Although stress hyperglycemia typically resolves as the acute illness or surgical stress abates, it is important to identify and track patients because 60% of patients admitted with new hyperglycemia had confirmed diabetes at 1 year. Furthermore stress induced by acute illness definitely impair metabolic control in known diabetic patients. Insulin is the therapy of choice in acutely ill hospitalised patients. You have to respect some important rules and algorithms, such as the Yale protocol, approaching insulin therapy in these patients, expecially to avoid the rollercoaster glycemic profile which subtends dangerous hypoglycemias and the increased risk of mortality. Use basal-bolus insulin regimens or continuous subcutaneous insulin infusion and tailor insulin regimens to the individual’s treatment.
New rapid-acting and long-acting insulin analogues profiles help to reach better glycemic control.
- The document discusses the history and evolution of glucose monitoring technologies from urine testing to current continuous glucose monitoring systems (CGM).
- It provides details on the advantages of real-time CGM (rtCGM) over self-monitoring of blood glucose (SMBG), including continuous readings without pain and ability to detect trends and prevent hypoglycemic events.
- The document compares different CGM systems like Dexcom G5 and G6, Medtronic Guardian Connect, and FreeStyle Libre Pro interms of features, calibration needs, and accuracy.
- It describes how sensor-augmented insulin pumps that suspend insulin delivery can help minimize hypoglycemia, and discusses hybrid closed-loop systems like
El documento describe diferentes tipos y regímenes de insulina para el tratamiento de la diabetes tipo 2. Explica que las insulinas basales como glargina se usan en combinación con agentes orales cuando el HbA1c está entre 7-9.5%, mientras que los regímenes basales-prandiales con NPH y cristalina son para HbA1c >9.5%. A pesar de su eficacia, el uso de insulina en Estados Unidos es bajo debido a barreras por parte de médicos y pacientes. Se recomiendan estrateg
- Correction insulin is preferable to sliding scale insulin for managing inpatient hyperglycemia as it treats current high blood sugars and prevents future highs through the use of basal, nutritional, and correctional insulin components.
- The case study patient should be started on correctional insulin therapy which includes initiation of basal insulin, nutritional insulin with meals, and additional correctional insulin for blood sugars over target.
- When initiating or adjusting insulin therapy in the hospital, consideration should be given to the patient's diabetes type and weight to determine the total daily insulin dose and regimen. Frequent monitoring and adjustments are important to achieve good glycemic control.
This document provides guidelines for managing diabetes care in the hospital. The goals are to prevent hyperglycemia and hypoglycemia, promote short hospital stays, and ensure effective care transitions. It recommends using computerized order sets for glucose control and ordering an HbA1c test on admission. Target blood glucose levels are outlined for critically ill and non-critically ill patients. Insulin therapy guidelines, treating hypoglycemia, and managing special situations like steroids or enteral feeding are also covered.
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
1) The document discusses guidelines for initiating and adjusting insulin therapy in patients with type 2 diabetes. It recommends starting with a long-acting basal insulin and titrating the dose based on fasting blood glucose levels.
2) If HbA1c levels remain above 7% after titrating the basal insulin, pre-meal insulin such as rapid-acting insulin should be added and titrated based on pre-meal blood glucose levels.
3) The algorithm outlines multiple steps for intensifying insulin therapy through addition of more injections and adjustment of doses to achieve target HbA1c and blood glucose levels.
- The document discusses the history and evolution of glucose monitoring technologies from urine testing to current continuous glucose monitoring systems (CGM).
- It provides details on the advantages of real-time CGM (rtCGM) over self-monitoring of blood glucose (SMBG), including continuous readings without pain and ability to detect trends and prevent hypoglycemic events.
- The document compares different CGM systems like Dexcom G5 and G6, Medtronic Guardian Connect, and FreeStyle Libre Pro interms of features, calibration needs, and accuracy.
- It describes how sensor-augmented insulin pumps that suspend insulin delivery can help minimize hypoglycemia, and discusses hybrid closed-loop systems like
El documento describe diferentes tipos y regímenes de insulina para el tratamiento de la diabetes tipo 2. Explica que las insulinas basales como glargina se usan en combinación con agentes orales cuando el HbA1c está entre 7-9.5%, mientras que los regímenes basales-prandiales con NPH y cristalina son para HbA1c >9.5%. A pesar de su eficacia, el uso de insulina en Estados Unidos es bajo debido a barreras por parte de médicos y pacientes. Se recomiendan estrateg
- Correction insulin is preferable to sliding scale insulin for managing inpatient hyperglycemia as it treats current high blood sugars and prevents future highs through the use of basal, nutritional, and correctional insulin components.
- The case study patient should be started on correctional insulin therapy which includes initiation of basal insulin, nutritional insulin with meals, and additional correctional insulin for blood sugars over target.
- When initiating or adjusting insulin therapy in the hospital, consideration should be given to the patient's diabetes type and weight to determine the total daily insulin dose and regimen. Frequent monitoring and adjustments are important to achieve good glycemic control.
This document provides guidelines for managing diabetes care in the hospital. The goals are to prevent hyperglycemia and hypoglycemia, promote short hospital stays, and ensure effective care transitions. It recommends using computerized order sets for glucose control and ordering an HbA1c test on admission. Target blood glucose levels are outlined for critically ill and non-critically ill patients. Insulin therapy guidelines, treating hypoglycemia, and managing special situations like steroids or enteral feeding are also covered.
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
1) The document discusses guidelines for initiating and adjusting insulin therapy in patients with type 2 diabetes. It recommends starting with a long-acting basal insulin and titrating the dose based on fasting blood glucose levels.
2) If HbA1c levels remain above 7% after titrating the basal insulin, pre-meal insulin such as rapid-acting insulin should be added and titrated based on pre-meal blood glucose levels.
