DIABETES MELLITUS TIPO 2 “Análisis de los objetivos, alternativas de tratamiento y riesgos en adultos mayores”
Resumen
La posibilidad de anormal tolerancia a la glucosa
y DM2 aumenta con la edad, en ellas coexisten Insulino
acción deficiente y disfunción betacelular, el
deterioro progresivo de la función betacelular determina
la respuesta terapéutica con los años de evolución.
Los beneficios del control metabólico adecuado
se mantienen y su importancia es aún mayor en adultos
mayores de 60 años en situaciones patológicas
frecuentes para este grupo, porque determinan un
mejor pronóstico; las opciones terapéuticas se reducen
por el estado cardiovascular, renal, la polimedicación,
estados depresivos, riesgo de hipoglucemias,
etc. Objetivo:Este estudio analiza los beneficios,
riesgos y aceptabilidad de un esquema simple de Insulina
glargina sola o combinada con antidiabéticos
orales(ADO) en DM mayores de 60 años con más de
5 años de evolución con o sin co-morbilidades, instaurado
en la práctica clínica habitual. Población y Metodo:
62 DM2(M/F:35/27)edad media de 68,7 ± 6,7
años (rango 60- 91 años ), años de DM2: 14,5±6,55
años (5 – 35 años), 11, 29% (7/62) sin co-morbilidad,
62,29% eran hipertensos, 53,3% dislipidémicos,
29,03% con Panvasculapatía como ACV, Cardiopatía
isquémica, IAM, vasculopatía periférica o antecedente
de revascularización, 22,6% microangiopatía;
4,8% Insuficiencia renal crónica y 4,8% depresión
importante. El 88,7 % recibe 3 o más drogas/día. Resultados:
Tiempo de tratamiento:12 ± 8,22 ( rango 3-
36) meses: El peso fue de 74,8±4,1 kg.; con IMC de
25,6±2,04 kg/m2, Glucemia Basal (GB) 181,4±58,5
mg/dl, HbA1c 9.03±1,7%. Inició esquema el 20,96%
por hipoglucemias a repetición y el 79,03% por mal
control sostenido. Recibieron Insulina Glargina(IG)
sola 16,13 %, 56.7% IG asociada a sulfonilureas,
14,5 % asociada a Metformina (MT), 3,22% a Repaglinida
y 8,06 % a Rosiglitazona más MT. A los
3, 6, 12 meses y al final el peso fue 77,04±6,8kg
(p=0,33), 72,3±5,6kg(p=O,31), 74.6±5,1kg(p=O,48,
73,1±6.45Kkg(p=0,38).GB:130±42.7mg/dL(p‹0,00
01),122.2±37.6mg/d/L(p‹0,0001),126,8±47, 2mg/dL
(p‹0,00006), 125.1±34,2 mg/dL(p‹0,0001). HbA1c
7,99±1,17%(p‹0,0001), 7,54±0.96% (p‹0,0001),
7,58±0.98%( p‹0,0001) y 7,39±0,87% (p‹0,0001).
Los lípidos no sufrieron variación significativa.
Las hipoglucemias de 26episodio/13DM2 se redujo
a 2/1, 29% se declaró satisfecho y 71% muy
satisfecho. Conclusiones: El tratamiento con IG
sola o con ADO, mejora el control metabólico establemente,
con menor riesgo de hipoglucemias en
una población de adultos mayores con o sin comorbilidades,
mediante un esquema de tratamiento
simplificado con un esquema de dosificación
ambulatorio sencillo.
Palabras clave
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- King H, Auber R, Herman W. Global Burden of Diabetes.
-2025.Prevalence, Numerical estimates,
and ProjectionsDiabetes Care 21:1414-1431,1998.-
- Hermans MP, Pepersack TM, Godeaux LH, Beyer
I, Ture A. Prevalence and determinants of impaired
glucose metabolism in Frail Elderly Patients: The
Belgian Elderly Diabetes Survey (BEDS). J Gereont
Series Biol Sc and Med Sc 60:241-247, 2005.-
- Jiménez JT, Palacios M, Cañete F, Barriocanal LA,
Medina U, Figueredo R, Martínez S, de Melgarejo MV,
Weik S, Kiefer R, Alberti KGMM, Moreno-Azorero R.
