Care for Diabetes mellitus, Hypertension and Dyslipidemia in … · 2019-03-05 · Care for Diabetes mellitus, Hypertension and Dyslipidemia in Primary care 2012 Department of Family

Care for Diabetes mellitus, Hypertension and Dyslipidemia in Primary care

2012Department of Family Medicine

Faculty of Medicine Ramathibodi HospitalMahidol University

Thursday, August 16, 12

Outline•Prevalence DM, HTN and DLP

•Clinical presentation of DM

•Management of DM, HTN and DLP

•Concept of Family Practice

•Concept of Chronic Care Model

Prevalence of DM in Thailand?

15-29 30-44 45-59 60-69 70-79 ≥ 80 Total

15.816.7

12.914.313.6

Male Female Total

The Thai National Health Examination Survey IV, 2009.

Clinical presentation of DM

แนวทางเวชปฏิบัติสําหรับโรคเบาหวาน 2554.

No clinical symptoms

Polyuria (osmotic diuresis)

Polydipsia

Weight loss

Criteria for Diagnosis DM

FPG ≥ 126 mg/dl x 2 times

75 g Oral Glucose Tolerance Test, OGTT ≥ 200 mg/dl

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, A random plasma glucose ≥ 200 mg/dl

Not recommend HbA1c for diagnosis

Prevalence of HTN in Thailand?

Prevalence of HTN in Thailand

15-29 30-44 45-59 60-69 70-79 ≥ 80 Total

55.951.7

57.452.3

53.951.1

Male Female Total

Prevalence of HTN in Thailand

21% 50%

Awear, no treatedUnawearTreat, not controlledTreated and controlled

The Silent KillerThursday, August 16, 12

Classification of blood pressure

Blood Pressure Classification SBP mmHg DBP mmHgOptimal <120 <80

Normal 120-129 80-84

High normal 130-139 85-89

Grade 1 hypertension (mild) 140-159 90-99

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) ≥180 ≥110

Isolated systolic hypertension ≥140 <90

Mancia G et al. J Hypertens. 2007 Jun;25(6):1105-87.แนวทางการรักษาโรคความดันโลหิตสูงในเวชปฏิบัติทั่วไป พ.ศ. 2555.

Prevalence of DLP in Thailand?

15-29 30-44 45-59 60-69 70-79 ≥ 80 Total

50.952.954.959.859.1

54.156.9

66.965.2

46.544.148.950.952.450.9

Male Female Total

Total cholesterol > 200

Total cholesterol > 240

15-29 30-44 45-59 60-69 70-79 ≥ 80 Total

19.420.4

25.227.4

21.424.2

30.233.4

16.715.51920.220.6

Male Female Total

Adult treatment panel III classification

LDL cholesterolLDL cholesterol

< 100 Optimal

100-129 Near or above optimal

130-159 Borderline high

160-189 High

≥ 190 Very high

Circulation 2002; 106:3143.

Total cholesterolTotal cholesterol< 200 Desirable200-239 Borderline high

≥ 240 High

HDL cholesterolHDL cholesterol< 40 Low

≥ 60 High

TriglyceridesTriglycerides

< 150 Desirable

150-199 Borderline high

200-499 High

≥ 500 Very high

Cardiovascular disease

CVD risks

CholesterolHTN DM Smoking

Obesity Genetic

Global CVD risks

LDL HDL

Case vignetteThursday, August 16, 12

ชาย 70 ปี อ่อนเพลีย ปัสสาวะบ่อย 1 เดือน โรคประจําตัวเบาหวาน ความดันโลหิตสูง และไขมันในเลือดสูง ประมาณ 20 ปี

จงซักประวัติและตรวจร่างกายเพิ่มเติม

ประวัติเพิ่มเติม•ปัสสาวะบ่อย ปริมาณมาก มากกว่า 10 ครั้งต่อวัน

กลางคืน 3-4 ครั้ง ใส ไม่มีฟอง ไม่แสบขัด กลั้นปัสสาวะได้ ปัสสาวะพุ่งดีไม่ต้องเบ่ง หิวน้ําบ่อย น้ําหนักปกติ

