Marshall Dahl MD, PhD, FRCPC

1
British Columbia Diabetes Collaborative Learning
Session 1

• Marshall Dahl MD, PhD, FRCPC
• Co-Chair

2
(No Transcript)
3
Diabetes Mellitus

• 1500 BC Egypt
• Ebers Papyrus describes a disorder with frequent
  urination and weight loss
• Diabetes is Greek for siphon
• Mellitus is Latin for sweet

4
Diabetes in Canada 1922
5
Diabetes in Canada 2004
6
Population Profile Canada

• Diabetes is prevalent
• Canada 1998 4.8 of adults diagnosed
• probably gt 7 of population
• 60,000 new cases annually
• Risk with age
• gt65 1 in 20
• gt85 1 in 5

7
Population Profile Groups at Risk

• Aboriginal
• Prior to 1940 rare
• Now 19-26 incidence
• South Asian
• 6 fold increase
• Other groups
• Chinese Canadian, Afro-Caribbean, Middle Eastern

8
Rationale

• Diabetes is serious
• Shortens life span by average of 13 years
• Increases risk of complications (eg. CVD 2-4
  times)
• Diabetes is costly
• Canada 1998 6.35-8.26 Billion

9
Overview

• Improved health and quality of life for people
  with diabetes
• Practical small-scale improvements in delivery of
  care
• Guidelines
• References for BC
• Canadian Diabetes Association 2003
• Review of Targets
• In-depth review and therapy
• workshops

10
Targets

• Use clinical judgement
• Glycemia
• A1C 7.0
• FPG 4.0-7.0 mmol/L
• 2hr postprandial PG 5.0-10.0
• Blood pressure 130/80
• Lipids
• LDL-C lt 2.5
• TC-HDL-C ratio lt 4.0

11
Many patients have inadequate glycemic control
CAN (2003)1
US (1988-1994)2
100
100
80
80
62
60
60
50
50
Percentage of subjects
Percentage of subjects
38
40
40
20
20
0
0
? 7
lt 7
gt 7
lt7
A1C ()
A1C ()
1 Harris S, et al, The Diabetes in Canada
Evaluation (DICE) Study, ADA 2003, 2162-PO 2
Harris MI, et al. Diabetes Care 1999 22403408.
12
UKPDS decreased risk of diabetes-related
complications associated with a 1 decrease in A1C
Observational analysis from UKPDS study data
Any diabetes- related endpoint
Diabetes- related death
All cause mortality
Peripheral vascular disease
Micro- vascular disease
Myocardial infarction
Cataract extraction
Stroke
Percentage increase in relative risk
corresponding to a 1 rise in HbA1C
12
14
14

19

21
21




37
43


Adapted from Stratton IM, et al. UKPDS 35. BMJ
2000 321405412.
13
2003 CDA Recommended Targets for Glycemic Control
A1C ()
FPG/preprandial PG (mmol/L)
2-hour postprandial PG (mmol/L)
Target for most patients
?7.0
4.0-7.0
5.0-10.0
?6.0
4.0-6.0
5.0-8.0
Normal range (considered for patients in whom
it can be achieved safely)
A1C glycosylated hemoglobin DCCT Diabetes
Control and Complications Trial FPG fasting
plasma glucose PG plasma glucose
14
Components of Glycemic Control
A1C lt7, lt6
2 h. Postprandial Plasma Glucose 5-10 mmol/L 5-8
mmol/L
Fasting/Preprandial Plasma Glucose 4-7
mmol/L 4-6 mmol/L
If can be achieved safely
15
The evolution of management guidelines

• Studies including UKPDS have highlighted the
• importance of glycemic control in reducing
  complications
• New guidelines include tighter targets for
  glycemic control
• Guidelines recognize importance of treating all
  aspects
• of the condition
• Current guidelines therefore include targets
  for
• ? glycemic control
• ? lipid levels
• ? blood pressure