3) The algorithm outlines multiple steps for intensifying insulin therapy through addition of more injections and adjustment of doses to achieve target HbA1c and blood glucose levels.
The EMPA-KIDNEY trial aims to evaluate whether empagliflozin can benefit patients with chronic kidney disease (CKD) and cardiovascular disease outcomes in patients with or without diabetes. The trial plans to enroll approximately 6,000 patients with CKD at risk of kidney disease progression, defined as an eGFR of 20-45 mL/min/1.73 m2 or an eGFR of 45-90 mL/min/1.73 m2 with albuminuria above 200 mg/g. Patients will be randomly assigned to receive empagliflozin 10 mg daily or placebo daily in addition to standard of care. The primary outcome is a composite of cardiovascular death, end-stage kidney disease,
This document discusses diabetes technology including continuous glucose monitoring (CGM) systems, insulin pumps, and smart pens. CGM systems can monitor glucose levels in real-time or intermittently and have been shown to help lower A1C levels and reduce hypoglycemic episodes when used regularly. Insulin pumps can also help improve glucose control and reduce complications compared to multiple daily injections. While this technology has benefits, it also has costs and limitations, so expectations must be managed. Future diabetes devices may include implantable sensors, combined insulin and glucagon delivery, but self-care will still be required to manage the disease.
Recent advancement in managing diabetic nephropathypp_shivgunde
This document discusses recent advances in managing and understanding diabetic nephropathy. It begins with an introduction to diabetes and chronic kidney disease prevalence and prognosis. It then covers the pathophysiology of diabetic nephropathy and the current standard tripartite approach of intensive blood glucose control, blood pressure control, and RAAS blockade. Novel therapeutic modalities such as exploiting the renin-angiotensin-aldosterone axis through dual or combined blockade and aldosterone antagonism are also discussed.
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
This document provides an overview of diabetes management guidelines from the American Diabetes Association. It defines diabetes, classifies the different types, and outlines diagnostic criteria. It discusses the major components of treatment including medical nutrition therapy, physical activity, smoking cessation, comprehensive medical evaluation, glycemic targets, glucose monitoring, and pharmacological therapies. Glycemic goals and treatment approaches are presented for both type 1 and type 2 diabetes in adults and children.
Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes, Moh'd sharshirMoh'd sharshir
This document summarizes the LEADER clinical trial which assessed the long-term cardiovascular safety of the diabetes drug liraglutide. The trial involved over 9,000 patients with type 2 diabetes at high risk of cardiovascular disease who were randomly assigned to receive either liraglutide or a placebo over a follow-up period of 3-5 years. The primary outcome was a composite of death from cardiovascular causes, non-fatal heart attack or non-fatal stroke. The results showed that liraglutide was associated with a lower rate of the primary composite outcome compared to placebo.
This document discusses insulin therapy, including its pharmacodynamics, mechanisms of action, types of insulin, insulin regimens, administration techniques, side effects, and patient education. Insulin is secreted by the pancreas and lowers blood glucose levels by facilitating glucose uptake into cells. It acts on the liver, muscle, adipose tissue, and other organs. Types include rapid, short, intermediate and long-acting insulins. Patient education focuses on proper administration, storage, monitoring, hypoglycemia treatment, and lifestyle factors.
This document discusses SGLT2 inhibitors and DPP-4 inhibitors for the treatment of type 2 diabetes. SGLT2 inhibitors work by increasing glucose excretion in the urine, independently of insulin. They modestly lower blood pressure and weight. DPP-4 inhibitors work by inhibiting the DPP-4 enzyme and increasing GLP-1 and GIP levels. Both classes have few hypoglycemia risks but SGLT2 inhibitors should be used with caution in those with kidney impairment. Empagliflozin and canagliflozin are recommended for patients with cardiovascular disease.
This case discusses a 62-year-old woman with type 1 diabetes and hypoglycemia unawareness who underwent professional continuous glucose monitoring on two occasions. The initial monitoring revealed no overnight hypoglycemia but significant hyperglycemia throughout the day. Therapy was adjusted based on these results. Follow-up monitoring showed fewer post-meal excursions but continued hyperglycemia after high-fat dinners. Examination of the patient's diary revealed she had been inaccurately recording her blood glucose levels. Professional CGM was useful in identifying patterns of hyperglycemia and informing changes to the patient's insulin regimen and dietary advice.
Real-Time Continuous Glucose Monitoring (rtCGM) provides numerous advantages over traditional Self-Monitoring of Blood Glucose (SMBG) such as frequent glucose readings without pain, accurate trends over time, and alerts for low and high glucose values. While rtCGM has improved glycemic control and reduced hypoglycemia, limitations include sensor inaccuracy particularly during times of rapid glucose change and sensor interference from certain substances. Newer rtCGM systems have increased accuracy and usability with features like longer wear time and lack of calibration, but individual devices differ in approved age range and indications. RtCGM is especially beneficial for patients with hypoglycemia unawareness or frequent hypoglycemic episodes and can help
This document discusses two case studies of patients with type 2 diabetes mellitus. For the first case, a 50-year old female patient with HbA1c of 8.5-9% on oral medications, the summary recommends starting basal insulin such as glargine or detemir 15-20 units at bedtime. For the second case, a 68-year old obese male patient with HbA1c of 10.5% on maximum oral medications, the summary recommends starting a total daily dose of insulin of 0.3-0.5 units/kg, starting with premixed insulin such as Mixtard 18/10 units. Both cases emphasize individualizing treatment targets and adjusting insulin doses based on self-
This document discusses insulin therapy for diabetes. It begins with a brief history of insulin's discovery in 1921 by Banting and Best in Toronto. It then covers normal insulin secretion patterns and the types of insulin available, including rapid-acting, short-acting, intermediate-acting, premixed, basal, and extended long-acting analog insulins. The document discusses initiating and titrating insulin using the ADA treatment algorithm, beginning with basal insulin and adding bolus insulin as needed based on blood glucose levels and HbA1c targets. It also covers starting and adjusting premixed insulin doses.
