Update on the management of Type 2 Diabetes

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1 Update on the management of Type 2 Diabetes Mona Nasrallah M.D Assistant Professor, Endocrinology American University of Beirut 10 th Annual Family Medicine Conference October 14,2011

2 Global Prevalence of Diabetes WHO global burden of disease study All age groups % Total (million) Hossain et al 2007 NEJM 356: 213.

3 Global Prevalence of Diabetes International Diabetes Federation All age groups % Total (million)

4 Diabetes Global Projections Hossain et al 2007 NEJM 356: 213.

5 Prevalence of T2D in Lebanon Prevalence 15.8 %in those age 40 years in Greater Beirut area Estimated population 40 years in 2010 is 1,378 million Estimated current diabetes prevalence in Lebanon Hirbli et al 2005 Diabetes Care 28: 1261

6 Prevalence of obesity in Lebanon Age (years) Gender 1997 # Obese% 2008/9 & Obese% 6-19 Boys Girls > 20 Men Women # Sibai et al, Obes Res :1353 & Unpublished data PHAN research group at AUB

7 World Diabetes Day November 12, Metropolitan Hotel Hosted by the EDL Society of Lebanon

8 Objectives Review current criteria for the diagnosis of diabetes mellitus, especially with the updated use of HbA1C Describe current and upcoming therapies for Type 2 Diabetes Construct an algorithm for diabetes therapy.

9 Current criteria for diagnosis Fasting plasma glucose 126 mg/dl Two-hour plasma glucose 200 mg/dl post OGTT Random plasma glucose 200 mg/dl with symptoms HbA1C 6.5 % NGSP standard, nonfasting, hemoglobinopathies In the absence of unequivocal hyperglycemia, repeat test ADA 2011 Diabetes Care, 34 : S1

10 Definition Glucose Prediabetes Diabetes mg/dl Fasting IFG hour IGT HbA1C % Prediabetes ADA, Diabetes Care 2010, 33: S3

11 Gestational Diabetes Previous Screen at weeks Two-step approach Use 50 gm, 1 hour PC and if high, 100 gm OGTT Follow-up post-partum 6-12 weeks and thereafter ADA 2011 Screen first trimester using non-pregnant criteria if at risk One-Step approach Screen at weeks with 75 gm OGTT Follow-up postpartum 6-12 weeks and every 3 years ADA, Diabetes Care 2011, 34: S3

12 Gestational diabetes: glucose cut-offs mg/dl Previous ADA 2011 Fasting hour hour hour 140 N/A ABNORMAL VALUES TWO OR MORE ONE OR MORE ADA, Diabetes Care 2011, 34: S3

13 Objectives Review current criteria for the diagnosis of diabetes mellitus, especially with the updated use of HbA1C Describe current and upcoming therapies for Type 2 Diabetes CLASSICS, NEW, ODD Construct an algorithm for diabetes therapy.

14 Pharmacotherapy for diabetes: CLASSICS Decrease Glucose absorption α-glucosidase inhibitors Acarbose miglitol Decrease Insulin demand Biguanides Metformin TZD Rosiglitazone Pioglitazone Increase Insulin supply Sulfonylureas Glimepiride Gliclazide Glyburide Glipizide Meglitinides Repaglinide Nateglinide Insulin Plasma glucose

15 Pharmacotherapy for diabetes: NEW GLP-1 agonists Secreted by intestine in response to glucose Slows gastric emptying, increase insulin, decrease glucagon Levels are low in diabetes DPP-IV inhibitors Prevents breakdown of endogenous GLP-1 Amylin analogs Co-secreted with insulin

16 Pharmacotherapy for diabetes: NEW Decrease Glucose absorption α-glucosidase inhibitors Decrease Insulin demand Biguanides TZD Increase Insulin supply Sulfonylureas Meglitinides Insulin GLP-1 agonists Exenatide, liraglutide DPP-IV inhibitors Sitagliptin, saxagliptin,vildagliptin Amylin analogs Pramlintide Plasma glucose

17

18 Pharmacotherapy for diabetes: ODD Decrease Glucose reabsorption Decrease Glucose absorption Decrease Insulin demand Increase Insulin supply SGLT2 inh Dapagliflozin α-glucosidase inhibitors Colesevelam Biguanides TZD Sulfonylureas Meglitinides Insulin GLP-1 agonists DPP-IV inhibitors Bromocriptine Amylin analogs Plasma glucose

19 Degree of HbA1C lowering MILD, MODERATE, HIGH Decrease Glucose reabsorption Decrease Glucose absorption Decrease Insulin demand Increase Insulin supply SGLT2 inh α-glucosidase inhibitors Colesevelam Biguanides TZD Sulfonylureas Meglitinides Insulin GLP-1 agonists DPP-IV inhibitors Bromocriptine Amylin analogs Plasma glucose

20 Effect on weight INCREASE, MILD/NEUTRAL, DECREASE Decrease Glucose reabsorption Decrease Glucose absorption Decrease Insulin demand Increase Insulin supply SGLT2 inh α-glucosidase inhibitors Colesevelam Biguanides TZD Sulfonylureas Meglitinides Insulin GLP-1 agonists DPP-IV inhibitors Bromocriptine Amylin analogs Plasma glucose

21 Customizing therapy Risk factor control Certain side-effects Additional points Metformin and vitamin B 12 deficiency Pioglitazone and bladder ca Pioglitazone and osteoporosis Dapagliflozin and breast and bladder ca DPP IV inhibitors and pancreatitis GLP-1 agonists and pancreatitis GLP-1 and medullary ca thyroid Drugs for T2D

22 Objectives Review current criteria for the diagnosis of diabetes mellitus, especially with the updated use of HbA1C Describe current and upcoming therapies for Type 2 Diabetes Construct an algorithm for diabetes therapy.

23

24 ADA and EASD, 2009 More updated guidelines from the UK not much different May 2011

25 Add DPPIV inh Add GLP-1 Amylin analogs Glucose abs inh Bromocriptine Adapted from ADA algorithm

26 Objectives Review current criteria for the diagnosis of diabetes mellitus, especially with the updated use of HbA1C Describe current and upcoming therapies for Type 2 Diabetes CLASSICS, NEW, ODD Construct an algorithm for diabetes therapy.

27 Diabetes Day November 12, Metropolitan Hotel Diabetes & Cancer: How Diabetes and Diabetes Therapy influence Cancer Risk Diabetes & CVD: Is T2D a CHD equivalent? Erectile Dysfunction: a new marker of CVD? T2D GENETICS: Past, Present and Future Role of Statins in CKD: Do we have the answer? Diabetes Risk on Statin Therapy: What is it and does it really matter? Post Prandial Hyperglycemia: should we really care?

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