Presentation is loading. Please wait.

Presentation is loading. Please wait.

Aggressive Hyperglycemia Management. Significant hospital hyperglycemia requires close follow-up Previously diagnosed diabetes and elevated A1C Without.

Similar presentations


Presentation on theme: "Aggressive Hyperglycemia Management. Significant hospital hyperglycemia requires close follow-up Previously diagnosed diabetes and elevated A1C Without."— Presentation transcript:

1 Aggressive Hyperglycemia Management

2 Significant hospital hyperglycemia requires close follow-up Previously diagnosed diabetes and elevated A1C Without previously diagnosed diabetes (with random BG >125 mg/dL) Pre-admission diabetes care plan requires revision Test (FBG, 2-hr OGTT) to differentiate between in- hospital hyperglycemia and T2DM once patient is metabolically stable Clement S et al. Diabetes Care. 2004;27:553-91. Conaway DLG et al. Am Heart J. 2006;152:1022-7. Hyperglycemic patients Post-discharge

3 Glucose control in ACS patients with diabetes often unknown or undertreated at discharge NoYes (n = 235) (n = 162) (n = 58) (n = 39) Conaway DLG et al. Am Heart J. 2006;152:1022-7. A1C Diabetes therapy adjusted Patients (%) N = 235 with diabetes + ACS (<7%)

4 EPIC-Norfolk: CV risk increases with A1C level A1C (%) WomenMen Events/ 100 persons Khaw K-T et al. Ann Intern Med. 2004;141:413-20. N = 10,232 P Trend < 0.001 across A1C categories for all endpoints CVD eventsAll deaths <55–5.45.5–5.96–6.46.5–6.9≥7<55–5.45.5–5.96–6.46.5–6.9≥7  1% A1C associated with:  20% CVD events,  22% mortality

5 UKPDS 33: Glycemic control declines over time UKPDS Group. Lancet. 1998;352:837-53. 9876098760 Years from randomization Diet (conventional treatment)Sulfonylurea or insulin (intensive treatment) 6.2% (upper limit of normal) 0 3 6 9 12 15 ADA target A1C, median (%) N = 3867 with newly diagnosed T2DM

6 Need for insulin increases over time Wright A et al. Diabetes Care. 2002;25:330-6. Chlorpropamide UKPDS 57: N = 826 with newly diagnosed T2DM 60 40 20 0 Patients requiring additional insulin (%) 123456 Glipizide Years from randomization ~53% of patients required additional insulin therapy by year 6

7 UKPDS 33: Effect of intensive glucose control on T2DM complications Relative risk reduction (%) UKPDS Group. Lancet. 1998;352:837-53. Any T2DM-related endpoint MIAll deaths T2DM- related death Micro- vascular endpoints P = 0.34P = 0.029P = 0.44P = 0.052P = 0.0099 Stroke P = 0.52 A1C 7% vs 7.9% with intensive vs conventional treatment All P values vs conventional treatment

8 UKPDS 34: Glucose control and CV outcomes n = 1704 overweight with T2DM; n = 342 metformin group UKPDS Group. Lancet. 1998;352:854-65. Favors metformin or intensive Favors usual care All-cause mortality Metformin Intensive MI Metformin Intensive Stroke Metformin Intensive 0.02 0.12 0.03 Aggregate endpointP* 012 *Metformin vs other intensive (sulfonylurea or insulin) Relative risk (95% CI)

9 Limitations of UKPDS Small difference in A1C between intensive and conventional groups: 7.0% vs 7.9% A1C exceeded current ADA <7% target Delay in adding multiple therapies Insufficient power to assess CV outcomes UKPDS Group. Lancet. 1998;352:837-53. Hypothesis-generating study

10 DCCT/EDIC: Intensive glucose control associated with reduced long-term CV risk DCCT/EDIC Study Research Group. N Engl J Med. 2005;353:2643-53. Any initial CV event* Time (years) N = 1441 with type 1 diabetes, mean baseline age 27  42% Risk (9%–63%) P = 0.02  57% Risk (12%–79%) P = 0.02 CV death, nonfatal MI, stroke* 52 events 31 events 25 events 11 events 0 0.12 0.08 0.10 0.06 0.04 0.02 05101520 0 0.12 0.08 0.10 0.06 0.04 0.02 05101520 DCCT ends A1C 7.4% vs 9.1% *Cumulative incidence ConventionalIntensive

11 EDIC year 11: Patient characteristics at mean age 45 Characteristic Intensive (n = 593) Conventional (n = 589) A1C (%)7.97.8 Current cigarette smoker (%)1411 BMI (kg/m 2 )28.427.6 Duration of diabetes (yr)2423 Blood pressure (mm Hg)120/75121/75 Hypertension (%)*3841 Hyperlipidemia (%) † 5248 Albumin excretion rate (%) ≥40 mg/24 hr917 ‡ ≥300 mg/24 hr2 6 ‡ *BP ≥140/90 mm Hg; † LDL-C ≥130 mg/dL ‡ P < 0.01 vs intensive treatment DCCT/EDIC Study Research Group. N Engl J Med. 2005;353:2643-53.

12 Glycemic control and vascular disease in T2DM N = 4472; 6 randomized trials Stettler C et al. Am Heart J. 2006;152:27-38. Incidence rate ratio (95% CI) 00.51 2 Any macrovascular* T2DM Cardiac † T2DM Peripheral vascular ‡ T2DM Cerebrovascular § T2DM Favors conventional glycemic control Favors intense glycemic control *1587 events; † 1197 events; ‡ 87 events; § 303 events 0.81 (0.73–0.91) 0.91 (0.80–1.03) 0.58 (0.38–0.89) 0.58 (0.46–0.74)

13 Diabetes management trials: Clinical trial horizon UKPDS DCCT/EDIC PROactive DREAM NAVIGATOR VADT ORIGIN ACCORD 200720102008 HEART 2D BARI 2D 1995-2006 RECORD ADVANCE 2009 Look AHEAD 2012

14 Ongoing trials of glucose lowering and CV outcomes StudyPopulation (N) IntensiveUsual carePrimary outcome VADTT2DM (~1700)≤6.08-9Composite CV events ADVANCET2DM (11,140)≤6.5~7.5Major vascular events ACCORDT2DM (~10,000)<6.0~7.5MI, stroke, CV death ORIGIN*IFG/IGT/T2DM (~10,000) FPG <95 mg/dL (glargine) <7 (no insulin) CV morbidity and mortality A1C target (%) *FPG is glycemic target for intervention group National Institutes of Health (NIH). www.clinicaltrials.gov Buse JB, Rosenstock J. Endocrinol Metab Clin N Am. 2005;34:221-35.


Download ppt "Aggressive Hyperglycemia Management. Significant hospital hyperglycemia requires close follow-up Previously diagnosed diabetes and elevated A1C Without."

Similar presentations


Ads by Google