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5.2.12. Heart failure The association between heart failure and increase in DM 2 risk has been assessed (42) in 2,616 non-diabetic patients with coronary disease (myocardial infarction and stable angina). The subgroup with advanced heart failure (class III from NYHA) had a higher risk to develop diabetes [RR 1.7 (CI 95%: 1.1- 2.6)]; this was not the case for class II from NYHA. The study was initially not designed for this target group and neither did it consider the patients’ physical exercise. Cohort Studies 2+ 5.2.13. Drugs Atypical antipsychotic drugs Some studies (43) suggest that patients with schizophrenia present a higher DM prevalence than the general population, though its cause has not been fully established. A review of 17 studies (44) states that the treatment with olanzapine and clozapine is associated with a higher risk to develop DM, in comparison to those patients who are not being treated or who receive treatment with classic antipsychotic drugs. It also concludes that more comparative studies are required among the different antipsychotic drugs. SR of different types of studies 1+/3 Diuretics and beta-blockers The HTA Clinical Practice Guideline from the National Institute for Clinical Excellence (NICE) states that there is a higher risk to develop diabetes when a combination of beta-blockers and thiazidic diuretics (45) is used. An SR (<strong>46</strong>) assessed the effect of the different types of antihypertensives in the incidence of DM, including very heterogeneous studies. It concluded that the ARBII blockers and ACE inhibitors were the antihypertensives less associated with diabetes, followed by calcium channel blockers and placebo , beta-blockers and diuretics. SR of RCT 1 + Other drugs Other drugs (47) involved in the development of diabetes are: glucocorticoids, oral contraceptives, tacrolimus, cyclosporine, nicotinic acid, protease inhibitor antiretroviral agents, gonadotropin agonist hormones, clonidine and pentamidine. RCT, cohort, case series 1+/2+/3 40 CLINICAL PRACTICE GUIDELINES IN THE NHS
5.3. DM 2 diagnosis 5.3.1. Diagnostic criteria The diagnostic criteria endorsed by the American Diabetes Association (ADA) in 1997 (48) and by the World Health Organisation (WHO) in 1999 (6) try to avoid the delay in the diagnosis in three possible ways; each one must be confirmed in the days to follow, if there is no unequivocal hyperglycaemia (see table 1). Table 1. DM 2 diagnostic criteria 1. Diabetes symptoms (polyuria, polydipsia and weight loss) and a casual plasma glucose (any time of the day) >200 mg/dl. 2. Two determinations of fasting plasma glucose >126 mg/dl.. Lack of caloric intake in the previous eight hours. 3. Two determinations of plasma glucose >200 mg/dl two fours after the oral glucose tolerance test with 75 g (OGTT). It is important to highlight that the current diagnostic thresholds to define diabetes are especially based on the increase of risk to suffer from microvascular complications (mainly retinopathy) (48). Glycaemia thresholds to define an increase in mortality and cardiovascular diseases are not established (49-51). Neither are there sufficient data to define normal glycaemia levels. Cohort Studies 2+ 5.3.2. Diagnostic methods Fasting plasma glucose This is the recommended method to diagnose diabetes and to perform population studies. It is a detailed, low cost, reproducible and easy-to use test. Glucose measure in plasma is approximately 11% higher than glucose measured in total blood in a fasting or basal stage. In non-basal stages (postprandial), both determinations are practically the same. Oral Glucose Tolerance Test (OGTT) This involves the determination of glycaemia in venous plasma two hours after a 75 g glucose intake in adults. Although it is a valid method to diagnose diabetes, recommendations on its use differ. CLINICAL PRACTICE GUIDELINE ON TYPE 2 DIABETES 41
Page 1: Clinical Practice Guideline on type
Page 4 and 5: A bibliographic record of this work
Page 7 and 8: Table of Contents Presentation 9 Au
Page 9 and 10: 11. Diabetic foot. Assessment, prev
Page 11: Presentation Care practice is becom
Page 14 and 15: Other collaborations Rosa Rico Itur
Page 16 and 17: 13. Which drug combination strategi
Page 19 and 20: Summary of recommendations Defi nit
Page 21 and 22: D CPG B B B B A daily single dose
Page 23 and 24: A B CPG Hypertense patients with DM
Page 25 and 26: Treatment for diabetic foot ulcers
Page 27: 1. Introduction Effective care for
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Page 87: Recommendations B/D A B CPG Patient
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it is believed that microalbuminuri
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Summary of evidence 1++ In hyperten
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An SR on drugs to treat diabetic ne
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(241), the response rate to placebo
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11. Diabetic foot. Assessment, prev
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11.2.2. Peripheral arterial disease
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11.4. Other preventive measures The
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B D CPG B Diabetic foot screening m
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11.5.4. Antibiotic treatment for in
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2+ The culture has a limited value
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• Promote healthy lifestyles: die
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In another recent RCT (289), sMBG w
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12.3. Contents and methods of an ed
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Assessment of self-management recor
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13.4. Referral criteria to medical
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Appendices Appendix 1. Levels of Ev
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Appendix 2. DM 2 diet Estimating ca
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CLINICAL PRACTICE GUIDELINE ON TYPE
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GPL-1 Analogues Biguanides Glitazon
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Devices FLEXPEN (Novo Nordisk): OPT
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Treatment for an unconscious patien
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Appendix 6. Assessment of macro- an
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Appendix 8. Use of monofilament Mon
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Indicators of final outcomes • Nu
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Impaired Glucose Tolerance (IGT): I
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IGT INSIGHT Trial IV LDL LH LIFE Tr
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Bibliography 1. Estrategia en diabe
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33. Iso H, Date C, Wakai K, Fukui M
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64. Screening for type 2 diabetes.
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97. Thomas DE, Elliott EJ, Naughton
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129. Lincoff AM, Wolski K, Nicholls
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157. Natarajan S, Liao Y, Cao G, Li
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185. de GG. Low-dose aspirin and vi
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214. Rahman M, Pressel S, Davis BR,
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245. NZGG. Management of type 2 dia
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279. Norris SL, Nichols PJ, Caspers
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