Concepts in the Treatment of Diabetes

JUNE 17, 2010
Diana Pichardo
The prevalence of type to Diabetes is growing n the US and while lifestyle changes along with pharmacotherapy are usually a must in the treatment and maintenance of the disease, understanding that it is a progressive disease and other comorbid factors must be treated as well was the main focus of the session on Diabetes featured at the Pri-Med Ny 2010 meeting, June 17.
Martin J. Abrahamson, MD, kicked off his presentation, titled “Insulin Treatment in Type 2 Diabetes,” describing a case involving the typical type 2 diabetes patient: a middle-aged gentleman, with a family history of diabetes, who follows a relatively steady diet of low carbs, whose illness appears to be worsening.
Abraham, an associate professor of medicine at Harvard Medical School, asked the audience two specific questions: 1. Why has the gentleman’s glycemic control deteriorated? and 2. What are his treatment options now?
A fair amount of audience members raised their hands concluding that the answer to question number one was “due to his insulin resistance getting worse,” while another group raised there hands in support of the idea that “his beta cell function is getting worse.”
Abrahamson said it was most likely the second response, that his beta cells were deteriorating, and preceded to discuss the concept of type 2 diabetes as a progressive disease and the eventual need to introduce insulin therapy into the treatment program.
“This man has reached the point where he does require insulin therapy,” he said.
“The problem is insulin therapy is often delayed despite poor glucose control.”
Some of the reasons it’s delayed are because physicians are reluctant to begin the therapy due to its complicated nature, the thought that a specialist will need to be involved, and its association with causing hypoglycemia. Patients are reluctant to start the program as well, he said.
However, Abrahmson “refutes” the claims and offered a few suggestions on how to begin introducing insulin to the equation and why it is needed.
About 50% of insulin beta cells are basal insulin and 50% are Prandial, so these are the two types of insulin to be introduced. The rational behind adding basal insulin is to normalize fasting glucose, he said. Clinical studies have shown that adding basal insulin to a therapy of two prescription drugs can help effectively lower Ac1, he said. By using basal insulin analog, less of a hypoglycemic effect will take place, he said.
“The trick of using Basal Insulin is to start at a safe low dose and titrate the dose,” he said.
Additionally the easiest and safest approach when starting insulin therapy is to start with basal insulin and then add prandial insulin if necessary, he said.

In his presentation, “Current Considerations in the Management of Type 2 Diabetes: Lessons Learned from Recent Clinical Trials,” Daniel Donovon, Jr., MD, discussed new therapies to treat diabetes and their role in combination therapy. He also reviewed the current goals and guidelines for treatment, and reviewed evidence from recent control trials regarding glycemic control BP, lipids, and cardiovascular outcomes.
Donovon Jr. is an associate professor of clinical medicine at Columbia University.
According to research, in 2005 23.6 million Americans had diabetes he noted.
For those with diabetes, good glycemic control can reduce the incidence of complications such as diabetic retinopathy or diabetic neuropathy, he said. Aggressive control of diabetes is critical, he stressed.
During his presentation, Donovon highlighted a factorial randomized trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes. The results of the study illustrated most of all that levels hypoglycemia played a role in determining how well the patient would perform.
Overall, in the treatment of type 1 and type 2 diabetes, Donovon said the most important goals are to achieve normal glucose levels, prevent complications, and optimize quality of life.  A key tool in doing so is making sure to educate the patient on self blood glucose monitoring, nutrition and exercise, and possible drug therapy. It is also imperative for physicians to detect and treat complications.
Donovon also discussed other goals to keep in mind when treating. Treating hypertension by decreasing blood pressure to < 130/80 mm Hg and treating cardiovascular were important aspects as well, he said.
“It’s not just a glucose disease,” he said.
“If we can prevent the complications, we can reduce the cost of the disease,” he said.

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