Medical care of diabetes - what s new?

Transcription

1 emedic research training 29 May 2012 Loimaa Medical care of diabetes - what s new? Markku Vähätalo Specialist in General Practice Special qualification for the treatment of diabetes Loimaa health centre

2 Cornerstone of diabetes care Diet and other lifestyle treatment Self-monitoring Never only this Medication

3 Treatment by diet The time for change and criticism is now What is the correct fat content in a diet? The Finnish Heart Association: saturated fat 10% 7% MOT TV programme: butter and cream are healthy How about carbohydrates? MOT TV programme: carbohydrates are detrimental Low-carbers: diet (even) completely without carbohydrates PHOTO:

4 Diet (2) Hold your horses and be sensible The ill effects of animal fats have been well proven There are people who can clearly tolerate a diet quite rich in cream and butter We cannot know in advance who belongs to which group There is no point changing the diet and cholesterol values of a relatively healthy elderly person

5 Diet (3) Carbohydrates are basic Finnish food We are all united in opposing "bad" carbohydrates (sugar, white flour) Everyone finds vegetables healthy A normal diet cannot be built on meat alone

6 Diet (4) What is still most important is calories There is two times more of them in fat An average Finn is not likely to calculate the exact percentage of saturated fat content in their diet Too much food is usually the most significant mistake in a diet Today, Finns also gain a lot of calories from alcohol

7 Medical care

8 Medical care trends in tablets Metformin is the most common and the first Everyone with no contra-indication should have it Nausea, diarrhoea Impaired kidney function (GFR < 60) Alcoholism Brand names Metforem, Diformin, Glucophage Large tablets, maximum amount with the most common strength (500 mg) 6 tablets per day Dosing not connected to eating in the morning and in the evening (8 am and 8 pm) if an uneven dosage, the main dose in the evening (e.g. 2+3) effects through liver effect about -1% HbA1c Inexpensive, may prevent cancer

9 Sulphonyl urea unpopular Brand names Amaryl, Euglucon, Mindiab Beat the pancreas to produce more insulin Inexpensive, specially reimbursable Efficient, - 1.5% HbA1c Adverse effects: May cause hypoglycaemia (to the elderly) Increase weight Safe for people with multiple illnesses? For example, together with metformin

10 Insulin sensitisers Only one brand name, Actos (Competact) Sensitise organs against the influence of one's own insulin Favourable impact on levels of fat in the blood The impact sets on slowly (1-2 months) Adverse effects: Swelling, decrease of hb, increased fracture susceptibility for women Deterioration of congestive hear failure Specially reimbursable, becoming less popular Suitable for combination medication

11 Meal tablets Brand names Novonorm, Starlix (meglitidines) Rare Taken 2-3 times per day before a meal Impact like with fast acting insulin (no insulin) In addition, the basic medicine to be taken in the morning is needed Novonorm special reimbursement

12 Gliptins Sitagliptin (Januvia, Xelevia) Vildagliptin (Galvus) Saxagliptin (Onglyza) Linagliptin (Trajenta) Increase insulin secretion after meals with the help of GLP-1 Do not cause weight gain Do not cause hypoglycaemia Combination preparations together with metformin (Janumet, Velmetia, Eucreas) All YE (except Trajenta)

13 Gliptins cont. Can also be used in case of renal failure HbA1c decrease appr. 0.8% units. If the starting point is poor balance, a bigger decrease is achieved Can be used with all the others Not worth using with sulphonylurea Also together with basic insulin

14 More effective in the same group Incretin Mimetics (Byetta/Victoza) Direct GLP-1 impact Helps lose weight Lowers blood sugar PHOTO: More effective than drugs in tablet format An injection, no titration Price still high E.g. Lantus 100 units/day, costs already the same

15 Byetta - exenatide Short acting Injection every morning and evening Nausea at first /month

16 Victoza (liraglutide) Long acting Injection once a day Nausea at first Appears more effective /month

17 The very newest Bydureon Byetta, injected only once a week Bydureon must be mixed Month's treatment 145, reimbursable as of 1 July 2012

18 Weight loss ORIGIN: Int J Obes (Lond) Jun;36(6): doi: /ijo Epub 2011 Aug 16.Safety, tolerability and sustained weight loss over 2 years with the once-daily human GLP-1 analog, liraglutide. Astrup A, Carraro R, Finer N, Harper A, Kunesova M, Lean ME, Niskanen L, Rasmussen MF, Rissanen A,Rössner S, Savolainen MJ, Van Gaal L; NN Investigators

19 Blood sugar (HbA1c) decline

20 Kela opinion Kela basic reimbursement (42%) possible: BI statement from a Specialist in Internal Medicine or General Practice BMI over 35 kg/m 2 (170 cm /100 kg) When blood sugar level has not stabilized with the help of tablets (HbA1c 7% or under) At least two tablet medicaments in use What about insulin? no? Lantus 75 units/day /month If reimbursable, there is the upper limit (everything over the own contribution of 700 to be reimbursed)

