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