Autoimmune Insulin Dependent Diabetes Mellitus (Type 1 Diabetes Mellitus) :
MANEJO ACTUAL DE LA DIABETES MELLITUS
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www.who.int/chp
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Expanding Priorities—Confronting Chronic Disease in Countries with Low Income
Gerard Anderson and Edward Chu argue that international health organizations need to greatly expand their efforts to
prevent and treat noncommunicable chronic diseases.
January 18, 2007
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Obesity and Diabetes in the Developing World — A Growing Challenge
January 18, 2007
Propelling an upsurge in cases of diabetes and hypertension is the growing prevalence of overweight and obesity. Drs. Parvez Hossain, Bisher Kawar, and Meguid El Nahas write that preventing obesity,
diabetes, and hypertension will require fundamental social and political changes.
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88
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12/04/2312/04/23
Dr. Enrique Mendoza
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12/04/2312/04/23
Dr. Enrique Mendoza
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Figure 1—Disorders of glycemia: etiologic types and stages. Even after presenting in ketoacidosis, these ∗patients can briefly return to normoglycemia without requiring continuous therapy (i.e., “honeymoon” remission); in rare instances, patients in these categories (e.g., Vacor toxicity, type 1 diabetes presenting ∗∗in pregnancy) may require insulin for survival.
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
DCCT
Intensive Insulin Treatment in Type 1 Diabetes
The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986, with permission.
Med
ian
Hb
A1c
(%)
11
10
9
8
7
6
50 1 2 3 4 5 6 7 8 9 10
Study Year
Conventional therapy
Intensive therapy
Normalrange
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
DCCT
Microvascular Risk Reduction With Intensive Treatment
Data from the Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.
Reduction inComplication Relative Risk
Retinopathy 63%
Nephropathy 54%
Neuropathy 60%
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
DCCT
Relationship of HbA1c to Risk of Microvascular Complications
Skyler. Endocrinol Metab Clin. 1996;25:243-254, with permission.
Rel
ativ
e R
isk
Retinopathy
Nephropathy
Neuropathy
Microalbuminuria
HbA1c (%)
15
13
11
9
7
5
3
1
6 7 8 9 10 11 12
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
UKPDS
Blood Glucose Control Study:Aims
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.
• To determine whether improved glycemic control will prevent clinical complications
• To determine whether treatment with a sulfonylurea, insulin, or metformin has specific advantages or disadvantages
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
UKPDS
Effect of Treatment on HbA1c
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853, with permission.
Conventional(10-y cohort)
9
8
7
6
00 3 6
6.2% upper limit of normal range
ADA goal
ADA action
9 12 15Time From Randomization (y)
Intensive(all patients)
Conventional(all patients)
Intensive(10-y cohort)
Med
ian
Hb
A1c
(%)
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12/04/2312/04/23
Dr. Enrique Mendoza
©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
UKPDS
Risk Reduction of Microvascular Complications
UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853, with permission.
% o
f P
atie
nts
Wit
h a
n E
ven
t
Intensive policy group25% overall risk reductionP=.0099
ConventionalIntensive
0 3 6
0
10
20
30
9 12 15Time From Randomization (y)
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12/04/2312/04/23
Dr. Enrique Mendoza
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Volume 359:1577-1589 October 9, 2008 Number 15
10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes
Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R. Matthews, F.R.C.P., and H. Andrew W. Neil, F.R.C.P.
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Volume 359:1577-1589 October 9, 2008 Number 15
10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes
Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R. Matthews, F.R.C.P., and H. Andrew W. Neil, F.R.C.P.
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Background During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of microvascular complications than did those receiving conventional dietary therapy. We conducted post-trial monitoring to determine whether this improved glucose control persisted and whether such therapy had a long-term effect on macrovascular outcomes.
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Methods Of 5102 patients with newly diagnosed type 2 diabetes, 4209 were randomly assigned to receive either conventional therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin or, in overweight patients, metformin) for glucose control. In post-trial monitoring, 3277 patients were asked to attend annual UKPDS clinics for 5 years, but no attempts were made to maintain their previously assigned therapies. Annual questionnaires were used to follow patients who were unable to attend the clinics, and all patients in years 6 to 10 were assessed through questionnaires. We examined seven prespecified aggregate clinical outcomes from the UKPDS on an intention-to-treat basis, according to previous randomization categories.