Recent advances in the management of Diabetes MellitusShailaBanu3
This document discusses recent advances in the management of diabetes mellitus. It outlines the goals of diabetes treatment which include maintaining normoglycemia, preventing complications, and improving quality of life. It describes various modalities for diabetes treatment including insulin analogs like glargine, degludec and detemir which have improved pharmacokinetic profiles compared to traditional insulins. It also discusses newer non-insulin therapies like GLP-1 receptor agonists liraglutide, albiglutide and dulaglutide which mimic the effects of endogenous GLP-1 and help with glycemic control and weight loss. The document provides a comprehensive overview of the therapy options available for type 1 and type 2 diabetes
Achieving Treatment Outcome With DPP4i for Diabetic Patient "Efficacy Beyond ...Suharti Wairagya
This document provides an overview of achieving treatment outcomes for diabetic patients using DPP4 inhibitors. It begins with background on the presenter and discusses prevalence of diabetes worldwide. It then covers updates on diabetes classification, diagnosis, and management approaches from ADA guidelines. It discusses antihyperglycemic therapy and PERKENI guidelines. The document focuses on incretins and DPP-4 inhibition, comparing different DPP4 inhibitors. Studies show vildagliptin provides better 24-hour glucose fluctuation control and reduction in oxidative stress compared to sitagliptin. The conclusion is that vildagliptin may be better than sitagliptin at reducing glycemic variability and its associated complications.
The document discusses diabetes and glycemic control. It notes that 7 in 10 people with diabetes do not achieve desired treatment outcomes. By 2045, it is estimated that over 736 million people globally will have diabetes. Currently, over 425 million people have diabetes and about half of people with type 2 diabetes do not know they have it. Intensive treatment can help reduce complications, but tight control is difficult to achieve due to hypoglycemia risk, which poses a considerable burden. New basal insulins like degludec aim to provide improved glycemic control and lower hypoglycemia risk compared to older insulins like glargine.
Carbohydrate counting is an effective meal planning method that was used in the Diabetes Control and Complications Trial. It involves assessing a patient's needs, developing an optimal carbohydrate intake pattern based on lifestyle and schedule, and teaching patients how to achieve euglycemia through various carbohydrate intake patterns. Summarizing key points from the document, carbohydrate counting decreases A1C by 1-2% in people with diabetes, achieves and maintains target blood glucose and lipid levels, and prevents or slows chronic diabetes complications by modifying nutrient intake and lifestyle.
This document provides guidelines for the treatment of dyslipidemia to reduce cardiovascular risk. It defines dyslipidemia as abnormal lipid levels measured in a blood sample. The guidelines classify risk based on LDL cholesterol, total cholesterol, and HDL cholesterol levels. They recommend screening adults over certain ages for lipid levels and cardiovascular risk. Risk is assessed using tools like the Framingham Risk Score. Treatment involves starting statin therapy, with the intensity based on a patient's risk category. Lifestyle changes and other medications may also be used. The guidelines aim to identify those who will benefit most from treatment to lower lipid levels and cardiovascular risk.
Prevenzione del tromboembolismo venoso (TEV) in medicina internaPlinio Fabiani
The majority of hospitalized patients have risk factors for VTE.
DVT is common in many groups of hospitalized patients.
DVT and PE acquired in hospital are often clinically silent.
DVT and symptomatic PE → fatal PE.
Costs of exams in symptomatic patients.
Risks and costs of the treatment of VTE is not prevented, eg .: bleeding.
The future increase in risk of VTE recurrence.
Thromboprophylaxis is highly effective in the prevention of DVT and proximal DVT.
The Cost/Effectiveness of prophylaxis has been repeatedly demonstrated.
The EMPA-KIDNEY trial aims to evaluate whether empagliflozin can benefit patients with chronic kidney disease (CKD) and cardiovascular disease outcomes in patients with or without diabetes. The trial plans to enroll approximately 6,000 patients with CKD at risk of kidney disease progression, defined as an eGFR of 20-45 mL/min/1.73 m2 or an eGFR of 45-90 mL/min/1.73 m2 with albuminuria above 200 mg/g. Patients will be randomly assigned to receive empagliflozin 10 mg daily or placebo daily in addition to standard of care. The primary outcome is a composite of cardiovascular death, end-stage kidney disease,
This document discusses diabetes technology including continuous glucose monitoring (CGM) systems, insulin pumps, and smart pens. CGM systems can monitor glucose levels in real-time or intermittently and have been shown to help lower A1C levels and reduce hypoglycemic episodes when used regularly. Insulin pumps can also help improve glucose control and reduce complications compared to multiple daily injections. While this technology has benefits, it also has costs and limitations, so expectations must be managed. Future diabetes devices may include implantable sensors, combined insulin and glucagon delivery, but self-care will still be required to manage the disease.
Recent advancement in managing diabetic nephropathypp_shivgunde
This document discusses recent advances in managing and understanding diabetic nephropathy. It begins with an introduction to diabetes and chronic kidney disease prevalence and prognosis. It then covers the pathophysiology of diabetic nephropathy and the current standard tripartite approach of intensive blood glucose control, blood pressure control, and RAAS blockade. Novel therapeutic modalities such as exploiting the renin-angiotensin-aldosterone axis through dual or combined blockade and aldosterone antagonism are also discussed.
