Preferred treatment options for patients with Diabetes

1. Preferred treatment options for patients with Diabetes Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood

2. Case Study – what would you do?What else do you need to know? • 29 year old Bangladeshi women • Type 2 diabetes for 4 years • Gliclazide 80mg bd , Metformin 850mg tds • BMI 29.7kg/m2 • FBS 9.7mmol/l HbA1c 9.3% • BP 152/88 • Total Chol 6.1mmol/l LDL Chol 4.3mmol/l

3. Diabetes is simple isn’t it?

4. Make it as simple and holistic as possible

5. Remember the diagnosis of Diabetes CVD risk progression begins before diabetes

6. but Diabetes is a progressive condition We need to risk stratify Between patients Between risks in same pt We must empower patients We need to have sufficient capacity to do ALL above Most care for people with diabetes is NOT rocket science

7. `I said pig,' replied Alice; `and I wish you wouldn't keep appearing and vanishing so suddenly: you make one quite giddy.' `All right,' said the Cat; and this time it vanished quite slowly, beginning with the end of the tail, and ending with the grin, which remained some time after the rest of it had gone. `Well! I've often seen a cat without a grin,' thought Alice; `but a grin without a cat! It's the most curious thing I ever saw in my life!

8. Understanding riskessential for proper prescribing MICROALBUMINURIA

9. Steno-2: An attempt to validate the efficacy of daily clinical practice, i.e. the multifactorial treatment of type 2 diabetes High risk type 2 diabetes patients A single center study An organisation which allowed for intensive intervention Longterm intervention STENO-2

10. Estimated impact of single risk factor interventions to reduce CVD in patients with type 2 diabetes • Relative risk 2-yr’s event • reduction reduction • None …… 11.0 % • Cholesterol (down by 0.6 mmol/l) 25 % 8.3 % • BP (down by 5/2 mm Hg) 27 % 6.0 % • HbA1c (down by 0.9 %) 13 % 5.2 % • Aspirin 9 % 4.7 % Cumulative relative risk reduction of about 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

11. Lifestyle, lifestyle, lifestyle and Drugs Hypertension options

12. Stepwise approach to the treatment of hypertension Severity of hypertension Other ß-blocker Calcium antagonist Diuretics ACE inhibitor/Angiotensin II antagonist STENO-2

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

14. PANCREAS Glucose lowering medications LIVER DECREASED INSULIN SECRETION INCREASED GLUCOSE PRODUCTION Therapy: Sulphonylureas Prandial Glucose Regulators incretins Insulin Therapy: Biguanides Thiazolidinediones incretins HYPERGLYCEMIA DECREASED Incretin production INTESTINE DECREASED PERIPHERAL GLUCOSE UPTAKE ADIPOSE TISSUE MUSCLE INCREASED GLUCOSE ABSORPTION Therapy: Thiazolidinediones Biguanides Therapy: Alpha-glucosidase inhibitors

15. Does it matter what drug you use?

16. Stepwise treatment of hyperglycaemia Gliclazide + NPH insulin BMI <27 Diet Gliclazide Gliclazide + Metformin Metformin + NPH insulin BMI ≥27 Metformin Diet But many other options available Time STENO-2

17. Glitazones

18. INCRETINS -cells increases insulin secretion glucose insulin GLP-1 GIP Rapidly inactivated by dipeptidyl peptidase IV meal

19. Incretin actions

20. Insulin is insulin…….. Just different onsets and durations of action Different devices Tailor to individual patient’s lifestyle

21. Putting it all together for 1 patient

22. The Care Planning Model

23. Case study – what would you do? • 43 yr old ♂ Type 2 DM for 11 years • Project Engineer on busy project UK↔USA • Keeps DNA • 98.2 Kg BMI 31kg/m2 BP 158/91 • HbA1c 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