1990 Obestiy

Transcription

1 1990 Obestiy

2 1995 Obesity

3 2000 Obesity

4 2003 Obesity

5 2006 obesity

6 2010 Obesity

7 2013 Obesity

8 2014 Obesity

9 LIFETIME DIABETES RISK Children born after the year 2,000 One in three Caucasian will develop diabetes lifetime One in two (50%) Hispanics will develop diabetes lifetime

10 Diabetes Prevention Program Reduction of development of diabetes in those with pre-diabetes percent. 7 percent weight loss 150 minutes of exercise Reduced cholesterol/saturated fat, increased fiber/good fats In those who met all 3 goals, 95% reduction in diabetes. Lifestyle was more effective over age 70 (70% reduction) Metformin more effective under 60, BMI over 35

11 More diabetes prevention Da Qing showed intervention had 41% mortality reduction at 17 years and 45% reduction in morbidity Study reproduced in multiple locations, obese, overweight and normal weight (China) and low cost at the YMCA ACT NOW, 72% reduction in diabetes development with 45 mg Actos

12 Importance of Diabetes Prevention Death rate of prediabetes based on time to diagnosis of diabetes mortality <10 yr yr <20 or none Diabetes Care 2016:39:

13 Cost/Benefit/A1C drop COST 30 DAY/90 DAY COUPON (min cost/max) BENIFIT A1C Metformin 5/10 Jardiance Insulin (to 6-8 A1C) Metformin XR 10/20 Metformin/victoza Metformin 1.5 Actos 15/25 Presumed (SGLT2/GLP1) Actos Glucotrol 15/24 Acarbose Sulfonyureas 1.5 Glucotrol XR 31/72 Actos GLP to 1.4 Acarbose 63/175 DPP4 SGLT2 0.4 to 1.1 Trajenta 364 5/150 Insulins Acarbose 0.4 to 0.9 Januvia 370 5/150 Sulfonyureas Oseni Oseni 370 4/100 Rest DPP Lantus Pen 262/379 25/100 Levemir pen 282/408 25/100 Farxiga 397 0/481

14 DIABETES DIAGNOSIS 2 measurements: Random > 200, 2 hour GTT >200, fasting glucose >126 or A1C > 6.5 PREDIABETES: fasting , 2 hour , A1C 5.7 to 6.4 Type 1 Diabetes: Autoantibodies AND needing insulin Type 2 diabetes: elevated glucose and no antibodies LADA(Latency autoimmune Diabetes of Adulthood): elevated glucoses, positive antibodies, no insulin for 6 months LADC (Latency Autoimmune Diabetes of Childhood)

15 LADA Type 1.5, mixed type ETC. Apparent type 2 who does not respond to oral agents well and rapidly goes to insulin: Check antibodies Late onset type 1 (over 30), check c-peptide Obese elevated glucose under age 30 10% of adults over 30 with Type 2 diabetes have antibodies and beta cell failure over time 25% of Type 2 under age 30 have antibodies and Beta cell failure Diabetes June 2015: Suppliment 54

16 LADA, why does it matter Really a continuum DM1 at 30 years with some insulin Know what you are treating, keep LADA off mealtime if possible (thin) or get them right on insulin, at least basal (obese) No literature on best way to treat though

17 LONG TERM BENEFITS OF CONTROL DCCT in type 1 s, 25% drop in complications for each 1% drop in A1C seen within 7 years. Legacy effect UKPDS similar drop in complications in type 2 Look Ahead: lifestyle changes in early diabetics can regress to no diabetes. Da Quing Chinese study on prevention

18 WHATS NEW New Insulin: Toujeo/Tresiba Insulin is Insulin is Insulin 1/1/1/1/1 Lantus/levemir/toujeo/tresiba/NPH NPH used 4 times per day is as effective as Lantus in studies (I have used it TID). $25 per vial at Sam s and Wallmart along with $25 for regular insulin per vial, NO PEN. Options after Long acting insulin and not in control Jardiance and outcomes, amazing Victoza and outcomes, nice but cost, convenience and poor coupon GLP better than mealtime insulin added to basal insulin SGLT2 can be added to basal Insulin safely and effectively

