Gastrolearning VII lezione Personalizzazione della terapia del Diabete Mellito - Prof. S. Del Prato (Università di Pisa) www.gastrolearning.it

1. National and global trends in
diabetes prevalence 1980-2008
2008,
N= 347 millions
1980, N= 153
millions
Danaei G et al Lancet 2011; 378:31

2. National and global trends in
diabetes prevalence 1980-2008
Effective preventive
interventions are needed, and
health systems should prepare
to detect and manage diabetes
and its sequelae
Danaei G et al Lancet 2011; 378:31

3. National and global trends in
diabetes prevalence 1980-2008
Effective preventive
interventions are needed, and
health systems should prepare
to detect and manage diabetes
and its sequelae
Danaei G et al Lancet 2011; 378:31

4. National and global trends in
diabetes prevalence 1980-2008
Effective preventive
interventions are needed, and
health systems should prepare
to detect and manage diabetes
and its sequelae
Danaei G et al Lancet 2011; 378:31

5. Macrovascular and microvascular
complications occur frequently in people with
diabetes
Macrovascular Microvascular
Prevalence (% patients)
Heart Chest CHD CHF Stroke Kidney Foot Eye
attack pain
Complications
CHD = Coronary heart disease
CHF = Congestive heart failure Deshpande AD, et al. Phys Ther 2008;88:1254

6. Hazard ratios for major causes of death,
according to baseline levels of fasting
glucose
The Emerging Risk Factors Collaboration. N Engl J Med 2011;364:829-841

7. ACCORD, ADVANCE & VADT – Effect of
intesive treatment on glycemic control
ACCORD
VADT ADVANCE

8. Effect of intensive glucose control in
T2DM patients
Primary Outcome Mortality
HR 95% CI P HR 95% CI P
VADT 1 0.87 0.73-1.04 NS VADT 1 1.0650.801-1.416 NS
ACCORD 2 0.90 0.78-1.04 NS ACCORD 2 1.22 1.01-1.46 0.04
ADVANCE 30.94 0.84-1.06 NS ADVANCE 30.93 0.83-1.06 NS
0.5 1.0 2.0 0.5 1.0 2.0
W. Duckworth et NEJM 2009;359:156; 2The ACCORD Study Group NEJM 2008;358:2545;
1
3
The ADVANCE Collaborative Group N EJM 2008,358:2560

9. Failure to observe reduction in
macrovascular events in ACCORD,
ADVANCE, and VADT
• Wrong sample size
…major CV risk factors already intensively treated
factors already
• Wrong drug
…insulin and insulin providing drugs
and insulin drugs
• Wrong hypothesis
…glycemia is not a major CV risk factor
• Wrong patient population
…advanced ATS in long standing T2DM patients
T2DM

10. VADT in the context of the “natural
history” of Type 2 diabetes
Generate a
Generate a Drive risk for
Drive risk for
negative
negative complications
complications
“legacy”
“legacy”
HbA1c (%)
TIME (years since diagnosis)
Del Prato S. Diabetologia 2009;52:1219

11. Long-Term Effects of Intensive Glucose
in Newly Diagnosed Type 2 Diabetic Patients
Intensive (SU/Ins) vs. Conventional glucose
control
HR (95%CI) HR (95%CI)
NNT
29.4 for 10 yrs*
Intensive (metformin) vs. Conventional glucose
control
HR (95%CI)
NNT HR (95%CI)
14 for 10 yrs*
Holman RR et al. N Engl J Med. 2008;359:1577–1589 *De Vries JH Diabetologia. 2011;54:705–706

12. The lesson of the intervention trials
• Aim at near-normal glycemic
• Aim at near-normal glycemic
control
control
• Adopt an uncompromised
• Adopt an uncompromised • Intensify CV risk factor Rx
• Intensify CV risk factor Rx
therapeutic insistence • Assess risk:benefit ratio
METABOLIC – HEMODYNAMIC ALTERATIONS
therapeutic insistence • Assess risk:benefit ratio
• Consider pathophysiological
• Consider pathophysiological • Individualize therapy
• Individualize therapy
Dysglycemia
basis (insulin resistance and β-
basis (insulin resistance and β- Diabetes
• Consider anti-
• Consider anti-
cell dysfunction)
cell dysfunction) hyperglycemic vs.
hyperglycemic vs.
• Individualize therapy hypoglycemic agents
Relative Risk
• Individualize therapy hypoglycemic agents
• Treat promptly all CV risk
• Treat promptly all CV risk
factors
factors
CVD
1.0
Plasma Glucose

