Healthy Outcomes through Peer Educators: Feasibility of a peer support diabetes prevention programme for African-American grandmother caregivers.

AIM: To assess the protocol feasibility and intervention acceptability of a community-based, peer support diabetes prevention programme (DPP) for African-American (AA) grandmother caregivers at risk for diabetes. MATERIALS AND METHODS: Grandmother caregivers were randomized in a 2:1 ratio to DPP (active comparator) or DPP plus HOPE (Healthy Outcomes through Peer Educators; intervention). DPP + HOPE incorporated support from a peer educator who met with participants in person or by telephone every week during the 1-year intervention. Outcomes included: (1) recruitment rates, outcome assessment, and participation adherence rates assessed quantitatively; and (2) acceptability of the programme assessed through end-of-programme focus groups. RESULTS: We successfully consented and enrolled 78% (n = 35) of the 45 AA grandmothers screened for eligibility. Eighty percent of participants (aged 64.4 ± 5.7 years) were retained up to Week 48 (74% for DPP [n = 17] and 92% for DPP + HOPE [n = 11]). All grandmothers identified social support, neighbourhood safety, and access to grocery stores as influences on their health behaviours. At Month 12, the active comparator (DPP) group and the intervention group (DPP + HOPE) had a mean change in body weight from baseline of -3.5 ± 5.5 (-0.68, -6.29) kg and - 4.4 ± 5.7 (-0.59, -8.2) kg, respectively. CONCLUSIONS: This viable study met the aim of educating and equipping AA grandmothers with the practical and sustained support needed to work toward better health for themselves and their grandchildren, who may be at risk for diabetes. The intervention was both feasible and acceptable to participating grandmothers and their organizations.

Improving refill adherence and hypertension control in black patients: Wisconsin TEAM trial.

OBJECTIVE: To assess the effectiveness and sustainability of a 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community chain pharmacies. DESIGN: Cluster randomized trial. SETTING: 28 chain pharmacies (14 TEAM and 14 control) in five Wisconsin cities from December 2006 to February 2009. PARTICIPANTS: 576 black patients with hypertension. INTERVENTION: Trained pharmacist-technician teams implemented a 6-month intervention using scheduled visits, Brief Medication Questionnaires (BMQs), and novel toolkits for facilitating medication adherence and pharmacist feedback to patients and physicians. Control participants received patient information only. MAIN OUTCOME MEASURES: Refill adherence (≥80% days covered) and changes in systolic blood pressure (SBP), diastolic blood pressure, and blood pressure control using blinded assessments at 6 and 12 months. RESULTS: At baseline, all patients had blood pressure of 140/90 mm Hg or more. Of those eligible, 79% activated the intervention (mean 4.25 visits). Compared with control participants at 6 months, TEAM participants achieved greater improvements in refill adherence (60% vs. 34%, P < 0.001), SBP (-12.62 vs. -5.31 mm Hg, P < 0.001), and blood pressure control (50% vs. 36%, P = 0.01). Six months after intervention discontinuation, TEAM participants showed sustained improvements in refill adherence ( P < 0.001) and SBP ( P = 0.004), though the difference in blood pressure control was not significant ( P < 0.05) compared with control participants. Analysis of intervention fidelity showed that patients who received the full intervention during months 1 through 6 achieved significantly greater 6- and 12-month improvements in refill adherence and blood pressure control compared with control participants. CONCLUSION: A team-based intervention involving community chain pharmacists, pharmacy technicians, and novel toolkits led to significant and sustained improvements in refill adherence and SBP in black patients with hypertension.

Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review.