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
This document provides an overview of diabetes management guidelines from the American Diabetes Association. It defines diabetes, classifies the different types, and outlines diagnostic criteria. It discusses the major components of treatment including medical nutrition therapy, physical activity, smoking cessation, comprehensive medical evaluation, glycemic targets, glucose monitoring, and pharmacological therapies. Glycemic goals and treatment approaches are presented for both type 1 and type 2 diabetes in adults and children.
Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes, Moh'd sharshirMoh'd sharshir
This document summarizes the LEADER clinical trial which assessed the long-term cardiovascular safety of the diabetes drug liraglutide. The trial involved over 9,000 patients with type 2 diabetes at high risk of cardiovascular disease who were randomly assigned to receive either liraglutide or a placebo over a follow-up period of 3-5 years. The primary outcome was a composite of death from cardiovascular causes, non-fatal heart attack or non-fatal stroke. The results showed that liraglutide was associated with a lower rate of the primary composite outcome compared to placebo.
This document discusses insulin therapy, including its pharmacodynamics, mechanisms of action, types of insulin, insulin regimens, administration techniques, side effects, and patient education. Insulin is secreted by the pancreas and lowers blood glucose levels by facilitating glucose uptake into cells. It acts on the liver, muscle, adipose tissue, and other organs. Types include rapid, short, intermediate and long-acting insulins. Patient education focuses on proper administration, storage, monitoring, hypoglycemia treatment, and lifestyle factors.
This document discusses SGLT2 inhibitors and DPP-4 inhibitors for the treatment of type 2 diabetes. SGLT2 inhibitors work by increasing glucose excretion in the urine, independently of insulin. They modestly lower blood pressure and weight. DPP-4 inhibitors work by inhibiting the DPP-4 enzyme and increasing GLP-1 and GIP levels. Both classes have few hypoglycemia risks but SGLT2 inhibitors should be used with caution in those with kidney impairment. Empagliflozin and canagliflozin are recommended for patients with cardiovascular disease.
This case discusses a 62-year-old woman with type 1 diabetes and hypoglycemia unawareness who underwent professional continuous glucose monitoring on two occasions. The initial monitoring revealed no overnight hypoglycemia but significant hyperglycemia throughout the day. Therapy was adjusted based on these results. Follow-up monitoring showed fewer post-meal excursions but continued hyperglycemia after high-fat dinners. Examination of the patient's diary revealed she had been inaccurately recording her blood glucose levels. Professional CGM was useful in identifying patterns of hyperglycemia and informing changes to the patient's insulin regimen and dietary advice.
Real-Time Continuous Glucose Monitoring (rtCGM) provides numerous advantages over traditional Self-Monitoring of Blood Glucose (SMBG) such as frequent glucose readings without pain, accurate trends over time, and alerts for low and high glucose values. While rtCGM has improved glycemic control and reduced hypoglycemia, limitations include sensor inaccuracy particularly during times of rapid glucose change and sensor interference from certain substances. Newer rtCGM systems have increased accuracy and usability with features like longer wear time and lack of calibration, but individual devices differ in approved age range and indications. RtCGM is especially beneficial for patients with hypoglycemia unawareness or frequent hypoglycemic episodes and can help
This document discusses two case studies of patients with type 2 diabetes mellitus. For the first case, a 50-year old female patient with HbA1c of 8.5-9% on oral medications, the summary recommends starting basal insulin such as glargine or detemir 15-20 units at bedtime. For the second case, a 68-year old obese male patient with HbA1c of 10.5% on maximum oral medications, the summary recommends starting a total daily dose of insulin of 0.3-0.5 units/kg, starting with premixed insulin such as Mixtard 18/10 units. Both cases emphasize individualizing treatment targets and adjusting insulin doses based on self-
This document discusses insulin therapy for diabetes. It begins with a brief history of insulin's discovery in 1921 by Banting and Best in Toronto. It then covers normal insulin secretion patterns and the types of insulin available, including rapid-acting, short-acting, intermediate-acting, premixed, basal, and extended long-acting analog insulins. The document discusses initiating and titrating insulin using the ADA treatment algorithm, beginning with basal insulin and adding bolus insulin as needed based on blood glucose levels and HbA1c targets. It also covers starting and adjusting premixed insulin doses.
Recent advances in the management of Diabetes MellitusShailaBanu3
This document discusses recent advances in the management of diabetes mellitus. It outlines the goals of diabetes treatment which include maintaining normoglycemia, preventing complications, and improving quality of life. It describes various modalities for diabetes treatment including insulin analogs like glargine, degludec and detemir which have improved pharmacokinetic profiles compared to traditional insulins. It also discusses newer non-insulin therapies like GLP-1 receptor agonists liraglutide, albiglutide and dulaglutide which mimic the effects of endogenous GLP-1 and help with glycemic control and weight loss. The document provides a comprehensive overview of the therapy options available for type 1 and type 2 diabetes
Achieving Treatment Outcome With DPP4i for Diabetic Patient "Efficacy Beyond ...Suharti Wairagya
This document provides an overview of achieving treatment outcomes for diabetic patients using DPP4 inhibitors. It begins with background on the presenter and discusses prevalence of diabetes worldwide. It then covers updates on diabetes classification, diagnosis, and management approaches from ADA guidelines. It discusses antihyperglycemic therapy and PERKENI guidelines. The document focuses on incretins and DPP-4 inhibition, comparing different DPP4 inhibitors. Studies show vildagliptin provides better 24-hour glucose fluctuation control and reduction in oxidative stress compared to sitagliptin. The conclusion is that vildagliptin may be better than sitagliptin at reducing glycemic variability and its associated complications.
