EL DR MENDOZA HACE UNA DISERTACION MAGISTRAL SOBRE EL MANEJO ACTUAL DE LA DIABETES Y LA FISIOLOGIA DE LAS INCRETINAS.

1. www.who.int/chp

2. January 18, 2007
Expanding Priorities—Confronting Chronic
Disease in Countries with Low Income
Gerard Anderson and Edward Chu argue that international
health organizations need to greatly expand their efforts to
prevent and treat noncommunicable chronic diseases.

4. January 18, 2007
Obesity and Diabetes in the Developing
World — A Growing Challenge
Propelling an upsurge in cases of diabetes and hypertension is the
growing prevalence of overweight and obesity. Drs. Parvez Hossain,
Bisher Kawar, and Meguid El Nahas write that preventing obesity,
diabetes, and hypertension will require fundamental social and
political changes.

8. 8

9. 07/15/2010
Dr. Enrique Mendoza

10. 07/15/2010
Dr. Enrique Mendoza

13. Figure 1—Disorders of glycemia: etiologic types and stages. ∗Even after presenting in ketoacidosis, these
patients can briefly return to normoglycemia without requiring continuous therapy (i.e., ―honeymoon‖
remission); ∗∗in rare instances, patients in these categories (e.g., Vacor toxicity, type 1 diabetes presenting in
pregnancy) may require insulin for survival.

20. DCCT
Intensive Insulin Treatment in Type 1 Diabetes
11
10 Conventional therapy
Median HbA1c (%)
9
8
7
Intensive therapy
6 Normal
range
5
0 1 2 3 4 5 6 7 8 9 10
Study Year
The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986, with permission.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

21. DCCT
Microvascular Risk Reduction With Intensive Treatment
Reduction in
Complication Relative Risk
Retinopathy 63%
Nephropathy 54%
Neuropathy 60%
Data from the Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

22. DCCT
Relationship of HbA1c to Risk of Microvascular Complications
15 Retinopathy
13 Nephropathy
Neuropathy
11
Microalbuminuria
Relative Risk
9
7
5
3
1
6 7 8 9 10 11 12
HbA1c (%)
Skyler. Endocrinol Metab Clin. 1996;25:243-254, with permission.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

26. UKPDS
Blood Glucose Control Study:
Aims
• To determine whether improved glycemic control will
prevent clinical complications
• To determine whether treatment with a sulfonylurea,
insulin, or metformin has specific advantages or
disadvantages
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

27. UKPDS
Effect of Treatment on HbA1c
9 Conventional
(10-y cohort)
Intensive
(10-y cohort)
Median HbA1c (%)
8
ADA action Conventional
(all patients)
Intensive
7 (all patients)
ADA goal
6 6.2% upper limit of normal range
0
0 3 6 9 12 15
Time From Randomization (y)
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853, with permission.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

28. UKPDS
Risk Reduction of Microvascular Complications
30
Conventional
Intensive
% of Patients With an Event
Intensive policy group
20 25% overall risk reduction
P =.0099
10
0
0 3 6 9 12 15
Time From Randomization (y)
UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853, with permission.
07/15/2010 Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.
©1999,
Dr. Enrique Mendoza

30. 07/15/2010
Dr. Enrique Mendoza

46. Volume 359:1577-1589 October 9, 2008 Number 15
10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes
Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R.
Matthews, F.R.C.P., and H. Andrew W. Neil, F.R.C.P.

47. Volume 359:1577-1589 October 9, 2008 Number 15
10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes
Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R.
Matthews, F.R.C.P., and H. Andrew W. Neil, F.R.C.P.

48. Background During the United Kingdom Prospective
Diabetes Study (UKPDS), patients with type 2 diabetes
mellitus who received intensive glucose therapy had a
lower risk of microvascular complications than did those
receiving conventional dietary therapy. We conducted
post-trial monitoring to determine whether this improved
glucose control persisted and whether such therapy had
a long-term effect on macrovascular outcomes.

