Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Outlines
• Prevalence
• Rationale for early initiation
• T2DM management and guideline
• Insulin Levemir® & A1Chieve study
Sources :
1. IDF Diabetes Atlas, 8th ed
Number of people with diabetes worldwide and per region in
2017 and 2045 (20-79 years)
Diabetes:
A Global Emergency
Sources :
1. IDF Diabetes Atlas, 8th ed
Prevalence of Obesity and Diabetes in Indonesia:
Health Basic Research, 2013
Insulin resistance
Insulin secretion
PPG
FPG
Microvascular complications
Macrovascular complications
1. Adapted from: Ramlo-Halsted BA, Edelman SV. Clincial Diabetes 2000;18(2): http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm
Hyperglycemia affects both micro-vascular and macro-vascular
complications
Soewondo, P, et al. The DiabCare Asia 2008 Study – Outcomes on control and complications of type 2 Diabetets
patients in Indonesia. Med J Indones 2010; 19:235-44)
Risk of complications increases as HbA1c increases
1000 patient-years
Microvascular disease
Incidence per
Myocardial infarction
Outlines
• Prevalence
• Rationale for early initiation
• T2DM management and guideline
• Insulin Levemir® & A1Chieve study
Poor glycemic control (HbA1c) is a global problem
•
Patients remain on multiple OAD therapy too long
8.9%
+0.2%
0.5%*
−1.0%*
Pre-treatment
Mean HbA1c (%)
Post-treatment
*p<0.001
OADs, oral antidiabetic drugs
Calvert et al. Br J Gen Pract 2007;57:455–60
Insulin remains the most efficacious glucose
lowering agent
Decrease in HbA1c: Potency of monotherapy
HbA1c %
CSII, continuous subcutaneous insulin infusion; MDI, multiple daily injection; OHA, oral hypoglycaemic agent
Weng et al. Lancet 2008;371:1753–60
ESW/MAR-17/RTD LVM-2017/001
Outlines
• Prevalence
• Rationale for early initiation
• T2DM management and guideline
• Insulin Levemir® & A1Chieve study
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
Anti-hyperglycemic therapy in adults with type 2 diabetes
A1C is greater than or equal 10%, blood glucose is greater than or equal 300 mg/dL, or
patient markedly symptomatic, consider combination injectable therapy.
Dual Therapy
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
Anti-hyperglycemic therapy in adults with type 2 diabetes
A1C is less than 9%, consider monotherapy.
Monotherapy
Triple Therapy
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
Anti-hyperglycemic therapy in adults with type 2 diabetes
A1C is less than 9%, consider monotherapy.
A1C is greater than or equal 10%, blood glucose is greater than or equal 300 mg/dL
or patient markedly symptomatic, consider combination injectable therapy.
Monotherapy
Dual Therapy
Triple Therapy Lifestyle Management + Metformin + 2 additional agent
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
Combination Injectable therapy for type 2 Diabetes
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
Fasting plasma glucose is having high contribution in HbA1c > 8,5%
Relative contribution to
overall hyperglycaemia
10
0
8 30%
45% 35%
0 50%
6 70%
(%)
0
4 70%
65%
0 55%
2 50%
30%
0
0
<7.3 7.3–8.4 8.5–9.2 9.3–10.2 >10.2
HbA1c quintiles
FPG PPG
Start: 4 units, or 0.1kg, or 10% basal dose. If A1C Start: Add additional injection before lunch
<8%, consider lower basal by same amount If goals not met, consider
changing to injectable Adjust: increase dose by 1-2 units or 10-15% once
Adjust: increase dose by 1-2 units or 10-15% once or therapy or twice weekly until SMBG target reached
twice weekly until SMBG target reached
For hypo: Determine & address cause; if no clear
For hypo: Determine & address cause; if no clear Reason for hypo, reduce dose by 2-4 units or 10-20%
Reason for hypo, reduce dose by 2-4 units or 10-20%
American Diabetes Association. Diabetes Care Volume 41, Supplement 1, January 2018
ESW/MAR-17/RTD LVM-2017/001
Outlines
• Prevalence
• Rationale for early initiation
• T2DM management and guideline
• Insulin Levemir® & A1Chieve study
Efficacy of Basal Insulin Focus on Detemir
29
Levemir®
2012–2014 tolerability profile
2010–2011 demonstrated over
2007–2009 •SOLVE™
A1chieve™ >17.000 patients7 10 years
TITRATE™ >66,000
2004–2006 of clinical
>224 patients3 patients5 •DIET™8
experience and
Klein et al1 6 evidence 1–8
PREDICTIVE™ TRANSITION™
Philis- >5.604 patients4
Tsimikas et al2
ESW/MAR-17/RTD LVM-2017/001
30
Adapted from Heise T et al. Diabetes. 2004;53:1614-20.
Home et al. Diabetes Res Clin Pract 2011;94:352–63
A1chieve overview
Insulin Detemir use in Indonesia
*p<0.001
Soewondo et al. DRCP 2013. 100;(Suppl 1):S10-S16
Detemir ± OAD:
Indonesia hypoglycaemia results
Baseline
24 weeks
Overall Major Nocturnal
No. of pt w/hypo 19 0 1 0 18 0
Percent with at least one
event
Significant improvement
(p<0.001)
*p<0.001
Soewondo et al. DRCP 2013. 100;(Suppl 1):S10-S16
Initiation & titration of basal Insulin
Goal: 3.9–5.0 Goal: 4.4–6.1
mmol/L mmol/L
(70–90 mg/dL)1 (80–110 mg/dL)1
If FPG If FPG
is +3 is
unit
>5.0 mmol/L (>90 mg/dL) >6.1 mmol/L (>110
s
mg/dL)
3.9–5.0 0 4.4–6.1
maintain current
mmol/L dose
mmol/L
(70–90 (80–110
mg/dL) –3 mg/dL)
<3.9 mmol/L (<70 mg/dL) unit <4.4 mmol/L (<80
s mg/dL)
Summary
• Indonesia is one of the largest diabetes population
• Insulin therapy is the most efficacious therapy and can reduce HbA1c up to
2,5%
• Starting with basal insulin detemir 10 U once daily and titrate based on
patient condition to reach glycemic control