T2DM Treatment - Type 2 Diabetes Mellitus Type Treating to...

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Type 2 Diabetes Mellitus Type 2 Diabetes Mellitus Treating to Target Treating to Target January 22, 2004. Dr. William Harper Assisstant Professor of Medicine McMaster University www.drharper.ca
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Macrovascular Microvascular Stroke Heart disease and hypertension 2-4 X increased risk Foot problems Diabetic eye disease (retinopathy and cataracts) Renal disease Peripheral Neuropathy Peripheral vascular disease Diabetes: Complications Diabetes: Complications Meltzer et al. CMAJ 1998;20(Suppl 8):S1-S29. Complications Erectile Dysfunction
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Disease Burden of Diabetes Mellitus Disease Burden of Diabetes Mellitus Leading cause of blindness (12.5% of cases) Leading cause of ESRD (42% of cases) 50% of all non-traumatic amputations 2.5x increase risk of stroke 2-4x increase in cardiovascular mortality DM responsible for 25% of cardiac surgeries Mortality in DM: 70% due to Cardiovascular disease
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Haffner et al, NEJM, 339(4):229-34, 1998. Haffner et al, NEJM, 339(4):229-34, 1998.
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Evans et al. Evans et al. BMJ 324: 939-942 April 2002 Cross-sectional study DM 1155 patients MI 1347 patients Cohort study DM 3477 patients MI 7414 patients
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How is CAD Different in Diabetics ? How is CAD Different in Diabetics ? > CAD extent Multi-vessel disease Distal disease – more difficult to revascularize Silent ischemia/MI Younger Women Worse outcomes despite revascularization Increased re-stenosis after PCI even with stents ACB: worse periop & long-term outcomes
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T2DM: “Rx to Targets” T2DM: “Rx to Targets” What are the targets?
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What are the targets? What are the targets? Cardiovascular risk factor modification ASA, Smoking Cessation Lipids Blood Pressure Proteinuria/DM nephropathy Angiotensin II attenuation benefits independent of BP Glycemic control Microvascular benefit Macrovascular benefit ? Target insulin resistance > insulin deficiency ?
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Canadian Lipid Working Group: Canadian Lipid Working Group: Target Levels in Diabetes Target Levels in Diabetes Canadian recommendations place patients with diabetes in “very high” risk group for CAD LDL TC/HDL ratio TG < 2.5 mmol/L < 4 < 2.0 mmol/L Statins effective in lowering LDL 1 Fibrates are useful for raising HDL, lowering TG 1,2 Some OHA may improve lipids, but are not indicated for lipid management 3 may need to use combo or Niacin cautiously
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n = 20,530 (3982 with Diabetes Mellitus) hi-risk patients age 40-80, prior CAD or PVD, DM, HTN (males age > 65) Non-fasting TC > 3.5 mM 5.5 year RCT: Simvastatin 40 mg od vs placebo Mortality ARR 1.8% (NNT 56) Vascular Event ARR 5.4% (NNT 19) Coronary event, Stroke, Revascularisation Benefit obtained even in low cholesterol patients: LDL baseline 2.5 mM 1.7 mM with Rx Prior LDL targets for hi-risk patients too high? Canadian Lipid Work Group 2.5 mM
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T2DM Treatment - Type 2 Diabetes Mellitus Type Treating to...

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