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
Thursday, August 16, 12
Prevalence of DM in Thailand?
Thursday, August 16, 12
Prevalence of DM in Thailand?
0
5
10
15
20
15-29 30-44 45-59 60-69 70-79 ≥ 80 Total
6.9
11.5
15.816.7
10.1
3.4
0.6
7.7
10.5
17.1
19.2
11.6
3.2
0.5
6
12.914.313.6
8.5
3.7
0.8
Male Female Total
The Thai National Health Examination Survey IV, 2009.
Thursday, August 16, 12
Clinical presentation of DM
แนวทางเวชปฏิบัติสําหรับโรคเบาหวาน 2554.
No clinical symptoms
Polyuria (osmotic diuresis)
Polydipsia
Weight loss
Thursday, August 16, 12
Criteria for Diagnosis DM
แนวทางเวชปฏิบัติสําหรับโรคเบาหวาน 2554.
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
Thursday, August 16, 12
Prevalence of HTN in Thailand?
Thursday, August 16, 12
Prevalence of HTN in Thailand
The Thai National Health Examination Survey IV, 2009.
0
15
30
45
60
15-29 30-44 45-59 60-69 70-79 ≥ 80 Total
21.4
55.951.7
44
29.5
12.7
2.9
21.3
57.452.3
44.9
30.5
10.1
0.3
21.5
53.951.1
42.8
28.3
15.4
4.6
Male Female Total
Thursday, August 16, 12
Prevalence of HTN in Thailand
The Thai National Health Examination Survey IV, 2009.
21%
21% 50%
9%
Awear, no treatedUnawearTreat, not controlledTreated and controlled
Thursday, August 16, 12
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.
Thursday, August 16, 12
Prevalence of DLP in Thailand?
Thursday, August 16, 12
Prevalence of DLP in Thailand?
The Thai National Health Examination Survey IV, 2009.
0
17.5
35
52.5
70
15-29 30-44 45-59 60-69 70-79 ≥ 80 Total
50.952.954.959.859.1
49.5
31.1
54.156.9
59.7
66.965.2
48.2
35.3
46.544.148.950.952.450.9
28.8
Male Female Total
Total cholesterol > 200
Thursday, August 16, 12
Prevalence of DLP in Thailand?
The Thai National Health Examination Survey IV, 2009.
Total cholesterol > 240
0
10
20
30
40
15-29 30-44 45-59 60-69 70-79 ≥ 80 Total
19.420.4
25.227.4
25.2
16.4
8.2
21.424.2
30.233.4
29.4
14.6
9.8
16.715.51920.220.6
18.3
6.6
Male Female Total
Thursday, August 16, 12
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.
Thursday, August 16, 12
Total cholesterolTotal cholesterol< 200 Desirable200-239 Borderline high
≥ 240 High
HDL cholesterolHDL cholesterol< 40 Low
≥ 60 High
Adult treatment panel III classification
Circulation 2002; 106:3143.
Thursday, August 16, 12
TriglyceridesTriglycerides
< 150 Desirable
150-199 Borderline high
200-499 High
≥ 500 Very high
Adult treatment panel III classification
Circulation 2002; 106:3143.
Thursday, August 16, 12
Cardiovascular disease
Thursday, August 16, 12
CVD risks
CholesterolHTN DM Smoking
Obesity Genetic
Global CVD risks
LDL HDL
?
