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www.who.int/chp
The global obesity pandemic: shaped by global drivers and local environments
Boyd A Swinburn, MD, Gary Sacks, PhD, Kevin D Hall, PhD, Klim McPherson, PhD, Diane T Finegood, PhD, Marjory L Moodie, DrPH and Steven L Gortmaker, PhD
The LancetVolume 378, Issue 9793, Pages 804-814 (August 2011)
DOI: 10.1016/S0140-6736(11)60813-1
Copyright © 2011 Elsevier Ltd Terms and Conditions
Figure 1
Source: The Lancet 2011; 378:804-814 (DOI:10.1016/S0140-6736(11)60813-1)
Terms and Conditions
Figure 2
Source: The Lancet 2011; 378:804-814 (DOI:10.1016/S0140-6736(11)60813-1)
Terms and Conditions
Figure 3
Source: The Lancet 2011; 378:804-814 (DOI:10.1016/S0140-6736(11)60813-1)
Terms and Conditions
Figure 4
Source: The Lancet 2011; 378:804-814 (DOI:10.1016/S0140-6736(11)60813-1)
Terms and Conditions
STANDARDS OF MEDICAL CARESTANDARDS OF MEDICAL CAREIN DIABETES—2011IN DIABETES—2011
A1C 6.5 – 7.5%**
Monotherapy
MET +
GLP-1 or DPP4 1
TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
MET + Colesevelam
AGI 3
2 - 3 Mos.***
2 - 3 Mos.***
2 - 3 Mos.***
Dual Therapy
MET +
GLP-1 or DPP4 1
+
TZD 2
Glinide or SU 4,7
A1C > 9.0%
No Symptoms
Drug Naive Under Treatment
INSULIN
± Other
Agent(s) 6
Symptoms
INSULIN
± Other
Agent(s) 6
INSULIN
± Other
Agent(s) 6
Triple Therapy
AACE/ACE Algorithm for Glycemic Control Committee
Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE
Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE
* May not be appropriate for all patients** For patients with diabetes and A1C < 6.5%,
pharmacologic Rx may be considered*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1 if PPG
2 TZD if metabolic syndrome and/or
nonalcoholic fatty liver disease (NAFLD)
3 AGI if PPG
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagoguewith multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy,insulin should be considered
MET +
GLP-1
or DPP4 1 ± SU 7
TZD 2
GLP-1
or DPP4 1 ± TZD 2
A1C 7.6 – 9.0%
Dual Therapy 8
2 - 3 Mos.***
2 - 3 Mos.***
Triple Therapy 9
INSULIN
± Other
Agent(s) 6
MET +
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
MET +
GLP-1
or DPP4 1+ TZD 2
GLP-1
or DPP4 1 + SU 7
TZD 2
MET † DPP4 1 GLP-1 TZD 2 AGI 3
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
A1C 6.5 – 7.5%**
Monotherapy
MET +
GLP-1 or DPP4 1
TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
MET +Colesevelam
AGI 3
2 - 3 Mos.***
Dual Therapy
MET +GLP-1 or DPP4 1
+
TZD 2
Glinide or SU 4,7
INSULIN
± Other Agent(s) 6
Triple Therapy
MET † DPP4 1 GLP-1 TZD 2 AGI 3
2 - 3 Mos.***
2 - 3 Mos.***
*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
3 AGI if PPG
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
MET +
GLP-1or DPP4 1
+ TZD 2
GLP-1or DPP4 1 + SU 7
TZD 2
A1C 7.6 – 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
Dual Therapy 8
MET +
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
2 - 3 Mos.***
Triple Therapy 9
2 - 3 Mos.***
INSULIN
± Other Agent(s) 6
*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy, insulin should be considered
No Symptoms
Drug Naive Under Treatment
Symptoms
MET +
GLP-1 or DPP4 1
± SU 7
TZD 2
GLP-1 or DPP4 1 ± TZD 2
A1C > 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
INSULIN
± Other Agent(s) 6
INSULIN
± Other Agent(s) 6
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
Recommendations:Recommendations:Glycemic Goals in Adults (1)Glycemic Goals in Adults (1)
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.
• Lowering A1C to below or around 7%– Shown to reduce microvascular and neuropathic
complications of diabetes– If implemented soon after diagnosis of diabetes,
associated with long-term reduction in macrovascular disease
• Therefore, a reasonable A1C goal for many non-pregnant adults is <7% (B)
Correlation of A1C with Estimated Correlation of A1C with Estimated Average Glucose (eAG)Average Glucose (eAG)
Mean plasma glucose
A1C (%) mg/dl mmol/l
6 126 7.0
7 154 8.6
8 183 10.2
9 212 11.8
10 240 13.4
11 269 14.9
12 298 16.5
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.
