Perriello G. Audit. 27.11 - 18.00.pps

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Società Italiana Gerontologia e Geriatria53° Congresso NazionaleGabriele PerrielloDipartimento di Medicina InternaUniversità di PerugiaTerapia Orale del Diabete tipo 2: nuove evidenze scientificheFirenze, 27 novembre 2008nznovembre Eterogeneity of T2DMβ-cellInsulinType 2Resistance DysfunctiondiabetesAdapted from: Beck-Nielson H et al. J Clin Invest 1994;94:1714–1721 and Saltiel AR, Olefsky JM. Diabetes 1996;45:1661–1669Clinical and FunctionalEterogeneity of Elderly T2DM1. Older individuals may have developed diabetes years earlier and may have significant complications2. Newly diagnosed may have had years of undiagnosed diabetes with resultant complications or may have few complications from the disease3. Older adults with diabetes may be frail and have other underlying chronic conditions, substantial diabetes-relatedcomorbidity, or limited physical or cognitive functioning4. Older individuals with diabetes have little comorbidity andare active5. Life expectancies are highly variable for this population,but often longer than clinicians realizeAmerican Diabetes Association: Standards of Medical Care in Diabetes—2008; Diabetes Care 31:S12-S54, 2008Algorithm for the metabolic management of type 2 diabetesetatypeADA/EASD Consensus StatementTier 1: Well-validated core therapiesLifestyle + MetforminLifestyle + MetforminAt diagnosis:+ +Basal insulinIntensive insulinLifestyle+Lifestyle + MetforminMetformin+aSulfonylureaSTEP 1 STEP ...

Informations

• Publié par: Irkoi
• Nombre de lectures: 104
• Langue: Romanian

Extrait

Società Italiana Gerontologia e Geriatria 53° Congresso Nazionale

GabriePlerriello Dipartime nto di Medicina Interna Università di Perugia

Terapia Orale del Diabete tipo 2:

nuove evidenze scientifiche

  m 

Eterogeneity of T2DM

Insulin

Resistance

Type 2 diabetes

βc-ell

Dysfunction

Adapted from: Beck-Nielson H et al . J Clin Invest 1994;94:1714–1721 and Saltiel AR, Olefsky JM. Diabetes 1996;45:1661–1669

1. 2.

3.

4. 5.

Clinical and Functional Eterogeneity of Elderly T2DM Older individuals may have developed diabetes years earlier and may have significant complications Newly diagnosed may have had years of undiagnosed diabetes with resultant complications or may have few complications from the disease Older adults with diabetes may be frail and have other underlying chronic conditions, substantial diabetes-related comorbidity, or limited physical or cognitive functioning Older individuals with diabetes have little comorbidity and are active Life expectancies are highly variable for this population, but often longer than clinicians realize

American Diabetes Association: Standards of Medical Care in Diabetes—2008; Diabetes Care 31:S12-S54, 2008

Algorithm for the metabolic management of ADA/EASD ConsensusStatement Tier 1: Well-validated core therapies

At diagnosis: Lifestyle + Metformin

Lifestyle + Metformin + Basal insulin

Lifestyle + Metformin + Sulfonylurea a

STEP 1  STEP 2 Tier 2: Less well-validated therapies

Lifestyle + Metformin + Pio it No hypogly g c l em a i z a one Oedema/CHF Bone loss Lifestyle + Metformin + onist b No hy G po L g P l - yc 1 e a m g ia Weight loss Nausea/vomiting

a Other than glibenclamide or chlorpropamide b Insufficient clinical use to be confident regarding safety

Lifestyle + Metformin + Pioglitazone + Sulfonylurea a

Lifestyle + Metformin + Basal insulin

type 2 diabetes

Lifestyle + Metformin + Intensive insulin

STEP 3

Nathan et al. Diabetes Care 31:1-11, 2008

Factors influencing targets and OHA choice

Life expectancy <5 yrs Functional and cognitive impairment Life-limiting  comorbidities Polytherapy Diabetic complications

HbA1c = 8%

Most OHA contraindicated

Long life expectancy Active Good functional status Otherwise healthy Few therapies No comorbidities No complications

HbA1c < 7%

All OHA recommended

American Geriatrics Society : Guidelines for improving the care of the older person with diabetes mellitus ; J Am Geriatr Soc 2003; 51:S265–S280

-16 p=0.052

-6

p=0.63

Retinopathy Cataract extraction Microvascular complications Albuminuria at 12 years MI Fatal myocardial infarction

Lowering HbA1c Reduces Risk of Complications* 0 -5 -10 -15 -20 -25 -30 -35 -40 *Percent risk reduction for 0.9% decrease in HbA 1c

-21 p=0.015 -24 -25 p=0.046 p=0.009

-34 p=0.00005

UKPDS. Lancet 1998; 352:837

Livelli mediani di emoglobina glicata

N. a rischio

Terapia standard

Terapia intensiva

N Engl J Med 358;24: 2545, 2008

Studio ACCORD n=10251; età media 62 (35% >65 anni) Terapia standard

Anni

Terapia intensiva

Effetti del controllo intensivo su outcome primario e decesso per qualsiasi causa

Outcome primario: infarto miocardio e ictus non fatali, e morte cardiovascolare

Outcome primario

N. a rischio Terapia intensiva Terapia standard

HR 0.90; 95% CI, 0.78 to 1.04; P = 0.16 Terapia standard

N Engl J Med 358;24: 2545, 2008

Anni

Terapia intensiva

Decesso per qualsiasi causa

N. a rischio erap a n ens va erap a s an ar

Studio ACCORD

HR 1.22; 95% CI, 1.01 to 1.46; P = 0.04

Anni

Terapia intensiva

Terapia standard

Effetti del controllo intensivo in gruppi di pazienti pre-selezionati

Studio ACCORD

“..Intensive blood glucose control may be better at protecting people who have lower cardiovascular risk and/or start off with better diabetes control”

N Engl J Med 358;24: 2545, 2008

Hypoglycemic efficacy of available oral agents for T2DM

Oral agent

M e t f o r m i n

Sulfonylureas

Glinides

Thiazolidinediones

Acarbose

Inzucchi SE. JAMA 2002;287:360

HbA1c change

1.62 (0.8 -3.0)

1.65 (0.9 -2.5)

1.30 (0.6 -1.9)

1.3 (1. 1 -1.6)

0.8 (0. 4 -1.3)

Metformin vs other OHAs

Aggregate Endpoint

Any diabetes related endpoint

Diabetes related deaths

All cause mortality

Myocardial infarction

Stroke

Peripheral vascular disease

Microvascular

UKPDS 34, Lancet 1998; 352: 854-65

p

0.0034

0.11

0.021

0.12

0.032

0.62

0.39