Diabetes Mellitus: een update Dr. Paul Van Crombrugge OLV Ziekenhuis, Aalst-Asse-Ninove olv 16 maart 2010
Diagnose? HbA1c? Hoe HbA1c rapporteren? Follow-up? Rol van labo? Behandeling? DPP4I? ICU? BG monitoring? Zorgtrajecten? Zwangerschapsdiabetes? olv
DIAGNOSE?
GLOBAL PROJECTIONS OF DIABETES (IN MILLIONS) 2003-2025 North America 25.0 39.7 59% 10.4 19.7 88% South and Central America 38.2 44.2 16% Africa 13.6 26.9 98% Europe Middle East WORLD 2003 = 189 million 2025 = 324 million Increase 72% 18.2 35.9 97% Asia 81.8 156.1 91% 1.1 1.7 59% Oceania
Frequency Distribution of 2-hour plasma glucose 4000 3000 2000 1000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2-hour plasma glucose (mmol/l)
Pima Prevalence of Retinopathy Retinopathy (%) 15 10 5 0 FPG 2hPG HbA1c FPG (mg/dl) 2hPG (mg/dl) HbA1c (%) 42-34- 3.3-87- 75-4.9-90- 86-5.1-93- 94-5.2-96- 102-5.4-98- 112-5.5-101- 120-5.6-104- 133-5.7-109- 154-5.9-120- 195-6.2-
Classification of Glucose Tolerance FPG 126 110 Impaired Fasting Glucose (IFG) Normal IGT Diabetes 2h PG 140 200
Proposed ADA Criteria FPG 126 100 Impaired Fasting Glucose (IFG) Normal IGT Diabetes 2h PG 140 200
olv WHO blijft 110 mg/dl cfr DECODE studie
olv Diabetes Care, 2009
olv EQA HbA1c Organised since 2002 by the IPH Scheme: 24 samples containing known concentrations of HbA1c allowing to estimate the bias from the DCCT value, have to be evaluated every two weeks (accuracy) About 20 samples are paired; so the reproducibility (%CV) can be calculated Linearity (correlation of results over the range 5%HbA1c 11%HbA1c can be calculated) Some samples contain carbamylated Hb, abnormal hemoglobin, or aged samples to test the ability of the used methods to detect interferences.
olv Methods used Worldwide: 30 methods are used based on the following principles: HPLC-methods (ion exchange/affinity) Immuno-assay methods (Electrophoretic methods) Methods based on different principles also measure (slightly) different glycated products Belgium: about 15 methods by 214 laboratories
olv Equipment used in 2006
olv Evolution 2002 2006 (1)
olv Evolution 2002 2006 (2)
olv Evolution 2002 2006 (2)
Evolution of equipment 46% of the laboratories changed their method! Decreased use Increased use
olv Results EQA 2007
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But: IFG, IGT Risk for DM? Risk for microvasc complications? Risk for macrovasc complications? olv
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HOE HBA1C RAPPORTEREN?
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olv Diabetes Care 2007
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Huidige situatie UK USA Netherlands Belgium??? werkgroep bezig olv
FOLLOW-UP? ROL VAN LABO?
Clinical Impact of Diabetes Mellitus Diabetes A 2- to 4- fold increase in cardiovascular mortality The leading cause of new cases of end stage renal disease The leading cause of new cases of blindness in workingaged adults The leading cause of nontraumatic lower extremity amputations olv www.hypertensiononline.org
principes follow-up DOEL: quality of life! vermijden complicaties zo normaal mogelijk leven leiden olv RISIKO management meten is weten plan actie meten reageer, enz meer dan bloedglucose alleen!!!
