Diabetes Mellitus: een update
Dr. Paul Van Crombrugge OLV Ziekenhuis, Aalst-Asse-Ninove
16 maart 2010
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Diagnose? HbA1c? Hoe HbA1c rapporteren? Follow-up? Rol van labo? Behandeling? DPP4I? ICU? BG monitoring? Zorgtrajecten? Zwangerschapsdiabetes?
DIAGNOSE?
GLOBAL PROJECTIONS OF DIABETES (IN MILLIONS) 2003-2025
38.2 44.2 16%
North America
25.0 39.7 59%
Africa
10.4 19.7 88%
South and Central America
13.6 26.9 98%
Asia Europe Middle East
18.2 35.9 97%
81.8 156.1 91%
Oceania
WORLD 2003 = 189 million 2025 = 324 million Increase 72%
1.1 1.7 59%
Distribution of 2-hour plasma glucose 4000
Frequency
3000
2000
1000
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2-hour plasma glucose (mmol/l)
Retinopathy (%)
Prevalence of Retinopathy Pima 15 10
FPG
2hPG HbA1c
5
FPG (mg/dl) 422hPG (mg/dl) 34HbA1c (%) 3.3-
87754.9-
90865.1-
0 93- 96- 98- 101- 104- 109- 12094- 102- 112- 120- 133- 154- 1955.2- 5.4- 5.5- 5.6- 5.7- 5.9- 6.2-
Classification of Glucose Tolerance
FPG 126
Diabetes Impaired Fasting Glucose (IFG)
110
IGT Normal
2h PG
140
200
Proposed ADA Criteria
FPG
Diabetes
126 Impaired Fasting Glucose (IFG)
100
IGT Normal
2h PG
140
200
WHO • blijft 110 mg/dl • cfr DECODE studie
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Diabetes Care, 2009
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EQA HbA1c • Organised since 2002 by the IPH • Scheme: 24 samples containing known concentrations of HbA1c allowing to estimate the bias from the DCCT value, have to be evaluated every two weeks (accuracy) • About 20 samples are paired; so the reproducibility (%CV) can be calculated • Linearity (correlation of results over the range 5%HbA1c – 11%HbA1c can be calculated) • Some samples contain carbamylated Hb, abnormal hemoglobin, or aged samples to test the ability of the used methods to detect interferences.
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Methods used • Worldwide: 30 ≠ methods are used based on the following principles: • HPLC-methods (ion exchange/affinity) • Immuno-assay methods • (Electrophoretic methods)
Methods based on different principles also measure (slightly) different glycated products • Belgium: about 15 ≠ methods by 214 laboratories
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Equipment used in 2006
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Evolution 2002 2006 (1)
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Evolution 2002 2006 (2)
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Evolution 2002 2006 (2)
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Evolution of equipment 46% of the laboratories changed their method!
Decreased use
Increased use
Results EQA 2007
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But: IFG, IGT • Risk for DM? • Risk for microvasc complications? • Risk for macrovasc complications?
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HOE HBA1C RAPPORTEREN?
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Diabetes Care 2007
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Huidige situatie • • • •
UK USA Netherlands Belgium??? – werkgroep bezig
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FOLLOW-UP? ROL VAN LABO?
Clinical Impact of Diabetes Mellitus Diabetes
A 2- to 4fold increase in cardiovascular mortality
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The leading cause of new cases of end stage renal disease
The leading The leading cause of cause of new cases nontraumatic of blindness lower in workingextremity aged adults amputations www.hypertensiononline.org
principes follow-up • DOEL: – quality of life! – vermijden complicaties – zo normaal mogelijk leven leiden
• RISIKO management
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– meten is weten – plan actie meten reageer, enz – meer dan bloedglucose alleen !!!