Thursday, August 16, 12
Case vignetteThursday, August 16, 12
ชาย 70 ปี อ่อนเพลีย ปัสสาวะบ่อย 1 เดือน โรคประจําตัวเบาหวาน ความดันโลหิตสูง และไขมันในเลือดสูง ประมาณ 20 ปี
Thursday, August 16, 12
จงซักประวัติและตรวจร่างกายเพิ่มเติม
Thursday, August 16, 12
ประวัติเพิ่มเติม•ปัสสาวะบ่อย ปริมาณมาก มากกว่า 10 ครั้งต่อวัน
กลางคืน 3-4 ครั้ง ใส ไม่มีฟอง ไม่แสบขัด กลั้นปัสสาวะได้ ปัสสาวะพุ่งดีไม่ต้องเบ่ง หิวน้ําบ่อย น้ําหนักปกติ
•มีปัญหาอวัยวะเพศไม่แข็งตัว
•ไม่เคยเจ็บหน้าอก/ไม่มีใจสั่นหวิว/แขนขาอ่อนแรง/ปากเบี้ยว/ปวดน่องขณะเดิน
Thursday, August 16, 12
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
Thursday, August 16, 12
ประวัติเพิ่มเติมMedications
•Metformin(500) 2X2
•Glibenclamide(5) 2X2
•HCTZ(25) 1X1
•Atenolol(50) 1X1
•Gemfibrozil(600) 1X1
•ASA(81) 1X1
Thursday, August 16, 12
ประวัติเพิ่มเติม•FBS 200-300 mg/dL
•BP150-160/90-100 mmHg
•HbA1c 9-10 mg%
Thursday, August 16, 12
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
Thursday, August 16, 12
จงเลือกการส่งตรวจที่สําคัญ
Thursday, August 16, 12
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
Thursday, August 16, 12
จงสรุปปัญหาแบบองค์รวม
Thursday, August 16, 12
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
Thursday, August 16, 12
จงบอกแนวทางการดูแลรักษา
Thursday, August 16, 12
Goals of management
Thursday, August 16, 12
Goals of managementPrevent Cardiovascular disease
Thursday, August 16, 12
Goals of management
Coronary heart diseaseCerebrovascular diseasePeripheral artery diseaseAortic atherosclerosis and aneurysm
Prevent Cardiovascular disease
Thursday, August 16, 12
Goals of managementPrevent Cardiovascular disease
Prevent Chronic kidney disease
Thursday, August 16, 12
Goals of managementPrevent Cardiovascular disease
Prevent Chronic kidney disease
Prevent Visual impairment - Blindness
Thursday, August 16, 12
Goals of managementPrevent Cardiovascular disease
Prevent Chronic kidney disease
Prevent Visual impairment - Blindness
Prevent Amputation
Thursday, August 16, 12
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]
Thursday, August 16, 12
Pharmacological management
Thursday, August 16, 12
Dose-effect relationships
Riddle MC. Am J Med. 2000 Apr 17;108(6) Suppl 1A:15S-22S.
Effe
ct
Half-maximal
Half-maximal
DoseMaximal
Maximal Therapeutic effect
Side effect
Thursday, August 16, 12
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
Diabetes Care. 2012 Apr 19. [Epub ahead of print]
Diet, exercise, and education
Thursday, August 16, 12
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
Diabetes Care. 2012 Apr 19. [Epub ahead of print]
Individualized
Diet, exercise, and education
Thursday, August 16, 12
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
Diabetes Care. 2012 Apr 19. [Epub ahead of print]
Individualized
Diet, exercise, and education
Thursday, August 16, 12
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
Diabetes Care. 2012 Apr 19. [Epub ahead of print]
Individualized
Diet, exercise, and education
Thursday, August 16, 12
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%
แนวทางเวชปฏิบัติสําหรับโรคเบาหวาน 2554.
Thursday, August 16, 12
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
Thursday, August 16, 12
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
Thursday, August 16, 12
Antihypertensive drug
1. Thiazide diuretics2. Calcium channel blockers3. ACE inhibitors4. Angiotensin receptor blockers5. β-blockers6. α-blockers7. Renin inhibitors8. Centrally acting drugs
Thursday, August 16, 12
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
Thursday, August 16, 12
Average reductions in BP over 24 hours
Law M et al. Health Technol Assess. 2003;7(31):1-94.
0
5
10
15
Thiazides BBs ACE inhibitors ARBs CCBs
Systolic BP Diastolic BP
Thursday, August 16, 12
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.
