Defining the role of incretin mimetic therapy in the management of type 2 diabetes.

Diabetes mellitus affects 21 million Americans; an additional 41 million individuals in this country have impaired glucose tolerance. These individuals are at high risk for developing not only diabetes, but eventually dying from the cardiovascular complications associated with chronic exposure to hyperglycemia. Not only do patients with diabetes carry a 1.5- to 4.5-fold increased risk of cardiovascular mortality, any microvascular complications they develop such as retinopathy, neuropathy, and nephropathy can have a profoundly negative effect on their quality of life. Even mild hyperglycemia is associated with macrovascular disease. Similarly, hyperglycemia that occurs concurrently during an acute myocardial infarction or stroke is associated with worse outcomes. Therefore, evidence suggests that both chronic and acute hyperglycemia lead to higher morbidity and mortality. As people age, their 2-hour postchallenge blood glucose level typically increases, often independent of their fasting glucose level. At diagnosis, 25% of patients with type 2 diabetes have normal fasting glucose levels. The incidence of isolated impaired glucose tolerance is approximately 3 times greater than isolated impaired fasting glucose. Therefore, most patients with asymptomatic diabetes have isolated postchallenge hyperglycemia. A growing body of literature supports targeting postprandial hyperglycemia to lower glycosylated hemoglobin (A1C) levels and reduce microvascular and macrovascular complications associated with chronic hyperglycemia. This article will evaluate a typical patient case and strategies employed by the patient and health care provider.