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With much of the developed world having the increasing sociologic and economic problems of an aging population, there is an increased awareness of educating patients to not only understand and follow the instructions of their medical teams but to have increased responsibility for their own care. Of all the chronic conditions, diabetes, for which there is no cure, is among the most expensive and education-intensive. The lifelong Type I insulin-dependent diabetics need to know how to adjust their life-style and activities but also how to take and adjust several times daily insulin injections, diet and exercise and how to keep a wary eye to avoid complications that might be life-threatening. Since individual instruction is not possible for the 100 million diabetics in the known world, this can be best accomplished by educating in groups.

The treatment of diabetes is still a problem more than a half-century after the discovery of insulin. Patients are now living significantly longer but until the development of oral hypoglycemic agents, the only direct treatment modalities were exercise, diet, and insulin. Before evaluating the effectiveness of treatment, a therapeutic goal must be determined. While there are no absolutely "hard" facts proving that "good control" is beneficial in preventing chronic complications of diabetes, increasing accumulation of "soft" data strongly suggests that normal blood glucose levels are most desirable, when possible, but not at the cost of severe or disabling hypoglycemic reactions. The development of the oral agents was a great public health advance in that many persons with early diabetes, but fearful of insulin injections, had less dread of "the pills" and sought treatment. The oral agents simplified care but this very simplification process often undermined the need for proper diet and good fundamental care. This often led to mediocre diabetes care. While useful, the oral agents have marked limitations and in some are effective only temporarily. The presently available oral agents are sulfonylureas and require a viable beta-cell system for success. This limits the number of diabetics responsive to such treatment. The general indications for tolbutamide, chlorpropamide, acetohexamide and tolazamide are in maturity-onset diabetics, generally beyond the age of 40 with diabetes of less than 10 years. They are contraindicated in juvenile-onset diabetics, in pregnant women, and usually in patients undergoing major surgery, and can become ineffective during periods of extreme stress or during severe infection. They can lower blood glucose levels if used in proper doses in properly selected patients. Contrary to several decades of documentation, it has become popular to suggest that the oral agents are not effective. They can be effective but for many reasons apparently were not in their use by the U.G.D.P. researchers. This might not be the fault of the oral agent used. If ineffective, they should be discontinued. Many, but not all, patients may respond to diet therapy, which is then the treatment of choice. Obviously insulin, though difficult to use for many persons and in itself able to induce several severe reactions if not used properly, is the only treatment (with diet) for the severe diabetic. There is a large spectrum of patients inbetween in whom the oral agents may be useful. The use of phenformin (phenethyl-biguanide) has been effectively curtailed because of many reported cases of lactic acidosis, and while it is doubtful that phenformin alone, in the absence of complicating factors, is the causative factor, it is capable of being an augmenting influence when other conditions, such as decreased kidney function, prevail...

Glyburide is an improved drug for the management of non-insulin-dependent diabetes mellitus (NIDDM). It is at least as effective as the first-generation oral hypoglycemics and is effective in doses that are considerably less than those needed with first-generation sulfonyl-ureas. While its mode of action is similar to that of other agents, glyburide has the unique feature of prolonged activity despite a short half-life and short duration in the body. Side effects are minimal, and toxic reactions have not been reported. While hypoglycemic episodes can occur, as with any blood glucose-lowering agent, they can be prevented by being alert to patients who may be more sensitive to oral agents. Unlike older sulfonylureas, about 50% of glyburide is excreted through the feces. In 14 years of worldwide experience, glyburide has rarely shown disulfiram-like effects and has not shown antidiuretic effects. While glyburide produces an insulin release response to glucose that parallels a normal physiological response, it appears to also decrease resistance to insulin and sensitize the receptors while utilizing the patient's available endogenous insulin. There are two major metabolites, but they are inert and are rapidly excreted, having no hypoglycemic effect. Considering the safety of glyburide and the large worldwide population that uses this agent, it is expected that this new second-generation hypoglycemic agent will greatly increase the therapeutic spectrum for NIDDM. Not only is it possible for more patients with diabetes to be treated, but many already being treated orally can achieve better regulation with this effective new oral agent.