Mefer sykurski af tegund 2Kennsla lknanema 15. mars 2007strur B. Hreiarsson

.B. f. 1950Lengi feitur. Tekur atenll vegna hrstings. Annars veri hraustur.Undanfarna mnui vaxandi slappleiki, orsti og mikil vaglt. Pirringur ftum og okusn.Fer til heimilislknis, sem mlir bls. 19.7 mmol/l.

Hva er til ra?

.B. f. 1950Skoun BMT: Svolti urr. Pls: 84, blr. 130/90. H: 179 cm, yngd 118 kg, BMI: 37 Mikil kvifita. Augnbotnar: 2 hrstingsbreytingar og einstaka mikroaneurysmar.

.B. f. 1950Rannsknir BMT: Bls. 18.3 mmol/l.Hemogl.:160 g/L, hvt blk.: 8.2 s, Na: 136 og K: 3.6 mmol/LKreatinin: 110 mmol/L.vag: glksi ++++, aceton +HbA1c: 11.4%, Klesterl: 6.4, Hdl: 0.91, Tg: 5.3 mmol/LEKG: elilegt.

Mefer?

Mefer teg. 2 sykurski grfar lnurFastandi bls. < 8.5, HbA1c 8.5 ea postprandial >11 og HbA1c >7: tflumeferFastandi bls. >15 : inslinmefer byrjun, evt. me tflum kvrun alltaf einstaklingsbundin, fer m.a.eftir einkennum og aldri

.B. f. 1950 .B. fkk Actrapid undir h, 6-8 ein 4 klst fresti ar til bls

Tegund 2 sykurskiAlvarlegur og algengur sjkdmurAlvarlegir fylgikvillar85-90 % allra me sykurskiGrunnbrestir: 1. Minnka inslnnmi frumum. 2. Galli betafrumum.

Markmi meferarG lanKoma veg fyrir bra fylgikvillaHindra ea draga r langvinnum fylgikvillum, .e. auka lfsgi- og lfslengd

Type 2 diabetes - a serious disease

The Steno Type 2 Study:microvascular complications00,511,52Favours intensive therapyFavours standard therapyProgression in autonomic neuropathyProgression in retinopathyProgression to nephropathyProgression in peripheral neuropathyOdds ratio

Antidiabetic treatmentTargets for glycaemic control Fasting blood glucose 4.5- 6.5 mmol/l(Postprandial BG< 9mmol/l)No hypoglycaemiaHbA1C < 7% (American Diabetes Association 2002)

Matari og hreyfing grundvallaratriiBora reglulega ekki sleppa mltumForast fnunnin kolvetni, srlega sykraa drykkiBora trefjark kolvetniMinnka fituneyslu

Eldri flokkar sykurskilyfjaBgvan: Glucophage (metformin).

Slfonylurea: Amaryl (glmepr), Daonil (glbenklam), Diamicron (glklaz), Mindiab (glpiz).

SlfnlrealyfKomu fram 1957rva inslnseytrun

Gallar: Geta valdi blsykurseklu (UKPDS: hj 17%, alvarleg hj 0.7%) yngdaraukning Hjartahrif??

Bgvan (1957) Metformin (Glucophage)Minnka nmyndun glksu lifur Auka inslnnmi?

Kostir: Valda ekki blsykureklu ea yngdaraukningu

Aukaverkanir: Meltingargindi, mjlkurblsr (sjaldgft) Cave: kreatinin> 150 micromol/L

Antidiabetic treatmentUK Prospective Diabetes Study (1998)Intensive glucose control policy maintained a lower HbA1cby mean 0.9 % over a median follow-up of 10 years from diagnosis of type 2 diabetes with relative risk reduction of:

Sulphonylurea or insulin: RR p NNT Any diabetes related endpoint 8% 0.03 31 Myocardial infarction 13% 0.05 48 Microvascular endpoints 23% 0.01 42

Metformin: Any diabetes related endpoint 26% 0.002 11 Myocardial infarction 36% 0.01 17 Microvascular endpoints 24% 0.19 49

(RR: relative risk; NNT: number needed to treat for 10 years)

Change in Weight (UKPDS)

Nrri lyf vi tegund 2 sykurskiHamla frsogi sykri r meltingarvegi: Alfa glucosidasa hemlar. acarbose (Glucobay), miglitol. rva inslnseytrun: (PRG) repaglin (NovoNorm), nateglin (Starlix). Auka inslnnmi frumum: troglitazon (Rezulin), rosiglitazon(Avandia), Avandamet (metformin og rosiglitazon)pioglitazon (Actos).

Acarbose (Glucobay) (1990)Hamlar afturkrft alfa glucosidasa mjgirni og tefur annig klofning oligo- og tvsykrungum, seinkar og minnkar glksuhkkun bli eftir mlt (um ca 3 mmol/l. a mealtali).Teki upphafi mltar.Aukaverkanir: vindgangur, uppemba, niurgangur o.fl., srlega eftir sykur.