As an integral part of the United States health care delivery system, pharmacists are ideally positioned to provide diabetes mellitus management. In this systematic review, we assessed the effectiveness of diabetes quality improvement strategies delivered by pharmacists in outpatient settings. Five electronic databases were searched for articles published through August 2007. Only randomized controlled trials, controlled clinical trials, or cohort studies with a control group were eligible for inclusion. All interventions targeted adults with type 1 or 2 diabetes and measured diabetes-related complications and/or surrogate outcomes of hemoglobin A1c (A1C), blood pressure, or lipid profiles. Study data were abstracted by one author and checked by a second author following a standardized template. Results were synthesized narratively, and study-specific effect measures were calculated for the outcomes of interest. Twenty-one articles met the inclusion criteria: nine randomized controlled trials, one controlled clinical trial, and 11 cohort studies. All interventions involved additional visits by pharmacists with expanded roles to care for adult patients with diabetes. The A1C was the primary outcome of interest for all but two studies. Results of this review revealed overall improvement in A1C for patients in a diverse group of settings and across multiple study designs. Studies with smaller numbers of participants and those performed in the United States generally showed greater improvements in intervention group measures of A1C. A greater effect was also noted when pharmacists were afforded prescriptive authority. Only a few studies examined health care resource use; their results suggested that pharmacist interventions can reduce long-term costs by improving glycemic control and thus diminishing future diabetes complications. Findings from this review are limited by flaws in the study designs, including the high potential for selection bias in the study populations. However, due to the clinical significance of reported improvements in A1C, further trials with pharmacist case managers are warranted. Prospective assessments of the comparable efficacy of pharmacists to improve diabetes outcomes through self-management education and pharmacologic management are recommended.

The pharmacist's role in maintaining adherence to insulin therapy in type 2 diabetes mellitus.

OBJECTIVE: To provide pharmacists with recommendations on how to help patients with type 2 diabetes mellitus (T2DM) achieve optimal glycemic control with insulin therapy by addressing common barriers to insulin and to improve adherence to therapy. DATA SOURCES: Articles identified from PubMed searches using the terms diabetes, insulin, monitoring, pharmacist, counseling, intensive antidiabetic therapy, glycemic control, adherence, and compliance in various combinations. DATA EXTRACTION: Studies selected provided information on glycemic control, patient counseling to support glycemic control, prevention of diabetes complications, barriers to initiating insulin treatment, and patient adherence to antidiabetic therapies. DATA SYNTHESIS: An abundance of data support achieving glycemic control for prevention of diabetes-associated complications. However, most patients with diabetes do not receive optimal therapy to attain and/or maintain glycemic goals. Insulin regimens, such as basal-insulin therapy, added to oral agents or basal-prandial approaches, are effective, but often are delayed or inadequately advanced. Additionally, some patients may not obtain maximal therapeutic benefit because of poor adherence to their treatment plans. Since patients may have more frequent or easy access to pharmacists in community, clinic, and hospital settings, pharmacists are in a position to identify adherence issues and barriers to insulin use and, through education and counseling, help their patients with T2DM optimize the use of insulin therapy. CONCLUSION: Pharmacists can play a pivotal role in improving adherence to insulin therapy and support the efforts of other members of the health care team in helping patients with T2DM attain and maintain glycemic goals.

Type 2 diabetes in children and adolescents--the next epidemic?

OBJECTIVE: To provide an overview of the incidence of type 2 diabetes in children and adolescents and provide direction for clinicians who care for children and adolescents. RESEARCH DESIGN AND METHOD: The data presented in this review were obtained from published literature and abstracts presented at scientific meetings. Clinical trials and review articles were identified using the search terms 'metabolic syndrome', 'type 2 diabetes mellitus', 'children', and 'adolescents' in a MEDLINE search from 1995-2005. Additionally, the bibliographies of the identified articles were reviewed. RESULTS: Type 2 diabetes is rising rapidly in children and adolescents worldwide. Changing a child's living environment to include physical activity, and a well balanced, low fat, high fiber diet, are important for the maintenance of a desirable body weight and improving insulin sensitivity. Maintaining euglycemia with metformin, sulfonylureas, thiazolinediones, and insulin is recommended. Effective treatment of co-morbid problems such as hypertension and dyslipidemia can decrease the risk of cardiovascular complications. CONCLUSIONS: The prevalence of type 2 diabetes in children will continue to rise until effective measures are taken to prevent obesity in this age group. Ensuring that children have a well-balanced low fat, high fiber, diet, combined with physical activity, will promote weight loss or maintenance, improve insulin sensitivity, and decrease the risk of diabetes and cardiovascular disease. Pharmacologic therapy is recommended for children who are unable to achieve satisfactory glycemic control through physical activity and diet.

Patient considerations in type 2 diabetes - role of combination dapagliflozin-metformin XR.

