Harnessing endocrine physiology for better clinical outcomes

Diabetes is a highly prevalent and costly disease with debilitating vascular and metabolic complications. The effects of both fasting plasma glucose (FPG) and postprandial glucose (PPG) excursions independently lead to an increased risk of morbidity and mortality. In patients with glucose levels that are fairly well controlled (ie, glycosylated hemoglobin [HbA1c] <7.3%), PPG excursions are the predominant form of hyperglycemia. In patients with poor HbA1c values (>8.5%), the pattern is one of both elevated FPG and PPG levels, with the predominant contribution resulting from an increase in fasting hyperglycemia. These data point to the need for a physiologically based basal-bolus insulin replacement strategy, with administration of basal insulin working to restore interprandial glucose levels and bolus insulin to simulate mealtime actions of the pancreas. Insulin also may offer beneficial anti-inflammatory, vasodilatory, antithrombotic, and antiapoptotic effects. Reductions in cardiometabolic risk factors and other parameters, therefore, focus attention on the early use of a basal-bolus insulin strategy. Challenges faced in the treatment of diabetes, including barriers and myths associated with the use of insulin, represent an area that urgently needs to be addressed. Patients and their caregivers need to be educated about the progressive nature of diabetes and the benefits of insulin to help them make informed decisions to ensure optimal diabetes care.