Thursday, August 16, 12
DiureticDrug Starting dose
(mg/day)Usual dose (mg/day)
Maximum dose
(mg/day)
Duration of action
(h)
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
Thursday, August 16, 12
Efficacy of low-dose Thiazide therapy
Carlsen JE et al. BMJ. 1990 Apr 14;300(6730):975-8.
80
100
120
140
160
180
1.25 2.5 5 10Baseline placebo
Systolic
Diastolic
Thursday, August 16, 12
Calcium channel blockers
Drug Starting dose
(mg/day)
Usual dose (mg/day)
Maximum dose
(mg/day)
Duration of action
(h)
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
Thursday, August 16, 12
ACE inhibitorsDrug Starting
dose (mg/day)
Usual dose (mg/day)
Maximum dose
(mg/day)
Duration of action
(h)
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
Thursday, August 16, 12
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
Thursday, August 16, 12
β-BlockersDrug Starting
dose (mg/day)
Usual dose (mg/day)
Maximum dose
(mg/day)
Duration of action
(h)
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
Thursday, August 16, 12
α-BlockersDrug Starting
dose (mg/day)
Usual dose (mg/day)
Maximum dose
(mg/day)
Duration of action
(h)
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
Thursday, August 16, 12
Combination therapy
0
10
20
30
40
120 130 140 150 160 170 180Valu
e Est
imat
ed re
duct
ion
in S
BP (m
mHg
)
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.
Thursday, August 16, 12
If partial response to monotherapy
Thursday, August 16, 12
If partial response to monotherapy
Add-on Therapy
Thursday, August 16, 12
If partial response to monotherapy
Add-on Therapy
Triple or
Quadruple Therapy
Thursday, August 16, 12
If partial response to monotherapy
Add-on Therapy
Triple or
Quadruple Therapy
CONSIDER•Non-adherence?•Secondary HTN?•Interfering drugs or lifestyle?•White coat effect?
Thursday, August 16, 12
DLP managementThursday, August 16, 12
CVD risks
CholesterolHTN DM Smoking
Obesity Genetic
Global CVD risks
LDL HDL
?
Thursday, August 16, 12
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.
Thursday, August 16, 12
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
129
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.
Thursday, August 16, 12
DLP Management
•Lifestyle modifications
•Medications
Thursday, August 16, 12
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
Thursday, August 16, 12
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
Thursday, August 16, 12
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
Thursday, August 16, 12
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
Thursday, August 16, 12
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
Thursday, August 16, 12
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.
Thursday, August 16, 12
Back to our patientThursday, August 16, 12
•Metformin(500) 2X2
•Glibenclamide(5) 2X2
•HCTZ(25) 1X1
•Atenolol(50) 1X1
•Gemfibrozil(600) 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
Thursday, August 16, 12
•Metformin(500) 2X2
•Glibenclamide(5) 2X2
•HCTZ(25) 1X1
•Atenolol(50) 1X1
•Gemfibrozil(600) 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
Thursday, August 16, 12
5
6
7
8
9
10
3 6 9 12 15 18 21 24 27 30 33 36
HbA1
c %
Months
Thursday, August 16, 12
5
6
7
8
9
10
3 6 9 12 15 18 21 24 27 30 33 36
HbA1
c %
Months
• Metformin(500) 2X2
• Glibenclamide(5) 1X2
• HCTZ(25) 1X1
• Atenolol(50) 1X1
• Gemfibrozil(600) 1X1
• ASA(81) 1X1
• Metformin(500) 2X2
• Glibenclamide(5) 2X2
• HCTZ(25) 1X1
• Atenolol(50) 1X1
• Gemfibrozil(600) 1X1
• ASA(81) 1X1
• Metformin(500) 2X2
• Glibenclamide(5) 2X2
• HCTZ(25) 1X1
• Atenolol(50) 1X1
• Gemfibrozil(600) 1X1
• ASA(81) 1X1
Thursday, August 16, 12
ลักษณะพิเศษของโรคเรื้อรัง (Chronic disease)
• เป็นข่าวร้าย
• เสียหายถาวร
•ดําเนินโรคไม่หยุดนิ่ง
•ทรุดดิ่งลงเรื่อยๆ
•มีชีวิตขึ้นลง เดี๋ยวทรงเดี๋ยวทรุด
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
Thursday, August 16, 12
Patient-centered medicine
•ค้นหาทั้งโรคและความเจ็บป่วย
• ช่วยเข้าใจคนทั้งคน
•หาหนทางร่วมกัน
•สร้างสรรค์งานป้องกัน/ส่งเสริม
•ต่อเติมความสัมพันธ์ที่ดี
•มีวิีถีอยู่บนความจริง
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
Thursday, August 16, 12
Patient-centered medicine
•ค้นหาทั้งโรคและความเจ็บป่วย
• ช่วยเข้าใจคนทั้งคน
•หาหนทางร่วมกัน
•สร้างสรรค์งานป้องกัน/ส่งเสริม
•ต่อเติมความสัมพันธ์ที่ดี
•มีวิีถีอยู่บนความจริง
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
เบาหวาน/ความดัน/ไขมันสูง?
