Dr Karen McNeil Consultant Endocrinologist

Transcription

1 Dr Karen McNeil Consultant Endocrinologist

2 Aged 53 Type 2 Diabetes 2010 HbA1c 7.9% ACR 5.3 mg/mmol What treatment?

3 MF 500 mg bd (misses midday dose) Control Symptoms, BGL Complications DR, DN, PN Associations Cardiovascular BMI..

4 Weight history: Onset, Peak, Now Diets, drugs, surgery What diet and exercise now Readiness Complications Sleep apnoea OA Cardiovascular etc

5 60 % of Australian adult males are overweight or obese Less than 16% of Australian men Gary s age have T2 DM or IGT 80% of patients with Type 2 DM are overweight or obese

6 % 35.5% 40 BMI>30 kg/m % 38.3% BMI>25Kg/m Adapted from Data from Walls et al.,(2012),australian Health Survey

7 Percentage Males Females Age group (years) Ausdiab 2006

8 Incidence (% per year) Males Females All Normal Overweight Obese Baseline BMI status Body mass index (BMI: weight/height 2 ) was categorised into three groups: (i) normal: BMI < 25.0 kg/m 2 ; (ii) overweight: kg/m 2 ; and (iii) obese: 30.0 kg/m 2. Ausdiab 2006

9 Not enough insulin secreting cells to get the job done Insulin requirement is proportional to body mass Lose enough weight and lose the diabetes

10 BMI 37 kg/m2, 123 kg and 180 cm BP 146/95 Full neck and crowded pharynx Skin tags and slight acanthosis Labs: Combined dyslipidaemia ACR 5.6 mg/mmol egfr 86

11 Perfect glycaemic control Target HbA1c < 7.0% Optimize MF and Weight loss Medication Cardiovascular risk factor management Co-morbidities : Sleep study Bariatric surgery discussion

12 Metformin Optimise Weight Loss BGL CSIRO Or VLCD Pharmacotherapy

13 Life Stage Obesogenic Environment Socioeconomic Status Genetics/Epi genetics Afferent Central Efferent Pathways BMI OSA/Medical /Psychiatric

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15 Total Energy Intake Total Energy Expenditure Efferent system Central integrating TEF PAL/NEAT Afferent BMR

16 Readiness What does success look like? To Gary To his doctor Medical management ( 3% successful ) Calorie restriction All diets work and don t work/food based Or VLCD GP Weight management Guidelines Ask and Assist Pharmacotherapy

17 30 minutes daily of at least moderate intensity physical activity on most days (Australian guidelines 1999) (similar guideline) Physical activity total of >150 mins per week (US, WHO 2008, 2010) ; Australia 2012 Cardiac assessment..??

18 BMI 34 (113 kg) HbA1c 7.8% Still on metformin Diet and exercise Maxed out Surgery Drug therapy options Oral vs injected What is metformin?

19 ??? Your view Gliptin? SGLT2 Inhibitor? Exenatide

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21 Metformin Metformin Sulfonylurea (SU)

22 Metformin Metformin Metiglinides Acarbose Sulfonylurea (SU) Thiazolidinediones (TZD)

23 Metformin Metformin Metiglinides Acarbose Sulfonylurea (SU) Thiazolidinediones (TZD)

24 Diabetic therapy Options Metformin Sulfonylurea (SU) DPP-4 inhibitor (DPP4i) GLP-1 receptor agonist DPP4i: Dipeptidyl peptidase-iv inhibitor; GLP-1: Glucagon-like peptide-1; SGLT2: Sodium-glucose co-transporter 2 Thiazolidinediones (TZD) SGLT2 inhibitor Insulin SGLT2 inhibitor Thiazolidinediones (TZD) Insulin GLP-1 receptor agonist 1. Inzucchi SE, et al. Diabetes Care 2012;35:

25 Weight neutral Diabetic therapy Options Metformin DPP-4 inhibitor (DPP4i) GLP-1 receptor agonist SGLT2 inhibitor SGLT2 inhibitor Insulin 1. Inzucchi SE, et al. Diabetes Care 2012;35:

26 Incretin based Dipeptidyl peptidase- 4 inhibitor (DPP4-I) gliptins Glucagon-like peptide-1 analogue (GLP1A) Exenatide, liraglutide Sodium-glucose Cotransporter-2 Dapagliflozin, empagliflozin gliflozins

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29 Inactivated by DPP-4

30 Inhibit DPP-4 Inactivated by DPP-4 Increase GLP-1

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32 Mean change in HbA 1c from baseline (%) 50 weeks 102 weeks Sita, Vilda, Saxa, Lina, Alogliptin HbA 1c reductions with saxagliptin + metformin at 50 weeks and 102 weeks *1,2 Saxagliptin 5mg + metformin n=191 Metformin + placebo n=179 Mean change -0.74% ** Mean change -0.72% ** n=15 observed, n=172 LOCF n=31 observed, n=184 LOCF Weeks Mean baseline HbA 1c 8.1%

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34 Exenatide kg Change in body weight (kg) * * * * Insulin glargine (Mean baseline body weight 88.3 kg) Byetta (Mean baseline body weight 87.5 kg) -2 * * +2.3 kg Weeks Insulin glargine n = Byetta n = Adapted from Klonoff DC et al. Curr Med Res Opin 2008; 24:

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39 109 kg HbA1c 6.9% Sita/MF 50/1000 mg bd???

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