49. Methods Of 5102 patients with newly diagnosed type 2
diabetes, 4209 were randomly assigned to receive either
conventional therapy (dietary restriction) or intensive therapy
(either sulfonylurea or insulin or, in overweight patients,
metformin) for glucose control. In post-trial monitoring, 3277
patients were asked to attend annual UKPDS clinics for 5
years, but no attempts were made to maintain their previously
assigned therapies. Annual questionnaires were used to follow
patients who were unable to attend the clinics, and all patients
in years 6 to 10 were assessed through questionnaires. We
examined seven prespecified aggregate clinical outcomes from
the UKPDS on an intention-to-treat basis, according to
previous randomization categories.

50. Results Between-group differences in glycated
hemoglobin levels were lost after the first year. In the
sulfonylurea–insulin group, relative reductions in risk
persisted at 10 years for any diabetes-related end point
(9%, P=0.04) and microvascular disease
(24%, P=0.001), and risk reductions for myocardial
infarction (15%, P=0.01) and death from any cause
(13%, P=0.007) emerged over time, as more events
occurred. In the metformin group, significant risk reductions
persisted for any diabetes-related end point
(21%, P=0.01), myocardial infarction (33%, P=0.005), and
death from any cause (27%, P=0.002).

51. Conclusions Despite an early loss of glycemic
differences, a continued reduction in microvascular risk and
emergent risk reductions for myocardial infarction and
death from any cause were observed during 10 years of
post-trial follow-up. A continued benefit after metformin
therapy was evident among overweight patients. (UKPDS
80; Current Controlled Trials number, ISRCTN75451837

52. Volume 359:1618-1620 October 9, 2008 Number 15
UKPDS and the Legacy Effect
John Chalmers, M.D., Ph.D., and Mark E. Cooper, M.D., Ph.D.

53. The United Kingdom Prospective Diabetes Study (UKPDS)
continues to produce important evidence concerning the
evolution of type 2 diabetes and its management. Two studies
published in this issue of the Journal provide some answers to
two questions of fundamental importance to patients with
diabetes and to physicians alike. In one article, Holman et al.
(UKPDS 80)1 provide data that confirm a so-called legacy
effect associated with intensive glucose control in patients
with type 2 diabetes, long after the cessation of randomized
intervention. This finding provides a fitting parallel to the
observations of the Diabetes Control and Complications
Trial/Epidemiology of Diabetes…

54. Volume 358:580-591 February 7, 2008 Number 6
Effect of a Multifactorial Intervention on Mortality in
Type 2 Diabetes
Peter Gæde, M.D., D.M.Sc., Henrik Lund-Andersen, M.D., D.M.Sc., Hans-Henrik
Parving, M.D., D.M.Sc., and Oluf Pedersen, M.D., D.M.Sc.

55. Background Intensified multifactorial intervention — with tight
glucose regulation and the use of renin–angiotensin system
blockers, aspirin, and lipid-lowering agents — has been shown
to reduce the risk of nonfatal cardiovascular disease among
patients with type 2 diabetes mellitus and microalbuminuria. We
evaluated whether this approach would have an effect on the
rates of death from any cause and from cardiovascular causes

56. Methods In the Steno-2 Study, we randomly assigned 160
patients with type 2 diabetes and persistent microalbuminuria to
receive either intensive therapy or conventional therapy; the
mean treatment period was 7.8 years. Patients were
subsequently followed observationally for a mean of 5.5
years, until December 31, 2006. The primary end point at 13.3
years of follow-up was the time to death from any cause.

57. Results Twenty-four patients in the intensive-therapy group
died, as compared with 40 in the conventional-therapy group
(hazard ratio, 0.54; 95% confidence interval [CI], 0.32 to 0.89;
P=0.02). Intensive therapy was associated with a lower risk of death
from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to
0.94; P=0.04) and of cardiovascular events (hazard ratio, 0.41; 95%
CI, 0.25 to 0.67; P<0.001). One patient in the intensive-therapy
group had progression to end-stage renal disease, as compared
with six patients in the conventional-therapy group (P=0.04). Fewer
patients in the intensive-therapy group required retinal
photocoagulation (relative risk, 0.45; 95% CI, 0.23 to 0.86; P=0.02).
Few major side effects were reported.

58. Conclusions In at-risk patients with type 2 diabetes,
intensive intervention with multiple drug combinations
and behavior modification had sustained beneficial
effects with respect to vascular complications and on
rates of death from any cause and from cardiovascular
causes.