• recente BG regeling • safety medicatie • chronische complicaties – Microangiopathie » Retinopathie » Nefropathie – Macroangiopathie – Neuropathie – Voet
• CV risico olv • varia
• recente BG regeling: • safety medicatie:
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• chronische complicaties: • CV risico:
HbA1c crea, lever amylase CK, electrolieten crea, µAU lipiden
• Varia:
urine
Relationship between endpoints and HbA1c or BP in the UKPDS -1
80
Rate ± 95% CI
Incidence (1000-pt-yr ) Microvascular endpoints
Myocardial infarction
60
HbA1c 40
HbA1c
BP
20 BP
0 5.0 7.0 9.0 11.0 5.0 7.0 9.0 11.0 110 130 150 170 110 130 150 170 HbA1c (%) or systolic BP (mmHg) HbA1c (%) or systolic BP (mmHg)
Microvascular Disease Hazard Ratio (photocoagulation, vitreous haemorrhage, renal failure) Intensive (SU/Ins) vs. Conventional glucose control
HR (95%CI)
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Lancet, Published Online January 27, 2010 DOI:10.1016/S0140-6736(09)61969-3
???? • • • • • •
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C-peptide? SK testen? Coeliakie? Hemochromatosis? Pancreaslijden? AI testen pancreas (BDR)
BEHANDELING – DPP4I
Progressive Hyperglycaemia on Monotherapy in Type 2 Diabetes 10
HbA1c (%)
9
Conventional Glyburide Metformin
8
7
6 0 0
2
4
6
8
10
Years from randomisation UKPDS 34. Lancet 1998; 352:85465
100
Progressive decline of -cell function in UKPDS ? ?
-cell function (% )
80
? ? 60
?
40
20
0 10 9 8
7
6 5
4 3
2 1 Years
0
1
2
3
4
5
6
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Diabetes 1995
klasse
generische naam
producten
biguaniden
metformine
gliniden
repaglinide
Glucophage®, Metformax®, Metformine® NovoNorm®
sulphonylurea
gliclazide
Diamicron®, Gliclazide®
glipizide
Glibenese®, Minidiab®
gliquidone
Glurenorm®
glibenclamide
Bevoren®, Daonil®, Euglucon®
gliclazide L.A.
Uni-diamicron®
glimepiride
Amarylle®
acarbose
Glucobay®
pioglitazone
Actos®
rosiglitazone
Avandia®
GLP-1 analogen
exenatide
Byetta®
DPP-4 inhibitoren
sitagliptine
Januvia®
glucosidase remmers glitazones
glucose onafh. secretie : - sulfonylurea - gliniden HYPO!!! glucose afh. secretie : - DPP-4 inhibitoren - GLP-1 analogen
secretagogen
insuli ne
sensitizers
gluco se sensitisering : - biguaniden - glitazones
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Schematic Representation of the Pancreatic Beta Cell, Illustrating the Role of the ATPSensitive Potassium (KATP) Channel in Insulin Secretion
Gloyn, A. L. et al. N Engl J Med 2004;350:1838-1849
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Thiazolidinediones Activation of PPAR Alters Expression of Specific Genes
retinoic
TZD
PPAR
RXR
AGGTCA X AGGTCA
gene sequence ppre
GLUT 4 Young Adipocytes
GLP-1 mimetica incretinomimetica (DPP4 inhibitor, gliptine GLP1 analoog, exenatide)
Incretine Effect Intravenous glucose (50g) Oral glucose (50 g)
IR insulin (mU/L)
Venous plasma glucose (mmol/L)
20 15 10 5 0 –10 –5 80
60
120
180
Normal incretin effect
40
0 –10 –5
*
* *
* * * *
60
120
180
Time (minutes) *p 0.05 vs. respective value after oral load IR=immunoreactive
1986;29:46–52.