•มีปัญหาอวัยวะเพศไม่แข็งตัว

•ไม่เคยเจ็บหน้าอก/ไม่มีใจสั่นหวิว/แขนขาอ่อนแรง/ปากเบี้ยว/ปวดน่องขณะเดิน

ประวัติเพิ่มเติม•ประวัติครอบครัว มารดาเป็นโรคความดันโลหิตสูง

และอัมพาตเมื่ออายุ 60 ปี

•มักจะลืมกินยาก่อนอาหารบ่อย ๆ ไม่ออกกําลังกาย ไม่ได้ทํางานประจํา

•กินข้าว 3 มื้อ มื้อละ 3-4 ทัพพี กาแฟวันละ 1 แก้ว กล้วยน้ําว้า วันละ 4 ลูก ชอบกินขนมจุกจิก และผลไม้

•สูบบุหรี่วันละ 10 มวน นาน 45 ปี

ประวัติเพิ่มเติมMedications

•Metformin(500) 2X2

•Glibenclamide(5) 2X2

•HCTZ(25) 1X1

•Atenolol(50) 1X1

•Gemfibrozil(600) 1X1

•ASA(81) 1X1

ประวัติเพิ่มเติม•FBS 200-300 mg/dL

•BP150-160/90-100 mmHg

•HbA1c 9-10 mg%

การตรวจร่างกาย•V/S: BP 150/90 mmHg PR 80/min regular

•BW 80 kg Height 165 cm BMI 29.4 waist circumference 100 cm.

•HEENT: no pale conjunctivae, no icteric sclerae

•CVS: no heaving PMI at 5th ICS, MCL, normal S1S2, no murmur, full peripheral pulses, no carotid bruit

•Foot examination: normal sensation, cracked skin, no callus or deformity, peripheral pulse 2+ both sides

จงเลือกการส่งตรวจที่สําคัญ

ผลการตรวจทางห้องปฏิบัติการ•FBS 240 mg/dL, HbA1c 9.8%

•TG 190, TC 220, HDL 40, LDL 140

•Cr 1.8 (eGFR 40), Electrolytes WNL, Uric acid 9.0

•Urine analysis: protein neg, sugar 1+, ketone neg

•UACR 45 mg/g (0-30)

•AST, ALT WNL

•ECG: normal

จงสรุปปัญหาแบบองค์รวม

Problem lists•Metabolic syndrome (DM, HTN, DLP and Obesity)•DM type 2 with

•R/O CKD (stage 3) - Diabetes nephropathy•Erectile dysfunction•Asymptomatic hyperuricemia•Smoking •Family history of CVD •Poor drug adherence•Sedentary lifestyle and poor diet control

จงบอกแนวทางการดูแลรักษา

Goals of management

Goals of managementPrevent Cardiovascular disease

Goals of management

Coronary heart diseaseCerebrovascular diseasePeripheral artery diseaseAortic atherosclerosis and aneurysm

Prevent Cardiovascular disease

Prevent Chronic kidney disease

Prevent Visual impairment - Blindness

Prevent Amputation

Approach to management of Hyperglycemia

Patient attitude/expected treatment effort

Highly motivated/excellent self-care Less motivated/poor self-care

Adverse event Low High

Disease duration Newly diagnosed Long standing

Life expectancy Long Short

Important comorbidities Absent Severe

Established vascular complications Absent Severe

Resources, support system Readily available Limited

Diabetes Care. 2012 Apr 19. [Epub ahead of print]

Pharmacological management

Dose-effect relationships

Riddle MC. Am J Med. 2000 Apr 17;108(6) Suppl 1A:15S-22S.

Half-maximal

DoseMaximal

Maximal Therapeutic effect

Side effect

Key Points•Glycemic targets and treatments

•The mainstay of treatment program

•Metformin is the preferred first-line drug

•After metformin, there are limited data

•The patient should participate in all treatment decisions

Diet, exercise, and education

Individualized

Expected HbA1c reduction as mono-therapy

Intervention Expected HbA1c reduction Lifestyle modification 1-2%Insulin 1.5-3.5%Metformin 1-2%Sulfonylurea 1-2%Glinide 1-1.5%TZDs 0.5-1.4%α-glucosidase Inhibitor 0.5-0.8%DPP-4 Inhibitor 0.8%GLP-1 Analog 1%

SulfonylureaDrug Duration, h Usual daily dose, mg Dosing per day

Glipizide 14 to 16 2.5 to 10 Once or divided

Gliclazide 24 40 to 240 Once

Glimepiride 24+ 2 to 4 Once

Glibenclamide 20 to 24+ 2.5 to 10 Once

HTN managementThursday, August 16, 12

Lifestyle modifications to prevent and manage HTN

Adapted from The JNC 7 report. JAMA. 2003 May 21;289(19):2560-72. Epub 2003 May 14.

