DIABETES MELLITUS Gd T de Enfermedades Cardiovasculares SNa

DIABETES MELLITUS Gd. T de Enfermedades Cardiovasculares SNa. MFAP Enero 2013 1

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MANEJO DE LA HIPERGLUCEMIA – ENFOQUE CENTRADO EN EL PACIENTE Nota: Según la ADA el objetivo glucémico del paciente con DM 2 es Hb. A 1 c <7, 0% (<53 mmol/mol) Inzucchi et al. Diabetología 2012; 55: 1577 -96 DM 2=diabetes mellitus tipo 2

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DM 2=diabetes mellitus tipo 2; GI=gastrointestinal; IC=insuficiencia cardiaca; FO=fractura ósea; ADOs= Antidiabéticos orales Inzucchi et al. Diabetología 2012; 55: 1577

DM 2=diabetes mellitus tipo 2; GI=gastrointestinal; IC=insuficiencia cardiaca; FO=fractura ósea; ADOs= Antidiabéticos orales Inzucchi et al. Diabetología 2012; 55: 1577

DM 2=diabetes mellitus tipo 2; GI=gastrointestinal; IC=insuficiencia cardiaca; FO=fractura ósea; ADOs= Antidiabéticos orales Inzucchi et al. Diabetología 2012; 55: 1577

DM 2=diabetes mellitus tipo 2; GI=gastrointestinal; IC=insuficiencia cardiaca; FO=fractura ósea; ADOs= Antidiabéticos orales Inzucchi et al. Diabetología 2012; 55: 1577

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ESTRATEGIAS SECUENCIALES DE INSULINA EN LA DIABETES MELLITUS TIPO 2 Inzucchi et al. Diabetología 2012; 55: 157796

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Recomendaciones Grado A: • Aspirina en prevención secundaria. El tratamiento con aspirina a dosis bajas se debe utilizar en todos los pacientes diagnosticados de enfermedad coronaria o ictus o accidente isquémico transitorio de forma indefinida. • Clopidogrel como alternativa a la aspirina. El tratamiento con clopidogrel está indicado en casos de alergia o intolerancia a la aspirina. • Doble antiagregación en el síndrome coronario agudo. La doble antiagregación (aspirina y clopidogrel) se debe utilizar después de un síndrome coronario agudo sin elevación segmento ST o revascularización coronaria e implantación de stent durante un año. Brotons Cuixart et al. Evidencias del tratamiento antiagregante. Recomendaciones 15 PAPPS. Aten Primaria. 2012; 44(12): 734 ---736

Grado C: • Aspirina en prevención primaria. No se recomienda el uso de aspirina de forma sistemática en prevención primaria de la enfermedad cardiovascular, en diabéticos o en pacientes asintomáticos con un índice tobillo-brazo <0, 95. De forma individualizada y valorando la preferencia del paciente se podría valorar su utilización si el riesgo SCORE ≥ 10%. • Grado D: • Doble antiagregación en la enfermedad cardiovascular crónica y estable. La doble antiagregación no es más eficaz que la aspirina sola y no está indicada en los pacientes con enfermedad cardiovascular crónica y estable, ya sea coronaria o de otra localización. • 16

EXECUTIVE SUMMARY: STANDARDS OF MEDICAL CARE IN DIABETES -2013 Antiplatelet agents Consider aspirin therapy (75– 162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10 -year risk >10%). This includes most men aged >50 years or women aged >60 years who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (C) Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10 -year CVD risk<5%, such as in men aged<50 years and women aged <60 years with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits. (C) In patients in these age-groups with multiple other risk factors (e. g. , 10 -year risk 5– 10%), clinical judgment is required. (E) Use aspirin therapy (75– 162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD. (A) For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. (B) Combination therapy with aspirin (75– 162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome. (B) DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 17

DYSLIPIDEMIA/LIPID MANAGEMENT Treatment recommendations and goals Lifestyle modification focusing on the reduction of Dyslipidemia/lipid Management fat, trans fat, and cholesterol intake; increase of n-3 fatty acids, viscous fiber and plant stanols/sterols; weight loss (if indicated); and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. (A) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: -with overt CVD (A) -without CVD who are over the age of 40 years and have one or more other CVD risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (A) For lower-risk patients than the above (e. g. , without overt CVD and under the age of 40 years), statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains above 100 mg/d. L or in those with multiple CVD risk factors. (C) In individuals without overt CVD, the goal is LDL cholesterol <100 mg/d. L (2. 6 mmol/L). (B) In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/d. L (1. 8 mmol/L), using a high dose of a statin, is an option. (B) If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 30– 40% from baseline is an alternative therapeutic goal. (B) Triglyceride levels <150 mg/d. L (1. 7 mmol/L) and HDL cholesterol >40 mg/d. L (1. 0 mmol/L) in men and >50 mg/d. L (1. 3 mmol/L) in women are desirable (C). However, LDL cholesterol–targeted statin therapy remains the preferred strategy. (A) Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not generally recommended. (A) Statin therapy is contraindicated in pregnancy. (B) DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 18

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