The document discusses diabetes and glycemic control. It notes that 7 in 10 people with diabetes do not achieve desired treatment outcomes. By 2045, it is estimated that over 736 million people globally will have diabetes. Currently, over 425 million people have diabetes and about half of people with type 2 diabetes do not know they have it. Intensive treatment can help reduce complications, but tight control is difficult to achieve due to hypoglycemia risk, which poses a considerable burden. New basal insulins like degludec aim to provide improved glycemic control and lower hypoglycemia risk compared to older insulins like glargine.
Carbohydrate counting is an effective meal planning method that was used in the Diabetes Control and Complications Trial. It involves assessing a patient's needs, developing an optimal carbohydrate intake pattern based on lifestyle and schedule, and teaching patients how to achieve euglycemia through various carbohydrate intake patterns. Summarizing key points from the document, carbohydrate counting decreases A1C by 1-2% in people with diabetes, achieves and maintains target blood glucose and lipid levels, and prevents or slows chronic diabetes complications by modifying nutrient intake and lifestyle.
This document provides guidelines for the treatment of dyslipidemia to reduce cardiovascular risk. It defines dyslipidemia as abnormal lipid levels measured in a blood sample. The guidelines classify risk based on LDL cholesterol, total cholesterol, and HDL cholesterol levels. They recommend screening adults over certain ages for lipid levels and cardiovascular risk. Risk is assessed using tools like the Framingham Risk Score. Treatment involves starting statin therapy, with the intensity based on a patient's risk category. Lifestyle changes and other medications may also be used. The guidelines aim to identify those who will benefit most from treatment to lower lipid levels and cardiovascular risk.
Prevenzione del tromboembolismo venoso (TEV) in medicina internaPlinio Fabiani
The majority of hospitalized patients have risk factors for VTE.
DVT is common in many groups of hospitalized patients.
DVT and PE acquired in hospital are often clinically silent.
DVT and symptomatic PE → fatal PE.
Costs of exams in symptomatic patients.
Risks and costs of the treatment of VTE is not prevented, eg .: bleeding.
The future increase in risk of VTE recurrence.
Thromboprophylaxis is highly effective in the prevention of DVT and proximal DVT.
The Cost/Effectiveness of prophylaxis has been repeatedly demonstrated.
Dietetico per il presidio ospedaliero del Mugello. Diete standard per la gest...cristinalucherini
Manuale per la compilazione di un dietetico per la ristorazione collettiva e ospedaliera con definizione dei criteri per la valutazione di diete standard per le varie patologie. Studio effettuato per un progetto messo in opera nell'ospedale del Mugello (Borgo San Lorenzo), Azienda Sanitaria Firenze, U.O. Dietetica Professionale. Dietista Dottoressa Cristina Lucherini
The document summarizes the minutes from a Sanofi general meeting held on May 4, 2015. It discusses Sanofi's financial results and performance, compensation policies, progress in research and development, and priorities and recent product launches. Key points included a review of 2014 results, executive compensation plans, an update on pipeline and recent approvals of new drugs to treat multiple sclerosis, diabetes, and other conditions.
The document discusses Sanofi and Regeneron's Phase 3 clinical trial program for sarilumab, an investigational IL-6 receptor monoclonal antibody for the treatment of rheumatoid arthritis. The program includes several trials involving over 5,000 patients total to evaluate sarilumab both as monotherapy and in combination with methotrexate or other disease-modifying anti-rheumatic drugs. The two largest trials, MOBILITY and TARGET, enrolled over 1,700 patients and evaluated sarilumab versus placebo for improving signs and symptoms of rheumatoid arthritis and physical function when added to background therapy. Results from these trials demonstrated statistically significant improvements for sarilumab compared to placebo.
This document summarizes a presentation on diabetes given on June 9th, 2015 in Boston. It includes the following:
1. An overview of the ELIXA trial results which found that lixisenatide was non-inferior to placebo in reducing cardiovascular events in patients with type 2 diabetes after acute coronary syndrome.
2. A discussion of lixisenatide both as a standalone treatment and in combination with basal insulin, highlighting data from clinical trials demonstrating its efficacy in lowering blood sugar and weight.
3. Updates on Sanofi's diabetes drugs Afrezza and Toujeo, including U.S. launch progress and real-world use.
4. An agenda for
The document discusses the global diabetes care market and insulin market. It notes that diabetes is a growing global epidemic driven by lifestyle changes and demographics. The insulin market has seen sustained double-digit growth due to factors like increasing diagnosis and treatment rates, intensifying insulin regimens, and device penetration. Insulin consumption is expected to continue increasing significantly in coming decades. Modern insulin now constitutes over 80% of the insulin market by value due to upgrades in treatment. Characteristics of the insulin industry include a chronic disease leading to long patient-drug relationships and brand loyalty.
Terapia insulinica in corso di trattamento cortisonico/Insulin treatment in p...Fabio Baccetti
Il trattamento insulinico più adatto nei pazienti con iperglicemia che assumono terapia corticosteroidea.
Insulin treatment in patient with hyperglycemia treated with corticosteroid therapy.
Slides presentate dai relatori durante il corso avanzato "Aspetti ematologici della malattia di Gaucher: dalla diagnosi al trattamento", che si è tenuto a Udine nei giorni 25 e 26 ottobre 2017.
Un gruppo di Diabetologi ed Endocrinologi OSR, tra cui specializzandi e specializzati dell’Università Vita-Salute San Raffaele, ha partecipato e presentato quattro importanti studi durante il 26° Congresso Nazionale della Società Italiana di Diabetologia, tenutosi a Rimini dal 4 al 7 Maggio
(http://www.siditalia.it/formazione/congressi-e-convegni/536-26-congresso-nazionale-rimini-4-7-maggio-2016)
Evidenze sul possibile uso delle piante officinali nella terapia ipoglicemizz...Grace Cosentino
In che modo la natura può esserci d'ausilio nell'approccio al Diabete? Una malattia che secondo dati e statistiche è in forte aumento e diffusa negli adulti e giovani. In questa presentazione vengono esposti alcuni dei risultati di ricerca più interessanti e incoraggianti dell'ultimo decennio dal punto di vista fitoterapico.
