DM tipo 2: Objetivos
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DM tipo 2: Objetivos

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CS Calvià

CS Calvià
Dic/2012

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  • Antihyperglycemic therapy in type 2 diabetes: general recommendations. Moving from the top to the bottom of the figure, potential sequences of antihyperglycemic therapy. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis (unless there are explicit contraindications). If the HbA 1c target is not achieved after ∼3 months, consider one of the five treatment options combined with metformin: a sulfonylurea, TZD, DPP-4 inhibitor, GLP-1 receptor agonist, or basal insulin. (The order in the chart is determined by historical introduction and route of administration and is not meant to denote any specific preference.) Choice is based on patient and drug characteristics, with the over-riding goal of improving glycemic control while minimizing side effects. Shared decision making with the patient may help in the selection of therapeutic options. The figure displays drugs commonly used both in the U.S. and/or Europe. Rapid-acting secretagogues (meglitinides) may be used in place of sulfonylureas. Other drugs not shown (α-glucosidase inhibitors, colesevelam, dopamine agonists, pramlintide) may be used where available in selected patients but have modest efficacy and/or limiting side effects. In patients intolerant of, or with contraindications for, metformin, select initial drug from other classes depicted and proceed accordingly. In this circumstance, while published trials are generally lacking, it is reasonable to consider three-drug combinations other than metformin. Insulin is likely to be more effective than most other agents as a third-line therapy, especially when HbA 1c is very high (e.g., ≥9.0%). The therapeutic regimen should include some basal insulin before moving to more complex insulin strategies (Fig. 3). Dashed arrow line on the left-hand side of the figure denotes the option of a more rapid progression from a two-drug combination directly to multiple daily insulin doses, in those patients with severe hyperglycemia (e.g., HbA 1c ≥10.0–12.0%). DPP-4-i, DPP-4 inhibitor; Fx's, bone fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor agonist; HF, heart failure; SU, sulfonylurea. a Consider beginning at this stage in patients with very high HbA 1c (e.g., ≥9%). b Consider rapid-acting, nonsulfonylurea secretagogues (meglitinides) in patients with irregular meal schedules or who develop late postprandial hypoglycemia on sulfonylureas. c See Table 1 for additional potential adverse effects and risks, under “Disadvantages.” d Usually a basal insulin (NPH, glargine, detemir) in combination with noninsulin agents. e Certain noninsulin agents may be continued with insulin (see text). Refer to Fig. 3 for details on regimens. Consider beginning at this stage if patient presents with severe hyperglycemia (≥16.7–19.4 mmol/L [≥300–350 mg/dL]; HbA 1c ≥10.0–12.0%) with or without catabolic features (weight loss, ketosis, etc.).

DM tipo 2: Objetivos DM tipo 2: Objetivos Presentation Transcript

  • Diabetes Mellitus Tipo 2:Objetivos del tratamiento
  • DIAGNÓSTICO DM2•HbA1c > 6,5%•Glucosa >= 126mg/dl REPETIR•Glucosa >=200 a las 2 h de TTOG•Glucosa >=200 con síntomas clásicos dehiperglucemia
  • CATEGORÍAS DE RIESGO DIABÉTICO AUMENTADO•Glucosa 100-125 mg/dl GBA•Glucosa 140-199 a 2 h de TTOG ITG•HbA1c 5,7-6,4 View slide
  • ELEMENTOS DE DECISIÓN View slide
  • OBJETIVOS DE CONTROL• HbA1c < 7%• HbA1c < 6,5 % si corta duración DM, larga expectativa de vida, no ECV• HbA1c < 8% historias de hipoglucemias, expectativa de vida limitada, complicaciones micro o macrovasculares, comorbilidad asociada.
  • ACTIVIDAD FÍSICA• 150’ / semana de ejercicio aeróbico moderado- intenso (50-70% de la FCM) al menos 3 /semana y no más de 2 días consecutivos sin ejercicio (A)• En ausencia de contraindicaciones, ejercicios de resistencia al menos dos veces por semana (A)
  • TRATAMIENTO DE LA HTA• Toma repetida de TAS>=130 o TAD>=80 confirma el diagnóstico de HTA• OBJETIVO TAS <130 TAD<80• MEV: peso, sal, alcohol, K, ejercicio• Uso de fármacos si TAS>130-139 o TAD>80-89 se mantiene 3m. También si TAS>=140 o TAD>=90 al diagnóstico o seguimiento.• IECA o ARA2 (suele ser necesario 2 o más)• Uno o más en dosis nocturna• No <110/75
  • TRATAMIENTO DE LA DISLIPEMIA ADA 2012 GEDAPS 2012DM SIN ECV LDL<100 (A) LDL<130 (RCV<10%) LDL<100(>10a, MAU, FG<60 o RCV>10%)DM CON ECV LDL<70 (B) LDL<100
  • TRATAMIENTO FARMACOLÓGICO• Momento diagnóstico: Metformina + intervenciones en el estilo de vida• Con síntomas marcados o elevada hiperglucemia inicial: Insulina con o sin otros agentes• Si tratamiento no insulínico no consigue resultados en 3-6 meses: otro ADO, agonista GLP- 1, o Insulina
  • Antihyperglycemic therapy in type 2 diabetes: general recommendations. Inzucchi S E et al. Dia Care 2012;35:1364-1379Copyright © 2011 American Diabetes Association, Inc.
  • ASPIRINA (75-162 mg/d)• PREVENCIÓN PRIMARIA: Si RCV>10% incluye la mayoría de varones>50, mujeres>60 con 1FRCV (ECV familiar, HTA, Tabaquismo, HLP, albuminuria)• No recomendarse en bajo riesgo <5%• Riesgo intermedio individualizar• PREVENCIÓN SECUNDARIA: con historia ECV (A)• Con ECV y alergia: Clopidrogel 75 mg/d• Combinado AAS+Clp tras 1 año del SCA