Glycemic Control and Weight Reduction Without Causing Hypoglycemia: The Case for Continued Safe Aggressive Care of Patients With Type 2 Diabetes Mellitus and Avoidance of Therapeutic Inertia

Diabetes mellitus (DM) is a major and growing concern in the United States, in large part because of an epidemic of obesity in America and its relation to type 2 DM. In affected patients, postprandial glucose may be an early indicator of glucose intolerance or a prediabetes condition, which may be a better predictor of cardiovascular risk than impaired fasting glucose level. Treating patients who have early signs of hyperglycemia, including elevated postprandial glucose level, with intensive glucose control that does not lead to weight gain, and ideally may be associated with weight reduction, may be vital to preventing or reducing later cardiovascular morbidity and mortality. Because hypoglycemia is an important complication of current DM treatments and may cause acute secondary adverse cardiovascular outcomes, not causing hypoglycemia is mandatory. Given that weight loss can significantly lower cardiovascular risk and improve other cardiovascular risk factors in patients with type 2 DM and that medications are available that can result in weight reduction without leading to hypoglycemia, the successful treatment of patients with type 2 DM should be individualized and should address the complete pathophysiologic process. This review is a hypothesis article that presents arguments against general approaches to the treatment of type 2 DM. An algorithm is presented in which the goal for managing patients with type 2 DM is to lower the blood glucose level as much as possible for as long as possible without causing hypoglycemia. In addition, body weight should ideally be improved, reducing cardiovascular risk factors and avoiding therapeutic inertia.