Treatment of type 2 diabetes.

Type 2 diabetes is a heterogeneous disease resulting from a dynamic interaction between defects in insulin secretion and insulin action. As most subjects are overweighted or obese, the initial treatment is optimization of the meal plan and enhancement of physical activity in order to obtain sustained weight reduction. In case of failure of life-style changes, various oral antihyperglycaemic agents may be used. Some are targeting defective insulin secretion (sulphonylureas, glinides) while others are targeting insulin resistance (metformin, thiazolidinediones). Criteria of drug selection should include both patient's characteristics (body weight, age, degree of hyperglycaemia, comorbidities) and pharmacological properties of the compound (mode of action, safety profile, cost). Monotherapy is usually recommended first, but combined therapy using drugs with additive or synergistic effects may be required to obtain appropriate blood glucose control. As the natural history of the disease is characterized by a progressive exhaustion of beta cells, exogenous insulin may be required in the long term, usually in combination with oral agents. Finally, as patients with type 2 diabetes are insulin-resistant and often have a metabolic syndrome, a multifactorial intervention including aggressive treatment of arterial hypertension and dyslipidaemia is recommended in order to reduce the incidence of cardiovascular complications.