Memorias Conferencia Científica Anual sobre Síndrome Metabólico 2017 - Programa Científico Futuro en el tratamiento de la DM2 Dr. Guillermo E. Umpierrez Professor of Medicine in the Division of Endocrinology at Emory University School of Medicine, Section Head, Diabetes and Endocrinology. USA. Editor en Jefe del BJM Open Diabetes Research and Care

1. Presente y Futuro del Manejo de
la Diabetes Tipo 2
Guillermo E. Umpierrez, MD, FACP, FACEGuillermo E. Umpierrez, MD, FACP, FACE
Professor of MedicineProfessor of Medicine
Director, Clinical Research Diabetes & Metabolism CenterDirector, Clinical Research Diabetes & Metabolism Center
Emory University School of MedicineEmory University School of Medicine
Director, Diabetes & Endocrinology SectionDirector, Diabetes & Endocrinology Section
Grady Health SystemGrady Health System

2. Relationships Company Name(s) Role
Equity, stock,
biomedical industry
companies or
publishers
•BMJ Open Diabetes Research &
Care
•ADA, Editor in Chief, Therapy for
Diabetes and Related Disorders
Editor-in-Chief
Board officer •Endocrine Society
•American Association Clinical
Endocrinologists
Council At Large
Board of Directors
Industry funds to
Emory University for
my research
Merck, Sanofi, Novo Nordisk
Astra Zeneca, Boehringer
Ingelheim
Investigator-Initiated
Research Projects
Industry Advisory/
Consultant activities
Dr. G. Umpierrez, Financial Relationships with Industry, 5/2017
• ADA Professional Practice Recommendation Committee
• AACE Diabetes Council and Guidelines Writing Committee
• Chairman National AACE Primary care Diabetes Education

3. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Diagnostico y drogas anti-diabeticas
1. Tratamiento de obesidad- medico/quirurgico
2. Tecnologia – bombas y mornitoreo continuo
1. Grandes retos:
1. Educacion del medico primario
2. Acceso a tecnologia y tratamiento
3. Alto costo de medicamentos antidiabeticos

4. Diabetes: Current rates and
projections
• CDC Press Release 2010: 1 in 3 adultsCDC Press Release 2010: 1 in 3 adults
with DM by 2050with DM by 2050
• JAMA 2014;311(17):1778.: Increase inJAMA 2014;311(17):1778.: Increase in
prevalence in youth between 2001 andprevalence in youth between 2001 and
2009 of T1D (20%) and T2D (30%)2009 of T1D (20%) and T2D (30%)
• ADA Report: health care costs for DMADA Report: health care costs for DM
increased by 40% to $245 billion betweenincreased by 40% to $245 billion between
2007 and 20122007 and 2012

5. Diabetes prevalence in the US leveling off?

6. Lower rates
of diabetes-
related
complications
in the US

7. Number of Cases
2015
IDF Diabetes Atlas, 7th
Edition, 2015
India
69.2
India
69.2
China
109.6
China
109.6
USA
29.3
USA
29.3
415
million
World
415 M
World
415 M

8. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Classification and Diagnostico
3. Tratamiento de obesidad- medico/quirurgico
4. Tecnologia – bombas y mornitoreo continuo
1. Manejo del paciente en el hospital y sala de
ancianos
2. Grandes retos:
1. Educacion del medico primario
2. Alto costo de medicamentos antidiabeticos

9. 1. Type 1 diabetes
– β-cell destruction
1. Type 2 diabetes
– Progressive insulin secretory defect
1. Gestational Diabetes Mellitus (GDM)
2. Other specific types of diabetes
– Monogenic diabetes syndromes
– Diseases of the exocrine pancreas, e.g., cystic
fibrosis
– Drug- or chemical-induced diabetes
Classification of Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24

10. Staging of Type 1 Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24

11. Pathogenesis of Type 1Diabetes
Variable insulitis
β-cell sensitivity to
injury
Interactions
between
genes
imparting
susceptibility
and resistance
Environmental
triggers and
regulators
Immune
dysregulation
Pre-diabetes
Overt diabetes
β-cellMass
Time
Loss of first-phase insulin
response
Glucose intolerance
Adapted from Atkinson MA, Eisenbarth GS. Lancet. 2001;358:221

