Växjö 20190213 Maria Thunander Överläkare med dr Medicinkliniken Centrallasarettet Växjö FoU Region Kronoberg Institutionen för Klin Vetenskaper Lunds Universitet 1 Clinical ID: 931811
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RiktlinjerBehandling av typ 2 diabetesVäxjö 2019-02-13
Maria ThunanderÖverläkare, med drMedicinkliniken, Centrallasarettet VäxjöFoU, Region KronobergInstitutionen för Klin Vetenskaper, Lunds Universitet
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Slide2Clinical InertiaVi väntar för länge med att intensifiera terapin!
EASD 2018 MT2
Slide3Att vänta påverkar möjlighet nå glykemiskt mål:
EASD 2018 MT3
Slide4Glukossänkande terapi T2D Sverige 2006-2013Svensk studie
fr läkemedelsregistret
Slide5Aktuellt vid typ 2 diabetesFramför allt: Nya behandlingsrekommendationer !2018-10-05Gemensamma för EASD och ADA Europa och USA
Kommer när till Sverige? – dock redan relativt anpassade svenska RLGLP1-RA och SGLT-2 rek FÖRE SU och insulin
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Slide6The most recent press releases from the American Diabetes Association:October 5, 2018 - urklipp
New Consensus Report from the American Diabetes Association® (ADA) and the European Association for the Study of Diabetes (EASD) Calls for Paradigm Shift to Patient-Centered Care for Type 2 Diabetes
Produced by an international panel of diabetes care experts assembled by the ADA and the EASD, the ADA-EASD Consensus Report calls for a
paradigm shift to patient-centered care and details the panel’s comprehensive review of the latest evidence.”
”
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Slide7Management of Hyperglycemia in Type 2 Diabetes, 2018: A Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes (ADA-EASD Consensus Report).Nya “roadmaps” (algorithms)
to help achieve optimal diabetes control and improved quality of lifejointly produced and presented by EASD and ADAproduced by an international panel of diabetes care experts the ADA-EASD Consensus Report calls for a paradigm shift to patient-centered care comprehensive review of the latest evidence. simultaneously published 5 oct in Diabetes Care, and Diabetologia.
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Slide8Nya behandlingsriktlinjer för Typ 2 diabetesGränsövergång Metformin fortfarande förstahandsval.
Första injektionsläkemedel bör ej vara insulin, utan GLP1-RAAndrahandsval utifrån patientens situation och behovNjurfunktion, hjärta, hypoglykemirisk, vikt, preferenser, förmågaSU endast om ekonomi är viktig fråga (”ej i Europa och Canada”)
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Slide9Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)An individualised programme
of MNT should be offered to all patients. - MatAll overweight and obese patients with diabetes should be advised of the health benefits of weight loss and encouraged to engage in a programme of intensive lifestyle management, which may include food substitutionIncreasing physical activity improves glycaemic control and should be encouraged in all people with type 2 diabetes.EASD 2018 MT
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Slide10Decision cycle for patient-centered glycaemic management in type 2 diabetesEASD 2018 MT
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Slide11Glucose-lowering medication in type 2 diabetes: overall approachEASD 2018 MT
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Slide12Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)Providers and healthcare systems should prioritize the delivery of
patient-centred care.Facilitating medication adherence should be specifically considered when selecting glucose-lowering medications.Among patients with type 2 diabetes who have established ASCVD, SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit are recommended as part of glycaemic management.EASD 2018 MT
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Slide13T2D and Established Atherosclerotic Cardiovascular disease (ASCVD) or Chronic Kidney Disease
(CKD)EASD 2018 MT13
Slide14Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)"What's new since 2015 is we recommend that these comorbidities be considered first and foremost,
……... Within the classes, preference is given to liraglutide among GLP-1 receptor agonists based on the LEADER trial, and empagliflozin among SGLT2 inhibitors based on EMPA-REG OUTCOME.EASD 2018 MT
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Slide15Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)Hjärtsvikt och njurpåverkan
:Among patients with ASCVD in whom HF coexists or is of special concern, SGLT2 inhibitors are recommended.For patients with type 2 diabetes and CKD, with or without CVD, consider the use of an SGLT2 inhibitor shown to reduce CKD progression or, if contraindicated or not preferred, a GLP-1 receptor agonist shown to reduce CKD progression
Patients with type 2 diabetes and kidney
disease are at an increased risk for cardiovascular events.
A substantial number of participants with an
eGFR of 30–60 mlmin−1[1.73m]−2were included in EMPA-REG OUTCOME, CANVAS, LEADER and SUSTAIN6
. An
important
finding
in the studies
was
reduction
of the
primary
ASCVD
outcome
even
among
participants
with
stage
3
CKD (
eGFR
30–60 ml min−1 [1.73 m]−2).
For SGLT2inhibitors,
this
contrasts
with
the
glucose-lowering
effect
,
which
diminishes
with
declining
eGFR
.
EASD 2018 MT
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Slide16Minimize weight gain or promote weight loss
EASD 2018 MT16
Slide17Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)Consensus recommendation:Metabolic surgery is a recommended treatment option for adults with type 2 diabetes and
(1) a BMI ≥ 40.0 kg/m2 (BMI ≥ 37.5 kg/m2 in people of Asian ancestry) or (2) a BMI of 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable non-surgical methods.EASD 2018 MT17
Slide18Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)Intensification of treatment beyond dual therapy to maintain glycaemic targets requires consideration of the impact of medication
side effects on comorbidities, as well as the burden of treatment and cost. In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are the preferred choice to insulin. For patients with extreme and symptomatic hyperglycaemia, insulin is recommended.EASD 2018 MT18
Slide19Minimera hypoglykemiEASD 2018 MT
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Slide20Intensifiering av injektions-terapiEASD 2018 MT
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Slide21Tabletter i kombination med injektionsterapiEASD 2018 MT
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Slide22Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)Patients who are unable to maintain glycaemic targets on basal insulin in combination with oral medications can have
treatment intensified with GLP-1 receptor agonists, SGLT2 inhibitors or prandial insulin.Access, treatment cost and insurance coverage should all be considered when selecting glucose-lowering medications.EASD 2018 MT22
Slide23Om kostnad är avgörandeEASD 2018 MT
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Slide24Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)
"The focus of this consensus report is not on what an individual's glycemic target should be or on how to select individualized goals, but rather how to achieve the individual patients' glycemic target taking into account patient factors and the ever-increasing choice of therapies available for glycemic control,"EASD 2018 MT24
Slide25Läkartidningen 2018 Nyström och Nathanson
Slide26Kronoberg , primärvård, Typ 2Okt 2018
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