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Type 2 diabetes Key slides 3; Management of blood glucose Lending our patients a hand

Type 2 diabetes Key slides 3; Management of blood glucose Lending our patients a hand. Glucose control Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008. Measure HbA 1c every 2 to 6 months, until stable on unchanging therapy, then every 6 months

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Type 2 diabetes Key slides 3; Management of blood glucose Lending our patients a hand

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  1. Type 2 diabetesKey slides 3;Management of blood glucoseLending our patients a hand

  2. Glucose control Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008 • Measure HbA1c every 2 to 6 months, until stable on unchanging therapy, • then every 6 months • Only offer self-monitoring of blood glucose as an integral part of self-management • education (discuss purpose, interpretation and how it should be acted upon) • see later for more details

  3. Algorithm for glucose control [1] Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008 Continued on next slide…

  4. Algorithm for glucose control [2] Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008 Continued from previous slide The guidance on glitazones, gliptins and exenatide will be updated in the NICE short clinical guideline ‘Newer agents for blood glucose in type 2 diabetes’, expected May 2009

  5. What is the guidance from NICE? NICE Clinical Guideline 66;May 2008 • Glitazones are third-line agents, as triple therapy with metformin and a SU if glycaemic control is insufficient (HbA1c>7.5%) • Or second-line agents (at HbA1c>6.5%), as dual therapy with metformin if hypoglycaemia on a SU a particular issue, or with a SU if metformin not tolerated/contraindicated • But there are safety issues; only pioglitazone▼ can be used with insulin The section covering glitazones, gliptins and exenatide will be updated in the NICE short clinical guideline ‘Newer agents for blood glucose in type 2 diabetes’, expected May 2009

  6. Do glitazones have POO data? CochraneRichter B, et al. Pioglitazone Cochrane Review 2006Richter B, et al. Rosiglitazone Cochrane Review 2007 Pioglitazone▼ • 22 RCTs (n=6,200 randomised to pioglitazone▼), included PROactive (average follow-up 34.5 months, primary endpoint: CV outcomes) Dormandy JA, et al. Lancet 2005;366:1279–1289 • Concluded: • no convincing evidence that patient-orientated outcomes (mortality, morbidity, adverse effects, costs, QoL) were positively influenced by pioglitazone ▼ • Oedema was significantly increased • Results of PROactive need confirmation; hypothesis generating Rosiglitazone • 18 RCTs (n=3,888 randomised to rosiglitazone), included ADOPT (average follow-up 4 years, primary endpoint: glycaemic control) Kahn SE, et al. N Engl J Med 2006;355:2427–2443 • Concluded: • No convincing evidence that patient-orientated outcomes (mortality, morbidity, adverse effects, costs, QoL) were positively influenced by rosiglitazone • Oedema was significantly increased • ADOPT indicated increased CV risk

  7. What did Drug Safety Update say?Drug Safety Update 2007;1 (5) • A Europe-wide safety and efficacy review found that the benefits of rosiglitazone • and pioglitazone▼ continue to outweigh the risks • However, the prescribing information has been updated to include warnings that: • - Rosiglitazone should be used in patients with ischaemic heart disease only after careful evaluation of every patient’s individual risk • - Rosiglitazone combined with insulin should be used only in exceptional cases and under close supervision

  8. Oral hypoglycaemics: Old vs. new drugsBolen S, et al. Ann Intern Med 2007;147:386–99 • Systematic review of 216 studies and 2 earlier systematic reviews of oral hypoglycaemics to January 2006 • Data on major clinical endpoints, eg CV mortality were limited, therefore inconclusive • But concluded that older agents have similar or superior effects to newer, more expensive agents on glycaemic control, lipids and other intermediate endpoints (body weight, BP, adverse effects, etc.) • Older agents: metformin, SU • Newer agents: glitazones, alpha-glucosidase inhibitors, eg acarbose and meglitinides

  9. Self-monitoring blood glucose Type 2 diabetes: the management of type 2 diabetes. NICE Clinical Guideline 66;May 2008 • Make available to: • Those on insulin • Those on oral medication to provide information on hypoglycaemia • Assess changes during medication or lifestyle changes, or illness • Ensure safety during activities, including driving • Assess at least annually in a structured way: • Self-monitoring skills • Quality and appropriate frequency of testing • The use made of results obtained • The impact on quality of life • The continued benefit • The equipment used

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