New therapeutic approaches to non-insulin-dependent diabetes mellitus

To review the new treatment strategies for non-insulin-dependent diabetes mellitus (NIDDM).

Various measures aimed at either increasing insulin secretion or decreasing insulin resistance are outlined. In addition, the management of obesity in patients with diabetes is discussed.

Two new sulfonylureas being investigated are repaglinide, which has a rapid onset of action, rapid reversal, and potential usefulness as a preprandial treatment of NIDDM, and glimepiride, the most potent sulfonylurea on a weight basis with an efficacy similar to that for glyburide. Metformin, an orally administered biguanide hypoglycemic agent, decreases blood glucose levels by 50 to 100 mg/dL and consistently improves triglyceride levels. Another agent for NIDDM therapy is acarbose, an a-glucosidase inhibitor. This agent avidly binds to intestinal disaccharidases and limits the postprandial increase in blood glucose. Troglitazone, a member of the thiazolidinedione class of insulin sensitizers, enhances insulin action and lowers blood glucose and blood pressure levels. In overweight patients with diabetes, fenfluramine has been the most effective centrally acting weight reduction agent.

Management of patients with NIDDM has become more complicated because of the increased variety of therapeutic options available. In each patient, nonpharmacologic treatment as well as lipid-lowering, blood pressure-lowering, and glucose-lowering agents must be considered.