20 15 10 5 0 –10 –5
60
120
180
120
180
80
60
20
Type 2 diabetes (n=14)
IR insulin (mU/L)
Venous plasma glucose (mmol/L)
Healthy controls (n=8)
60
Diminished incretin effect
40 * *
20 0 –10 –5
*
60
Time (minutes)
Nauck M et al Diabetologia
Incretins Regulate Glucose Homeostasis Through Effects on Islet Cell Function
Ingestion of food
Glucose dependent
Insulin from beta cells (GLP-1 and GIP)
GI tract
Release of incretin gut hormones
Pancreas Beta cells Alpha cells
Insulin increases peripheral glucose uptake
Blood glucose control
Active GLP-1 and GIP
Glucagon from alpha cells (GLP-1) Glucose dependent
Increased insulin and decreased glucagon reduce hepatic glucose output
Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145:2653–2659; Zander M et al Lancet 2002;359:824–830; Ahrén B Curr Diab Rep 2003;3:365–372; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:1427–1483.
GLP-1 en GIP Worden Aangemaakt en Vrijgegeven door de Darmen als Respons op Voedselinname L-Cell (ileum)
ProGIP
Proglucagon
GLP-1 [7–36 NH2] GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1 Aangepast van Drucker DJ. Diabetes Care. 2003; 26: 2929–2940.
GIP [1–42]
K-Cell (jejunum)
GAL/EUC-16-01/09-5309
GLP-1 [7–37]
GLP-1: glucagon-like peptide-1 GIP: glucose dependent insulinotropic polypeptide Upon ingestion of food…
• Stimulates glucose-dependent
insulin secretion
• Suppresses glucagon secretion • Slows gastric emptying GLP-1 is secreted from the L-cells in the intestine
• Reduces food intake • Improves insulin sensitivity
Long term effects demonstrated in animals… This in turn…
• Increases beta-cell mass and
maintains beta-cell efficiency Drucker DJ. Curr Pharm Des 2001; 7:1399-1412 Drucker DJ. Mol Endocrinol 2003; 17:161-171
mmol/L
pmol/L
*
*
*
*
*
*
*
150 100 50 0
250 200 150 100 50 0
*
*
*
*
*
*
*
*
40 30 20 10 0
20
20
15
15
10 5 0 –30
*
*
*
10 *
0
60
120
*P <0.05 Patients with type 2 diabetes (N=10)
When glucose levels approach normal values, insulin levels decrease.
When glucose levels approach normal values, glucagon levels rebound.
5
Infusion
GLP-1
pmol/L
Glucagon
10.0 7.5 5.0 2.5 0
Placebo
mU/L
Insulin
pmol/L
Glucose
mg/dL
Insulin and Glucagon Levels in Patients With Type 2 15.0 250 Diabetes 12.5 200
0 180
240
Minutes Adapted from Nauck MA et al. Diabetologia. 1993;36:741–744. Copyright © 1993 Springer-Verlag.
15
GLP-1 Preserved Morphology of Human Islet Cells In Vitro Control
GLP-1–treated cells
Day 1
Day 3
Day 5
Adapted from Farilla L et al Endocrinology 2003;144:5149–5158.
Islets treated with GLP-1 in culture were able to maintain their integrity for a longer period of time.
metabolisme van GLP-1 GLP-1 T ½ = 1-2 min!!!
Meal Intestinal GLP-1 release Active GLP-1
DPP-4 DPP-4 inhibitor
GLP-1 = glucagon-like peptide–1; DPP-4= dipeptidyl-peptidase–4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
GLP-1 inactive
metabolisme van GLP-1 Meal GLP-1 analoog
Intestinal GLP-1 release Active GLP-1
DPP-4 DPP-4 inhibitor
GLP-1 = glucagon-like peptide–1; DPP-4= dipeptidyl-peptidase–4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
GLP-1 inactive
metabolisme van GLP-1 Meal GLP-1 analoog
Intestinal GLP-1 release Active GLP-1
DPP-4 DPP-4 inhibitor
GLP-1 = glucagon-like peptide–1; DPP-4= dipeptidyl-peptidase–4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
GLP-1 inactive
GLP-1 mimetica incretinomimetica (DPP4 inhibitor, gliptine)
DPP-4 inhibitoren (gliptines)
sitagliptin :
Januvia® (MSD)
vildagliptin: Galvus ®
(Novartis)
HbA1c
FPG
8.2
10.5
8.0
10.0
7.8
FPG (mmol/L)
HbA1c (% ± SE)
sitagliptin: 24-week Add-on Therapy to Metformin
7.6
9.5
9.0
7.4 7.2
8.5
Placebo (n=224)
Placebo (n=226)
Sitagliptin 100 mg (n=453)
7.0 0
6
Sitagliptin 100 mg qd (n=454)
8.0
12 Weeks
18
24
0
6
12
Weeks
SE = standard error All-patients-as-treated population LSM between-group differences at week 24 (95% CI): in HbA1C vs placebo = –0.65% [–0.77, –0.53] (P<0.001); in FPG vs placebo = –1.4 mmol/L [–1.7, –1.1] (P<0.001) To convert FPG from mmol/L to mg/dL divide by 0.05551 Copyright © 2006 American Diabetes Association. From Diabetes Care®, Vol. 29,2006; 2632–2637 Reprinted with permission from the American Diabetes Association.
