Reversibilità delle complicanze nel diabete tipo 2 - … · Rischio operatorio troppo alto; ......
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Transcript of Reversibilità delle complicanze nel diabete tipo 2 - … · Rischio operatorio troppo alto; ......
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3° WORKSHOP CONGIUNTO SICOb – SID – SIO
L’integrazione tra terapia medica e chirurgica nel trattamento del paziente obeso diabetico
7 marzo 2014
Reversibilità delle complicanze nel diabete
tipo 2
Roberto Fabris
Unità Bariatrica - Clinica Medica III
Azienda Ospedaliera di Padova
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Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults Aged 18 Years or older
Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%
No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
2010
2010
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Placebo
Metformin
Lifestyle
Cum
ula
tive incid
ence
of dia
bete
s (
%)
40
30
20
10
0 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Year
Diabetes Prevention Program
DPP. N Engl J Med. 2002; 346: 393-403
RR*
58%
*Reduction in risk of progressing to type 2 diabetes versus placebo
RR*
31%
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Franco M et al., BMJ 2013
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Farmacoterapia
Modifiche dello stile di vita
Dieta Attività fisica
Chirurgia
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Tecniche chirurgiche bariatriche
Restrittive Malassorbitive Miste
Bendaggio Gastrico (AGB)
Diversione Bilio-Pancreatica (DBP)
By-Pass Gastrico Roux-en-Y
(GBP)
Diversione Bilio-Pancreatica con switch duodenale
(DBP+DS)
Sleeve Gastrectomy (SG)
Plicatura Gastrica
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Indicazioni alla Chirurgia Bariatrica ✦ BMI > 40 kg/m2 (3° grado)
✦ BMI > 35 kg/m2 (2° grado) in presenza di comorbilità associate all’obesità
(Diabete mellito tipo 2, Ipertensione arteriosa, Cardiopatia ischemica,
OSAS, patologie da sovraccarico scheletrico)
✦ Età compresa tra 18 e 60 anni *;
✦ Obesità di durata superiore ai 5 anni;
✦ Dimostrato fallimento di precedenti tentativi di perdere peso e/o di
mantenere la perdita di peso con tecniche non chirurgiche;
✦ Piena disponibilità ad eseguire controlli medici per tutta la vita dopo
l’intervento chirurgico.
Controindicazioni alla Chirurgia Bariatrica ✤ Obesità secondaria a causa endocrinologia suscettibile di trattamento
specifico;
✤ Rischio operatorio troppo alto;
✤ Presenza di patologie gravi non legate all’obesità;
✤ Malattie psichiatriche severe;
✤ Abuso di alcol o di droghe;
✤ Bulimia Nervosa.
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Sjöström L et al., JAMA 2012
Swedish Obese Subjects (SOS) trial
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Swedish Obese Subjects (SOS) trial
Sjöström L et al., New Engl J Med 2007
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Sjöström L et al., JAMA 2012
Swedish Obese Subjects (SOS) trial
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Busetto L et al, Obesity Surgery 2011
Remissione del DM tipo 2 dopo chirurgia bariatrica
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Criteria for assessment of the effect of bariatric surgery on remission of T2DM
• Partial remission: hyperglycaemia below diagnostic thresholds for diabetes (HbA1c >6%, but < 6.5%, FPG 100–125 mg/dl), at least 1-year duration, no active pharmacological therapy or on-going procedures.
• Complete remission: Normal glycaemic measures (HbA1c normal range (<6%), FPG <100 mg/dl), at least 1-year duration, no active pharmacological therapy or on-going procedures.
• Prolonged remission: Complete remission of at least 5-year duration.
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Surgically induced improvement of T2DM may be considered effective if:
• Post-operative insulin dose ≤ 25% of the pre-operative one
• Post-operative oral anti-diabetic treatment dose ≤ 50% of the pre-operative one
• Post-operative reduction in HbA1c > 0.5% within 3 months or reaching < 7.0%.
