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Preferred treatment options for patients with Diabetes . Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood. Case Study – what would you do? 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/m 2

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preferred treatment options for patients with diabetes

Preferred treatment options for patients with Diabetes

Dr Jon Tuppen GPwSI

Beechwood Surgery Brentwood

case study what would you do what else do you need to know
Case Study – what would you do?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
remember the diagnosis of diabetes
Remember the diagnosis of Diabetes

CVD risk progression begins before diabetes

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

Most care for people with diabetes is NOT rocket science
slide7

`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!

steno 2

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

estimated impact of single risk factor interventions to reduce cvd in patients with type 2 diabetes
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;111:633-642

Turner R.C. BMJ 1998;316:823-828

He et al. JAMA 1999;282:2027-2034

Antitrombotic Trialits BMJ 2002;324:71-86

STENO-2

slide12

Stepwise approach to the treatment of hypertension

Severity of hypertension

Other

ß-blocker

Calcium antagonist

Diuretics

ACE inhibitor/Angiotensin II antagonist

STENO-2

cholesterol
Cholesterol
  • Total Cholesterol to 4 mmol/l
  • LDL Cholesterol to 2 mmol/l

CARDS

HPS

Jt British Soc

glucose lowering medications

PANCREAS

Glucose lowering medications

LIVER

DECREASED INSULIN SECRETION

INCREASED GLUCOSE PRODUCTION

Therapy:

Sulphonylureas

Prandial Glucose Regulators

incretins

Insulin

Therapy:

Biguanides

Thiazolidinediones

incretins

HYPERGLYCEMIA

DECREASED

Incretin production

INTESTINE

DECREASED PERIPHERAL

GLUCOSE UPTAKE

ADIPOSE TISSUE

MUSCLE

INCREASED

GLUCOSE

ABSORPTION

Therapy:

Thiazolidinediones

Biguanides

Therapy:

Alpha-glucosidase inhibitors

stepwise treatment of hyperglycaemia

Stepwise treatment of hyperglycaemia

Gliclazide

+

NPH insulin

BMI <27

Diet

Gliclazide

Gliclazide

+

Metformin

Metformin

+

NPH insulin

BMI ≥27

Metformin

Diet

But many other options available

Time

STENO-2

slide18

INCRETINS

-cells

increases insulin secretion

glucose

insulin

GLP-1

GIP

Rapidly inactivated by dipeptidyl peptidase IV

meal

insulin is insulin

Insulin is insulin……..

Just different onsets and durations of action

Different devices

Tailor to individual patient’s lifestyle

case study what would you do
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