18
24
Vildagliptine Toegevoegd aan Metformine: Reductie van HbA1c over 24 Weken Associatie met metformine (2.1 g dagelijks gemiddelde) PBO + met (n=130) Vilda 50 mg 1x/dag + met (n=143) Vilda 50 mg 2x/dag + met (n=143)
8.4 8.2 8.0
*
7.8
−0.7% vs PBO
7.6
−1.1% vs PBO
7.4
*
7.2 −4
0
4
8
12
16
Tijd (weken van behandeling) HbA1c=hemoglobine A1c; met=metformine; PBO=placebo; vilda=vildagliptine *P <0.001. Primair intention-to-treat populatie. Bosi E, et al. Diabetes Care 2007; 30: 890-895.
20
24
GAL/EUC-16-01/09-5309
Gemiddelde HbA1c (%)
8.6
sitagliptin vs Sulfonylurea: 52-week Add-on to Metformin HbA1c Baseline HbA1C Category <7%
0.0
n=117
112
≥7 to <8% 179
167
9%
≥8 to <9% 82
82
-1.11
-1.13
33
21
n=117
Change from baseline in HbA1c (%)
-0.2 -0.4
-0.14 -0.26
-0.6
-0.8
-0.59
-0.53
-1.0 -1.2 -1.4 -1.6 -1.8
Sitagliptinb + metformin Sulfonylurea + metformin
-2.0 aSpecifically
glipizide; bSitagliptin (100 mg/day) with metformin (≥1500 mg/day); Per-protocol population Adapted from Nauck et al. Diabetes Obes Metab. 2007;9:194–205.
-1.68 -1.76
sitagliptin: 24-week Add-on Therapy to Metformin GI-related AEs Sitagliptin 100 mg (n=464)
Placebo (n=237)
n
(%)
n
(%)
Abdominal pain
10
(2.2)
9
(3.8)
Diarrhea
12
(2.6)
6
(2.5)
Nausea
6
(1.3)
2
(0.8)
Vomiting
5
(1.1)
2
(0.8)
All-patients-as-treated population GI = gastrointestinal Adapted from Charbonnel et al. Diabetes Care. 2006;29:2638–2643.
sitagliptin vs Sulfonylurea: 52-week Add-on to Metformin weigth hypoglycemia 50 3
Sulfonylurea + metformin (n=416) Sitagliptin 100 mg/day + metformin (n=389)
40 Incidence (%)
Body weight (kg ± SE)
2 1 0
32% 30
P<0.001
20
-1
10
-2
5%
0
-3 0
12
24
38
52
Weeks
Week 52 Sulfonylurea + metformin (n=584) Sitagliptin 100 mg/day + metformin (n=588)
aSpecifically
glipizide; bAll-patients-as-treated population. LS = least squares; LSM between-group difference at week 52 (95% CI): in body weight = –2.5 kg [–3.1, –2.0] (P<0.001); LSM change from baseline at week 52: glipizide: +1.1 kg; sitagliptin: –1.5 kg (P<0.001) Adapted from Nauck et al. Diabetes Obes Metab. 2007;9:194–205.
