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27-29 2012

. .

&

..

:
2025
> 480


()

2 85-95%

400

2010
347

350
300
250

2000
150

200
150
100

1985
30

50
0
1985

1990

1995

2000

2005

2010

2015

2020

2025

http://www.idf.org/home/index.cfm?node=264



( )
(32%
10 20%
)


(, , ,
, )

.
.

2 4


3

8/10

4

50%
..
1 Fong


(
) 5

DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99


1):S99S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94
1):S94S98.
3 Kannel WB, et al.
al. Am Heart J 1990; 120:672
120:672676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78
1):S78S79.


/
,

MI/


HCG 2011


&

DCCT

Kumamoto

UKPDS

9 7.2%

9 7%

8 7%

Retinopathy

63%

69%

17-21%

Nephropathy

54%

70%

24-33%

Neuropathy

60%

Improved

Cardiovascular
disease

41%

16%*

HbA1C

*p=0.052

DCCT/EDIC study: 11-year follow up (total 17 years), showed 57%


reduction in CVD risk.
UKPDS: 10 year follow up (total 20 years), showed significant reduction in
CVD risk
DCCT Research Group. N Engl J Med 1993;329:977
UKPDS 33: Lancet 1998; 352, 837837-853
DCCT--EDIC study:NEJM 2006;353:2643
DCCT
Holman etal:NEJM2008;359



LDL.

Life Style
-
..

..
350
300
250
200
150
100
50

200
126

250
200

150
100
50
0

-
-10

-5

10

15

20

25

30

()

()


(
))


Statement ADA & EASD 2006,2008

+ Metformin


-
*

+ +/-

Diabetes Care 2006; 29 :1963


:1963 -72

Consesus Statement ADA & EASD 2008


2008. Diab
Diab.. Care 2008
2008; 31
31:: 11- 3

8%
7%
6%

HbA1c %

9%

10%

10

15

8%
7%
6%

HbA1c %

9%

10%

10

15

2:


(-
))

GIP

GLP--1
GLP

(-
))

GLP-1=glucagon
GLP1=glucagon--like peptide
peptide--1; GIP=glucoseGIP=glucose-dependent insulinotropic polypeptide.
Brubaker PL et al. Endocrinology 2004;145:2653
2004;145:2653
2659; Zander M et al. Lancet 2002;359:824
2002;359:824
930; Ahren B. Curr Diab Rep 2003;3:365
2003;3:365

372; Buse JB et al. In Williams Textbook of Endocrinology.


Endocrinology. 10th ed. Philadelphia, Saunders, 2003:1427
2003:14271483; Drucker DJ. Diabetes
Care 2003;26:2929
2003;26:2929
2940.


GLP 11
-
GLP 12,4
GP 3

Visbol etal Diabetes 2001; 50:6091, Kjems etal Diabetes 2003; 52:
3802, Visbol etal JCEM 2003; 88: 48973, Mejer and Nauck Eurr Diab.
Rep 2006;6:1944



A] Glucagon
Glucagon--like peptidepeptide-1 *
Liraglutide
GLP
GLP--1*

Exenatide
B] IV
(DPP--IV)**
(DPP
Sitagliptin
Vildagliptin

* -

Saxagliptin

**


2
2
A 2011
A1c > 8.5%
( )

A1C < 8.5%


+ 1

A1C > 9%
()

+
TZD
MET +
GLP-1 DPP-4
SU GLIN

2-3
>7%

+
TZD
MET +
GLP-1 DPP-4
SU GLIN


+ +/-

2-3
>7%

A1c<8%


A1c<8%
A1c>8%

+
TZD + SU
MET +
GLP-1 DPP-4 2 + SU
GLP-1 DPP-4 + TZD
2-3
>7%

1.

2.

3.

DPP
DPP--4 ()


+ +

A1c>8%

2-3
>7%


2 201
2011
1.
) :
--
) - :
--
) - :
2.

