Transcript Slide 1
Preferred treatment options for patients with Diabetes Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood Case Study – what would you do? What else do you need to know? • • • • • • • 29 year old Bangladeshi women Type 2 diabetes for 4 years Gliclazide 80mg bd , Metformin 850mg tds BMI 29.7kg/m2 FBS 9.7mmol/l HbA1c 9.3% BP 152/88 Total Chol 6.1mmol/l LDL Chol 4.3mmol/l Diabetes is simple isn’t it? Make it as simple and holistic as possible Remember the diagnosis of Diabetes CVD risk progression begins before diabetes Most care for people with diabetes is NOT rocket science • but Diabetes is a progressive condition • We need to risk stratify – Between patients – Between risks in same pt • We must empower patients • We need to have sufficient capacity to do ALL above `I said pig,' replied Alice; `and I wish you wouldn't keep appearing and vanishing so suddenly: you make one quite giddy.' `All right,' said the Cat; and this time it vanished quite slowly, beginning with the end of the tail, and ending with the grin, which remained some time after the rest of it had gone. `Well! I've often seen a cat without a grin,' thought Alice; `but a grin without a cat! It's the most curious thing I ever saw in my life! Understanding risk essential for proper prescribing MICROALBUMINURIA Steno-2: •An attempt to validate the efficacy of daily clinical practice, i.e. the multifactorial treatment of type 2 diabetes •High risk type 2 diabetes patients •A single center study •An organisation which allowed for intensive intervention •Longterm intervention STENO-2 Estimated impact of single risk factor interventions to reduce CVD in patients with type 2 diabetes Relative risk reduction • • • • • • • None Cholesterol (down by 0.6 mmol/l) BP (down by 5/2 mm Hg) HbA1c (down by 0.9 %) Aspirin …… 25 % 27 % 13 % 9% 2-yr’s event reduction 11.0 % 8.3 % 6.0 % 5.2 % 4.7 % Cumulative relative risk reduction of about 57% • Huang et al. Am J Med 2001;111:633-642 Turner R.C. BMJ 1998;316:823-828 He et al. JAMA 1999;282:2027-2034 Antitrombotic Trialits BMJ 2002;324:71-86 STENO-2 HYPERTENSION OPTIONS Lifestyle, lifestyle, lifestyle and Drugs Stepwise approach to the treatment of hypertension Severity of hypertension Other ß-blocker Calcium antagonist Diuretics ACE inhibitor/Angiotensin II antagonist STENO-2 Cholesterol • Total Cholesterol to 4 mmol/l • LDL Cholesterol to 2 mmol/l CARDS HPS Jt British Soc Glucose lowering medications INCREASED GLUCOSE PRODUCTION LIVER PANCREAS DECREASED INSULIN SECRETION Therapy: Sulphonylureas Prandial Glucose Regulators incretins Insulin Therapy: Biguanides Thiazolidinediones incretins DECREASED Incretin production INTESTINE INCREASED GLUCOSE ABSORPTION Therapy: Alpha-glucosidase inhibitors HYPERGLYCEMIA DECREASED PERIPHERAL GLUCOSE UPTAKE MUSCLE ADIPOSE TISSUE Therapy: Thiazolidinediones Biguanides Does it matter what drug you use? Class of Drug average reduction in FBS HbA1c Reduction (mmol/l) (%) Sulphonylurea 3.3-3.9 0.8-2.0 Metaglinides 3.6-4.2 0.5-2.0 Metformin 2.8-3.9 1.5-2.0 Thiazolidinedione 3.3-4.3 1.4-2.6 α glucosidase inhibitor 1.9-2.2 0.7-1.0 sibutramine (responders33%) rimonabant 1.4-3.8 0.5-1.6 0.7 Stepwise treatment of hyperglycaemia BMI <27 BMI ≥27 Diet Gliclazide Gliclazide + Metformin Diet Metformin But many other options available STENO-2 Gliclazide + NPH insulin Metformin + NPH insulin Time Glitazones -cells INCRETINS increases insulin secretion glucose insulin GLP-1 GIP meal Rapidly inactivated by dipeptidyl peptidase IV Incretin actions Insulin is insulin…….. •Just different onsets and durations of action •Different devices •Tailor to individual patient’s lifestyle Putting it all together for 1 patient The Care Planning Model Case study – what would you do? • • • • • • • • 43 yr old ♂ Type 2 DM for 11 years Project Engineer on busy project UK↔USA Keeps DNA 98.2 Kg BMI 31kg/m2 BP 158/91 HbA1c 8.3% eGFR >60ml/min Total Chol 6.1mmol/l LDL 3.90mmol/l NovoRapid 8u / 8u / 8u Levemir 10u mane Atorvastatin 10mg Lisinopril 10mg