Future management of diabetes mellitus

A review of therapies for diabetes mellitus reveals little that is new for the diabetic today. Also, there is little evidence that progression of diabetic complications can be slowed or halted with currently available therapeutic modalities that are acceptable to patients and can be applied in an everyday clinical setting. Few new drugs are likely to be ready for marketing in the immediate future, and most of the pharmacologic approaches that are now under study do not address the basic problem of lost sensitivity of the beta cell to endogenous glucose. In the longer term, it is likely that an oral insulin, allowing more convenient management of diabetes, will be available, as well as several new drug classes that may offer therapy adjunctive to insulin. As more is learned of the cellular physiology of the islet cell and the pathology of diabetes mellitus, some additional therapeutic breakthrough may occur. It is highly likely that an implantable or portable infusion system, either of the closed- or open-loop type, will be available when technologic problems are overcome. Islet cell transplantation may provide a definitive treatment for diabetes. At the very least, the questions should be resolved relating to careful physiologic control of the metabolic aberrations of diabetes mellitus. Unfortunately, because of the relatively slow evolution of diabetic vascular pathology, it will be several decades before current studies can provide the answers. If present hypotheses are confirmed, future therapeutic approaches can be more clearly defined; if the hypotheses must be rejected, the therapeutic dilemmas will remain.