งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Update on DM treatment Thongchai Pratipanawatr. เราทำไมต้องรักษาโรคเบาหวาน ?

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งานนำเสนอเรื่อง: "Update on DM treatment Thongchai Pratipanawatr. เราทำไมต้องรักษาโรคเบาหวาน ?"— ใบสำเนางานนำเสนอ:

1 Update on DM treatment Thongchai Pratipanawatr

2 เราทำไมต้องรักษาโรคเบาหวาน ?

3 1. ให้ผู้ป่วยอายุยืนยาว 2. ให้ผู้ป่วยไม่เจ็บไม่ป่วย 3. ให้ผู้ป่วยให้ผู้ป่วยมีความสุข

4 The impact of type 2 diabetes

5 50% of type 2 diabetes patients have complications at the time of diagnosis Retinopathy, glaucoma or cataracts Nephropathy Neuropathy MICROVASCULAR MACROVASCULAR Cerebrovascular disease Coronary heart disease Peripheral vascular disease UKPDS Group. UKPDS 33. Lancet 1998; 352:837–853.

6 Thai Diabetic Registry Project: Diabetic complications J Med Assoc Thai 2006; 89(Suppl 1): S1-9

7 National Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995. Atherosclerosis in Diabetes ~80% of all diabetic mortality –75% from coronary atherosclerosis –25% from cerebral or peripheral vascular disease >75% of all hospitalizations for diabetic complications

8 Causes of death in Thai diabetes pts

9 American Diabetes Association. Diabetes Care 2004; 27 (Suppl. 1):S15–S35. Current ADA treatment targets HbA 1c < 7% Blood pressure < 130/80 mmHg LDL-cholesterol < 100 mg/dl (2.6 mmol/l) HDL-cholesterol Men> 40 mg/dl (1.1 mmol/l) Women > 50 mg/dl (1.3 mmol/l) Triglycerides < 150 mg/dl (1.7 mmol/l) Aspirin ASA mg/day Others

10 Thai Diabetic Registry Project: Metabolic targets 2003 J Med Assoc Thai 2006; 89(Suppl 1): S1-9

11 American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54. Dyslipidemia/lipid management 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 and have one or more other CVD risk factors. (A)

12 American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54. Dyslipidemia/lipid management For lower-risk patients than those specified above (e.g., without overt CVD and under the age of 40). Statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains 100 mg/dl or in those with multiple CVD risk factors (E).

13 American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54. Dyslipidemia/lipid management In individuals without overt CVD, the primary goal is an LDL cholesterol 100 mg/dl. (A) In individuals with overt CVD, a lower LDL cholesterol goal of 70 mg/dl. (E) If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 40% from baseline is an alternative therapeutic goal. (A)

14 Percentage of Thai diabetic patients who may need lipid lowering agents Patient*NCEP III target New 2005 ADA lipid target AllAge >40 No need for lipid lowering agents Need for lipid lowering agents

15 Glycemic control

16 A1C<7% Prepandial glucose Post pandial<180

17

18

19 Tier 1:Glucose lowering intervensions

20 Tier 2:Glucose lowering intervensions

21 Other interventions

22 Tier 1: Well-validated therapies

23 Tier 2: Less well-validated therapies

24 Recent diabetic trials 1. UKPDS 10 yrs Follow up –Glycemic control and macrovascular complication 2. ADVANCE –Tight glycemic control (HbA1c<6.5) reduce complications Microvascular Macrovascular 3.ACCORD –Tight glycemic control (HbA1c<6.0) reduce complications Microvascular Macrovascular N Engl J Med 2008;359: N Engl J Med 2008;358: N Engl J Med 2008;358:

25 Summerize the studies on glycemic control and complications UKPDS 1 ADVANCE 2 ACCORD 3 OnsetNewly810 Prior CVD03235 Target FPG(mg/%) 108vs270 HbA1c(%) 6.5 vs 7-8 HbA1c(%) 6.0 vs 7-8 F/U(yr) N Engl J Med 2008;359: N Engl J Med 2008;358: N Engl J Med 2008;358:

26 Summerize the studies on glycemic control and complications UKPDS 1 ADVANCE 2 ACCORD 3 HbA1c (%)6.4 vs vs 7.5 MicrovasBetter Same CVDBetterSameWorst Sudden death N Engl J Med 2008;359: N Engl J Med 2008;358: N Engl J Med 2008;358:

27 Glycemic control and complications 1. UKPDS 10 yrs Follow up –Microvascular(~6yrs)Yes –MacrovascularYes 2. ADVANCE (HbA1c<6.5) F/U 5 year –MicrovascularYes –MacrovascularNo 3.ACCORD (HbA1c<6.0) F/U 3.4 yrs –MicrovascularYes –MacrovascularNo(worst) N Engl J Med 2008;359: N Engl J Med 2008;358: N Engl J Med 2008;358:

28 A1C Goals For Clinical Practice A1C (%) ~70% have A1C > 7 % Thailand Diabetic Registry. < 7 < 6.5 ADA Target ADVANCE Target ADA 2006: “The HbA 1c goal for the individual patient is an HbA 1c as close to normal (<6%) as possible without significant hypoglycemia” ACCORD Target

29 Management for type 1 diabetes

30 วิธีการใช้ยาฉีดอินสุลิน เบาหวานชนิดที่ 1 –Multiple insulin injection ( 4 injections/ day ) –Continuous insulin infusion pump เบาหวานชนิดที่ 2 –Mix and split ( 2 injections/ day ) or –Oral hypoglycemic agent + bedtime insulin

31

32 Hypertension control

33 What is BP optimal target? Answer: BP<130/80 mmHg

34 จะเลือกใช้ยาลดความดันอย่างไร ?

35 ACE inhibitor If fail Add Thiazide diuretic

36 จะเลือกใช้ยาลดความดันอย่างไร ? ACE inhibitor + Thiazide diuretic If fail Add B-blocker or Ca blocker

37 จะเลือกใช้ยาลดความดันอย่างไร ? ไม่สามารถใช้ ACE inhibitor เช่น ไอ Thiazide diuretic or A II blocker

38 Management of dyslipidemia

39 Lipid treatment (LDL target) Without CVD –Age<40 LDL <100 mg/dl –Age>40 Cholesterol ≥135: Start Statin –Aim 30-40% reduction and LDL<100

40 Lipid treatment (LDL target) With CVD –Cholesterol ≥135: Start Statin –Aim 30-40% reduction and LDL<70

41 Percentage of Thai diabetic patients who may need lipid lowering agents Patient*NCEP III target New 2005 ADA lipid target AllAge >40 No need for lipid lowering agents Need for lipid lowering agents

42 Other dyslipidemia TG >400 mg/dl : Fibrate HDL<40 mg/dl – Primary prevention: no medication – secondary prevention: Fibrate

43 Anti-platelet agents

44 ASA( mg/day) A secondary prevention A primary prevention –Age>40 year or –Additional risk factor F Hx, HT, smoking, dyslipidemia or albuminurea Not recommended for age<21, no data for age<30.

45 Thank you


ดาวน์โหลด ppt Update on DM treatment Thongchai Pratipanawatr. เราทำไมต้องรักษาโรคเบาหวาน ?

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