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Type 2 diabetes mellitus—current therapies and the emergence of surgical options

Nature Reviews Endocrinology volume 7, pages 408–419 (2011)Cite this article

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Abstract

Patients with type 2 diabetes mellitus (T2DM) are usually treated with pharmacologic agents in combination with lifestyle modification. The development of new antidiabetic agents, such as insulin analogs and incretin-based therapies, has led to treatment strategies that enable many patients with T2DM to achieve target HbA1c levels (≤7.0%). However, many factors—including those related to the patient or the health-care provider, drug inadequacies and adverse effects—can interfere with the ability of some patients to reach metabolic targets. Clinical data from the USA indicate that HbA1c concentration, blood pressure and serum levels of lipids in patients with T2DM are progressively decreasing toward the target goals set by the American Diabetes Association. These improvements in metabolic regulation have led to a 30–40% decrease in reported microvascular and macrovascular complications of diabetes mellitus in the USA. Gastric bypass surgery in morbidly obese individuals with T2DM leads to remission of the diabetes mellitus in the majority of patients and improvement in the rest. A major contributor to this improvement is an alteration in gastrointestinal hormone secretions. Interventional surgery might, therefore, be considered a reasonable therapeutic alternative for overweight and obese (BMI <35 kg/m²) patients with T2DM who do not respond to medical therapy.

Key Points

  • Lifestyle modification in combination with current pharmacologic therapies can achieve targets of metabolic control in many patients with type 2 diabetes mellitus (T2DM)

  • Factors related to the patient, health-care provider and drug regime can interfere with patients reaching these targets

  • In the USA, control of HbA1c, blood pressure and lipid values improved during 1988–1994, and were reflected in 30–40% decreases in vascular complications in patients with T2DM

  • Gastric bypass surgery in morbidly obese patients with T2DM causes remission of their diabetes mellitus or marked improvement in hyperglycemia within several weeks of the surgery

  • The mechanisms by which gastric bypass surgery improves diabetes mellitus include dramatic alterations in gastrointestinal hormone secretory patterns

  • Long-term efficacy and safety data from comparative studies are needed to evaluate gastric bypass surgery as a primary therapy for patients with T2DM and a BMI <35 kg/m2

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Figure 1: Changes in HbA1c, blood pressure and serum lipid values in NHANES data from 1998–2006.
Figure 2: Change in incidence of diabetic complications in the population of the USA from 1995 to 2003, 2006 or 2007 depending on the data available.

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  1. Department of Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, NY 11203, New York, USA

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H. E. Lebovitz has been on the Advisory Board for Amylin, American Type Culture Collection, Biocon Pharma, Indigene, Intarca Pharmaceuticals, Merck, Metacure and Poxel Pharma. He has also acted as a consultant for Amylin, AstraZeneca, Biocon Pharma, Enzymotec, GlaxoSmithKline, Metacure and Sanofi–Aventis; has been a speaker for GlaxoSmithKline; is on the Board of Directors of Metacure; and owns stocks in Merck.

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Lebovitz, H. Type 2 diabetes mellitus—current therapies and the emergence of surgical options. Nat Rev Endocrinol 7, 408–419 (2011). https://doi.org/10.1038/nrendo.2011.10

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