Manejo de la hiperglucemia con fármacos no insulínicos en pacientes adultos con diabetes tipo 2

Treatment of diabetes mellitus type 2 (DM2) includes healthy eating and exercise (150 minutes/week) as basic pillars. For pharmacological treatment, metformin is the initial drug except contraindication or intolerance; in case of poor control, 8 therapeutic families are available (6 oral and 2 injectable) as possible combinations. An algorithm and some recommendations for the treatment of DM2 are presented. In secondary cardiovascular prevention, it is recommended to associate an inhibitor of the sodium-glucose cotransporter type 2 (iSGLT2) or a glucagon-like peptide-1 receptor agonist (arGLP1) in patients with obesity. In primary prevention if the patient is obese or overweight metformin should be combined with iSGLT2, arGLP1, or inhibitors of type 4 dipeptidylpeptidase (iDPP4). If the patient does not present obesity, iDPP4, iSGLT2 or gliclazide, sulfonylurea, recommended due to its lower tendency to hypoglycaemia, may be used.     

Grado de control metabólico y de factores de riesgo cardiovascular en pacientes con diabetes tipo 2 con y sin enfermedad cardiovascular

AimsTo determine the proportion of patients with type 2 diabetes with and without cardiovascular disease achieving the main cardiovascular goals.MethodsDesign: Cross-sectional study. Setting: A regional health district in a European country, Spain. Year: 2013. Participants: Adult patients diagnosed with type 2 diabetes with and without cardiovascular disease. Measurements: Study using secondary data obtained from electronic records of clinical history. Haemoglobin A1c, blood pressure, LDL cholesterol, smoking and medication were covered. n=49,658ResultsThe proportion of patients with diabetes achieving cardiovascular goals (among those with recent measurement) was: haemoglobin A1c 68.8% (CI95%:68.2%-69.4%), blood pressure 74.3% (CI95%:73.9%-74.7%), LDL cholesterol 59.8% (CI95%:59.0%-60.6%), tobacco 80.2% (CI95%:79.6%-80.8%). Only 40%-67% of patients has recent measurement. Only 48.0% (CI95%: 46.6%-49.4%) of patients who needed statins were receiving them. Higher proportion of patients with cardiovascular disease were achiving goals. Differences were small but significant.ConclusionsCardiovascular goals were measured in around half of patients with diabetes. Proportion of patients achiving cardiovascular goals were similar to published and best in patients with cardiovascular disease but it could improve. This points to prioritising interventions in this group of patients at very high risk, improving the implementation of guidelines and patient adherence.     

Resultados de un programa de telemedicina para pacientes con diabetes tipo 2 en atención primaria

ObjectiveTo evaluate the impact of a telemedicine program on self-perceived health in patients with type 2 diabetes in primary care, as well as patient acceptance of and satisfaction with this program.MethodWe conducted an 18-month follow-up through telemedicine in 52 diabetic patients. The study design was non-experimental (before and after). In addition to weekly electronic transmission of fasting glucose levels, we regularly provided advice to patients about healthy habits.ResultsNo statistically significant differences were observed when mean blood glucose values were compared during follow-up. However, at the end of participation, the mean score in self-perceived health was significantly higher than at the initial assessment (70.5 ± 12.8 vs. 62.8 ± 15.0, p = 0.02). After 18 months of participation in the telemedicine program, 57.7% of patients were satisfied and 38.5% were very satisfied.ConclusionsAlthough glycemic control did not improve during the follow-up, electronic transmission of information was found to be feasible and satisfactory for patients. The patients reported a higher level of self-perceived health.     

Panorama de los tratamientos actuales disponibles para los pacientes con diabetes tipo 2. Algoritmo terapéutico de la ADA/EASD. Seguridad y tolerabilidad

Type 2 diabetes is defined by chronic hyperglycemia due to at least two pathogenic alterations: resistance to the action of peripheral insulin and insufficient pancreatic insulin secretion. The pharmacological treatment of hyperglycemia in type 2 diabetes should be individualized. The choice of specific oral drug (or combination of drugs) is based on the drug's physiological mechanism, the general recommendations of the clinical practice guidelines, systematic reviews and analysis of data from clinical trials and observational studies. In general terms, clinical practice guidelines recommend starting with lifestyle modifications together with metformin, either from the outset or at 3 months; the combination should be individualized depending on the patient's profile. Therapy may be intensified every 3-6 months until targets (HbA1c 6.5-7.5%) have been reached. To chose the second drug, both its efficacy (mechanism of action) and side effects (hypoglycemic episodes, effect on weight, intestinal effects, edema/cardiac insufficiency and renal or liver insufficiency) should be considered. The controversy on the safety of oral drugs and insulin is constantly reviewed. The cardiovascular safety of intensive hyperglycemia treatment in patients with type 2 diabetes, particularly with certain agents, is an open debate. Finally, the association between insulin and cancer has aroused huge interest but the clinical significance of this association remains uncertain and further analyses are required to clarify this issue.     