Scompenso cardiaco a frazione di eiezione preservata - Heart failure with pre...Plinio Fabiani
HFpEF (heart failure with preserved ejection fraction) is a challenge for cardiologists, internists and geriatricians since virtually no treatment demonstrated significant improvement of hard end-points in many multicentric interventional clinical trials. HFpEF is as relevant as HFrEF (heart failure with reduced ejection fraction) in terms of epidemiological aspects, i.e incidence, prevalence, mortality, hospital admission.
The pivotal approach to HFpEF seems to be treatment and prevention of comorbidities, more than a pharmacological approach merely directed to heart failure, while in HFrEF beta-blockers, ACEI/ARBs, Mineralcorticoid Antagonists clearly demonstrated to improve prognosis.
Le comorbilità nel paziente con scompenso cardiacoPlinio Fabiani
Comorbidities affect clinical hystory and life expectancy in people with chronic heart failure (CHF). Hospital re-admissions are direct consequence of difficulties in management of CHF. Appropriate pathways are essential following an episode of acute heart failure. Chronic renal failure, diabetes and anemia are significantly connected with mortality and hospital admission in patients with chronic heart failure. Most of the patients (74%) have three or more comorbidieties. Hospital admissions mainly explain the economic burden of CHF. Non-cardiac comorbidities increase preventable hospitalizations (i.e. ambulatory care sensitive conditions). It's mandatory to ensure a seamless transition from inpatient to outpatient care for all patients, and transfer logistic and professional management from hospital to territory to improve quality of life, life expectancy and reduce economic burden of CHF.
The influence of thyroid function on hemodynamic balance, heart rate and rhythm is well known by every clinical practitioner. But which is the real impact of different conditions, both clinical and subclinical, on cardiovascular risk? What are the evidence based data supporting thyroid responsibility? Are they weak or strong? This is the issue of the presentation.
Il ruolo dell’ecocardiografia nell’ictus acutoPlinio Fabiani
What can we expect from echocardiography in the acute phase of stroke ? We can seek not only for clots in the heart chambers , vegetations adherent to valves, or aortic arch atheromas, but any favorable condition that can facilitate atrial fibrillation , the leading cause of cardioembolic stroke .
Antiaggregazione per la prevenzione secondaria dopo ictus ischemico: mono o d...Plinio Fabiani
Antiaggregazione per la prevenzione secondaria dopo ictus ischemico: mono o doppia?
Rassegna dei trials clinici e metanalisi sulla singola o doppia antiaggrgazione piastrinica nella prevenzione delle recidive di ictus, in rapporto al rischio emorragico.
Il rischio tromboembolico nelle patologie arteriose e venose della donna 3Plinio Fabiani
This document discusses risk factors for thromboembolism in women, including reproductive factors and diseases that are more common in women. It provides statistics on the incidence of venous thromboembolism and notes that women are at higher risk during pregnancy and postpartum, as well as when using oral contraceptives or undergoing hormone replacement therapy. The document also examines differences in stroke risk factors and outcomes between men and women.
Il rischio tromboembolico nelle patologie arteriose e venose della donna 3
La terapia insulinica in ospedale
1. Il paziente diabetico in ospedale:
La terapia insulinica
Plinio Fabiani
Medicina Interna
Ospedale di Portoferraio
2. Il sottoscritto Plinio Fabiani
ai sensi dell’art. 3.3 sul Conflitto di Interessi, pag. 17 del Reg. Applicativo
dell’Accordo Stato-Regione del 5 novembre 2009,
dichiara
X che negli ultimi due anni NON ha avuto rapporti diretti di finanziamento
con soggetti portatori di interessi commerciali in campo sanitario
che negli ultimi due anni ha avuto rapporti diretti di finanziamento con i
seguenti soggetti portatori di interessi commerciali in campo sanitario:
- ………………..
- ……………………….
- ……………………..
3. FADOI GEMINI E FADOI PRACTICE
• Il 23% dei ricoveri nei reparti di medicina interna riguarda persone con
diabete, secondo i dati rilevati dagli studi
• FADOI GEMINI e FADOI PRACTICE, ricoverati
diabetici non diabetici
4. DIABETE E RISCHIO DI OSPEDALIZZAZIONI
• Il tasso di ricovero ordinario nei diabetici è il 62% più alto rispetto ai non
diabetici (343 contro 212 per mille persone)
• rispetto al non diabetico di pari sesso e età per quasi tutte le cause (+188%
per scompenso cardiaco,
• +120% per insufficienza respiratoria, +129% per infarto miocardico, +46% per
aritmia) (6).
www.siditalia.it/images/Documenti/NEWS/Rapporto_Arno_Diabete_2015.pdf
5. IPERGLICEMIA E MORTALITÀ INTRAOSPEDALIERA
(ICU)
Glicemia (valore medio)
Krinsley JS. Mayo Clin Proc 2003; 78(12):1471-8
Stanford Hospital -1826 pz Dal 01-10-1999 al 04-04-2002
Mortalità (%)
6. Mod da: F. Farrokhi et al.Best
Practice & Research Clinical
Endocrinology & Metabolism
25 (2011) 813–824
7. MORTALITY RISK IS GREATER IN HYPERGLYCEMIC
PATIENTS WITHOUT HISTORY OF DIABETES
111-145
146-199
200-300
>300
MeanBG(mg/dL)
Odds Ratio Odds Ratio
History Diabetes,
N= 62,868
No History Diabetes,
N=152,910
Falciglia M, et al. Crit Care Med. 2009;37:3001-3009.
