to a registered dietitian or certified diabetes educator, and rates of physician counseling about diet remain low. This article provides an overview of the current recommendations for the nutritional management of T2DM, which are endorsed by the American Diabetes Association (ADA). Medical nutrition therapy, which provides a flexible and individualized approach to diet, emphasizes the total number (rather than the type) of carbohydrate consumed. Because fat intake also affects glycemia and cardiovascular risk, a reduction in daily mono- and polyunsaturated fat intake is recommended for most patients with T2DM. Weight loss plays an important adjunct role in treating patients with T2DM, because the majority of individuals with T2DM are overweight or obese. Patient lifestyle modification, which encompasses diet, physical activity, and behavioral therapy, can be used to facilitate weight loss in conjunction with several different dietary approaches. These include low-carbohydrate, low-fat, low-glycemic index, and Mediterranean diets. Studies have demonstrated that modest weight loss (5%-10% of body weight) is associated with significant improvements in patient measures of glycemic control, lipids, blood pressure, and other cardiovascular risk factors. Furthermore, a modest weight loss of as little as 4.5 kg can result in reducing the glycated hemoglobin level by approximately 0.5%. Pharmacologic agents, when combined with these approaches, may further augment weight loss. Familiarity with these principles can help physicians provide dietary counseling to their patients with T2DM and obesity.Postgraduate Medicine 01/2014; 126(1):139-52. DOI:10.3810/pgm.2014.01.2734 · 1.70 Impact Factor
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ABSTRACT: Type 2 diabetes (T2D) - particularly with concurrent obesity ('diabesity') - is an intensifying global public-health problem. Medical needs and market opportunities in the T2D space have propelled discovery efforts aimed at inventing new synthetic T2D drugs differentiable by improved safety and efficacy and/or the ability to modulate emerging T2D targets. Particularly for moderately and severely obese individuals, weight-loss (bariatric) surgery offers an effective means of reducing obesity-driven T2D that is superior in many respects to medical T2D management. Yet, not all overweight or obese individuals with T2D qualify for bariatric surgery, and current healthcare resources are inadequate for applying surgical T2D control to more than a very small segment of qualified patients. Bariatric surgery is no guarantee of 'curative' T2D abrogation, significant rates of T2D non-remission or re-emergence having been observed in diabesity patients following bariatric procedures. Preoperative glucose control by oral hypoglycemic drugs reduces the chance of T2D recurrence post-surgery, and diabesity patients in whom glycemic indices have been improved by bariatric surgery may still require some level of T2D pharmacotherapy. Laboratory and clinical data indicate that synthetic T2D drugs can improve T2D-related outcomes following bariatric procedures, and current T2D drug-discovery efforts are being informed by the metabolic advantages associated with bariatric surgery. These circumstances intensify the need for and extend the impact of T2D drug discovery by demonstrating multiple levels of interplay between medical and surgical approaches to improve the health of individuals with diabesity and, perhaps, approach the overarching goal of decreasing long-term cardiovascular mortality.Expert Opinion on Drug Discovery 01/2014; 9(3). DOI:10.1517/17460441.2014.876988 · 3.54 Impact Factor
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ABSTRACT: Aim: GPR119 is a G protein-coupled receptor (GPCR) that is highly expressed in pancreatic β-cells and intestinal L-cells and facilitates glucose-stimulated insulin secretion (GSIS). GPR119 may represent a novel target for the treatment of metabolic disorders. Here, we sought to identify novel small-molecule GPR119 agonists. Methods: A cell-based high-throughput screening assay was established using HEK293 cells stably expressing GPR119 and pCRE-luc reporter plasmid (HEK293/GPR119/pCRE-luc). A compound library composed of 1440 compounds was screened. Mouse β-cell line MIN-6 and isolated mouse islets were used to evaluate the effects of candidate compounds on GSIS in vitro. Results: Three compounds with novel structures (ZSY-04, -06, and -13) were found to activate GPR119-mediated signaling and to induce GPR119 desensitization. The EC50 values of ZSY-04, -06, and -13 in stimulating intracellular cAMP accumulation in HEK293/GPR119 cells were 2.758, 3.046, and 0.778 μmol/L, respectively. Furthermore, all three compounds displayed high selectivity for GPR119, and did not activate other 9 GPCRs tested. Moreover, all three compounds significantly increased GSIS in both MIN-6 mouse β-cells and isolated mouse islets at concentration of 10 μmol/L. Conclusion: Three novel small-molecule GPR119 agonists (ZSY-04, -06, and -13) with high receptor selectivity and capacity to induce GSIS in vitro were discovered. These compounds are potential candidates to be structurally optimized into drugs for the treatment of type 2 diabetes.Acta Pharmacologica Sinica 03/2014; 35(4). DOI:10.1038/aps.2014.8 · 2.91 Impact Factor
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