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This website for under 18's from Roche Diabetes Care contains some great interactive tools to help you and your family learn more about diabetes and encourage you to get more involved.
Accu-Chek Connect is designed to provide diabetes care information, clinical evidence, case studies and tools to support healthcare professionals make timely and effective therapy decisions, helping patients to become more engaged in their diabetes self-management.
The 3-day fasting, pre-prandial and postprandial SMBG testing plan provided in our tool helps your patients follow the 7-point profile SMBG regimen listed in the IDF guidelines.
15 International Diabetes Federation Clinical Guidelines Taskforce and SMBG International Working Group. This website contains information on products which is targeted to a wide range of audiences and could contain product details or information otherwise not accessible or valid in your country. Diabetes has reached epidemic proportions and is a major global burden, especially in developing countries.1 Type 2 diabetes is associated with significant morbidity and decreased life expectancy due to its complications, which include heart disease, stroke, amputation, blindness, and kidney failure. Diabetes care is complex, involving a range of interventions, including education, lifestyle modification (diet, physical activity), medications for control of blood glucose and risk factors for cardiovascular disease, and ongoing monitoring and review. The UKPDS (United Kingdom Prospective Diabetes Study) demonstrated that tighter blood glucose control reduced complications in people with newly diagnosed type 2 diabetes. The benefits of multifactorial intervention were demonstrated in the Steno-2 study.10,11 Subjects in the intensive therapy group received multifactorial treatment including behavior modification and pharmacological therapy for hyperglycemia, hypertension, and dyslipidemia, while the conventional group was treated according to national guidelines. The range of pharmacological agents for the control of blood glucose continues to increase.
Most of the data relating to pharmaceutical interventions are based on efficacy in improving blood glucose, which is generally similar between agents, depending on whether the agent is used as first-, second-, or third-line therapy.
The IDF is an umbrella international nongovernmental organization of over 200 national diabetes associations in over 160 countries and has been leading the global diabetes community since 1950. The IDF Clinical Guidelines Task Force focuses on developing guidelines and clinical care recommendations which are globally relevant.13 Clinical management guidelines are a routine part of clinical practice and are an essential starting point for improving clinical care. All people with diabetes should have access to the broad range of diabetes services and therapies, and no person should be denied any element of effective diabetes care. Recommended care is evidence-based care which is costeffective in most countries with a well-developed service base, and with health care funding systems consuming a significant part of national wealth. Comprehensive care includes the most up-to-date and complete range of health technologies that can be offered to people with diabetes, with the aim of achieving best possible outcomes.
The generic IDF treatment algorithm (Figure 1, page 12)14 takes into consideration available evidence and differences in global availability, access, and cost of medications.13 The algorithm is not proscriptive, but rather is formulated as a template for local adaptation by individual countries which do not have their own algorithms. There is a wide range of blood glucose–lowering agents; however, availability and access tomany of these is limited in many middle- and low-income countries. Lifestyle changes, including diet modification, increase in physical activity, weight reduction in those that are overweight, and smoking cessation, are essential components of the management of type 2 diabetes.
Metformin is generally considered the first-choice oral medication, unless contraindicated, eg, in the presence of renal impairment.
Global alternatives to metformin as first-line therapy include sulfonylureas or α-glucosidase inhibitors. Although considered as a class, there may be intrinsic differences between the various sulfonylureas. Alternative second-line therapies include an α-glucosidase inhibitor or DPP-4 inhibitor. If diabetes control remains unsatisfactory and a third agent is required, the usual approach options include either adding a third oral agent or commencing insulin. The UKPDS established the effectiveness of intensive therapy based on insulin treatment in reducing vascular complications compared with conventional therapy.3 Insulin options include adding once-daily basal insulin or twice-daily premixed insulin, usually in combination with oral blood glucose–lowering medications.
The final step in the algorithm is to intensify insulin therapy with basal and mealtime insulins. The author has received fees for participating in advisory boards or speaking engagements from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Glaxo- SmithKline, Merck & Co, Novartis, Novo Nordisk, Roche Diagnostics, and Servier. Risk for CHD and Diabetes Based on Number of Metabolic Syndrome Criteria CHD 0 Diabetes Sattar N et al.
VOEDING DOEL: Bereiken van goede regulatie van diabetes Preventie van complicaties 5-10 % van het gewicht vermageren op 6 maand tot 1 jaar Belang van middelomtrek!! The AACE recommendations are almost identical to target values published in the International Diabetes Federation (IDF) Guideline on Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes15. Please be aware that we do not take any responsibility for accessing such information which may not comply with any valid legal process, regulation, registration or usage in the country of your origin. You can find out more about them and how to change your cookie settings by viewing our Privacy & Cookie Policy.