These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.
Glycemic Recommendations for Non-Glycemic Recommendations for Non-Pregnant Adults with Diabetes (1)Pregnant Adults with Diabetes (1)
A1C <7.0%*
Preprandial capillary plasma glucose
70–130 mg/dl* (3.9–7.2 mol/l)
Peak postprandial capillary plasma glucose†
<180 mg/dl* (<10.0 mmol/l)
*Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
Treatment Options
Pharmacological agents
Type 2 diabetes across generations: from pathophysiology to prevention and management
Christopher J Nolan, FRACP, Peter Damm, DMSc and Marc Prentki, PhD
The LancetVolume 378, Issue 9786, Pages 169-181 (July 2011)
DOI: 10.1016/S0140-6736(11)60614-4
Copyright © 2011 Elsevier Ltd Terms and Conditions
Figure 1
Source: The Lancet 2011; 378:169-181 (DOI:10.1016/S0140-6736(11)60614-4)
Terms and Conditions
Metformin. In most of the world, metformin is the only biguanide available. Its major effect is to decrease hepatic glucose output and lower fasting glycemia. Typically, metformin monotherapy will lower A1C levels by 1.5 percentage points (27,49). It is generally well tolerated, with the most common adverse effects being gastrointestinal. Metformin monotherapy is not usually accompanied by hypoglycemia and has been used safely, without causing hypoglycemia, in patients with prediabetic hyperglycemia (50). Metformin interferes with vitamin B12 absorption but is very rarely associated with anemia (27). The major nonglycemic effect of metformin is either weight stability or modest weight loss, in contrast with many of the other blood glucose–lowering medications. The UKPDS demonstrated a beneficial effect of metformin therapy on CVD outcomes (7), which needs to be confirmed. Renal dysfunction is considered a contraindication to metformin use because it may increase the risk of lactic acidosis, an extremely rare (less than 1 case per 100,000 treated patients) but potentially fatal complication (51). However, recent studies have suggested that metformin is safe unless the estimated glomerular filtration rate falls to 30 ml/min (52).
3434
IDF20053
IDF20053
Pacífico Asiático4 2009220092
NICE 20021
NICE 20021
MetforminaMetformina
1. UK National Clinical Guidelines for T2DM 2002. Rev 20052. Nathan DM et al. Diabetes Care 2009;31(1):193-2033. IDF Clinical Guidelines Task Force. Diabet Med 2006;23:579-934. Asian Pacific Type 2 Diabetes Practical Targets & Treatment. 4th Ed
Las Guías reconocen a la Metformina como el tratamiento base en la Diabetes Tipo 21-4
Dr. Enrique Mendoza
Institution: COMPLEJO HOSP DR AAM | Sign Out | Sign In as Individual | Contact Subscription Administrator at your institution | FAQ
MetforminMetformin
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
MONOTHERAPY
Metformin: Effect on Glucose and Insulin
Adapted from Jackson, et al. Diabetes. 1987;36:632-640, with permission.
BaselineMetformin
080
120
160
200
240
280
320
360
1 2 3
Oralglucose
Oralglucose
Time (h)0
0
20
40
60
1 2 3Time (h)
Plasma Glucose Serum Insulin
mg/
dL
U/L
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
MONOTHERAPY
Metformin:Effect on HbA1c
Adapted from De Fronzo, et al. N Engl J Med. 1995;333:541-549, with permission.
1
Diet + placebo
Diet + metformin
*P <.001
0
** * * * *
0 9 13Treatment (wk)
17 21 25 29
–1
–2
+0.4%
–1.4%
Ch
ange
in M
ean
Hb
A1c
(%)
The consensus report concluded that “Although still limited, early evidence suggests that metformin is associated
with a lower risk of cancer and that
IV. PREVENTION/DELAY OF IV. PREVENTION/DELAY OF TYPE 2 DIABETESTYPE 2 DIABETES
Recommendations:Recommendations:Prevention/Delay of Type 2 DiabetesPrevention/Delay of Type 2 Diabetes• Refer patients with IGT (A), IFG (E), or A1C 5.7-
6.4% (E) to support program– Weight loss 7% of body weight– At least 150 min/week moderate activity
• Follow-up counseling important (B);third-party payors should cover (E)
• Consider metformin if multiple risk factors, especially if hyperglycemia (e.g., A1C>6%) progresses despite lifestyle interventions (B)
• In those with prediabetes, monitor for development of diabetes annually (E)
ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2011;34(suppl 1):S16.
