Diabetes Update 2016: What Bartleby the Scrivener Can Teach Us About Diabetes Care

This series of perspectives is designed to help practitioners evaluate some of the latest glucose management strategies in hopes of easing the hard work of providing diabetes care.

Between 1980 and 2014, the worldwide prevalence of diabetes increased from 4.3% to 9.0% for men and from 5.0% to 7.0% for women.¹ No country had a statistically significant decrease in prevalence during this time frame. About 422 million people in the world now have diabetes, and its current direct annual cost is about $825 billion. Half of all adults with diabetes live in five countries: China, India, the United States, Brazil, and Indonesia. These statistics do not include the large percentage of the population with metabolic syndrome who do not meet the criteria for a diagnosis of diabetes, yet are at risk for diabetes complications. Most of the diabetes burden is due to type 2 diabetes associated with the obesity epidemic, but the prevalence of type 1 diabetes is also increasing for reasons that are unknown.²

Pharmaceutical and medical device companies have responded by developing oral agents and injectable peptides with novel mechanisms of action, modified insulin preparations, continuous glucose sensors, and a wide variety of insulin delivery technologies. New approaches have great potential, but keeping up with diabetes management options has become hard work for both patients and providers.

Hard work is perhaps not the best way to ensure compliance, a notion reinforced by a character in a famous short story by Herman Melville, Bartleby the Scrivener. Bartleby, a legal secretary, goes through a particularly labor intensive period, and then responds to subsequent requests with “I would prefer not to.”

Clinicians hear this or its equivalent today from diabetic patients asked to take another medication, change their glucose-monitoring regimen, alter their diet, modify their exercise routine, and reprogram their new insulin delivery device. In this issue, physicians at Washington University present a series of perspectives designed to help practitioners evaluate some of the latest glucose management strategies in hopes of easing the hard work of providing diabetes care.

Diet, exercise, and the generic drug metformin are reasonable initial therapies for most people with type 2 diabetes. However, there is no consensus optimum diet or exercise regimen in diabetes. Metformin, an agent with a still uncertain mechanism of action that may have benefits beyond simple blood sugar control, is sometimes poorly tolerated and often insufficient for reaching treatment goals. SGLT2 (sodium-glucose co-transporter 2) inhibitors, GLP-1 (glucagon like peptide-1) agonists, DPP-4 (dipeptidyl peptidase 4) inhibitors, and new insulin preparations are available to help patients control their diabetes. These new medicines, some like empagliflozin that have unexpected benefits on mortality, are reviewed by Drs. Sarah Bou Malham and Cynthia Herrick.

Despite some limitations, continuous glucose monitoring devices use an implanted catheter to provide glucose information that can decrease hypoglycemia and improve blood sugar control. Insulin pumps employing delivery systems ranging from the simple to the sophisticated are available, and some interface with glucose monitoring devices. Clinical trials are evaluating closed loop systems capable of controlling insulin delivery in response to glucose levels. Drs. Brian Muegge and Garry Tobin present an overview of how these technologies can enhance patient care.

While the prevalence of diabetes continues to increase, visual impairment due to diabetic retinopathy is declining in part because of therapies directed at some of the mechanisms that contribute to microvascular dysfunction. Antagonism of abnormal blood vessel formation and suppression of inflammation act at fairly late stages of diabetic retinopathy but they preserve vision. Drs. Stanford Taylor and Rithwick Rajagopal summarize the underlying rationale and the options available to treat eye disease in diabetes.

Metabolic syndrome, a common disorder that is a strong risk factor for the development of type 2 diabetes, shares clinical features with Cushing’s syndrome, an uncommon disorder characterized by central obesity, insulin resistance, and hyperlipidemia. Drs. Kevin Bauerle and Charles Harris address the possibility that metabolic syndrome may represent a form of subclinical glucocorticoid excess and how pharmacologic disruption of glucocorticoid signaling might provide benefits for people with diabetes.

Advances in mechanistic-based treatments for cystic fibrosis, a common genetic disease, have substantially improved survival. In addition to pulmonary complications, patients with cystic fibrosis have pancreatic abnormalities. Because patients with cystic fibrosis live longer, their pancreatic dysfunction now commonly leads to diabetes, which has different clinical manifestations than other forms of diabetes. Drs. Marina Litvin and Schola Nwachukwu review state-of-the-art management for cystic fibrosis related diabetes.

One of the most dreaded complications of diabetes is renal failure. Proteinuria is a marker for renal disease in people with diabetes, but also indicates risk for cardiovascular disease in this population. Optimal management includes appropriate glucose control, blood pressure control through interruption of the renin-angiotensin system, and statin therapy in early stages of kidney disease. Drs. Victoria Bouhairie and Janet McGill provide recommendations for managing diabetic kidney disease including the importance of measuring the urinary albumin-creatinine ratio and estimating the glomerular filtration rate early in the course of disease.

Bartleby the Scrivener, the character in Melville’s story, gave up and perished. A major goal of chronic diabetes care should be to support patients through multidisciplinary team approaches so that disease management becomes easy. No one should feel the urge to respond to new diabetes treatment options with, “I would prefer not to.”

Biography

Clay F. Semenkovich, MD, is Chief of the Division of Endocrinology, Metabolism, and Lipid Research and Irene E. and Michael M. Karl Professor at Washington University in St. Louis.

Contact: csemenko@dom.wustl.edu