Why should anyone bother to put a textbook together? I have often wondered about this, even while doingthe job myself. All those who have engaged in this activity will tell you that the work will be harder thanyou can imagine, that chasing reluctant authors is a depressing business, and that there are easier ways ofmaking money. Worse still, the book you produce will typically have many competitors, and is destined tosuffer from built-in obsolescence. All these are questions for those who create a textbook. For you, thereader, the question is: should you consider looking further into this one?

 

    I think you should. The reason, I suggest, is that physicians treat patients, and that this is a book abouttreatment. Therapy for diabetes is life-long, monotonous, demanding, and has benefits that are mostlydeferred into a distant future. Pleasing though it is for patients to learn that their cholesterol, blood pressure,or glycated haemoglobin have fallen within the target range, the fact is that they often feel no betterin consequence, and may sometimes actually feel worse. The main argument we can offer them in defenceof a demanding diabetes regimen is that—as Maurice Chevalier said of old age – it is so very preferable tothe alternative.

 

    A celebrated physician once remarked that it is not the disease that has the patient, but the patient thathas the disease, that matters. Nowhere is this more true than for diabetes, for which no treatment will workunless the patient is committed to its success. Insulin is often its own argument, since patients feel somuch better for it that they are often reluctant to stop. This is not the case when it comes to pills: peoplelike to ask for them, but are less enthusiastic when it comes to swallowing them on a regular basis—andno medication will work if the patient is not taking it.

 

    Doctors are, or should be, passionate advocates for the benefits of the treatment they offer. Their passionand their advocacy provide the core element in therapy. However, how do we know which treatmentis best? Guidelines are necessary and useful, but choosing the right set of treatments, with the help of theperson who will have to take them, is the essence of good medicine. And here the choices become evermore complex. Since diabetes is so intimately involved with lifestyle, especially in the overweight, behaviourchange is the necessary prelude to any other intervention. Beyond this point, the options proliferate.There are currently nine classes of glucose lowering medication in development or on the pharmacist’sshelf, each with its advantages and disadvantages. Further choices as to lipid-lowering and antihypertensiveagents will have to be made, with the possible addition of anti-obesity medication. And behindthese routine elements of therapy come all the special situations, pregnancy, foot ulcers, erectile dysfunction,and so forth. The diabetes physician must be equipped to deal with all of these, and this is abook which covers them all, which is refreshingly up to date, and currently seems to have no competitors.

 

    It might seem that there is no lack of good advice about medication for diabetes. Specialist associationsissue an unending stream of guidelines, and government agencies are increasingly guided by advisorybodies such as the National Institute for Clinical Excellence (NICE) in the UK, bodies which review theevidence and advice as to how money for health care should be spent. Meanwhile, big Pharma continues togenerate new therapies, at ever-increasing cost to the consumer. According to one analysis, global drug costsof US$3.8 billion dollars for diabetes in 1995 expanded to an estimated US$17.8 billion in 2005, and areprojected to hit US$27.9 billion by 2010 [1]. As these estimates reveal, we have entered a realm ofunsustainable costs and diminishing returns. And it is here, at the cutting edge of pharmacological intervention,that evidence-based medicine lets us down, for the sources of information are controlled bythose who wish us to invest in their therapy.

 

    How then do we make the best choice for the patient sitting in front of us? At the end of the day, thewisest advice will usually come from experienced, impartial, and critical clinicians, which is what thisbook has to offer.