13. Management of Hyperglycemia in Type 2 Diabetes: A Patient-
Centered Approach
Diabetes Care – Diabetologia June 2012

14. Glycaemic targets in diabetes.
The ADA/AHA position statement
A1c <7.0% A1cA1c >7.0%
• >7.0%
• Short duration of diabetes • History of severe
• Long life expectancy hypoglycemia
• No significant • Limited life expectancy
cardiovascular disease • Long-standing diabetes
• Advanced micro- and
MAY GAIN ADDITIONAL macrovascular
MICROVASCULAR BENEFIT AS WELL complications
AS MACROVASCULAR PROTECTION
Patient’s phenotype B =body weight
B
Skyler J, et al Diabetes Care 2009;32:187

15. Beyond the ADA/EASD algorithm

16. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
Age
Age MIDDLE
MIDDLE ELDERL
ELDERL
YOUNG
YOUNG
AGE
AGE Y
Y
Complications* or
Complications* or
Disease duration
Disease duration
>10yrs
>10yrs
–
– +
+ –
– +
+ –
– +
+
A1c target 6.5-
6.5- 7.0-
7.0-
A1c target <6.0
<6.0 <6.5
<6.5 <6.5
<6.5 <7.0
<7.0
7.0
7.0 8.0
8.0
A1c at
A1c at <9.0%
<9.0% >9.0
>9.0
diagnosis
diagnosis
Initial
Initial Metformi
Metformi Consider
Consider
therapy
therapy n
n insulin
insulin
*Micro- and macrovascular complications Pozzilli P …. Del Prato S Diabetes Metab Res Rev 2010; 26:239

17. Effect of noninsulin antidiabetic drugs
added to metformin on glycemic
control
-0,8
Phung OJ et al JAMA 2010; 303:1410

18. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION

19. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION

20. Glycaemic control and all-cause
mortality – A U shaped curve?
100
90
Age at baseline (years)
80
70
60
50
40
Currie JE et al Lancet 2010; 375:481

21. Glycaemic control and all-cause
mortality – A U shaped curve?
100
90
Age at baseline (years)
80
70
60
50
40
Currie JE et al Lancet 2010; 375:481

22. Glycaemic control and all-cause
mortality – A U shaped curve?
Currie JE et al Lancet 2010; 375:481

23. High prevalence of T2DM in the elderly
population
20
17.6
18
16 14.9
Prevalence (%)
14
12
10
7.9
8
6
4
2.1
2
0.2
0
12–19 20–39 40–59 60–74 ≥75
Age (years)
National Health and Nutrition Examination Survey (NHANES) 2005–2006. T2DM=type 2 diabetes mellitus.
Adapted from Cowie CC, et al. Diabetes Care. 2009;32:287–294.

24. The management of T2DM in the
elderly is challenging
Risk factors Geriatric
syndromes
Ageing Depression
Diabetes
Disability
complications
Comorbidity Malnutrition
Increased
Urinary
Hyperglycaemia
incontinence mortality
Hypoglycaemia Falling
Lack of Cognitive
social support impairment
Ageing, diabetic microvascular and macrovascular complications, hyperglycaemia, hypoglycaemia,
multiple morbidity and lack of social support are risk factors for the geriatric syndromes
T2DM=type 2 diabetes mellitus.
Araki A, Ito H. Geriatr Gerontol Int. 2009;9:105–114.

25. The Consequences of Hypoglycaemia
Hospitalisation
Coma 3
costs4
Cardiovascular
Death2,3 complications3
Weight gain by
Increased risk defensive eating5
of dementia1 HYPOGLYCAEMIA
Loss of
Reduced consciousness3
quality of life7
Increased risk Increased risk
of car accident6 of seizures3
1
Whitmer RA, et al. JAMA. 2009;301:1565–1572; 2Bonds DE, et al. BMJ. 2010;340:b4909; 3 Barnett AH. Curr Med Res Opin.
2010;26:1333–1342; 4Jönsson L, et al. Value Health . 2006;9:193–198; 5Foley JE, Jordan J. Vasc Health Risk Manag .
2010;6:541–548; 6Begg IS, et al. Can J Diabetes. 2003;27:128–140; 7McEwan P, et al. Diabetes Obes Metab . 2010;12:431–436.

