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Type 2 Diabetes Outpatient management

Alex Gonzalez MD, FACP. Type 2 Diabetes Outpatient management. Diabetes in the U.S. 25 million people with Diabetes 8.3% of the population 350.000 children. DIABESITY IN USA. 21 st century Mona Lisa. Diagnosis of Diabetes. HbA1c 6.5% or higher.

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Type 2 Diabetes Outpatient management

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  1. Alex Gonzalez MD, FACP Type 2 Diabetes Outpatient management

  2. Diabetes in the U.S. • 25 million people with Diabetes • 8.3% of the population • 350.000 children.

  3. DIABESITY IN USA

  4. 21st century Mona Lisa

  5. Diagnosis of Diabetes • HbA1c 6.5% or higher. The diagnostic cut point of 6.5% is associated with increased prevalence of Retinopathy The laboratory should be certified. Point of care assays are not acceptable.

  6. Diagnosis of Diabetes Fasting Plasma Glucose 126 mg/dL or higher 2-Hour post glucose load Plasma Glucose of 200mg/dL or higher Random Plasma Glucose of 200 mg/dl or higher with symptoms of hyperglycemia. Home glucose monitoring meters are not adequate for diagnosis

  7. Diagnosis of Diabetes • HbA1c 6.5% or higher. Not advised in patients with reduced red blood cell lifespan (sickle cell, hemolytic anemia, iron deficiency anemia, chronic renal or hepatic disease…). In those patients you should use plasma glucose levels for the diagnosis of Diabetes

  8. Prediabetes • HbA1c 5.7% to 6.4%. Impaired Fasting Glucose (IFG): Fasting Plasma Glucose 100 to 125 mg/dL Impaired Glucose Tolerance (IGT): 2 hour after glucose load values of 140 to 199 mg/dL High risk for Cardiovascular Disease, HTN, Dyslipidemia and Central Obesity. Some may have early signs of Retinopathy, Neuropathy and Nephropathy.

  9. Diabetes Prevention Program 3239 patients with Prediabetes Placebo Metformin Lifestyle changes: Weight loss (8%) Walk 150 minutes/week NEJM:2002.346:393-403

  10. Cardiovascular Protection in T2DM • .

  11. LANDMARK STUDIESDCCT and UKPDS Trials. Type 1 (DCCT) Type 2 (UKPDS) Several thousand patients randomized to standard and intensive diabetes care. The patients were relatively young, had been recently diagnosed with diabetes and most had no preexisting cardiovascular disease.

  12. DCCT

  13. DCCT. Cardiovascular outcomes

  14. ACCORD Trial (2008) • 10,000 patients with T2DM were randomized to standard or intensive therapy to evaluate the impact of good control on chronic diabetes complications • The patients were older, with longer duration of diabetes and most had preexisting cardiovascular disease • RESULTS: • No impact on cardiovascular outcomes • 23% higher risk of death in the intensive group. (257 vs 203 deaths)

  15. ADVANCE Trial (2008) • 11,140 patients with type 2 diabetes randomized to intensive and usual care. The intensively treated achieved A1c levels of 6.5% • After 5 years intensive glucose control produced no benefit from CV deaths or death from any cause • Intensive control decreased incidence of renal disease (microalbuminuria/nephropathy)

  16. (Veterans Affairs Diabetes Trial)VDAT (2009) • Designed to compare the effects of intensive glucose control vs standard control in veterans with type 2 DM • 1,791 patients • 7.5 years • Mean A1c difference between groups was 1.5 % • Researchers found no difference in deaths/CVD morbidity

  17. Why different outcomes? • Different patients • DCCT/UKPDS patients were younger, had shorter duration of Diabetes, and most had no cardiovascular disease • ACCORD/ADVANCE/VADT patients were older, had had Diabetes for many years, and most had cardiovascular disease

  18. RECOMMENDATIONS • Aggressive treatment for younger, recently diagnosed diabetics with minimal or no cardiovascular disease. Goal A1c as close to 6% as possible • More gentle treatment for older diabetics with cardiovascular disease and longer duration of diabetes. Goal A1c 7.5% • Do not reduce the HBA1c rapidly, gradual lowering over 6 months recommended

  19. Individualizing Glycemic targets in Type 2 Diabetes Mellitus Ann Intern Med. 2011;154:554-559

  20. Control of Lipids • Most patients require Statins. • Fibric Acid Derivatives,Nicotinic Acid,Ezetimibe (Zetia),Bile Acid Binding Resins… added to Statins, do not improve cardiovascular outcomes or all cause mortality.

  21. Control of Lipids Aggressively lowering lipid levels increases mortality in patients 80 years and older Petersen et all. Lipid lowering to the end? Age,Ageing. 2010;39(6):674-680.

  22. Control of Arterial Hypertension • ACCORD Hypertension subgroup Patients treated to lower the systolic blood pressure to 120 mm/Hg did no better than those whose systolic pressure was 140.

  23. Control of Arterial Hypertension Recomendations • Blood Pressure Goal of 130/80 Adjust to symptoms in older patients

  24. Control of Lipids Recommendations Statins Add Omega 3 FAs, Fibrates or Nicotinic Acid to patients with Triglycerides >500 mg/dL to prevent Pancreatitis. Patients intolerant to Statins: Omega 3 FAs Option: Fibrates/Nicotinic Acid.

  25. Cardiovascular Protection in T2DM • .

  26. In Summary • Individualize Glycemic Control, adjusted to age, duration of Diabetes, existing cardiovascular disease etc. • Control the Arterial Hypertension. • Correct the Dyslipidemia. • Use common sense !!!

  27. Watch out !

  28. Questions ?

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