1. Preferred treatment options for patients with Diabetes Dr Jon Tuppen GPwSI Beechwood Surgery Brentwood

2. Case Study – what would you do? What else do you need to know? 29 year old Bangladeshi women Type 2 diabetes for 4 years Gliclazide 80mg bd, Metformin 850mg tds BMI 29.7kg/m 2 FBS 9.7mmol/l HbA 1 c 9.3% BP 152/88 Total Chol 6.1mmol/l LDL Chol 4.3mmol/l

3. Diabetes is simple isn’t it?

4. Make it as simple and holistic as possible

5. CVD risk progression begins before diabetes Remember the diagnosis of Diabetes

6. Most care for people with diabetes is NOT rocket science but Diabetes is a progressive condition We need to risk stratify –Between patients –Between risks in same pt We must empower patients We need to have sufficient capacity to do ALL above

7. `I said pig,' replied Alice; `and I wish you wouldn't keep appearing and vanishing so suddenly: you make one quite giddy.' `All right,' said the Cat; and this time it vanished quite slowly, beginning with the end of the tail, and ending with the grin, which remained some time after the rest of it had gone. `Well! I've often seen a cat without a grin,' thought Alice; `but a grin without a cat! It's the most curious thing I ever saw in my life!

8. Understanding risk essential for proper prescribing MICROALBUMINURIA

9. Steno-2: An attempt to validate the efficacy of daily clinical practice, i.e. the multifactorial treatment of type 2 diabetes High risk type 2 diabetes patients A single center study An organisation which allowed for intensive intervention Longterm intervention STENO-2

10. Estimated impact of single risk factor interventions to reduce CVD in patients with type 2 diabetes Relative risk 2-yr’s event reduction reduction None …… 11.0 % Cholesterol (down by 0.6 mmol/l) 25 % 8.3 % BP (down by 5/2 mm Hg) 27 % 6.0 % HbA1c (down by 0.9 %) 13 % 5.2 % Aspirin 9 % 4.7 % Cumulative relative risk reduction of about 57% Huang et al. Am J Med 2001;111:633-642 Turner R.C. BMJ 1998;316:823-828 He et al. JAMA 1999;282:2027-2034 Antitrombotic Trialits BMJ 2002;324:71-86

11. HYPERTENSION OPTIONS Lifestyle, lifestyle, lifestyle and Drugs

12. STENO-2 ACE inhibitor/Angiotensin II antagonist Diuretics Calcium antagonist ß-blocker Other Severity of hypertension Stepwise approach to the treatment of hypertension

13. Cholesterol Total Cholesterol to 4 mmol/l LDL Cholesterol to 2 mmol/l CARDS HPS Jt British Soc

14. Glucose lowering medications INCREASED GLUCOSE PRODUCTION HYPERGLYCEMIA INCREASED GLUCOSE ABSORPTION MUSCLE ADIPOSE TISSUE INTESTINE DECREASED PERIPHERAL GLUCOSE UPTAKE Therapy: Thiazolidinediones Biguanides PANCREAS LIVER DECREASED INSULIN SECRETION Therapy : Sulphonylureas Prandial Glucose Regulators incretins Insulin Therapy: Biguanides Thiazolidinediones incretins Therapy: Alpha-glucosidase inhibitors DECREASED Incretin production

15. Does it matter what drug you use? Class of Drug average reduction in FBS (mmol/l) HbA1c Reduction (%) Sulphonylurea3.3-3.90.8-2.0 Metaglinides3.6-4.20.5-2.0 Metformin2.8-3.91.5-2.0 Thiazolidinedione3.3-4.31.4-2.6 α glucosidase inhibitor1.9-2.20.7-1.0 sibutramine (responders33%)1.4-3.80.5-1.6 rimonabant0.7

16. Stepwise treatment of hyperglycaemia STENO-2 Diet Gliclazide Metformin Gliclazide + NPH insulin Metformin + NPH insulin Time BMI <27 BMI ≥27 Gliclazide + Metformin But many other options available

17. Glitazones

18. insulin glucose meal GLP-1 GIP  -cells Rapidly inactivated by dipeptidyl peptidase IV increases insulin secretion INCRETINS

19. Incretin actions

20. Insulin is insulin…….. Just different onsets and durations of action Different devices Tailor to individual patient’s lifestyle

21. Putting it all together for 1 patient

22. The Care Planning Model

23. Case study – what would you do? 43 yr old ♂ Type 2 DM for 11 years Project Engineer on busy project UK↔USA Keeps DNA 98.2 Kg BMI 31kg/m 2 BP 158/91 HbA 1 c 8.3% eGFR >60ml/min Total Chol 6.1mmol/l LDL 3.90mmol/l NovoRapid 8u / 8u / 8u Levemir 10u mane Atorvastatin 10mgLisinopril 10mg