 |
|
 |
- May 17, 2008 |
|
|
Welcome to the #1 online source of information for Diabetes Specialists! An international online community of more than 10,000 Diabetes Specialists.
CME on Diabetes is a website built to transmit top-level CME conferences given by international experts in endocrinology, insulin resistance, prediabetes, metabolic syndrome and type 2 diabetes. More than 2.6 million slides have been viewed since the website launch. Thank you for your continued support and commitment!
|
|
|
| Presentation |
|
"Type 2 diabetes-Early : Aggressive Treatment Strategies"Dr. Amir Hanna (biography)
English - 2002-11-23 - 27 minutes
|
 | (46 slides) |
Summary :
Studies in Type 1 and 2 diabetes clearly show that using intensive regimens in the management of hyperglycemia results in significant reduction in microvascular disease and a trend towards amelioration of macrovascular disease (1-4). Early aggressive glycemic control in Type 1 diabetes resulted in long-term protection against microvascular disease (5).
Treatment paradigms in type 2 diabetes have advocated a slow approach towards attaining glycemic control (6) in-spite of the presence of diabetes related complications in 20-50% of subjects at the time of diagnosis (3,7). A new paradigm of early utilization of combination therapy should be considered when faced with glucose levels significantly above normal (FPG >10 mmol/L, PPG > 14 mmol/L and HbA1c > 8.4%). This is aimed at reaching target blood glucose levels as early as possible in the course of therapy. This approach is to be followed by efforts to maintain such levels by frequent measurement of pre- and post-prandial glucose levels, utilization of drugs with less rates of secondary failure aiming at attaining glucose and HbA1c levels as close to normal as possible. The early utilization of combinations of oral agents results in better glycemic parameters compared to mono-therapy.
Other advantages of combination therapy include:
1. Targeting the different pathogenic factors contributing to hyperglycemia: insulin resistance, impaired beta cell function and increased hepatic glucose production.
2. The use of sub-maximal doses of different oral agents, decreasing the possible side effects of such medications (8).
3. Avoidance of the effects of glucose toxicity, which could contribute to decreased insulin sensitivity and further reduction in beta cell response to hyperglycemia.
Utilization of the stepwise approach in studies like the UKPDS was associated with progressive increase in HbA1c to the extent of 0.3% per year. In the UKPDS, only a minority of patients were able to attain HbA1c < 7%: 50% at 3 years and 25% at 9 years (9). The decline in glycemic control was ascribed to deterioration of islet cell insulin secretion. Factors like the delay in attaining control, the use of agents with known secondary failure rate of 5% per year and the lack of intensive insulin treatment should be also counted as contributors to such failure. Combination therapy with rosiglitazone and metformin (10) was shown to improve blood glucose control with less effect on weight gain and no hypoglycemia, other combinations used early on in the course of diabetes treatment resulting better glycemic control (11).
In summary: changing the present treatment paradigm in Type 2 diabetes to a more aggressive approach to attain and maintain blood glucose levels as close to normal as possible should be applied. The availability of multiple combinations of oral agents, and or insulin will help us attain such goal.
Learning objectives :
The participant will learn about the rationale for early combination therapy and the use of different agents in mono- or combination therapy:
- Decreasing HbAIc to 7% reduces microvascular complications
- This target is not achieved in the majority of patients
- Initial combination therapy decreases glucose more than mono-therapy and has less side effects
- Complication prevention for type 2 diabetes should start promptly after diagnosis
- Agents used in combination therapy should be tailored to the individual patient
- The stepwise approach should be left behind in favour of early/initial combination therapy targeting HbA1c < 7%
- Choice of agents should take into account results of clinical studies, rate of secondary failure and non glycemic effects
Bibliographic references :
1. The Diabetes Control and Complications Trial Research Group. The effect of intensive therapy of diabetes on the developpment and progression of long-term complications in insulin-dependent diabtes mellitus. N Engl J Med 1993: 329:977-986
2. Ohkubo Y, Kishikawa H, Araki E et al. Intensive Insulin Therapy prevents the progression of diabetic microvascular complications in Japanese patients with Non-insulin dependent Diabetes Mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995; 28:103-117
3. UKPDS Group. Intensive Blood Glucose control with sulponylurea or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). Lancet 1998; 352:837-853.
4. Effect of Intesive blood-glucose control with metformin on complications in overweight patients with Type 2 diabetes (UKPDS 34) Lancet 1998; 352 (9131): 854-865
5. Retinopathy and Nephropathy in patients with Type1 Diabetes Four Years after a Trial of Intensive Therapy. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions And Complications Research Group. N Engl J Med 2000; 3452:381-389
6. Meltzer S, Leiter L, Daneman D et al. 1998 Clinical Practice Guidelines for the Management And Complications Research Group. N Engl J Med 2000; 3452:381-389.
7. Nathan DM. N Engl J Med 2002; 347:1342.
8. Riddle M. American J Med 2000; 106 (6A): 165-22S.
9. UKPDS JAMA 1999; 281:2005.
10. Fonseca V et al. JAMA 2000; 283:1695-1702.
11. Garber AJ, Larsen J, Schneider SH, et al. Diabetes Obes Metab 2002; 4(3) 201-8.
|
|
|
|
|
|
| Search our website |
 |
| |
Would you like to know more about insulin resistance? Are you looking for information pertaining to Type 2 Diabetes? You can find what you are looking for in over 2000 references available on CMEonDiabetes. |
| |
|
|
| Social |
|
| |
Let others know about this presentation.
|
|
|
|
