[Differential type 2 diabetes therapy based on pathophysiological aspects]

Type 2 Diabetes is characterized by a deficit in early insulin secretion and increased insulin resistance. Based on the measurement of fasting and 2 h postprandial blood glucose a simple typing of hyperglycemia is possible in isolated fasting hyperglycemia (IFH), isolated postprandial hyperglycemia (IPH) and combined hyperglycemia (CH). IFH is predominantly associated with insulin resistance whereas in IPH a more pronounced insulin deficit is found. This and other simple parameters such as BMI, comorbidities and age are the basis of differential therapy with OAD if best efforts with life style modification fail to reach the target values of the lipid triad. Patients with IFH profit particularly from metformin and long acting sulfonylureas (glimepiride, glibenclamide). Patients with IPH are candidates for prandial antidiabetics (AGI, nateglinide, repaglinide). Antihyperglycemic agents such as metformin and AGI bear no risk of hyperglycemia and reduce body weight. Prandial insulin secretagogues have lower risk of weight gain and hypoglycemia than long acting sulfonylureas. They are therefore beneficial in obese patients and the elderly. The same principles are valid for combination treatment. With exception of insulin secretagogues all OAD can be combined if monotherapy fails to reach the target levels of the gluco-triad. Instead of a stepwise treatment algorithm an individualized therapy based on pathophysiology and comorbidities taking into account the global risk seems to be beneficial.