Objetivos en diabetes: de la "evidencia" al sentido común José Manuel Millaruelo Trillo. Centro de Salud Torrero La Paz. Zaragoza. Miembro de la red GEDAPS Aragón

1. Los objetivos terapéuticos en diabetes:
¿basados en la evidencia?
Jose Manuel Millaruelo Trillo
Centro de Salud Torrero La Paz. RedGDPS Aragón. Zaragoza

2. Los objetivos terapéuticos en diabetes no están
muchas veces justificados, son medicalizadores
y tienen escasos beneficios netos
• biblia
• milongas
• menos es mas
• nadar
• 17

3. Porque debemos confirmar la credibilidad de las guías
How to Decide Whether a Clinical
Practice Guideline Is Trustworthy
Ransohoff D, Pignone M, Sox H
JAMA 2013; 309: 139-40
Failure of clinical practice guidelines to
meet Institute of Medicine standards:
two more decades of little, if any,
progress.
Kung J, Miller R, Mackowiak P.
Arch Intern Med. 2012;172:1628-1633
Scientific Evidence Underlying the
ACC/AHA Clinical Practice Guidelines
Tricoci P, MD, Allen J, Kramer J, Califf R
JAMA 2009; 301:831-842

4. ¿Qué pasa con las GPC?
PLoS ONE 8(4): e58625
Pocos participantes 91% menos de 500
Excluyen a mayores de 75 (algunos 65) Solo incluyen 0.6%
Corta duración 1.4 años
Fármacos vs prevención 74.8% vs 10%
Outcome primario (mortalidad, ECV) 1.4%

5. • Diabetes = enfermedad cardiovascular
• 80% muertes por ECV
• Diabetes: 1ª causa ceguera (edad laboral)
• Diabetes: 1ª causa de IR terminal
• Amputaciones por diabetes: cada vez más
• ….
Recibimos una información sesgada ó
desinformar para influenciar (en diabetes)

6. Is diabetes a coronary risk equivalent? Systematic review and meta-analysis
Diabet. Med. 26, 142–148 (2009)

7. La diabetes como enfermedad cardiovascular: bla, bla, bla,…
39% 26% 35%
Diabetes and risk of mortalitya: the CPS-II cohort, 1982–2008
Diabetes Care Publish Ahead of Print,
published online June 14, 2012

8. Datos de ceguera legal por RD de la ONCE

9. Causas de insuficiencia renal terminal

10. Aumentar la importancia del problema no significa
que aumente su gravedad: la clave es la prevalencia
Prevalencia = Incidencia x tiempo - mortalidad

11. Declining Rates of Hospitalization for Nontraumatic Lower-Extremity
Amputation in the Diabetic Aged 40 Years or Older: U.S., 1988–2008
Diabetes Care 35:273–277, 2012

14. Del racionamiento a evitar gasto inútil
Developing Quality Measures to Address Overuse JAMA, May 8, 2013—Vol 309, No. 18

16. Objetivos de la ADA 2013

17. Individualizar objetivos: Objetivos comunes implica mala practica
Ann Intern Med. 2011;154:554-559

18. ¿Debería ser 7 la cifra mágica?
Currie, CJ.: Survival as a function of HbA1c in
people with type 2 diabetes: a retrospective
cohort study www.thelancet.com Published
online January 27, 2010

19. Relationship between HbA1c levels and risk of cardiovascular adverse outcomes
and all-cause mortality in overweigh and obese cardiovascular high-risk women
and men with type 2 diabetes
Diabetologia. 2012 ;55:2348-55

20. All-cause mortality in relation to glycated haemoglobin
in individuals with newly diagnosed type 2 diabetes
British Journal of Diabetes
& Vascular Disease 2013 13: 22

21. The relationship between glycaemic control and heart
failure in 83,021 patients with type 2 diabetes
Diabetologia (2012) 55:2946–2953
Poor glycaemic control (HbA1c >7% is associated
with an increased risk of hospitalisation for
heart failure in patients with type 2 diabetes

22. Relationship between HbA1c and risk of all-cause hospital
admissions among people with Type 2 diabetes
“A threshold of 61 mmol/mol (7.7%) was associated
with the lowest rate of all-cause hospital admissions”
Diabet Med. 2013 May 22.
doi: 10.1111/dme.12235.
[Epub ahead of print]

23. Relationship Between Glycemic Control and Diabetes-Related
Hospital Costs in Patients with Type 1 or Type 2 Diabetes
Mellitus
J Manag Care Pharm. 2010;
16(4):264-75
the odds of having at least 1 diabetes-
related hospitalization were not significantly
associated with higher mean A1c except for
patients with mean A1c of at least 10%.

24. ¿Por qué solo miramos lo biológico?
Ostgren C. Associations of HbA1c and educational level with risk of cardiovascular e
in 32 871 drug-treated patients with Type 2 diabetes. Diabet. Med. 30, e170–e177 (2

25. Incongruencia o contradicción
Si lo que nos preocupa es lo macrovascular, ¿porque utilizamos
para los objetivos los datos de lo microvascular?
¿Por que se utilizan como objetivos de tratamiento cifras que no han
demostrado mejorar la evolucion de las complicaciones?

26. La diabetes es causa importante de mortalidad en edades
medias de la vida
Taylor K. All-Cause and Cardiovascular Mortality inMiddle-Aged PeopleWith Type2
Diabetes Compared With People Without Diabetes in a Large U.K. Primary Care Database.
Diabetes Care Publish Ahead of Print, published online February 22, 2013

27. ¿Qué decir de la TA?
Reappraisal of European guidelines on
hypertension management: a European
Society of Hypertension Task Force
document

28. Intensive and Standard Blood Pressure Targets in
Patients With Type 2 Diabetes Mellitus
“Use of a Single Target
Blood Pressure Level
in Type 2 Diabetes Mellitus
for All Cardiovascular
Risk Reduction”
Arch Intern Med
2012 ;172:1296-303

29. Effects of intensive blood pressure reduction on myocardial infarction
and stroke in diabetes: a meta-analysis in 73 913 patients
Journal of Hypertension 2011, 29:1253–1269

30. Blood presure and stroke risk in diabetic
americans

31. Aggressive Blood Pressure Control Increases Coronary Heart
Disease Risk Among Diabetic Patients
Diabetes Care Publish Ahead of Print, published online May 20, 2013

32. ¿Qué decir del colesterol?
Identifying Patients for Aggressive
Cholesterol Lowering: The Risk Curve
Concept. Am J Cardiol 2006;98:1405–
1408

33. Contra el LDL como objetivo
Rodney A. Hayward and Harlan M. Krumholz. Circ Cardiovasc Qual Outcomes
2012;5;2-5; Adult Treatment Panel IV of the National Institutes of Health
Three Reasons to Abandon Low-Density Lipoprotein Targets

35. De la dificultad de nadar contra corriente

36. Médicos de los números, médicos de las personas

39. Preguntas, por favor…