Page 475 - fbkCardioDiabetes_2017

vv

Cardio Diabetes Medicine 2017 451

Patient Selection excellent weight loss and major improvement of T2D,
at least in the short to medium term (1–3 years).
- Patients’ eligibility for metabolic surgery should
be assessed by a multidisciplinary team including - LAGB is effective in improving glycemia in patients
surgeon(s), internist(s) or diabetologist(s)/ with obesity and T2D, but is associated with greater
endocrinologist(s), and dietitian(s) with specific risk for reoperation/revision compared with RYGB.
expertise in diabetes care.
- Contraindications for metabolic surgery include Postoperative Follow-Up
diagnosis of T1D (unless surgery is indicated for other - After surgery, patients should continue to be
reasons, such as severe obesity); current drug or managed by multidisciplinary teams including
alcohol abuse; uncontrolled psychiatric illness; lack diabetologists/endocrinologists, surgeons,
of comprehension of the risks/benefits, expected nutritionists, and nurses with specific diabetes
outcomes, or alternatives; and lack of commitment expertise.
to nutritional supplementation and long-term follow- - Postoperative follow-up should include surgical
up required with surgery.
and nutritional evaluations at least every 6 months,
- Metabolic surgery is recommended as an option and more often if necessary, during the first 2
to treat T2D in patients with the following conditions: postoperative years and at least annually thereafter.
Class III obesity (BMI ≥40 kg/m2), regardless of the - Within the first 6 months after surgery, patients
level of glycemic control or should be carefully evaluated for glycemic control and
antidiabetes medication(s) tapered.. Further medical
Complexity of glucose-lowering regimens.
treatment of T2D after this initial 6-month period
Class II obesity (BMI 35.0–39.9 kg/m2) with should be dosed accordingly. Stable nondiabetic
inadequately controlled glycemia should be documented for at least two
3-month HbA1c cycles before considering complete
hyperglycemia despite lifestyle and optimum medical
therapy. withdrawal of glucose-lowering drugs,.
- Metabolic surgery should also be considered - In the event of plasma glucose levels rapidly
to be an option to treat T2D in patients with class approaching the normal range early postoperatively,
I obesity (BMI 30.0–34.9 kg/m2) and inadequately appropriate adjustments to medical therapy should
controlled hyperglycemia despite optimal medical be implemented. Metformin, thiazolidinediones, GLP-
treatment by either oral or injectable medications 1 analogs, DPP-4 inhibitors, β-glucosidase inhibitors,
(including insulin).

- All BMI thresholds used in these recommendations
should be reconsidered depending on the ancestry
of the patient. For example, for patients of Asian
descent, the BMI values above should be reduced
by 2.5 kg/m2.

Preoperative Workup
- Preoperative patient evaluation should include
assessment of endocrine, metabolic, physical,
nutritional, and psychological health.
- In order to reduce the risk for postoperative
infection, improve glycemic control before surgery. and SGLT2 inhibitors are suitable drugs for early
postoperative diabetes management due to their low
Choice Of Procedure risk of inducing hypoglycemia.
- RYGB is a well-standardized surgical procedure, and Algorithm for the treatment of T2D, as recommended
among the four accepted operations for metabolic by DSS-II. Meds = medications. [5]
surgery, it appears to have a more favorable risk-
benefit profile in most patients with T2D. Fig: Algorithm for the treatment of T2DM, as
recommended by DSS-II. The indications above are
- VSG is an effective procedure that results in
intended for patients who are appropriate candidates.

Cardio Diabetes Medicine