Modification Approximate SBP Reduction

Weight reduction 5-20 mmHg / 10 kg

Adopt DASH eating plan 8-14 mmHg

Dietary sodium reduction 2-8 mmHg

Physical activity 4-9 mmHg

Reduction of excessive alcohol intake 2-4 mmHg

Antihypertensive drug

1. Thiazide diuretics2. Calcium channel blockers3. ACE inhibitors4. Angiotensin receptor blockers5. β-blockers6. α-blockers7. Renin inhibitors8. Centrally acting drugs

What is 1st line of drug?A. Beta-blockers

B. Thiazide diuretics

C. ACE inhibitors

D. Angiotensin II receptor blockers (ARBs)

E. Long-acting calcium channel blockers

Average reductions in BP over 24 hours

Law M et al. Health Technol Assess. 2003;7(31):1-94.

Thiazides BBs ACE inhibitors ARBs CCBs

Systolic BP Diastolic BP

Choice of Antihypertensive drug

Age ≤ 55 Age > 55

Step 1 A C/D

Step 2 A + C/D C/D + A

Step 3 A + C + DA + C + D

Step 4 A + C + D + consider an α- or β-blockerA + C + D + consider an α- or β-blocker

ดัดแปลงจากแนวทางการรักษาโรคความดันโลหิตสูงในเวชปฏิบัติทั่วไป พ.ศ. 2555.

DiureticDrug Starting dose

(mg/day)Usual dose (mg/day)

Maximum dose

(mg/day)

Duration of action

HCTZ 12.5 12.5-50 QD 100 6-12

Indapamide 1.25 2.5-5.0 QD 5 15-18

Chlorthalidone 12.5 12.5-50 QD 100 48-72

Furosemide 20 20-120 bid 600 6-8

Efficacy of low-dose Thiazide therapy

Carlsen JE et al. BMJ. 1990 Apr 14;300(6730):975-8.

1.25 2.5 5 10Baseline placebo

Systolic

Diastolic

Calcium channel blockers

Drug Starting dose

(mg/day)

Usual dose (mg/day)

Maximum dose

(mg/day)

Duration of action

Amlodipine 5 5-10 QD 10 24

Felodipine 5 5-10 QD 20 24

Nifedipine SR 30 30-60 QD 60 24

Verapamil SR 120 240-480 QD 480 24

Diltiazem XR 180 180-480 480 24

ACE inhibitorsDrug Starting

dose (mg/day)

Usual dose (mg/day)

Maximum dose

(mg/day)

Duration of action

Captopril 12.5 12.5-50 bid/tid 150 6-12

Enalapril 5 5-10 QD/bid 40 12-24

Lisinopril 10 20-40 QD 40 24

Ramipril 2.5 2.5-20 QD/bid 40 24

Angiotensin receptor blockers

Drug Lowest effective dose

(mg/day)

Starting dose

Lowest dose with near maximal BP

lowering

Maximum dose

Candesartan 4 16 4 32

Irbesartan 75 150 75 300

Losartan 50 50 50 100

Olmesartan 20 20 20 40

Telmisartan 20 80 40 80

Valsartan 20 80 80 320

β-BlockersDrug Starting

dose (mg/day)

Usual dose (mg/day)

Maximum dose

(mg/day)

Duration of action

Propranolol 40 40-120 bid 480 >12

Atenolol 50 50-100 QD 200 24

Metoprolol 50 50-150 bid 400 12

Carvedilol 6.25 6.25-25 bid 50 6

Bisoprolol 5 5-20 QD 40 12

α-BlockersDrug Starting

dose (mg/day)

Usual dose (mg/day)

Maximum dose

(mg/day)

Duration of action

Prazosin 1 2-6 bid/tid 20 6-12

Terazosin 1 2-5 QD/bid 20 12-24

Doxazosin 1 2-4 QD 16 24

Combination therapy

120 130 140 150 160 170 180Valu

Pretreatment SBP (mmHg)

1 drug half standard dose 1 drug standard dose2 drugs half standard dose 2 drugs standard dose3 drugs half standard dose 3 drugs standard dose

Law MR et al. BMJ. 2009 May 19;338:b1665. doi: 10.1136/bmj.b1665.

If partial response to monotherapy

Add-on Therapy

Triple or

Quadruple Therapy

Add-on Therapy

Triple or

Quadruple Therapy

CONSIDER•Non-adherence?•Secondary HTN?•Interfering drugs or lifestyle?•White coat effect?

