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Remissione del diabete tipo 2: Terapia Medica Dr. Monica Nannipieri

Remissione del diabete tipo 2: Terapia Medica Dr. Monica Nannipieri Dipartimento di Medicina Clinica e Sperimentale Università di Pisa. Therapeutic implications of the pathogenesis of type 2 diabetes.

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Remissione del diabete tipo 2: Terapia Medica Dr. Monica Nannipieri

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  1. Remissione del diabete tipo 2: Terapia Medica Dr. Monica Nannipieri Dipartimento di Medicina Clinica e Sperimentale Università di Pisa

  2. Therapeutic implications of the pathogenesis of type 2 diabetes • Effective treatment of type 2 diabetes requires multiple drugs used in combination to correct multiple pathophysiological defects • Treatment should be based on known pathogenic abnormalities and not simply on reduction of HbA1C • Therapy must be started early in the natural history of type 2 diabetes to prevent progressive beta-cell failure DecreasedIncretin Effect IncreasedLipolysis DecreasedInsulinSecretion Hyperglycemia IncreasedGlucagonSecretion IncreasedGlucoseReabsorption Islet-a cell IncreasedHGP DecreasedGlucose Uptake NeurotransmitterDysfunction Adapted from De Fronzo RA, Diabetes 2009

  3. Therapeutic implications of the pathogenesis of type 2 diabetes

  4. Therapeutic implications of the pathogenesis of type 2 diabetes

  5. 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

  6. Therapeutic implications of the pathogenesis of type 2 diabetes Begin with these options if metformin contraindicated Consider initial insulin therapy when A1c >10-12% Consider initial dual combination therapy when A1c >9% Diabetes Care 2012, Diabetologia 2012

  7. [..] 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 predisposition The 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 Diab Care, vol 32 n 11 November 2009

  8. HbA1c < 6.5% Glycemia 100-125 mg/dl HbA1c < 6.0% Glycemia < 100 mg/dl Buse JB et al. Diab Care 2009

  9. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes 6.5 Mingrone G NEJM 2012

  10. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? DIABETES REMISSION AFTER WEIGHT LOSS INTERVENTION Randomized control trial, 4 years follow-up 4503 pts Gregg EW JAMA 2012

  11. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.

  12. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? 118 pts in CSII for 2 wks, 53 non remission 65 in remission for >1year Chen A, Diabetes Care 2012

  13. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? b-cell Function 188 patients 68.9% 60.6% 49.5% Liu J End Jap 2012

  14. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? Liu J End Jap 2012

  15. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? 42 patients 42 patients 84 patients Wen XU, Chin Med J 2009

  16. Weng J, Lancet 2008

  17. Is it possible to have Remission of Type 2 Diabetes with Medical Therapy? When? Predictors of successful sustained euglycemia Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.

  18. SUMMARY • The effects of medical treatment on diabetes are related to improvement or restoration of: • insulin sensitivity (life style, weight loss); • b-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: • longer diabetes duration; • less BMI.

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