12. • Blood glucose rather than A1C should be used to
dx type 1 diabetes in symptomatic individuals. E
• Screening for type 1 diabetes with an antibody
panel is recommended only in the setting of a
clinical research study or in a first-degree family
members of a proband with type 1 diabetes. B
www.DiabetesTrialNet.org
Type 1 Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24

14. Criteria for the Diagnosis of Diabetes
A1C ≥6.5%
OR
Fasting plasma glucose (FPG)
≥126 mg/dl (7.0 mmol/l)
OR
Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l)
during an OGTT
OR
A random plasma glucose ≥200 mg/dl (11.1 mmol/l)
ADA. I. Classification and Diagnosis. Diabetes Care 2012;34(suppl 1):S13. Table 2.
A1C ≥6.5%
ADA. I. Classification and Diagnosis. Diabetes Care 2012;34(suppl 1):S13. Table 2.

15. FPG 100–125 mg/dL
(5.6–6.9 mmol/L): IFG
OR
2-h plasma glucose 140–199 mg/dL (7.8–11.0
mmol/L): IGT
OR
A1C 5.7–6.4%
Prediabetes*
* For all three tests, risk is continuous, extending below the lower limit of a
range and becoming disproportionately greater at higher ends of the range.
American Diabetes Association Standards of Medical Care in Diabetes.
Classi cafi tion and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24

16. Glycemic Targets

17. Approach to Management of
Hyperglycemia
ADA. V. Diabetes Care. Diabetes Care. 2015;37(suppl 1):S25.

18. Approach to Management of
Hyperglycemia
ADA. V. Diabetes Care. Diabetes Care. 2015;37(suppl 1):S25.
Individualization of Care
is needed for the
Management of Patients
with Diabetes

19. Current Antihyperglycemic Medications
Sulfonylureas
Generalized
insulin
secretagogue
12 Groups with
Different Mechanisms
of Action
α-Glucosidase
Inhibitors
Delay CHO
absorption
Biguanide
Reduces hepatic
insulin
resistance
TZDs
Reduce
peripheral insulin
resistance
Amylin
Analog
Suppresses
glucagon
GLP-1 Analogs
Stimulate β cells
Suppress
glucagon
Colesevelam
Bile acid
sequestrant
Bromocriptine
Hypothalamic
pituitary reset
Insulin
Replacement
Therapy
Glinides
Restore
postprandial
insulin
patterns
DPP-4
Inhibitors
Restore
GLP-1 Level

20. Antihyperglycemic Therapy in
Type 2 Diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Approaches to Glycemic Treatment. Diabetes Care 2016; 39 (Suppl. 1): SX

22. EFFICACY
Lowering HgA1c
EFFICACY
Lowering HgA1c
SAFETY
Hypoglycemia
Prevention
SAFETY
Hypoglycemia
Prevention
Management of Type 2 Diabetes
Individualized Algorithm

23. Hypoglycemia and Annualized Mortality
Rates Within Treatment Groups: ACCORD
None
>1
0
1
2
3
4
5
Standard
Intensive
1.0 1.3
4.9
2.9
Percent(%)perYear
Requiring Medical Assistance
(HMA)‡
None
≥1
0
1
2
3
4
5
Standard
Intensive
1.0 1.2
3.7
2.8
Percent(%)perYear
Requiring Any Assistance, Medical
orNon-medical (HA)†
Adapted from: Bonds DE, et al. BMJ. 2010 Jan 8;340:b4909. doi: 10.1136/ bmj.b4909.
n=201/
16315*
n=53/
1924*
n=176/
17297*
n=21/
564*
n=220/
17031*
n=34/
1208*
n=180/
17516*
n=17/
345*
Mortality Rate (n=451 deaths)
* Person-years
† p = .076 forinteraction between history of hypoglycemia requiring any assistance and glycemia intervention
‡ p = .009 forinteraction between history of hypoglycemia requiring medical assistance and glycemia intervention

24. EFFICACY
Lowering HgA1c
EFFICACY
Lowering HgA1c
SAFETY
Hypoglycemia
Prevention
SAFETY
Hypoglycemia
Prevention
Management of Type 2 Diabetes
Cardiovascular
Disease
Prevention
Cardiovascular
Disease
Prevention

