Type 2 diabetes Key slides 3 Management of blood glucose Lending our patients a hand

1
Type 2 diabetesKey slides 3 Management of blood
glucose Lending our patients a hand
2
Glucose control Type 2 diabetes the management
of type 2 diabetes. NICE Clinical Guideline
66May 2008

• Measure HbA1c every 2 to 6 months, until stable
  on unchanging therapy,
• then every 6 months
• Only offer self-monitoring of blood glucose as
  an integral part of self-management
• education (discuss purpose, interpretation and
  how it should be acted upon)
• see later for more details

3
Algorithm for glucose control 1 Type 2
diabetes the management of type 2 diabetes.
NICE Clinical Guideline 66May 2008
Continued on next slide
4
Algorithm for glucose control 2 Type 2
diabetes the management of type 2 diabetes.
NICE Clinical Guideline 66May 2008
Continued from previous slide
The guidance on glitazones, gliptins and
exenatide will be updated in the NICE short
clinical guideline Newer agents for blood
glucose in type 2 diabetes, expected May 2009
5
What is the guidance from NICE? NICE Clinical
Guideline 66May 2008

• Glitazones are third-line agents, as triple
  therapy with metformin and a SU if glycaemic
  control is insufficient (HbA1c gt7.5)
• Or second-line agents (at HbA1c gt6.5), as dual
  therapy with metformin if hypoglycaemia on a SU a
  particular issue, or with a SU if metformin not
  tolerated/contraindicated
• But there are safety issues only pioglitazone?
  can be used with insulin

The section covering glitazones, gliptins and
exenatide will be updated in the NICE short
clinical guideline Newer agents for blood
glucose in type 2 diabetes, expected May 2009
6
Do glitazones have POO data? CochraneRichter B,
et al. Pioglitazone Cochrane Review 2006Richter
B, et al. Rosiglitazone Cochrane Review 2007

• Pioglitazone?
• 22 RCTs (n6,200 randomised to pioglitazone?),
  included PROactive (average follow-up 34.5
  months, primary endpoint CV outcomes)
  
• Dormandy JA, et al. Lancet 200536612791289
• Concluded
• no convincing evidence that patient-orientated
  outcomes (mortality, morbidity, adverse effects,
  costs, QoL) were positively influenced by
  pioglitazone ?
• Oedema was significantly increased
• Results of PROactive need confirmation
  hypothesis generating
• Rosiglitazone
• 18 RCTs (n3,888 randomised to rosiglitazone),
  included ADOPT (average follow-up 4 years,
  primary endpoint glycaemic control)
  
• Kahn SE, et al. N Engl J Med 200635524272443
• Concluded
• No convincing evidence that patient-orientated
  outcomes (mortality, morbidity, adverse effects,
  costs, QoL) were positively influenced by
  rosiglitazone
• Oedema was significantly increased
• ADOPT indicated increased CV risk

7
What did Drug Safety Update say?Drug Safety
Update 20071 (5)

• A Europe-wide safety and efficacy review found
  that the benefits of rosiglitazone
• and pioglitazone? continue to outweigh the
  risks
• However, the prescribing information has been
  updated to include warnings that
• - Rosiglitazone should be used in patients with
  ischaemic heart disease only after careful
  evaluation of every patients individual risk
• - Rosiglitazone combined with insulin should be
  used only in exceptional cases and under close
  supervision

8
Oral hypoglycaemics Old vs. new drugsBolen S,
et al. Ann Intern Med 200714738699

• Systematic review of 216 studies and 2 earlier
  systematic reviews of oral hypoglycaemics to
  January 2006
• Data on major clinical endpoints, eg CV mortality
  were limited, therefore inconclusive
• But concluded that older agents have similar or
  superior effects to newer, more expensive agents
  on glycaemic control, lipids and other
  intermediate endpoints (body weight, BP, adverse
  effects, etc.)
• Older agents metformin, SU
• Newer agents glitazones, alpha-glucosidase
  inhibitors, eg acarbose and meglitinides

9
Self-monitoring blood glucose Type 2 diabetes
the management of type 2 diabetes. NICE Clinical
Guideline 66May 2008

• Make available to
• Those on insulin
• Those on oral medication to provide information
  on hypoglycaemia
• Assess changes during medication or lifestyle
  changes, or illness
• Ensure safety during activities, including
  driving

• Assess at least annually in a structured way
• Self-monitoring skills
• Quality and appropriate frequency of testing
• The use made of results obtained
• The impact on quality of life
• The continued benefit
• The equipment used