26. ADVANCE – Association of severe hypoglycemia
with the risk of an adverse clinical outcome or
death
Zoungas S. et al N Engl J Med 2010;363:1410

27. The risk of severe hypoglycaemia: post hoc
epidemiological analysis of the ACCORD study
Miller ME et al . BMJ 2010;340: b5444
C D B C P<0.0001
A
P=0.01
P=0.03 P<0.03
P<0.0001
P<0.0001
P<0.0001
Diabetes duration BMI Serum creatinine
(years) (kg/m )
2
(µmol/l)
*History of peripheral neuropathy (yes vs. no); **per 1 year increase

28. Antidiabetic agents and risk of
hypoglycemia
High risk Low risk

 Insulin therapy1
1 
 Metformin6
6

 Sulphonylureas2
2 
 a-glucosidase inhibitors7
7

 Glinides (less than SUs)1,3
1,3 
 Thiazolidinediones6,8
6,8

 Drug-drug interaction can 
 GLP-1 agonists9
9
potentiate hypoglycemia4,5
4,5

 DPP-4 inhibitors10-12
10-12
1. Henderson JN, et al. Diabet Med. 2003;20:1016; 2. Bolen S, et al. Ann Intern Med. 2007;147:386; 3. Kahn SE, et al. N Engl J Med. 2006;355:2427;
4. Krentz AJ, Bailey CJ. Drugs. 2005;65:385; 5. Prandin® (repaglinide) package insert. Novo Nordisk; June 2006; 6. Kahn SE, et al. N Engl J Med. 2006;355:2427;
7. Cefalu WT. Nature. 2007;81:636; 8. Bolen S, et al. Ann Intern Med . 2007;147:386; 9. DeFronzo RA, et al. Diabetes Care. 2005;28:1092;
10. Stonehouse A. Curr Diabetes Rev 2008;4:101; 11. Aschner P et al. Diabetes Care. 2006; 29:2632; 12. Rosenstock J et al. Diabetes Obes Metab 2008;10:376.

29. Vildagliptin in the very elderly T2DM patients
∆ HBA1c ∆ Body Weight
Achieving A1c ≤7.0 Hypoglycemia
Age ≥75 yr (MonoRx, N=62; Add-on, N=25) Age <75 yr (MonoRx, N=2303; Add-on, N=910)
Schweizer A et al. Diabetes Obes Metab 2011; 13:55

30. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION

31. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION

32. Frequency distribution of BMI and waist
circumference in T2DM patients. The Pisa
Diabetes Survey
Women (n.918) Men (n. 680)
200 200
160 160
BMI
Count
Count
120 120 m±sd:
80 80 28.7±8.2
range: 16-52
40 40
0 0
15 20 25 30 35 40 45 50 55 15 20 25 30 35 40 45 50 55
200 200
160 160
Count
120 Waist
Count
120
80 m±sd:106.0±12.3
80
range: 70-156
40 40
0 0
60 80 100 120 140 160 60 80 100 120 140 160

33. Frequency distribution of BMI and waist
circumference in T2DM patients. The Pisa
Diabetes Survey
Women (n.918) Men (n. 680)
200 200
160 160
BMI
Count
Count
120 120 m±sd:
80 80 28.7±8.2
range: 16-52
40 40
0 0
15 20 25 30 35 40 45 50 55 15 20 25 30 35 40 45 50 55
200 200
160 160
Count
120 Waist
Count
120
80 m±sd:106.0±12.3
80
range: 70-156
40 40
0 0
60 80 100 120 140 160 60 80 100 120 140 160

34. Frequency distribution of BMI and waist
circumference in T2DM patients. The Pisa
Diabetes Survey
Women (n.918) Men (n. 680)
200 200
160 160
BMI
Count
Count
120 120 m±sd:
80 80 28.7±8.2
range: 16-52
40 40
0 0
15 20 25 30 35 40 45 50 55 15 20 25 30 35 40 45 50 55
200 200
160 160
Count
120 Waist
Count
120
80 m±sd:106.0±12.3
80
range: 70-156
40 40
0 0
60 80 100 120 140 160 60 80 100 120 140 160