There is, however, strong evidence that the diabetes burden can be reduced by improving diabetes management. It diminishes quality of life, impacts on employment and life opportunities, and has wide-ranging economic implications for the individual, the family, and society. Ide- ally, intervention, especially pharmacotherapy, would be based on demonstrating a benefit in reducing morbidity and premature mortality; however, few interventions have data on these end points. 3 The intensively treated group had significantly fewer microvascular complications and lower incidence of the composite end point compared with the conventionally treated group. Intensive therapy significantly reduced cardiovascular disease, nephropathy, retinopathy, and autonomic neuropathy by about 50%. The evidence base for deciding on a particular treatment or combination is limited by a lack of evidence directly comparing many of the choices. Therefore, ultimately, individual treatment choices are more often based on other considerations.
Their recommendations synthesize the evidence to identify practices and processes of diabetes care that lead to better outcomes.


While guideline recommendations are based on best available evidence, it is clear that treatment guidance cannot be truly evidence-based because of a lack of studies comparing all available options of treatment combination. However, it is recognized that in many parts of the world, the implementation of particular standards of care is limited by lack of resources.
Recommended care should be available to all people with diabetes and the aim of any health care system should be to achieve this level of care. It acknowledges that standard medical resources and fully trained health professionals are often unavailable in poorly funded health care systems. However, the evidence base supporting the use of some of these expensive or new technologies is relatively weak.
The algorithm will be continuously updated as new evidence, particularly the results of current outcomes studies, becomes available. Treatment algorithms are intended to provide guidance on ways in which these therapies can be used either alone or in combination. This recommendation is based on metformin’s favorable effect on weight, low risk of hypoglycemia, and low cost, but gastrointestinal intolerance is common and the need to monitor renal function is problematic in many health systems.
Sulfonylureas are commonly used and efficacious, but can be associated with weight gain and an increased risk of hypoglycemia. Schramm et al18 examined mortality and cardiovascular risk associated with available insulin secretagogues compared with metformin in a nationwide Danish study. Of the many options, the IDF recommends the addition of a sulfonylurea as the usual approach for people taking metformin. Options for a third oral agent include a DPP-4 inhibitor, an α-glucosidase inhibitor, or a thiazolidinedione. Weight increase was seen with insulin and thiazolidinediones, and insulin resulted in twice the absolute number of severe hypoglycemic episodes compared with noninsulin blood glucose–lowering therapies.
While there is ongoing debate about these two approaches, a recent systematic review reported the percentage of people reaching an HbA1c target of 29 The IDF algorithm lists GLP-1 RAs as an alternative third-line approach mainly on the basis of their limited global availability and their cost. Many approaches have been used with varying success, but the most effective are multidimensional and locally specific.14 Greater support is needed for guideline implementation.
Gross JL, Kramer CK, Leitao CB, et al; Diabetes and Endocrinology Metaanalysis Group (DEMA). Om het te downloaden, raad, alsjeblieft, deze presentatie aan je vrienden in de sociale netwerken.
Despite this, the care received by many people with diabetes is less than optimal worldwide. There is considerable evidence that the diabetes burden can be reduced by improving diabetes management. Instead, potential benefits are based on demonstrating a favorable effect on improving intermediate outcomes, such as lowering glycated hemoglobin (HbA1c). The Kumamoto study4 confirmed the benefits of intensive treatment in reducing the development or progression of microvascular complications.
The benefits of intervention are observed not only during the study period, but also continue for several years after the intensive intervention—the so-called legacy effect. These include unwanted consequences such as risk of hypoglycemia and weight gain, which are inevitable with insulin, but differ between other agents and between studies. Because of this limitation, IDF guidance is best described as evidence-informed consensus which seeks to balance available evidence with other important individual, practical, and societal considerations. The IDF has developed a practical approach to promote the implementation of cost-effective evidence-informed care in settings between which resources vary widely. However, in recognition of the considerable variations in resources throughout the world, other levels of care are described which acknowledge low- and high-resource situations.
Nevertheless, this level of care aims to achieve with limited resources a high proportion of what can be achieved by recommended care. The IDF algorithm is structured to provide a stepwise approach to intensifying therapy if blood glucose targets are not met. Subsequent treatment changes are based on failure to achieve target HbA1c after a 3-month period, taking into account tolerability and hypoglycemia. Outcome studies—the UKPDS3 and the ADVANCE study7—showed that intensive therapy with sulfonylurea-based treatment improved long-term outcomes. All-cause mortality, cardiovascular mortality, and a composite end point with the different medications were assessed over a median 3.3 years of follow-up.
The alternative approach is touse an &alpga;-glucosidase inhibitor, a DPP-4 inhibitor, or a thiazolidinedione. Thiazolidinediones effectively lower blood glucose, but their side effects and increasing safety concerns have seen their use decrease. Plans for implementation should be developed at the same time as the guidelines are being formulated and should be considered an integral part of the planning stage of guideline development.
Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS).
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34).
Effect of metformin on cardiovascular events and mortality: a meta-analysis of randomized clinical trials.


Mortality and cardiovascular risk associated with different insulin secretagogues compared with metformin in type 2 diabetes, with or without a previous myocardial infarction: a nationwide study.