25. Under Consideration:
ADA Standards of Medical Care in Diabetes - 2018
Monotherapy Me ormin
A1C not at goal
Dual therapy
ASCVD?
Yes
Add agent with evidence of CV risk reduc on:
- SGLT2-I (empagliflozin or canagliflozin)
- GLP1-RA (liraglu de)
No

26. EMPA-REG TRIAL
• Study medication was given in addition to standard of care
– Glucose-lowering therapy was to remain unchanged for first 12 weeks
• Treatment assignment double masked
• The trial was to continue until at least 691 patients experienced an adjudicated
primary outcome event
Randomised and
treated
(n=7020)
Empagliflozin 10 mg
(n=2345)
Empagliflozin 25 mg
(n=2342)
Placebo
(n=2333)
Screening
(n=11531)
Zinman, B et al. NEJM 2015;373:2117-28.

27. Primary outcome:
3-point MACE (CV death, MI, stroke)
20
HR 0.86
(95.02% CI 0.74, 0.99)
p=0.0382*
Cumulative incidence function. MACE, Major Adverse Cardiovascular Event; HR, hazard ratio.
* Two-sided tests for superiority were conducted (statistical significance was indicated if p≤0.0498)
Zinman, B et al. NEJM 2015;373:2117-28.

28. Cardiovascular Death
Cumula ve incidence func on. HR, hazard ra o
Empagliflo in 10 mg
HR0.65
(95% CI 0.50, 0.85)
p=0.0016
Empagliflozin 25 mg
HR0.59
(95% CI 0.45, 0.77)
p=0.0001
Zinman, B et al. NEJM 2015;373:2117-28.

29. LEADER TRIAL
Liraglutide and Cardiovascular
Outcomes in Type 2 Diabetes
Marzo et al. N Engl J Med 2016;375:311-22

30. Semaglutide and Cardiovascular Outcomes
in Patients with Type 2 Diabetes
MARZO ET AL. NEJM 375;1874-88, 2016
The primary composite outcome was the first occurrence of cardiovascular death,
nonfatal myocardial infarction, or nonfatal stroke.

31. TZDSU SGLT2DPP4 BASALGLP1
FROM GLUCO-CENTRIC TO CARDIOVASCULAR-CENTRIC?
INDIVIDUALIZATION ACCORDING TO CV RISK?
SPEAKE OPINION: DOES NOT REPRESENT ADA OR AACE POSITION
METFORMIN

32. Insulin use among patients with T2D, 200-
2010
Lipska et al. JAMA, July 2014

33. NPH Insulin
Insulin
Glargine
Insulin Detemir
Biosimilar
Insulin
Glargine
Glargine
U-300
Degludec
Insulin type
Human;
intermediate-
acting
Analogue; long-
acting
Analogue; long-
acting
Analogue; long-
acting
Analogue; long-
acting
Analogue; long-
acting
Onset 2-4 hours 1.3 hours 1.3 hours N/A 6 hours 1 hour
Peak 4-10 hours
No pronounced
peak
Relatively flat
No pronounced
peak
Flat Flat
Effective
duration
10-16 hours Up to 24 hours Up to 24 hours Up to 24 hours ≤36 hours Up to 42 hours
Half-life Unknown* 14 hours 5-7 hours ~23 hours ~25 hours
Steady state Unknown 2 days 2 days 4 days 2-3 days
Currently Available Basal Insulins
Porcellati. Diabetes Care 30(10)2447-2452, 2007
Lucidi P, et al. Diabetes Care. 2011;34:1312-1314.
Niswender K. Clinical Diabetes. 2009;27:60-68.
US Food & Drug Administration. Drugs@FDA: FDA Approved Drug Products. http://www.accessdata.fda.gov.
*NPH insulin (isophane insulin suspension) package insert