recente BG regeling safety medicatie chronische complicaties CV risico Microangiopathie» Retinopathie» Nefropathie Macroangiopathie Neuropathie Voet olv varia
recente BG regeling: safety medicatie: chronische complicaties: CV risico: HbA1c crea, lever amylase CK, electrolieten crea, µau lipiden Varia: urine olv
Relationship between endpoints and HbA 1c or BP in the UKPDS 80 Incidence (1000-pt-yr -1 ) Rate ± 95% CI 60 Microvascular endpoints Myocardial infarction 40 HbA1c HbA1c 20 BP BP 0 5.0 7.0 9.0 11.0 110 130 150 170 HbA1c (%) or systolic BP (mmhg) 5.0 7.0 9.0 11.0 110 130 150 170 HbA1c (%) or systolic BP (mmhg)
Microvascular Disease Hazard Ratio (photocoagulation, vitreous haemorrhage, renal failure) Intensive (SU/Ins) vs. Conventional glucose control HR (95%CI) olv
olv Lancet, Published Online January 27, 2010 DOI:10.1016/S0140-6736(09)61969-3
???? C-peptide? SK testen? Coeliakie? Hemochromatosis? Pancreaslijden? AI testen pancreas (BDR) olv
BEHANDELING DPP4I
HbA1c (%) Progressive Hyperglycaemia on Monotherapy in Type 2 Diabetes 10 9 8 Conventional Glyburide Metformin 7 6 0 0 2 4 6 8 10 Years from randomisation UKPDS 34. Lancet 1998; 352:854 65
-cell function (% ) Progressive decline of -cell 100 80 60 function in UKPDS????? 40 20 0 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 Years Adapted from UK Prospective Diabetes Study (UKPDS) Group. Diabetes 1995
klasse generische naam producten biguaniden metformine Glucophage, Metformax, Metformine gliniden repaglinide NovoNorm sulphonylurea gliclazide Diamicron, Gliclazide glipizide Glibenese, Minidiab gliquidone Glurenorm glibenclamide Bevoren, Daonil, Euglucon gliclazide L.A. Uni-diamicron glimepiride Amarylle glucosidase remmers acarbose Glucobay glitazones pioglitazone Actos rosiglitazone Avandia GLP-1 analogen exenatide Byetta DPP-4 inhibitoren sitagliptine Januvia
secretagogen sensitizers insuli ne glucose onafh. secretie : - sulfonylurea - gliniden glucose afh. secretie : - DPP-4 inhibitoren - GLP-1 analogen gluco se sensitisering : - biguaniden - glitazones HYPO!!!
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Schematic Representation of the Pancreatic Beta Cell, Illustrating the Role of the ATP- Sensitive Potassium (KATP) Channel in Insulin Secretion Gloyn, A. L. et al. N Engl J Med 2004;350:1838-1849
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Thiazolidinediones GLUT 4 Young Adipocytes Activation of PPAR Alters Expression of Specific Genes TZD PPAR RXR retinoic AGGTCA X AGGTCA gene sequence ppre
GLP-1 mimetica incretinomimetica (DPP4 inhibitor, gliptine GLP1 analoog, exenatide)
IR insulin (mu/l) IR insulin (mu/l) Venous plasma glucose (mmol/l) Venous plasma glucose (mmol/l) Incretine Effect Intravenous glucose (50g) Oral glucose (50 g) Healthy controls (n=8) Type 2 diabetes (n=14) 20 20 15 10 5 15 10 5 0 10 5 60 120 180 10 5 60 120 180 80 60 40 20 Normal incretin effect * * * * * * * 0 80 60 40 20 Diminished incretin effect * * * 0 0 10 5 60 120 180 10 5 60 120 180 *p 0.05 vs. respective value after oral load IR=immunoreactive 1986;29:46 52. Time (minutes) Time (minutes) Nauck M et al Diabetologia
Incretins Regulate Glucose Homeostasis Through Effects on Islet Ingestion of food GI tract Release of incretin gut hormones Active GLP-1 and GIP Cell Function Pancreas Beta cells Alpha cells Glucose dependent Insulin from beta cells (GLP-1 and GIP) Insulin increases peripheral glucose uptake Blood glucose control Glucagon from alpha cells (GLP-1) Glucose dependent Increased insulin and decreased glucagon reduce hepatic glucose output Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145:2653 2659; Zander M et al Lancet 2002;359:824 830; Ahrén B Curr Diab Rep 2003;3:365 372; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:1427 1483.