PURPOSE: The purpose of this review article is to provide guidance to health care providers regarding the use of dapagliflozin-metformin XR (extended release) as a therapeutic option for the treatment of patients with type 2 diabetes mellitus (T2DM). METHODS: The PubMed database was searched through August 2015 to identify clinical trials and meta-analyses evaluating the use of the sodium-glucose cotransporter type 2 inhibitor dapagliflozin administered as monotherapy or in combination with metformin. RESULTS: Fourteen studies were included for this review, six of which evaluated dapagliflozin in combination with metformin, one of which evaluated dapagliflozin monotherapy, and four of which evaluated dapagliflozin as an add-on therapy to other antidiabetic agents. The combination of dapagliflozin and metformin resulted in an A1C decrease of up to 2%, weight loss of 2-3 kg, and modest systolic blood pressure decrease of 3-5 mmHg. However, long-term effects on cancer and cardiovascular health are still being investigated. Providing patients with a fixed-dose combination therapy such as dapagliflozin-metformin XR can increase medication adherence and patient satisfaction, and improve glycemic control. Dapagliflozin-metformin XR is ideal because it can be administered orally once a day, is associated with a low risk of hypoglycemia, and provides the added benefit of weight reduction and modest blood pressure lowering. CONCLUSION: The unique combined mechanism of action and favorable efficacy and safety profile of dapagliflozin-metformin XR support consideration of this fixed-dose combination as a treatment option for patients with T2DM.

Dapagliflozin: a new sodium-glucose cotransporter 2 inhibitor for treatment of type 2 diabetes.

PURPOSE: The pharmacologic properties and clinical efficacy of dapagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor for the treatment of type 2 diabetes, are reviewed. SUMMARY: Dapagliflozin (Farxiga, AstraZeneca) is a selective SGLT2 inhibitor approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. Dapagliflozin lowers blood glucose independent of insulin secretion and action by inhibiting renal reabsorption of glucose, thus promoting increased urinary excretion of glucose. Dapagliflozin has been shown to improve glycemic parameters in patients with type 2 diabetes when used as monotherapy or in combination with metformin, glimepiride, pioglitazone, sitagliptin, or insulin. Dapagliflozin treatment is associated with weight reduction, it has a low intrinsic propensity to cause hypoglycemia, and it may offer the advantage of a complementary mechanism of action when added to other therapies. During Phase III clinical trials, dapagliflozin was generally well tolerated, with an overall frequency of adverse events similar to that reported with placebo use. However, increased rates of genital and, in some trials, urinary tract infections have been reported in dapagliflozin-treated groups relative to placebo groups. Pooled data from clinical trials indicated an imbalance in bladder cancer cases between dapagliflozin-treated and placebo groups; however, most cases were diagnosed within one year of exposure. Ongoing research is expected to further delineate the effects of dapagliflozin on bladder cancer risk and cardiovascular safety measures. CONCLUSION: Dapagliflozin, an SGLT2 inhibitor, offers a novel treatment option for type 2 diabetes that is independent of insulin secretion or action.

Pharmacologic management of diabetic nephropathy.

BACKGROUND: Diabetes mellitus and hypertension are leading causes of end stage renal disease in the United States. Drug therapy that focuses on tight glycemic control and blood pressure control reduces the progression of nephropathy and cardiovascular complications. Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce the progression of renal disease in patients with diabetes. The angiotensin II receptor blockers (ARBs) losartan and irbesartan have also been shown to reduce microalbuminuria compared with placebo. The nondihydropyridine calcium channel blockers (CCBs) verapamil and diltiazem have been shown to be as effective as an ACE inhibitor in reducing urinary albumin excretion. OBJECTIVE: This paper reviews the pathophysiology and diagnosis of diabetic nephropathy and recent clinical trials assessing the most appropriate therapeutic options for delaying the progression of nephropathy in patients with diabetes. METHODS: Primary and review articles that addressed the pathophysiology, diagnosis, and therapeutic options for attenuating the progression of diabetic nephropathy were retrieved through a MEDLINE search (January 1990 to August 2002) and the bibliographies of identified articles were reviewed. English-language sources were searched using the following search terms: diabetes mellitus, nephropathy, proteinuria, ACE inhibitors, and ARBs. Studies published in peer-reviewed journals that were determined to be methodologically sound, with appropriate statistical analysis of the results, were selected for inclusion in this review. RESULTS: Patients with type 1 diabetes mellitus and evidence of nephropathy should be started on an ACE inhibitor unless contraindicated. The ARBs and ACE inhibitors are viable choices for patients with type 2 diabetes mellitus and evidence of proteinuria. Patients who experience adverse events such as dry cough with ACE inhibitors can be switched to ARBs. Clinical literature suggests that if monotherapy with an ACE inhibitor or ARB does not provide an adequate response, a nondihydropyridine CCB should be added to the regimen. Nondihydropyridine CCBs should also be considered when ACE inhibitors and ARBs are contraindicated. CONCLUSIONS: ACE inhibitors and ARBs should be considered first-line therapy for patients with type 2 diabetes mellitus and nephropathy. The ACE inhibitors are still the drug of choice for patients with type 1 diabetes mellitus and evidence of incipient or overt nephropathy. If therapeutic goals are not achieved with an ACE inhibitor or ARB, then the addition of a nondihydropyridine CCB should be considered.