Thursday, August 16, 12
Patient-centered medicine
•ค้นหาทั้งโรคและความเจ็บป่วย
• ช่วยเข้าใจคนทั้งคน
•หาหนทางร่วมกัน
•สร้างสรรค์งานป้องกัน/ส่งเสริม
•ต่อเติมความสัมพันธ์ที่ดี
•มีวิีถีอยู่บนความจริง
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
เบาหวาน/ความดัน/ไขมันสูง?
เป็นแล้วรักษาหาย?
Thursday, August 16, 12
Patient-centered medicine
•ค้นหาทั้งโรคและความเจ็บป่วย
• ช่วยเข้าใจคนทั้งคน
•หาหนทางร่วมกัน
•สร้างสรรค์งานป้องกัน/ส่งเสริม
•ต่อเติมความสัมพันธ์ที่ดี
•มีวิีถีอยู่บนความจริง
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
เบาหวาน/ความดัน/ไขมันสูง?
เป็นแล้วรักษาหาย?
กินอะไรได้/ไม่ได้?
Thursday, August 16, 12
Patient-centered medicine
•ค้นหาทั้งโรคและความเจ็บป่วย
• ช่วยเข้าใจคนทั้งคน
•หาหนทางร่วมกัน
•สร้างสรรค์งานป้องกัน/ส่งเสริม
•ต่อเติมความสัมพันธ์ที่ดี
•มีวิีถีอยู่บนความจริง
สไลด์จากผศ.พญ.สายพิณ หัตถีรัตน์
เบาหวาน/ความดัน/ไขมันสูง?
เป็นแล้วรักษาหาย?
กินอะไรได้/ไม่ได้?
ไม่เห็นมีอาการ?
Thursday, August 16, 12
แนะนําอย่างไร?
Thursday, August 16, 12
แนะนําอย่างไร?
Diet control / Exercise
Thursday, August 16, 12
Insulin Management
Thursday, August 16, 12
Thursday, August 16, 12
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
Thursday, August 16, 12
Aspirin?
Thursday, August 16, 12
Aspirin?Prevent Cardiovascular disease
Thursday, August 16, 12
Aspirin?Prevent Cardiovascular disease
Antiplatelet
Thursday, August 16, 12
Aspirin?Prevent Cardiovascular disease
Antiplatelet
Male age > 50Female age > 60 With CVD risk
Thursday, August 16, 12
Aspirin?Prevent Cardiovascular disease
Antiplatelet
Male age > 50Female age > 60 With CVD risk
Aspirin 75-162 mg/day
Thursday, August 16, 12
Chronic Care Model in Community Setting?
Thursday, August 16, 12
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.
Thursday, August 16, 12
แหล่งค้นคว้าเพิ่มเติม•http://www.ra.mahidol.ac.th/dpt/FM/home
•http://thaifp.com/
Thursday, August 16, 12
Question?Thursday, August 16, 12