34. Meta-Analysis: U300 Glargine vs U100 Glargine:
Safety and Efficacy
*Confirmed (≤70 mg/dL) or severe hypoglycemia from 00:00–05:59 h.
SE = standard deviation; LOV = last on-treatment value.
Ritzel R, et al. Presentation 90-LB 74th ADA Scientific Sessions June 13-17, 2014, San Francisco, CA. http://
ada.scientificposters.com/epsAbstractADA.cfm?id=1. Accessed August 15, 2014.
M6
U100
U300
WeightChange(Kg)
Mean±SE
1.5
-0.5
Base
line
1.0
0.5
0.0
M4W12W8W4W2 LOV
p=0.039
HbA1c(%)Mean±SE
7.6
8.4
7.0
Baseline 6 MonWeek 12
7.2
8.2
8.0
7.4
7.8
U100
U300
LSmean difference (95% CI)
between groups:
000 (-0.08 to 0.07)%
NocturnalHypo-Events*
perParticipant-Year
2
6
0
5
4
1
3
3.06
2.10
p=0.0002
RR
31%
U100 U300

35. Degludec vs Glargine In Type 2 DM
Garber AJ, et al. Lancet. 2012;379(9285):1498-1507.
0 16 4028 524 3220 4412 3624 488
8.6
7.8
0
A1C(%)
7.0
8.2
8.4
7.6
7.4
8.0
7.2
70
62
0
A1C(mmol/mol)
54
66
68
60
58
64
56
Insulin Degludec once-daily
(N=744)
Insulin Glargine once-daily
(N=248)
Time (weeks) 2.0
1.0
0
CumulativeEvents
perParticipant
0 16
Time (weeks)
4028
0.2
52
1.4
1.8
0.8
1.6
0.6
1.2
0.4
4 3220 4412 3624 488
Nocturnal Hypoglycemia
Equal Efficacy, Less Nocturnal
Hypoglycemia with Degludec but no
difference in severe hypoglycemia

36. Insulin
glargine
Aroda VR, et al. Diabetes Care. 2016;39:1972-1980. Used with permission.
9.0
8.5
8.0
7.5
7.0
6/5
Screening Baseline 8 12 24 30
Week
iGlarLixi
8.5%
8.1%
7.5%
6.9%
iGlarLixi
Mean Difference
(95% CI) P Value
versus insulin glargine -0.52% (-0.63, -0.40) P<.0001
Mean
(95% CI)
A1C (%)
Fixed-Dual Combination
LixiLan-L: Mean A1C Change

37. Mean values (±SEM) based on FAS and LOCF-imputed data; EOT = end of trial;
- - - ADA/EASD HbA1c target <7.0%; AACE HbA1c target ≤6.5%
Time (weeks)
HbA1c(%)
0.0
8.5
8.0
7.5
7.0
6.5
0 2 4 6 8 10 12 14 16 18 20 22 24 26
-1.28%
∆HbA1C EOT
7.0%
Liraglutide (n=414)
-1.44% 6.9%
IDeg (n=413)
-1.91%* 6.4%
*p<0.0001 vs. IDeg
and vs. Liraglutide
IDegLira (n=833)
p-values are from an ANCOVA
Gough, Bode et al, Lancet Diab Endo 2014
IDegLira- DUAL 1: HbA1c over time

38. 100
80
60
40
20
0
IDegLira (n=833)
IDeg (n=413)
Liraglutide (n=414)p<0.0001
p<0.0001
Values based on FAS and LOCF-imputed data; p-values are from a logistic regression model
%ofsubjects
80.6
65.1
60.4
69.7
47.5
41.1
p<0.0001
p<0.0001
HbA1c <7.0% HbA1c ≤6.5%
DUAL 1: Percentage of subjects to target
Gough, Bode et al, Lancet Diab Endo 2014

39. www.GoodRx.com/, accessed June 18, 2016,
(lowest price for New Haven, CT 06510)
$4.
$733.
183 X (!)