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Criteria for assessment of effect of bariatric surgery on optimization of metabolic status
and some other co-morbid conditions
• HbA1c ≤ 6%, no hypoglycaemia, total cholesterol < 4 mmol/l, LDL-cholesterol < 2 mmol/l, triglycerides < 2.2 mmol/l, blood pressure < 135/85 mmHg, >15% weight loss,
• or lowering of HbA1c by >20%, LDL< 2.3 mmol/l, blood pressure < 135/85 mm Hg with reduced medication from pre-operative status
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Schauer et al, NEJM 2012
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SOS Study, Carlsson et al, NEJM 2012
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SOS Study, Carlsson et al, NEJM 2012
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Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis
Total Gastric Banding Gastroplasty Gastric Bypass BPD/DS
% EBWL 55.9 46.2 55.5 59.7 63.6
% Resolved overall 78.1 56.7 79.7 80.3 95.1
% Resolved<2 y 80.3 55.0 81.4 81.6 94.0
% Resolved≥2 y 74.6 58.3 77.5 70.9 95.9
Buchwald et al, The American Journal of Medicine 2009
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Sjöström L, J Intern Med 2013
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Rury et al, N Engl J Med 2008
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Glycated Hemoglobin Levels during 2 Years of Follow-up
Mingrone et al, NEJM 2012
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Mingrone et al, NEJM 2012
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Pontiroli et al, Diabetes Care 2005
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Brethauer et al, Ann Surg 2013
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Brethauer et al, Ann Surg 2013
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Brethauer et al, Ann Surg 2013
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Bariatric Surgery and Cardiovascular Events in Diabetic Subjects (SOS)
Romeo et al, Diabetes Care 2012
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Iaconelli et al, Diabetes Care 2011
Effects of Bilio-Pancreatic Diversion on Diabetic Complications
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Effects of Bilio-Pancreatic Diversion on Diabetic
Complications
Iaconelli et al, Diabetes Care 2011
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García G et al, Nutr Hosp. 2013
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Haimoto et al., Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2012
Reduction in urinary albumin excretion with a moderate low-carbohydrate diet
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Effects of Bariatric Surgery on micro- and macrovascular complications
Johnson et al, J Am Coll Surg 2013
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Brethauer et al, Ann Surg 2013
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Effects of Bilio-Pancreatic Diversion on Diabetic Complications
Iaconelli et al, Diabetes Care 2011
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Retrospective study 52 obese T2DM patients (RYGB, LAGB, LSG), mean follow up 66 months DN 37,6% (microalbuminuria 31,3%, macroalbuminuria 6,3%) DN remission : 58,3% DN progression: 25% after 66 months (vs 10-20%/year)
Heneghan et al, Surgery for Obesity and Related Diseases 2013
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Improvement of endothelial function (Arteriole-to-venule ratio of retinal vessels)
after bariatric surgery.
Lammert et al, Obesity 2012
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Effects of Bariatric Surgery on diabetic retinopathy
Thomas et al., J Diabetes Complications 2013
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Neuropathy scores before and 6 months after RYGB.
Müller-Stich et al, Ann Surg 2013
A: Neuropathy Symptom Score (NSS)
B: Neuropathy Deficit Score (NDS)
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SOS Study, Carlsson et al, NEJM 2012
NNT: 1.3 (IFG)
7.0 (NFG)
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Sjöström L, J Intern Med 2013
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Conclusioni
• La chirurgia bariatrica è in grado di ottenere un calo
ponderale significativo e sostenuto nel tempo e la rapida
remissione del diabete o il significativo miglioramento del
compenso glicemico, con riduzione del numero e della
posologia dei farmaci ipoglicemizzanti
• Lo stato di remissione si accompagna alla riduzione del
profilo di rischio cardiovascolare e dell’incidenza di
complicanze macrovascolari
• I dati finora disponibili suggeriscono un vantaggio anche
sulle complicanze microvascolari