Choosing injectable therapy: The metabolic fulcrum

Area of Science:

• Endocrinology
• Metabolic Disorders
• Pharmacotherapy

Background:

• Type 2 diabetes mellitus (T2DM) management requires personalized therapeutic strategies.
• Current treatment approaches may not fully address the diverse metabolic profiles of T2DM patients.
• A metabolic classification system can optimize clinical decision-making.

Purpose of the Study:

• To introduce a metabolic fulcrum-based approach for classifying individuals with diabetes.
• To define three distinct metabolic categories: predominantly catabolic, eubolic, and predominantly maladaptive anabolic.
• To correlate these metabolic classifications with appropriate injectable therapy choices in T2DM.

Main Methods:

• Development of a clinical decision-making hypothesis based on metabolic categorization.
• Classification of patients into catabolic, eubolic, or anabolic phenotypes.
• Linking metabolic phenotypes to specific injectable treatment recommendations.

Main Results:

• Predominantly catabolic patients may benefit from intensive insulin therapy or dual-action insulins (e.g., premixed, insulin degludec aspart).
• Eumetabolic patients can be managed with a broad range of available pharmacotherapies.
• Maladaptive anabolic patients may respond to glucagon-like peptide-1 receptor agonists (GLP1RA), with a combination of GLP1RA and basal insulin as a potential next step.

Conclusions:

• A metabolic fulcrum-based classification provides a systematic framework for guiding injectable therapy selection in T2DM.
• Personalizing treatment based on metabolic phenotype (catabolic, eubolic, anabolic) can enhance therapeutic efficacy.
• This approach offers a refined strategy for optimizing T2DM management beyond conventional methods.