metformina de un siglo a otro. años locos

www.who.int/chp

The global obesity pandemic: shaped by global drivers and local environments

Boyd A Swinburn, MD, Gary Sacks, PhD, Kevin D Hall, PhD, Klim McPherson, PhD, Diane T Finegood, PhD, Marjory L Moodie, DrPH and Steven L Gortmaker, PhD

The LancetVolume 378, Issue 9793, Pages 804-814 (August 2011)

DOI: 10.1016/S0140-6736(11)60813-1

Copyright © 2011 Elsevier Ltd Terms and Conditions

http://www.thelancet.com/journals/lancet/article/S0140-6736(11)60813-1/abstract

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Figure 1

Source: The Lancet 2011; 378:804-814 (DOI:10.1016/S0140-6736(11)60813-1)

Terms and Conditions



Figure 2





Figure 3





Figure 4




STANDARDS OF MEDICAL CARESTANDARDS OF MEDICAL CAREIN DIABETES—2011IN DIABETES—2011

A1C 6.5 – 7.5%**

Monotherapy

MET +

GLP-1 or DPP4 1

TZD 2

Glinide or SU 5

TZD + GLP-1 or DPP4 1

MET + Colesevelam

AGI 3

2 - 3 Mos.***

2 - 3 Mos.***

2 - 3 Mos.***

Dual Therapy

MET +

GLP-1 or DPP4 1

+

TZD 2

Glinide or SU 4,7

A1C > 9.0%

No Symptoms

Drug Naive Under Treatment

INSULIN

± Other

Agent(s) 6

Symptoms

INSULIN

± Other

Agent(s) 6

INSULIN

± Other

Agent(s) 6

Triple Therapy

AACE/ACE Algorithm for Glycemic Control Committee

Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE

Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE

* May not be appropriate for all patients** For patients with diabetes and A1C < 6.5%,

pharmacologic Rx may be considered*** If A1C goal not achieved safely

† Preferred initial agent

1 DPP4 if PPG and FPG or GLP-1 if PPG

2 TZD if metabolic syndrome and/or

nonalcoholic fatty liver disease (NAFLD)

3 AGI if PPG

4 Glinide if PPG or SU if FPG

5 Low-dose secretagogue recommended

6 a) Discontinue insulin secretagoguewith multidose insulin

b) Can use pramlintide with prandial insulin

7 Decrease secretagogue by 50% when added to GLP-1 or DPP-4

8 If A1C < 8.5%, combination Rx with agents that cause hypoglycemia should be used with caution

9 If A1C > 8.5%, in patients on Dual Therapy,insulin should be considered

MET +

GLP-1

or DPP4 1 ± SU 7

TZD 2

GLP-1

or DPP4 1 ± TZD 2

A1C 7.6 – 9.0%

Dual Therapy 8

2 - 3 Mos.***

2 - 3 Mos.***

Triple Therapy 9

INSULIN

± Other

Agent(s) 6

MET +

GLP-1 or DPP4 1

or TZD 2

SU or Glinide 4,5

MET +

GLP-1

or DPP4 1+ TZD 2

GLP-1

or DPP4 1 + SU 7

TZD 2

MET † DPP4 1 GLP-1 TZD 2 AGI 3

Available at www.aace.com/pub© AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE

