Type 2 diabetes mellitus: choosing the right therapeutic strategy

Goal of treatment: Prevention of diabetic micro and macroangiopathy is the goal of treatment in type 2 diabetes mellitus. A well-controlled glucose le vel is the key to prevention of microangiopathy; there is no threshold leve l. Antihypertensive treatment, with the goal of blood pressure below 130/80 mmHg, is also beneficial in preventing aggravation of microangiopathy. For macroangiopathy, prevention is based in priority on treatment of other ris k factors for cardiovascular disease; the threshold level for drug treatmen t and the therapeutic objective are those defined for secondary prevention in non-diabetic patients, i.e. blood pressure below 140/80 mmHg and LDL cho lesterol under 1.30 g/l. The beneficial effect of lower glucose levels on p reventing macrovascular risk was not formally demonstrated by the UKPDS, pr obably because the difference between the control and the treatment group H bAlc levels was minimal, 0.9 points. Revisiting strategy: It is thus time to revisit the preventive strategy for type 2 diabetes mellitus, i.e. step-by-step increments, as currently propo sed for worsening glucose levels. Metformine should be prescribed if the Hb Alc is above normal in order to achieve the demonstrated benefit in prevent ion of microangiopathy and in the hope, motivated by pathophysiology data, of preventing insulin failure. Slow-release insulin at bedtime should be ad ded to the oral hypoglycemiants if lasting glucose exceeds 1.60 or 1.80 g/l , even ii the HbAlc remains below 8%. New hypoglycemiants: The role of these new agents in this more "aggressive" strategy remains to be defined. Glinides will have to demonstrate their su periority over sulfamides (fewer episodes of hypoglycemia with comparable e fficacy) to justify their high cost. Glitazones will have to demonstrate a beneficial effect in second intention combination with metformine on cardio vascular morbidity mortality in type 2 diabetes patients with a metabolic i nsulin-resistance syndrome and visceral obesity. Observance: Since patients with type 2 diabetes mellitus are often taking 3 to 6 tablets to control their glucose level, 3 to control blood pressure, plus another to lower the lipid level and finally one more for an antiplatl et effect, reducing the number of tablets and patient education will most c ertainly help improve therapeutic observance. (C) 2001, Masson, Paris.