35. Frequency distribution of BMI and waist
circumference in T2DM patients. The Pisa Diabetes
Survey

36. Baseline BMI is associated with increased
CV mortality in treatment trials*
0.40
(logarithmically transformed)
MentelHenzel-Odds Ratio
0.32
0.24
0.16
0.08
0.00
-0.08
-0.16
-0.24
-0.32
-0.40
27.2 27.7 28.2 28.7 29.2 29.7 30.2 30.7 31.2 31.7 32.2
BMI at baseline (Kg/m2)
*UKPDS Group. Lancet 1998;352:837; UKPDS Group Lancet 1998;352:854; Darmandy JA et al Lancet 2005;366:1279;
ADVANCE Collaborative Group. N Engl J Med 2008;358:2560; ACCORD Study Group. N E ngl J Med 2008;358:2545.
Duckworth et al N Engl J Med 2009;360:129.
Mannucci E. et al Nutr Metab Cardiovasc Dis. 2009 May 7. [Epub ahead of

37. Pooled between-group differences in body
weight with monotherapy and combination
therapies.
Bennett WL et al Ann Intern Med. 2011;154:602-613.

38. Effect of noninsulin antidiabetic drugs
added to metformin on glycemic control
Phung OJ et al JAMA 2010 ; 303:1410

39. T2DM treatment – a composite endpoint
↓=BMI
↑BMI
↓HYPOs
↑HYPOs
Efficacy
Efficacy

40. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATIONS
DURATION

41. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATIONS
DURATION

42. The Renal Insufficiency And Cardiovascular
Events (RIACE) Italian multicentre study
eGFR <60 ml/min Both Albuminuria
100
80
60
Percent
40
20
0 ≤45 46-60 61-75 >75
n. 113 (21.4%) n. 1,067 (26.8%) n. 3,100 (37.0%) n. 1,628 (56.4%)
n. 528 n. 3,986 n. 8,374 n. 2,885
RIACE Study Group, unpublished data

43. Tolerability and efficacy of vildagliptin in T2DM
patients with moderate or severe renal
insufficiency
a
Number of patients ≥65 years with moderate RI were 113 (vildagliptin) and 102 (placebo) and with severe RI were 64 (vildagliptin) and 46 (placebo).
AEs=adverse events; RI=renal impairment; SAEs=serious adverse events; vilda=vildagliptin.
Lukashevich V et al Diabet Obes Metab 2011;13:942

44. Tolerability and efficacy of vildagliptin in T2DM
patients with moderate or severe renal
insufficiency
Moderate RI Severe RI
Mean Change from Between-treatment Mean Change from Between-treatment
Baseline to End Point Difference vs Placebo Baseline to End Point Difference vs Placebo
N= 157 128 N= 122 95
BL= 7.86 7.79 BL= 7.69 7.65
Adjusted Mean Change from
Adjusted Mean Change from
Baseline in HbA1c (%)
* Baseline in HbA1c (%) *
Vildagliptin 50 mg once daily Placebo
*P <0.0001 vs placebo. Full analysis set. BL=baseline; HbA1c=haemoglobin A1c; RI=renal impairment; T2DM=type 2 diabetes mellitus.
Lukashevich V et al Diabet Obes Metab 2011;13:942

45. Most prescribed medications in diabetis
persons – ARNO 2010
Atorvastatin (s)
Atorvastatin (s)
Metoprolol (s)
Metoprolol (s) Rosuvastatin (s)
Rosuvastatin (s)
Warfarin (s)
Warfarin (s) Simvastatin (s)
Simvastatin (s)
Diltiazem (s)
Diltiazem (s) Carbamazepine 
Carbamazepine
Phenobarbital 
Phenobarbital
Phentoyn 
Phentoyn
Clarithromycin 
Clarithromycin Phluoxetine 
Phluoxetine
Erythromycin 
Erythromycin Midazolam (s)
Midazolam (s)
Fluconazole 
Fluconazole
Ketoconazole 
Ketoconazole
Rifampicin 
Rifampicin
Dexamethasone 
Dexamethasone
Diclofenac
Diclofenac
(s) – substrate;  – inhibitor;  –cythocrome p-450 inducer

46. Interaction of DPP4 Inhibitors with Cytochrome
p450
Vildagliptin Sitagliptin Saxagliptin
Substrate for CYP3A4 No Low Yes
CYP3A5 No No Yes
CYP2C8 No Very low No
Dose proportion Yes Yes Yes
Meal effect No No No
Drug interaction No No Yes
Dose reduction with
No No Yes (2.5 mg)
CYP3A4 inhibitors
Scheen A J. Diabetes, Obesity and Metabolism 2010; 12:648–658