Vildagliptine: Even Doeltreffend als Glimepiride in Associatie m Metformine op 52 Weken Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride
In Associatie met Metformine (~1.9 g dagelijks gemiddelde)
Glimepiride tot 6 mg 1x/dag + metformine
−0.4% NI: 97.5% CI (0.02, 0.16)
−0.5%
Tijd (weken) CI=confidence interval; HbA1c=hemoglobine A1c; NI=niet inferieur Per protocol populatie. Vildagliptine (n=1396); glimepiride (n=1393). Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157–166.
GAL/EUC-16-01/09-5309
Gemiddelde HbA1c (%)
Vildagliptine 50 mg 2x/dag + metformine
Vildagliptine: Geen Gewichtstoename In Associatie Metformine (~1.9 g dagelijks gemiddelde)
−1.8 kg verschil
Tijd (weken) Vildagliptine 50 mg 2x/dag + metformine Glimepiride tot 6 mg 1x/dag + metformine Per protocol populatie. Vildagliptine (n=1396); glimepiride (n=1393). Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157–166.
GAL/EUC-16-01/09-5309
Lichaamsgewicht (kg)
Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride
Vildagliptine vs Glimepiride: Hypoglycemische Voorvallen bij Toevoeging aan Metformine Behandeling (Graad 2 en Vermoeden van Graad 2)
1389 1383
1389 1383
Ernstige Voorvallen
Vildagliptine 50 mg 2x/dag + metformine Glimepiride tot 6 mg 1x/dag + metformine Safety population. Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157–166.
GAL/EUC-16-01/09-5309
1389 1383
Aantal Hypoglycemische Voorvallen
Aantal voorvallen
Incidentie (%)
n=
Patiënten met >1 Hypos (%)
Aantal voorvallen
Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride
DPP-4 inhibitoren (gliptines) pro goede glycemiedaling weinig hypo’s geen gewichtstoename weinig neveneffecten (iets meer bovenste luchtwegen infecties) mogelijk beta-cel protectief contra kostprijs nog geen studies met harde eindpunten nog geen lange termijn gegevens over veiligheid Als ze hun beloften waar maken, zullen ze de sulfonylurea van hun troon stoten !!!
GLP-1 mimetica incretinomimetica (GLP1 analoog, exenatide)
Antistoff en!
Gila monster, “Heloderma lizard”
Combination with metformin : Adverse Events Placebo (N = 113)
Exenatide (5) Exenatide (10) (N = 110) (N = 113)
Nausea Diarrhea
23% 8%
36% 12%
45% 16%
Upper Respiratory Tract Infection Vomiting Nasopharyngitis Hypoglycemia
11%
14%
10%
4%
11%
12%
10%
9%
4%
5%
5%
5%
De Fronzo et al. Diabetes Care 05;28:1092-1100
exenatide (Byetta®) : 3 j resultaten 217 patiënten open verlenging na gerandomiseerde studies max. dosis metformine en/of sulfonylurea + 10 µg Byetta® 2 x /d
Klonoff et al. CurrMedResOp
exenatide (Byetta®) : 3 j resultaten
Klonoff et al. CurrMedResOp
GLP-1 analogen pro goede glycemiedaling weinig hypo’s sterke gewichtsdaling (maar nausea) vooral interessant bij morbide obesitas mogelijk beta-cel protectief contra SC injectie is probleem lichaamsvreemd proteïne acute pancreatitis
Byetta LAR® : 1x/wk
Kim et al. Diabetes Care 2007;30:1487-93
Van Gaal et al, Eur J Endocr 2008
scenario’s
A. metformine: geen intolerantie of contraïndicatie STAP A1 (bij diagnose)
STAP A2
STAP A3
STAP A4
goed gevalideerd: levensstijl + metformine
metformine + secretagoog
metformine + secretagoog + basale insuline
metformine (+ secretagoog) + intensieve insuline
minder goed gevalideerd: metformine + gliptine
metformine + gliptine + basale insuline
pro: - gebruiksgemak (geen titratie) - lage kans op hypoglycemie - gewichtsneutraal contra: - geen lange termijn gegevens - duurder
metformine + secretagoog + exenatide pro: - gebruiksgemak (geen titratie) - lage kans op hypoglycemie - geeft gewichtsdaling contra: - nausea - SC injectie 2/d - onvoldoende lange termijn gegevens - veel duurder
B. metformine: intolerantie of contraïndicatie STAP B1 (bij diagnose)
STAP B2
STAP B3
STAP B4
secretagoog + basale insuline
(secretagoog) + intensieve insuline
goed gevalideerd: levensstijl
secretagoog
minder goed gevalideerd: secretagoog + glitazone pro: - uitstellen spuitjes contra: - veel neveneffecten - veiligheid op lange termijn? - duurder
secretagoog + exenatide pro: gebruiksgemak (geen titratie) lage kans op hypoglycemie geeft gewichtsdaling contra: nausea SC injectie 2/d onvoldoende lange termijn gegevens veel duurder in België niet toegelaten!!!