40. JAMA July 4, 2017 Volume 318, Number 1
25 - 10025 - 100
350-400350-400
250-350250-350
200-400200-400

41. Future of Treatment of T2D
• Antidiabetic agents:
– Safety and efficacy
– Avoidance of hypoglycemia & weight gain
– Cardiovascular safety
– Early combination therapy

42. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Diagnostico y drogas anti-diabeticas
1. Tratamiento de obesidad- medico/quirurgico
2. Tecnologia – bombas y mornitoreo continuo
1. Grandes retos:
1. Educacion del medico primario
2. Alto costo de medicamentos antidiabeticos

43. Treatment of Obesity
LifestyleIntervention
BariatricSurgery
Medications

44. NHLBI Obesity Treatment Guidelines
http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf.
*Bariatric surgeries require lifestyle medical follow-up.
ⱡ
FDA approved gastric band surgery for patients with BMI ≥30 and one weight related medical condition (February 2011).

45. Recent Additions to Obesity Pharmacotherapy
Phentermine and topiramate extended-release [package insert]. Mountain View, CA : Vivus; 2012. Lorcaserin hydrochloride [package insert]. Woodcliff
Lake, NJ: Eisai Inc.; 2012. Clinicaltrials.gov. Cardiovascular Outcomes Study of Naltrexone SR/Bupropion SR in Overweight and Obese Subjects With
Cardiovascular Risk Factors (The Light Study). 2012. Clinicaltrials.gov. Effect of Liraglutide on Body Weight in Non-diabetic Obese Subjects or
Overweight Subjects With Co-morbidities: SCALE™ - Obesity and Pre-diabetes. 2011.

46. Lorcaserin ─ BLOOM Study:
Body Weight Over Years 1 and 2
Smith SR, et al. NEJM. 2010;363:245-256. Study Week
0 8 16 24 32 40 48 56 64 72 80 88 96 104
BodyWeight(kg)
102
100
98
96
94
92
90
0
Year 1
Placebo in year 1 and 2 (n = 684)
Lorcaserin in year 1, placebo in year 2 (n = 275)
Lorcaserin in year 1 and 2 (n = 564)
Year 2

47. Remission
less likely
with longer
duration of
diabetes

48. Surgery
associated with
>50% reduction
in microvascular
complications

49. Surgery
associated with
30% reduction in
macrovascular
complications

50. Histological
Finding
Prevalence
Before
Prevalence
After
Steatosis 89.7% 2.9%
Hepatocellular
Ballooning
58.9% 0%
Centrilobular
Fibrosis
50% 25%
Note: no improvements in portal tract
inflammation and fibrosis
Gastric Bypass Surgery and NAFLD
18 months after Roux-en-Y, weight loss 50 kg
Liu X et al, Obesity Surgery 17:486-
492, 2007
BEFORE
AFTER

51. The open circles represent the number of bariatric operations
performed as inpatient procedures in 2006 and 2007.
Annual number of bariatric operations in the USA
Livingston et al. Am J Surg. 2010 Sep; 200(3): 378–385.

52.  Less invasive surgeries
(Obes Surg 2008;18:294)
 Intraduodenal sleeves
 Bypass only the duodenum and upper
jejunum
 Done endoscopically
 For patients with lower BMI’s?
(Depaula AL (Brazil) Surg Endosc 2008 Oct 2)
 For younger and older patients?
(Busetto L Obesity 2008;16:334)
The Future

53. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Diagnostico y drogas anti-diabeticas
1. Tratamiento de obesidad- medico/quirurgico
2. Tecnologia – bombas y mornitoreo continuo
1. Grandes retos:
1. Educacion del medico primario
2. Alto costo de medicamentos antidiabeticos

54. Continuous
subcutaneous
insulin infusion
(CSII)

55. Diabetes 2014;63:Supplement 1 A212-A343.

56. FDA Approves Threshold
Suspend Feature

57. Less nocturnal
hypoglycemia
(38% reduction)
with threshold
suspend feature

58. Bionic Pancreas

59. • Adults: average glucose 133 mg/dLAdults: average glucose 133 mg/dL
(bionic) vs 159 mg/dL (pump); P<0.001(bionic) vs 159 mg/dL (pump); P<0.001
• Adolescents: average glucose 138 mg/dLAdolescents: average glucose 138 mg/dL
(bionic) vs 157 mg/dL (pump); P=0.004(bionic) vs 157 mg/dL (pump); P=0.004
• Adults: Percent of time hypoglycemic 4.1%Adults: Percent of time hypoglycemic 4.1%
(bionic) vs 7.3% (pump); P=0.01(bionic) vs 7.3% (pump); P=0.01
• Adolescents: Percent of timeAdolescents: Percent of time
hypoglycemic 6.1% (bionic) vs 7.6%hypoglycemic 6.1% (bionic) vs 7.6%
(pump); P=0.23(pump); P=0.23

60. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Diagnostico y drogas anti-diabeticas
1. Tratamiento de obesidad- medico/quirurgico
2. Tecnologia – bombas y mornitoreo continuo
1. Grandes retos:
1. Educacion del medico primario
2. Alto costo de medicamentos antidiabeticos

61. Tratamiento Futuro T2D
1. La epidemia de diabetes
2. Diagnostico y drogas anti-diabeticas
1. Tratamiento de obesidad- medico/quirurgico
2. Tecnologia – bombas y mornitoreo continuo
1. Grandes retos:
1. Educacion del medico primario
2. Alto costo de medicamentos antidiabeticos

62. 1950 1960 1970 1980 1990 2000 2010
9
8
7
6
5
4
3
2
1
NumberofMedicationClasses
10
11
insulin
Sulfonylureas
Biguanides
Angiotensin II
receptor
blockers
ACE
Inhibitors
Ca2+
channel
blockers
β-blockers
diuretics
central
α-2 agonists
peripheral
α-1 blockers
adrenergic
neuronal
blockers
Renin inhibitors
vasodilators
Half-Century of HTN & T2DM Medications in
U.S. SGLT-2
inhibitors
α-GIs
TZDs
Glinides
GLP-1R
Agonists
DPP-4
inhibitors
Amylin mimetics
Biguanides
Bile acid
sequestrants
Dopamine agonists
12

63. An cipa on of
DrugEfficacy
Concernsof
‘Adverse Effects’
Desire for
Added Benefits
MEDICATION CHOICE?
“Personalizing” Type 2 Diabetes Therapy

64. Current Problem: Poor Glycemic Control (HbA1c)
across US and Emory
Lipska, K.J., et al., US Data, Diabetes Care, 2016
Emory Clinical Data Warehouse, HbA1c values (n= 29,875) in patients with diabetes, 11/2015-10/2016 (all
Barriers to diabetes
care:20-25% have A1c
>8%
•Lack diabetes education
•Too many patients and not
enough time during visits
•Lack of resources to teach
patients on injectables
(insulin and GLP1-RA)

65. https://www.washingtonpost.com/news/wonk/wp/2016/10/31/why-insulin-prices-have-kept-rising-for-95-years/
List Price of Humalog Insulin: Adjusted for inflation,
the current price is 700% higher than it was 20 years ago

66. Cost of Insulin: Historic Review
• Insulin patent sold to the University of Toronto for $3, or $1
for each person listed (Banting, Best, Macleoud)
– to ensure that no company would have a monopoly and
patients would have affordable access to a safe,
effective drug.
– they hoped their discovery was a kind of gift to
humanity.”
• Drugstore ads from the 1960s published in The
Washington Post advertised insulin for as little as 84 cents
a vial.
– The most expensive version listed in the ad was less
than $2 a vial
• Insulin that carried a list price of $17 a vial in 1997 is priced
at $138 today.
– Humalog launched two decades ago with a sticker price
of $21 a vial has been increased to $255.

67. https://www.washingtonpost.com/news/wonk/wp/2016/10/31/why-insulin-prices-have-kept-rising-for-95-years/
Spending on Insulin has Increased Faster Than
Other Diabetes Drugs

68. Tratamiento Futuro T2D
• La epidemia de diabetes es uno de los grande retos en
salud publica mundial
– Complicaciones y alto costo
• Nuevas drogas orales e injectables, pero no hay datos de
un major control glucemico en estudio de poblacion
de”mundo real”
• Tratamiento de obesidad- medico/quirurgico. Mas de 100
millones de pacienes con sobrepeso y obesidad en USA.
No al alcance de la poblacion.
• Tecnologia – bombas y mornitoreo continuo, un gran
futuro para el paciente con diabetes tipo 1.
• Grandes retos:
– Educacion del medico primario
– Alto costo de medicamentos antidiabeticos

69. Thank you!Thank you!
geumpie@emory.edu