) - (3
(3 ), ,
HbA1--c <7% (6,5%)
HbA1
) - : -
+
+ (?)
(?)--
)

NHANES III : Prevalence of Elevated Blood


Pressure* in Diabetic Adults

20

40

60

80

100

Percent
NHANES III=Third US National Health and Nutrition Examination Survey (1988-1994)
*130/85 mmHg or current use of prescription medication for hypertension

Geiss LS, et al. Am J Prev Med. 2002;22:422002;22:42-48.

&

120--129/
120
80--84
80

130--139/
130
85--89
85

1
()
140--159 /
140
90--99
90

2
()
160--179/
160
100--109
100

3
()
>180/ >110

1-2

3 >
,

ESH and ESC

J Hypertension 2007

mmHg

1-2

>3

120-129
80-84

130-139
85-89

1
140-159
90--99

2
160-179
100-109

3 AY
>180
>110

ESH and ESC: J Hypertension 2007

ACCORD study: ( < 120 mmHg) vs


( < 140 mmHg)

(Mean BP 133.5mm Hg)

(Mean BP 119.3mmHg)

EJM 2010;363:15752010;363:1575-1585

( < 120 mmHg)



( < 140 mmHg)
ACCORD study: 4733 , Fu= 4,7

EJM 2010;363:15752010;363:1575-1585

: ARBs vs placebo
11 : 84300

p<0,07

p<0,01

American Journal of hypertension epub ahead of print feb


feb.. 2011

Diabetes Care 2011;34(supplement 2):s3042):s304-s307

.
.

(SBP<130 mmHg)

Am. J. Cardiol
Cardiol.. doi:10.1016/j.amjcard.2011.02.319

.
2011

. . < 130 mmHg (C)


. . <80 mmHg (B)


3 5 gr.
, Lifestyle ,

140 mmHg 90 mmHg


mmHg,, /
130 139 mmHg
mmHg,, . ( L.S.
) ()
1 (C)

/

GFR>30
( ) GFR
GFR<
< 30 (C)
(B)

..
ADA 2012
:

<130 mmHg (C) - <80 mmHg

()


()

. DASH (B)
130
130--139 mmHg / 8080-89 mmHg

()
>140 mmHg / >90 mmHg : ()
ACE
ACE--I ARBs
ARBs.. (C)


()
/ ,

()

ACE
ACE--I , ARBs

()
110110-129/65
129/65--79 mmHg
ACE--I ARBs
ACE
()

Diab.Care 2012,Suppl1



LDL.


VLDL
Lp(a) (;)
DL
DL
, LDL
.


TRENDS in Endocrinology & Metabolism 2001; 12 (5) : 225225-30

UKPDS Study:



(n=280)


.
(n=192)

P
value

P value

LDL

<0.0001

LDL

0.0022

HDL

0.0001

0.0074

Hemoglobin
A1C

0.0022

0.025

0.0065

HDL

0.026

0.056

HemoglobinA1C

0.053

Turner RC, et al. BMJ 1998;316: 823823-28

10

(n
(n = 16032)

LDL

4S-DM

Simvastatin 2040mg vs plac

50%

42.5%

186 to 11mg/dl
(36%)

ASPEN2o

Atorvastatin
10mg vs plac

34%

12.7%

112 to 79 mg/dl
(29%)

HPS-DM

Simvastatin 40
mg vs plac

17%

7.5%

123 to 84 mg/dl
(31%)

CARE-DM

Pravastatin
40mg vs plac

13%

5.4%

136 to 99 mg/dl
(27%)

TNT-DM

Atorvastatin
80mg vs 10mg

18%

4.7%

99 to 77 mg/dl
(22%)

HPS-DM

Simvastatin
40mg vs plac

34%

6.0%

124 to 86 mg/dl
(31%)

CARDS

Atorvastatin
10mg vs plac

35%

4%

118 to 71 mg/dl
(40%)

ASPEN

Atorvastatin
10mg vs plac

19%

1.9%

114 to 80 mg/dl
(30%)

ASCOT-DM

Atorvastatin
10mg vs plac

8%

0.9%

125 to 82 mg/dl
(34%)