A comparison of efficacy and safety of vildagliptin and gliclazide in combination with metformin in patients with type 2 diabetes inadequately controlled with metformin alone: a 52-week, randomized study.
Safety and efficacy of treatment with sitagliptin or glipizide in patients with type 2 diabetes inadequately controlled on metformin: a 2-year study. The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated with sitagliptin or a sulphonylurea during Ramadan: a randomised trial. Acarbose reduces the risk for myocardial infarction in type 2 diabetic patients: metaanalysis of seven long-term studies.
Effect of antidiabetic agents added to metformin on glycemic control, hypoglycemia and weight change in patients with type 2 diabetes: a network meta-analysis. Triple therapy in type 2 diabetes: insulin glargine or rosiglitazone added to combination therapy of sulfonylurea plus metformin in insulin-naive patients. Effect of antihyperglycemic agents added to metformin and a sulfonylurea on glycemic control and weight gain in type 2 diabetes: a network meta-analysis. Treatment regimens with insulin analogues and haemoglobin A1c target of Diabetes Res Clin Pract. Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus. Despite the available evidence, the care received by many people with diabetes is less than optimal worldwide.2 Guidelines are an essential tool for addressing this situation.
Any benefits should be balanced against the occurrence of undesirable effects, including hypoglycemia, weight gain, and treatment side effects. If adequate glucose control is not achieved and a third agent is required, there are five classes of agents from which to choose.
Cost to the individual, the health care system, and society is an important consideration, and cheaper, well established, and efficacious treatments (eg, metformin and sulfonylureas) continue to be widely used and recommended in guidelines globally.
It also provides advice on what is considered a usual or alternative approach to selecting a therapy. Compared with metformin, glimepiride, glibenclamide, glipizide, and tolbutamide were associated with increased all cause and cardiovascular mortality and increased incidence of the composite end point. Adverse effects include weight gain and fluid retention, which may result in peripheral edema and congestive heart failure. The International Diabetes Federation (IDF) has developed global guidelines including a treatment algorithm for people with type 2 diabetes. A focus of the International Diabetes Federation (IDF) is to provide globally relevant guidance to improve the quality and consistency of diabetes care through the development and implementation of guidelines. Other considerations that are important from an IDF perspective include availability and cost of therapies.
The usual approach represents therapies which would usually be chosen first unless contraindicated. Considering other relevant factors such as availability and cost, combined metformin and sulfonylurea therapy remains an effective and safe treatment which is widely used throughout the world.
Increasingly recognized is the greater incidence of fractures, especially in females.26 Some regulatory authorities have acted in relation to possible adverse cardiovascular effects with rosiglitazone and a possible link with bladder cancer with pioglitazone. Limitations in the evidence base mean that recommendations and guidance are best described as evidence- informed consensus. On an individual level, clinical decision making requires more than just taking into account efficacy of a particular treatment.
The options increase dramatically if different agents in each class are taken into account. These therapies are effective, safe, relatively inexpensive, and widely available globally. The strength of evidence was low or insufficient to support conclusions about the comparative effectiveness of diabetes medications on all-cause mortality, cardiovascular morbidity and mortality, and microvascular outcomes. In addition, rates of hypoglycemia vary with different sulfonylureas, being lowest with gliclazide.19 These differences in rates of hypoglycemia are reflected in clinical trials comparing sulfonylureas and DPP-4 inhibitors added to metformin,20,21 and during fasting associated with Ramadan,22 in which gliclazide is associated with less hypoglycemia. Although thiazolidinediones are included as an option in the IDF algorithm, other choices are favored. While there is an extensive range of blood glucose– lowering therapies, availability and cost limits access to many of these options in many middle- and low-income countries.
Factors which influence the treatment used in a particular patient include contraindications, potential side effects, patient preference, local availability and prescribing restrictions, and cost to the individual and health care system.
There are at least three different types of sulfonylureas, four DPP-4 inhibitors, two GLP-1 RAs, and three broad insulin regimens, ie, 2160 (30 x 3 x 4 x 2 x 3) possible combinations for triple therapy, and clearly not all of these have been compared. The alternative approach indicates other therapeutic options which could be used if the usual approach therapies are contraindicated, not tolerated, or not considered suitable for a particular individual.
It is encouraging that with the newer classes of agents a broader approach is being used to undertake direct comparative studies. Hanefeld et al24 performed ameta-analysis on the effect of the α-glucosidase inhibitor acarbose on cardiovascular events in seven randomized, placebo-controlled studies of at least 52 weeks’ duration and found significantly reduced risk for myocardial infarction and any cardiovascular event. The usual approach recommended in the IDF algorithm is use of metformin as first-line therapy followed by a sulfonylurea when a second agent becomes necessary, and moving to a third oral agent or insulin if glycemic targets are not achieved. The generic IDF treatment algorithm is not proscriptive, but rather is formulated as a template for local adaptation by individual countries which do not have their own algorithms.



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