Type 2 Diabetes in Practice An Expert Commentary With Clifford J. Bailey, PhD A Clinical Context Report

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Type 2 Diabetes in Practice An Expert
Commentary With Clifford J. Bailey, PhDA
Clinical Context Report
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Clinical Context Type 2 Diabetes in
PracticeExpert Commentary

• Jointly Sponsored by
• ?
• and

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Clinical Context Type 2 Diabetes in
PracticeExpert Commentary

• This activity is supported by an independent
  educational grant from Boehringer Ingelheim
  Pharmaceuticals, Inc. which was made possible, in
  part, through a collaboration with Eli Lilly and
  Company.

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Type 2 Diabetes in PracticeClinical Context
Series
The goal of this series is to provide up-to-date
information and multiple perspectives on the
pathogenesis, patient identification, symptoms,
risk factors, and current and emerging treatments
and best practices in the management of type 2
diabetes.
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Type 2 Diabetes in PracticeClinical Context
SeriesTarget Audience
Endocrinologists, cardiologists, diabetes
educators, primary care physicians, nurses, nurse
practitioners, physician assistants, pharmacists,
and other healthcare professionals involved in
the care of patients with type 2 diabetes.
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Activity Learning Objective

• Upon successful completion of this educational
  program, participants should be able to?

• Review the relevance and significance of the
  activity in the broader context of clinical care.?

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CME Information Physicians

• Statement of Accreditation
• This activity has been planned and implemented
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  Policies of the Accreditation Council for
  Continuing Medical Education through the joint
  sponsorship of the Projects In Knowledge and
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  accredited by the ACCME to provide continuing
  medical education for physicians.

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CME Information

• Credit Designation
• Projects In Knowledge designates this enduring
  material for a maximum of 0.5 AMA PRA Category 1
  Credits.
• Physicians should claim only the credit
  commensurate with the extent of their
  participation in the activity.

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CME Information Physicians

• Credit for Family Physicians
• MedPage Today "News-Based CME" has been reviewed
  and is acceptable for up to 2098 Elective credits
  by the American Academy of Family Physicians.
  AAFP accreditation begins January 1, 2011. Term
  of approval is for one year from this date. Each
  article is approved for 0.5 Elective credits.
  Credit may be claimed for one year from the date
  of each article.

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CE Information Nurses

• Statement of Accreditation
• Projects In Knowledge, Inc. (PIK) is accredited
  as a provider of continuing nursing education by
  the American Nurses Credentialing Centers
  Commission on Accreditation.
• Projects In Knowledge is also an approved
  provider by the California Board of Registered
  Nursing, Provider Number CEP-15227.
• This activity is approved for 0.50 nursing
  contact hours.
• There is no fee for this activity.

DISCLAIMER Accreditation refers to educational
content only and does not imply ANCC, CBRN, or
PIK endorsement of any commercial product or
service.
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CE Information Pharmacists

• Projects In Knowledge is accredited by the
  Accreditation Council for Pharmacy Education
  (ACPE) as a provider of continuing pharmacy
  education. This program has been planned and
  implemented in accordance with the ACPE Criteria
  for Quality and Interpretive Guidelines. This
  activity is worth up to 0.5 contact hours (0.05
  CEUs). The ACPE Universal Activity Number
  assigned to this knowledge-type activity is
  0052-9999-11-1779-H04-P.

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Discussant

• Clifford J. Bailey, PhD
• Professor of Clinical Medicine
• Aston University
• Department of Life Health Sciences
• Birmingham, UK

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Disclosure Information

• Clifford J. Bailey, PhD,
• disclosed the following relevant financial
  relationships?
• Board Member/Advisory Panel Boehringer Ingelheim
  Pharmaceuticals Bristol-Myers Squibb
  GlaxoSmithKline Merck Sharp Dohme Limited
  Novo Nordisk Roche Pharmaceuticals.
• Research Support sanofi-aventis.

