Type 2 diabetes: treat to target.
ABSTRACT Traditionally, practitioners have reserved insulin therapy for patients with type 2 diabetes until diet, exercise, and treatment with oral agents have failed to maintain glycemic control. Increasing evidence, however, supports advancing insulin therapy earlier in treating diabetes, not only to normalize glycemic control and emulate normal physiologic insulin secretion, but also to delay or prevent disease-associated comorbidity.
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ABSTRACT: Type II diabetes is a major cause of morbidity and mortality, both from an increased risk of developing cardiovascular disease and from specific diabetic complications. At present, patients are often treated to prevent marked hyperglycaemia, that induces symptoms such as thirst. Moderately raised glucose levels are then accepted. At present, it is uncertain whether Type II diabetes should be treated more intensively, with diet, tablet or insulin therapy to maintain near-normal glucose levels, in order to prevent the onset of complications. The Diabetes Control and Complications Trial (DCCT) in insulin-dependent diabetic subjects with a mean age of 27 years has indicated that intensive therapy to achieve a haemoglobin A1c level of 7.1%, compared with 9.0% in a 'standard control group', will retard the progress of diabetic microvascular disease. It is not known whether this is similarly beneficial in Type II diabetic subjects, where the main complication is cardiac disease, or whether the even better control that can be obtained with pharmaceutical therapy in Type II diabetic patients would be worthwhile. It is similarly not known whether treatment with sulphonylurea, metformin or insulin is particularly beneficial or whether any of these therapies is potentially harmful. The UK Prospective Diabetes Study (UKPDS) has randomly allocated 4209 newly diagnosed Type II diabetic patients to different therapies and is determining: (a) whether improved glucose control will delay the onset of clinical complications; and (b) whether any specific therapy has advantages or disadvantages.Diabetes Research and Clinical Practice 09/1995; 28 Suppl:S151-7. · 2.74 Impact Factor
Article: Insulin therapy in type II diabetes.[show abstract] [hide abstract]
ABSTRACT: When diet therapy is no longer effective in keeping the fasting plasma glucose level < 6 mmol l-1, a basal insulin supplement from a long-acting insulin such as ultralente can be added instead of using a sulphonylurea or metformin. The dose of insulin required can be predicted from the level of the fasting plasma glucose and the degree of obesity, which provides an index of the accompanying insulin resistance. The risk of hypoglycaemia is minimal provided that the dose is adjusted according to the fasting plasma glucose concentration and the patient can continue a normal life-style without restrictions concerning exercise or the size of individual meals. If given in appropriate doses a basal insulin supplement does not induce marked weight gain and insulin therapy is equally appropriate in patients with insulin deficiency and insulin resistance. Maintaining near-normal glucose concentrations probably outweights a putative risk of hyperinsulinaemia. In more severely affected patients, such as those with sulphonylurea failure, soluble insulin to cover meals in addition to a basal insulin supplement is needed. At this stage it is usual to stop tablet therapy and treat patients with either a basal and prandial insulin regimen or with twice daily soluble and isophane mixtures. Nevertheless, in elderly patients in whom regular meals cannot be guaranteed, continuing with sulphonylurea therapy and adding a basal insulin supplement can be a safe and effective way of preventing hyperglycaemic symptoms.Diabetes Research and Clinical Practice 08/1995; 28 Suppl:S179-84. · 2.74 Impact Factor
Article: Insulin analogues.The Lancet 02/1997; 349(9044):47-51. · 39.06 Impact Factor