Dialogue and Diagnosis - American Osteopathic Association

InsideOut
(continued from inside front cover)
cent studies have supported the use of
insulin as the first treatment for
patients with T2DM. In addition, the
mantra “once on insulin always on insulin”
no longer seems to be the case.
Many patients only intermittently
need insulin, during acute illnesses or
periods of hyperglycemia.
The glucagon-like peptide-1 (GLP-1)
receptor agonists—injectable incretinbased
medications—have dramatically
changed the acceptability of injection
therapy. These agents, as is explained
in the present supplement, address crucial
issues in diabetes care and can improve
both fasting plasma and post -
prandial glucose levels. Unlike many
other antidiabetic medications, GLP-1
receptor agonists are associated with
weight loss. This promise of weight loss
has appeared to help many patients
“overcome” their fear of needles.
The American Diabetes Association/
European Association for the Study of
Diabetes 9 and American Association of
Clinical Endocrinologists 10 have updated
their treatment recommendations
to better reflect the variety of available
treat ment options. Current treatment
recommendations underscore the need
for lifestyle change and the use of pharmacologic
treatment at the time of
diagnosis. The recommendations also
emphasize efforts to achieve the lowest
possible HgA 1c level without unacceptable
hypoglycemia. In recognition of
the progressive, multifactorial nature of
diabetes mellitus, 11 recent treatment
recommendations emphasize the use
of combination therapy with agents
that have complementary mechanisms
of action.
This comprehensive approach to
diabetes management is based on evidence
that typical glycemic-control parameters,
such as HgA 1c level, fasting
plasma and postprandial glucose excursions,
and hypoglycemia, have an impact
on cardiovascular disease risk,
Dialogue and Diagnosis // September 2012
mortality, quality of life, and clinical
outcomes in individuals with diabetes
mellitus. 9
The present issue of Dialogue and
Diagnosis provides practical strategies
for introducing and adjusting
injectable treatments in patients with
diabetes mellitus and for improving patient
acceptance and adherence. Joseph
M. Tibaldi, MD, describes the “how
and when” of introducing insulin for a
patient whose T2DM has progressed.
His case report also highlights factors
that are indicative of patients with
atypical forms of diabetes mellitus.
These atypical forms may represent as
much as 10% of diabetes cases.
Jeffrey S. Freeman, DO, reviews the
new treatment algorithms for diabetes
mellitus, and he discusses the risks and
benefits of oral and injectable treat -
ments. He uses a case report to show
how a physician can decide on the progression
of treatment on the basis of
patient wishes while addressing both
glycemic and nonglycemic effects.
James R. LaSalle, DO, discusses the role
of the incretin-based agents in treating
patients with advanced diabetes mellitus.
He presents data supportive of the
use of incretin-based agents for patients
who are already taking insulin.
We hope that this monograph will
help the reader better understand the
application of both newer and older
treatments for patients with diabetes
mellitus throughout the full spectrum
of disease. The reader should gain an
appreciation of the nonglycemic benefits
of treatment and be better able to
use a shared medical-decision
approach in the care of patients with
T2DM.
References
1. Centers for Disease Control and Prevention.
National Diabetes Fact Sheet: National Estimates
and General Information on Diabetes and
Prediabetes in the United States, 2011. Atlanta,
GA: US Department of Health and Human
Services, Centers for Disease Control and
Prevention; 2011.
2. Rowley WR, Bezold C. Creating public
awareness: state 2025 diabetes forecasts
[published online ahead of print January 27,
2012]. Popul Health Manag. 2012;15(4):194-200.
3. Zafar A, Davies M, Azhar A, Khunti K. Clinical
inertia in management of T2DM [published
online ahead of print August 16, 2010]. Prim
Care Diabetes. 2010;4(4):203-207.
4. Ziemer DC, Miller CD, Rhee MK, et al. Clinical
inertia contributes to poor diabetes control in a
primary care setting. Diabetes Educ.
2005;31(4):564-571.
5. Peyrot M, Rubin RR, Lauritzen T, et al;
International DAWN Advisory Panel. Resistance
to insulin therapy among patients and providers:
results of the cross-national Diabetes Attitudes,
Wishes, and Needs (DAWN) study. Diabetes Care.
2005;28(11):2673-2679.
6. Grant RW, Wexler DJ, Watson AJ, et al. How
doctors choose medications to treat type 2
diabetes: a national survey of specialists and
academic generalists [published online ahead of
print March 2, 2007]. Diabetes Care.
2007;30(6):1448-1453.
7. Grant RW, Lutfey KE, Gerstenberger E, Link
CL, Marceau LD, McKinlay JB. The decision to
intensify therapy in patients with type 2
diabetes: results from an experiment using a
clinical case vignette. J Am Board Fam Med.
2009;22(5):513-520.
8. Nakar S, Yitzhaki G, Rosenberg R, Vinker S.
Transition to insulin in Type 2 diabetes: family
physicians’ misconception of patients’ fears
contributes to existing barriers. J Diabetes
Complications. 2007:21(4);220-226.
9. Handelsman Y, Mechanick JI, Blonde L, et al;
AACE Task Force for Developing Diabetes
Comprehensive Care Plan. American Association
of Clinical Endocrinologists Medical Guidelines
for Clinical Practice for developing a diabetes
mellitus comprehensive care plan. Endocr Pract.
2011;17 suppl 2:1-53.
10. American Diabetes Association. Standards of
medical care in diabetes-2012. Diabetes Care.
2012;35 suppl 1:S11-S63.
11. Defronzo RA. Banting Lecture. From the
triumvirate to the ominous octet: a new
paradigm for the treatment of type 2 diabetes
D&D
mellitus. Diabetes. 2009;58(4):773-795.
Jay H. Shubrook Jr., DO, is an associate
professor of family medicine and a
diabetologist. He serves as the director
of clinical research and director of the
Diabetes Fellowship at Ohio University
Heritage College of Osteopathic
Medicine. He is a Fellow of the
American College of Osteopathic Family
Physicians. He can be reached at
shubrook@ohio.edu.
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