Editorial

Steven V. Edelman, MD, and Derek LeRoith, MD, PhD

As the number of people with prediabetes and diabetes around the globe increases, so do our understanding of this metabolic condition and our pharmacologic armamentarium. Diabetes was once thought of as a condition of insulin deficiency; however, we now know that the cause of type 2 diabetes mellitus (DM) is much more complicated with the newly described incretin and endocannabinoid pathways. In addition, there are multiple consequences of hyperglycemia and insulin resistance, including hypertension, dyslipidemia, inflammation, and impaired fibrinolysis, which create new opportunities for therapeutic intervention to reduce the microvascular and macrovascular complications of diabetes.

From articles you may have missed, in this issue of Insulin we take a new and detailed look at the pathophysiology of type 2 DM and the metabolic consequences of hyperglycemia and insulin resistance. We also take a close look at newer therapeutic modalities that interact with the endocannabinoid system, such as rimonabant and the incretin pathway with dipeptidyl peptidase-IV (DPP-IV) inhibitors. DPP-IV inhibitors have and will continue to have an important role in our treatment algorithm for type 2 DM because they address several important defects in type 2 DM, including insulin deficiency and glucagon excess. These new targets for therapy will not only help practitioners in the fight to control diabetes; they also have important physiologic implications.

We are also including 2 articles in this issue that are somewhat different. One article addresses the pharmacoeconomic issues in diabetes care, which is such an important topic, considering our limited health care dollars. The other article addresses the rarely discussed topic of patient education and its role in controlling diabetes. With the increasing cost of newer therapies, we will need to take a close look at the cost-benefit ratio of these agents to properly prioritize and ration their use. Patient education will always be an important piece of the therapeutic puzzle and, unfortunately, this topic is not taken seriously enough. We hope you find the contents of this issue informative and thought provoking.

Metabolic Consequences of Hyperglycemia and Insulin Resistance

Paul S. Jellinger

Insulin is a pleiotropic hormone that exerts a multitude of effects on metabolism and various cellular processes in the body. The main metabolic actions of insulin are to stimulate glucose uptake in skeletal muscle and the heart and to suppress the production of glucose and very-low-density lipoprotein in the liver.

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DPP-4 Inhibitors

Bo Ahren

Inhibition of dipeptidyl peptidase 4 (DPP-4) is a novel treatment for type-2 diabetes. DPP-4 inhibition prevents the inactivation of glucagon-like peptide 1 (GLP-1), which increases levels of active GLP-1. This increases insulin secretion and reduces glucagon secretion, thereby lowering glucose levels.

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Pharmaco-economic Issues for Diabetes Therapy
Julia M. Bottomley and Frank D. Raymond

Pharmaco-economics in diabetes primarily relates to making choices about antidiabetic pharmaceuticals, and this is being influenced by global trends. Trends include increasing numbers of patients with diabetes, with increasing costs of caring for people with diabetes, and an ever-present focus on the costs of pharmaceuticals which are predicted to increase as the pace of development of new medications parallels the increasing incidence of the condition.

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A Trial of Empowerment-Based Education in Type 2 Diabetes - Global Rather Than Glycaemic Benefits
Helen Cooper, Katie Booth, and Geoff Gill

We have assessed the effect of a structured, empowerment-based educational system ("LAY or "Look After Yourself") for patients with type 2 diabetes. This structured educational programme, aimed at encouraging selfhelp, was associated with only limited benefits in glycaemic control, but there were significant educational and psychological benefits.

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Insulin Therapy: The Question This Issue

Anuj Bhargava

What is the evidence supporting early "insulinization" therapy in type 2 diabetes mellitus (DM)?

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Responses to October 2008 Case Study

Jack Leahy and Derek LeRoith

This was the case of a 50-year-old man with a 4-year history of type 2 diabetes mellitus (DM) that responded initially to lifestyle changes and again when combination glyburide/metformin was added. However, over the past 6 months, the patient's 2-hour postdinner blood glucose level had risen to 180 to 200 mg/dL and his glycosylated hemoglobin (A1C) level had risen to 7.5%.

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"Diabetes Tactics" Case Studies

Anisha D. Patel and William V. Tamborlane, on behalf of CADRE

A 3-year-old white twin boy was brought to the emergency department (ED) because of lethargy, nausea, and vomiting for 3 days. He had a 2-week history of polyuria, polydipsia, and weight loss (11 lb). He had no symptoms of upper respiratory infection, fever, or sick contacts.

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Correction

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Taking Insulin

Provided by Learning About Diabetes, Inc.

Insulin works best when you inject into the fatty parts of the body just under the skin.

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