GAL/EUC-16-01/09-5309 GLP-1 en GIP Worden Aangemaakt en Vrijgegeven door de Darmen als Respons op Voedselinname L-Cell (ileum) ProGIP Proglucagon GLP-1 [7 37] GIP [1 42] GLP-1 [7 36 NH 2 ] K-Cell (jejunum) GIP=glucose-dependent insulinotropic peptide; GLP-1=glucagon-like peptide-1 Aangepast van Drucker DJ. Diabetes Care. 2003; 26: 2929 2940.
GLP-1: glucagon-like peptide-1 GIP: glucose dependent insulinotropic polypeptide Upon ingestion of food Stimulates glucose-dependent insulin secretion Suppresses glucagon secretion Slows gastric emptying GLP-1 is secreted from the L-cells in the intestine This in turn Reduces food intake Improves insulin sensitivity Long term effects demonstrated in animals Increases beta-cell mass and maintains beta-cell efficiency Drucker DJ. Curr Pharm Des 2001; 7:1399-1412 Drucker DJ. Mol Endocrinol 2003; 17:161-171
pmol/l pmol/l mmol/l Insulin and Glucagon Levels in Patients With Type 2 Diabetes Glucose 15.0 12.5 10.0 7.5 5.0 2.5 0 * * * * * * * 250 200 150 100 50 0 mg/dl Placebo GLP-1 *P <0.05 Patients with type 2 diabetes (N=10) Insulin 250 200 150 100 50 0 * * * * * * * * 40 30 20 10 0 mu/l When glucose levels approach normal values, insulin levels decrease. 20 20 Glucagon 15 10 5 0 30 15 * 10 * * * 5 Infusion 0 0 60 120 180 240 Minutes pmol/l When glucose levels approach normal values, glucagon levels rebound. Adapted from Nauck MA et al. Diabetologia. 1993;36:741 744. Copyright 1993 Springer-Verlag. 15
GLP-1 Preserved Morphology of Human Islet Cells In Vitro Control GLP-1 treated cells Day 1 Day 3 Islets treated with GLP-1 in culture were able to maintain their integrity for a longer period of time. Day 5 Adapted from Farilla L et al Endocrinology 2003;144:5149 5158.
metabolisme van GLP-1 Meal Intestinal GLP-1 release GLP-1 T ½ = 1-2 min!!! Active GLP-1 DPP-4 DPP-4 inhibitor GLP-1 inactive GLP-1 = glucagon-like peptide 1; DPP-4= dipeptidyl-peptidase 4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
metabolisme van GLP-1 Meal Intestinal GLP-1 release GLP-1 analoog Active GLP-1 DPP-4 DPP-4 inhibitor GLP-1 inactive GLP-1 = glucagon-like peptide 1; DPP-4= dipeptidyl-peptidase 4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
metabolisme van GLP-1 Meal Intestinal GLP-1 release GLP-1 analoog Active GLP-1 DPP-4 DPP-4 inhibitor GLP-1 inactive GLP-1 = glucagon-like peptide 1; DPP-4= dipeptidyl-peptidase 4 Adapted from Rothenberg P, et al. Diabetes. 2000;49(suppl 1):A39.