Volume 352:1223-1236 March 24, 2005 Number 12
Clinical Therapeutics Metformin for the Treatment of the Polycystic
Ovary Syndrome
John E. Nestler, M.D.
N Engl J MedVolume 358(1):47-54
January 3, 2008
Original Article Metformin versus Insulin for the Treatment of
Gestational Diabetes
Janet A. Rowan, M.B., Ch.B., William M. Hague, M.D., Wanzhen Gao, Ph.D., Malcolm R. Battin, M.B., Ch.B., M. Peter Moore, M.B., Ch.B., for the MiG
Trial Investigators
N Engl J MedVolume 358(19):2003-2015
May 8, 2008
Study Overview
• This open-label trial compared insulin with metformin (with supplemental insulin if required) for the treatment of gestational diabetes mellitus
• The rates of neonatal complications were similar in the two groups, and more women in the metformin group than in the insulin group reported that they would choose their assigned treatment again
• These results provide support for the use of metformin as initial treatment for gestational diabetes in women who require pharmacologic therapy
Conclusion
• In women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin
• The women preferred metformin to insulin treatment
UKPDS: Post –Trial MonitoringSurvival and Myocardial Infarction
Metformin*Sulfonylureas * / Insulin *
Su
rvivalM
I
Holman RR. NEJM ,2008; 359: 1577 - 89
-33%
-36%
-39%
-27%
-15%
-13%
* Including glibenclamide, ** vs Lifestyle
-8%
-14%
*
Conclusion
• Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up
• A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837.)
A1C 6.5 – 7.5%**
Monotherapy
MET +
GLP-1 or DPP4 1
TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
MET + Colesevelam
AGI 3
2 - 3 Mos.***
2 - 3 Mos.***
2 - 3 Mos.***
Dual Therapy
MET +
GLP-1 or DPP4 1
+
TZD 2
Glinide or SU 4,7
A1C > 9.0%
No Symptoms
Drug Naive Under Treatment
INSULIN
± Other
Agent(s) 6
Symptoms
INSULIN
± Other
Agent(s) 6
INSULIN
± Other
Agent(s) 6
Triple Therapy
AACE/ACE Algorithm for Glycemic Control Committee
Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE
Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE
* May not be appropriate for all patients** For patients with diabetes and A1C < 6.5%,
pharmacologic Rx may be considered*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1 if PPG
2 TZD if metabolic syndrome and/or
nonalcoholic fatty liver disease (NAFLD)
3 AGI if PPG
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagoguewith multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy,insulin should be considered
MET +
GLP-1
or DPP4 1 ± SU 7
TZD 2
GLP-1
or DPP4 1 ± TZD 2
A1C 7.6 – 9.0%
Dual Therapy 8
2 - 3 Mos.***
2 - 3 Mos.***
Triple Therapy 9
INSULIN
± Other
Agent(s) 6
MET +
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
MET +
GLP-1
or DPP4 1+ TZD 2
GLP-1
or DPP4 1 + SU 7
TZD 2
MET † DPP4 1 GLP-1 TZD 2 AGI 3
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
Current Guidelines for Diabetes Management
Country or region
UK (NICE)
Australia
Asia-Pacific
Fra (AFSSAPS)
Germany (DDG)
S Afr (SEMDSA)
Lat Am (ALAD)
USA (ADA)
Europe (EASD)
IDF (global)
Year
2005/8
2004
2005
1999
2003
2002
2007
2006/8/9
2006/8/9
2005
BMI definition
of overweight
(kg/m2)
>25
None
>23
>28
>25-27
>25
>27
>25
>25
>25
Overweight
Metformin
Metformin
Metformin
Metformin
Metformin
Consider met
Metformin
Metformin
Metformin
Metformin
Non-overweight
Consider metformin
Initiate with metformin
Metformin, SU,TZD,AGI
Metformin, SU or AGI
Insulin secretagogue
No recommendation
Metformin
Metformin
Metformin
Metformin,SU
Recommendations for initiating pharmacologic
therapy after failure of diet and exercise
Big Question is what to add to Metformin
Choice of agents for combination therapy
Metformin
AcarboseMiglitolVoglibose
RosiglitazonePioglitazone
GlipizideGliclazideGlimepirideGlibenclamide Repaglinide
Nateglinide
SitagliptinVildagliptin
Emerging
Established
Fixed Dose Combinationsreducing the pill burden
1. Metformin + Glibenclamide (Glucovance ®)
2. Metformin + Glimepiride ( Amaryl M ®)
3. Metformin + Rosiglitazone (Avandamet ®)
4. Metformin + Pioglitazone (Competact®)
5. Metformin + Sitagliptin (Janumet®)
6. Metformin + Vildagliptin (Eucreas® Jalra M)
Choice of agents for combination therapy
Metformin
AcarboseMiglitolVoglibose
RosiglitazonePioglitazone
GlipizideGliclazideGlimepirideGlibenclamide Repaglinide
Nateglinide
SitagliptinVildagliptin
Emerging
Established
Management of type 2 diabetes: new and future developments in treatment
Abd A Tahrani, MD, Clifford J Bailey, PhD, Stefano Del Prato, MD and Anthony H Barnett, MD
The LancetVolume 378, Issue 9786, Pages 182-197 (July 2011)
DOI: 10.1016/S0140-6736(11)60207-9
Copyright © 2011 Elsevier Ltd Terms and Conditions
Figure 1
