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Drs datta 9th august 2012

type 1 with obesity. Deficiency of insulin plus National Institute for Health and Clinical Excellence (NICE):
T2D treatment algorithm1

Consider SU if:
HbA1c ≥6.5% after
lifestyle intervention
Consider substituting
Consider adding
DPP-4 or TZD for SU if:
DPP-4 or TZD if:
Consider adding sitagliptin
or TZD:
•Instead of insulin if insulin is
unacceptable
Consider adding exenatide
to MET and SU if
Increase insulin dose and intensify regimen.
Consider adding pioglitazone if:
• A TZD has previously had marked effect or blood glucose control is inadequate with high-dose insulin MET = metformin, SU = sulphonylureas, TZD = thiazolidinedione, DPP-4= dipeptidyl peptidase-4 inhibitor
1. Adapted from: National Institute for Health and Clinical Excellence. Clinical Guideline 87. Type 2 diabetes - newer agents (a partial update of CG66): quick reference guide.
Scottish Intercollegiate Guidelines Network (SIGN):
T2D treatment algorithm1

1st LINE OPTIONS in addition to lifestyle measures; START ONE OF
Usual approach
Sulphonylurea* (SU)
Alternative approach
Metformin (MET)
• If intolerant to metformin• If weight loss/osmotic symptoms * Continue medication if EITHER individualised target
achieved OR HbA1c falls >0.5% (5.5 mmol/mol) in 3-6
2nd LINE OPTIONS in addition to lifestyle measu
res, adherence to medication and dose optimisation; ADD ONE OF Thiazolidinedione*
DPP-4 inhibitor*
• If hypos a concern (e.g. driving, occupational hazards, at risk of • If hypos a concern (e.g. driving, occupational hazards, at risk of falls) and if no congestive heart failure 3rd LINE OPTIONS in addition to lifestyle measures, adherence to medication and dose optimisation; ADD OR SUBSTITUTE WITH ONE OF
ORAL (continue MET/SU if tolerated)
INJECTABLE (if willing to self inject; continue MET/SU if tolerated)
Thiazolidinedione*
DPP-4 inhibitor*
Insulin* (inject before bed)
GLP-1 agonists*
• If osmotic symptoms/rising HbA1c; NPH insulin initially • If hypos a concern, use basal analogue • Add prandial insulin with time if required DPP-4= dipeptidyl peptidase-4 inhibitor; GLP-1 = glucagon-like peptide 1
Adapted from: Scottish Intercollegiate Guidelines Network. Management of diabetes: a national clinical guideline. March 2010. Prescribers should refer to the British National Formularh Medicines C updated guidance on licensed indications, full contraindications and monitoring requirements.
• Food Plan - Dietitian with knowledge of for 3 months unless glucose very highreinforced by dietitian If you add sulphonylurea or insulin the weight will go up and appetite will be - maybe but TOO Much. Portion size. Smaller plate . I can not exercise because of back/heart - exercise does not burn many calories- c - Rubbish obese have higher BMR than normal weight .v.v.rare metabolic problems associated with obesity only gland that’s wrong is ………….
lter eating habits permanently – food plan/life style ifficult – food is pleasurable + social -eating is a habit. Stop eating when full. LEAVE FOOD . Never tell obese T2D to snack between meals/ have a . Anticipate exercise and take less medication before it 500mg with main meal for two weeks then 500mg BD etc • Try Metformin SR if bowel intolerant • If not to target send to NASTY dietitian! • Check eGFR reduce dose if renal impairment esponse v variable better if not diagnosed too ay need to add in prandial regulator with • Food Plan –isocaloric – restrict fast • Consider sulphonylureas – gliclazide • Can still use metformin – for insulin • Add basal long acting insulin if fasting glucose is 97 11 17.586 10 15.575 9 13.564 8 11.553 7 9.5

Source: http://generalpracticemedicine.org/DrsDattamodified2.pdf

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J. Glenn Morris, Jr. Cholera has affected humans for at least a millennium We are currently in the throes of the seventh pandemic and persists as a major cause of illness and death worldwide, (caused by V. cholerae of the El Tor biotype), which with recent epidemics in Zimbabwe (2008–2009) and Haiti originated almost 50 years ago in the Celebes. In contrast (2010). Clinically, evidence

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cionales y Propiedad Intelectual del Insti- Prieto enfoca su práctica en derecho em-tuto de las Naciones Unidas UNITAR, en presarial, corporativo y comercial, derecho Gobierno Electrónico del Instituto Tecnoló- de las tecnologías, propiedad intelectual, gico de Monterrey, entre otros. Desde 1999 inversión extranjera, zonas francas, dere-hasta el 2006 desarrolló su carrera profesio- cho i

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