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Results Between-group differences in glycated hemoglobin levels were lost after the first year. In the sulfonylurea–insulin group, relative reductions in risk persisted at 10 years for any diabetes-related end point (9%, P=0.04) and microvascular disease (24%, P=0.001), and risk reductions for myocardial infarction (15%, P=0.01) and death from any cause (13%, P=0.007) emerged over time, as more events occurred. In the metformin group, significant risk reductions persisted for any diabetes-related end point (21%, P=0.01), myocardial infarction (33%, P=0.005), and death from any cause (27%, P=0.002).
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Conclusions Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837
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Volume 359:1618-1620 October 9, 2008 Number 15
John Chalmers, M.D., Ph.D., and Mark E. Cooper, M.D., Ph.D.
UKPDS and the Legacy Effect
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The United Kingdom Prospective Diabetes Study (UKPDS) continues to produce important evidence concerning the evolution of type 2 diabetes and its management. Two studies published in this issue of the Journal provide some answers to two questions of fundamental importance to patients with diabetes and to physicians alike. In one article, Holman et al. (UKPDS 80)1 provide data that confirm a so-called legacy effect associated with intensive glucose control in patients with type 2 diabetes, long after the cessation of randomized intervention. This finding provides a fitting parallel to the observations of the Diabetes Control and Complications Trial/Epidemiology of Diabetes…
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Volume 358:580-591 February 7, 2008 Number 6
Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes
Peter Gæde, M.D., D.M.Sc., Henrik Lund-Andersen, M.D., D.M.Sc., Hans-Henrik Parving, M.D., D.M.Sc., and Oluf Pedersen, M.D., D.M.Sc.
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Background Intensified multifactorial intervention — with tight glucose regulation and the use of renin–angiotensin system blockers, aspirin, and lipid-lowering agents — has been shown to reduce the risk of nonfatal cardiovascular disease among patients with type 2 diabetes mellitus and microalbuminuria. We evaluated whether this approach would have an effect on the rates of death from any cause and from cardiovascular causes
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Methods In the Steno-2 Study, we randomly assigned 160 patients with type 2 diabetes and persistent microalbuminuria to receive either intensive therapy or conventional therapy; the mean treatment period was 7.8 years. Patients were subsequently followed observationally for a mean of 5.5 years, until December 31, 2006. The primary end point at 13.3 years of follow-up was the time to death from any cause.
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Results Twenty-four patients in the intensive-therapy group died, as compared with 40 in the conventional-therapy group (hazard ratio, 0.54; 95% confidence interval [CI], 0.32 to 0.89; P=0.02). Intensive therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to 0.94; P=0.04) and of cardiovascular events (hazard ratio, 0.41; 95% CI, 0.25 to 0.67; P<0.001). One patient in the intensive-therapy group had progression to end-stage renal disease, as compared with six patients in the conventional-therapy group (P=0.04). Fewer patients in the intensive-therapy group required retinal photocoagulation (relative risk, 0.45; 95% CI, 0.23 to 0.86; P=0.02). Few major side effects were reported.
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Conclusions In at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes.
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Treatment Options
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Lifestyle interventions
The major environmental factors that increase the risk of type 2 diabetes are overnutrition and a sedentary lifestyle, with consequent overweight and obesity (39,40). Not surprisingly, interventions that reverse or improve these factors have been demonstrated to have a beneficial effect on control of glycemia in established type 2 diabetes (41). Unfortunately, the high rate of weight regain has limited the role of lifestyle interventions as an effective means of controlling glycemia in the long term. The most convincing long-term data indicating that weight loss effectively lowers glycemia have been generated in the follow-up of type 2 diabetic patients who have had bariatric surgery. In this setting, with a mean sustained weight loss of 20 kg, diabetes is virtually eliminated (42– 45).
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FACTORES DE RIESGO
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Pharmacological agents
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The consensus report concluded that “Although still limited, early evidence suggests that metformin is associated
with a lower risk of cancer and that
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exogenous insulin is associated with an increased cancer risk. Further research is needed to clarify these issues and evaluate if insulin glargine is more
strongly associated with cancer risk compared with other insulins.”