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 2
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 3
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 4
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 5
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 6
Source: The Lancet 2011; 378:182-197 (DOI:10.1016/S0140-6736(11)60207-9)
Terms and Conditions
Figure 6
Source: The Lancet 2011; 378:169-181 (DOI:10.1016/S0140-6736(11)60614-4)
Terms and Conditions
VI. PREVENTION AND MANAGEMENT OFDIABETES COMPLICATIONS
• CVD is a major cause of morbidity, mortality for those with diabetes
• Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD
• Diabetes itself confers independent risk• Benefits observed when individual cardiovascular risk
factors are controlled to prevent/slow CVD in people with diabetes
Cardiovascular Disease (CVD) in Cardiovascular Disease (CVD) in Individuals with DiabetesIndividuals with Diabetes
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Screening and diagnosis• Measure blood pressure at every routine diabetes visit• If patients have systolic blood pressure
≥130 mmHg or diastolic blood pressure ≥80 mmHg– Confirm blood pressure on a separate day– Repeat systolic blood pressure ≥130 mmHg or diastolic
blood pressure ≥80 confirms a diagnosis of hypertension (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Goals• A goal systolic blood pressure <130 mmHg is
appropriate for most patients with diabetes (C)• Based on patient characteristics and response to
therapy, higher or lower systolic blood pressure targets may be appropriate (B)
• Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (1)• Patients with a systolic blood pressure 130–139
mmHg or a diastolic blood pressure 80–89 mmHg– May be given lifestyle therapy alone for a maximum of 3
months– If targets are not achieved, patients should be treated
with the addition of pharmacological agents (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (2)• Patients with more severe hypertension
(systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) at diagnosis or follow-up– Should receive pharmacologic therapy in addition
to lifestyle therapy (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (3)• Lifestyle therapy for hypertension
– Weight loss if overweight– DASH-style dietary pattern including reducing
sodium, increasing potassium intake– Moderation of alcohol intake– Increased physical activity (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (4)• Pharmacologic therapy for patients with diabetes and hypertension
– Pair with a regimen that includes either an ACE inhibitor or angiotensin II receptor blocker
– If one class is not tolerated, the other should be substituted• If needed to achieve blood pressure targets
– Thiazide diuretic should be added to those with estimated GFR ≥30 ml x min/1.73 m2
– Loop diuretic for those with an estimated GFR <30 ml x min/1.73 m2 (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (5)• Multiple drug therapy (two or more agents at
maximal doses)– Generally required to achieve blood pressure
targets (B)• If ACE inhibitors, ARBs, or diuretics are used
– Kidney function, serum potassium levels should be monitored (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control
Treatment (6)• In pregnant patients with diabetes and chronic
hypertension– Blood pressure target goals of 110–129/65–79 mmHg are
suggested in interest of long-term maternal health and minimizing impaired fetal growth
• ACE inhibitors, ARBs, contraindicated during pregnancy (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Screening• In most adult patients
– Measure fasting lipid profile at least annually• In adults with low-risk lipid values (LDL
cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl)– Lipid assessments may be repeated every 2 years
(E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (1)• To improve lipid profile in patients with diabetes,
recommend lifestyle modification (A), focusing on– Reduction of saturated fat, trans fat, cholesterol intake– Increased n-3 fatty acids, viscous fiber,
plant stanols/sterols– Weight loss (if indicated)– Increased physical activity
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (2)• Statin therapy should be added to lifestyle
therapy, regardless of baseline lipid levels, for diabetic patients:– with overt CVD (A)– without CVD who are >40 years of age and have
one or more other CVD risk factors (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (3)• For patients at lower risk (e.g., without
overt CVD and <40 years of age) (E)– Statin therapy should be considered in addition
