Optimizing glycemic control and minimizing the risk of hypoglycemia in patients with type 2 diabetes

Diabetic microvascular and macrovascular complications arise from hyperglycemia, presenting an increasing healthcare burden as the diabetic population continues to grow. Clinical trial evidence indicates that antihyperglycemic medications are beneficial with regard to microvascular disease (retinopathy, renal impairment, and perhaps neuropathy); however, the benefit of aggressive use of these medications with regard to cardiovascular risk has been less clear in recent studies. These studies were confounded by the propensity of the antihyperglycemic medications involved to cause hypoglycemia, which itself presents cardiovascular risk. This article presents additional context for these seemingly discordant results and maintains that the achievement of glycemic targets is warranted in most patients and provides cardiovascular benefit, provided that hypoglycemia is avoided and the treatment regimen is tailored to the needs of the individual patient. A treatment approach that is driven by these principles and emphasizes diet and exercise, a combination of noninsulin antidiabetic agents, not including sulfonylureas and glinides, and judicious use of insulin is also presented.