Controversies in Diabetes in 2013-a Brief Update

Incidence of diabetes is increasing worldwide at an alarming rate. Therefore, a proper understanding of the mechanisms and efficient treatment of the disease is becoming increasingly important. The article briefly describes controversies in type 1 diabetes (T1DM) pathogenesis and diagnosis (genetic background, accelerator hypothesis, new autoantibodies, new information on LADA - latent autoimmune diabetes in adults, and the role of TRAIL - tumor necrosis factor-related apoptosis-inducing ligand) and treatment (how to deal with fluctuations of blood glucose concentrations and the occurrence of hypoglycemia, the role of healthy lifestyle, especially physical exercise, and a proper diet, treatment of insulin resistance and the challenges in detecting diabetic neuropathy). Moreover, issues in the pathogenesis of macrovascular complications in type 2 diabetes (T2DM) are considered (novel risk factors - vascular hyperglycemic memory, hypoglycemia, altered profile of microRNAs expression, impaired function of vascular progenitor cells, altered fibrin clot properties and iron-induced blood coagulation). Modern treatment of T2DM, based on lifestyle intervention and antidiabetic drugs, is full of controversies and it seems that over time the number of uncertainties is constantly increasing. Recent trials have reported disappointing results in lifestyle intervention (LOOK-AHEAD) and antihyperglycemic treatment (ACCORD, SAVOR-TIMI 53, EXAMINE, concerns about sulfonylureas safety). Moreover, there are considerable deviations from treatment targets that are recommended by the guidelines (blood glucose, hypertension, blood lipids) in real-life clinical practice in patients at different stages of the disease development. It seems that beneficial modification of the natural history of diabetes is unlikely in the foreseeable future unless we are able to obtain a more in-depth understanding of the pathomechanisms of the disease.