GLP-1 mimetica incretinomimetica (DPP4 inhibitor, gliptine)
DPP-4 inhibitoren (gliptines) sitagliptin : Januvia (MSD) vildagliptin: Galvus (Novartis)
HbA 1c (% ± SE) FPG (mmol/l) sitagliptin: 24-week Add-on Therapy to Metformin 8.2 HbA 1c 10.5 FPG 8.0 10.0 7.8 9.5 7.6 7.4 9.0 7.2 Placebo (n=224) Sitagliptin 100 mg (n=453) Sitagliptin 100 mg qd (n=454) 7.0 8.0 0 6 12 18 24 0 6 12 18 24 Weeks Weeks SE = standard error All-patients-as-treated population LSM between-group differences at week 24 (95% CI): in HbA 1C vs placebo = 0.65% [ 0.77, 0.53] (P<0.001); in FPG vs placebo = 1.4 mmol/l [ 1.7, 1.1] (P<0.001) To convert FPG from mmol/l to mg/dl divide by 0.05551 Copyright 2006 American Diabetes Association. From Diabetes Care, Vol. 29,2006; 2632 2637 Reprinted with permission from the American Diabetes Association. 8.5 Placebo (n=226)
GAL/EUC-16-01/09-5309 Gemiddelde HbA1c (%) Vildagliptine Toegevoegd aan Metformine: Reductie van HbA1c over 24 Weken Associatie met metformine (2.1 g dagelijks gemiddelde) PBO + met (n=130) 8.6 Vilda 50 mg 1x/dag + met (n=143) Vilda 50 mg 2x/dag + met (n=143) 8.4 8.2 8.0 7.8 * 7.6 0.7% vs PBO 7.4 1.1% vs PBO 7.2 * HbA1c=hemoglobine A1c; met=metformine; PBO=placebo; vilda=vildagliptine *P <0.001. Primair intention-to-treat populatie. Bosi E, et al. Diabetes Care 2007; 30: 890-895. 4 0 4 8 12 16 20 24 Tijd (weken van behandeling)
Change from baseline in HbA 1c (%) sitagliptin vs Sulfonylurea: 52-week Add-on to Metformin HbA1c 0.0-0.2-0.4-0.6-0.8-1.0-1.2-1.4-1.6-1.8-2.0 n=117 Baseline HbA 1C Category <7% 7 to <8% 8 to <9% 9% n=117 112 179 167 82 82 33 21-0.14-0.26-0.59 Sitagliptin b + metformin Sulfonylurea + metformin -0.53-1.11-1.13-1.76-1.68 a Specifically glipizide; b Sitagliptin (100 mg/day) with metformin ( 1500 mg/day); Per-protocol population Adapted from Nauck et al. Diabetes Obes Metab. 2007;9:194 205.
sitagliptin: 24-week Add-on Therapy to Metformin GI-related AEs Sitagliptin 100 mg (n=464) Placebo (n=237) n (%) n (%) Abdominal pain 10 (2.2) 9 (3.8) Diarrhea 12 (2.6) 6 (2.5) Nausea 6 (1.3) 2 (0.8) Vomiting 5 (1.1) 2 (0.8) All-patients-as-treated population GI = gastrointestinal Adapted from Charbonnel et al. Diabetes Care. 2006;29:2638 2643.
Body weight (kg ± SE) Incidence (%) sitagliptin vs Sulfonylurea: 52-week Add-on to Metformin weigth hypoglycemia 50 3 Sulfonylurea + metformin (n=416) 2 1 Sitagliptin 100 mg/day + metformin (n=389) 40 30 32% P<0.001 0 20-1 -2 10 5% -3 0 12 24 38 52 Weeks 0 Week 52 Sulfonylurea + metformin (n=584) Sitagliptin 100 mg/day + metformin (n=588) a Specifically glipizide; b All-patients-as-treated population. LS = least squares; LSM between-group difference at week 52 (95% CI): in body weight = 2.5 kg [ 3.1, 2.0] (P<0.001); LSM change from baseline at week 52: glipizide: +1.1 kg; sitagliptin: 1.5 kg (P<0.001) Adapted from Nauck et al. Diabetes Obes Metab. 2007;9:194 205.
