Treat Early/Treat Aggressively: Examining a New Paradigm in Diabetes Management
Including proceedings from a roundtable held in Chicago, Illinois
Activity Date: October 2009  — Activity Info: Volume 6, (6)
Goals & Objectives | Faculty | Complete Pre-Test Activity | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)




L. Brian Cross, PharmD, CDE*

In the United States, more than 1.3 million Americans develop type 2 diabetes mellitus (T2DM) yearly, and the vast majority of those with T2DM are obese or overweight.1,2 As a result of their diabetes, these individuals have a 2- to 4-fold higher risk of stroke, and are 3 to 4 times more likely to die from cardiovascular disease than individuals without diabetes.3 In addition, diabetes and its complications were estimated to cost more than $174 billion in the United States in 2007.4

The real cost of diabetes, however, manifests in the personal suffering endured by the millions of individuals with diabetes who are at risk for microvascular and macrovascular complications5 that can result in lost limbs, blindness, kidney disease, and other complications.6

The care providers seeing people with diabetes most frequently, community pharmacists can play a pivotal role in managing T2DM by becoming more heavily involved in all aspects of patient care. Assessing patient health status and adherence to standards of care, making therapeutic recommendations to physicians, referring patients to other healthcare professionals, and monitoring outcomes are all areas in which community pharmacists can provide an important service. Managed care pharmacists play an equally important role as they are closely involved in formulary design and agent substitution and have a significant impact on the medications patients receive. Both community and managed care pharmacists require ongoing diabetes education on treatment guidelines, newer pharmacotherapies, and ongoing research concerning long-term efficacy and new proposals for more aggressive, early treatment. In order to effectively improve diabetes management, pharmacists must adopt an uncompromising “treat to target” approach to care.7 This involves early pharmacologic interventions and persistent titration of those medications to achieve glycemic control and maintain targets safely.

This issue of University of Tennessee Advanced Studies in Pharmacy is based on the proceedings of a roundtable discussion among clinical ambulatory care and managed care pharmacists held in Chicago, Illinois, on May 8, 2009. The overall goal of the roundtable and this monograph is to help pharmacists better understand emerging treatments for the management of T2DM.

Tom A. Elasy, MD, MPH, remarks on the changing landscape of diabetes care with the emergence of many new treatment options over the last 2 decades. Dr Elasy reviews the side effects and contraindications of traditional oral agents and describes the novel study that first described “the incretin effect” by demonstrating varied physiologic responses to glucose dependence on the mode of administration. The study led to the development of incretin-based therapies.

According to Susan Cornell, PharmD, CDE, FAPhA, FAADE, T2DM is a disease in which “multiple organs are broken and multiple drugs are needed to fix multiple problems.” Over time, the b cells of patients with T2DM lose the ability to produce insulin; therefore, control of blood glucose with current oral agents becomes difficult. These agents also produce undesirable side effects, such as edema, weight gain, and gastrointestinal intolerance, which may result in noncompliance with therapy. As a result of these problems, research has focused on new agents with novel mechanisms of action. Dr Cornell explains why b cells are so important in the search for newer drugs and describes evidence showing that the dipeptidyl peptidase-4 inhibitors may improve b-cell function.

John R. White, Jr, PharmD, PA-C, discusses the importance of lifestyle modifications in prevention of diabetes. He also reviews the potential role of existing and developing pharmacologic agents in delaying disease progression and emphasizes the need for early and aggressive interventions.

The monograph concludes with 2 case studies and potential approaches to patient management, based on the Consensus Statement released in December 2008 by the American Diabetes Association and the European Association for the Study of Diabetes. In addition, this monograph features discussion highlights from the entire faculty, which also includes Carlos A. Alvarez, PharmD, MSc, BCPS, Michael P. Kane, PharmD, FCCP, BCPS, Sheldon J. Rich, RPh, PhD, and Philip T. Rodgers, PharmD, BCPS, CDE, CPP, FCCP.

It is imperative that pharmacists are equipped to monitor their patients’ overall health status, glycemic data, drug interactions, and side effects to determine if there is a need for a change in their current regimen. Not all patients visit their primary care provider regularly, and adherence with medication regimens is generally low for those with chronic conditions. Given the correct tools, pharmacists are in an excellent position to help ensure that diabetes care is continuous and patient centered.



1. Geiss LS, Pan L, Cadwell B, et al. Changes in incidence of diabetes in US adults, 1997-2003. Am J Prev Med. 2006;30:371-377.

2. Bloomgarden ZT. American Diabetes Association Annual Meeting, 1999: diabetes and obesity. Diabetes Care. 2000;23:118-124.

3. American Diabetes Association. Complications of diabetes in the United States. Available at: Accessed February 2, 2009.

4. Economic costs of diabetes in the US in 2007. Diabetes Care. 2008;31:596-615.

5. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.

6. Centers for Disease Control and Prevention. National diabetes fact sheet 2007. Available at: pubs/pdf/ndfs_2007.pdf. Accessed December 3, 2008.

7. Davidson A, Parkin CG. Early and aggressive treatment with persistent titration to goal—a new paradigm in diabetes management. Business Briefing. North Am Pharmacother. 2005 August:39-43.

*Associate Professor, University of Tennessee Health Science Center, Colleges of Pharmacy and Medicine, Memphis, Tennessee; Pharmacotherapy Specialist, Holston Medical Group, Department of Integrated Health Management Services, Kingsport, Tennessee. Address correspondence to: L. Brian Cross, PharmD, CDE, Pharmacotherapy Specialist, Holston Medical Group, Department of Integrated Health Management Services, Stone Plaza Medical Office Building, 105 West Stone Drive, Suite 5D, Kingsport, TN 37660. E-mail: .

The content in this monograph was developed with the assistance of a medical writer. The authors made substantial contributions to the intellectual content of the articles by conceiving and designing the original presentations, researching references and studies, drafting the manuscripts, reviewing and revising the manuscripts, and/or providing supervision.

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