64. Treatment Options

65. Lifestyle interventions
The major environmental factors that increase the risk of type 2
diabetes are overnutrition and a sedentary lifestyle, with
consequent overweight and obesity (39,40). Not
surprisingly, interventions that reverse or improve these factors have
been demonstrated to have a beneficial effect on control of glycemia
in established type 2 diabetes (41). Unfortunately, the high rate of
weight regain has limited the role of lifestyle interventions as an
effective means of controlling glycemia in the long term. The most
convincing long-term data indicating that weight loss effectively
lowers glycemia have been generated in the follow-up of type 2
diabetic patients who have had bariatric surgery. In this setting, with
a mean sustained weight loss of 20 kg, diabetes is virtually
eliminated (42– 45).

72. FACTORES DE RIESGO

74. Pharmacological agents

146. The consensus report concluded that
―Although still limited, early evidence
suggests that metformin is associated
with a lower risk of cancer and that

147. exogenous insulin is associated with an
increased cancer risk. Further research is
needed to clarify these issues and
evaluate if insulin glargine is more
strongly associated with cancer risk
compared with other insulins.‖

148. Emerging evidence suggests that
metformin has a range of biological
mechanisms that reduce tumour growth
beyond its ability to increase
insulin sensitivity. The enhanced binding
of insulin glargine to IGF-I receptors is a
theoretical concern, but might not translate
to an actual increase in cancer risk.

149. Summary
The guidelines and treatment algorithm presented here emphasize
the following:
● Achievement and maintenance of near
normoglycaemia (A1C 7.0%)
● Initial therapy with lifestyle intervention
and metformin
● Rapid addition of medications, and
transition to new regimens, when target
glycemic goals are not achieved or sustained
● Early addition of insulin therapy in patients
who do not meet target goals

150. A1C 6.5 – 7.5%** A1C 7.6 – 9.0% A1C > 9.0%
Drug Naive Under Treatment
Symptoms No Symptoms
Monotherapy Dual Therapy 8
MET † DPP4 1 GLP-1 TZD 2 AGI 3
GLP-1 or DPP4 1 GLP-1
or TZD 2 INSULIN or DPP4 1 SU 7 INSULIN
2 - 3 Mos.*** MET +
Other MET + TZD 2 Other
SU or Glinide 4,5 Agent(s) 6 Agent(s) 6
Dual Therapy
GLP-1
TZD 2
GLP-1 or DPP4 1 2 - 3 Mos.*** or DPP4 1
MET + TZD 2
Triple Therapy 9 * May not be appropriate for all patients
Glinide or SU 5 ** For patients with diabetes and A1C < 6.5%,
GLP-1 pharmacologic Rx may be considered
+ TZD 2
TZD + GLP-1 or DPP4 1 or DPP4 1
*** If A1C goal not achieved safely
† Preferred initial agent
Colesevelam MET + 1 DPP4 if  PPG and  FPG or GLP-1 if  PPG
MET + GLP-1 AACE/ACE Algorithm for Glycemic
3 or DPP4 1 Control Committee 2 TZD if metabolic syndrome and/or
AGI + SU 7
*** Cochairpersons: nonalcoholic fatty liver disease (NAFLD)
2 - 3 Mos. TZD 2 Helena W. Rodbard, MD, FACP, MACE 3 AGI if  PPG
Paul S. Jellinger, MD, MACE
Triple Therapy 4 Glinide if  PPG or SU if  FPG
2 - 3 Mos.*** Zachary T. Bloomgarden, MD, FACE
Jaime A. Davidson, MD, FACP, MACE
5 Low-dose secretagogue recommended
TZD 2 Daniel Einhorn, MD, FACP, FACE
6 a) Discontinue insulin secretagogue
MET + with multidose insulin
Alan J. Garber, MD, PhD, FACE b) Can use pramlintide with prandial insulin
GLP-1 or + James R. Gavin III, MD, PhD
7 Decrease secretagogue by 50% when added
DPP4 1 Glinide or SU 4,7 INSULIN George Grunberger, MD, FACP, FACE
to GLP-1 or DPP-4
*** Yehuda Handelsman, MD, FACP, FACE
2 - 3 Mos. Other Edward S. Horton, MD, FACE 8 If A1C < 8.5%, combination Rx with agents
Agent(s) 6 Harold Lebovitz, MD, FACE that cause hypoglycemia should be used
Philip Levy, MD, MACE with caution
INSULIN Etie S. Moghissi, MD, FACP, FACE 9 If A1C > 8.5%, in patients on Dual Therapy,
Stanley S. Schwartz, MD, FACE insulin should be considered
Other
Agent(s) 6
Available at www.aace.com/pub
© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

151. LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM
A1C 6.5 – 7.5%** FOR GLYCEMIC CONTROL
Monotherapy
MET † DPP4 1 GLP-1 TZD 2 AGI 3
2 - 3 Mos.***
Dual Therapy
GLP-1 or DPP4 1
MET + TZD 2
Glinide or SU 5
TZD + GLP-1 or DPP4 1
Colesevelam *** If A1C goal not achieved safely
MET +
3 † Preferred initial agent
AGI
1 DPP4 if  PPG and  FPG or GLP-1
*** if  PPG
2 - 3 Mos. 2 TZD if metabolic syndrome and/or
Triple Therapy nonalcoholic fatty liver disease
(NAFLD)
3 AGI if  PPG
TZD 2
MET + 4 Glinide if  PPG or SU if  FPG
GLP-1 or + 5 Low-dose secretagogue
Glinide or SU 4,7 recommended
DPP4 1
6 a) Discontinue insulin
2 - 3 Mos.*** secretagogue with multidose
insulin
b) Can use pramlintide with
INSULIN prandial insulin
7 Decrease secretagogue by 50%
Other
when added to GLP-1 or DPP-4
Agent(s) 6
Available at www.aace.com/pub
© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

152. LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM
A1C 7.6 – 9.0% FOR GLYCEMIC CONTROL
Dual Therapy 8
GLP-1 or DPP4 1
MET + or TZD 2
SU or Glinide 4,5
2 - 3 Mos.***
*** If A1C goal not achieved safely
Triple Therapy 9 † Preferred initial agent
1 DPP4 if  PPG and  FPG or GLP-1
GLP-1 if  PPG
+ TZD 2 2 TZD if metabolic syndrome and/or
or DPP4 1
nonalcoholic fatty liver disease
MET + GLP-1 (NAFLD)
4 Glinide if  PPG or SU if  FPG
or DPP4 1 + SU 7
5 Low-dose secretagogue
TZD 2 recommended
6 a) Discontinue insulin
*** secretagogue with multidose
2 - 3 Mos. insulin
b) Can use pramlintide with
prandial insulin
7 Decrease secretagogue by 50%
INSULIN when added to GLP-1 or DPP-4
8 If A1C < 8.5%, combination Rx with
Other agents that cause hypoglycemia
Agent(s) 6 should be used with caution
9 If A1C > 8.5%, in patients on Dual
Therapy, insulin should be
considered
Available at www.aace.com/pub
© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

153. LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM
A1C > 9.0% FOR GLYCEMIC CONTROL
Drug Naive Under Treatment
Symptoms No Symptoms
GLP-1 or DPP4 1
INSULIN SU 7 INSULIN
Other MET + TZD 2 Other
Agent(s) 6 Agent(s) 6
GLP-1 or DPP4 1 TZD 2
1 DPP4 if  PPG and  FPG or GLP-1
if  PPG
2 TZD if metabolic syndrome and/or
nonalcoholic fatty liver disease
(NAFLD)
6 a) Discontinue insulin
secretagogue with multidose
insulin
b) Can use pramlintide with
prandial insulin
7 Decrease secretagogue by 50%
when added to GLP-1 or DPP-4
Available at www.aace.com/pub
© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

157. Rosiglitazone
and IHD Risk

158. Pioglitazone and
IHD Risk

159. Pioglitazone vs
Rosiglitazone and
IHD Risk

160. Thiazolidinediones
and Heart Failure
Risk

161. Recommendations
to Reduce Vascular
Disease in Patients
with Type 2
Diabetes Mellitus