New frontiers in the management of type 2 diabetes

Type 2 diabetes is a chronic, debilitating disease characterized by insulin resistance, impaired insulin secretion, and hyperglycaemia, and afflicting at least 171 million people worldwide (31.7 million in India). This chronic disease is not benign and patients with diabetes suffer from numerous microvascular and macrovascular complications which cause a lot of morbidity and mortality. Results from the UKPDS (United Kingdom Prospective Diabetes Study) clearly demonstrate that tight glucose and blood pressure control in patients with type 2 diabetes prevents the development of and delays the progression of microvascular complications and possibly macrovascular disease. In addition, results from the UKPDS and other studies like the Heart Protection Study (HPS) have also shown that treatment of concomitant risk factors like lipids and blood pressure and the use of aspirin have favourable effects on cardiovascular complications and mortality in patients with type 2 diabetes. In order to achieve glycaemic goals, we have several anti-hyperglycaemic agents in our therapeutic armamentarium today. However, despite their availability, we have not been able to achieve glycaemic goals in our patients with diabetes due to a variety of reasons. However, there appears to be hope for the future. The progress of research in all fields of diabetes therapeutics from diabetes treatment to continuous glucose monitoring systems to novel insulin delivery systems has been spectacular. These advances have resulted in newer pharmacologic agents, implantable glucose sensors and inhaled insulin. There is also hope that large scale implementation of intensive lifestyle programmes and education efforts may help to prevent diabetes in high risk individuals. Indeed, the repertoire of options and strategies currently available (and in the pipeline) to treat and prevent/delay diabetes and its complications is impressive. In this review, we will discuss the evolving cardiovascular benefits of the thiazolidinediones (TZDs); describe in detail the newer glucose lowering gut hormones with novel mechanisms of action; delineate the recent advances in non invasive insulin delivery systems (including inhaled insulin); review the ongoing developments in continuous glucose measuring devices and finally present an update on the prevention of diabetes.