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Emerging evidence suggests that metformin has a range of biological mechanisms that reduce tumour growth beyond its ability to increase
insulin sensitivity. The enhanced binding of insulin glargine to IGF-I receptors is a theoretical concern, but might not translate to an actual increase in cancer risk.
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SummaryThe guidelines and treatment algorithm presented here emphasize the following:● Achievement and maintenance of near
normoglycaemia (A1C 7.0%)● Initial therapy with lifestyle intervention
and metformin● Rapid addition of medications, and
transition to new regimens, when targetglycemic goals are not achieved or sustained
● Early addition of insulin therapy in patientswho do not meet target goals
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A1C 6.5 – 7.5%**
Monotherapy
MET +
GLP-1 or DPP4 1
TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
MET + Colesevelam
AGI 3
2 - 3 Mos.***
2 - 3 Mos.***
2 - 3 Mos.***
Dual Therapy
MET +
GLP-1 or DPP4 1
+
TZD 2
Glinide or SU 4,7
A1C > 9.0%
No Symptoms
Drug Naive Under Treatment
INSULIN
± Other
Agent(s) 6
Symptoms
INSULIN
± Other
Agent(s) 6
INSULIN
± Other
Agent(s) 6
Triple Therapy
AACE/ACE Algorithm for Glycemic Control Committee
Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE
Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE
* May not be appropriate for all patients** For patients with diabetes and A1C < 6.5%,
pharmacologic Rx may be considered*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1 if PPG
2 TZD if metabolic syndrome and/or
nonalcoholic fatty liver disease (NAFLD)
3 AGI if PPG
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagoguewith multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy,insulin should be considered
MET +
GLP-1
or DPP4 1 ± SU 7
TZD 2
GLP-1
or DPP4 1 ± TZD 2
A1C 7.6 – 9.0%
Dual Therapy 8
2 - 3 Mos.***
2 - 3 Mos.***
Triple Therapy 9
INSULIN
± Other
Agent(s) 6
MET +
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
MET +
GLP-1
or DPP4 1+ TZD 2
GLP-1
or DPP4 1 + SU 7
TZD 2
MET † DPP4 1 GLP-1 TZD 2 AGI 3
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
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A1C 6.5 – 7.5%**
Monotherapy
MET +
GLP-1 or DPP4 1
TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
MET +Colesevelam
AGI 3
2 - 3 Mos.***
Dual Therapy
MET +GLP-1 or DPP4 1
+
TZD 2
Glinide or SU 4,7
INSULIN
± Other Agent(s) 6
Triple Therapy
MET † DPP4 1 GLP-1 TZD 2 AGI 3
2 - 3 Mos.***
2 - 3 Mos.***
*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
3 AGI if PPG
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
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MET +
GLP-1or DPP4 1
+ TZD 2
GLP-1or DPP4 1 + SU 7
TZD 2
A1C 7.6 – 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
Dual Therapy 8
MET +
GLP-1 or DPP4 1
or TZD 2
SU or Glinide 4,5
2 - 3 Mos.***
Triple Therapy 9
2 - 3 Mos.***
INSULIN
± Other Agent(s) 6
*** If A1C goal not achieved safely
† Preferred initial agent
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
4 Glinide if PPG or SU if FPG
5 Low-dose secretagogue recommended
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution
9 If A1C > 8.5%, in patients on Dual Therapy, insulin should be considered
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No Symptoms
Drug Naive Under Treatment
Symptoms
MET +
GLP-1 or DPP4 1
± SU 7
TZD 2
GLP-1 or DPP4 1 ± TZD 2
A1C > 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR
GLYCEMIC CONTROL
Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
INSULIN
± Other Agent(s) 6
INSULIN
± Other Agent(s) 6
1 DPP4 if PPG and FPG or GLP-1if PPG
2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)
6 a) Discontinue insulin secretagogue with multidose insulin
b) Can use pramlintide with prandial insulin
7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4
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Rosiglitazone and IHD Risk
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Pioglitazone and IHD Risk
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Pioglitazone vs Rosiglitazone and
IHD Risk
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Thiazolidinediones and Heart Failure
Risk
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Recommendations to Reduce Vascular Disease in Patients
with Type 2 Diabetes Mellitus
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