Prevalence of diebetes mellitus and associated cardiovascular
risk factors in an adult urban population in
Paraguay. Diabetic Med;15:334-338, 1998.
- Marshall McBean A, Li S, Gilbertson DT, Collins AJ.
Differences in Diabetes Prevalence, Incidence, and
Mortality Among the Elderly of Four Racial/Ethnic
Groups: Whites, Blacks, Hispanics, and Asians. Diabetes
Care 27:2317-2324, 2004
- Polonsky K. S., Sturis J., Bell G. I. Seminars in Medicine
of the Beth Israel Hospital, Boston: Non-Insulin-
Dependent Diabetes Mellitus — A Genetically
Programmed Failure of the Beta Cell to Compensate
for Insulin Resistance N Engl J Med; 334:777-783,
-
- UK Prospective Diabetes Study Group:UK Prospective
Diabetes Study 16: overview of 6 years’ therapy
of type II diabetes :a progressive disease. Diabetes
:1249-1258,1995.
- Stratton Im,Adler AI, Neil HA, Matthews DR,Manley
SE,Cull CA,Hadden D, Turner RC, Holman RR: Association
of glycaemia with macrovascular and microvascular
complications of type 2 diabetes(UKPDS
: progressive observational study. BMJ 321:405-
, 2000.
- Klein R, Klein BEK, Moss SE: Relation of glycemic
control to diabetic microvascular complications of
diabetes mellitus. Ann Intern Med 124: 90-96,1996.
- UK Prospective Diabetes Study Group 33:Intensive
blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of
complications in patients with type 2 diabetes.Lancet,
:837-53. Lancet,1998.
- Menielly GS,Tessier D: Diabetes in Elderly adults. J.
Gerontol 56ª:M5-M13, 2001.
- Sommerfield AJ, Deary IJ, Frier BM. Acute Hyperglycemia
after mood stete and Impairs Cognitive Performance
in People With Type 2 Diabetes . Diabetes
Care27:2335-2340, 2004.-
- American Diabetes Association: standars of medical
care in diabetes(position statement). Diabetes Care
(supp 1): S15-S35, 2004.-
- California Healthcare Foundation American Geriatrics
Society Panel Improving Care for Elders with diabetes
: guidelines for improving the care of the older
person with diabetes mellitus. J Am Geriatr Soc51:
S265-S280, 2003.-
- Shorr Ri, Franse L,Resnick HE,Di Bari M,Johnson
KC,Pahor M, Glycemic control of older adult with
type 2 diabetes:findings from the Third National
Health and Nutrition examination survey, 1988-1994.
J Am Geriatr Soc48:264-267, 2000.-
- Hiss RG. Barriers to care in non insulin- dependent
diabetes mellitus. The Michigan experienc, Ann Intern
Med,: 124 146-148, 1996.-
- Uusitupa MIJ, Niskanen LK, Siitonen O, Voutilainen
E, Pyorala K. Ten-year cardiovascular mortality in relation
to risk factors and abnormalities in lipoprotein
composition in type 2 (non–insulin-dependent) diabetic
and non-diabetic subjects. Diabetologia;36:1175.
-
- Harris M I. Undiagnosed NIDDM, clinical and public
health issues. Diabetes Care 16:642-652,1993.
- UKPDS Gruop: UK Prospective Diabetes Study 6:
complications in newly diagnosed type 2 diabetic
patients and their association with different clinical
and biochemical risk factors. Diabetes Res 13: 1-11.-
,1990.-
- Joshi N., Caputo G. M., Weitekamp M. R., Karchmer
A.W Primary Care: Infections in Patients with Diabetes
Mellitus. N Engl J Med; 341:1906-1912, 1999.