DLP managementThursday, August 16, 12

CVD risks

CholesterolHTN DM Smoking

Obesity Genetic

Global CVD risks

LDL HDL

Assess CV riskDMEstablished CVDHTCKDSmokingBMI ≥ 30Family history of premature CVDHDL-C < 40 mg/dL

Reiner Z et al. Heart J. 2011 Jul;32(14):1769-818. Epub 2011 Jun 28.

ATP III LDL-cholesterol goals

Risk category LDL-cholesterol goal (mg/dL)

LDL-cholesterol level at which to initiate therapeutic lifestyle changes (mg/dL)

LDL-cholesterol level at which to consider drug therapy (mg/dL)

Coronary heartdisease (CHD) orCHD risk equivalent(10-year risk >20%)

<100 (Optional < 70) ≥100 ≥130; drug optional at 100 to

2 or more risk factors (10-year risk ≤20%) ≤130 ≥130 10-year risk 10 to 20%: >130

10-year risk <10%: ≥160

0 to 1 risk factor ≤160 ≥160 ≥190; LDL-cholesterol lowering drug optional at 160 to 189

Grundy SM et al. Circulation 2004;110:227-39.

DLP Management

•Lifestyle modifications

•Medications

Average effects of different classes of lipid lowering drugs on serum lipids

Drug class LDL cholesterol HDL cholesterol Triglycerides

Bile acid sequestrates ↓ 15 to 30 percent 0 to slight increase No change*

Nicotinic acid ↓ 10 to 25 percent ↑ 15 to 35 percent ↓ 25 to 30 percent

HMG CoA reductase inhibitors

↓ 20 to 60 percent ↑ 5 to 10 percent ↓ 10 to 33 percent

Gemfibrozil ↓ 10 to 15 percent ↑ 15 to 25 percent ↓ 35 to 50 percent

Fenofibrate (micronized form)

↓ 6 to 20 percent ↑ 18 to 33 percent ↓ 41 to 53 percent

Cholesterol absorption inhibitors

↓ 17 percent No change No change

Omega 3 fatty acids ↑ 4 to 49 percent ↑ 5 to 9 percent ↓ 23 to 45 percent

Properties of statinsVariable Atorvastatin Fluvastatin Pravastatin Rosuvastatin Simvastatin

LDL cholesterol reductions

38-54 percent (10-80)

17-33 percent (20-80)

19-40 percent (10-40)

52-63 percent (10-40)

28-48 percent (10-80 mg)

Elimination half-life, hours

15-30 0.5-2.3 1.3-2.8 19 2-3

Solubility Lipophilic Lipophilic Hydrophilic Hydrophilic Lipophilic

Cytochrome 450 metabolism

3A4 2C9 - Limited 2C9 3A4, 3A5

Effect of food on absorption of drug

None Negligible Decreased absorption

None None

Optimal time of administration

Evening Bedtime Bedtime Anytime Evening

Renal excretion of absorbed dose, %

2 <6 20 10 13

38-54 percent (10-80)

17-33 percent (20-80)

19-40 percent (10-40)

52-63 percent (10-40)

28-48 percent (10-80 mg)

15-30 0.5-2.3 1.3-2.8 19 2-3

None None

2 <6 20 10 13

38-54 percent (10-80)

17-33 percent (20-80)

19-40 percent (10-40)

52-63 percent (10-40)

28-48 percent (10-80 mg)

15-30 0.5-2.3 1.3-2.8 19 2-3

None None

2 <6 20 10 13

38-54 percent (10-80)

17-33 percent (20-80)

19-40 percent (10-40)

52-63 percent (10-40)

28-48 percent (10-80 mg)

15-30 0.5-2.3 1.3-2.8 19 2-3

None None

2 <6 20 10 13

Management of Hypertriglyceridemia

•TG > 880 mg/dL - Risk of acute pancreatitis

•Lifestyle modification - Reduce TG 20-30%

•The evidence on the benefit of lowering elevated TG levels is still modest

Reiner Z et al. Heart J. 2011 Jul;32(14):1769-818. Epub 2011 Jun 28.