Improving blood pressure control in a pharmacist-managed hypertension clinic.

OBJECTIVE: To determine whether pharmaceutical care provided by a pharmacist-managed hypertension clinic results in better treatment outcomes when compared with traditional health care from a primary care physician. DESIGN: Prospective, controlled study SETTING: Veterans Affairs Medical Center, Philadelphia, Pennsylvania. PATIENTS: Fifty six patients with essential hypertension; 27 were randomly assigned to the intervention group and 29 to the control group. INTERVENTION: Patients in the intervention group were scheduled monthly to meet with a clinical pharmacist who made appropriate changes in prescribed drugs, adjusted dosages, and provided drug counseling in accordance with the hypertension guidelines in the sixth report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Patients in the control group received standard care from their physicians. The study period was 6 months. MEASUREMENTS AND MAIN RESULTS: Treatment outcomes were measured by changes in compliance, blood pressure, and patient satisfaction. The Short Form-36 health survey and a patient satisfaction survey were used to measure changes in patient satisfaction, and a compliance evaluation survey measured compliance. Twenty-one (81%) patients in the intervention group attained their blood pressure goal of below 140/90 mm Hg at the completion of the study versus only eight (30%) in the control group (p < 0.0001). Of 11 patients with diabetes in the intervention group, 10 (91%) attained their blood pressure goal (< 130/80 mm Hg) versus only two (12 %) of 16 patients with diabetes in the control group (p < 0.0001). No significant differences in patient satisfaction or compliance were reported between the intervention and control groups. CONCLUSIONS: Pharmaceutical care improves blood pressure control and results in more patients with hypertension reaching their blood pressure goal.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors: a growing class of antidiabetic agents.

Although several treatment options are available to reduce hyperglycemia, only about half of individuals with diagnosed diabetes mellitus (DM) achieve recommended glycemic targets. New agents that reduce blood glucose concentrations by novel mechanisms and have acceptable safety profiles are needed to improve glycemic control and reduce the complications associated with type 2 diabetes mellitus (T2DM). The renal sodium-glucose co-transporter 2 (SGLT2) is responsible for reabsorption of most of the glucose filtered by the kidney. Inhibitors of SGLT2 lower blood glucose independent of the secretion and action of insulin by inhibiting renal reabsorption of glucose, thereby promoting the increased urinary excretion of excess glucose. Canagliflozin, dapagliflozin, and empagliflozin are SGLT2 inhibitors approved as treatments for T2DM in the United States, Europe, and other countries. Canagliflozin, dapagliflozin, and empagliflozin increase renal excretion of glucose and improve glycemic parameters in patients with T2DM when used as monotherapy or in combination with other antihyperglycemic agents. Treatment with SGLT2 inhibitors is associated with weight reduction, lowered blood pressure, and a low intrinsic propensity to cause hypoglycemia. Overall, canagliflozin, dapagliflozin, and empagliflozin are well tolerated. Cases of genital infections and, in some studies, urinary tract infections have been more frequent in canagliflozin-, dapagliflozin-, and empagliflozin-treated patients compared with those receiving placebo. Evidence from clinical trials suggests that SGLT2 inhibitors are a promising new treatment option for T2DM.

Identifying knowledge deficits of food insecure patients with diabetes.

