Abstract
Type 2 diabetes mellitus is a disease characterized by a progressive failure of β cells on a background of significant insulin resistance. An individualized approach has its meaning especially in long-term decompensated patients, where the knowledge of the predominant patophysiologic mechanism can help to better conduct the therapy.
A patient with near none secretion surely won't benefit from secretagogues or incretin therapy, on the other hand a patient with high resistance on insulin therapy is in risk of developing a circulus vitiosus: higher doses - weight gain caused by anabolic effect of insulin with contribution of over-eating due to hypoglycemias - increasing resistance - increasing doses of insulin. This article is a reflection of possible approach to patients with decompensated type 2 diabetes with already exhausted treatment intensification possibilities.
How to recognize patients who would benefit from a complex therapy change in the sense of decrease or withdrawal of insulin and switch to other treatment (especially incretins) from patients in whom would this change lead only to further decompensation? An important tool is certainly to reveal the prevalent pathophysiology in the given patient. So, in the first part of the article, existing methods of determination of insulin secretion and magnitude of insulin resistance are mentioned, with the reflection of their possible use in clinical practice.
In the next part, the article tries to point out the possible predicting factors of success of selected change of therapy in these patients (in this case the conversion to GLP-1 analogues or drastic weight reduction) by comparing results of selected interventional studies.