Targeting acute hyperglycaemia in clinical practice

The UKPDS established the benefit of tight glycaemic control in preventing microvascular disease but was unable to demonstrate an effect on cardiovascular disease. This may have been due to the limitation of traditional agents, which were unable to maintain particularly tight glycaemic control in the participants. A number of new oral agents and insulins are now available and show promise in achieving better glycaemic control, which is maintained for longer. Side effects of weight gain and hypoglycaemia may also be less frequent and some of the new therapies have direct effects on post-prandial glucose. However, the precise clinical benefit of new treatments has yet to be established, particularly in terms of relevant clinical outcomes such as death or cardiovascular disease. Many of the existing data are derived from regulatory studies, which establish safety and equivalence and do not often define clinical benefit or value for money. However, some trials, which do measure relevant endpoints are in progress and are due to report in the next few years. It seems likely that many of the new treatments will supplant existing therapy and the hope is that this will result in better glycaemic control and less micro- and macro-vascular disease.