19 Mixed Insulin

20 Jardiance and EMPAREG 7028 patients for 3.1 years 38% reduction of heart attack/cva 32% reduction in ALL CAUSE DEATH!!!!! 33% reduction in admission for heart failure 39% reduction in progression to macroalbuminuria and 44% reduction in doubling of creatinine. NEJM 2015, Vol 373:

21 Victoza and outcome 9340 patients for 3.5 years Reduction in CV disease, decrease 13% Reduction in CV death, decrease 22% Overal reduction in mortality, decrease 13% Powerful, weight loss, lower BP but expensive and not a great coupon and injection. NEJM vol:375(4), , July 28, 2016

22 Once Weekly GLP-1 vs 3 times per day mealtime insulin added to Basal insulin A1C drop of 0.7 to 1.1 (similar both groups) 1/3 severe hypoglycemia, ½ of any hypoglycemia. 2.5 kg weight loss vs 2 kg weight gain Clincal diabetes April 2015, 33(2),73-75

23 Adding SGLT2 to basal/bolus insulin Starting A1C 8.3 Aggressive titration in both groups. Finishing A1C at 52 weeks 7.5 insulin mg Jardiance, mg Jardiance. No increase in hypoglycemia 9-11 unit drop in daily insulin dose 2.5 kg weight loss vs insulin group Diabets Care2014, July, 37(7),

24 Seriousness of Kidney disease Some would argue there is no increase in death in diabetes unless you have kidney disease. ACCORD trial for very tight control, it appeared all excess death was accounted for with those with kidney disease (ie don t push for tight control with kidney disease unless it is very easy) Diabetes and kidney disease increase risk of death from 30% to %1600 (GFR<30 and microalbumin above 300). This combo has a 5 year mortality of greater than 50%, worse than lung cancer. Screen for it and follow closely, adjust treatments based on disease

25 Kidney disease and medications Insulins, Actos, trajenta, Trulicity NO DOSE adjustments Metformin ok to use to GFR of 30, some will say 15 GLP s: adjust dose, usually can t use under 30 other than trulicity SGLT2 s: don t use under GFR 45 except farxiga (not under 30) Sulfonyureas, variable recommendation, usually not dose adjustment DPP4 s: Adjust dose except trajenta

26 Patient stories 26 y/o male, overweight, DKA, diagnosed as type 1, pilot in military 24 y/o type 2, on basal bolus therapy, just delivered, not losing the weight. 75 and 77 year old, basal bolus therapy, A1C s around 10 and can t afford insulin. 85 y/o 12 years pre-diabetes, parents, 9 siblings and most of her kids are diabetic 47 year old, basal/bolus therapy, A1C in 9 s, not checking glucose often 45 y/o Hispanic, no insurance, A1C 11, FH of amputation/dialysis/cva

27 Don t Believe the Headlines, diabetes drugs Metformin and Metabolic acidosis FALSE Avandia and cardiac risk FALSE Actos and Bladder Cancer.FALSE DPP4 and pancreatitis..true, then false, then True?? GLP-1 and Pancreatitis.FALSE Lantus and increase Cancer.FALSE SLGT2 s (except Jardiace), increase acute kidney failure??? What is the common connection? All these problems are already markedly increased in diabetes no matter what the treatment

28 Diet drinks: Good, Bad or Ugly (don t believe the headlines) Randomized trials Don t believe the reverse association from the media (the doors are really bad at McDonalds, people that go through them gain weight, get diabetes and hypertension, we need to fix those doors!!!) More likely to lose weight More likely to keep weight off Less desserts and sweets on average

29 NORMOGLYCEMIC DKA??? Can happen in type 1 and type 2. More Common with dehydration/illness. More common in Type 2 that have antibodies Increased with both SGLT2 s and GLP s. Relative hypoinsulinemia Stop either medication if Type 1 or 1.5 and severe illness or dehydration. If you have the right symptoms but normal glucose, check for ketones Consider ketone strips for urine.