Diabetes%20Update

1
Diabetes Update
Facts, Trends and Observations

• Bruce Bode, MD, FACE
• Atlanta Diabetes Associates

2
Ultimate Goals Of Diabetes Treatment
No Long Term Diabetes Complications No Acute
Diabetes Complications
Sustained Normal Blood Glucose Control Lowest
Incidence of Hypoglycemia


Best Quality of Life with a Chronic Disease
3
Relative Risk of Progression of Diabetic
Complications
RELATIVE RISK
Mean A1C
DCCT Research Group, N Engl J Med 1993,
329977-986.
4
Lifetime Benefits ofIntensive Therapy (DCCT)

• Gain of 15.3 years of complication free living
  compared to conventional therapy
• Gain of 5.1 years of life compared to
  conventional therapy

DCCT Study Group, JAMA 1996, 2761409-1415.
5
DCCT

• 10 reduction in HbA1c
• 43 reduced risk of retinopathy progression
• 18 increased risk of severe hypoglycemia with
  coma and/or seizure

DCCT Research Group, N Engl J Med 1993,
329977-986.
6
Lowering A1C Reduces Risk of Complications
United Kingdom Prospective Diabetes Study (UKPDS)
0 -10 -20 -30 -40 -50
Any diabetes-related endpoint Microvascular
endpoint MI Retinopathy Albuminuria at 12 years
-12
-16
p0.029
p0.052
-21
-25
Reduction in risk ()
p0.015
p0.0099
-34
p0.000054
Percent risk reduction per 0.9 decrease in
HbA1C UKPDS. Lancet. 1998352837-853.
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New Targets of Intensive Diabetes Management

• Near-normal glycemia
• A1C less than 6.5
• Post-prandial lt140 mg/dl
• Avoid short-term crisis
• Hypoglycemia
• Hyperglycemia
• DKA
• Minimize long-term complications
• Improve QOL

ADA Clinical Practice Recommendations,
2001. AACE and EASD DCCT Research Group, N Engl J
Med 1993, 329977-986.
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How Are We Doing?
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U.S. Diabetes Prevalence

• Diabetes kills 1 American every 3 minutes
• New case diagnosed every 40 seconds
• More deaths than AIDS and breast cancer combined
• Average life expectancy 15 years less than
  non-diabetes population
• Afflicts over 177 million people worldwide
• 300 million afflicted by 2025

18 Million
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World View

• 177 million worldwide
• 4th leading cause of death by disease
• India 33 million people with diabetes
• China 23 million people with diabetes
• Population of diabetes will double to triple by
  2025
• One out of every three Americans born today will
  develop diabetes

Time magazine December 2003 CDC
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Costs Continue to Increase (U.S.)
Diabetes Care 26917-932, 2003
12
Percentage of Patients With DiabetesHaving A1C
lt7
US Adults With Diagnosed Diabetes in
1988-94 NHANES III
100
Percent at goal
73
80
60
45
38
40
26
20
0
Whole population
Diet alone
Oral agents
Insulin
Therapy used
Harris MI, et al. Diabetes Care. 199922403-408.
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Lessons from the DCCT and UKPDSSustained
Intensification of Therapy is Difficult
DCCT EDIC (Type 1)
UKPDS (Type 2),Insulin Group
10
8
9.0
8.1
7.9
8
7.3
A1C ()
A1C ()
7
Baseline
6
6
Normal
4
0
0
6.5
4
6 yrs
0
2
4
6
8
10 yrs
DCCT
EDIC

DCCT/EDIC Research Group. New Engl J Med 2000
342381-389 Steffes M et al. Diabetes 2001 50
(suppl 2)A63 UK Prospective Diabetes Study Group
(UKPDS) 33 Lancet 1998 352837-853
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Relationship between BG in Target and A1C Level
41
33
45
49
18
14
A1C 7
A1C 8
46
42
12
Within Target Above Target Below Target
A1C 8.5
Brewer K, Chase P, Owen S, Garg S, Diabetes Care
1998, 212.
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Primary Objectives of Effective Management
lGæde P, Vedel P, Larsen N, Jensen GVH, Parving
H-H, Pedersen O. Multifactorial intervention and
cardiovascular disease in patients with type 2
diabetes. N Engl J Med. 2003348383-393.
Diagnosis
A1C
9
8
7
Reduction of both micro- and macro- vascular
event rates by 75!
SBP mm Hg
145
130
LDL mg/dL
140
100
45
50
55
60
65
75
70
80
85
90
Patient Age
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How is diabetes currently being treated?
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Roper Starch Worldwide

• Gold Standard market research study of diabetes
  patients 18 years and older
• Self reported information
• Conducted annually in the U.S.
• N 6,000

Roper Starch Worldwide, 2002
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PROGRESSION TO INSULIN USE (US)Among Type 2
diabetic patients sampled
Prior Therapy Prior Therapy
Prior Therapy 43 no prior
therapy 51 exclusive pills 66 no prior
therapy 41 exclusive pills 14 insulin 18
diet/no med 5 diet to pills 13 pills to
insulin 8 insulin
Roper Starch Worldwide, 2002
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Trends Among Insulin Injectors
Pump Therapy
Conventional 54
15
Intensive Therapy 46
31
Multiple Daily Injections
2001

Pump Therapy
Conventional
20
Intensive Therapy 57
43
37
Multiple Daily Injections
2002
Roper Starch Worldwide, 2002
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ADA Physician Reported Treatment ChoicesBased on
aggregate responses (N213)
Insulin Treated Patients
23 Conventional (1-2 shots/day) 57 Intensive(3
or more shots/day) 20 Insulin Pump Therapy
ADA 2003, Physician Survey, Medtronic MiniMed
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Total Patients Using Insulin Pumps
Estimated figures for 2003
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Other Possible Contributions to Intensive
Management

• PATIENT ATTITUDES AND BEHAVIORS

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DEMOGRAPHICS (US) By education and income
EDUCATION

High School or less
College
INCOME LEVEL
lt 35K
35K - 75K
gt 100K

Roper Starch Worldwide, 2002
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HCPs Frequently Visited By Patients
What type of healthcare professional do you
normally visit for your diabetes care?


TYPE 2
TYPE 1
Roper Starch Worldwide, 2002
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Most Feel That They Are In Good Control
Are you satisfied with your diabetes control?
Needs improvement Good control
incidence
within total
sample
81
19
US
Roper Starch Worldwide, 2002
26
Most Patients Are Satisfied With Their Health
Roper Starch Worldwide, 2002
27
Self-Reported A1C Results
Roper Starch Worldwide, 2002
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Summary

• Diabetes prevalence and costs continue to grow
• Lower treatment targets will likely drive the
  adoption of more intensive management
• The use of intensive insulin management continues
  to grow with a notable increase in insulin pump
  use
• A potential barrier to intensive management is
  patients lack of awareness and perception of
  good control