Tendencias en el consumo de alcohol en los adolescentes escolarizados españoles a lo largo de la primera década del siglo xxi

ObjectiveTo determine trends in beer, wine, and liquor consumption among Spanish adolescents in 2002, 2006, and 2010, as well as drunkenness trends during the same period.MethodThe study sample was composed of 23,169 adolescents aged 15 to 18 years old: 7,103 in 2002, 10,443 in 2006 and 5,623 in 2010. In the three time points of the study, the data were representative of Spanish adolescent students. We used the alcohol consumption questionnaire designed by the international team of the Health Behavior in School-aged Children (HBSC) study. We estimated odds ratios and 95% confidence intervals through logistic regressions.ResultsThe main results showed a decrease in frequent consumption of wine and liquor from 2002 to 2010. This decrease was maintained after controlling for the variability due to the participants’ gender and age. However, an increasing trend was found in drunkenness episodes in the different cohorts of the adolescents under study.ConclusionsThe results of this study are of particular importance in the analysis of the effects of the public health policies implemented during this time period. We also found changes in consumption patterns of the various alcoholic drinks, which may constitute key information in the design of new public health policies.     

Efectos de la integración de grupos de ayuda mutua sobre la adherencia al programa de continuidad en el cuidado a pacientes con dependencia del alcohol realizado en Atención Primaria

ObjectivesTo demonstrate the effects of including mutual aid associations into a continuing care programme for patients with alcohol dependence carried out by Primary Care teams.SitePrimary Care Teams belonging to the attendance area of the University Hospital 12 de Octubre at Madrid.Participants207 participants with alcohol dependence treated in an intensive hospital outpatient-setting programme were included in a continuing care programme carried out by a Primary Care team for a four-year period.InterventionsPatients were randomised into two intervention modalities. The first group was followed up while receiving a treatment modality known as «monitoring recovery» (Group A, n = 97). The other group, in addition to the above-mentioned intervention, attended to a mutual aid association included in the Federation of Alcoholics of the Community of Madrid (FACOMA) in which the programme «Help Yourself-Help Us» was carried out (Group B, n = 112).Main OutcomesDropout rates on the sessions designed to monitor their recovery from their alcohol dependence and other comorbid medical conditions.ResultsPatients in Group B reached higher rates of therapeutic adherence to the programme (47.9% vs. 14.7%, p < 0.01), as well as for the comorbid medical issues when compared to Group A.ConclusionsIncluding mutual aid associations that carried out the «Help yourself-Help Us» programme for a four-year period improves outcomes related to therapeutic adherence in patients with alcohol dependence attending Primary Care teams.     

Guía de práctica clínica sobre el manejo del paciente con dispepsia. Actualización 2012

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made.To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).     

La diabetes mellitus y el riesgo cardiovascular. ¿Es necesario el tratamiento integral de la diabetes mellitus tipo 2 y los factores de riesgo cardiovascular?

Cardiovascular disease (CVD) is the first cause of death in the Spanish population among both diabetics and non-diabetics. In diabetes, CVD is between 2 and 4 times more frequent, earlier and more aggressive. With current measures, approximately 50% of CVD can be prevented. The risk factors for CVD in diabetes are hypertension, dyslipidemia, smoking, obesity and sedentariness. More than 80% of patient with type 2 diabetes have hypertension and dyslipidemia and approximately 15% continue to smoke. However, all these factors are controlled in at least 10%. Although dyslipidemia is the most influential and least treated factor, the greatest benefit for CVD prevention is obtained with integrated intervention on all risk factors, reducing blood pressure to below 140/80 mmHg, low-density lipoprotein cholesterol (LDL-c) to below 100 mg/dl, encouraging smoking cessation, regular physical activity and maintaining a healthy weight (BMI < 25 kg/m²). In secondary prevention or persons with microvascular disease, the targets may be stricter (blood pressure 130/80 mmHg and LDL-c 80 mg/dl). Drug treatment should always include an angiotensin converting-enzyme inhibitor or an angiotensin II receptor antagonist and a statin. Aspirin should be reserved for patients in secondary prevention or with very high CV risk. Consequently, interventions should be prioritized according to the foreseeable risk for each patient, which can be estimated through the SCORE scale or other scales such as Regicor or UKPDS, with a SCORE > 5% indicating high risk. These high-risk patients should receive personalized care.     

Tendencias en el consumo de alcohol en adolescentes escolarizados en España (2010-2018)

ObjectiveTo analyze trends in beer, wine, and distilled spirits consumption, as well as drunkenness among school-aged adolescents in Spain from 2010 to 2018 by sex and age.MethodThe sample is composed of 35,310 adolescents aged 15 to 18. The data is representative of the adolescent school population in Spain in 2010, 2014, and 2018. The alcohol consumption questionnaire and the drunkenness questionnaire provided by the international team of the study were employed. Prevalence Ratios and 95% confidence intervals were estimated using Poisson regression models with robust variance.Resultsthe data show a general decrease in alcohol consumption (beer, wine, as well as distilled spirits) and in drunkenness, but the decrease mainly occurs between 2010 and 2014. Sex differences (higher consumption and drunkenness among boys) are found among adolescents aged 17-18 but not in the age group of 15-16 years old. Older adolescents show higher levels of consumption and drunkenness than younger adolescents.ConclusionThe results confirm the relevance of carrying out specific analyses in order to identify risk groups which are not detected through general analyses. This data highlights the need to maintain alcohol prevention and control policies due to the risk of stabilization in alcohol-related behaviours.