to lifestyle therapy if LDL cholesterol remains >100 mg/dl
– In those with multiple CVD risk factors
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (4)• In individuals without overt CVD
– Primary goal is an LDL cholesterol<100 mg/dl (2.6 mmol/l) (A)
• In individuals with overt CVD– Lower LDL cholesterol goal of <70 mg/dl
(1.8 mmol/l), using a high dose of a statin, is an option (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (5)• If targets not reached on maximal tolerated statin therapy
– Alternative therapeutic goal: reduce LDL cholesterol ~30–40% from baseline (A)
• Triglyceride levels <150 mg/dl (1.7 mmol/l), HDL cholesterol >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirable– However, LDL cholesterol–targeted statin therapy remains the
preferred strategy (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management
Treatment recommendations and goals (6)• If targets are not reached on maximally tolerated
doses of statins– Combination therapy using statins and other lipid
lowering agents may be considered to achieve lipid targets
– Has not been evaluated in outcome studies for either CVD outcomes or safety (E)
• Statin therapy is contraindicated in pregnancy
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Kaplan–Meier Curve for the Primary End Point.
The AIM-HIGH Investigators. N Engl J Med 2011. DOI: 10.1056/NEJMoa1107579
Causal Diagram of the Relationships among Niacin, Major Lipid Levels, and Clinical Outcomes.
Giugliano RP. N Engl J Med 2011. DOI: 10.1056/NEJMe1112346
Recommendations: Glycemic, Blood Recommendations: Glycemic, Blood Pressure, Lipid Control in AdultsPressure, Lipid Control in Adults
A1C <7.0%*
Blood pressure <130/80 mmHg†
LipidsLDL cholesterol <100 mg/dl
(<2.6 mmol/l)‡
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.
†Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.
‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of statin, is an option.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31. Table 12.
Recommendations:Recommendations:Antiplatelet Agents (1)Antiplatelet Agents (1)
• Consider aspirin therapy (75–162 mg/day) (C)– As a primary prevention strategy in those with type 1 or type 2
diabetes at increased cardiovascular risk (10-year risk >10%)– Includes most men >50 years of age or women >60 years of age
who have at least one additional major risk factor• Family history of CVD• Hypertension• Smoking• Dyslipidemia• Albuminuria
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
Recommendations:Recommendations:Antiplatelet Agents (2)Antiplatelet Agents (2)
• Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C)• 10-year CVD risk <5%: men <50 and women <60 years
of age with no major additional CVD risk factors • In patients in these age groups with multiple
other risk factors (e.g., 10-year risk 5%-10%) clinical judgment is required (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
Recommendations:Recommendations:Antiplatelet Agents (3)Antiplatelet Agents (3)
• Use aspirin therapy (75–162 mg/day)– Secondary prevention strategy in those with diabetes with a
history of CVD (A)• For patients with CVD, documented aspirin allergy
– Clopidogrel (75 mg/day) should be used (B)• Combination therapy with ASA (75–162 mg/day) and
clopidogrel (75 mg/day)– Reasonable for up to a year after an acute coronary
syndrome (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
Hypertension Implementing NICE guidance
August 2011
NICE clinical guideline 127
Updated guidance
This guideline updates and replaces ‘Hypertension: management of hypertension in adults in primary care’ (NICE clinical guideline 34, 2006).
NICE clinical guideline 34 was a partial update of ‘Hypertension’ (NICE clinical guideline 18, 2004).
This update was produced in collaboration with the British Hypertension Society
NICE Pathway
The NICE Hypertension pathway shows all the recommendations in the Hypertension guideline
Click here to go to NICE Pathways
website
What this presentation covers
• Background
• Scope
• Key priorities for implementation and
updated areas
• Areas not updated
• Costs and savings
• Discussion
• Find out more
Background
High Blood Pressure:
• Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.
• Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state.
• Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:– 7% from heart disease – 10% from stroke.
Epidemiology
• Hypertension is common in the UK population.
• Prevalence influenced by age and lifestyle factors.
• 25% of the adult population in the UK have hypertension.
• 50% of those over 60 years have hypertension.
• With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.