A1C 6.5 – 7.5%**

Monotherapy

MET +

GLP-1 or DPP4 1

TZD 2

Glinide or SU 5


MET +Colesevelam

AGI 3

2 - 3 Mos.***

Dual Therapy

MET +GLP-1 or DPP4 1

+

TZD 2

Glinide or SU 4,7

INSULIN

± Other Agent(s) 6

Triple Therapy


2 - 3 Mos.***

2 - 3 Mos.***

*** If A1C goal not achieved safely


1 DPP4 if PPG and FPG or GLP-1if PPG

2 TZD if metabolic syndrome and/or nonalcoholic fatty liver disease (NAFLD)

3 AGI if PPG



6 a) Discontinue insulin secretagogue with multidose insulin




LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR

GLYCEMIC CONTROL

MET +

GLP-1or DPP4 1

+ TZD 2

GLP-1or DPP4 1 + SU 7

TZD 2

A1C 7.6 – 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR

GLYCEMIC CONTROL


Dual Therapy 8

MET +

GLP-1 or DPP4 1

or TZD 2

SU or Glinide 4,5

2 - 3 Mos.***

Triple Therapy 9

2 - 3 Mos.***

INSULIN

± Other Agent(s) 6

*** If A1C goal not achieved safely










9 If A1C > 8.5%, in patients on Dual Therapy, insulin should be considered

No Symptoms


Symptoms

MET +

GLP-1 or DPP4 1

± SU 7

TZD 2

GLP-1 or DPP4 1 ± TZD 2

A1C > 9.0%LIFESTYLE MODIFICATION AACE/ACE DIABETES ALGORITHM FOR

GLYCEMIC CONTROL


INSULIN

± Other Agent(s) 6

INSULIN

± Other Agent(s) 6






Recommendations:Recommendations:Glycemic Goals in Adults (1)Glycemic Goals in Adults (1)

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S19.

• Lowering A1C to below or around 7%– Shown to reduce microvascular and neuropathic

complications of diabetes– If implemented soon after diagnosis of diabetes,

associated with long-term reduction in macrovascular disease

• Therefore, a reasonable A1C goal for many non-pregnant adults is <7% (B)

Correlation of A1C with Estimated Correlation of A1C with Estimated Average Glucose (eAG)Average Glucose (eAG)

Mean plasma glucose

A1C (%) mg/dl mmol/l

6 126 7.0

7 154 8.6

8 183 10.2

9 212 11.8

10 240 13.4

11 269 14.9

12 298 16.5

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.

These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.

Glycemic Recommendations for Non-Glycemic Recommendations for Non-Pregnant Adults with Diabetes (1)Pregnant Adults with Diabetes (1)

A1C <7.0%*

Preprandial capillary plasma glucose

70–130 mg/dl* (3.9–7.2 mol/l)

Peak postprandial capillary plasma glucose†

<180 mg/dl* (<10.0 mmol/l)

*Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.

Treatment Options

Pharmacological agents

Type 2 diabetes across generations: from pathophysiology to prevention and management

Christopher J Nolan, FRACP, Peter Damm, DMSc and Marc Prentki, PhD

The LancetVolume 378, Issue 9786, Pages 169-181 (July 2011)

DOI: 10.1016/S0140-6736(11)60614-4


Figure 1



Metformin. In most of the world, metformin is the only biguanide available. Its major effect is to decrease hepatic glucose output and lower fasting glycemia. Typically, metformin monotherapy will lower A1C levels by 1.5 percentage points (27,49). It is generally well tolerated, with the most common adverse effects being gastrointestinal. Metformin monotherapy is not usually accompanied by hypoglycemia and has been used safely, without causing hypoglycemia, in patients with prediabetic hyperglycemia (50). Metformin interferes with vitamin B12 absorption but is very rarely associated with anemia (27). The major nonglycemic effect of metformin is either weight stability or modest weight loss, in contrast with many of the other blood glucose–lowering medications. The UKPDS demonstrated a beneficial effect of metformin therapy on CVD outcomes (7), which needs to be confirmed. Renal dysfunction is considered a contraindication to metformin use because it may increase the risk of lactic acidosis, an extremely rare (less than 1 case per 100,000 treated patients) but potentially fatal complication (51). However, recent studies have suggested that metformin is safe unless the estimated glomerular filtration rate falls to 30 ml/min (52).

3434

IDF20053

IDF20053

Pacífico Asiático4 2009220092

NICE 20021

NICE 20021

MetforminaMetformina

1. UK National Clinical Guidelines for T2DM 2002. Rev 20052. Nathan DM et al. Diabetes Care 2009;31(1):193-2033. IDF Clinical Guidelines Task Force. Diabet Med 2006;23:579-934. Asian Pacific Type 2 Diabetes Practical Targets & Treatment. 4th Ed

Las Guías reconocen a la Metformina como el tratamiento base en la Diabetes Tipo 21-4

Dr. Enrique Mendoza

Institution: COMPLEJO HOSP DR AAM | Sign Out | Sign In as Individual | Contact Subscription Administrator at your institution | FAQ

MetforminMetformin

Dr. Enrique Mendoza

©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.

