Appropriate, timely, and rational treatment of type 2 diabetes mellitus: Meeting the challenges of primary care

Diabetes now affects >24 million people in the United States. As the prevalence of diabetes continues to increase, long-term complications of diabetes have emerged as major health care issues. Although much focus has been placed on diabetes, it is important to note that prediabetes, the intermediate state of type 2 diabetes mellitus (DM), is not benign. The progression to type 2 DM for patients with impaired glucose tolerance (IGT) is 6% to 10% per year; for persons with both impaired fasting glucose and IGT, the cumulative incidence of diabetes in 6 years may be as high as 60%. Given the significant clinical and financial impact of both conditions, it is vital that clinicians initiate treatment of diabetes and prediabetes early and aggressively. Despite advances in diabetes treatment, many health care providers do not initiate or intensify therapy appropriately during patient visits, which contributes to poor diabetes control. Although management of blood pressure and lipid levels can be complex, glycemic control is often problematic for patients and their clinicians. Thus, clinicians must learn to use the various pharmacologic and nonpharmacologic strategies effectively to achieve glucose targets in their patients with type 2 DM. Patients with prediabetes should be managed with a combination of lifestyle intervention and appropriately timed pharmacotherapy. Pancreatic β-cell preservation should be a primary metabolic target.