7
8. IPERGLICEMIA AL RICOVERO
• a) diabete mellito noto preesistente al ricovero;
• b) diabete mellito di prima diagnosi durante la degenza,
persistente dopo la dimissione;
• c) iperglicemia correlata alla degenza o iperglicemia da
stress: si tratta di persone non note come diabetiche, con
un’iperglicemia comparsa per la prima volta durante il
ricovero e regredita alla dimissione.
7. Greci LS, Kailasam M, Malkani S, et al. Utility of HbA1c levels for diabetes case
finding in hospitalized patients with hyperglycemia. Diabetes Care 2003;26:1064-
1068
La distinzione fra queste forme non è sempre immediata. A tale scopo, di
grande utilità è la misurazione dell’HbA1c, che andrebbe sempre eseguita
al momento del ricovero in ospedale
9. Paziente non noto come diabetico : HbA1c
< 6.5% > 6.5%
Iperglicemia da Stress Diabete di nuova diagnosi
Diabete noto :grado di compenso glicemico
< 7% : buono >8% : scadente
10. ALCUNE DEFINIZIONI
• Hyperglycemia in hospitalized patients has been defined as blood
glucose >140 mg/dL (7.8 mmol/L). Blood glucose levels that are
significantly and persistently above this level require reassessing
treatment.
• An admission A1C value >6.5% (48 mmol/mol) suggests that diabetes
preceded hospitalization.
• Hypoglycemia in hospitalized patients has been defined as blood
glucose <70 mg/dL (3.9 mmol/L) and severe hypoglycemia as <40
mg/dL (2.2 mmol/L) (6).
Diabetes Care 2016;39(Suppl. 1):S99–S104 | DOI: 10.2337/dc16-S016
11. TERAPIA DEL DIABETE NEL PAZIENTE OSPEDALIZZATO
• L’utilizzo dei principali farmaci ipoglicemizzanti orali o iniettivi diversi
dall’insulina (secretagoghi, biguanidi, tiazolidinedioni, incretine, gliflozine)
presenta notevoli limitazioni in caso di patologie acute e pertanto il loro uso va
considerato attentamente durante il ricovero ospedaliero ed è in genere
controindicato o inopportuno nel paziente critico.
• La somministrazione di insulina è pertanto la terapia di scelta nel paziente
diabetico ospedalizzato non stabilizzato.
• (Livello della prova VI, Forza della raccomandazione B)
12. • Sono, purtroppo, carenti trial clinici in grado di definire gli obiettivi glicemici
nei degenti non critici.
• Pur essendo ormai acquisito l’effetto negativo di valori glicemici elevati
sull’esito della degenza, negli ultimi anni l’obiettivo di mantenere anche
durante il ricovero target glicemici sovrapponibili a quelli usati nella gestione
ambulatoriale ha lasciato il posto a un atteggiamento di maggiore prudenza
13. • La terapia insulinica per via sottocutanea deve seguire uno schema
programmato che preveda l’uso di insulina basale. Questo schema deve essere
integrato da un algoritmo di correzione basato sulla glicemia al momento
dell’iniezione. Il metodo di praticare insulina solamente “al bisogno” (sliding
scale) deve essere abbandonato.
14. NEL TUO REPARTO, COME VIENE CORRETTA LA DOSE DI
INSULINA
REGOLARE/RAPIDA PRIMA DEI PASTI? (N=660)
1. Applicando il metodo “sliding scale”,
e quindi secondo il valore di glicemia
riscontrato prima della
somministrazione di insulina
2. Le modifiche vengono eseguite
secondo specifiche istruzioni basate
sulle caratteristiche del paziente e
sull’andamento delle glicemie dei
giorni precedenti
3. Si utilizza un fattore di correzione per
modificare la dose di insulina a
seconda dei valori delle glicemie e
della dose giornaliera di insulina
4. Viene sempre consultato il
diabetologo
5. Viene consultato il diabetologo solo
in situazioni particolarmente critiche
Boli di correzione (supplemento)
La riduzione del glucosio per 1 unità di insulina rapida
Usa la regola del 1700 o del peso per determinare F.C.
(Fattore di correzione)
FC = 1700 diviso la Dose Totale Giornaliera(DTG)
( es. se DTG = 56 unità: CF = 1700/56 = 30
mediamente 1 unità di insulina ridurrà il BG di 30
mg/dl)
FC = 3000 diviso il peso in Kg
15.
16. NICE - SUGAR
• Worldwide, multicenter (6104 pts, 42 hospitals)
• Expected to be in ICU > 3 days
• Intensive glucose control: 81-108 mg/L
• Conventional glucose control: < 180mg/dL
• Iv insulin given if glu > 180
• Mean glucose intensive control: 108
• Mean glucose conventional control: 144
17. NICE - SUGAR
• Intensive glucose control increased 90 day mortality
• Intensive control mortality 27.5%
• Conventional control mortality 24.9%
18. Tight Glycemic Control in Critically Ill Adults
A Meta-analysis of 26 Randomized Controlled Trials
(13,567 patients)
Severe
Hypoglycemia
(≤40 mg/dL)
Griesdale DE, et al. CMAJ. 2009;180:821-827.
18
20. RACCOMANDAZIONE DEGLI STANDARD ITALIANI
• A fronte di risultati contrastanti, pur dando per acquisita l’esigenza di evitare
un’iperglicemia marcata nei pazienti ricoverati in area critica, è evidentemente
necessaria una riconsiderazione dell’atteggiamento di grande aggressività
terapeutica adottato negli ultimi anni. In accordo con un editoriale del New
England Journal of Medicine (30) e con il documento congiunto ADA-AACE del
giugno 2009 (4) pertanto, in attesa di nuove evidenze, un obiettivo di 140-180
mg/dl, pare al momento ragionevole.