MONOTHERAPY

Metformin: Effect on Glucose and Insulin

Adapted from Jackson, et al. Diabetes. 1987;36:632-640, with permission.

BaselineMetformin

080

120

160

200

240

280

320

360

1 2 3

Oralglucose

Oralglucose

Time (h)0

0

20

40

60

1 2 3Time (h)

Plasma Glucose Serum Insulin

mg/

dL

U/L

Dr. Enrique Mendoza

©1999, Medical Age Publishing, Division of Snyder Healthcare Communications Worldwide, Stamford, Connecticut. All rights reserved.

MONOTHERAPY

Metformin:Effect on HbA1c

Adapted from De Fronzo, et al. N Engl J Med. 1995;333:541-549, with permission.

1

Diet + placebo

Diet + metformin

*P <.001

0

** * * * *

0 9 13Treatment (wk)

17 21 25 29

–1

–2

+0.4%

–1.4%

Ch

ange

in M

ean

Hb

A1c

(%)

The consensus report concluded that “Although still limited, early evidence suggests that metformin is associated

with a lower risk of cancer and that

IV. PREVENTION/DELAY OF IV. PREVENTION/DELAY OF TYPE 2 DIABETESTYPE 2 DIABETES

Recommendations:Recommendations:Prevention/Delay of Type 2 DiabetesPrevention/Delay of Type 2 Diabetes• Refer patients with IGT (A), IFG (E), or A1C 5.7-

6.4% (E) to support program– Weight loss 7% of body weight– At least 150 min/week moderate activity

• Follow-up counseling important (B);third-party payors should cover (E)

• Consider metformin if multiple risk factors, especially if hyperglycemia (e.g., A1C>6%) progresses despite lifestyle interventions (B)

• In those with prediabetes, monitor for development of diabetes annually (E)

ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2011;34(suppl 1):S16.

Volume 352:1223-1236 March 24, 2005 Number 12

Clinical Therapeutics Metformin for the Treatment of the Polycystic

Ovary Syndrome

John E. Nestler, M.D.

N Engl J MedVolume 358(1):47-54

January 3, 2008

Original Article Metformin versus Insulin for the Treatment of

Gestational Diabetes

Janet A. Rowan, M.B., Ch.B., William M. Hague, M.D., Wanzhen Gao, Ph.D., Malcolm R. Battin, M.B., Ch.B., M. Peter Moore, M.B., Ch.B., for the MiG

Trial Investigators

N Engl J MedVolume 358(19):2003-2015

May 8, 2008

Study Overview

• This open-label trial compared insulin with metformin (with supplemental insulin if required) for the treatment of gestational diabetes mellitus

• The rates of neonatal complications were similar in the two groups, and more women in the metformin group than in the insulin group reported that they would choose their assigned treatment again

• These results provide support for the use of metformin as initial treatment for gestational diabetes in women who require pharmacologic therapy

Conclusion

• In women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin

• The women preferred metformin to insulin treatment

UKPDS: Post –Trial MonitoringSurvival and Myocardial Infarction

Metformin*Sulfonylureas * / Insulin *

Su

rvivalM

I

Holman RR. NEJM ,2008; 359: 1577 - 89

-33%

-36%

-39%

-27%

-15%

-13%

* Including glibenclamide, ** vs Lifestyle

-8%

-14%

*

Conclusion

• Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up

• A continued benefit after metformin therapy was evident among overweight patients. (UKPDS 80; Current Controlled Trials number, ISRCTN75451837.)

