Läkemedelsverkets riktlinjer Typ 2-diabetes, en behandlingsalgoritm

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1 Läkemedelsverkets riktlinjer Typ 2-diabetes, en behandlingsalgitm Hyperglykemi Hypertoni Dyslipidemi Livsstilsåtgärder, rökstopp Metfmin Monoterapi ACE-I/ARB/BB/CBB/HTC** Statin* SU eller insulin NPH till natten måltidsinsulin tvåfasinsulin måltids- NPH-insulin *** Akarbos Analogt basinsulin -hämmare Glitazoner GLP-1-analog Meglitinider Kombinationsbehandling Vidare utredning *I första hand generiskt simvastatin **Läkemedelsvalet styrs bland annat av kontraindikationer, njurfunktion, hjärtsjukdom och förmån/ rabatter. I vissa fall kan kombinations-behandling vara indicerad redan från start. ***Dessal läkemedel ska betraktas som alternativa möjligheter när glukoskontroll inte uppnåtts med andra medel. Läkemedlen står således inte i någon inbördes rangdning. Ref: Läkemedelsbehandling vid typ-2 diabetes- ny rekommendation

2 Me#min och sen då är det dags a4 ändra behandlingsriktlinjerna? Lena Landstedt- Hallin och Michael Alvarsson

3 One of the first steps in the management of patients with type 2 diabetes mellitus is setting glycemic goals. SFD LLH/MA Ann Intern Med. 2011;154:

4 Mål för HbA 1c Socialstyrelsen 2010 Riktvärden för HbA 1c -mål är < 52 mmol/mol (6,0%) Följande fakter kan innebära att målnivån för HbA 1c bör höjas: frekventa svåra hypoglykemier svåra mikro- eller makrovaskulära komplikationer annan svårare sjukdom begränsad återstående livslängd Målvärden och behandling bör anpassas hos mycket gamla patienter (förslagsvis HbA 1c <8% dvs. <73 mmol/mol), med syfte att uppnå symtomfrihet. Följande fakter kan innebära att en lägre målnivå för HbA 1c bör eftersträvas: nydiagnostiserad diabetes debut i lägre ålder låg risk för oupptäckt hjärt-kärlsjukdom Referens: Socialstyrelsens nationella riktlinjer för diabetesvården SFD LLH/MA

5 April 2012 Publicerat i Diabetes Care och Diabetologia Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach Position Statement of the American Diabetes Association (ADA) and the European Association f the Study of Diabetes (EASD)

6 SFD LLH/MA

7 Målsättning för blodsockerkontroll/hba 1c fakter att väga samman Lägre/tuffare målvärde Högre målvärde Patientens inställning till behandling och förväntad kapacitet till egenvård Högmotiverad, följsam till behandling Mycket god kapacitet för egenvård Låg motivation, dålig följsamhet Begränsad förmåga till egenvård Risk med ev. hypoglykemi, andra oönskade händelser Låg risk Hög risk Diabetesduration Nydiagnosticerad Lång duration Förväntad återstående livslängd Lång Kt Viktiga andra sjukdomar Saknas Få/milda Svåra Kända kärlkomplikationer Saknas Få/milda Svåra Resurser, suppt/stöd Fritt översatt av Lena Landstedt-Hallin ADA/EASD Position Statement 2012 Lättillgängliga Begränsade

8 Vilket mål ska man då sikta mot? 52 mmol/mol? 73 mmol/mol? eller kanske 47 mmol/mol? Utanför skola? Tättbebyggt område? Landsväg? Sätt och tänk jämna mål! SFD LLH/MA

9 ADA-EASD Position Statement: Management of Hyperglycemia in T2DM 3. Blodsockersänkande behandling - Livss@l Table4er & injicerade läkemedel som ej är insulin Insulin

10 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin GLP-1 recept SU SU est risk variable Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

11 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Me complex insulin strategies Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk edema, HF, fx s Inhibit intermediate neutral rare est risk variable If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Insulin # (multiple daily doses) GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin Hälso- Sulfonylurea och Inhibit sjukvården bör GLP-1 recept vid läkemedelsbehandling SU av SU typ 2-diabetes SU dinera SU eller insulin som andrahandsval (priitet 4). Vid insulinbehandling av typ 2-diabetes välja NPH-insulin, kombinationsinsulin eller måltidsinsulin med eller utan NPH-insulin som förstahandsval (prio 3).

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13 Hälso- och sjukvården bör vid läkemedelsbehandling av typ 2-diabetes dinera SU eller insulin som andrahandsval (priitet 4).

14 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Inhibit intermediate neutral rare GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Inhibit priitet 10 GLP-1 recept SU SU SU est risk variable Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

15 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination Metfmin GLP-1 recept SU SU est risk variable (der not meant to denote any specific preference): : priitet 10 Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

16 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): : priitet 10 Metfmin GLP-1 recept SU SU est risk variable Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

17 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit Insulin Akarbos (SoS: prio 9) Metfmin GLP-1 recept SU SU GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Saknas: est risk variable Metfmin Meglitinider/repaglinid (SoS: prio 4) If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

18 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Inhibit intermediate neutral rare GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Nästa Inhibit steg: GLP-1 recept SU SU SU Trippelkombinationer! est risk variable Metfmin Insulin En något Insulin förenklad (= försvenskad ) variant (utan glitazoner) If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

19 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin GLP-1 recept SU SU est risk variable Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

20 Initial drug monotherapy Side effects Two drug combinations* Maj side effect(s) Three drug combinations Healthy eating, weight control, increased physical activity Metfmin neutral/loss GI / lactic acidosis If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination (der not meant to denote any specific preference): Metfmin Metfmin Metfmin Metfmin Metfmin moderate risk Metfmin edema, HF, fx s Metfmin SU Inhibit intermediate neutral rare Metfmin Inhibit GLP-1 recept loss GI If needed to reach individualized HbA1c target after ~3 months, proceed to 3-drug combination (der not meant to denote any specific preference): Metfmin GLP-1 recept SU SU est risk variable Metfmin If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months, proceed to a me complex insulin strategy, usually in combination with 1-2 non-insulin agents: Me complex insulin strategies Insulin # (multiple daily doses)

21 ADA-EASD Position Statement: Management of Hyperglycemia in T2DM HUVUDPUNKTER i dokumentet Mål för blodsocker och val av blodsockersänkande läkemedel måste individualiseras Kost, mo@on & utbildning: grunden för all behandling vid T2DM Om kontraindika=oner saknas är me#min förstahandsläkemedlet Dåligt med data som stöd för val av läkemedel ejer me#min. FörnuBigt ad kombinera 1-2 andra läkemedel (per os eller injicerade) minimera bieffekter. I slutändan kommer många pa=enter behöva insulin ensamt eller i kombina@on med andra läkemedel för ad upprädhålla blodsockerkontrollen Alla behandlingsbeslut bör med pa@enten (med fokus på preferenser, behov & värderingar) Reduk@on av kardiovaskulär risk huvudfokus för behandlingen Fritt översatt av Lena Landstedt-Hallin ADA/EASD Position Statement 2012 Diabetes Care, Diabetologia. 19 April 2012