Practical Diabetes Care

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fmatter Untitled © Contents Acknowledgments Introduction Clinical trials and organizations:abbreviations and acronyms 1 Classification, diagnosis and presentation, 1 Key points A PRACTICAL CLASSIFICATION OF DIABETES TYPE 1 DIABETES Table 1.1 Phenotypic features of Type 1 diabetes. Epidemiology; Type 1 diabetes in China Further clinical pointers to Type 1 diabetes AUTOIMMUNE ASSOCIATIONS OF TYPE 1 DIABETES Box 1.1 Autoimmune conditions associated with Type 1 diabetes. TYPE 2 DIABETES Table 1.2 Diagnosing Type 2 diabetes in adults. Latent autoimmune diabetes of adults (LADA): a valuable epidemiologicalconcept, but of limited value in immediate clinical decision‐making Figure 1.1 Prevalence of Type 2 diabetes in the United Kingdom by ethnicity (age‐ and sex‐standardized). ch2 3 Infections and the diabetic foot, 49 4 Eyes and kidneys, 77 5 Neuropathy, musculoskeletal and skin, 115 6 Diabetes and the cardiovascular system, 141 7 Type 1 diabetes: glycaemic control, 171 ch8 9 Type 2 diabetes: weight loss, exercise and other ‘lifestyle’ 10 Type 2 diabetes: glycaemic control, 241 Key points INTRODUCTION THE PROGRESSIVE NATURE OF TYPE 2 DIABETES Practice point: GLYCAEMIC CONTROL AND COMPLICATIONS IN TYPE 2DIABETES Microvascular complications UKPDS VADT, ACCORD, ADVANCE Practice point Macrovascular complications VADT, ACCORD, ADVANCE Multimodal intervention (Steno‐2) Practice point TARGETS FOR GLYCAEMIC CONTROL INTYPE 2 DIABETES Box 10.1 UK (NICE) and USA (ADA) targets for glycaemic control. SELF‐MONITORING OF BLOOD GLUCOSE INTYPE 2 DIABETES PHARMACOLOGICAL MANAGEMENTOF HYPERGLYCAEMIA Table 10.1 Drugs, patents and long‐term cardiovascular benefits. INTENSIFICATION OF TREATMENT IN TYPE 2 DIABETES GLYCAEMIC EFFICACY (MAGNITUDEOF ANTIHYPERGLYCAEMIC EFFECT) (TABLE 10.2) Figure 10.2 Intensification of antihyperglycaemic treatment. Source: from NICE guidelineNG28, 2015. Tableˇ10.2 Thumbnail characteristics ofdiabetes agents (adapted fromADA). Durability of effect METFORMIN Glycaemic efficiency and durability Practice point Practice point Effects on weight and risk of hypoglycaemia Side effects Practice point Metformin and renal impairment Table 10.3 Metformin dosing in CKD. Practice point Metformin in liver disease Lactic acidosis Contrast‐induced nephropathy and lactic acidosis Vitamin B12 deficiency AGENTS TO BE USED AFTER METFORMIN SULFONYLUREAS AND PRANDIAL GLUCOSE REGULATORS(MEGLITINIDES) Key practice points Mechanism of action Glycaemic efficiency and durability Effects on weight and hypoglycaemia Figure 10.4 Glycaemic control in the patients in the ADVANCE trial. Glycaemia is stablethroughout in all groups, with no evidence for glycaemic failure in those on gliclazide monotherapy. Practice point Practice point Box 10.2 Clinical characteristics of patients developing severe sulfonylurea‐relatedhypoglycaemia. Non‐glycaemic effects Drug interactions Meglitinides: repaglinide and nateglinide DRUGS ACTING ON THE INCRETIN SYSTEM DPP‐4 INHIBITORS (GLIPTINS) Glycaemic efficiency and durability Practice point Table 10.4 Dosing of DPP‐4 inhibitors (gliptins) in renal impairment. Effects on weight and risk of hypoglycaemia Non‐glycaemic effects and adverse effects GLP-1-RECEPTOR AGONISTS Tableˇ10.5 GLP˙1˙receptor agonist drugs. Glycaemic efficiency and durability GLP‐1‐receptor agonists in long‐duration trials Practice point NICE Guidance (2010/2015–2016) Continuous subcutaneous exenatide Effects on weight and risk of hypoglycaemia Hypoglycaemia Practice point Cardiovascular outcomes in long‐term studies of patients with establishedvascular disease Practice point Side effects Table 10.6 Clinical characteristics of patients recruited into long‐term cardiovascular outcomestudies with GLP‐1‐receptor agonists liraglutide (LEADER), semaglutide (SUSTAIN‐6),and exenatide (ELIXA), and the SGLT2‐inhibitor empagliflozin (EMPA REG OUTCOME). Pancreatic SGLT2 INHIBITORS (‘FLOZINS’) Key practice points Glycaemic efficiency and durability Table 10.7 SGLT2 inhibitor drugs. Effects on weight and risk of hypoglycaemia Non‐glycaemic effects Practice point Side effects Genito‐urinary and bones Practice point Normoglycaemic diabetic ketoacidosis Practice point OTHER NON‐INSULIN AGENTS Acarbose: α‐glucosidase inhibitors Pramlintide and bromocriptine Colesevelam INSULIN TREATMENT 11 Hypertension, 315 12 Lipids, 359 13 Clinical aspects of the metabolic syndrome, 387 ch14 ch15 index