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Disclosure Information

• Dori F. Zaleznik, MD, Associate Clinical
  Professor of Medicine, Harvard Medical School,
  Boston Crystal Phend and Dorothy Caputo, MA,
  RN, BC-ADM, CDE, Nurse Planner, have disclosed
  that they have no relevant financial
  relationships or conflicts of interest with
  commercial interests related directly or
  indirectly to this educational activity.
• The staffs of Projects In Knowledge and MedPage
  Today have no relevant financial relationships or
  conflicts of interest with commercial interests
  related directly or indirectly to this
  educational activity.

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Type 2 Diabetes Global Prevalence

• More than doubled worldwide from 1980 to 2008
• From 8.3 to 9.8 among adult men
• From 7.5 to 9.2 among adult women

Source Danaei G, et al Lancet 2011 378 31-40.
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Microvascular Risk Reduction With Better Glycemic
Control

• United Kingdom Prospective Diabetes Study (UKPDS)
• Each percentage point decrease in hemoglobin A1c
  reduced microvascular complication risk by 35
• Diabetes Control and Complications Trial (DCCT)
• A two-percentage point reduction in hemoglobin
  A1c cut occurrence of microvascular complications
  by 39 to 76

Sources UKPDS Group Lancet 1998 352
837-853. DCCT Research Group N Engl J Med 1993
329 977-986.
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Recent Trials of More Intensive Glucose Control

• Mean diabetes duration at baseline
• Action to Control Cardiovascular Risk in Diabetes
  (ACCORD) 10 years
• Action in Diabetes and Vascular Disease
  Preterax and Diamicron Modified Release
  Controlled Evaluation (ADVANCE) 8 years
• Veterans Affairs Diabetes Trial (VADT) 11.5
  years

Sources ACCORD Study Group N Engl J Med 2008
358 2545-2559. ADVANCE Collaborative Group N
Engl J Med 2008 358 2560-2572. Duckworth W, et
al N Engl J Med 2009 360 129-139.
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Early Start Matters

• UKPDS Micro- and macrovascular benefits from
  more intensive glucose management in newly
  diagnosed type 2 diabetes
• VADT No micro- or macrovascular benefits from
  more intensive glucose management in advanced
  type 2 diabetes

Sources Holman RR, et al N Engl J Med 2008 359
1577-1589. Holman RR, et al N Engl J Med 2008
359 1565-1576. Duckworth W, et al N Engl J Med
2009 360 129-139.
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Once-Weekly Exenatide (Bydureon)

• Extended release formulation of twice-daily
  exenatide (Byetta)
• FDA approval declined in October 2010
• European Medicines Agency granted approval in
  June 2011

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Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

• Sitagliptin (Januvia)
• Saxagliptin (Onglyza)
• Linagliptin (Tradjenta) Approved by FDA in May
  2011

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G-Protein-Coupled Receptor Stimulation

• Raises GLP-1 levels indirectly
• Oral delivery
• Early phase research

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Summary
At the end of this activity, participants should
understand

• Type 2 diabetes prevalence is on the rise,
  bringing with it a pending tide of cardiovascular
  complications
• Deterioration of beta-cell function contributes
  to progression of type 2 diabetes, which often is
  marked by worsening insulin resistance as well.
  Both processes are typically well under way by
  the time of diagnosis

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Summary

• Better glycemic control is linked to reduced risk
  of microvascular disease and, over the long term,
  lower risk of macrovascular disease as well
• Early intervention is key to these effects, as
  the ACCORD, VADT, and other trials have shown
  that more intensive efforts are largely
  ineffective later in the course of type 2
  diabetes
• Animal studies have suggested that very early use
  of incretin drugs can delay beta-cell decline

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Summary

• Incretin mimetics new to the clinic and on the
  horizon include the DPP-4 inhibitor linagliptin,
  which was approved by the FDA earlier this year,
  and a once-weekly formulation of the GLP-1
  receptor agonist drug exenatide recently approved
  in Europe that is under review in the U.S.
• A novel class of oral drugs that raise GLP-1
  indirectly through G-protein-coupled receptor
  stimulation is in early stage development