UNLABELLED: The purpose of this project was to identify the self-care needs of adults with diabetes who experience food insecurity. A cross-sectional study design and methodology were used to attain the study data. We invited 153 adults with diabetes who utilized the St Vincent de Paul Food Pantry to complete the diabetes knowledge test. The reliability of the sample was calculated using Cronbach's coefficient α. To determine validity, differences in test scores were examined by diabetes type and treatment, educational attainment, and receipt of diabetes education. RESULTS: The coefficient α for the general test and the insulin-use subscale indicated that both were moderately reliable, α> 0.60. General test scores were significantly associated with educational attainment (p<0.01) and prior diabetes education (p<0.05). We found that participants who attained education beyond high school or previously received diabetes education scored significantly higher on the test compared to those with less than high school education or not receiving diabetes education (p<0.05). Adults with type 1 diabetes had higher general and insulin use scores compared to adults with type 2 diabetes, however the difference was not statistically significant. While general knowledge about diabetes is not a predictor of self-care behavior, it is needed to perform daily self-care activities. Health care providers should assess diabetes knowledge in low income patients who experience food insecurity regularly to identify any gaps in knowledge that can compromise self-care behaviors.

Lessons Learned from a Community Based Lifestyle Intervention for Youth at Risk for Type 2 Diabetes.

PURPOSE: This pilot study examined the feasibility and acceptability of a peer led diabetes prevention intervention for youth in an underserved community. METHODS: Children and adolescents randomized to the intervention group participated in a one year program which included peer support, physical activity, and family nutrition, and behavior modification sessions. Participants were asked about their satisfaction with the study and possible benefits, what they learned, and whether they would recommend participation to a friend. Youth randomized to the control group received monthly healthy lifestyle educational materials through the mail. RESULTS: Children and adolescents (n=67) with an average age of 12.5 years and BMI greater than or equal to 85 percentile for age and sex were enrolled in the study. The average monthly participation rate varied between 90 and 50 percent with a mean rate of 82 percent. Ninety four percent of parents reported being very satisfied with the program and all (100%) reported they would recommend the program to a friend. All the children and adolescents (100%) reported that they enjoyed working with the youth peer coaches and 94% felt their assigned coach was a good role model. The observed changes in BMI z-score trended towards improvement in the intervention group, but this study was underpowered to detect differences between groups. CONCLUSION: The peer led diabetes prevention program was feasible and acceptable and demonstrated potential for improving health behaviors.

Weight perceptions of parents with children at risk for diabetes.

BACKGROUND: The growing epidemic of obesity and diabetes among African American, Latino American, and Native American children in the United States has led to increasing focus on strategies for prevention. However, little is known about the perceptions toward weight, nutrition, and physical activity among these youth. This pilot study explored the perceptions of body weight among overweight and obese children and their parents. RESULTS: Thirty eight children, ages 8-16 years who were enrolled in a diabetes prevention study were surveyed to assess their perception of their weight. Nearly all (84%) of the children were obese. When asked whether they considered themselves to be overweight, African-American children were less likely to report that they were overweight than other children (33% vs. 80% of other children, p = 0.01). The parents of these children (n = 29) were also surveyed to assess their perception of their child's weight. The parents of two-thirds (65%) of the children reported that the child was overweight, while the rest reported their child was underweight or the right weight. African-American parents were less likely to report that their child's weight was unhealthy compared to other parents (46% vs. 77%, p = 0.069). CONCLUSIONS: This study's findings indicate that future intervention efforts should assess children's and parents' awareness of obesity and diabetes risk and these factors should be considered when developing prevention interventions for families with youth at risk for diabetes in underserved communities.

Identifying children at risk for type 2 diabetes in underserved communities.

PURPOSE: The purpose of this study was to identify and assess health behaviors among ethnic minority children at high risk for type 2 diabetes. METHODS: Diabetes screenings were conducted at community centers, churches, and local neighborhood health fairs in Madison, Wisconsin. During these events, diabetes risk assessment surveys were given to parents of children between the ages of 10 to 19 years. Parents who identified their children as having 2 or more risk factors for type 2 diabetes were invited to have their child screened for type 2 diabetes. RESULTS: A total of 86 children between the ages of 10 to 19 years (mean age = 13; 58% male) were screened for diabetes. Fifty-one percent of the children were overweight or obese with 38% having >3 risk factors for type 2 diabetes. While there was no significant difference in the nutritional habits reported between normal, overweight, or obese children, fewer overweight and obese children reported exercising at least 30 minutes 5 to 7 days a week compared to children with a normal weight (P = .033). CONCLUSION: Prevention of diabetes is a powerful public health intervention. Targeted diabetes screening in disadvantaged, underserved communities is an effective way to identify families with children at risk for type 2 diabetes. In addition, information obtained from these screenings can assist researchers and clinicians in designing accessible and affordable health promotion interventions that are culturally relevant to the youth and families within the community.

