Therapy of Type 2 Diabetes Mellitus: UPDATE Glycemic Goals in the Care of Patients with Type 2 Diabetes- 2013 ADA and AACE Guidelines: Room For Improvement.

Therapy of Type 2 Diabetes Mellitus: UPDATE

Glycemic Goals in the Care of Patients with Type Glycemic Goals in the Care of Patients with Type 2 Diabetes- 2013 ADA and AACE Guidelines:2 Diabetes- 2013 ADA and AACE Guidelines:

Room For Improvement Room For Improvement

(Be HAPPY/ Avoid Burnout, While Caring for Patients with DM)(Be HAPPY/ Avoid Burnout, While Caring for Patients with DM)

Stan Schwartz MD, FACP, FACEAffiliate, Main Line Health System

Clinical Associate Professor of Medicine, Emeritus, U of Pa.

Part 8

Non-Insulin Therapy for Type II Diabetes

Concurrent Therapy

The ABCs of Diabetes Care:Recommended Goals

A1C

ADA recommends < 7.0% in general, < 6.0% in selected individuals

AACE/IDF recommend ≤ 6.5%

Blood pressure

< 130/80 mm Hg

Cholesterol

LDL-C: < 100 mg/dL (< 70 mg/dL in very high-risk patients)

HDL-C: > 40 mg/dL in men and > 50 mg/dL in women

Non–HDL-C: < 130 mg/dL (< 100 mg/dL in high-risk patients)

Triglycerides: < 150 mg/dL

American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S54.AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):3-68.IDF Clinical Guidelines Task Force. Diabet Med. 2006;23:579-593. AACE = American Association of Clinical Endocrinologists

IDF = International Diabetes Federation

Strategy Strategy ComplicationComplication Reduction of Reduction of ComplicationComplication

Blood glucose control ▪ Heart attack 37%1

Blood pressure control

▪ Cardiovascular disease

▪ Heart failure

▪ Stroke

▪ Diabetes-related deaths

51%2

56%3

44%3

32%3

Lipid control

▪ Coronary heart disease mortality

▪ Major coronary heart disease event

▪ Any atherosclerotic event

▪ Cerebrovascular disease event

35%4

55%5

37%5

53%4

Treating the ABCs Reduces Diabetic Complications

1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:837-853.2 Hansson L, et al. Lancet. 1998;351:1755-1762. 3 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:703-713.4 Grover SA, et al. Circulation. 2000;102:722-727.5 Pyŏrälä K, et al. Diabetes Care. 1997;20:614-620.

Steno-2- Synergy in Care- Treating Glucose, BP, Lipids

7

8

USE GLP-1 RECEPTOR AGONISTS AND SGLT-2 Inhibitors for Wt. Reduction

9

Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes,

Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIAMatch Patient Characteristics to Drug Characteristics

Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes,

Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIAMatch Patient Characteristics to Drug Characteristics

5.Gut CHOAbsorption:

Incretin,Pramlintide,Glucosidase inh.

Peripheralglucose uptake

--

-

1.Pancreatic insulin

Secretion:Incretin, ranolazine

2.Pancreatic glucagon

Secretion- Incretin

HYPERGLYCEMIA

6.Fat- TZD, metformin

7.Brain-TZD,INCRETIN,bromocryptine

8.Kidney-

SGLT2

3.Muscle- TZD, Incretin

4.Liver

Hepatic glucose production:

Metformin, incretin

De

The New ADA Guidelines for Type 2 Diabetes:AKA- David Nathan’s Regimen-

DNR- COST BASED

The New ADA Guidelines for Type 2 Diabetes:AKA- David Nathan’s Regimen-

DNR- COST BASEDRevised Treatment AlgorithmRevised Treatment Algorithm

Intensive insulin

At diagnosis:Lifestyle + metforminSTEP 1

STEP 2

Tier 1* Tier 2†

STEP 3

Add basal insulin

Add sulfonylurea

Add GLP-1 agonist

Add pioglitazone ± SU

HbA1C >7.0%

NOT Glyburide, chlorpropamide NOT Rosiglitazone

New ADA Guidelines- 4/20/12New ADA Guidelines- 4/20/12

Inzucchi,Diabetologia4/20/12

SU most prominent

Added back glyburideForEUROPEAN SENSIBILITIES

NO MEDICAL LOGIC

Also, SLOW COMBO TX