DefinitionsStage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or higher and• ABPM or HBPM average is 135/85 mmHg or higher.
Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg or higher.
Severe hypertension: • Clinic BP is 180 mmHg or higher or• Clinic diastolic BP is 110 mmHg or higher.
Scope
Groups not included are people with diabetes, secondary causes of hypertension, accelerated hypertension or acute hypertension, pregnant women, and children and young people aged under 18.
Clinical management of primary hypertension in adults who may, or may not, have pre-existing cardiovascular disease.
Key priorities for implementation
• Diagnosis.
• Initiating and monitoring antihypertensive drug treatment.
• Choosing antihypertensive drug treatment.
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
Diagnosis (1)
When using the following to confirm diagnosis, ensure: ABPM:–at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosisHBPM:–two consecutive seated measurements, at least 1 minute apart–blood pressure is recorded twice a day for at least 4 days and preferably for a week–measurements on the first day are discarded – average value of all remaining is used.
Diagnosis (2)
Offer antihypertensive drug treatment to people:• who have stage 1 hypertension, are aged under 80 and
meet identified criteria• who have stage 2 hypertension at any age.
If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider:
• specialist evaluation of secondary causes of hypertension• further assessment of potential target organ damage.
Initiating drug treatment
Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below:
• 140/90 mmHg in people aged under 80• 150/90 mmHg in people aged 80 and over
Monitoring drug treatment (1)
For people identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment.
Aim for ABPM/HBPM target average of:• below 135/85 mmHg in people aged under 80• below 145/85 mmHg in people aged 80 and over.
Monitoring drug treatment (2)
White-coat effect: a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.
Care pathway
CBPM ≥160/100 mmHg & ABPM/HBPM
≥ 150/95 mmHg
Stage 2 hypertension
Consider specialist referral
Offer antihypertensive drug treatment
Offer lifestyle interventions
If younger than 40 years
If target organ damage present or 10-year cardiovascular risk > 20%
Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication
Offer patient education and interventions to support adherence to treatment
CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg
Stage 1 hypertension
Step 4
Summary of antihypertensive
drug treatment
Aged over 55 years or black person of African or Caribbean family origin of any age
Aged under55 years
C2A
A + C2
A + C + D
Resistant hypertension
A + C + D + consider further diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
Step 1
Step 2
Step 3
KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic
See slide notes for details of footnotes 1-5
Offer people aged 80 and over the same antihypertensive drug treatment as people aged over 55, taking into account any comorbidities.
Drug treatment
Choosing antihypertensive drug treatment
Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated.
When using an automated device:
•palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually
•ensure that the device is validated* and an appropriate cuff size for the person’s arm is used.
Measuring blood pressure:updated recommendations
* See notes
Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension.
For all people with hypertension offer to:
–test urine for presence of protein–take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol–examine fundi for hypertensive retinopathy–arrange a 12-lead ECG.
Assessing cardiovascular risk and target organ damage:
updated recommendations
Lifestyle interventionsOffer guidance and advice about:
– diet (including sodium and caffeine intake) and exercise
– alcohol consumption
– smoking.
Patient education and adherenceProvide:
– information about benefits of drugs and side effects
– details of patient organisations
– an annual review of care.
Additional recommendations
Costs and savings for total population of England
Year Change in diagnosis cost
(£m)
Change in treatment cost
(£m)
Net resource impact
(£m)Year 1 £5.1 − £2.5 £2.6
Year 2 £5.1 − £5.8 − £0.7
Year 3 £5.1 − £9.1 − £4.0
Year 4 £5.1 −£12.4 − £7.3
Year 5 £5.1 −£15.7 −£10.5
Costs and savings of using ABPM to confirm diagnosis of hypertension
Discussion
• How do our diagnosis and treatment pathways for people with hypertension need to change in order to bring them in line with this guidance?
• What innovative ways can we think of to enhance our capacity to deliver ABPM to people who need it?
• What action do we need to take to ensure our blood pressure monitoring devices are properly validated, maintained and regularly calibrated?
• Who within our team needs briefing or training to ensure consistent implementation?
NHS Evidence
Visit NHS Evidence for the best available evidence on all aspects of cardiovascular disease
Click here to go to the NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG127 for:
Visit http://pathways.nice.org.uk/pathways/hypertension to access the hypertension NICE pathway (see slide 3)
• audit support• baseline assessment tool• clinical case scenarios• implementation advice• podcast
• the guideline • the quick reference guide• ‘Understanding NICE guidance’• costing report and template
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