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![Page 1: Preferred treatment options for patients with Diabetes Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood.](https://reader035.fdocuments.in/reader035/viewer/2022062718/56649e875503460f94b8bc21/html5/thumbnails/1.jpg)
Preferred treatment options for patients with Diabetes
Dr Jon Tuppen GPwSI
Beechwood Surgery Brentwood
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Case Study – what would you do?Case Study – what would you do?What else do you need to know?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
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Diabetes is simple isn’t it?
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Make it as simple and holistic as possible
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CVD risk progression begins before diabetes
Remember the diagnosis of Diabetes
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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
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`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!
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Understanding riskessential for proper prescribing
MICROALBUMINURIA
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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
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STENO-2
Estimated impact of single risk factor interventions to reduce CVD in patients with type 2 diabetes
• Relative risk 2-yr’s event• reduction reduction
• None …… 11.0 %• Cholesterol (down by 0.6 mmol/l) 25 %
8.3 %• BP (down by 5/2 mm Hg) 27 % 6.0 %• HbA1c (down by 0.9 %) 13 % 5.2 %• Aspirin 9 % 4.7 %
Cumulative relative risk reduction of about 57% •
Huang et al. Am J Med 2001;111:633-642Turner R.C. BMJ 1998;316:823-828He et al. JAMA 1999;282:2027-2034Antitrombotic Trialits BMJ 2002;324:71-86
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HYPERTENSION OPTIONS
Lifestyle, lifestyle, lifestyle
and
Drugs
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STENO-2
ACE inhibitor/Angiotensin II antagonist
Diuretics
Calcium antagonist
ß-blocker
OtherSeverity of hypertension
Stepwise approach to the Stepwise approach to the treatment of hypertension treatment of hypertension
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Cholesterol
• Total Cholesterol to 4 mmol/l
• LDL Cholesterol to 2 mmol/l
CARDSHPS
Jt British Soc
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Glucose lowering medications
INCREASED GLUCOSE
PRODUCTION
HYPERGLYCEMIA
INCREASEDGLUCOSE
ABSORPTION
MUSCLE ADIPOSE TISSUE
INTESTINE DECREASED PERIPHERAL
GLUCOSE UPTAKE Therapy:
ThiazolidinedionesBiguanides
PANCREASLIVER DECREASED
INSULIN SECRETION
Therapy:Sulphonylureas
Prandial Glucose RegulatorsincretinsInsulin
Therapy:Biguanides
Thiazolidinedionesincretins
Therapy:Alpha-glucosidase inhibitors
DECREASEDIncretin
production
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Does it matter what drug you use?
Class of Drug
average reduction in FBS
(mmol/l)HbA1c Reduction
(%)
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%) 1.4-3.8 0.5-1.6rimonabant 0.7
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Stepwise treatment of hyperglycaemia
STENO-2
Diet
Diet
Gliclazide
Metformin
Gliclazide+
NPH insulin
Metformin+
NPH insulin
Time
BMI <27
BMI ≥27
Gliclazide+
Metformin
But many other options available
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Glitazones
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insulinglucose
meal
GLP-1
GIP
-cells
Rapidly inactivated by dipeptidyl peptidase IV
increases insulin secretionincreases insulin secretion
INCRETINS
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Incretin actions
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Insulin is insulin……..
•Just different onsets and durations of action
•Different devices
•Tailor to individual patient’s lifestyle
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Putting it all together for 1 patient
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The Care Planning Model
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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