Type 2 diabetes - unispital-basel.ch

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Type 2 diabetes Marc Y Donath

Transcript of Type 2 diabetes - unispital-basel.ch

Page 1: Type 2 diabetes - unispital-basel.ch

Type 2 diabetes

Marc Y Donath

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Urinary glucose excretion via SGLT2 inhibition

SGLT2

SGLT2inhibitor

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Glukosurie / Tag mit SGLT2i50-80 g Glucose = 200-320 Kalorien =

12 – 20 Zuckerwürfeln

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Cardiomyocytes

Control Glucose

Dyntar et al. Diabetes 50: 2105-13

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Type 2 diabetes=

Protection against Overnutrition

Islet:Protection

= Insulin production↓

Fat, liver, muscle:Protection

= Insulin sensitivity ↓

Kidney:Protection

= Glucosuria

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Glucose disposal:HbA1c reflects only glycemia

Nash

Obesity

Retinopathy

Heart failure

Nephropathy

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Donath et al, Nature Reviews Immunology, 2019

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Outcome from anti-diabetic drugsMacro-

vascularHeart failure

CKD Retinopathy NASH Diabetes progression

SGLT2i - + + ? ? ?GLP1a + - - ? ? ?DPP-IVi - - - ? ? ?SU harm ? harm ? - ? ? ?Anti-IL-1β + + ? (+) ? +

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Therapeutic scheme

1.Lifestyle2.Metformin (?)3. Individualization :

A. Early case: GLP-1a (BMI>28), SGLT2i (or DPP4i ?) B. Established cardiovascular disease: SGLT2i (heart failure) GLP-1a (obese)

C. Aging: SGLT2iD. Lean, Uncontrolled diabetes or GFR < 30 : Basal insulin E. BMI>35 (with diabetes>30?): consider bariatric surgery

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Lifestyle

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GLP-1 analogaDaily Liraglutide:

Victoza Saxenda (obesity dosing) Xultophy (Liraglutide & Insulin-Degludec)

Lixisenatid Lyxumia Suliqua (Lixisenatid & Insulin-Glargin)

Once‐weekly Exenatide Once Weekly Sustained-release

Bydureon Dulaglutide

Trulicity Semaglutide

Ozempic

Oral Semaglutide

Rybelsus

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• HbA1c↓• Body weight ↓( 80-100 gr. glucose = ~ 300-400 cal/day) • Blood pressure ↓• No hypoglyceamia• All combination possible (incretin limits)

BUT: • Genital infections• Ketoacidosis

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SGLT2 Inhibitors

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SGLT2 Inhibitors• Empagliflozin

• Jardiance• Canagliflozin

• Invokana• Dapagliflozin

• Forxiga• Ertugliflozin

• Steglatro

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Patient, 79 year old:

- BMI 22- HbA1c 10.6%- Heart failure- Treated with Metformin and Sitagliptin

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Patient, 79 year old:

- BMI 22- HbA1c 10.6%- Heart failure- Treated with Metformin and Sitagliptin

Stop SitagliptinStart SGLT2 inhibition

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Patient, 77 year old:

- BMI 28- HbA1c 6.6%- MI 10 years ago- Feels well- Treated with Metformin and Sitagliptin

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Patient, 77 year old:

- BMI 28- HbA1c 6.6%- MI 10 years ago- Feels well- Treated with Metformin and Sitagliptin

Stop SitagliptinStart SGLT2 inhibition

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Patient, 52 year old:

- BMI 29- HbA1c 6.2%- MI 3 years ago- Treated with Metformin

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Patient, 52 year old:

- BMI 29- HbA1c 6.2%- MI 3 years ago- Treated with Metformin

Ad GLP-1 agonistConsider combination with SGLT2 inhibition

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Patient, 47 year old:

- Polyuria & polydipsia for 3 weeks- BMI 28- HbA1c 14.8%- Urin keton bodies ++++

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Patient, 47 year old:

- Polyuria & polydipsia for 3 weeks- BMI 34- HbA1c 14.8%- Urin keton bodies ++++

Saline & lifestyle intervention

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Patient, 45 j:Diabetes Typ 2, ED 06.04.20:- 136 Kg- Glucose 25.0 mmol/l- HbA1c 14.3 % - Ketonkörper ++++

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Patient, 45 j:Diabetes Typ 2, ED 06.04.20:- 136 Kg- Glucose 25.0 mmol/l- HbA1c 14.3 % - Ketonkörper ++++Lifestyle intervention1 Monat Lantus (lockdown)Ozempic30.6.21:- 100 Kg- HbA1c 5.2 %

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