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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

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

slide2
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
slide3
Algorithm for glucose control [1]

Type 2 diabetes: the management of type 2 diabetes.

NICE Clinical Guideline 66;May 2008

Continued on next slide…

slide4
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

slide6
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
slide9
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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