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We are surprised to see that the letter by Dr Curtis is published as a critique of our editorial on ‘Current, new and emerging therapies for managing hyperglycaemia of type 2 diabetes’.1 He has used the pages of the BJGP to promulgate a personal view against the tide of epidemiological and clinical trial evidence that glucose lowering has been shown to reduce microvascular events in type 2 diabetes. On the basis of the extensive evidence, consensus guidelines from national and international diabetes organisations (for example International Diabetes Foundation, American Diabetes Association, Diabetes UK, as well as NICE) have recommended the use of HbA1c as a therapeutic target — which he omitted to address. The newer trials of ADVANCE and ACCORD were trials of ‘how low should one go’ in terms glycaemic targets as measured by HbA1c. It is of interest that Dr Curtis fails to accept the results of the ADVANCE study where there were published treatment benefits on renal events.
The aim of our editorial was to summarise the differing drug classes available for the management of the hyperglycaemia and not to review major randomised outcome trials. There is now a wider drug choice which might allow tailoring of therapy to individuals – many of whom are overweight or poor responders to current therapies. The progressive nature of type 2 diabetes, ignored by Dr Curtis, is a key therapeutic factor resulting in a need for combination of therapies and thus a potential role for newer therapies. Due to these reasons, plus the limited glucose lowering effects of all drug classes, therapeutic agents with different modes of action to enhance glucose lowering are often required. Current clinical practice often includes considering the use of alternative drug classes that do not affect weight, since this is one of the important adverse effects of subcutaneous insulins, as well as oral insulin secretagogues and thiazolidinediones.
We owe it to our patients to be aware of therapeutic advances and place them in the context of present therapies in order to improve glycaemia and reduce the burden of diabetes-related complications.