A Pharmacist's Guide to Recent Treatment Guidelines On Type 2 Diabetes
Activity Date: July 2007  — Activity Info: Volume 4, (6)
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A Pharmacist's Guide to Recent Treatment Guidelines On Type 2 Diabetes
L. Brian Cross, PharmD, CDE*

In light of recent research and discoveries, health professionals now have a much deeper understanding of diabetes mellitus (DM), a complex disorder whose pathophysiologic cascade affects multiple organs well beyond the endocrine system. The hyperglycemia that ensues from the vicious combination of insulin resistance and inadequate insulin secretion leads to an ever-growing list of devastating complications, including retinopathy with potential loss of vision, nephropathy leading to renal failure, peripheral neuropathy with risk of foot ulcers and amputations, and autonomic neuropathy causing gastrointestinal, genitourinary, and cardiovascular symptoms. Patients with DM have an increased incidence of hypertension, dyslipidemia, and cerebrovascular and cardiovascular disease. To put these complications into perspective, the rates of death from heart disease and the risk of stroke are 2 to 4 times higher in adults with diabetes compared to individuals without diabetes.

What makes this disease all the more alarming is its steadily rising prevalence, which, just from 1990 to 2000, has increased by 49%. According to the National Institute of Diabetes and Digestive and Kidney Diseases, just over 20 million peopleÑ7% of the population–have diabetes, of which 6.2 million people are not yet diagnosed. Many of these undiagnosed patients will present to their physicians for the first time having already suffered some of the long-term sequelae of the disease. The comforts of a modern-day sedentary lifestyle and overabundance of food have contributed substantially to the role of obesity in the development of type 2 DM, particularly in children and adolescents, who are being diagnosed more frequently with this type of DM.

Despite all the morbidity and mortality associated with DM, its prognosis does not have to be grim. Advances in the understanding of the mechanisms underlying the development and progression of type 2 DM have led to a transformation in how this disease is managed. Researchers are pursuing earlier and more aggressive treatment approaches that may help to preempt type 2 DM and its complications. Although the treatment of hyperglycemia has historically had center stage in the treatment of DM, therapies directed at other coincident features, such as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin resistance, have now also become a major focus of research and therapy. The development of new classes of blood glucose-lowering medications to supplement older therapies has increased the treatment options for type 2 DM. Whether used alone or in combination with other blood glucose-lowering interventions, newer agents have provided more choices for practitioners and patients, and heightened uncertainty regarding the most appropriate means of treating this widespread disease.

Because the treatment approach for type 2 DM is dynamic, due in part to numerous reviews and guidelines published in recent years, it is critical for clinicians, particularly pharmacists, to stay abreast of the most recent recommendations. Pharmacists in the community and hospital setting have become vital to diabetes screening and management programs. It is not uncommon for a pharmacist to be the first and most frequent healthcare provider a patient with diabetes encounters.

This issue of University of Tennessee Advanced Studies in Pharmacy is dedicated to educating ambulatory pharmacists on the most recent recommendations and case-based approaches for managing type 2 DM. Stephen N. Davis, MD, FRCP, and Jean-Venable R. Goode, PharmD, BCPS, FAPhA, provide an extensive discussion on the pathophysiology and management of type 2 DM, with a focus on recent guideline recommendations. In exploring the latest theories behind the pathophysiology of type 2 DM, Dr Davis, who is Chief of the Diabetes Division at the Vanderbilt University School of Medicine, focuses on the contribution of insulin resistance and impaired insulin secretion in the progression from glucose intolerance to overt diabetes. He cites recent studies examining prevention strategies and reviews glycemic goals of therapy and principles in selecting antihyperglycemic interventions. Dr Goode, Director of the Community Pharmacy Practice Program at Virginia Commonwealth University, provides a discussion of recent guideline recommendations regarding specific pharmacologic agents, as well as a stepwise approach for initiating and advancing interventions. She also offers an update on the newest drugs and formulations available for type 2 DM. Dr Davis and Dr Goode also have contributed case studies that detail the comprehensive disease-management approach that is required to manage DM and its common comorbidities. Dr Davis provides an illustration of the challenges involved in managing patients with new-onset type 2 DM, and Dr Goode offers a community-pharmacy perspective on optimizing the treatment of a poorly controlled patient presenting to a community diabetes program. Her case study illustrates the vital role pharmacists play in improving the outcomes of patients with DM, particularly struggling patients, many of whom would never have reached their glycemic goals without a pharmacist's intervention. By documenting measurable differences in patient care, such as improved glycemic, blood pressure, and lipid control rates, many pharmacist-based community programs are making a real difference in the outlook for the millions affected by this daunting disease.

*Associate Professor, University of Tennessee Health Science Center, Colleges of Pharmacy and Medicine, Memphis, Tennessee; Co-Director, Department of Disease Management, Holston Medical Group, Kingsport, Tennessee.
Address correspondence to: L. Brian Cross, PharmD, CDE, Co-Director, Department of Disease Management, Holston Medical Group, Indian Path Medical Office Building, 2204 Pavilion Drive, Suite 110, Kingsport, TN 37660. E-mail:

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents
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