Repaglin (NovoNorm) og Nateglin (Starlix)Endurvekja fyrsta fasa inslnseytingarHalda postprandial blsykurhkkun skefjumMinna insln bli milli mlta, v minni htta sykurfalli en vi slfnylureaNateglin einungis skr hr til notkunar sem vibt vi metformin mefer

Dose Titration of Repaglinide in Patients with Inadequately Controlled Type 2 Diabetes Comparison Between Two Strategies

Authors: Klaus Klendorf1, Johan Eriksson2, Kre I Birkeland3, Thomas Kjellstrm4, Astradur B. Hreidarsson5

Repaglinide rannskn385 sj. me ur mehndlaa teg 2 sykurski. Meal HbA1c: 8.2 1.5 mmol/LMefer me repaglinide (NovoNorm, Prandin) 4-5 mnuiByrjunarskammtur 0.5 mg. fyrir mltir, hkka 2 vikna fresti ar til markmisbls. ea max skammti (4 mg fyrir mltir) var n

Repaglinide rannsknSlemba 2 jafna hpa:A hpur mldi f. bls., markmi : 4.4 6.1 mmol/LB hpur mldi bls. 2 klst eftir mat, markmi: 4.4 8 mmol/L

Repaglinide rannskn NiursturHpur A (me fstubls.) lkkai HbA1c um 1.4%Hpur B (me postprandial bls) lkkai HbA1c um 1.2% (P=0.03) a a hafa fstublsykur a leiarljsi kom annig betur t. 96 (25%) fundu fyrir hypoglycemiskum einkennum, ar af fkk 1 slmt blsykurfall

Occurrence of hypoglycemia(Repaglinide vs. Glipizide) Madsbad el al, Diabetic Medicine 2001

Thiazolidinedion lyf (Gltazon)Bindast vitkum frumukjarna (PPAR-gamma).Auka inslnnmi og bta ar me flutning sykri inn vva-, lifrar- og fitufrumur.Draga r nmyndun sykurs lifur.Bta betafrumu starfsemiHagst hrif blfitur.Hagst hrif blrsting.Blgueyandi ?(lkka CRP)

Gltazon lyfActos (pogltazon): tflur 15 og 30 mg.

Avandia (rosgltazon): tflur 4 og 8 mg.

Hmarksverkun nst eftir 8 - 12 vikur.

Evrpu ekki leyft a nota me inslni

AukaverkanirBjgur hj 3-4% sjklinga (hjartabilun: frbending)yngdaraukning (2-4 kg), fita undir h eykst, en kvifita minnkar!Mlt er me v a fylgjast me lifrarstarfsemi ca 2 mn. fresti fyrsta ri.

Kostir inslnmeferarLeirttir inslnskortMinnkar glucose toxicity (hyperglycemian sjlf hindrar inslnseytrun og veldur inslnvinmi)Btir inslnseytrun betafrumuBlir nturofframleislu glksu lifrinni

Gallar inslnmeferarStungulyfyngdaraukningHtta blsykurfllum

Inslnvibt vi tflumeferBetafrumurnar hafa tmt sig af inslni yfir daginn vegna mltaseytrunar.essvegna m.a. aukin nmyndun glksu lifur yfir nttina.Gefa langvirkt insln (Insulatard, Humulin NPH ea Lantus (Glargin)) fyrir httinn(Undantekning: steramefer, gefa inslni a morgni) Nota ar sem tflumefer ein sr dugir ekki Einnig sem upphafsmefer nokkra daga ea vikur til a hvla betafrumurnar

Inslnvibt vi tflumefer Inslinrf einstaklingsbundin: (0.15 0.5 ein/kg) Byrja t.d. me 10 ein kl. 22 Ef fastandi bls. > 7 rj daga r, auka insuln um 2 ein. o.s.frv. (hrra bls.markmi hj eldra flki v. httu blsykurfalli) Ef fastandi bls. < 4 tvo daga r, minnka insln um 2 ein.

Insulin treatment of NIDDM : The FINFAT studyResults after 12 months* p < 0.05 compared with other groupsYki-Jrvinen H et al. Diabetologia 1997;40 (Suppl 1)

Adapted from Yki-Jrvinen et al, An Int Med 1999Comparison of bedtime insulin regimens in type 2 diabetes. (1 year of treatment)-3-2-1 0 5 0 1 2 3 4NPH + Glib + Met**

Insulin treatment of NIDDMWhich kind of insulin regimen should be used ?The Steno ProtocolBedtime NPH insulin in combination with metformin twice daily to obese patientsBedtime NPH insulin in combination with sulfonylureas twice daily to lean patients and if contraindications against metformin

Lantus og Levemir grunninsln

Hgt og stugt frsogLangvarandi verkunJafnt frsog fr degi til dagsStugri blsykurMinni htta sykurfllum

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

A-chain

B-chain

Phe

Val

Asn

Gin

His

Leu

Cys

Gly

Ser

His

Leu

Val

Glu

Als

Leu

Tyr

Leu

Val

Cys

Gly

Glu

Arg

Gly

Phe

Phe

Tyr

Thr

Pro

Lys

Thr

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

NH2

S

S

S

S

S

S

Tyr

Thr

Asp

Lys

Thr

Tyr

Thr

Lys

Pro

Thr

Insulin Lispro:

Structure of human insulin, insulin Lispro, insulin Aspart and insulin Glargine

Insulin Aspart:

: Insulin Glargine

Gly

Arg

Arg

Vi br veikindi eru viss sykurskilyf til amaMetformin (Glucophage): auka httu mjlkurblsringu, valda lystarleysi o.fl. Frbending: nrnabilun (krea> 150 micromol/L)

Thiazolidinedion lyf (Actos og Avandia): m ekki nota ef hjartabilun og ekki me inslni

Teg. 2 sjklingar urfa gjarnan insln vi lagGefa langvirkt insulin, t.d. NPH ea Insulatard fyrir nttina til a bla nturofframleislu glksu lifrinni, byrja t.d. 0.15 0.2 ein/kg. Gefa hravirkt insln daginn skv. bls. fyrir mltir Ef steramefer gefa NPH ea Insulatard a morgni.

Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatmentIlkova, Cerasi et al, Diabetes Care 1997

13 ngreindir teg. 2 DM (mean postprandial bls. 16.9 mmol/L, HbA1c: 11.0%) fengu krftuga inslnmefer 2 vikur.9 lyfjalausir og matari eingngu eftir 9 50 mnui!