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Editor's Message  |   May 2010
Helping Patients Manage Type 2 Diabetes Mellitus
Author Notes
  • Address correspondence to Craig W. Spellman, DO, PhD, 701 W 5th St, Texas Tech University Health Sciences Center, Department of Internal Medicine, Odessa, TX 79763-4206. E-mail: craig.spellman@ttuhsc.edu 
Article Information
Endocrinology / Diabetes
Editor's Message   |   May 2010
Helping Patients Manage Type 2 Diabetes Mellitus
The Journal of the American Osteopathic Association, May 2010, Vol. 110, S1. doi:
The Journal of the American Osteopathic Association, May 2010, Vol. 110, S1. doi:
James R. Gavin, III, MD, PhD; Mark W. Stolar, MD; Jeffrey S. Freeman, DO; and I gathered in New Orleans one morning last November to discuss practical solutions to the clinical management of patients with various stages of type 2 diabetes mellitus (T2DM). Dr Gavin, the program chair, took the lead by posing difficult clinical scenarios, and Dr Stolar, Dr Freeman, and I discussed those scenarios. Sometimes debate ensued and a different appreciation of the well-known diabetes studies would emerge, but more often than not, we arrived at a therapeutic consensus. 
The clinical review presented in this supplement to JAOA—the Journal of the American Osteopathic Association highlights the key points in our discussion. Overall, a good case is made for the early introduction of incretin-based therapies, highlighting their effects on insulin and glucagon secretion and their pleiotopic effects on tissues and lipid metabolism. This idea is reinforced by the new American Diabetes Association/European Association for the Study of Diabetes and American Association of Clinical Endocrinologists T2DM treatment pathways, in which incretin-based therapy is squarely positioned as an early treatment option. 
In our collaborative article, we discuss key elements in the management of T2DM, new medications, and algorithms. I hope that we also succeed in illuminating the following three perspectives, which may be underappreciated yet form the underpinnings for the modern therapeutic interventions: 
  • Perspective 1. The legacy effect is a remarkable finding. Specifically, early intensive glycemic control therapy, even if only for a few years, has lasting benefits. We discuss the United Kingdom Prospective Diabetes Study (UKPDS) 10-year follow-up of patients with T2DM in our clinical review article, but we know that the legacy effect also exists for type 1 diabetes mellitus as evidenced by the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications data. How remarkable that tight glycemic control for 5 years or less still results in decreased end-organ damage nearly 20 years later despite lax management allowing the HbA1c to creep up to greater than 8%. The mechanism is unknown, but the message is clear: Early recognition and aggressive treatment of diabetes pays long-term dividends.
  • Perspective 2. Our discussion of cardiovascular trials offers a different vantage point concerning standard versus intensive management of T2DM. I would venture that the majority of physicians, if polled, believe that intensive therapy is associated with a slight increased risk of death compared to standard therapy. However, this is not true. In addition, a suggestion is offered to compare the Finnish data with the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial and see what new conclusions develop. Thus, failure to optimize therapy for every patient at every appropriate time cannot be justified based on arguments that intensive control leads to increased death.
  • Perspective 3. An underlying theme throughout the following article concerns how we view our roles in treating patients with diabetes. Basically, we promote that the physician's role is to advise, educate, and recommend action plans. Because any medical regimen can be easily defeated by inappropriate lifestyle choices, it is the patient's responsibility to be proactive and to actively participate in the management of his or her disease to reach the appropriate blood pressure, lipid, and glucose goals.
Further, I suspect many readers will glean hints on what the future holds for defining HbA1c goals. I look forward to participating in that conversation in the future. 
 Dr Spellman has no relevant financial interests to disclose.
 
 This supplement is supported by an independent educational grant from Merck & Co, Inc.