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Unmet needs and emerging risks/benefits shaping future
trends in the use of T2DM treatments

There are certainly a number of important unmet needs in T2DM, but
how will these shape the management of this condition? How will T2DM
be managed in the next ten or even the next twenty years? Naturally,
this is speculation, but we base it on the information we have reviewed
above and in the previous chapters. We can be fairly certain that met-
formin will remain the gold standard antidiabetic treatment simply be-
cause of the long experience with the drug, its high level of efficacy,
good tolerability profile, overall cost-effectiveness and possible ben-
efits beyond simple glycaemic control (cardiovascular protection and
reduced risk of cancer). In contrast we will very likely see a progressive
move away from SUs, TZDs and glinides due to potential safety and
tolerability issues.

Future trends in the use of incretin therapies such as the DPP-4 inhibi-
tors and the GLP-1 mimetics/analogues are more difficult to speculate
on. Both are effective in improving glycaemia, but many questions still
linger over this therapeutic approach. In part, these questions have
been addressed by emerging DPP-4 inhibitors that possess high poten-
cy, high selectivity and non-renal elimination. The GLP-1 mimetics and
analogues may become increasingly important because of their very
high level of glycaemic efficacy and associated weight loss, although
the need for subcutaneous injections will always be a significant barrier
to their widespread use.

With metformin as the gold standard the importance of combination
therapy will also continue to rise as those people poorly controlled on
metformin monotherapy are treated with combination regimens con-
taining familiar OADs and those with novel modes of action that are still
in development. The earlier use of combination therapy in T2DM will
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probably also increase over time. Furthermore, we can expect that
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treatment decisions in T2DM will increasingly hinge on a number of fac-
tors, rather than just the glycaemic lowering ability and tolerability pro-
file of a drug. 93, 94 Factors such as comorbidities (e.g. renal impairment),
compliance and adherence, CV protection and cost-effectiveness will
all be important in the more holistic management of T2DM. 93, 94

A further likely trend is the increasing influence of patient organisa-
tions and other groups in driving the issue of patient-centric treatment,
which has always been something of a neglected area in the man-
agement of chronic conditions. To improve the way in which individu-
als with T2DM are treated we may see a progressive move to tailored
therapy that builds on advances in the understanding of the genetics
of this disease as well as the various products of the drug development
pipeline.

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