Gemiddelde HbA1c (%) CI=confidence interval; HbA1c=hemoglobine A1c; NI=niet inferieur Per protocol populatie. Vildagliptine (n=1396); glimepiride (n=1393). Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157 166. GAL/EUC-16-01/09-5309 Vildagliptine: Even Doeltreffend als Glimepiride in Associatie m Metformine op 52 Weken Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride In Associatie met Metformine (~1.9 g dagelijks gemiddelde) Vildagliptine 50 mg 2x/dag + metformine Glimepiride tot 6 mg 1x/dag + metformine 0.4% 0.5% NI: 97.5% CI (0.02, 0.16) Tijd (weken)
GAL/EUC-16-01/09-5309 Lichaamsgewicht (kg) Vildagliptine: Geen Gewichtstoename Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride In Associatie Metformine (~1.9 g dagelijks gemiddelde) 1.8 kg verschil Tijd (weken) Vildagliptine 50 mg 2x/dag + metformine Glimepiride tot 6 mg 1x/dag + metformine Per protocol populatie. Vildagliptine (n=1396); glimepiride (n=1393). Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157 166.
GAL/EUC-16-01/09-5309 Incidentie (%) Aantal voorvallen Aantal voorvallen Vildagliptine vs Glimepiride: Hypoglycemische Voorvallen bij Toevoeging aan Metformine Behandeling Duur: 52 weken Toegevoegd aan metformine: vildagliptine vs glimepiride Patiënten met >1 Hypos (%) Aantal Hypoglycemische Voorvallen Ernstige Voorvallen (Graad 2 en Vermoeden van Graad 2) n = 1389 1383 1389 1383 1389 1383 Safety population. Ferrannini E, et al. Diabetes Obes Metab. 2009; 11: 157 166. Vildagliptine 50 mg 2x/dag + metformine Glimepiride tot 6 mg 1x/dag + metformine
DPP-4 inhibitoren (gliptines) pro goede glycemiedaling weinig hypo s geen gewichtstoename weinig neveneffecten (iets meer bovenste luchtwegen infecties) mogelijk beta-cel protectief contra kostprijs nog geen studies met harde eindpunten nog geen lange termijn gegevens over veiligheid Als ze hun beloften waar maken, zullen ze de sulfonylurea van hun troon stoten!!!
GLP-1 mimetica incretinomimetica (GLP1 analoog, exenatide)
Antistoff en!
Gila monster, Heloderma lizard
Combination with metformin : Adverse Events Placebo (N = 113) Exenatide (5) (N = 110) Exenatide (10) (N = 113) Nausea 23% 36% 45% Diarrhea 8% 12% 16% Upper Respiratory Tract Infection 11% 14% 10% Vomiting 4% 11% 12% Nasopharyngitis 10% 9% 4% Hypoglycemia 5% 5% 5% De Fronzo et al. Diabetes Care 05;28:1092-1100
exenatide (Byetta ) : 3 j resultaten 217 patiënten open verlenging na gerandomiseerde studies max. dosis metformine en/of sulfonylurea + 10 µg Byetta 2 x /d Klonoff et al. CurrMedResOp
exenatide (Byetta ) : 3 j resultaten Klonoff et al. CurrMedResOp
pro GLP-1 analogen goede glycemiedaling weinig hypo s sterke gewichtsdaling (maar nausea) vooral interessant bij morbide obesitas mogelijk beta-cel protectief contra SC injectie is probleem lichaamsvreemd proteïne acute pancreatitis
Byetta LAR : 1x/wk Kim et al. Diabetes Care 2007;30:1487-93
Van Gaal et al, Eur J Endocr 2008
scenario s
A. metformine: geen intolerantie of contraïndicatie STAP A1 (bij diagnose) STAP A2 STAP A3 STAP A4 goed gevalideerd: levensstijl + metformine metformine + secretagoog metformine + secretagoog + basale insuline metformine (+ secretagoog) + intensieve insuline minder goed gevalideerd: metformine + gliptine pro: - gebruiksgemak (geen titratie) - lage kans op hypoglycemie - gewichtsneutraal contra: - geen lange termijn gegevens - duurder metformine + gliptine + basale insuline metformine + secretagoog + exenatide pro: - gebruiksgemak (geen titratie) - lage kans op hypoglycemie - geeft gewichtsdaling contra: - nausea - SC injectie 2/d - onvoldoende lange termijn gegevens - veel duurder
B. metformine: intolerantie of contraïndicatie STAP B1 (bij diagnose) STAP B2 STAP B3 STAP B4 goed gevalideerd: levensstijl secretagoog secretagoog + basale insuline (secretagoog) + intensieve insuline minder goed gevalideerd: secretagoog + glitazone pro: - uitstellen spuitjes contra: - veel neveneffecten - veiligheid op lange termijn? - duurder secretagoog + exenatide pro: - gebruiksgemak (geen titratie) - lage kans op hypoglycemie - geeft gewichtsdaling contra: - nausea - SC injectie 2/d - onvoldoende lange termijn gegevens - veel duurder - in België niet toegelaten!!!
