搜索
Earlytherapyandregimenchoicefortype2diabetesinWesternpatientsBjörnEliassonSahlgrenskaUniversityhospitalandUniversityofGothenburg,SwedenGoodglucose-loweringtreatment:requirements•Efficacious(glucose-lowering)•Safe•cardiovascularoutcometrials•Fewside-effects•weight•hypoglycaemia•ReasonablepriceExperience,scienceandpriceOldpharmacologicagentsNewpharmacologicagentsExperienceLongShortSciencePoorSolidPriceLowHighCVOT-CardiovascularoutcometrialDiabetes2009;58:773–95.AvailableoptionsMetforminSulfonylureaSGLT-2inhibitorsDPP-4inhibitorsGLP-1receptoragonistsPioglitazoneAcarboseInsulinMetforminProsConsMultiplebeneficialeffectsGastrointestinalsideeffectsLowpriceKidneyfunctionCVOT:UKPDS,SwedishNDR,MetaanalysesLacticacidosisOptimalpatient:Atdiagnosis;overweight/obese;normalrenalfunctionBMJOpen2012;2:e001076.doi:10.1136/bmjopen-2012-001076SulfonylureaProsConsExperienceWeightgainEfficaciousnessHypoglycemiaCVOT:UKPDS,ADVANCEKidneyfunctionOptimalpatient:Second-line;notbadrenalfunctionNEnglJMed2008;358:2560-72.NEnglJMed2008;358:2560-72.CumulativeIncidencesofEvents,AccordingtoGlucose-ControlStrategySGLT-2inhibitorsProsConsHbA1cFungalinfectionsBloodpressurePrizeCVOT:EMPA-REGNoteffectiveinrenalimpairmentOptimalpatient:Second-line;highCVDriskpatients;overweight/obese,normalrenalfunctionDOI:10.1056/NEJMoa1504720Cumulativeincidencefunction.MACE,MajorAdverseCardiovascularEvent;HR,hazardratio3-pointMACE15Empagliflozin10mgHR0.85(95%CI0.72,1.01)p=0.0668Empagliflozin25mgHR0.86(95%CI0.73,1.02)p=0.0865DPP-4inhibitorsProsConsEfficaciousnessNosideeffectsCVOT:EXAMINE,SAVOR-TIMI,TECOSPrizeOptimalpatient:Second-thirdline;reducedrenalfunctiontecosNEnglJMed2015;373:232-42NEnglJMed2015;373:232-42GLP-1receptoragonistsProsConsHbA1cInjectionApetite,weightGastrointestinalsideeffectsGlucagonsuppressionNauseaCVOT:ELIXANotinrenalinsufficiencyOptimalpatient:Obese;highinsulindoseAmHeartJ2015;169:631-638.e7(death,AMI,stroke)PioglitazoneProsConsGlucose-loweringefficaciousnessWeightDyslipidemia,fattyliverEdemaCVOT:PROactiveFracturesOptimalpatient:Insulinresistant;lean/overweight;fattyliver,renallyimpairedLancet2005;366:1279–89Lancet2005;366:1279–89AcarboseProsConsNosystemicabsorptionGastrointestinalsideeffectsCVOT:STOP-NIDDMModerateglucose-loweringefficaciousnessOptimalpatient:(Notfrequentlyused)Somediets?;pre-diabetes?Dateofdownload:11/1/2015Copyright©2015AmericanMedicalAssociation.Allrightsreserved.From:AcarboseTreatmentandtheRiskofCardiovascularDiseaseandHypertensioninPatientsWithImpairedGlucoseTolerance:TheSTOP-NIDDMTrialJAMA.2003;290(4):486-494.doi:10.1001/jama.290.4.486InsulinProsConsMuchdebatedEfficaciousnessInjectionSeveraloptionsHypoglycemiaCVOT:ORIGINWeightgainOptimalpatient:Whennothingelseworks;insulindeficiencyNEnglJMed2012DOI10.1056/NEJMoa1203858NEnglJMed2012DOI10.1056/NEJMoa1203858Treatmentguidelines•2examples•EuropeandUSA•SwedenDiabetesCare2015;38:140–149DiabetesCare2015;38:140–1492015-02-17SwedishNationalguidelinesfordiabetescare(3.0,17Feb2015)TreatmentPriorityIndicationMetformin1MonotherapyInsulin3Add-onmetforminInsulin,repaglinideorSU4MonotherapyRepaglinideorSU4Add-onmetforminGLP-1receptoragonist6Add-onmetforminDPP-4inhibitor7Add-onmetforminAcarbose9Monotherapyoradd-onmetforminPioglitazone10Monotherapyoradd-onmetforminSGLT-2inhibitor10Monotherapyoradd-onmetformin(Regionalguideline,WesternSweden)•Type2diabetestreatmentalgorithminRegionWesternSweden•Individualisation•Earlyandintensivetreatment•Monitor•Switchiffailureorside-effects1.lifestyle+metformin2.secondline=SU/insulin3.thirdline=therest(Translation)Conclusions•8differentclassesofagents•Glucose-loweringabilitiescomparable•Variouseffectprofileswithprosandcons•Cardiovascularsafetyandeffectsimportant•Tailoring-individualisation