Algoritmo  de  tratamiento  de  la  hiperglucemia  en  la  diabetes  tipo  2    

arGLP1: agonistas del receptor del péptido similar al glucagón 1; F: fármacos; FG: filtrado glomerular; GME: glucemia media estimada; iDPP4: inhibidores de la dipeptidil peptidasa 4; IMC: índice de masa corporal; iSGLT2: inhibidores del cotransportador de sodio y glucosa 2; Met: metformina; Pio: pioglitazona; Repa: repaglinida; SU: sulfonilureas.

 

                                                                       

                                 

The  algorithm  has  two  input  options:  as  glycosylated  hemoglobin  (HbA1c)   or   (GME)   and   according   to   the   predominant   clinical  situation  (renal  failure,  advanced  age  and  obesity),  which  helps  to  assess  therapy  options  and  customize  treatment.      HbA1c  <  8  %:  In  some  patients  it  is  possible  to  achieve  the  goal  by  simply  changing   lifestyles   (diet  and  exercise).   If   it   fails  within  3-­‐6  months,   it   is   recommended   to   introduce  Met  with   a  progressive  dose  of  up  to  2-­‐3  tablets  per  day  (or  maximum  tolerated).  In  case  of   intolerance  or   contraindication,   it   is   possible   to  opt   for   an   SU  (gliclazide   or   glimepiride)   or   iDPP4   (in   case   there   is   high   risk   of  hypoglycemia,   advanced   age   or   renal   failure).   If   monotherapy  target  is  not  achieved,  it  will  be  combined  with  SU,  iDPP4  or  other  oral  drug  (to  be  individualized).  If  the  target  is  not  reached,  a  third  oral  drug,  basal  insulin  or  arGLP1  will  be  added.    HbA1c   8-­‐10   %:   Although   it   is   possible   to   be   used   with  monotherapy   in   asymptomatic   patients,   it   seems   reasonable   to  start  with  low  doses  of  two  diabetes  drugs  (Met  +  SU  or  iDPP4)  or  basal  insulin  +  Met,  if  the  patient  is  very  symptomatic.  HbA1c   >   10  %:  The  patient   is   usually   very   symptomatic.   If   he   or  she   experiences   recent  weight   loss,   it   is   preferable   to   start  with  basal   insulin  associated   to  Met.   In   some  symptomatic   cases,   it   is  possible  to  try  with  low  doses  of  two  drugs  (Met  +  SU  or  iDPP4).    Clinical  conditioning  (from  high  to  low)  1.   Renal   failure   with   GFR   <30   ml/min:   Since   there   is  contraindication   for  Met,   SU,   iSGLT2   and   arGLP1,   the   preferable  drug   would   be   iDPP4   (with   or   without   dose   adjustments).  Increased   risk   of   hypoglycemia   and   the   associated   three   daily  intakes  make   Repa   preferable   over   iDPP4.   Pio   presents   a   worse  safety  profile,  therefore  being  considered  as  a  second  option.  As  a  third,  the  best  one  would  be  insulin.  2.  Age  >  75  yeard/fragile  patient:  Advanced  age  is  associated  with  an   increased  risk  of  hypoglycemia,   thereby  opting  on   the  second  step   for   iDPP4   instead   of   an   SU.   It   is   necessary   to   pay   special  attention  to  possible  impaired  renal  function.  3.   Obesity   degree   2   (BMI   >   35   kg/m2):   At   a   second   level   it   is  possible  to  opt  for  arGLP1  or  iSGLT2  because  both  are  associated  with   weight   loss.   Some   ArGLP1   are   more   effective   to   reduce  HbA1c,   but   its   cost   is   significantly   higher.   Lixisenatide  once  daily  and   exenatide   have   a  mainly   postprandial   action,   liraglutide   and  exenatide   once   weekly   have   a   mainly   basal   action,   making  possible  to  individualize  choices  according  to  the  patient’s  profile.  These  patients  should  consider  opting  for  bariatric  surgery        

Therapeutic  Guidelines    1. Therapeutic   objectives   and   interventions   should   be   based  

on  clinical  judgment.  Both  will  be  defined  and  planned  in  a  personalized  way.    

2. Therapeutic  goals  should  have  a  global  and  comprehensive  approach,  in  order  to  reduce  cardiovascular  risk,  acute  and  chronic   complications   and   improve   quality   of   life.   In   this  sense,   it   is   paramount   to   control   blood  pressure   (<140/90  mmHg)  and  lipids  (LDL  <100  mg/dl).  

