Riktlinjer Behandling av typ 2 diabetes Vxj 2019

Riktlinjer Behandling av typ 2 diabetes Växjö 2019 -02 -13 Maria Thunander Överläkare, med dr • Medicinkliniken, Centrallasarettet Växjö • Fo. U, Region Kronoberg • Institutionen för Klin Vetenskaper, Lunds Universitet 1

Clinical Inertia Vi väntar för länge med att intensifiera terapin! EASD 2018 MT 2

Att vänta påverkar möjlighet nå glykemiskt mål: EASD 2018 MT 3

Glukossänkande terapi T 2 D Sverige 2006 -2013 Svensk studie fr läkemedelsregistret

Aktuellt vid typ 2 diabetes • Framför allt: Nya behandlingsrekommendationer ! • 2018 -10 -05 • Gemensamma för EASD och ADA • Europa och USA • Kommer när till Sverige? – dock redan relativt anpassade svenska RL • GLP 1 -RA och SGLT-2 rek FÖRE SU och insulin 5

The 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. ” 6

Management 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 life • • • jointly produced and presented by EASD and ADA produced 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. 7

Nya behandlingsriktlinjer för Typ 2 diabetes Gränsövergång • Metformin fortfarande förstahandsval. • Första injektionsläkemedel bör ej vara insulin, utan GLP 1 -RA • Andrahandsval utifrån patientens situation och behov • Njurfunktion, hjärta, hypoglykemirisk, vikt, preferenser, förmåga • SU endast om ekonomi är viktig fråga (”ej i Europa och Canada”) 8

Management 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. - Mat • All 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 substitution • Increasing physical activity improves glycaemic control and should be encouraged in all people with type 2 diabetes. EASD 2018 MT 9

Decision cycle for patient-centered glycaemic management in type 2 diabetes EASD 2018 MT 10

Glucose-lowering medication in type 2 diabetes: overall approach EASD 2018 MT 11

Management 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, SGLT 2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit are recommended as part of glycaemic management. EASD 2018 MT 12

T 2 D and Established Atherosclerotic Cardiovascular disease (ASCVD) or Chronic Kidney Disease (CKD) EASD 2018 MT 13

Management 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 SGLT 2 inhibitors based on EMPA-REG OUTCOME. EASD 2018 MT 14

Management 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, SGLT 2 inhibitors are recommended. • For patients with type 2 diabetes and CKD, with or without CVD, consider the use of an SGLT 2 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 e. GFR of 30– 60 mlmin− 1[1. 73 m]− 2 were included in EMPA-REG OUTCOME, CANVAS, LEADER and SUSTAIN 6. An important finding in the studies was reduction of the primary ASCVD outcome even among participants with stage 3 CKD (e. GFR 30– 60 ml min− 1 [1. 73 m]− 2). For SGLT 2 inhibitors, this contrasts with the glucose-lowering effect, which diminishes with declining e. GFR. EASD 2018 MT 15

Minimize weight gain or promote weight loss EASD 2018 MT 16

Management 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/m 2 (BMI ≥ 37. 5 kg/m 2 in people of Asian ancestry) or • (2) a BMI of 35. 0– 39. 9 kg/m 2 (32. 5– 37. 4 kg/m 2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable non-surgical methods. EASD 2018 MT 17

Management 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 MT 18

Minimera hypoglykemi EASD 2018 MT 19

Intensifiering av injektions-terapi EASD 2018 MT 20

Tabletter i kombination med injektionsterapi EASD 2018 MT 21

Management 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, SGLT 2 inhibitors or prandial insulin. • Access, treatment cost and insurance coverage should all be considered when selecting glucose-lowering medications. EASD 2018 MT 22

Om kostnad är avgörande EASD 2018 MT 23

Management 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 MT 24

Läkartidningen 2018 Nyström och Nathanson

Kronoberg , primärvård, Typ 2 Okt 2018 26