- Davi G, Ciabattoni G, Consoli A, Mezzetti A, Falco A,
Santarone S, Pennese E, Vitacolonna E, Bucciarelli T,
Costantini F, Capani F, Patrono C: In vivo formation
of 8-iso-prostaglandin f2alpha and platelet activation
in diabetes mellitus: effects of improved metabolic
control and vitamin E supplementation. Circulation
:224–229, 1999
- Prandoni P, Bilora F, Marchiori A, Bernardi E,
Petrobelli F, Lensing AWA, , Prins MH, Girolami A.
An Association between Atherosclerosis and Venous
Thrombosis N Engl J Med 348:1435-1441, 2003.-
- Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycaemia
and increased risk of death after myocardial
infarction in patients with o without diabetes: a systematic
overview. Lancet;355:773-778, 2000.
- Umpierrez GE, Isaacs SD, Bazargan H, et al Hyperglycemia:
an independent marker of in-hospital mortality
in patients with undiagnosed diabetes. J Clin Edocrinol
Metab;87:978-982, 2002.
- Furnary AP, Zerr KJ, Grunkemeier GL, et al. Hyperglycemia
: a predictor of mortality following CABG in
diabetics. Circulation;100(18):I-591, 1999.
- Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycemia
and prognosis of stroke in non-diabetic and diabetic
patients: a systematic overview. Stroke;32:2426-
, 2001
- Krinsley JS. Association Between Hyperglycemia
and Increased Hospital Mortality in a Heterogeneous
Population of Critically Ill Patients. Mayo Clin Proc.
:1471-1478, 2003.-
- Clement S, Braithwaite SS, Magee MF, Ahmann A,
Smith EP, Rebecca G. Schafer RG, Hirsch IB , Management
of Diabetes and Hyperglycemia in Hospitals.
Position Statements. Diabetes Care 27:553-591,
- Alexiewicz J, Kumar D, Smogorzewski M, Klin M,
Massry S: Polymorphonuclear leukocytes in non-insulin-
dependent diabetes mellitus: abnormalities in
metabolism and function. Ann Intern Med 123:919–
, 1995
- Muggeo M, Verlato G, Bonora E, Zoppini G, Corbellini
M, De Marco R. The Verona Diabetes Study.
Long-term Instability of Fasting Plasma Glucose, a
Novel Predictor of Cardiovascular Mortality in Elderly
Patients With Non–Insulin-Dependent Diabetes
Mellitus. Circulation; 96:1750-1754, 1997.
- Malmberg K, Norhammar A, Wedel H, Ryden I. Glycometabolic
state at admission: important risk marker
of mortality in conventionally treated patients with
diabetes and acute MI ; long-term results from the Diabetes
and Insulin-Glucose Infusion in Acute Myocardial
Infarction (DIGAMI) study. Circulation;99:2626-
, 1999.
- Van den Berghe G, Wouters P, Weekers F, et al. Intensive
insulin therapy in the critically ill patients. N
Engl J Med;345:1359-1367, 2001.
- Furnary AP, Gao G, Grunkemeier GL, et al. Continous
insulin infusion reduces mortality in patients with diabetes
undergoing coronary artery bypass grafting. J
Thorac Cardiovasc Surg;125:1007-1021, 2003.
- Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso
M. Mortality from Coronary Heart Disease in Subjects
with Type 2 Diabetes Subjects with and without Prior
Myocardil Infarction. NEJM.339:229-234, 1998.-
- Stamler J, Vaccaro O, Neaton J et al Cardiovascular
mortality and diabetes. Ageadjusted CVD mortality
according to the presence of other risk factors-
(361,662 male MRFIT screenees) Diabetes Care; 16:
-444, 1993
- Thrainsdottir IS,Aspelund T, Thorgeirsson G, y cols.
