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
Poner a Trabajar a la Innovación Contenido Título del Libro: Making Innovation Work Introducción: cómo se innova Autor: T. Davila, M. Epstein y R. Shelton determina qué se innova. Cartografía de la innovación. Elegir destino: cómo diseñar una estrategia de innovación vencedora. EL AUTOR : Tony Davila es profesor de la Graduate School of Business de la
Equine Metabolic Syndrome - Clare McKinstry, MRCVS Here is a scenario many horse or pony owners may find familiar. I was presented with a pony cal ed “Alfie”. he is a much loved, 8 year old, Shetland pony gelding who has a previous history of mild to moderate episodes of laminitis. His companion “Snowy”, is also an 8 year old Shetland pony gelding but has had no previous episodes