Endocrine Abstracts

Glucose lowering treatment in patients with type 2 diabetes aims at reducing hyperglycaemic symptoms, preventing acute hyperglycaemic crisis and delaying the onset and progression of microvascular complications. The impact of glucose control on cardiovascular complications remains uncertain, however, a modest benefit is likely to be present.

The cornerstones of treatment remain education, motivation and counseling on healthy eating behavior and moderate physical activity. As only a minor proportion of subjects will reach glycaemic targets with these measures alone, pharmacological antihyperglycaemic treatment is indicated in most patients. Despite non-convincing hard evidence, metformin is the first drug of choice for those who can tolerate it, starting with low dose and increasing slowly. When insufficient to control hyperglycaemia, sulphonylureas have been the drug of choice to combine with metformin for many decades. However, its use has been challenged by epidemiological and experimental studies of possible serious side effects, although recent reviews fail to show evidence of harm of second and third generation agents. DPP4-inhibitors that increase endogenous incretin responses have a favorable side effect profile, particularly less hypoglycaemia and weight-gain than SU, however to a considerable higher cost. Although some safety data from medium-time follow-up studies begin to emerge, we will have a lot more data from hard-endpoint studies in the next 1–2 years. SGLT2-inhibitors that increase urinary glucose (an energy) loss, also compare favorably to SU regarding hypoglycaemic risk and effects on body weight. However, we still await the results of the first end-point studies with these agents, and their use should be limited to patients that cannot tolerate other agents or have special needs. Despite several new classes of oral antihyperglycamic agents, injection therapies with insulin and/or the new GLP1-agonists is needed after many years of type 2 diabetes in a significant proportion of individuals. A single daily dose of basal insulin in a treat-to-target regimen in combination with metformin is usually the preferred start of injection therapy. It is easy to handle, relatively cheap and will often allow reaching glycaemic aims. However, it requires at least some blood glucose monitoring by the patient, it may result in weight gain and increase the risk of hypoglycaemia. The use of GLP1-agonists usually requires less BG monitoring, will reduce body weight 2–4 kg, and seldom give hypoglycaemia. However they are more expensive than insulin in most cases and there are lack of long-term outcome studies. The large and increasing number of antihyperglycaemic agents enable us to individualize treatment regimens, to maximize effects and minimize side effects and costs.