3. The   goal   of   glycemic   control   will   be   established   on   an  individual   basis   taking   into   account   the   patient's   age  (chronological  age  of   the  patient  will  be  modulated  by  the  biological   age),   evolution   of   the   disease   over   the   years,  presence   of   micro   and   macrovascular   complications,  comorbidity  associated,  as  well  as  capabilities  and  available  resources  to  achieve  this  objective.    

4. In   younger   patients   without   complications,   it   should   be  tried   to   achieve   a   goal   of   HbA1c   as   close   as   possible   to  normal   without   increased   risk   of   hypoglycemia,   at   least  during  the  first  ten  years  of  evolution.    

5. In   fragile   or   poor   life   expectancy   patients,   objectives   and  interventions   that   prevent   symptoms   of   the   disease   and  improve  or  maintain  life  quality  shall  prevail.  

6. Diabetes   education   of   patients   and   their   relatives   (or  carers)   must   be   the   cornerstone   of   all   interventions,  therefore   having   to   be   structured   and   planned,   including  specific   recommendations   on   diet,   physical   activity   and  pharmacological  treatment.    

7. Periodical  clinical  follow  up  is  essential  to  avoid  past  inertia  and   to   achieve   goals.   All   therapeutic   changes   must   be  assessed  after  three  months.  

8. Therapeutic  objectives  and  interventions  need  to  be  agreed  with   the   patient   to   achieve   maximum   adherence   and  prevent  therapeutic  failures.                      

Individualized  objectives  according  to  age,  duration  of  diabetes  and  presence  of  complications  or  comorbidities    

 Age      

Duration  of  diabetes  mellitus  and  existance  of  complications  or  morbidities  

HbA1c  objective  

≤  65  years  

No  serious  complications  or  comorbidities   <  7.0  %*  >  15  years  of  evolution  or  with  serious  

complications  or  comorbidities   <  8.0  %  

66-­‐75  years  

≤  15  years  of  evolution  without  serious  complications  or  comorbidities   <  7.0  %  

>  15  years  of  evolution  without  serious  complications  or  comorbidities   7.0-­‐8.0  %  

With  serious  complications  or  comorbidities   <  8.5  %**  

>  75  years   <  8.5  %**  Based  on:  Ismail-­‐Beiji  F,  et  al.  Ann  Intern  Med  2011;  154:554-­‐9.  *  It  is  possible  to  set  an  objective  of  HbA1c  ≤  6.5  %  in  young  patients  who  have  recent  diabetes  with  monotherapy  or  nonpharmacological  therapy.   **  It  is  mandatory  to  preserve  control  over  the  symptoms  of  hyperglycemia,  regardless  of  HbA1c  target.    

Main  effects  of  drugs  (monotherapy)      

Drug  type   HbA1c  Reduction    

Risk  of  hypoglycemia  

Effect  on  body  weight  

Cost  

Met   +++   -­‐   Neutral  or  reduction   Low  

SU   +++   ++   Increase   Low  Repa   ++   +   Increase   Medium  iDPP4   +   -­‐   Neutral   High  arGLP1   +/++   -­‐   Reduction   Very  High  iSGLT2   +   -­‐   Reduction   High  Pioglitazona   +++   -­‐   Increase   High  Insulin   ++++   +++   Increase   Medium/High  Based  on  the  consensus  ADA/EASD.  Diabetes  Care  2012;  35:1364-­‐79.    Citation:  Alemán  JJ,  Artola  S,  Franch  J,  Mata  M,  Millaruelo  JM  y  Sangrós  J,    in  name  of  RedGDPS.  Recomendaciones  para  el  tratamiento  de  la  diabetes  mellitus  tipo  2:  control  glucémico.  2014.  Available  in http://www.redgdps.org/    Creative  Commons  Atributtion  License  

Recommendations  for  treatment  of  

Type  2  Diabetes  Mellitus:  glycemic  control  

   

     Personalized   treatment   is   currently   the  

paradigm   in   the   therapeutic   approach   to   Diabetes  type   2.   When   making   decisions,   clinicians   have   to  cater   to   the   specific   characteristics   of   the   disease,  comorbidities,   patient   preferences   and   available  resources.      

 The   aim   of   Therapeutic   Algorithm   of  

RedGDPS  is  to  assist  clinicians  in  decision  making  for  individualized   assessment   of   Diabetes   type   2.   It  contemplates   all   clinical   situations   in   adult   patients  with   diabetes   mellitus   type   2   (excluding   pregnant  women)   which   were   considered  most   relevant   and  common  in  our  practice    

 These  recommendations  are  not  intended  to  

serve   as   a   standard   and   do   not   substitute   clinical  judgment  or  preclude  other  therapeutic  options  that  may  be  equally  valid  or  complementary.  Administrative   or   economic   factors   may   also  condition  decisions.  

RedGDPS.  2014.  

Creative  Commons  Attribution  License