Prevention of Herpes Zoster and Postherpetic Neuralgia
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Transcript Prevention of Herpes Zoster and Postherpetic Neuralgia
Barriers to Diabetes Control
Mark E. Molitch, MD
NHANES: Achieving ADA
Recommendations, 2003-2006
• Individuals reaching glycemic control targets:
• HbA1c <7%
57.1%
• Individuals achieving other ADA goals of therapy:
• BP <130/80 mm Hg
45.5%
• LDL <100 mg/dL
46.5%
• Only 12.2% of individuals met all 3 goals
Abbreviations: BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein;
NHANES, National Health and Nutrition Examination Survey
Cheung BM, et al. Am J Med. 2009;122:443-453.
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Treatment Algorithm for Type 2 Diabetes
STEP 1
At diagnosis:
Lifestyle + Metformin
HbA1c >7.0%
STEP 2
Add basal
insulin
STEP 3
Add
sulfonylurea
Add DPP-4
inhibitor
Add GLP-1
agonist
Add
pioglitazone
Intensive insulin
NOT glyburide, chlorpropamide
NOT rosiglitazone
Abbreviations: DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide
Nathan DM, et al. Diabetes Care. 2009;32:193-203.
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Combination Therapy in Type 2 Diabetes:
Decision Considerations
HbA1c efficacy
Reductions from baseline
Reaching target
Synergy of mechanisms of action
Side effects and toxicity profile
Frequency and severity of hypoglycemia
Effect on weight gain
Avoiding polypharmacy and complex
regimens
Compliance and convenience
Cost
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Barriers to Diabetes Control
•
•
•
•
Clinical inertia
Financial
Adverse effects of oral agents
Insulin
•
•
•
Fear of injections
Fear of hypoglycemia
Complexity of management
• Targets of treatment
•
Need to adjust to individual patient
• Cultural
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Earlier and More Aggressive Intervention May Improve
Treating to Target Compared With Conventional Therapy
Typical progression is to wait for HbA1c to reach 8–9%
before moving to next step
Monotherapy
Uptitrate dose of
monotherapy
Add 2nd and then
3rd drug
Moving more aggressively
to more potent treatment can
achieve goal of HbA1c
of < 7% more quickly
Add basal insulin
then multiple
insulin injections
per day
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Advantages & Disadvantages of Type 2 Diabetes Medications
Class (examples)
Potency
Risk of hypoglycemia
Weight
Other
(glipizide,
glyburide, glimepiride)
+++
+++
Greatest
increase
Less likely to maintain
control as monotherapy
Meglitinides (nateglinide,
+
++
Increase
Short acting
Metformin
+++
+
Neutral
Thiazolidinediones
++
+
Greatest
increase
Fluid retention, worsen
CHF, fractures. Risk of
cardiac events.
+
+
Decrease
Intestinal gas, poor
tolerance
+
+
Neutral
+
+
Decrease
Injection, GI effects
+++
+++
Greatest
increase
Injection
Sulfonylureas
rapaglinide)
(Rosiglitazone,
Pioglitazone)
α-Glucosidase
inhibitors (acarbose,
GI intolerance, rare
lactic acidosis
miglitol)
DPP-4 inhibitors
(sitagliptin, saxagliptin,
Headache, risk of
infection
linagliptin)
GLP-1 analogs
(exenatide, liraglutide)
Insulin
AACE/ACE Diabetes Algorithm for Glycemic Control. Endrocr Pract. 2009;15:540-559.
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Barriers to Insulin Therapy: Common Concerns
Insulin therapy might cause:
• Worsening insulin resistance
– But reduction of glucose toxicity improves resistance
• More cardiovascular risk
– But reduction in glucose improves cardiovascular risk
• Weight gain
– Yes, it does occur with improved metabolic efficiency
• Hypoglycemia
– Very rare with type 2 diabetes
– Common with type 1 diabetes as approaching optimum
glycemic control
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Challenges and Opportunities in Minority
Populations
•
•
•
•
•
•
Rapidly growing populations
High rates of type 2 diabetes and its complications
Groups with unique culture, health beliefs, myths,
and food preferences
Diverse level of education and socio-economic status
Insufficient culturally oriented diabetes care, education,
and research programs
Health care system and health professional barriers
Cultural competency is key to approaching patients in a
beneficial way
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Why We Cannot Always Extrapolate to
Older Adults with Diabetes
• Heterogeneity
• Comorbid conditions
– Functional limitations
– Cognitive decline
• Polypharmacy
• Life expectancy versus
– Time to incidence or progression of microvascular
or macrovascular complications
– Time to expected benefit of intervention
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