A1C 6.5 – 7.5%**

Monotherapy

MET +

GLP-1 or DPP4 1

TZD 2

Glinide or SU 5


MET + Colesevelam

AGI 3

2 - 3 Mos.***

2 - 3 Mos.***

2 - 3 Mos.***

Dual Therapy

MET +

GLP-1 or DPP4 1

+

TZD 2

Glinide or SU 4,7

A1C > 9.0%

No Symptoms


INSULIN

± Other

Agent(s) 6

Symptoms

INSULIN

± Other

Agent(s) 6

INSULIN

± Other

Agent(s) 6

Triple Therapy

AACE/ACE Algorithm for Glycemic Control Committee

Cochairpersons:Helena W. Rodbard, MD, FACP, MACEPaul S. Jellinger, MD, MACE

Zachary T. Bloomgarden, MD, FACEJaime A. Davidson, MD, FACP, MACEDaniel Einhorn, MD, FACP, FACEAlan J. Garber, MD, PhD, FACEJames R. Gavin III, MD, PhDGeorge Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACEEdward S. Horton, MD, FACEHarold Lebovitz, MD, FACEPhilip Levy, MD, MACEEtie S. Moghissi, MD, FACP, FACEStanley S. Schwartz, MD, FACE

* May not be appropriate for all patients** For patients with diabetes and A1C < 6.5%,

pharmacologic Rx may be considered*** If A1C goal not achieved safely


1 DPP4 if PPG and FPG or GLP-1 if PPG

2 TZD if metabolic syndrome and/or

nonalcoholic fatty liver disease (NAFLD)

3 AGI if PPG



6 a) Discontinue insulin secretagoguewith multidose insulin




9 If A1C > 8.5%, in patients on Dual Therapy,insulin should be considered

MET +

GLP-1

or DPP4 1 ± SU 7

TZD 2

GLP-1

or DPP4 1 ± TZD 2

A1C 7.6 – 9.0%

Dual Therapy 8

2 - 3 Mos.***

2 - 3 Mos.***

Triple Therapy 9

INSULIN

± Other

Agent(s) 6

MET +

GLP-1 or DPP4 1

or TZD 2

SU or Glinide 4,5

MET +

GLP-1

or DPP4 1+ TZD 2

GLP-1

or DPP4 1 + SU 7

TZD 2



Current Guidelines for Diabetes Management

Country or region

UK (NICE)

Australia

Asia-Pacific

Fra (AFSSAPS)

Germany (DDG)

S Afr (SEMDSA)

Lat Am (ALAD)

USA (ADA)

Europe (EASD)

IDF (global)

Year

2005/8

2004

2005

1999

2003

2002

2007

2006/8/9

2006/8/9

2005

BMI definition

of overweight

(kg/m2)

>25

None

>23

>28

>25-27

>25

>27

>25

>25

>25

Overweight

Metformin

Metformin

Metformin

Metformin

Metformin

Consider met

Metformin

Metformin

Metformin

Metformin

Non-overweight

Consider metformin

Initiate with metformin

Metformin, SU,TZD,AGI

Metformin, SU or AGI

Insulin secretagogue

No recommendation

Metformin

Metformin

Metformin

Metformin,SU

Recommendations for initiating pharmacologic

therapy after failure of diet and exercise

Big Question is what to add to Metformin

Choice of agents for combination therapy

Metformin

AcarboseMiglitolVoglibose

RosiglitazonePioglitazone

GlipizideGliclazideGlimepirideGlibenclamide Repaglinide

Nateglinide

SitagliptinVildagliptin

Emerging

Established

Fixed Dose Combinationsreducing the pill burden

1. Metformin + Glibenclamide (Glucovance ®)

2. Metformin + Glimepiride ( Amaryl M ®)

3. Metformin + Rosiglitazone (Avandamet ®)

4. Metformin + Pioglitazone (Competact®)

5. Metformin + Sitagliptin (Janumet®)

6. Metformin + Vildagliptin (Eucreas® Jalra M)

Choice of agents for combination therapy

Metformin

AcarboseMiglitolVoglibose

RosiglitazonePioglitazone

GlipizideGliclazideGlimepirideGlibenclamide Repaglinide

Nateglinide

SitagliptinVildagliptin

Emerging

Established

Management of type 2 diabetes: new and future developments in treatment

Abd A Tahrani, MD, Clifford J Bailey, PhD, Stefano Del Prato, MD and Anthony H Barnett, MD

