Mansur E. Shomali

Optimizing the Care of Patients With Type 2 Diabetes Using Incretin-Based Therapy: Focus on GLP-1 Receptor Agonists.

T he management of patients with type 2 diabetes remains a frequent and often unresolved challenge encountered in clinical practice. The complex pathophysiology, the numerous barriers and difficulties faced by patients, and the rapid rise in obesity prevalence contribute to the enormity of this challenge, making it essential that patient management be individualized. Fortunately, advances in treatment provide greater opportunities to individualize therapy. For example, insulin analogs are vastly improved compared to the animal-sourced insulins that were used for decades; they also have important advantages compared to short- and intermediate-acting human insulins.1,2 Another advance has been the development of glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors that act on the incretin system to stimulate insulin secretion and inhibit glucagon secretion, both in a glucose-dependent manner.3–7 GLP-1 receptor agonists currently available in the United States are exenatide twice daily (BID), exenatide once weekly (QW), and liraglutide; currently available DPP-4 inhibitors are alogliptin, linagliptin, saxagliptin, and sitagliptin. Although both drug classes work via the incretin system, there are important differences between the two. This article highlights these differences and provides a more focused discussion of strategies to initiate and optimize the use of the GLP-1 receptor agonists in collaboration with patients. The results of clinical trials, particularly head-to-head comparisons, serve as the primary evidence base for this discussion. However, strict inclusion and exclusion criteria and abbreviated descriptions of study methodology in many clinical trials present challenges in applying these results to the care of individual patients.8 Because evidence-based medicine is about integrating the best external evidence with clinical experience, as described by Sackett et al.9 and others,10,11 this article supplements the evidence base with the authors experience as a clinician and investigator. The article is not intended to …

Pituitary and Pituitary Region Tumors: Medical Therapy Perspective

The management of tumors in or around the pituitary region requires specialized attention to both issues of mass effect on the adjacent critical structures and to the diagnosis and management of endocrine dysfunction. Careful assessment of endocrine function is necessary before therapy for a number of reasons. First, the nature of the pituitary lesion needs to be determined. Tumors of pituitary origin have the potential to respond to medical therapy. In fact, medical therapy is preferred as a primary therapy over surgery and radiation for some tumor subtypes such as prolactinomas. Tumors not of pituitary origin do not respond to medical therapy and should be treated with the other modalities. Second, syndromes of pituitary hormone excess may occur and may be an important factor in the choice of therapy. Third, these patients need to be treated for the hypopituitarism that may occur as a result of the mass lesion or of the treatments thereof.