The Assotiation Between Glucose Adnormalities and
Heart Failure in the Population –Based Reykjavik
Study.Diabetes Care.28:612-616, 2005.-
- Wilson PW ,Kannen WB. Obesity, diabetes and cardiovascular
disease in elderly . Am Geriat Cardiol
:119-123, 2002.-
- Predicted prevalence of microvascular complications
in people with diabetes (2000) Data from WHO. IDF
Task Force Diabetes Health Economics: Facts, Figures
and Forecasts: 1999.-
- Ohkudo Y, Kishikawa H, Araki E, Miyata T, Isami S
Motoyoshi S, Koyima Y, Furuyoshi N, Shichire M :
Intensive insulin therapy prevents the progression of
diabetic microvascular complications in japanese patients
with non-insulin-dependent diabetes mellitus a
randomized prospective 6 year study. Diabetes Res
Clin Pract 28 : 103-117,1995.-
- Tanaka Y, Atsumi Y , matsuoka K, Onuma T , Tohjima
T, Kawamori R, Role of glycemic control and
blood pressure in the development and progression
of nephropathy in elderly JapaneseNIDDM patients .
Daibetes Care 21: 116-120, 1998.-
- Davidson M. Early Insulin Therapy for Type 2 Diabetic
Patients : more Cost than Benefit. Diabetes Care
, 2005.-
- Hu FB, Stampeer MJ, Haffner SM, Solomon CG,
Willet WC, Manson JE. Elevated Risk of Cardiovascular
Disease Prior to Clinical Diagnosis of Type 2
Diabetes. Diabetes Care 25 :1129-1134. 2002.
- Gaede P, Vedel P, Larsen N, Jensen GHV, Parving HH,
Pedersen O. Multifactorial intervención and cardiovascular
disease in patients with type 2 diabetes. N
Engl J Med 348:383-393, 2003.-
- Ahmed S,Bassan MM, Gaede P. To the editors. Multifactorial
Intervention and Cardiovascular Disease
in Type 2 Diabetes. N Engl J Med 348: 1925-1927,
:- Gaede P, Pedersen O. Intensive Integrated Therapy of
Type 2 Diabetes . Diabetes Care 53:S39-S47, 2004.-
- Cryer PE. Hypoglycaemia; The limiting factor on the
glycaemic manegement of Type I and Type II diabetes:
Diabetologia 45:937-948, 2002.-
- Cryer PE, Davis ND, Shamoon H. Hypoglucemia in
Diabetes. Diabetes Care 26:1902- 1012,2003.-
- American Diabetes Association Workgroup on Hypoglucaemia.
Defining and Reporting Hypoglycaemia in
Diabetes. Diabetes Care 28:12451249, 2005.
- Leckie AM,Graham MK,Grant JB, Ritchie PJ, Freir
Bm. Frecuency, severity and Mortality Occurring in
the Workplace in People With Insulin -Treated Diabetes.
Diabetes Care 28: 1333-1338, 2005.-
- Leese GP, Wang J, Broomhall J, kelly P, Marsden A,
Morrison W, Frier BM, Morris AD. Frecuency of Severe
Hypoglycemia Requering Emergency Treatment
in Type 1 and Type 2 Diabetes. Diabetes Care 26:
-1180, 2003.-
- Shishihiri M, Kishikawa H,Ohkudo Y, Wake N. Longterm
of the Kumamoto Study on optimal diabetes
control in Type 2 diabetic patients. Diabetes Care 23:
Suppl 2:B12-B29,2000.-
- Cryer PE, Fisher JN, Shamoon H. Hypoglucemia .
Diabetes Care 17:734-755,1994.-
- Home PD, Boulton AJM, Jimenez JT, Landgraf R,
Osterbrink B, Christiansen JS. Isssues relating to the
early or earlier use of insulin in type 2 Diabetes. Practical
Diab Int 2003;20: 63-71
- Sommerfield AJ,Deary IJ, McAuly V, Frier BM.