Back to our patientThursday, August 16, 12

•HCTZ(25) 1X1

•Atenolol(50) 1X1

•ASA(81) 1X1

Management?•FBS 240 mg/dL,

HbA1c 9.8%

•TG 190, TC 220, HDL 40, LDL 140

•Cr 1.8 (eGFR 40), UACR 45 mg/g (0-30), Uric acid 9.0

•BP150/90 mmHg

•HCTZ(25) 1X1

•Atenolol(50) 1X1

•ASA(81) 1X1

Management?•FBS 240 mg/dL,

HbA1c 9.8%

•TG 190, TC 220, HDL 40, LDL 140

•Cr 1.8 (eGFR 40), UACR 45 mg/g (0-30), Uric acid 9.0

•BP150/90 mmHgDiet control / E

xercise

3 6 9 12 15 18 21 24 27 30 33 36

Months

3 6 9 12 15 18 21 24 27 30 33 36

Months

• Metformin(500) 2X2

• Glibenclamide(5) 1X2

• HCTZ(25) 1X1

• Atenolol(50) 1X1

• Gemfibrozil(600) 1X1

• ASA(81) 1X1

• HCTZ(25) 1X1

• ASA(81) 1X1

• HCTZ(25) 1X1

• ASA(81) 1X1

ลักษณะพิเศษของโรคเรื้อรัง (Chronic disease)

• เป็นข่าวร้าย

• เสียหายถาวร

•ดําเนินโรคไม่หยุดนิ่ง

•ทรุดดิ่งลงเรื่อยๆ

•มีชีวิตขึ้นลง เดี๋ยวทรงเดี๋ยวทรุด

สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์

Patient-centered medicine

•ค้นหาทั้งโรคและความเจ็บป่วย

• ช่วยเข้าใจคนทั้งคน

•หาหนทางร่วมกัน

•สร้างสรรค์งานป้องกัน/ส่งเสริม

•ต่อเติมความสัมพันธ์ที่ดี

•มีวิีถีอยู่บนความจริง

เบาหวาน/ความดัน/ไขมันสูง?

เป็นแล้วรักษาหาย?

กินอะไรได้/ไม่ได้?

ไม่เห็นมีอาการ?

แนะนําอย่างไร?

Diet control / Exercise

Insulin Management

Insulin type Onset Peak DurationLong-actingLong-actingLong-actingLong-acting

Glargine 90 minutes None 24 hours

Detemir 3 to 4 hours 6 to 8 hours 6 to 23 hours

Intermediate-actingIntermediate-actingIntermediate-actingIntermediate-acting

NPH 1 to 2 hours 4 to 10 hours 14 or more hours

Short-actingShort-actingShort-actingShort-acting

Aspart 15 minutes 1 to 3 hours 3 to 5 hours

Lispro 15 minutes 30 to 90 minutes 3 to 5 hours

Regular 30 to 60 minutes 2 to 4 hours 5 to 8 hours

MixedMixedMixedMixed

NPH/lispro or aspart 15 to 30 minutes Dual 14 to 24 hours

NPH/regular 30 to 60 minutes Dual 14 to 24 hours

Aspirin?

Aspirin?Prevent Cardiovascular disease

Antiplatelet

Male age > 50Female age > 60 With CVD risk

Antiplatelet

Male age > 50Female age > 60 With CVD risk

Aspirin 75-162 mg/day

Chronic Care Model in Community Setting?

สรุปประสบการณ์การเรียนรู้Thursday, August 16, 12

แหล่งค้นคว้าเพิ่มเติม• แนวทางเวชปฏิบัติสําหรับโรคเบาหวาน พ.ศ. 2554. พิมพ์ครั้งที ่2.

กรุงเทพมหานคร: บริษัทศรีเมืองการพิมพ์ จํากัด; 2554.

• Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1:S11-61.

• แนวทางการรักษาโรคความดันโลหิตสูงในเวชปฏิบัติทั่วไป พ.ศ. 2555. พิมพ์ครั้งที่ 1. กรุงเทพมหานคร: บริษัทฮั่วน้ําพร้ินติ้ง จํากัด; 2555.

• McCormack T, Krause T, O'Flynn N, et al. Management of hypertension in adults in primary care: NICE guideline.Br J Gen Pract. 2012 Mar;62(596):163-4.

• Reiner Z, Catapano AL, De Backer G, et al. ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818. Epub 2011 Jun 28.

แหล่งค้นคว้าเพิ่มเติม•http://www.ra.mahidol.ac.th/dpt/FM/home

•http://thaifp.com/

Question?Thursday, August 16, 12

Care for Diabetes mellitus, Hypertension and Dyslipidemia in … · 2019-03-05 · Care for Diabetes mellitus, Hypertension and Dyslipidemia in Primary care 2012 Department of Family

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