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PubMed2002

[When diet and oral antidiabetics are no longer enough. Optimal management of the diabetic patient with insulin].

In recent years, the approach to the insulin treatment of type 2 diabetics has undergone a change. Age and clinical status of the patient are decisive determinants for the selection of the appropriate form of treatment. The therapeutic strategy aims to achieve insulin substitution matched to the therapeutic objective, that is, continuous monitoring should be carried out to enable adaptation of the form and intensity of treatment to meet the target end point HbA1c < 6.5%. This necessity results in the earlier use of insulin in all, not only obese, type 2 diabetics. As a compromise solution, a certain percentage of these diabetics will have to be satisfied with simpler forms of insulin substitution and a higher HbA1c value. Attention is drawn to the other parameters of the metabolic syndrome, such as blood pressure, weight, and lipid metabolism. Particular importance attaches to non-pharmacological measures, in particular with the aim of avoiding a further increase in weight due to the treatment with insulin.

Combined Modality Therapy↗
PubMed2002

Rosiglitazone and pioglitazone: new preparations. Two new oral antidiabetics both poorly assessed.

(1) Treatment of type 2 (non insulin-dependent) diabetes is based on lifestyle measures and management of cardiovascular risk. (2) The reference first-line drug therapy for type 2 diabetes, when drug therapy is needed, is single-agent treatment with metformin (a biguanide) for overweight patients, or with glibenclamide (a glucose-lowering sulphonylurea) for other patients. (3) If monotherapy fails to control blood glucose levels adequately, most clinical guidelines then recommend a combination of metformin with a glucose-lowering sulphonylurea, although the few available comparative clinical data raise the possibility of excess mortality with this treatment. (4) Rosiglitazone and pioglitazone (glitazones that reduce insulin resistance) have been authorized in the European Union for combination with a glucose-lowering sulphonylurea (for patients in whom metformin is ineffective or poorly tolerated) or with metformin (for obese patients). (5) None of the available trials of rosiglitazone and pioglitazone include data on mortality or morbidity. (6) There are fewer data on pioglitazone than on rosiglitazone. (7) According to short-term comparative trials, rosiglitazone and pioglitazone are more effective than placebo on blood glucose levels. Combinations of rosiglitazone or pioglitazone with metformin or with glucose-lowering sulphonylureas have not been compared with the metformin + glucose-lowering sulphonylurea combination or with insulin. (8) Rosiglitazone and pioglitazone frequently cause weight gain. (9) Pioglitazone has a slightly favourable effect on lipid profiles, unlike rosiglitazone, which increases LDL-cholesterol levels. (10) The main side effect of rosiglitazone and pioglitazone is sodium and water retention, which can provoke oedema, anaemia (by haemodilution), and even heart failure. Rosiglitazone and pioglitazone are also hepatotoxic. (11) Combining rosiglitazone with insulin is contraindicated, owing to the increased risk of heart failure. The same applies to pioglitazone. (12) In practice, neither rosiglitazone nor pioglitazone has a place in the management of type 2 diabetes, except in the context of strictly controlled long-term comparative clinical trials.

Administration, Oral↗