Preferred treatment options for patients with Diabetes

Dr Jon Tuppen GPwSI

Beechwood Surgery Brentwood

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

Diabetes is simple isn’t it?

Make it as simple and holistic as possible

CVD risk progression begins before diabetes

Remember the diagnosis of 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

`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!

Understanding riskessential for proper prescribing

MICROALBUMINURIA

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

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

HYPERTENSION OPTIONS

Lifestyle, lifestyle, lifestyle

and

Drugs

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

Cholesterol

• Total Cholesterol to 4 mmol/l

• LDL Cholesterol to 2 mmol/l

CARDSHPS

Jt British Soc

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

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

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

Glitazones

insulinglucose

meal

GLP-1

GIP

-cells

Rapidly inactivated by dipeptidyl peptidase IV

increases insulin secretionincreases insulin secretion

INCRETINS

Incretin actions

Insulin is insulin……..

•Just different onsets and durations of action

•Different devices

•Tailor to individual patient’s lifestyle

Putting it all together for 1 patient

The Care Planning Model

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