Short. Term, Delayed and Working Memory Are Impaired
during Hypoglycemia in Individuals With Type
Diabetes. Diabetes Care 26 :390-396,2003
- UK Prospective Diabetes Study Group. Wrigth,Aburde
ACF,Paisey RB,Holman RR. (UKPDS 57). Sulfonylureas
Inadequacy. Diabetes Care 25:330-336,2002
- Rosenstock J. Redefiniendo la terapia insulinica en
la Diabetes Tipo2 . Desde el reemplazo insulínico a
la preservación de la célula β 63trd Scientific Sessions
of the American Diabetes Association. New Orleans.
- Meneilly GS, Veldhuis JD, Elahi D. Deconvolution
analysis of rapid insulin pulses before and after six
weeks of continuous subcutaneous administration of
GLP-1 in elderly patients with type 2 diabetes. J Clinical
Endoc & Metab, 10.1210/jc.2004-2100, 2005.-
- Henry RR, Mudaliar S, Chu N, Kim D, Armstrong
D, Davis TT, An B, Reinhardt RR Young and Elderly
Type 2 Diabetic Patients Inhaling Insulin with
the AERx® Insulin Diabetes Management System: A Pharmacokinetic and Pharmacodynamic Comparison
J Clin Pharmacol, 43:1228-1234, 2003.
- Chan JL, Abrahamson MJ, Pharmacological Management
of Type 2 Diabetes Mellitus: Rationale for
Rational Use of Insulin. Mayo Clin Proc;78:459-467,
- Zaangeneh F;. Kudva YC, Basu A Insulin Sensitizers.
Mayo Clin Proc;78:471-479, 2003.-
- Nathan DM Initial Manegement of Glycemia in Type
Diabetes mellitus N Engl J Med 347:1342-1349,
- Misbin RI, Green L, Stadel Bv, Gueriguian JL, Gubbi
A, Fleming GA. Lactic acidosis in patients with diabetes
traeted with metformin. N Engl J Med 338:265-
,1998.-
- Masoudi FA, Inzucchi SE, Wang Y, Havranek EP,
Foody JM, Krumholz HM Thiazolidinediones, Metformin,
and Outcomes in Older Patients With Diabetes
and Heart Failure.Circulation.;111:583-590,2005.
- Yki-Järvinen H, Thiazolidinediones. N Engl J Med
:1106-1118
- Klonoff DC, Barrett BJ, Nolte MS, RCohen RM, and
Wyderski R .Hypoglycemia following inadvertent and
factitious sulfonylurea overdosages. Diabetes Care,
Apr 1995; 18: 563 - 567.
- Burge MR, Schmitz-Fiorentino K, Fischette C,
Qualls CR, David S. Schade DS A Prospective Trial
of Risk Factors for Sulfonylurea-Induced Hypoglycemia
in Type 2 Diabetes Mellitus JAMA.;279:137-
, 1998.-
- Caulfield MT, O’Brien KD.Cardiovascular Safety of
Oral Antidiabetic Agents: The Insulin Secretagogues.
Clin. Diabetes 20: 81 – 84, 2002.
- Turner RC, Cull CA, Frighi V, Holman RR, and for
the UK Prospective Diabetes Study Group.Glycemic
Control With Diet, Sulfonylurea, Metformin, or Insulin
in Patients With Type 2 Diabetes Mellitus: Progressive
Requirement for Multiple Therapies (UKPDS 49)
JAMA, 281: 2005 – 2012, 1999.-
- United Kingdom Prospective Diabetes Study 24:
A 6-Year, Randomized, Controlled Trial Comparing
Sulfonylurea, Insulin, and Metformin Therapy
in Patients with Newly Diagnosed Type 2 Diabetes
That Could Not Be Controlled with Diet Therapy
Ann Intern Med, 128: 165 – 175, 1998.
- De Fronzo RA Pharmacologic Therapy for Type 2
Diabetes Mellitus. Ann Intern Med, 131: 281 – 303,
- Zinman B, Ross S, Campos RV, Strack T. Effectiveness
of human ultralente versus NPH insulin in providing
basal insulin replacement for an insulin lispro
multiple daily injection regimen. A double-blind randomized
prospective trial. The Canadian Lispro Study
Group. Diabetes Care, 22: 603 – 608, 1999.