kostprijs voor equipotente dosissen kost aan maatschappij : € / maand metformine 2 x 850 mg/d :
4.1
gliclazide 3 x 80 mg/d :
13.5
pioglitazone 1 x 30 mg :
41.0
sita/vildagliptine 1 x 100 mg/d :
45.0
exenatide 2 x 5 of 10 µg/d :
106.0
Insulatard 40 E/d :
30.1
ICU
goed diabetesbeleid tijdens hospitalisatie •
betere outcome in acute situaties en postoperatief
•
kortere hospitalisatieduur
•
grotere tevredenheid van patiënt
glycemie-streefdoelen : •
80 - 180 mg/dl in meeste omstandigheden
•
80 - 110 mg/dl bij zwaar zieken op ICU/CCU
als dit veilig kan bereikt worden!!! -> ter discussie op dit moment
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effect op mortaliteit ALL PATIENTS
.
100
p = 0.005
Intensive - 43%
Conventional
90
Long-stay patients p = 0.007 100
90
80
- 48% 80
HOSPITAL SURVIVAL (%)
ICU SURVIVAL (%)
100
ALL PATIENTS p = 0.01
Intensive - 34%
Conventional
90
Long-stay patients p = 0.02 100
80
90 80
- 36%
70 0
40
80
120
0 20 40 60 80 100120
DAYS AFTER INCLUSION
0
70 0
100
200
50 100 150 200
DAYS AFTER INCLUSION
Long-stay = > 5d = ± 1 patient op 3 Van den Berghe et al. NEJM 2001;345:1359 -1367
effect op morbiditeit RRR (%)
NNT
60 40 20 0
0
Blood stream infections
46
**
28
Antibiotics > 10 days
35
**
17
Dialysis / Hemofiltration
41
**
29
Critical illness polyneuropathy
44
****
4
Mechanical ventilation > 14 days
37
**
22
ICU stay > 14 days
27
**
23
** p ≤ 0.01
20
40
**** p < 0.0001
Van den Berghe et al. NEJM 2001;345:1359 -1367
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Aalst Glycemia Insulin Protocol (ALGIP) CABG met CPB: 651 pat. (483 niet-DM, 168 DM); 18.893 metingen
BG < 40 mg/dl (2.2 mM):
geen
BG < 60 mg/dl (3.3 mM): intraoperatief : ICU (24u) :
niet-DM 0.02% 0.16%
DM 0.07% 0.22%
Lecomte et al. Anesth Analg 2008;107:51–8
OLV Aalst cardiale chirurgie met CPB start glycemieprotocol in 2005: 80-110 mg/dl (4.5-6 mmol/l) restrospectieve analyse : 2004 (n=305) 2005-6 (745)
Lecomte et al.
