How Do the New Insulin Secretagogues Compare?
- Robert M. Cohen, MD and
- Barbara A. Ramlo-Halsted, MD
- From the Division of Endocrinology/Metabolism, Department of Medicine, University of Cincinnati College of Medicine and Medical Service, Cincinnati VA Medical Center, Cincinnati, Ohio
The availability of diabetes drugs with new properties in the last several years has prompted excitement about potential new and unique advantages for diabetes care. That has certainly been the case with the new insulin secretagogues, repaglinide and nateglinide, which have earlier onset and shorter duration of action than the sulfonylureas. The niche that insulin secretagogues occupy brings unique challenges to determining their therapeutic role. At present, they are expected to be effective only for a distinct window in the natural history of the disease process, stimulating insulin secretion as it is in the process of waning. One of our challenges is to enlarge that window and to define its limits more clearly as we are working toward near-normal glycemic control. So how, in practice, do the new secretagogues compare with older, more familiar agents that act at the very same sulfonylurea receptor? What criteria determine which patient will benefit more from one class or another? Do the newer agents in fact lead to better glycemic control? Do they fulfill the promise of stimulating insulin secretion while reducing hypoglycemia risk? Is there any reason to think one may offer benefits over another in preserving β-cell function early in the course of type 2 diabetes, leading to prolongation of tight control without requiring insulin? And the question we can’t avoid: Are they worth the extra cost compared with the earlier agents? Several recent reviews provide excellent surveys of the literature on the new insulin secretagogues (1,2). But several of these questions have not been answered and, given the costs and other realities of clinical research, some …