47. UKPS 23: Risk Factors for CHD
HbA1c (%) Age (yrs)
Systolic BP (mmHg) LDL-cholesterol mmol/l)
Turner RC et al BMJ 316:823-828, 1999

48. Metformin: a multitasking medication
 FA
 Insulin action   Insulin sensitivity
 glucose   LDL
production   body weight
  PAI-1
Metformin
 Insulin action
 β-cell function
• antioxidant effects
• neutralisation of AGE
 Insulin   adhesion molecule
secretion*
  differentiation of
inflammatory cells into
macrophages
 lipolysis   improved microcirculation
* Indirectly through reduced glucotoxicity or GLP-1 enhancement; ** Independently of glycemic lowering ?

49. AMI, stroke, CHF and all-cause mortality in elderly
medicare patients treated with pio- or rosiglitazone
Bone fracture!
Heart failure!
Graham at al., JAMA 2007; 304:411

50. Potential cardiovascular protective
properties of incretin-based therapies
INCRETIN-BASED THERAPY
METABOLIC EFFECTS CV EFFECTS
 Glycemic control  Endothelial function
= Body weight  Anti-ischemic effect
 Blood pressure  Angiogenesis
 CV risk factors  Myocardial
 lipid profile
 lipid profile metabolism
 inflammation
 inflammation  Cardiac function

51. Ongoing pre- and post-approval outcome
studies
Source: clinicaltrials.goc and sponsor’s web sites

52. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATIONS
DURATION

53. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION

54. The lesson of the intervention trials
Reducing hypoglycemia
Reducing hypoglycemia
Preventing body weight
Preventing body weight
METABOLIC – HEMODYNAMIC ALTERATIONS
gain
gain
Dysglycemia

 Diabetes
Increase adherence
Increase adherence
Relative Risk
Reduce clinical inertia
Reduce clinical inertia
CVD
1.0
Plasma Glucose

55. Association between A1C and adherence
8.8
8.0
Adjusted A1c (%)
7.2
6.4
5.6
-0.15% per 10% increase in adherence
-0.15% per 10% increase in adherence
4.8
4.0
0 10 20 30 40 50 60 70 80 90 100
Adherence(%)
Adjusted for Baseline A1C and the ODM Regimen* Rozenfeld Y. Am J Manag Care. 2008;14: 71

56. Insulin sensitivity and secretion in individuals with
different degrees of glucose tolerance with ( ) and
without ( ) family history for T2DM
HOMA IR β-index
Log [pmol insulin.120min-1 .m-2]
NGT IGT DM
NGT IGT DM
NGT, normal glucose tolerance; IGT, impaired glucose tolerance; IR, insulin
resistance
Del Prato S, Marchetti P, Bonadonna RC. Diabetes 2002; 51 (Suppl 1):S109

57. Sulfonylurea-induced beta-cell
apoptosis in cultured human islets
Solvent Repaglinide 0.01 µM Control GLP-1–treated cells
Day 1
Nateglinide 10 µM Glibenclamide 0.1 µM
Day 3
Day 5
Maedler K, et al. J Clin Endocrinol Metab . 2005;90:501 Farilla L et al. E ndocrinology . 2003;144:5149

58. VERIFY
Vildagliptin Efficacy in combination with metfoRmIn For earlY treatment of T2DM
Circa 2000 mostly drug-naïve T2DM patients
HbA1c 6.5% to 7.5%
1:1 randomization
5-year follow-up
Multinational
double-blind, parallel group study
To test the hypothesis whether early treatment combination with VILDA-MET
will result in lower treatment failure rate or in lower rate of loss in glycemic
control (HbA1c) over time than with MET alone.

59. VERIFY
Vildagliptin Efficacy in combination with metfoRmIn For earlY treatment of T2DM
Other objectives include
evaluation of rate of fasting plasma glucose (FPG) progression over time,
change in HbA1c over time,
time to insulin initiation,
development or progression of micro- and macrovascular complications,
changes in body weight,
HOMA-B/IR,
health status,
safety and tolerability
Insulin secretion rate relative to glucose (ISR/G)
oral glucose insulin sensitivity (OGIS)
microalbuminuria tests
retinal photography with microaneurism counts

60. The A1C and ABCD of glycaemia management
in T2DM: a physician’s personalized approach
AGE
BODY WEIGHT
COMPLICATION
DURATION
tiology
E ducation
conomy

