A Consensus Report by the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) Diabetes Technology Working Group, International Consensus on Risk Management of Diabetic Ketoacidosis in Patients With Type 1 Diabetes Treated With Sodium–Glucose Cotransporter (SGLT) Inhibitors, Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, The Full Range of Therapeutic Options: Lifestyle Management, Medication, and Obesity Management, Obesity Management Beyond Lifestyle Intervention. These include additional focus on lifestyle management and diabetes self-management education and support. The details of the search strategy, the results, and the classification for the included articles are available at https://dx.doi.org/10.17632/h5rcnxpk8w.1. has nothing to disclose. The available evidence for cardiovascular event reduction in patients with type 2 diabetes and clinical CVD is derived from trials in which the participants were not meeting glycemic targets (HbA1c ≥53 mmol/mol [≥7%] at baseline). Instead, there are many good options and professional guidelines usually recommend individually selected eating patterns that emphasize foods of demonstrated health benefit, that minimize foods of demonstrated harm, and that accommodate patient preference and metabolic needs, with the goal of identifying healthy dietary habits that are feasible and sustainable. All authors approved the version to be published. These medications are of high efficacy in lowering glucose in the setting of normal renal function (51,52,103). The benefits and role of enhanced monitoring of glucose and other variables leveraged with real-time informatics-based approaches to adapt treatment on an individual basis has great potential but has not been elucidated. With regards to medication management, for patients with clinical cardiovascular disease, a sodium–glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. 1). If so, in what populations? 1). A standard approach for optimizing basal insulin regimens is to titrate the dose based on a target fasting glucose concentration, which is a simple index of effectiveness. 1 and underpin the approach to management and care. There is an increasing call for the use of technology and telemedicine to improve patients’ health (238). In particular, patients with higher pretreatment HbA1c, higher BMI, longer duration of disease, and a greater number of oral glucose-lowering medications are more likely to require intensified therapy (168). reports personal fees from Eli Lilly, Merck, Novo Nordisk, and Intarcia and grants from Merck and Ligand during the conduct of the study; personal fees from Eli Lilly, Merck, Novo Nordisk, and Intarcia and grants from Merck and Ligand outside the submitted work. However, since only 15–20% of patients with type 2 diabetes conform to the characteristics of patients in these trials, other clinical features need to be considered in the majority when selecting second medications to add to metformin (Figs. For example, SGLT2 inhibitors can be added to insulin regimens to lower blood glucose levels without increasing insulin doses, weight gain, or hypoglycemia (219–221). Because of the new evidence for the benefit of specific medications to reduce mortality, heart failure (HF), and progression of renal disease in the setting of established CVD, their use was considered compelling in this patient group. While the medication was safe (noninferior), the HR for MACE in the entire trial was 0.91 (95% CI 0.83, 1.0; P = 0.06) not reaching the threshold for demonstrated superiority versus placebo; ARR was 0.8% (49). A final approach to glycemic management when basal insulin plus oral medications is insufficient to achieve HbA1c targets is intensified insulin regimens (Figs. Very recent trials of different eating patterns in type 2 diabetes have typically also included weight reduction, hindering firm conclusions regarding the distinct contribution of dietary quality. were the writing group members for the American Diabetes Association. This beautifully restored 1957 Star Mist Blue Thunderbird convertible/hard top is powered by a V8 engine with an automatic transmission. SDS; CLS432051 ; CF45, capacity 45 cryovial or FACS tubes; pricing. HbA1c results may be discrepant from the patient’s true mean glycemia in certain racial and ethnic groups, and in conditions that alter red blood cell turnover, such as anemia, end-stage renal disease (ESRD) (especially with erythropoietin therapy), and pregnancy, or if an HbA1c assay sensitive to hemoglobin variants is used in someone with sickle cell trait or other hemoglobinopathy. Dosages of immediate-release metformin start at 500 mg once or twice a day with meals and should be increased as tolerated to a target dosage of 1,000 mg twice a day. An individualized program of MNT should be offered to all patients. However, metformin may lower risk for cardiovascular mortality compared with sulfonylurea therapy (100). Because the benefits of intensive glucose control emerge slowly, while the harms can be immediate, people with longer life expectancy have more to gain from intensive glucose control. Good glycemic management yields substantial and enduring reductions in onset and progression of microvascular complications. Marked hyperglycemia is associated with symptoms including frequent urination, thirst, blurred vision, fatigue, and recurring infections. Nonetheless, the use of less expensive agents, such as metformin, sulfonylureas, and human insulin, remain effective options (Figs. C.M. DSMES significantly improves clinical and psychological outcomes, improves glycemic control, reduces hospital admissions, improves patient knowledge, and reduces the risk of all-cause mortality (22,26–31). Pragmatic designs will enhance generalizability of results and reduce cost. Covalent modifications, such as methylation and demethylation of lysine residues in histones, play important roles in chromatin dynamics and the regulation of gene expression. As detailed in the “Medications for Lowering Glucose” section, the glucose-lowering medications that can be added to metformin have distinct profiles of action, efficacy, and adverse effects (100,193). Current therapy is clearly inadequate. Because baseline BMI does not predict surgical benefits on