The LancetVolume 378, Issue 9786, Pages 182-197 (July 2011)

DOI: 10.1016/S0140-6736(11)60207-9


Figure 1



Figure 2



Figure 3



Figure 4



Figure 5



Figure 6



VI. PREVENTION AND MANAGEMENT OFDIABETES COMPLICATIONS

• CVD is a major cause of morbidity, mortality for those with diabetes

• Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD

• Diabetes itself confers independent risk• Benefits observed when individual cardiovascular risk

factors are controlled to prevent/slow CVD in people with diabetes

Cardiovascular Disease (CVD) in Cardiovascular Disease (CVD) in Individuals with DiabetesIndividuals with Diabetes

ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.

Recommendations: Recommendations: Hypertension/Blood Pressure ControlHypertension/Blood Pressure Control

Screening and diagnosis• Measure blood pressure at every routine diabetes visit• If patients have systolic blood pressure

≥130 mmHg or diastolic blood pressure ≥80 mmHg– Confirm blood pressure on a separate day– Repeat systolic blood pressure ≥130 mmHg or diastolic

blood pressure ≥80 confirms a diagnosis of hypertension (C)



Goals• A goal systolic blood pressure <130 mmHg is

appropriate for most patients with diabetes (C)• Based on patient characteristics and response to

therapy, higher or lower systolic blood pressure targets may be appropriate (B)

• Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B)



Treatment (1)• Patients with a systolic blood pressure 130–139

mmHg or a diastolic blood pressure 80–89 mmHg– May be given lifestyle therapy alone for a maximum of 3

months– If targets are not achieved, patients should be treated

with the addition of pharmacological agents (E)



Treatment (2)• Patients with more severe hypertension

(systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) at diagnosis or follow-up– Should receive pharmacologic therapy in addition

to lifestyle therapy (A)



Treatment (3)• Lifestyle therapy for hypertension

– Weight loss if overweight– DASH-style dietary pattern including reducing

sodium, increasing potassium intake– Moderation of alcohol intake– Increased physical activity (B)



Treatment (4)• Pharmacologic therapy for patients with diabetes and hypertension

– Pair with a regimen that includes either an ACE inhibitor or angiotensin II receptor blocker

– If one class is not tolerated, the other should be substituted• If needed to achieve blood pressure targets

– Thiazide diuretic should be added to those with estimated GFR ≥30 ml x min/1.73 m2

– Loop diuretic for those with an estimated GFR <30 ml x min/1.73 m2 (C)



Treatment (5)• Multiple drug therapy (two or more agents at

maximal doses)– Generally required to achieve blood pressure

targets (B)• If ACE inhibitors, ARBs, or diuretics are used

– Kidney function, serum potassium levels should be monitored (E)



Treatment (6)• In pregnant patients with diabetes and chronic

hypertension– Blood pressure target goals of 110–129/65–79 mmHg are

suggested in interest of long-term maternal health and minimizing impaired fetal growth

• ACE inhibitors, ARBs, contraindicated during pregnancy (E)


Recommendations:Recommendations:Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management

Screening• In most adult patients

– Measure fasting lipid profile at least annually• In adults with low-risk lipid values (LDL

cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl)– Lipid assessments may be repeated every 2 years

(E)



Treatment recommendations and goals (1)• To improve lipid profile in patients with diabetes,

recommend lifestyle modification (A), focusing on– Reduction of saturated fat, trans fat, cholesterol intake– Increased n-3 fatty acids, viscous fiber,

plant stanols/sterols– Weight loss (if indicated)– Increased physical activity



Treatment recommendations and goals (2)• Statin therapy should be added to lifestyle

therapy, regardless of baseline lipid levels, for diabetic patients:– with overt CVD (A)– without CVD who are >40 years of age and have

one or more other CVD risk factors (A)



Treatment recommendations and goals (3)• For patients at lower risk (e.g., without

overt CVD and <40 years of age) (E)– Statin therapy should be considered in addition

to lifestyle therapy if LDL cholesterol remains >100 mg/dl

– In those with multiple CVD risk factors



Treatment recommendations and goals (4)• In individuals without overt CVD

– Primary goal is an LDL cholesterol<100 mg/dl (2.6 mmol/l) (A)