kostprijs voor equipotente dosissen kost aan maatschappij : / maand metformine 2 x 850 mg/d : 4.1 gliclazide 3 x 80 mg/d : 13.5 pioglitazone 1 x 30 mg : 41.0 sita/vildagliptine 1 x 100 mg/d : 45.0 exenatide 2 x 5 of 10 µg/d : 106.0 Insulatard 40 E/d : 30.1
ICU
olv goed diabetesbeleid tijdens hospitalisatie betere outcome in acute situaties en postoperatief kortere hospitalisatieduur grotere tevredenheid van patiënt glycemie-streefdoelen : 80-180 mg/dl in meeste omstandigheden 80-110 mg/dl bij zwaar zieken op ICU/CCU als dit veilig kan bereikt worden!!! -> ter discussie op dit moment
ICU SURVIVAL (%). effect op mortaliteit HOSPITAL SURVIVAL (%) 100 ALL PATIENTS p = 0.005 100 ALL PATIENTS p = 0.01 90 Long-stay patients 100 p = 0.007 Intensive - 43% Conventional 90 Long-stay patients 100 p = 0.02 Intensive - 34% Conventional 90 80 90 80 80-48% 80-36% 0 40 80 120 70 70 0 100 200 0 20 40 60 80 100120 0 50 100 150 200 DAYS AFTER INCLUSION DAYS AFTER INCLUSION Long-stay = > 5d = ± 1 patient op 3 Van den Berghe et al. NEJM 2001;345:1359-1367
effect op morbiditeit Blood stream infections ** Antibiotics > 10 days ** Dialysis / Hemofiltration ** Mechanical ventilation > 14 days ** ICU stay > 14 days ** RRR (%) NNT 60 40 20 0 0 20 40 46 28 35 17 41 29 Critical illness polyneuropathy **** 44 4 37 22 27 23 ** p 0.01 **** p < 0.0001 Van den Berghe et al. NEJM 2001;345:1359-1367
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Aalst Glycemia Insulin Protocol (ALGIP) CABG met CPB: 651 pat. (483 niet-dm, 168 DM); 18.893 metingen BG < 40 mg/dl (2.2 mm): geen BG < 60 mg/dl (3.3 mm): niet-dm DM intraoperatief : 0.02% 0.07% ICU (24u) : 0.16% 0.22% Lecomte et al. Anesth Analg 2008;107:51 8
OLV Aalst cardiale chirurgie met CPB start glycemieprotocol in 2005: 80-110 mg/dl (4.5-6 mmol/l) restrospectieve analyse : 2004 (n=305) 2005-6 (745) Lecomte et al.