16
UKPDS BP Control Study
in Type 2 Diabetes
Effect of BP on Complications Risk
Any Diabetes
Diabetes
-
Heart
Microvascular
Related
Related
Stroke
Failure
Endpoints
Endpoint
Death
0
-
10
-
20
-
24
-
30
Risk
-
32
Reduction
-
40
-
37
()
-
44
-
50
Benefits of 144/82 vs. 154/87
-
60
-
56
-
70
17
TARGETS OF TREATMENT LIPIDS
Moderate risk younger age with short duration
of DM, no complications and no other CVD
risks. Optimal TG is lt 1.5 mmol/L. Optimal apo B
is lt 0.9 g/L.
18
Heart Protections Study MAJOR VASCULAR EVENTS
SIMVASTATIN
PLACEBO
Rate ratio 95 CI
Vascular
event
(10269)
(10267)
STATIN better
PLACEBO better
898
1212
Major coronary
444
585
Any stroke
939
1205
Revascularisation
24 SE 3
2033
2585
ANY OF ABOVE
reduction
(19.8)
(25.2)
(2Plt0.00001)
0.4
0.6
0.8
1.0
1.2
1.4
19
Microvascular Goals

• Kidneys
• Albumin Creatinine Ratio
• Eyes
• Retinopathy Screening
• Feet and Neuropathy
• Examination

20
Albumin Creatinine Ratio (ACR)

• ACR Treatment Threshold
• Not a target because normalization may not be
  possible

21
SCREENING FOR NEPHROPATHY
WHEN Type 1 annually after puberty and 5 years
of DM Type 2 at diagnosis and then annually
WHAT Urine dip or urine RM for non-diabetic
renal disease Random urine ACR for diabetic
nephropathy

• ACR Abnormal
• gt 20 mg/mmol men
• gt 28 mg/mmol women
• Diabetic nephropathy
• diagnosed

ACR Normal lt 2.0 mg/mmol men lt 2.8 mg/mmol
women Re-screen in 1 year
ACR Equivocal 2.0 - 20 mg/mmol men 2.8 - 28
mg/mmol women
Up to 2 repeat random urines for ACR performed 1
week to 2 months apart
2 or 3 abnormal ACRs
Only 1 abnormal ACR re-screen in 1 year
Diabetic nephropathy
22
Retinopathy, Neuropathy and Foot Examination

• Guidelines reinforce need for regular screening
  history and physical examination
• Ensure patient receives dilated pupil examination
  at diagnosis, then every one to two years or as
  indicated
• Check annually for symptoms or findings such as
  peripheral anesthesia or pain, erectile
  dysfunction or gastrointestinal disturbance
• Examine feet at least annually, more frequently
  for those at high risk

23
VASCULAR AND RENAL PROTECTION
VASCULAR PROTECTION Lifestyle modification ACE
inhibitors Antiplatelet therapy Dyslipidemia
therapy Glycemic control Smoking cessation
Check BP and Screen for nephropathy
Hypertensive
BP at target and no nephropathy
BP at target but nephropathy present
Check BP at each visit, re-screen for nephropathy
in 1 year
Treat according to hypertension guidelines
Treat according to nephropathy guidelines
24
Treatment of hyperglycemia Type 2 Diabetes

• Antihyperglycemic agents should be initiated if
  glycemic targets not met after 2-3 months of
  lifestyle intervention
• Antihyperglycemic agents should be started
  concomitantly with lifestyle if A1C levels are
  greater than 9
• The lag period before adding other agent(s)
  should be kept to a minimum to achieve glycemic
  targets within 6-12 months
• Unless contraindicated, metformin should be used
  first line other agents should be considered in
  the order they appear in the treatment algorithm
• Insulin therapy should be initiated if targets
  cannot be achieved with lifestyle changes and
  oral therapy

25
Personalized Care

• Judicious application of targets to clinical
  situation
• Often, the most significant improvements occur
• When a person with diabetes takes charge of their
  health
• When we provide tools and techniques to assist
  this process
• When we organize care in an efficient manner to
  make this happen

26
Summary

• We are embarking on a project that will
• Use common, evidence-based clinical guidelines
• Involve practical, focussed, small-scale changes
  in care delivery systems
• Improve the health and quality of life for people
  with diabetes in British Columbia

27
(No Transcript)