• In individuals with overt CVD– Lower LDL cholesterol goal of <70 mg/dl

(1.8 mmol/l), using a high dose of a statin, is an option (B)



Treatment recommendations and goals (5)• If targets not reached on maximal tolerated statin therapy

– Alternative therapeutic goal: reduce LDL cholesterol ~30–40% from baseline (A)

• Triglyceride levels <150 mg/dl (1.7 mmol/l), HDL cholesterol >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirable– However, LDL cholesterol–targeted statin therapy remains the

preferred strategy (C)



Treatment recommendations and goals (6)• If targets are not reached on maximally tolerated

doses of statins– Combination therapy using statins and other lipid

lowering agents may be considered to achieve lipid targets

– Has not been evaluated in outcome studies for either CVD outcomes or safety (E)

• Statin therapy is contraindicated in pregnancy


Kaplan–Meier Curve for the Primary End Point.

The AIM-HIGH Investigators. N Engl J Med 2011. DOI: 10.1056/NEJMoa1107579

Causal Diagram of the Relationships among Niacin, Major Lipid Levels, and Clinical Outcomes.

Giugliano RP. N Engl J Med 2011. DOI: 10.1056/NEJMe1112346

Recommendations: Glycemic, Blood Recommendations: Glycemic, Blood Pressure, Lipid Control in AdultsPressure, Lipid Control in Adults

A1C <7.0%*

Blood pressure <130/80 mmHg†

LipidsLDL cholesterol <100 mg/dl

(<2.6 mmol/l)‡

*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

†Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.

‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of statin, is an option.

ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31. Table 12.

Recommendations:Recommendations:Antiplatelet Agents (1)Antiplatelet Agents (1)

• Consider aspirin therapy (75–162 mg/day) (C)– As a primary prevention strategy in those with type 1 or type 2

diabetes at increased cardiovascular risk (10-year risk >10%)– Includes most men >50 years of age or women >60 years of age

who have at least one additional major risk factor• Family history of CVD• Hypertension• Smoking• Dyslipidemia• Albuminuria



• Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C)• 10-year CVD risk <5%: men <50 and women <60 years

of age with no major additional CVD risk factors • In patients in these age groups with multiple

other risk factors (e.g., 10-year risk 5%-10%) clinical judgment is required (E)



• Use aspirin therapy (75–162 mg/day)– Secondary prevention strategy in those with diabetes with a

history of CVD (A)• For patients with CVD, documented aspirin allergy

– Clopidogrel (75 mg/day) should be used (B)• Combination therapy with ASA (75–162 mg/day) and

clopidogrel (75 mg/day)– Reasonable for up to a year after an acute coronary

syndrome (B)


Hypertension Implementing NICE guidance

August 2011

NICE clinical guideline 127

Updated guidance

This guideline updates and replaces ‘Hypertension: management of hypertension in adults in primary care’ (NICE clinical guideline 34, 2006).

NICE clinical guideline 34 was a partial update of ‘Hypertension’ (NICE clinical guideline 18, 2004).

This update was produced in collaboration with the British Hypertension Society

NICE Pathway

The NICE Hypertension pathway shows all the recommendations in the Hypertension guideline

Click here to go to NICE Pathways

website

What this presentation covers

• Background

• Scope

• Key priorities for implementation and

updated areas

• Areas not updated

• Costs and savings

• Discussion

• Find out more

Background

High Blood Pressure:

• Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.

• Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state.

• Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:– 7% from heart disease – 10% from stroke.

Epidemiology

• Hypertension is common in the UK population.

• Prevalence influenced by age and lifestyle factors.

• 25% of the adult population in the UK have hypertension.

• 50% of those over 60 years have hypertension.

• With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.

DefinitionsStage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or higher and• ABPM or HBPM average is 135/85 mmHg or higher.

Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg or higher.

Severe hypertension: • Clinic BP is 180 mmHg or higher or• Clinic diastolic BP is 110 mmHg or higher.