21. PROTOCOLLO DI YALE PER LA TERAPIA INFUSIVA
• 1) INFUSIONE DI INSULINA: miscelare 1 unità di insulina umana regolare per 1 ml di sol.
fisiologica 0,9% NaCl (es. 50 U insulina in 50 ml fisiologica).Somministrare con pompa di
infusione (con incrementi di 0,5 U/h).
• 2) PRIMING: prima di iniziare l’infusione, iniettare 50 ml della soluzione nei tubi di
infusione (per saturare i siti di legame insulinico nei tubi).
• 3) TARGET GLICEMICO: 120-160 mg/dl.
• 4) BOLO e VELOCITÀ DI INFUSIONE INIZIALE DELL’INSULINA: dividere GM per 100, poi
arrotondare alla più vicina 0,5 U per il bolo e per la velocità di infusione iniziale.
• Esempi:
• 1) GM iniziale = 325 mg/dl: 325:100=3,25, arrotondato a 3,5: praticare bolo ev 3,5 U, ed
iniziare infusione a 3,5 U/h
• 2) GM iniziale = 174 mg/dl: 148:70=1,74, arrotondato a 1,5: praticare bolo ev 1,5 einiziare
infusione a 1,5U/h
1) GM iniziale = 325 mg/dl: 325:100=3,25,
arrotondato a 3,5: praticare bolo ev 3,5 U, ed
iniziare infusione a 3,5 U/h
22. 75 – 99 100-139 140-199 > 200 Istruzioni
Glic. >50mg/dl/hr
Infusione 2D
Glicemia mg/dl
Glicemia
Glicemia
> 25 mg/dl/h
Glic. 1-50 mg
dl/h o Invariata
Glic. Invariata
o 1-25 mg
Infusione 1D
Glicemia
Glicemia invar.
o 1-25 mg
Glic. 1-50 mg
mg/dl/h
Glic. 26-55
mg dl/h
Non si varia
l’infusione
Glicemia invar. o
1-25 mg/dl/h
Glic. 26-50
mg/dl/h
Glic. 51-75
mg dl/h
Glic. 56-100
mg dl/h
Infusione 1D
Glic. > 25
mg/dl/h
Glic. >50 mg
dl/h
Glic. 75 mg
dl/h
> Glic. >100
mg/dl/h
Sospensione inf.
per 30 m’ e poi
Infus.di 1D
Infusione attuale di
Insulina U/hr
Variazione di un delta
U/hr
Variazione di due delta
U/hr
< 3.0 0.5 1
3-6 1 2
6.5-9.5 1.5 3
10-14.5 2 4
15-19.5 3 6
21
SCHEMA A
SCHEMA B
( 2 U )
( 1 U )
( 1 U )
(1 U)
23. TERAPIA INFUSIONALE ENDOVENOSA
• La terapia infusionale endovenosa trova una sua precisa indicazione
nell’ambito dei reparti di terapia intensiva, ma anche nei reparti di degenza
ordinaria, medici e chirurgici, spesso si preferisce optare per questo tipo di
approccio terapeutico, necessario nel paziente che non si alimenta per os e
nel paziente con valori non a target con la terapia sottocutanea. Oltre alla
chetoacidosi diabetica e allo scompenso iperosmolare non chetosico, le
indicazioni principali comprendono l’iperglicemia nelle
• seguenti condizioni:
• a) periodo perioperatorio;
• b) interventi di cardiochirurgia;
• c) trapianto d’organo;
• d) shock cardiogeno;
• d) terapia steroidea ad alte dosi;
• e) nutrizione parenterale.
24. RIPRISTINO DELLA TERAPIA SOTTOCUTANEA NELLA
FASE POST-CRITICA
• Superata la fase critica, può essere programmato il passaggio dalla terapia
insulinica endovenosa a quella sottocutanea.
• Per effettuare tale passaggio è necessario calcolare le quantità di insulina che
il paziente ha ricevuto nelle ultime 24 ore al fine di ottenere il fabbisogno
insulinico giornaliero.
• Tale fabbisogno (prudentemente ridotto di un 20%) deve essere
somministrato per il 50% come insulina basale e per il 50% come insulina
prandiale. L’analogo basale deve essere somministrato 2-3 ore prima di
sospendere la terapia insulinica infusiva
27. Approccio personalizzato
aspettativa di vita più breveaspettativa di vita più lunga
Target HbA1c
più stretto
Target HbA1c
più blando
Altri fattori che influenzano il target:
1) Durata della malattia 2) Comorbilità) Malattia vascolare 3) abitudini
Adattato da Inzucchi SE, et al Diabetes Care 2015;38:140-149
HbA1c 7%
53 mmol/mol
28.
29. Years from Diagnosis
β-cellFunction(%)
100
80
60
40
20
0
Type 2 Diabetes:
Disease of Progressive β-cell Failure
The UK Prospective Diabetes Study
Possible
initial loss
of -cell
function
Lebovitz HE. Diabetes Review. 1999;7:139-153.
IGT
Post-prandial
hyperglycemia
35. 25 % less nocturnal hypoglycemia
Rates of nocturnal hypoglycemia:
•4.41 (deg) vs. 5.86 (gla) episodes
per patient-year of exposure; 0.75
[95% CI 0.59 to 0.96]; p=0.21
36. U300 is a new long-acting basal insulin with a more
even and prolonged PK/PD profile vs glargine
U300
Glargine
Reduction of volume by 2/3
Reduction of depot surface by 1/2
U300
Same amount of units
Steinstraesser A et al. Diabetes Obes Metab. 2014;16:873-6; Becker RHA et al. Diabetes Care. 2014 Aug 22. pii: DC_140006. [Epub ahead of print]
Stesse
unità di
insulina
in 1/3 di
volume
Glargine