1 mmol
mmol/l
/l
LDL
baseline

26

Lancet 2010;376:16702010;376:1670-1681

rosuvastatin atorvastatin

CORALL study

24 open label rosuvastatin


40mg
40
mg atorvastatin 80mg

HbA1C: Atorva Baseline A1C 7,4% 7,7% (p=0,003)


(p=0,003)
Rosuva Baseline A1C 7,6% 7,9
7,9% (p=0,001)
(p=0,001)
FPG:

Atorva Baseline A1C 8,7mmol/l 9,5mmol/l


(p=0,002)
Rosuva Baseline A1C 9,1mmol/l 9,4mmol/l
(p=NS)

Diab.. Medicine december 2011


Diab

2011

:
LDL< 100mg% (A)
:
LDL< 70mg% ()
LDL ,
LDL 30% - 40% ()
LDL :
TG < 150 mg% HDL > 40 mg% ()
()
HDL > 50 mg% ()
()
non HDL Apo B
- LDL < 100mg%,
100mg%, non HDL < 130 mg%
Apo B < 90 mg% (E)
- LDL < 70mg%,
70mg%, non HDL < 100 mg%
Apo B < 80 mg% (E)

. .:
Screening,,
Screening
ADA 2012

Screening:: .
Screening
profile (LDL < 100mg%, HDL > 50mg% < 150 mg%)
2 ()

:
CVD : LDL <100mg% (A)
CVD LDL < 70 mg% ()
TG < 150mg% HDL>40mg% ()
() >50mg%
>50mg% (
( )
) ( C )

::

- life style (
( . , trans , 3,
) ()
- :
CVD (A)
CVD > 40
( A )
- CVD < 40 LDL > 100mg%
L. S. ()
-
LDL 30 40 %
()
- ,
CVD ()

Diabetes Care 2012;suppl 1

LDL
LDL--C:
ESC/EAS 2011

EHJ 2011;32:17692011;32:1769-1818

:
ESC/EAS 2011

EHJ 2011;32:17692011;32:1769-1818


ADA 2012

aspirin (75 - 162 mg)



(10 >10%) >
50 > 60
(
CVD, , , , / ) ( C )
aspirin
, < 50
< 60 .

( C )
aspirin ( 75 162 mg)
CVD ()

CVD clopidogrel ( B )
aspirin ( 75 162 mg)
clopidogrel (75mg/.)
()
Diabetes Care 2012
2012;suppl 1
1

CVD

Statement ADA 2012

<130/ 80 mmHg

LDL

<100 mg/dl
.LDL
>40+ .. ()

LDL>100 . ()

-<150 mg/dl

DL

DL>40 mg/dl () >50 mg/dl ()

:75 -162 mg/ . >50


() >60 () 1
) (C)

- 1C <7%
1C (<6%)

(25)

5-7%

150 min/ .
90 min/ .



LDL.



Steno2 Study

. Risk reduction : 50%

NNT:5

Goede P et al. NEJM 2003; 348: 383383-393.



Sure Study

Treatment targets:
1) BP<130/80 mmHg
2) HbA1c<7%
3) LDL<100mg%
4) TG<150mg%
5) aMea or ARBs

Diabetes Care 2009;32:9772009;32:977-982

:
CVD
Hong Kong diabetes Registry:
6386 T2DM patients, 5,7 years FU

IDMPS> 9900 T2D patients


40

0.20

All 3 targets

35

0.16
1c < 7%
BP < 130/80 mmHg
LDL C < 2,8 mmol/L

0.14
0.12

No targets
achieved

30
25

0.10
0.08

1 target
achieved

0.06
0.04

50% risk
reduction

2 - 3 targets
achieved

0.02

20
15
10

0.00
0

Cumulative incidence of CHD (%)

0.18

A1c < 7%

Observation time (years)

10

5
0
Asia

EE

S Am

All

Kong A, et al Diabetes Care 2007


Chan JCN, et al Diabetes Care 2009

1924
...


Joslin EP. The treatment of diabetes mellitus, 3rd edition. London, H.Kimpton,
1924

2011
201
1
To

,

Editorial: R . Nesto
Nesto.. Am. J .Med 2010
2010;;

!!!!!