Betrouwbare, snelle BG s!!! Bloedglucosemeter Bloedgas analyser HemoCue olv
% paired results < -25-25 - -20,1-20 - -15,1-15 - -10,1-10 - -5,1-5 - -0,1 0-4,9 5-9,9 10-14,9 15-19,9 20-24,9 > 25 Deviation split sample 25% 20% 15% 10% 5% 0% % deviation 2000 -> 91 % of results w ithin 20 % deviation 2001 -> 95 % of results w ithin 20 % deviation 2002 -> 96 % of results w ithin 20 % deviation Diab Medecine 2004
olv Bloedgas analyser
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ZORGTRAJECTEN
RIZIV-diabetes dubbelproject 9/04 6/06 7/03 6/07 Optimalisering DM2 zorg KUL GEMEENSCHAPPELIJK UA/UG Aansturing Huisarts - Top-down - MCH SHARED CARE ZORGMANAGEMENT Aansturing Patiënt - Bottom-up - Dicht tegen bestaande structuren olv WETENSCHAPPELIJKE ANALYSE (controleregio)
www.zorgtrajectenaalst.be/dpa/
organisatie diabeteszorg in België diabetesconventie referentievpk 3 inj 2 inj 1 inj conv. ZTJ diabetespas OAD DPA dieet onbeken d
zorgtraject diabetes: doelgroep type 2 diabetes 1 of 2 injecties insuline of incretine mimeticum (of intentie om te starten bij onvold. controle onder max. OAD,) bijkomende voorwaarden: - GMD - moet op consultatie kunnen komen
zorgtraject diabetes: principes huisarts: stuurt de zorg diabeteseducator: geeft informatie, leert zaken aan, apotheker: zelfcontrolemateriaal diabetescentrum: 1x / j langsgaan (meer z.n.) geeft ook raad tussendoor leidt het team van de 1 ste lijn op financiële stimuli: - patiënt geen remgelden voor raadplegingen bij zijn huisarts en alle specialisten voor deze aandoening - huisarts forfait - diabetoloog forfait
zorgtraject diabetes: educatie op voorschrift van huisarts (vermelding zorgtraject diabetes ) door diabetes-educator in 1 ste lijn - mag ook in diabetescentrum, op specifieke vraag van huisarts 1. onvoldoende 1 ste lijnseducatoren 2. complexe medische toestand verplicht bij - start insuline of incretinemimetica: 2.5 u - overgang van 1 naar 2 injecties: 1u - onvoldoende metabole controle (A1c > 7.5%): 1u
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ZWANGERSCHAPSDIABETES
Gestational DM Glucose intolerance with onset or first recognition during pregnancy Only small minority has BG levels that would be diagnostic of DM outside pregnancy Te be regarded as diabetes in evolution cfr diagnosis diabetes: 10% in first months postpartum 5 to 10% /year olv
Gestational DM Niet enkel aandacht voor de short-term outcome v/d foetus (gynecoloog) Ook aandacht voor de long-term outcome (endocrinoloog, HA) van moeder kind olv
Pederson principle
ACHOIS trial
ACHOIS trial First study showing benefits of intensive treatment of GDM with less perinatal morbidity!! BABY MOTHER Less nursery admission Less pre-eclampsia Less adverse outcome Better psychological outcome postpartum More frequently induction at 38 weeks without more cesarian sections
Hoe evalueren? 50 g challenge (niet nuchter): als > 140 mg/dl: 100 g ogtt 100 g ogtt 3 uur grenzen: 95-180-155-140 mg/dl
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behandelingsdoelen Metabool: Nuchter: < 95 mg/dl 1u pp: < 140 mg/dl 2u pp: <120 mg/dl Cave: als mean BG < 85 mg/dl: small for gestational! olv
90%: Dieet Lichaamsbeweging 10%: Preprandiale insuline olv
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Actuele voorstellen: ter discussie!! olv Diabetes Care, March 2010
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Lange termijn FU van moeder
DM2 can be delayed or prevented - 5.6 kg 20 min exerc/dag olv NEJM 2002;346:393-403
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