Volume 112, Issue s11

The increased number of cases of type 2 diabetes mellitus (both diagnosed and undiagnosed) parallels the current epidemic of obesity in the United States. Despite receiving treatment, many patients do not achieve established therapeutic goals. Type 2 diabetes mellitus is a progressive disease characterized by multiple abnormalities that extend beyond β-cell dysfunction and insulin resistance. Incretin-based agents, including glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors, have become important options in the therapeutic paradigm for patients with type 2 diabetes mellitus. The author reviews physiologic mechanisms of the incretin system and discusses the practical application of GLP-1 receptor agonists and DPP-4 inhibitors in improving GLP-1 dynamics in patients with type 2 diabetes mellitus.

Two glucagon-like peptide-1 (GLP-1) receptor agonists are currently approved for use in patients with type 2 diabetes mellitus: exenatide and liraglutide. Both of these injectable agents improve glycemic control as monotherapy or as combination therapy with oral agents. Overall, GLP-1 receptor agonists provide additive effects in dual and triple therapy regimens. In a clinical trial, the use of liraglutide resulted in greater improvements in glycosylated hemoglobin and fasting plasma glucose levels compared to exenatide, although the effects of exenatide on postprandial plasma glucose levels were greater. Clinical trials have also demonstrated statistically significant weight reduction, small beneficial effects on blood pressure, and unchanged lipid profiles with GLP-1 receptor agonists. The author reviews clinical trial data on the use of GLP-1 receptor agonists for patients with type 2 diabetes mellitus, outlines potential contraindications of these agents, and discuses the role of GLP-1 receptor agonists in algorithms for the initiation and advancement of treatment.

Control of blood glucose levels and restoration of pancreatic islet function are among the goals of physicians seeking to improve outcomes in patients with type 2 diabetes mellitus (T2DM). A growing body of evidence supports the use of incretins to achieve these goals, and current guidelines recommend earlier and more frequent use of these agents. However, in patients with T2DM, treatment paradigms should always be individualized. The author discusses issues for physicians to consider when adjusting T2DM therapy, including patient comorbidities, glucose control patterns, and potential adverse effects. The importance of patient education and practical points for initiating a glucagon-like peptide-1 receptor agonist are also reviewed.

The authors present a case of a 46-year-old woman with type 2 diabetes mellitus who has been on a treatment regimen involving diet, exercise, and metformin. After 2 years of treatment, she has a body mass index of 35 and a glycosylated hemoglobin level of 8.0%, and this level is increasing. Her physician recommends adding a glucagon-like peptide-1 (GLP-1) receptor agonist to her treatment regimen, prompting her to ask several questions. The authors present these questions along with proposed answers, highlighting the practical application of GLP-1 receptor agonists in the context of common patient concerns.