The Team Education and Adherence Monitoring (TEAM) trial: pharmacy interventions to improve hypertension control in blacks.

Recent studies suggest that involving pharmacists is an effective strategy for improving patient adherence and blood pressure (BP) control. To date, few controlled studies have tested the cost-effectiveness of specific models for improving patient adherence and BP control in community pharmacies, where most Americans obtain prescriptions. We hypothesized that a team model of adherence monitoring and intervention in corporately owned community pharmacies can improve patient adherence, prescribing, and BP control among hypertensive black patients. The Team Education and Adherence Monitoring (TEAM) Trial is a randomized controlled trial testing a multistep intervention for improving adherence monitoring and intervention in 28 corporately owned community pharmacies. Patients in the 14 control pharmacies received "usual care," and patients in the 14 intervention pharmacies received TEAM Care by trained pharmacists and pharmacy technicians working with patients and physicians. Data collectors screened 1250 patients and enrolled 597 hypertensive black patients. The primary end points were the proportion of patients achieving BP control and reductions in systolic and diastolic BP measured after 6 and 12 months. Secondary end points were changes in adherence monitoring and intervention, patient adherence and barriers to adherence, prescribing, and cost-effectiveness. Researchers also will examine potential covariates and barriers to change. Involving pharmacists is a potentially powerful means of improving BP control in blacks. Pharmacists are in an excellent position to monitor patients between clinic visits and to provide useful information to patients and physicians.

Should drug therapy be personalized based on race?

The A-HeFT (African American Heart Failure Trial) showed that isosorbide/hydralazine was associated with significant reductions in mortality in African Americans with heart failure compared with placebo. The results of a recently published genetic substudy identified a gene variant related to nitric oxide synthase production that attributed to the treatment response observed in patients enrolled in the A-HeFT. This finding suggests that isosorbide/hydralazine's ability to improve heart failure outcomes is tied to a genetic trait that may be more prevalent in African Americans than whites, but is not necessarily related to perceived race.

Pramlintide for the treatment of diabetes mellitus.

OBJECTIVE: To provide an overview of the role of amylin, as well as that of pramlintide, a synthetic analog of amylin, in maintaining glucose homeostasis; and discuss the pharmacology, pharmacokinetics, efficacy, adverse effects, and role of pramlintide in the control of postprandial hyperglycemia. DATA SOURCES: The data presented in this review were obtained from published literature, abstracts presented at scientific meetings, and information on file with the manufacturer. MEDLINE searches (1986-March 2003) using the search terms pramlintide and amylin were conducted to identify clinical trials and review articles. Additionally, the bibliographies of the identified articles were reviewed. DATA SYNTHESIS: Clinical trials have demonstrated that amylin in combination with insulin controls postprandial glucose levels by decreasing food intake, slowing gastric emptying, and suppressing glucagon secretion. Clinical trials also showed significant decreases in mean plasma glucose levels and glycosylated hemoglobin, as well as the added benefits of weight loss and reduction in insulin doses. The most commonly reported adverse effects associated with pramlintide in clinical trials were gastrointestinal complaints and hypoglycemia, which occurred most frequently during initiation of therapy. CONCLUSIONS: The administration of insulin alone often does not result in optimal metabolic control. The treatment of amylin deficiency, in addition to insulin deficiency, may be warranted in order to obtain glucose homeostasis. The role of pramlintide, an amylin analog, will become clearer as more clinical data become available.

Insulin strategies for type 2 diabetes mellitus.

OBJECTIVE: To review the currently available insulin analogs and the benefits of insulin therapy in the treatment of type 2 diabetes mellitus. DATA SOURCES: A MEDLINE search (1990-March 2004) was conducted using insulin and type 2 diabetes mellitus as search terms to identify clinical trials and review articles. The bibliographies of identified articles were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes. DATA SYNTHESIS: Since its discovery in 1922, insulin therapy has been the only available pharmacologic treatment for type 1 diabetes and a mainstay therapy for patients with type 2 diabetes who fail to obtain glycemic control with oral antidiabetic agents. This article reviews the current insulin analogs available on the market and insulin regimens that are designed to mimic the pancreatic beta-cells' response to a glucose load. CONCLUSIONS: Insulin therapy is often withheld until late in the disease process for patients with type 2 diabetes mellitus. This results in an enormous burden of disease for patients. Insulin therapy is beneficial in obtaining glycemic control and may attenuate the complications associated with diabetes.