Betrouwbare, snelle BG’s!!! • Bloedglucosemeter • Bloedgas analyser • HemoCue
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Deviation split sample
% paired results
25%
20%
15%
10%
5%
0% < -25
-25 - -20,1
-20 - -15,1
-15 - -10,1
-10 - -5,1
-5 - -0,1
0 - 4,9
5 - 9,9
10 - 14,9
15 - 19,9
20 - 24,9
> 25
% deviation 2000 -> 91 % of results w ithin 20 % deviation 2001 -> 95 % of results w ithin 20 % deviation 2002 -> 96 % of results w ithin 20 % deviation
Diab Medecine 2004
• Bloedgas analyser
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ZORGTRAJECTEN
RIZIV-diabetes dubbelproject 9/04
6/06
6/07
7/03
Optimalisering DM2 zorg GEMEENSCHAPPELIJK KUL
Aansturing Huisarts
SHARED CARE
UA/UG
Aansturing Patiënt
- Top-down
- Bottom-up
- MCH
- Dicht tegen bestaande structuren
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ZORGMANAGEMENT
WETENSCHAPPELIJKE ANALYSE (controleregio)
www.zorgtrajectenaalst.be/dpa/
organisatie diabeteszorg in België ≥3 inj diabetesconventie referentieVPK
2 inj 1 inj
diabetespas
OAD dieet
onbeken d
conv.
DPA
ZTJ
zorgtraject diabetes: doelgroep type 2 diabetes 1 of 2 injecties insuline of incretine mimeticum (of intentie om te starten bij onvold. controle onder max. OAD,)
bijkomende voorwaarden: - GMD - moet op consultatie kunnen komen
zorgtraject diabetes: principes huisarts: stuurt de zorg
diabeteseducator: geeft informatie, leert zaken aan, … apotheker: zelfcontrolemateriaal
diabetescentrum: 1x / j langsgaan (meer z.n.) geeft ook raad tussendoor leidt het team van de 1ste lijn op financiële stimuli: - patiënt geen remgelden voor raadplegingen bij zijn huisarts en alle specialisten voor deze aandoening - huisarts forfait - diabetoloog forfait
zorgtraject diabetes: educatie op voorschrift van huisarts (vermelding “zorgtraject diabetes”)
door diabetes-educator in 1ste lijn - mag ook in diabetescentrum, op specifieke vraag van huisarts 1. onvoldoende 1ste lijnseducatoren 2. complexe medische toestand
verplicht bij - start insuline of incretinemimetica: ≥ 2.5 u - overgang van 1 naar 2 injecties: ≥ 1u - onvoldoende metabole controle (A1c > 7.5%): ≥ 1u
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ZWANGERSCHAPSDIABETES
Gestational DM • Glucose intolerance with onset or first recognition during pregnancy • Only small minority has BG levels that would be diagnostic of DM outside pregnancy • Te be regarded as diabetes in evolution cfr diagnosis diabetes: – 10% in first months postpartum – 5 to 10% /year
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Gestational DM • Niet enkel aandacht voor de short-term outcome v/d foetus (gynecoloog) • Ook aandacht voor de long-term outcome (endocrinoloog, HA) van – moeder – kind
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Pederson principle
ACHOIS trial
ACHOIS trial First study showing benefits of intensive treatment of GDM
with less perinatal morbidity !! BABY
MOTHER
Less nursery admission
Less pre-eclampsia
Less adverse outcome
Better psychological outcome postpartum
More frequently induction at 38 weeks without more cesarian sections
Hoe evalueren? • 50 g challenge (niet nuchter): als > 140 mg/dl: 100 g oGTT • 100 g oGTT 3 uur grenzen: 95-180-155-140 mg/dl
of (WHO)
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behandelingsdoelen • Metabool: – Nuchter: – 1u pp: – 2u pp:
< 95 mg/dl < 140 mg/dl <120 mg/dl
Cave: als mean BG < 85 mg/dl: small for gestational !
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• 90%: – Dieet – Lichaamsbeweging
• 10%: – Preprandiale insuline
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Actuele voorstellen: ter discussie!!
Diabetes Care, March 2010
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Lange termijn FU van moeder
DM2 can be delayed or prevented
- 5.6 kg 20 min exerc/dag
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NEJM 2002;346:393-403
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