Missing the Point: Substituting Exenatide for Nonoptimized Insulin
Going from bad to worse!
- Julio Rosenstock, MD1 and
- Vivian Fonseca, MD, FRCP2
- 1Dallas Diabetes and Endocrine Center at Medical City, Dallas, Texas
- 2Tulane University Health Sciences Center, New Orleans, Louisiana
- Address correspondence and reprint requests to Julio Rosenstock, MD, Dallas Diabetes and Endocrine Center at Medical City, 7777 Forest Ln., C-685, Dallas, TX 75230. E-mail: juliorosenstock{at}dallasdiabetes.com
The recent American Diabetes Association/European Association for the Study of Diabetes consensus treatment algorithm for type 2 diabetes has advanced basal insulin treatment as a much earlier therapeutic option following a structured target-driven strategy (1). However, the misconception by both providers and patients that insulin should be regarded as the therapy of last resort still prevails and is perhaps the main barrier to insulin treatment, even at the price of many years of poor glycemic control. Insulin is the most effective diabetes agent, only limited by hypoglycemia; however, when used inappropriately in nonphysiological and nonoptimized regimens, many patients treated with insulin remain poorly controlled (2).
In the last decade, several new treatments have been developed for treating type 2 diabetes. It is conceivable that the initial American Diabetes Association/European Association for the Study of Diabetes consensus algorithm may eventually be revised to include additional therapeutic options for early use in combination with metformin once evidence regarding sustained efficacy and safety accumulates (3). New agents have been tested in combination with insulin with the main purpose of establishing a “proof of concept” of an independent effect by keeping insulin therapy unchanged or not optimized. However, this “regulatory approval approach” often resulted in relatively small A1C reductions, and at the end of the trials the mean levels often remained far above the desired A1C targets (4,5,6). Although some of these combinations may provide benefits such as reduced insulin resistance, less weight gain, lower insulin requirements, and possibly less hypoglycemia (4,5,6,7), none of these secondary gains can substitute for the primary objective of reaching the recommended glycemic targets.
The concept of adding a new therapy to insulin was the initial strategy employed with troglitazone to get fast regulatory approval in 1997. The …