21 Incretin Mimetic vs. Gliptins Incretin Mimetic Injectable GLP-1 content increases Strong impact on HbA1c Insulin secretion +++ Glucagon - Decreases weight Gliptin (DPP-4 inhib.) Tablet GLP-1 content physiological HbA1c drop about 0.8%, bigger when starting from a higher level Insulin secretion ++ Glucagon - Weight neutral

22 Medicaments that impact incretins Eating GI tract GLP-1 analogues Release of incretins from intestines Pancreas β cells α cells Glucose dependent Insulin from beta cells (GLP-1 and GIP) Insulin increases the use of glucose by muscles Better glucose balance DPP-4 inhibitor X DPP-4 enzyme Inactive incretins Glucagon of alpha cells (GLP-1) Dependent on glucose insulin and glucagon reduce the glucose production of liver Origin: Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145: ; Zander M et al Lancet 2002;359: ; Ahrén B Curr Diab Rep 2003;3: ; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:

23 And when these do not help? As a result of a long illness, the pancreas always gets tired in the end Sugar levels increase The weight often goes down Addition of medicine no longer fixes the blood sugar It is time to start taking insulin The C peptide test helps Type 2 diabetes will not turn into type 1 diabetes There will be some of the same characteristics, e.g. an increased danger of coma (ketoacidosis)

24 Insulins today Analogues rule Analogue = genetically modified insulin, amino acid content modified chemically Solutions no longer have precipitation, and they do not have to be mixed prior to injecting. So called insulin human not used much any more Only Protaphane can sometimes be encountered (NPH insulin) Long acting analogue Lantus and Levemir Rapid acting insulins Humalog, Novorapid and Apidra

25 Benefits of long-acting analogues Lantus (insulin glargine) Levemir (insulin detemir) Better impact profile Even one injection may be sufficient (+ meal insulin) T2DM does not usually require meal insulin Less hypoglycaemia Less formation of antibodies Daily profiles vary less

26 Detriments More expensive (appr. 2 x) Today, all in the YE group for a patient Some exotic side effects Cancerous impact under debate. Apparently diabetes comes with an elevated cancer frequency, not insulin

27 Acting times of insulins Actrapid Protaphane Levemir Lantus KUVA:

28 Actrapid is already history Still used at polyclinics to lower high blood sugar Longer acting time has certain advantages In normal home care they can be harmful ("tail effect") Rapid insulins have better dosing equipment (pens etc.)

29 Rapid-acting insulins now Lispro insulin (Humalog) Insulin aspart (NovoRapid) Insulin glulisin (Apidra)

30 Rapid-acting insulin pens Humalog Kwikpen Novorapid Flexpen Apidra SoloStar No major differences in practice The pens are becoming similar Preference "between the ears" KUVA:

31 Is insulin always good in T2D? The problem is mainly the weight increasing impact It should be prevented by adjusting the diet, but many are not able to do it Hypoglycaemia rare with insulin, as well Injecting is not a problem today Incretin Mimetics will play a major role in the future, if the price becomes reasonable No long-term side effects

32 What about type 1 diabetes? Insulin is the only proper treatment Without it the patient will die, although slowly Child diabetics often have a remission at the beginning of the treatment They can manage for a while without insulin Perhaps it's better to continue the injections Metformin is taken into use again The middle-aged number one may make the stomach bigger Incretin Mimetics are being studied at T1DM

33 Multiple injections usually the best solution At first, the pancreas of type 1 diabetics produces some insulin, the need is lower then If the pancreas is removed, the need is 50 units/day New long acting drugs require parallel use of rapid insulin NPH insulins (Protaphane) cause a small peak, which can be beneficial Ready mixes for some Novomix, Humulin Mix

34 One or two long ones? Lantus can usually be given as one injection For people at an active age in the morning, for the elderly in the evening Rapid-acting insulin at meals, usually 2(-3) x/day The unit amounts of insulin clearly lower than in T2DM When changing, one must remember to lower the dosage Levemir requires 2 injections Some skin reactions at first

35 In the future? Degludec basic insulin only every other day Rapid injections needed at meals Long, steady impact Benefit?

36 Patient a 50-year-old female patient, T1DM fell ill at the age of kg / 160 cm crea 72 alb-cre < 0.9 RR menopause other drugs Cardace, Spesicor, Estradot diabetes medication: Lantus 26 in the morning NovoRapid 2-4 units at meals diabetes balance: HbA1c 10.7% (v.a. < 6%)

37 Patient a 50-year-old female patient 60.0 kg / 160 cm crea 72 alb-cre < 0.9 RR menopause other drugs Cardace, Spesicor, Estradot diabetes medication: Lantus 26 in the morning NoveRapid 2-4 units at meals diabetes balance: HbA1c 10.7%

38 Patient Trend line The trend line should be here

39 What can we learn from this patient? TIDM treatment is also not always easy Fear of sugar may "paralyse" a person Frequent monitoring of blood sugar is not always useful What should be done? Tried in addition to a diabetes doctor Psychology, psychiatrist The last resort is now an endocrinologist

40 Pump treatment still rare

41 Thank you for your attention!