Incretin mimetics: promising new therapeutic options in the treatment of type 2 diabetes.

Objective: To review the current state of diabetes treatment from a clinical and management perspective and explore the role that new biologic pharmaceuticals may offer patients who fail to meet or maintain glycemic goals with existing treatment options.

Summary: Key clinical areas involve the role that insulin resistance and beta-cell dysfunction/failure play in the progression of type 2 diabetes as well as current treatment modalities and how they address those core defects. Management issues include a discussion of the economics of the disease and the implications of the United Kingdom Prospective Diabetes Study (UKPDS)--that good glucose control reduces the occurrence of microvascular complications and improves quality of life for diabetic patients. While an intensive approach may be costly in the short term, statistics on the rising pandemic of the disease argue compellingly for early and aggressive treatment to delay fatal complications and improve the quality of life for persons suffering from type 2 diabetes. Current pharmaceutical regimens are not successfully enabling patients with type 2 diabetes to reach glycemic goals. The ramifications of this failure have profound repercussions in the managed care organization environment. Fortunately, new treatment modalities are in various stages of development. These will be reviewed with a more in-depth exploration of the potential of incretin mimetics, a new biologic, injectable class of drugs for the treatment of type 2 diabetes. Emphasis will be given to exenatide, an incretin mimetic that demonstrates particular efficacy for patients not achieving glycemic goal with oral medications and are insulin naive. Biologics are administered by injection or infusion and are generally costly. Apart from their cost, however, what is even more critical to managed care executives and decision makers is that these medications indicate a trend in pharmacotherapy, a groundswell of new medications. In addition, few practitioners and even fewer health care executives understand molecular medicine. The key message is that making formulary decisions about these pharmaceuticals will become more pressing every year.

Conclusion: Managed care executives will be faced with the significant challenge of investing their limited resources in the most clinically and fiscally responsible manner within a milieu of ever increasing pharmacologic options that could significantly strain budgets and result in less than optimal patient outcomes.