glycemia or hard outcomes and the improvement in glycemic control occurs early through weight-independent mechanisms (183), metabolic surgery may be considered for those with a BMI of 30.0–34.9 kg/m2 (27.5–32.4 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities with reasonable nonsurgical methods. However, in type 2 diabetes, they have been associated with only modest benefits (15). The Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants with Diabetic Nephropathy (CREDENCE) trial examining canagliflozin in CKD with proteinuria has been stopped at a planned interim analysis for achieving the primary efficacy end point (62). A fragmented health care system may contribute to therapeutic inertia and impair delivery of patient-centered care. Innovation in methods and implementation would transform diabetes prevention and care. Glycemic management is primarily assessed with the HbA1c test, which was the measure studied in trials demonstrating the benefits of glucose lowering (2). Diabetes confers substantial independent ASCVD risk, and most people with type 2 diabetes have additional risk factors such as hypertension, dyslipidemia, obesity, physical inactivity, chronic kidney disease (CKD), and smoking. Título: Professor: Turma: QUESTÕES DO SUPERPROFESSOR MEC NELSON RODRIGUES MARTINHO FILHO CURSO DE FÍSICA DO ENSINO MÉDIO The availability of glucose-lowering medications, patient support systems, and blood glucose-monitoring devices can differ worldwide, depending on a region’s economy, culture, and health care system. Among patients with ASCVD in whom HF coexists or is of special concern, SGLT2 inhibitors are recommended (Figs. More time- and cost-efficient research paradigms to address patient-centered end points will need to be developed through regulatory reform and leveraging informatics and coordinated learning health care systems. Different models of care are being implemented globally. Alone or with metformin, they do not increase the risk for hypoglycemia. Everything is new and restored. SGLT2 inhibitors have been associated with an increased risk of acute kidney injury, dehydration, and orthostatic hypotension; caution should be taken when SGLT2 inhibitors are used in combination with diuretics and/or ACE inhibitors and angiotensin receptor blockers. Providing patient-centered care that acknowledges multimorbidity, and is respectful of and responsive to individual patient preferences and barriers, including the differential costs of therapies, is essential to effective diabetes management (16). 4), important considerations include the weight reduction associated with SGLT2 inhibitors and GLP-1 receptor agonists, the weight neutrality of DPP-4 inhibitors, and the weight gain associated with sulfonylureas, basal insulin, and TZDs. The range of combinations available with current oral medications allows many people to reach glycemic targets safely. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Shared decision making in endocrinology: present and future directions. Some studies have suggested a benefit for preventing CVD (98), but this has not been supported by the results of a recent meta-analysis (99). The performance of the test is generally excellent for NGSP-certified assays and laboratories (www.ngsp.org) (11). GLP-1 receptor agonists are currently delivered by subcutaneous injection. Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that are experienced in the management of diabetes and gastrointestinal surgery. This fully customized 57 Nomad has been an ongoing project over the... 1955 Ford Crown Victoria. Some reviews and surveys have been published on the subject of MOT. The weight gain associated with sulfonylureas is relatively modest in large cohort studies and the incidence of severe hypoglycemia is lower than with insulin (152). Basal insulin refers to longer-acting insulin that is meant to cover the body’s basal metabolic insulin requirement (regulating hepatic glucose production), in contrast to bolus or prandial insulin, which is meant to reduce glycemic excursions after meals. Glipizide, glimepiride, and gliclazide may have a lower risk for hypoglycemia compared with other sulfonylureas (152,154). Sulfonylureas are associated with weight gain and risk for hypoglycemia and down titration of dose to reduce the risk of hypoglycemia results in higher HbA1c (146,149,150). reports grants and personal fees from Novo Nordisk, personal fees from Johnson & Johnson, and personal fees from Fractyl Inc., during the conduct of the study. Basal insulin is the preferred initial insulin formulation in patients with type 2 diabetes. Access, treatment cost, and insurance coverage should all be considered when selecting glucose-lowering medications. Where the current evidence is strongest for a specific medication within a class, it is noted. Within health care systems, variance in medication coverage is based on different assessments of cost-effectiveness. 1):S1–S70, v, Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient–2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Progression of albuminuria was the most prevalent component of the composite renal end point, whereas the other components (doubling of serum creatinine, ESRD, or renal death) did not contribute substantially to the benefit. Basic science. Adverse effects for the class are discussed in the section “The Full Range of Therapeutic Options: Lifestyle Management, Medication, and Obesity Management.”. Drug development. While this may be due to the short time frame of the studies and the low event rate in those without ASCVD, the finding is consistent across the reported trials. Cost, side effects, and modest efficacy limit the role of pharmacotherapy in long-term weight management. The changing face of diabetes complications. Compared with the knowledge base guiding dual therapy of type 2 diabetes, there is less evidence guiding these choices (205). Results from a substudy of UKPDS (n = 342) showed benefits of initial treatment with metformin on clinical outcomes related to diabetes, with less hypoglycemia and weight gain than with insulin or sulfonylureas (98). Choosing glucose-lowering medication in those with established ASCVD, HF, and CKD. 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