61. The evolving complexity of T2DM pathogenesis
accounts for treatment evolution
Islet b-cell
DPP4-I
DPP4-I DPP4-I
DPP4-I
GLP-1 agonists
GLP-1 agonists GLP-1 agonists
GLP-1 agonists
GK agonists
GK agonists Bile acid sequestrants
Bile acid sequestrants TZDs Increased
TZDs
GPRs, IL-receptor
GPRs, IL-receptor Dual/Pan PPARs
Dual/Pan PPARs
Impaired Lipolysis
antagonist
antagonist Decreased 11βHSD-I
11βHSD-I
Insulin Secretion
Incretin Effect
Islet a-cell
DPP4-I
DPP4-I
GLP-1 agonists
GLP-1 agonists
SGLT2-I
SGLT2-I
Glucagon receptor
Glucagon receptor
antagonist
antagonist
Increased
Increased Glucose
Glucagon Reabsorption
Secretion TZDs
TZDs
Metformin
Metformin Dual/Pan PPARs
Dual/Pan PPARs
GK agonists
GK agonists Metformin
Metformin
Glucagon receptor
Glucagon receptor
antagonists
antagonists Bromocriptin
Bromocriptin
Increased
HGP Decreased
Glucose
Neurotransmitter Dysfunction Uptake

62. The evolving complexity of T2DM pathogenesis
accounts for treatment evolution
Islet b-cell
DPP4-I
DPP4-I DPP4-I
DPP4-I
GLP-1 agonists
GLP-1 agonists GLP-1 agonists
GLP-1 agonists
GK agonists
GK agonists Bile acid sequestrants
Bile acid sequestrants TZDs Increased
TZDs
GPRs, IL-receptor
Impaired GPRs, IL-receptor Dual/Pan PPARs
Dual/Pan PPARs
Lipolysis
antagonist
antagonist Decreased 11βHSD-I
11βHSD-I
Insulin Secretion
Incretin Effect
Islet a-cell
DPP4-I
DPP4-I
GLP-1 agonists
GLP-1 agonists
SGLT2-I
SGLT2-I
Glucagon receptor
Glucagon receptor
antagonist
antagonist
Increased
Increased Glucose
Glucagon Reabsorption
Secretion TZDs
TZDs
Metformin
Metformin Dual/Pan PPARs
Dual/Pan PPARs
GK agonists
GK agonists Metformin
Metformin
Glucagon receptor
Glucagon receptor
antagonists
antagonists Bromocriptin
Bromocriptin
Increased
HGP Decreased
Glucose
Neurotransmitter Dysfunction Uptake

63. A roadmap for selecting antihyperglycemic
agents for treatment of Type 2 diabetes
*potential β-cell protection?
Adapted from Drucker DJ et al Diabetes Care 2010; 33:428

64. Conclusion
While we await for effective and safe
preventative approaches we must
appreciate that pharmacologic
intervention together with lifestyle
modification:
•Can provide strict and long-term glycemic control
•This may not necessarily ensure clear cut benefits
in term of long-term complications, unless
•Proper therapy is initiated early in the course of
the disease
•Individualized early intervention can be more
effective though not necessarily simpler

65. Glucose lowering management in
Type 2 diabetes - the way forward

66. Glucose lowering management in
Type 2 diabetes - the way forward
B C
D
A E
Etiology
Complications Education
Body Diabetes
Age Economy
Weight Duration

67. The A1C and the diabetes alphabet
Foot care Quality of life
Guidelines Risk of CV disease
Hypoglycemia Statins
Insulin Treat-to-target
Liver steatosis Urgency
Monitoring Validation
Organization W
Prevention Y
Z

68. The A1C and the diabetes alphabet
Foot care Quality of life
Guidelines Risk of CV disease
Hypoglycemia Statins
Insulin Treat-to-target
Liver steatosis Urgency
Monitoring Validation
Organization Win against diabetes
Prevention Y
Z

69. The A1C and the diabetes alphabet
Foot care Quality of life
Guidelines Risk of CV disease
Hypoglycemia Statins
Insulin Treat-to-target
Liver steatosis Urgency
Monitoring Validation
Organization Win against diabetes
Prevention You are the specialists
Z

70. The A1C and the diabetes alphabet
Foot care Quality of life
Guidelines Risk of CV disease
Hypoglycemia Statins
Insulin Treat-to-target
Liver steatosis Urgency
Monitoring Validation
Organization Win against diabetes
Prevention You are the specialists
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