Remissione del diabete tipo 2: Terapia Medica Dr. Monica Nannipieri
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Remissione del diabete tipo 2: Terapia Medica
Dr. Monica NannipieriDipartimento di Medicina Clinica e Sperimentale
Università di Pisa
Adapted from De Fronzo RA, Diabetes 2009
IncreasedGlucagonSecretion
NeurotransmitterDysfunction
DecreasedIncretin Effect
IncreasedHGP Decreased
Glucose Uptake
IncreasedGlucoseReabsorption
IncreasedLipolysis
Hyperglycemia
DecreasedInsulin
Secretion
Islet- cell
1. Effective treatment of type 2 diabetes requires multiple drugs used in combination to correct multiple pathophysiological defects
2. Treatment should be based on known pathogenic abnormalities and not simply on reduction of HbA1C3. Therapy must be started early in the natural history of type 2 diabetes to prevent progressive beta-cell failure
Therapeutic implications of the pathogenesis of type 2 diabetes
Therapeutic implications of the pathogenesis of type 2 diabetes
Therapeutic implications of the pathogenesis of type 2 diabetes
ADA-EASD Position Statement: Management of Hyperglycemia in T2DM
• Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
- Individualization is key:
Tighter targets (6.0 - 6.5%) - younger, healthier Looser targets (7.5 - 8.0%+) - older, comorbidities,
hypoglycemia prone, etc.
- Avoidance of hypoglycemia
PG = plasma glucose
Diabetes Care 2012, Diabetologia 2012
Therapeutic implications of the pathogenesis of type 2 diabetes
Consider initial
Consider initial
insulin therapy
insulin therapy
when A1c >10-12%
when A1c >10-12%Consider initial
Consider initial
insulin therapy
insulin therapy
when A1c >10-12%
when A1c >10-12%
Begin with these
Begin with these
options if metformin
options if metformin
contraindicated
contraindicatedBegin with these
Begin with these
options if metformin
options if metformin
contraindicated
contraindicated
Consider initial dual
Consider initial dual
combination therapy
combination therapy
when A1c >9%
when A1c >9%Consider initial dual
Consider initial dual
combination therapy
combination therapy
when A1c >9%
when A1c >9%
Diab Care, vol 32 n 11 November 2009
[..] For a chronic illness such as diabetes, it may be more accurate to use the term remission than cure. Current or potential future therapies for type 1 and type 2 diabetes will likely always leave patients at risk for relapse, given underlying pathophysiologic abnormalities and/or genetic predispositionThe authors agreed upon the following definitions, which are the same for type 1 and type 2 diabetes: Remission is defined as achieving glycemia below the diabetic range in the absence of active pharmacologic (anti-hyperglycemic medications, immunosuppressive medications) or surgical (ongoing procedures such as repeated replacement of endoluminal devices) therapy
Buse JB et al. Diab Care 2009
HbA1c < 6.5%Glycemia 100-125 mg/dl
HbA1c < 6.0%Glycemia < 100 mg/dl
Mingrone G NEJM 2012
Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes
6.5
DIABETES REMISSION AFTER WEIGHT LOSS INTERVENTION
Gregg EW JAMA 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
Randomized control trial, 4 years follow-up 4503 pts
Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
Chen A, Diabetes Care 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
118 pts in CSII for 2 wks,53 non remission65 in remission for >1year
Liu J End Jap 2012
68.9%60.6%
49.5%
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? -cell Function
188 patients
Liu J End Jap 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
Wen XU, Chin Med J 2009
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
84 patients42 patients 42 patients
Weng J, Lancet 2008
Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.
Predictors of successful sustained euglycemia
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
When?
SUMMARY
The effects of medical treatment on diabetes are related to improvement
or restoration of:
a.insulin sensitivity (life style, weight loss);
.-cell function (hormonal factors and reduction of glucotoxicity and
lipotoxicity).
Rate of success of medical treatment in terms of diabetes remission may
depend on the extent of -cell dysfunction/loss at time of treatment and,
hence, could be lower for:
a.longer diabetes duration;
b.less BMI.