Scope

Groups not included are people with diabetes, secondary causes of hypertension, accelerated hypertension or acute hypertension, pregnant women, and children and young people aged under 18.

Clinical management of primary hypertension in adults who may, or may not, have pre-existing cardiovascular disease.

Key priorities for implementation

• Diagnosis.

• Initiating and monitoring antihypertensive drug treatment.

• Choosing antihypertensive drug treatment.

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

Diagnosis (1)

When using the following to confirm diagnosis, ensure: ABPM:–at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosisHBPM:–two consecutive seated measurements, at least 1 minute apart–blood pressure is recorded twice a day for at least 4 days and preferably for a week–measurements on the first day are discarded – average value of all remaining is used.

Diagnosis (2)

Offer antihypertensive drug treatment to people:• who have stage 1 hypertension, are aged under 80 and

meet identified criteria• who have stage 2 hypertension at any age.

If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider:

• specialist evaluation of secondary causes of hypertension• further assessment of potential target organ damage.

Initiating drug treatment

Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below:

• 140/90 mmHg in people aged under 80• 150/90 mmHg in people aged 80 and over

Monitoring drug treatment (1)

For people identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment.

Aim for ABPM/HBPM target average of:• below 135/85 mmHg in people aged under 80• below 145/85 mmHg in people aged 80 and over.

Monitoring drug treatment (2)

White-coat effect: a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Care pathway

CBPM ≥160/100 mmHg & ABPM/HBPM

≥ 150/95 mmHg

Stage 2 hypertension

Consider specialist referral

Offer antihypertensive drug treatment

Offer lifestyle interventions

If younger than 40 years

If target organ damage present or 10-year cardiovascular risk > 20%

Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

Offer patient education and interventions to support adherence to treatment

CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

Step 4

Summary of antihypertensive

drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

See slide notes for details of footnotes 1-5

Offer people aged 80 and over the same antihypertensive drug treatment as people aged over 55, taking into account any comorbidities.

Drug treatment

Choosing antihypertensive drug treatment

Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated.

When using an automated device:

•palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually

•ensure that the device is validated* and an appropriate cuff size for the person’s arm is used.

Measuring blood pressure:updated recommendations

* See notes

Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension.

For all people with hypertension offer to:

–test urine for presence of protein–take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol–examine fundi for hypertensive retinopathy–arrange a 12-lead ECG.

Assessing cardiovascular risk and target organ damage:

updated recommendations

Lifestyle interventionsOffer guidance and advice about:

– diet (including sodium and caffeine intake) and exercise

– alcohol consumption

– smoking.

Patient education and adherenceProvide:

– information about benefits of drugs and side effects

– details of patient organisations

– an annual review of care.

Additional recommendations

Costs and savings for total population of England

Year Change in diagnosis cost

(£m)

Change in treatment cost

(£m)

Net resource impact

(£m)Year 1 £5.1 − £2.5 £2.6

Year 2 £5.1 − £5.8 − £0.7

Year 3 £5.1 − £9.1 − £4.0

Year 4 £5.1 −£12.4 − £7.3

Year 5 £5.1 −£15.7 −£10.5

Costs and savings of using ABPM to confirm diagnosis of hypertension

Discussion

• How do our diagnosis and treatment pathways for people with hypertension need to change in order to bring them in line with this guidance?

• What innovative ways can we think of to enhance our capacity to deliver ABPM to people who need it?

• What action do we need to take to ensure our blood pressure monitoring devices are properly validated, maintained and regularly calibrated?

• Who within our team needs briefing or training to ensure consistent implementation?

NHS Evidence

Visit NHS Evidence for the best available evidence on all aspects of cardiovascular disease

Click here to go to the NHS Evidence

website

Find out more

Visit www.nice.org.uk/guidance/CG127 for:

Visit http://pathways.nice.org.uk/pathways/hypertension to access the hypertension NICE pathway (see slide 3)

• audit support• baseline assessment tool• clinical case scenarios• implementation advice• podcast

• the guideline • the quick reference guide• ‘Understanding NICE guidance’• costing report and template

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