Monday, December 18, 2006

Medicating T2DM

There is obviously tremendous interest in the management of T2DM (Type 2 Diabetes Mellitus), partly because of the severe threat of coronary artery disease in patients with T2DM, and also partly because of the diabetes fraternity's strategy to prevent diabetes with a revision of criteria for "pre-diabetes".

Obesity is an increasing problem, and with obesity comes hypertension, T2DM and metabolic syndrome. Life style changes seems the logical strategy, except that it is not so easy. It involves tremendous sacrifice. Even the best of my patients, often "relax" after starting so well. That is why, an effective, but safe drug is so important. Which drug fits the bill?

At the just concluded World Diabetes Congress at Cape Town, South Africa, Dr Steven Khan (Seattle) presented "A Diabetes Outcome Progression Trial (ADOPT)" . This was a study of 4360 middle age caucasians who were untreated T2DM in a multicenter, RCT manner, comparing Avandia (rosiglitazone), metformin, and a sulphonylurea.

Avandia came out most effective, being able to achieve good glycemic control quickest, with the least treament failure. Avandia, however, is expensive and also had significant side effects of water retention and heart failure. So, choosing the best drug continues to be an issue. It is good to note that Avandia and metformin are insulin sensitisers and in the face of metabolic syndrome and obesity with prediabetes, may be the drug of choice. Sad to say, it's cost that will make us chose metformin. Metformin however does have a side effect rate of almost 15%, including GIT upsets and acidosis in patients with renal dysfunction. So yes, diabetes can be easily treated, but the "best" agent remains elusive although Avandia must certainly be a good agent, at least on the basis of ADOPT.

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