Favored treatment alternatives for patients with Diabetes

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Favored treatment choices for patients with Diabetes Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood

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Case Study – what might you do? What else do you have to know? 29 year old Bangladeshi ladies Type 2 diabetes for a long time Gliclazide 80mg bd , Metformin 850mg tds BMI 29.7kg/m 2 FBS 9.7mmol/l HbA 1 c 9.3% BP 152/88 Total Chol 6.1mmol/l LDL Chol 4.3mmol/l

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Diabetes is straightforward would it say it isn't?

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Make it as basic and all encompassing as could be expected under the circumstances

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Remember the finding of Diabetes CVD hazard movement starts before diabetes

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however Diabetes is a dynamic condition We have to chance stratify Between patients Between dangers in same pt We should engage patients We need adequate ability to do ALL above Most look after individuals with diabetes is NOT advanced science

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`I said pig,' answered Alice; `and I wish you wouldn't continue showing up and vanishing so all of a sudden: you make one entirely wired.' `All right,' said the Cat; and this time it vanished gradually, starting with the end of the tail, and consummation with the smile, which stayed some time after whatever is left of it had gone. `Well! I've frequently observed a feline without a smile,' thought Alice; `but a smile without a feline! It's the most inquisitive thing I ever found in my life!

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Understanding danger crucial for legitimate recommending MICROALBUMINURIA

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Steno-2: An endeavor to approve the viability of day by day clinical practice, i.e. the multifactorial treatment of sort 2 diabetes High hazard sort 2 diabetes patients A solitary focus ponder An association which considered escalated mediation Longterm intercession STENO-2

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Estimated effect of single hazard component mediations to diminish CVD in patients with sort 2 diabetes Relative hazard 2-yr's occasion reduction decrease None … … 11.0 % Cholesterol (around 0.6 mmol/l) 25 % 8.3 % BP (around 5/2 mm Hg) 27 % 6.0 % HbA1c (around 0.9 %) 13 % 5.2 % Aspirin 9 % 4.7 % Cumulative relative hazard lessening of around 57% Huang et al. Am J Med 2001;111:633-642 Turner R.C. BMJ 1998;316:823-828 He et al. JAMA 1999;282:2027-2034 Antitrombotic Trialits BMJ 2002;324:71-86 STENO-2

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Lifestyle, way of life, way of life and Drugs Hypertension choices

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Stepwise way to deal with the treatment of hypertension Severity of hypertension Other ß - blocker Calcium adversary Diuretics ACE inhibitor/Angiotensin II rival STENO-2

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Cholesterol Total Cholesterol to 4 mmol/l LDL Cholesterol to 2 mmol/l CARDS HPS Jt British Soc

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PANCREAS Glucose bringing down prescriptions LIVER DECREASED INSULIN SECRETION INCREASED GLUCOSE PRODUCTION Therapy : Sulphonylureas Prandial Glucose Regulators incretins Insulin Therapy: Biguanides Thiazolidinediones incretin s HYPERGLYCEMIA DECREASED Incretin creation INTESTINE DECREASED PERIPHERAL GLUCOSE UPTAKE ADIPOSE TISSUE MUSCLE INCREASED GLUCOSE ABSORPTION Therapy: Thiazolidinediones Biguanides Therapy: Alpha-glucosidase inhibitors

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Does it matter what sedate you utilize?

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Stepwise treatment of hyperglycaemia Gliclazide + NPH insulin BMI <27 Diet Gliclazide + Metformin + NPH insulin BMI ≥27 Metformin Diet But numerous different choices accessible Time STENO-2

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INCRETINS  - cells expands insulin discharge glucose insulin GLP-1 GIP Rapidly inactivated by dipeptidyl peptidase IV dinner

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Incretin activities

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Insulin will be insulin… … .. Simply extraordinary onsets and terms of activity Different gadgets Tailor to individual patient's way of life

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Putting it all together for 1 tolerant

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The Care Planning Model

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Case concentrate on – what might you do? 43 yr old ♂ Type 2 DM for a long time Project Engineer on occupied venture UK↔USA Keeps DNA 98.2 Kg BMI 31kg/m 2 BP 158/91 HbA 1 c 8.3% eGFR >60ml/min Total Chol 6.1mmol/l LDL 3.90mmol/l NovoRapid 8u/8u/8u Levemir 10u mane Atorvastatin 10mg Lisinopril 10mg