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Dr Karen McNeil
Consultant Endocrinologist
Aged 53
Type 2 Diabetes 2010
HbA1c 7.9%
ACR 5.3 mg/mmol
What treatment ?
MF 500 mg bd (misses midday dose)
Control• Symptoms, BGL
Complications• DR, DN, PN
Associations• Cardiovascular
• BMI……..
Weight history:• Onset, Peak, Now
• Diets, drugs, surgery
• What diet and exercise now
• Readiness
Complications• Sleep apnoea
• OA
• Cardiovascular etc
60 % of Australian adult males are
overweight or obese
Less than 16% of Australian men Gary’s
age have T2 DM or IGT
80% of patients with Type 2 DM are
overweight or obese
0
10
20
30
40
50
60
70
80
2011 2025
BMI>30 kg/m2
BMI>25Kg/m2
27.5%
42.2%
35.5%
38.3%
Adapted from Data from Walls et al.,(2012),Australian Health
Survey
0.1
2.6
6.8
16.1
21.6 22.4
0.42.3
5.5
9.9
16.1
24.5
0
5
10
15
20
25
30
25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75+
Males
Females
Age group (years)
Pe
rce
nta
ge
Ausdiab 2006
0.4
1.8
0.4
0.7
1.4
0.4
0.8
1.6
0.8
0.0
0.4
0.8
1.2
1.6
2.0
Normal Overweight Obese
Males
Females
All
Baseline BMI status
Inc
ide
nc
e (
% p
er
ye
ar)
Body mass index (BMI: weight/height2) was categorised into three groups: (i) normal: BMI < 25.0 kg/m2;
(ii) overweight: 25.0─29.9 kg/m2; and (iii) obese: ≥ 30.0 kg/m2.
Ausdiab 2006
Lose enough weight and lose the diabetes
Insulin requirement is proportional to body mass
Not enough insulin secreting cells to get the job done
BMI 37 kg/m2, 123 kg and 180 cm
BP 146/95
Full neck and crowded pharynx
Skin tags and slight acanthosis
Labs:• Combined dyslipidaemia
• ACR 5.6 mg/mmol
• eGFR 86
Perfect glycaemic control
• Target HbA1c < 7.0%
• Optimize MF and
• Weight loss
• MedicationCardiovascular risk factor managementCo-morbidities : Sleep studyBariatric surgery discussion
Metformin Optimise
Weight Loss
• BGL
• CSIRO
• Or VLCD
• Pharmacotherapy
Afferent
Central
Efferent
Pathways
BMI
Genetics/Epigenetics
‘Obesogenic’ Environment
Life Stage
Socioeconomic Status
OSA/Medical/Psychiatric
Total Energy Intake
Total Energy Expenditure
BMR
PAL/NEAT
TEF
Afferent
Central integrating
Efferent system
ReadinessWhat does success look like?
• To Gary
• To his doctor
• Medical management (‘3% successful’)
Calorie restriction• All diets work and don’t work/food based
• Or VLCD
GP Weight management Guidelines• “Ask and Assist……
Pharmacotherapy
30 minutes daily of at least moderate
intensity physical activity on most
days (Australian guidelines 1999)
(similar guideline) Physical activity
total of >150 mins per week (US, WHO
2008, 2010) ; Australia 2012
Cardiac assessment……..??
BMI 34 (113 kg)
HbA1c 7.8%
Still on metformin• Diet and exercise
• “Maxed out”
• Surgery
• Drug therapy options
• Oral vs injected
• What is metformin?
??? Your view
Gliptin?
SGLT2 Inhibitor?
Exenatide
Metformin
Sulfonylurea
(SU)
Metformin
Metformin
Sulfonylurea
(SU)
Metformin
Metiglinides
AcarboseThiazolidinediones
(TZD)
Metformin
Sulfonylurea
(SU)
Metformin
Metiglinides
AcarboseThiazolidinediones
(TZD)
1. Inzucchi SE, et al. Diabetes Care 2012;35:1364–1379.
DPP4i: Dipeptidyl peptidase-IV inhibitor; GLP-1: Glucagon-like peptide-1;
SGLT2: Sodium-glucose co-transporter 2
SGLT2 inhibitor
Sulfonylurea
(SU)
GLP-1 receptor
agonist
InsulinThiazolidinediones
(TZD)
DPP-4 inhibitor
(DPP4i)
Metformin
InsulinThiazolidinediones
(TZD)SGLT2 inhibitorGLP-1 receptor
agonist
Diabetic therapy
Options
1. Inzucchi SE, et al. Diabetes Care 2012;35:1364–1379.
SGLT2 inhibitor
GLP-1 receptor
agonist
DPP-4 inhibitor
(DPP4i)
Metformin
InsulinSGLT2 inhibitor
Weight neutral
Diabetic therapy
Options
Incretin based • Dipeptidyl peptidase- 4 inhibitor (DPP4-I)
‘gliptins’
• Glucagon-like peptide-1 analogue (GLP1A)
• Exenatide, liraglutide
Sodium-glucose Cotransporter-2• Dapagliflozin, empagliflozin
• ‘gliflozins’
Inactivated
by DPP-4
Inactivated
by DPP-4
Inhibit DPP-4
Increase GLP-1
Sita, Vilda, Saxa, Lina, Alogliptin
HbA1c reductions with saxagliptin + metformin at 50 weeks and 102
weeks*1,2
Mean baseline HbA1c 8.1%
Weeks
Me
an
ch
an
ge
in
HbA
1c
fro
m b
ase
line
(%)
Saxagliptin 5mg +
metformin n=191
Metformin + placebo
n=179
Mean change
-0.74%**
Mean change
-0.72%**
102 w
eeks
50
weeks
n=15 observed,
n=172 LOCF
n=31 observed,
n=184 LOCF
Klonoff DC et al. Curr Med Res Opin 2008; 24: 275−86.
Exenatide
2
1
0
-1
-2
-3
Ch
ang
e in b
od
y w
eig
ht
(kg)
Weeks
Insulin glargine
(Mean baseline body weight 88.3 kg)
+1.8 kg
+2.3 kg
Byetta
(Mean baseline body weight 87.5 kg)
**
*
*
*
*
Adapted from
0 2 4 8 12 18 26
Insulin glargine n = 267 266 261 253 251 246 244
Byetta n = 281 277 275 261 245 235 231
sglt2-endocrine-cme-grand-rounds-final-
9-638
109 kg
HbA1c 6.9%
Sita/MF 50/1000
mg bd
???
multicultural_group_of_people