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Oral antidiabetic agents. A guide to selection
1Department of Medicine, CHU Sart Tilman, Liège, Belgium. Andre.Scheen@chu.ulg.ac.be
Abstract:
Type 2 diabetes mellitus (formerly named non-insulin-dependent diabetes mellitus or NIDDM) is a heterogeneous disease resulting from a dynamic interaction between defects in insulin secretion and insulin action. Various pharmacological approaches can be used to improve glucose homeostasis via different modes of action: sulphonylureas essentially stimulate insulin secretion, biguanides (metformin) act by promoting glucose utilisation and reducing hepatic-glucose production, alpha-glucosidase inhibitors (acarbose) slow down carbohydrate absorption from the gut and thiazolidinediones (troglitazone) enhance cellular insulin action on glucose and lipid metabolism. These pharmacological treatments may be used individually for certain types of patients, or may be combined in a stepwise fashion to provide more ideal glycaemic control for most patients. Selection of oral antihyperglycaemic agents as first-line drug or combined therapy should be based on both the pharmacological properties of the compounds (efficacy and safety, profile) and the clinical characteristics of the patient (stage of disease, bodyweight, etc.). Mildly hyperglycaemic patients should preferably be treated with metformin, acarbose or thiazolidinediones (which are not associated with any hypoglycaemic risk), while more severely hyperglycaemic individuals should receive a sulphonylurea. In moderately hyperglycaemic patients, sulphonylureas should be preferred in nonobese patients while metformin, and probably also thiazolidinediones, should have priority in obese insulin-resistant type 2 diabetic patients. Acarbose is mainly indicated to reduce post-prandial glucose fluctuations and improve glycaemic stability. Each antihyperglycaemic agent may also be combined with insulin therapy to improve glycaemic control and/or reduce the insulin requirement of diabetic patients after secondary failure to oral treatment. Finally, safety should be taken into account in elderly patients and/or those with renal impairment, especially as far as the use of sulphonylureas (higher risk of hypoglycaemia) and metformin (higher risk of lactic acidosis) is concerned.
Insights
Type 2 diabetes management involves various oral medications targeting insulin secretion and action. Treatment selection depends on patient characteristics and drug profiles for optimal glycemic control.
Area of Science:
- Endocrinology
- Pharmacology
Background:
- Type 2 diabetes mellitus (T2DM) arises from complex interactions affecting insulin secretion and action.
- Pharmacological agents offer diverse mechanisms to improve glucose homeostasis.
Purpose of the Study:
- To review pharmacological approaches for managing type 2 diabetes mellitus.
- To guide the selection and combination of oral antihyperglycemic agents based on patient profiles and drug properties.
Main Methods:
- Review of pharmacological agents including sulphonylureas, biguanides (metformin), alpha-glucosidase inhibitors (acarbose), and thiazolidinediones (troglitazone).
- Analysis of treatment strategies based on patient characteristics (e.g., glycemic severity, obesity, insulin resistance, renal impairment) and drug efficacy/safety profiles.
- Consideration of combination therapy with insulin for secondary treatment failure.
Main Results:
- Different drug classes target specific pathophysiological defects in T2DM.
- Treatment selection should be individualized: metformin, acarbose, or thiazolidinediones for mild hyperglycemia; sulphonylureas for severe hyperglycemia.
- Metformin and thiazolidinediones are prioritized for obese, insulin-resistant patients; sulphonylureas for non-obese patients.
- Acarbose is beneficial for post-prandial glucose control.
- Combination therapy with insulin may be necessary.
- Safety considerations are crucial for elderly patients and those with renal impairment, particularly regarding sulphonylureas and metformin.
Conclusions:
- Individualized selection and combination of oral antihyperglycemic agents are key to effective T2DM management.
- Tailoring therapy based on patient-specific factors and drug characteristics optimizes glycemic control and minimizes risks.
- Careful consideration of safety profiles is essential, especially in vulnerable patient populations.