Transcript Diapositiva 1

Remissione del diabete tipo 2: Terapia Medica
Dr. Monica Nannipieri
Dipartimento di Medicina Clinica e Sperimentale
Università di Pisa
Therapeutic implications of the pathogenesis of type 2 diabetes
Decreased
Insulin
Secretion
Islet-a cell
Decreased
Incretin Effect
Hyperglycemia
Increased
Lipolysis
Increased
Glucagon
Secretion
Increased
Glucose
Reabsorption
1.
Effective treatment of type 2 diabetes requires multiple drugs used in combination to correct multiple pathophysiological
defects
2.Increased
Treatment should be based on known pathogenic abnormalities and not simply on reduction
of HbA1C
Decreased
HGP
3. Therapy must be started early in the natural history of type 2 diabetes to prevent progressive
beta-cell
failure
Glucose
Uptake
Neurotransmitter
Dysfunction
Adapted from De Fronzo RA, Diabetes 2009
Therapeutic implications of the pathogenesis of type 2 diabetes
Therapeutic implications of the pathogenesis of type 2 diabetes
ADA-EASD Position Statement:
Management of Hyperglycemia in T2DM
•
Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
- Individualization is key:
 Tighter targets (6.0 - 6.5%) - younger, healthier
+
 Looser targets (7.5 - 8.0% ) - older, comorbidities,
prone, etc.
- Avoidance of hypoglycemia
PG = plasma glucose
hypoglycemia
Therapeutic implications of the pathogenesis of type 2 diabetes
Diabetes Care 2012, Diabetologia 2012
[..] For a chronic illness such as diabetes, it may be more accurate to use the
term remission than cure. Current or potential future therapies for type 1 and
type 2 diabetes will likely always leave patients at risk for relapse, given
underlying pathophysiologic abnormalities and/or genetic predisposition
The authors agreed upon the following definitions, which are the same for type
1 and type 2 diabetes: Remission is defined as achieving glycemia below the
diabetic range in the absence of active pharmacologic (anti-hyperglycemic
medications, immunosuppressive medications) or surgical (ongoing procedures
such as repeated replacement of endoluminal devices) therapy
Diab Care, vol 32 n 11 November 2009
HbA1c < 6.5%
Glycemia 100-125 mg/dl
HbA1c < 6.0%
Glycemia < 100 mg/dl
Buse JB et al. Diab Care 2009
Bariatric Surgery versus Conventional Medical Therapy for Type 2
Diabetes
6.5
Mingrone G NEJM 2012
Is it possible to have Remission of Type 2 Diabetes with
Medical Therapy?
DIABETES REMISSION AFTER WEIGHT LOSS INTERVENTION
Randomized control trial, 4 years follow-up 4503 pts
Gregg EW JAMA 2012
Is it possible to have Remission of Type 2 Diabetes with
Medical Therapy?
Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
118 pts in CSII for 2 wks,
53 non remission
65 in remission for >1year
Chen A, Diabetes Care 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
b-cell Function
188 patients
68.9%
60.6%
49.5%
Liu J End Jap 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
Liu J End Jap 2012
Is it possible to have Remission of Type 2 Diabetes with Medical Therapy?
84 patients
42 patients
42 patients
Wen XU, Chin Med J 2009
Weng J, Lancet 2008
Is it possible to have Remission of Type 2 Diabetes with
Medical Therapy?
When?
Predictors of successful sustained euglycemia
Retnakaran R, Zinman B, Diabetes, Obesity and Metabolism, 2012.
SUMMARY
The effects of medical treatment on diabetes are related to improvement
or restoration of:
a.insulin sensitivity (life style, weight loss);
b.b-cell function (hormonal factors and reduction of glucotoxicity and
lipotoxicity).
Rate of success of medical treatment in terms of diabetes remission may
depend on the extent of b-cell dysfunction/loss at time of treatment and,
hence, could be lower for:
a.longer diabetes duration;
b.less BMI.