Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand
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Type 2 diabetes Key slides 3; Management of blood glucose Lending our patients a hand. Glucose control Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008. Measure HbA 1c every 2 to 6 months, until stable on unchanging therapy, then every 6 months

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Type 2 diabetes Key slides 3; Management of blood glucose Lending our patients a hand

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Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand

Type 2 diabetesKey slides 3;Management of blood glucoseLending our patients a hand


Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand 1345749

Glucose control

Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008

  • Measure HbA1c every 2 to 6 months, until stable on unchanging therapy,

  • then every 6 months

  • Only offer self-monitoring of blood glucose as an integral part of self-management

  • education (discuss purpose, interpretation and how it should be acted upon)

  • see later for more details


Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand 1345749

Algorithm for glucose control [1]

Type 2 diabetes: the management of type 2 diabetes.

NICE Clinical Guideline 66;May 2008

Continued on next slide…


Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand 1345749

Algorithm for glucose control [2]

Type 2 diabetes: the management of type 2 diabetes.

NICE Clinical Guideline 66;May 2008

Continued from previous slide

The guidance on glitazones, gliptins and exenatide will be updated in the NICE short clinical guideline ‘Newer agents for blood glucose in type 2 diabetes’, expected May 2009


What is the guidance from nice nice clinical guideline 66 may 2008

What is the guidance from NICE? NICE Clinical Guideline 66;May 2008

  • Glitazones are third-line agents, as triple therapy with metformin and a SU if glycaemic control is insufficient (HbA1c>7.5%)

  • Or second-line agents (at HbA1c>6.5%), as dual therapy with metformin if hypoglycaemia on a SU a particular issue, or with a SU if metformin not tolerated/contraindicated

  • But there are safety issues; only pioglitazone▼ can be used with insulin

The section covering glitazones, gliptins and exenatide will be updated in the NICE short clinical guideline ‘Newer agents for blood glucose in type 2 diabetes’, expected May 2009


Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand 1345749

Do glitazones have POO data? CochraneRichter B, et al. Pioglitazone Cochrane Review 2006Richter B, et al. Rosiglitazone Cochrane Review 2007

Pioglitazone▼

  • 22 RCTs (n=6,200 randomised to pioglitazone▼), included PROactive (average follow-up 34.5 months, primary endpoint: CV outcomes)

    Dormandy JA, et al. Lancet 2005;366:1279–1289

  • Concluded:

    • no convincing evidence that patient-orientated outcomes (mortality, morbidity, adverse effects, costs, QoL) were positively influenced by pioglitazone ▼

    • Oedema was significantly increased

    • Results of PROactive need confirmation; hypothesis generating

      Rosiglitazone

  • 18 RCTs (n=3,888 randomised to rosiglitazone), included ADOPT (average follow-up 4 years, primary endpoint: glycaemic control)

    Kahn SE, et al. N Engl J Med 2006;355:2427–2443

  • Concluded:

    • No convincing evidence that patient-orientated outcomes (mortality, morbidity, adverse effects, costs, QoL) were positively influenced by rosiglitazone

    • Oedema was significantly increased

    • ADOPT indicated increased CV risk


What did drug safety update say drug safety update 2007 1 5

What did Drug Safety Update say?Drug Safety Update 2007;1 (5)

  • A Europe-wide safety and efficacy review found that the benefits of rosiglitazone

  • and pioglitazone▼ continue to outweigh the risks

  • However, the prescribing information has been updated to include warnings that:

  • - Rosiglitazone should be used in patients with ischaemic heart disease only after careful evaluation of every patient’s individual risk

  • - Rosiglitazone combined with insulin should be used only in exceptional cases and under close supervision


Oral hypoglycaemics old vs new drugs bolen s et al ann intern med 2007 147 386 99

Oral hypoglycaemics: Old vs. new drugsBolen S, et al. Ann Intern Med 2007;147:386–99

  • Systematic review of 216 studies and 2 earlier systematic reviews of oral hypoglycaemics to January 2006

  • Data on major clinical endpoints, eg CV mortality were limited, therefore inconclusive

  • But concluded that older agents have similar or superior effects to newer, more expensive agents on glycaemic control, lipids and other intermediate endpoints (body weight, BP, adverse effects, etc.)

    • Older agents: metformin, SU

    • Newer agents: glitazones, alpha-glucosidase inhibitors, eg acarbose and meglitinides


Type 2 diabetes key slides 3 management of blood glucose lending our patients a hand 1345749

Self-monitoring blood glucose

Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008

  • Make available to:

  • Those on insulin

  • Those on oral medication to provide information on hypoglycaemia

  • Assess changes during medication or lifestyle changes, or illness

  • Ensure safety during activities, including driving

  • Assess at least annually in a structured way:

  • Self-monitoring skills

  • Quality and appropriate frequency of testing

  • The use made of results obtained

  • The impact on quality of life

  • The continued benefit

  • The equipment used


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