- Herman WH, Ilag LL, Johnson SL, Martin CL, Sinding
J, Al Harthi A, Plunkett CD,. LaPorte FB, Ray
Burke, Brown MB, Halter JB, Raskin P A Clinical
Trial of Continuous Subcutaneous Insulin Infusion
Versus Multiple Daily Injections in Older Adults
With Type 2 Diabetes Diabetes Care 28: 1568-
, 2005.-
- King A,Armstrong D.A Comparison of Basal Insulin
Delivery: Continuous subcutaneous insulin infusion
versus glargine. Diabetes Care, 26: 1322, 2003
- Strowig SM, Avilés-Santa ML, Raskin P. Comparison
of Insulin Monotherapy and Combination Therapy
With Insulin and Metformin or Insulin and Troglitazone
in Type 2 Diabetes. Diabetes Care, 25: 1691–
, 2002.
- Lepore M, Pampanelli S, Fanelli C, Porcellati
F, Bartocci L, Di Vincenzo A, Cordoni C, Costa
E, Brunetti P, Bolli GB. Pharmacokinetics and
pharmacodynamics of subcutaneous injection of
long-acting human insulin analog glargine, NPH
insulin, and ultralente human insulin and continuous
subcutaneous infusion of insulin lispro
Diabetes,49: 2142 – 2148, 2000.
- Yki-Jarvinen H, Dressler A, Ziemen M. Less nocturnal
hypoglycemia and better post-dinner glucose
control with bedtime insulin glargine compared with
bedtime NPH insulin during insulin combination therapy
in type 2 diabetes. HOE 901/3002 Study Group
Diabetes Care, 23: 1130 – 1136, 2000.
- Fritsche A, Schweitzer MA, Häring HU. Glimepiride
Combined with Morning Insulin Glargine, Bedtime
Neutral Protamine Hagedorn Insulin, or Bedtime Insulin
Glargine in Patients with Type 2 Diabetes: A
Randomized, Controlled Trial. Ann Intern Med, 138:
– 959, 2003.-
- Bretzel RG, Arnolds S, Medding J, Linn T. A Direct
Efficacy and Safety Comparison of Insulin Aspart,
Human Soluble Insulin, and Human Premix Insulin
(70/30) in Patients With Type 2 Diabetes. Diabetes
Care, 27: 1023 – 1027, 2004.
- Riddle MC, Rosenstock J, Gerich J. The Treat-to-Target
Trial: Randomized addition of glargine or human
NPH insulin to oral therapy of type 2 diabetic patients
Diabetes Care, 26: 3080 – 3086, 2003.-
- Rosenstock J, Dailey G, Massi-Benedetti M, Fritsche
A, Lin Z, Salzman A. Reduced Hypoglycemia Risk
With Insulin Glargine: A meta-analysis comparing insulin
glargine with human NPH insulin in type 2 diabetes.
Diabetes Care; 28: 950 – 955, 2005.
- Standl E, Maxeiner S, Raptis S, Karimi-Anderesi
Z, Matthias Axel Schweitzer MA the HOE901/4009
Study Group.Good Glycemic Control With Flexibility
in Timing of Basal Insulin Supply: A 24-week
comparison of insulin glargine given once daily in the
morning or at bedtime in combination with morning
glimepiride Diabetes Care, Feb 2005; 28: 419 - 420.
- Raskin P, Allen E, Hollander P, Lewin A, Gabbay
RA, Hu P, Bode B, Garber A for the INITIATE Study
Group. Initiating Insulin Therapy in Type 2 Diabetes:
A comparisonof biphasic and basal insulin analogs.
Diabetes Care, Feb 2005; 28: 260 - 265.
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Facultad de Ciencias Médicas. Universidad Nacional de Asunción
