Summer Salad

January/February 2009

FocusSummer Salad

Controversies in type 2 diabetes

An update

Volume 38, No.1, January/February 2009 Pages 22-25

Bu B Yeap

Background

Controversy has emerged concerning the risks associated with glitazone therapy in type 2 diabetes, specifically bone fracture and myocardial infarction. Results from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study have stimulated debate about appropriate glycated haemoglobin (HbA1c) targets.

Objective/s

This article examines the context for glitazone therapy in patients with type 2 diabetes, the risks associated with pioglitazone and rosiglitazone, and arguments for targeting HbA1c at the threshold of 7%.

Discussion

Pioglitazone and rosiglitazone can be employed as oral therapy in patients with type 2 diabetes and preserved endogenous insulin secretion. Potential benefits and risks of each agent should be considered. An acceptable initial target for HbA1c is 7%. Lowering HbA1c to 6.5% did not reduce macrovascular complications in patients with type 2 diabetes, but did reduce new or worsening nephropathy. Aggressive therapy aiming to lower HbA1c to <6% in patients with type 2 diabetes at especially high risk of cardiovascular disease may lead to a higher risk of mortality.

Patients with type 2 diabetes undergo a transition over time from an initial state of predominant insulin resistance to progressive impairment of beta cell function. While beta cell secretion of insulin is preserved, lifestyle measures to reduce insulin resistance are indicated, and additional drug therapy is often necessary. Metformin and sulphonylureas are common first and second line therapies. Options to intensify therapy include the use of a glitazone or an alternative agent such as exenatide, or to commence insulin.

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Correspondence afp@racgp.org.au

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