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Transcript of Therapy of Type 2 Diabetes Mellitus: UPDATE Glycemic Goals in the Care of Patients with Type 2...
Therapy of Type 2 Diabetes Mellitus: UPDATE
Glycemic Goals in the Care of Patients with Type Glycemic Goals in the Care of Patients with Type 2 Diabetes- 2013 ADA and AACE Guidelines:2 Diabetes- 2013 ADA and AACE Guidelines:
Room For Improvement Room For Improvement
(Be HAPPY/ Avoid Burnout, While Caring for Patients with DM)(Be HAPPY/ Avoid Burnout, While Caring for Patients with DM)
Stan Schwartz MD, FACP, FACEAffiliate, Main Line Health System
Clinical Associate Professor of Medicine, Emeritus, U of Pa.
Part 8
Non-Insulin Therapy for Type II Diabetes
Concurrent Therapy
The ABCs of Diabetes Care:Recommended Goals
A1C
ADA recommends < 7.0% in general, < 6.0% in selected individuals
AACE/IDF recommend ≤ 6.5%
Blood pressure
< 130/80 mm Hg
Cholesterol
LDL-C: < 100 mg/dL (< 70 mg/dL in very high-risk patients)
HDL-C: > 40 mg/dL in men and > 50 mg/dL in women
Non–HDL-C: < 130 mg/dL (< 100 mg/dL in high-risk patients)
Triglycerides: < 150 mg/dL
American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S54.AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):3-68.IDF Clinical Guidelines Task Force. Diabet Med. 2006;23:579-593. AACE = American Association of Clinical Endocrinologists
IDF = International Diabetes Federation
Strategy Strategy ComplicationComplication Reduction of Reduction of ComplicationComplication
Blood glucose control ▪ Heart attack 37%1
Blood pressure control
▪ Cardiovascular disease
▪ Heart failure
▪ Stroke
▪ Diabetes-related deaths
51%2
56%3
44%3
32%3
Lipid control
▪ Coronary heart disease mortality
▪ Major coronary heart disease event
▪ Any atherosclerotic event
▪ Cerebrovascular disease event
35%4
55%5
37%5
53%4
Treating the ABCs Reduces Diabetic Complications
1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:837-853.2 Hansson L, et al. Lancet. 1998;351:1755-1762. 3 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:703-713.4 Grover SA, et al. Circulation. 2000;102:722-727.5 Pyŏrälä K, et al. Diabetes Care. 1997;20:614-620.
Steno-2- Synergy in Care- Treating Glucose, BP, Lipids
7
8
USE GLP-1 RECEPTOR AGONISTS AND SGLT-2 Inhibitors for Wt. Reduction
9
Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes,
Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIAMatch Patient Characteristics to Drug Characteristics
Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes,
Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIAMatch Patient Characteristics to Drug Characteristics
5.Gut CHOAbsorption:
Incretin,Pramlintide,Glucosidase inh.
Peripheralglucose uptake
--
-
1.Pancreatic insulin
Secretion:Incretin, ranolazine
2.Pancreatic glucagon
Secretion- Incretin
HYPERGLYCEMIA
6.Fat- TZD, metformin
7.Brain-TZD,INCRETIN,bromocryptine
8.Kidney-
SGLT2
3.Muscle- TZD, Incretin
4.Liver
Hepatic glucose production:
Metformin, incretin
De
The New ADA Guidelines for Type 2 Diabetes:AKA- David Nathan’s Regimen-
DNR- COST BASED
The New ADA Guidelines for Type 2 Diabetes:AKA- David Nathan’s Regimen-
DNR- COST BASEDRevised Treatment AlgorithmRevised Treatment Algorithm
Intensive insulin
At diagnosis:Lifestyle + metforminSTEP 1
STEP 2
Tier 1* Tier 2†
STEP 3
Add basal insulin
Add sulfonylurea
Add GLP-1 agonist
Add pioglitazone ± SU
HbA1C >7.0%
NOT Glyburide, chlorpropamide NOT Rosiglitazone
New ADA Guidelines- 4/20/12New ADA Guidelines- 4/20/12
Inzucchi,Diabetologia4/20/12
SU most prominent
Added back glyburideForEUROPEAN SENSIBILITIES
NO MEDICAL LOGIC
Also, SLOW COMBO TX