Promising new approaches
Authors: Ii C. A. Reasner 
Published: March 2003

Summary. Insulin resistance in liver and muscle tissue, together with β‐cell secretory defects, leads to overt type 2 diabetes mellitus. In the early stages of this progressive disorder, glycaemic control can be established through diet and exercise alone. Indeed, in some patients, marked weight reduction can lead to normalized fasting blood glucose. As a consequence, pharmacological approaches to weight loss have been investigated as a new option for the management of type 2 diabetes in obese patients. The serotonin‐ and noradrenaline‐reuptake inhibitor sibutramine has emerged as the most promising agent in the treatment of obesity, although it appears to be less effective in diabetic patients than in non‐diabetic patients. Other weight‐reducing agents of potential benefit include noradrenergic anorexiants, orlistat, leptin, and β3‐ agonists.

Insulin and insulin secretagogues, the oldest available antidiabetic drugs, have been used to compensate for β‐cell secretory defects in patients with type 2 diabetes. Repaglinide, a new, fast‐acting insulin secretagogue with a short duration of action, reduces postprandial hyperglycaemia when taken shortly before meals. Other novel antidiabetic agents are currently under development, including pramlintide (an amylin analogue) and glucagon‐like peptide. Pramlintide slows gastric emptying and delays glucose absorption, and glucagon‐like peptide is the most potent endogenous stimulator of glucose‐induced insulin release.

Recent advances in type 2 diabetes therapy have seen the development of the thiazolidinediones (troglitazone, rosiglitazone, and pioglitazone), which improve insulin resistance in patients whose diabetes is poorly controlled by diet and exercise therapy. Thiazolidinediones bind to peroxisome proliferator‐activated receptor‐γ (PPAR‐γ) and act through a process involving gene regulation at a transcriptional level. Troglitazone, the first approved drug in the class, has been shown to decrease plasma glucose levels as monotherapy but is more effective in combination with sulphonylureas, metformin, or insulin. However, despite its generally good safety profile, troglitazone has been associated with severe idiosyncratic hepatocellular injury. There have been more than

150 spontaneous reports of serious hepatic events, including at least 25 instances in which patients died or required a liver transplant.

Rosiglitazone, the most potent thiazolidinedione, is still in clinical development, as is pioglitazone. To date, rosiglitazone has been shown to have no reported cases of idiosyncratic drug reactions leading to jaundice or liver failure and no clinically significant drug interactions with cytochrome P450 3A4–metabolized drugs such as nifedipine. Although the available data for pioglitazone are limited to the results of short‐term studies, it is reported to be safe and well tolerated.

Combination therapy is increasingly important in type 2 diabetes management following failure of monotherapy because complementary mechanisms of action of the different classes of oral agents demonstrate synergistic effects when used in combination. Oral agents may also be used as adjuncts to insulin for achieving glycaemic control.