Objetivos en diabetes: de la "evidencia" al sentido común

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Objetivos en diabetes: de la "evidencia" al sentido común
José Manuel Millaruelo Trillo. Centro de Salud Torrero La Paz. Zaragoza. Miembro de la red GEDAPS Aragón

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Objetivos en diabetes: de la "evidencia" al sentido común

  1. 1. Los objetivos terapéuticos en diabetes:¿basados en la evidencia?Jose Manuel Millaruelo TrilloCentro de Salud Torrero La Paz. RedGDPS Aragón. Zaragoza
  2. 2. Los objetivos terapéuticos en diabetes no estánmuchas veces justificados, son medicalizadoresy tienen escasos beneficios netos• biblia• milongas• menos es mas• nadar• 17
  3. 3. Porque debemos confirmar la credibilidad de las guíasHow to Decide Whether a ClinicalPractice Guideline Is TrustworthyRansohoff D, Pignone M, Sox HJAMA 2013; 309: 139-40Failure of clinical practice guidelines tomeet Institute of Medicine standards:two more decades of little, if any,progress.Kung J, Miller R, Mackowiak P.Arch Intern Med. 2012;172:1628-1633Scientific Evidence Underlying theACC/AHA Clinical Practice GuidelinesTricoci P, MD, Allen J, Kramer J, Califf RJAMA 2009; 301:831-842
  4. 4. ¿Qué pasa con las GPC?PLoS ONE 8(4): e58625Pocos participantes 91% menos de 500Excluyen a mayores de 75 (algunos 65) Solo incluyen 0.6%Corta duración 1.4 añosFármacos vs prevención 74.8% vs 10%Outcome primario (mortalidad, ECV) 1.4%
  5. 5. • Diabetes = enfermedad cardiovascular• 80% muertes por ECV• Diabetes: 1ª causa ceguera (edad laboral)• Diabetes: 1ª causa de IR terminal• Amputaciones por diabetes: cada vez más• ….Recibimos una información sesgada ódesinformar para influenciar (en diabetes)
  6. 6. Is diabetes a coronary risk equivalent? Systematic review and meta-analysisDiabet. Med. 26, 142–148 (2009)
  7. 7. La diabetes como enfermedad cardiovascular: bla, bla, bla,…39% 26% 35%Diabetes and risk of mortalitya: the CPS-II cohort, 1982–2008Diabetes Care Publish Ahead of Print,published online June 14, 2012
  8. 8. Datos de ceguera legal por RD de la ONCE
  9. 9. Causas de insuficiencia renal terminal
  10. 10. Aumentar la importancia del problema no significaque aumente su gravedad: la clave es la prevalenciaPrevalencia = Incidencia x tiempo - mortalidad
  11. 11. Declining Rates of Hospitalization for Nontraumatic Lower-ExtremityAmputation in the Diabetic Aged 40 Years or Older: U.S., 1988–2008Diabetes Care 35:273–277, 2012
  12. 12. Del racionamiento a evitar gasto inútilDeveloping Quality Measures to Address Overuse JAMA, May 8, 2013—Vol 309, No. 18
  13. 13. Objetivos de la ADA 2013
  14. 14. Individualizar objetivos: Objetivos comunes implica mala practicaAnn Intern Med. 2011;154:554-559
  15. 15. ¿Debería ser 7 la cifra mágica?Currie, CJ.: Survival as a function of HbA1c inpeople with type 2 diabetes: a retrospectivecohort study www.thelancet.com Publishedonline January 27, 2010
  16. 16. Relationship between HbA1c levels and risk of cardiovascular adverse outcomesand all-cause mortality in overweigh and obese cardiovascular high-risk womenand men with type 2 diabetesDiabetologia. 2012 ;55:2348-55
  17. 17. All-cause mortality in relation to glycated haemoglobinin individuals with newly diagnosed type 2 diabetesBritish Journal of Diabetes& Vascular Disease 2013 13: 22
  18. 18. The relationship between glycaemic control and heartfailure in 83,021 patients with type 2 diabetesDiabetologia (2012) 55:2946–2953Poor glycaemic control (HbA1c >7% is associatedwith an increased risk of hospitalisation forheart failure in patients with type 2 diabetes
  19. 19. Relationship between HbA1c and risk of all-cause hospitaladmissions among people with Type 2 diabetes“A threshold of 61 mmol/mol (7.7%) was associatedwith the lowest rate of all-cause hospital admissions”Diabet Med. 2013 May 22.doi: 10.1111/dme.12235.[Epub ahead of print]
  20. 20. Relationship Between Glycemic Control and Diabetes-RelatedHospital Costs in Patients with Type 1 or Type 2 DiabetesMellitusJ Manag Care Pharm. 2010;16(4):264-75the odds of having at least 1 diabetes-related hospitalization were not significantlyassociated with higher mean A1c except forpatients with mean A1c of at least 10%.
  21. 21. ¿Por qué solo miramos lo biológico?Ostgren C. Associations of HbA1c and educational level with risk of cardiovascular ein 32 871 drug-treated patients with Type 2 diabetes. Diabet. Med. 30, e170–e177 (2
  22. 22. Incongruencia o contradicciónSi lo que nos preocupa es lo macrovascular, ¿porque utilizamospara los objetivos los datos de lo microvascular?¿Por que se utilizan como objetivos de tratamiento cifras que no handemostrado mejorar la evolucion de las complicaciones?
  23. 23. La diabetes es causa importante de mortalidad en edadesmedias de la vidaTaylor K. All-Cause and Cardiovascular Mortality inMiddle-Aged PeopleWith Type2Diabetes Compared With People Without Diabetes in a Large U.K. Primary Care Database.Diabetes Care Publish Ahead of Print, published online February 22, 2013
  24. 24. ¿Qué decir de la TA?Reappraisal of European guidelines onhypertension management: a EuropeanSociety of Hypertension Task Forcedocument
  25. 25. Intensive and Standard Blood Pressure Targets inPatients With Type 2 Diabetes Mellitus“Use of a Single TargetBlood Pressure Levelin Type 2 Diabetes Mellitusfor All CardiovascularRisk Reduction”Arch Intern Med2012 ;172:1296-303
  26. 26. Effects of intensive blood pressure reduction on myocardial infarctionand stroke in diabetes: a meta-analysis in 73 913 patientsJournal of Hypertension 2011, 29:1253–1269
  27. 27. Blood presure and stroke risk in diabeticamericans
  28. 28. Aggressive Blood Pressure Control Increases Coronary HeartDisease Risk Among Diabetic PatientsDiabetes Care Publish Ahead of Print, published online May 20, 2013
  29. 29. ¿Qué decir del colesterol?Identifying Patients for AggressiveCholesterol Lowering: The Risk CurveConcept. Am J Cardiol 2006;98:1405–1408
  30. 30. Contra el LDL como objetivoRodney A. Hayward and Harlan M. Krumholz. Circ Cardiovasc Qual Outcomes2012;5;2-5; Adult Treatment Panel IV of the National Institutes of HealthThree Reasons to Abandon Low-Density Lipoprotein Targets
  31. 31. De la dificultad de nadar contra corriente
  32. 32. Médicos de los números, médicos de las personas
  33. 33. Preguntas, por favor…

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