Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2 / Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program

Objetivo: Identificar controversias existentes en el manejo habitual de los pacientes con diabetes mellitus tipo2 (DM2) y contrastarlas con la última evidencia científica y guías clínicas, con el fin de optimizar y homogeneizar el tratamiento de los pacientes con DM2 en la atención primaria (AP) en España. Material y métodos: 240 médicos de familia respondieron a un cuestionario online sobre el manejo de 6 perfiles de pacientes con DM2 de complejidad creciente. Resultados: Los factores clínicos más influyentes en la elección del tratamiento antihiperglucémico son una HbA1c >10% y la presencia de enfermedad cardiovascular (ECV), aunque en el paciente evolucionado cobran más relevancia la tasa de filtrado glomerular estimada y el riesgo de hipoglucemia. En el paciente recién diagnosticado con HbA1c>9% se sigue iniciando el tratamiento con monoterapia (24%). En el paciente no controlado con metformina suelen añadirse inhibidores de la dipeptidil peptidasa4 (iDPP4, 54%) seguido de inhibidores del cotransportador sodio-glucosa tipo2 (iSGLT2, 39%). Los agonistas del receptor del péptido similar al glucagón tipo1 (arGLP1) se asocian principalmente al paciente con DM2 obeso. En el paciente no controlado con metformina+sulfonilurea (SU) se prefiere sustituir la SU a añadir un tercer agente antihiperglucémico al tratamiento (77% vs. 23%). Conclusiones: Todavía persiste en AP un enfoque del tratamiento de la DM2 centrado en la reducción de la HbA1c y en la seguridad de los tratamientos. Por ello, los iDPP4 son fármacos ampliamente utilizados. Los iSGLT2 se reservan habitualmente para pacientes con DM2 y ECV y los arGLP1 para pacientes con DM2 obesos, siendo su uso muy limitado (AU)

Aim: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. Material and methods: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. Results: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). Conclusions: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low (AU)

[Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program]. / Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2.

AIM: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. MATERIAL AND METHODS: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. RESULTS: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). CONCLUSIONS: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low.

[The effect of pre-infarction unstable angina on the size of myocardial necrosis]. / Efecto de la angina inestable preinfarto en el tamaño de la necrosis miocárdica.

INTRODUCTION AND OBJECTIVES: Recent studies suggest that preinfarction angina (PA) might induce less myocardial necrosis. The objective of this study is to evaluate whether patients with PA have smaller myocardial infarctions. METHODS: Patients with acute myocardial infarction of less than 12 hours since the onset symptoms were included. PA was defined as unstable angina at rest during the 7 days before the infarction. Infarct size was assessed with the area under the curve of CK-MB levels in the 24 hours following the onset of the infarct. RESULTS: One hundred-seventy nine patients were included, 75 (41.9%) with PA. There were more men in the group with PA (89.3% vs 70.2%, p = 0.004) and a higher prevalence of ex-smokers (38.7% vs 19.2%, p = 0.006). We did not find significant differences in myocardial infarction size between both groups, but a statistically significant interaction between PA and pre-treatment with sulfonylurea drugs was noted (p = 0.050). CONCLUSIONS: Preinfarction angina does not seem to induce less myocardial necrosis in this study. There is a significant interaction between preinfarction angina and pre-treatment with sulfonylurea drugs.