Targeting the pathophysiology of type 2 diabetes: rationale for combination therapy with pioglitazone and exenatide

Revisiting weight reduction and management in the diabetic patient: Novel therapies provide new strategies

Weight gain has been so synonymous with diabetes care that overweight/obesity is considered an intractable aspect of diabetes and its management. A healthy body mass index (BMI) is paramount, however, in preserving the cardiometabolic profile, slowing the course of the disease and extending the life expectancy of patients. It is also key to fostering a healthy and productive society at large. Two trends in care press us to challenge our assumptions about weight control in this population by reconsidering traditional approaches to the management of diabetes. First, new anti-diabetes drug classes have emerged that are more "weight-friendly" than previously available treatments and "gentler" on the faltering β cell. Second, novel anti-obesity agents are proving efficacious in patients with diabetes. This paper presents the composite of newer and older anti-obesity and anti-diabetic drugs. It makes recommendations for anti-diabetic regimens and processes of care that engender weight loss, or neutralize or minimize weight gain, while getting many patients to their glycated hemoglobin (HbA1c) goal. Anti-obesity agents that can be safely and effectively incorporated into these regimens for the patient needing supplemental support are reviewed in detail.

Evidence-based practice use of incretin-based therapy in the natural history of diabetes

The incretin class of anti-hyperglycemic agents, including glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-inhibitors, is an important addition to the therapeutic armamentarium for the management of appropriate patients with type 2 diabetes mellitus as an adjunct to diet and exercise and/or with the agents metformin, sulfonylureas, thiazolidinediones, or any combination thereof. More recently, US Food and Drug Administration (FDA)-approved indications for incretins were expanded to include use with basal insulin. This review article takes an evidence-based practice approach in discussing the importance of aggressive treatment for diabetes, the principles of incretin physiology and pathophysiology, use of glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, and patient types and contexts where incretin therapy has been found beneficial, from metabolic syndrome to overt diabetes.

Combination therapy: a new strategy to manage diabetes and its complications

Diabetes mellitus is the most common metabolic disorder. The major cause of mortality and morbidity here is due to the complications caused by increased glucose concentrations. All the available commercial antidiabetic drugs are associated with side effects. The combination therapy could be a new and highly effective therapeutic strategy to manage hyperglycemia. Combination of commercial drugs with phytochemicals may reduce the side effects caused by these synthetic drugs. Herbal products have been thought to be inherently safe, because of their natural origin and traditional use rather than based on systemic studies. New formulation and cocrystallisation strategies need to be adopted to match the bioavailability of the drug and the phytochemical. This review describes in detail, the observed synergy and mechanism of action between phytochemicals and synthetic drugs in effectively combating. The mode of action of combination differs significantly than that of the drugs alone; hence isolating a single component may lose its importance thereby simplifying the task of pharma industries.

Glycemic control and weight reduction without causing hypoglycemia: the case for continued safe aggressive care of patients with type 2 diabetes mellitus and avoidance of therapeutic inertia

Diabetes mellitus (DM) is a major and growing concern in the United States, in large part because of an epidemic of obesity in America and its relation to type 2 DM. In affected patients, postprandial glucose may be an early indicator of glucose intolerance or a prediabetes condition, which may be a better predictor of cardiovascular risk than impaired fasting glucose level. Treating patients who have early signs of hyperglycemia, including elevated postprandial glucose level, with intensive glucose control that does not lead to weight gain, and ideally may be associated with weight reduction, may be vital to preventing or reducing later cardiovascular morbidity and mortality. Because hypoglycemia is an important complication of current DM treatments and may cause acute secondary adverse cardiovascular outcomes, not causing hypoglycemia is mandatory. Given that weight loss can significantly lower cardiovascular risk and improve other cardiovascular risk factors in patients with type 2 DM and that medications are available that can result in weight reduction without leading to hypoglycemia, the successful treatment of patients with type 2 DM should be individualized and should address the complete pathophysiologic process. This review is a hypothesis article that presents arguments against general approaches to the treatment of type 2 DM. An algorithm is presented in which the goal for managing patients with type 2 DM is to lower the blood glucose level as much as possible for as long as possible without causing hypoglycemia. In addition, body weight should ideally be improved, reducing cardiovascular risk factors and avoiding therapeutic inertia.

Exenatide Use in the Management of Type 2 Diabetes Mellitus

Exenatide is a GLP-1 (glucagon-like peptide-1) agonist that has been approved in the UK for use in the management of Type 2 Diabetes Mellitus (T2DM) since 2006. It acts by increasing glucose-induced insulin release and by reducing glucagon secretion postprandially. It therefore increases insulin secretion and reduces glucose levels, especially postprandially. It also reduces gastric emptying and acts centrally to promote satiety. In clinical practice it reduces HbA1c (range; -0.4% to -1.3%), fasting and postprandial blood glucose levels and is the only antidiabetic agent (together with liraglutide; a human GLP-1 analogue) to promote weight loss (range; -1.5 kg to -5.5 kg). It can be used as monotherapy or in combination with metformin and/or sulphonylureas (SU) and/or thiazolinediones (TZD). When compared with insulin it causes similar reductions in HbA1c and glucose levels, but unlike insulin it has the advantage of inducing weight loss. Its main side effect is gastrointestinal (GI) disturbances; nausea is the commonest GI adverse effect, albeit usually mild and transient. Hypoglycaemia is uncommon, especially when used as monotherapy or in combination with metformin. In this review article we scrutinize the currently available evidence for use of exenatide in the management of T2DM.

Pioglitazone for the treatment of type 2 diabetes in patients inadequately controlled on insulin

Insulin resistance and impaired beta-cell function are primary defects that occur early in the course of development of type 2 diabetes. Insulin resistance leads to hyperinsulinemia in order to maintain normal glucose tolerance. In most cases of type 2 diabetes, beta-cell dysfunction develops subsequent to the development of insulin resistance, and it is not until such beta-cell dysfunction develops that any abnormality in glucose tolerance is seen. Insulin resistance is a primary defect in type 2 diabetes. The risk of coronary heart disease is significantly increased in patients with type 2 diabetes. Cardiovascular disease causes 80% of all diabetic mortality, and in 75% of those cases, it is a result of coronary atherosclerosis. These points provide a rationale for early and aggressive management of cardiovascular risk in patients with diabetes. Thiazolidinediones represent an effective tool for targeting some features of this increased risk as they decrease insulin resistance and can prevent and/or delay diabetes progression.