Presentation on theme: "Reducing Risk in Type 1 Diabetes – A Practical Approach"— Presentation transcript:
1Reducing Risk in Type 1 Diabetes – A Practical Approach Jay S Skyleron behalf of theGlobal Partnership for Effective Diabetes ManagementThis slideset was developed in 2009 with support from GlaxoSmithKline
2Aschner P, et al. Int J Clin Pract 2009: in press. Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T1DM careThere are considerable gaps in care of adults with T1DM:High proportion continue to develop complicationsMajority do not achieve glycemic goalsPatients face many challenges e.g. insulin dose adjustment, hypoglycaemia, impact on daily lifeAschner P, et al. Int J Clin Pract 2009: in press.
3Aschner P, et al. Int J Clin Pract 2009: in press. Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T1DM careThe Global Partnership has developed practical guidance to improve care in T1DM by addressing:management of hyperglycemiainsulin therapymanagement of CV risk factorspsychological aspectsteam approach to careAschner P, et al. Int J Clin Pract 2009: in press.
5DCCT: Early intensive therapy reduced the incidence of retinopathy and microalbuminuria in T1DM Cumulative incidence of retinopathy progressionCumulative incidence of microalbuminuria6054% risk reduction*6039% risk reduction*505040Conventional40ConventionalPatients (%)30Patients (%)302020IntensiveIntensive1010123456789123456789Time (years)Time (years)*Intensive vs conventional treatment Median HbA1c during 6.5 year follow-up period: intensive group, 7.3%; conventional group, 9.1%. N = 1441DCCT Research Group. N Engl J Med 1993; 329:977–986.Copyright 1993 Massachusetts Medical Society. All rights reserved.
7Cumulative incidence of non-fatal MI, stroke or death from CVD DCCT/EDIC: glycemic control reduces macrovascular complications in T1DMCumulative incidence of non-fatal MI, stroke or death from CVDConventional treatmentYears0.060.040.020.00DCCT (intervention period) EDIC (observational follow-up)57% risk reduction in non-fatal MI, stroke or CVD death*Intensive treatment*Intensive vs conventional treatment. N = 1441DCCT/EDIC Study Research Group. N Engl J Med 2005; 353:2643–2653.Copyright 2005 Massachusetts Medical Society. All rights reserved.
12Glycemic targets for individuals with T1DM CharacteristicADACDAIDFNICE (UK)HbA1c< 7.0%≤ 7.0%6.2–7.5%≤ 6.5–7.5%Fasting⁄ preprandial glucose, mg⁄dl (mmol/l)70–130(3.9–7.2)72–126(4.0–7.0)91–120(5.1–6.5)72–144(4.0–8.0)Postprandial glucose, mg⁄dl (mmol/l)< 180*(< 10.0)90–180†(5.0–10.0)136–160‡(7.6–9.0)< 180‡ADA = American Diabetes Association; CDA = Canadian Diabetes Association; IDF = International Diabetes Federation; NICE = National Institute for Health and Clinical ExcellenceThe CDA guidelines note that HbA1c goals and strategies must be tailored to the individual with diabetes, with consideration given to individual risk factors.ADA and CDA glycaemic targets are for type 1 and type 2 diabetes.* Peak postprandial capillary plasma glucose.† 90–144 mg/dl (5.0–8.0 mmol/l) if HbA1c target not being met.‡ Capillary postprandial glucose 1–2 h after meal.ADA. Diabetes Care 2009; 32(Suppl. 1):S13–S61. CDA. Can J Diabetes 2008; 32(Suppl. 1):S1–S201. IDF. Desktop guide to Type 1 (insulin-dependent) diabetes, 1998; Brussels: IDF. NICE. Clinical Guideline ; London, UK: NICE.
13Majority of patients with T1DM do not reach glycemic targets 87%83%81%74%Percentage not reaching HbA1c target (%)UK1HbA1c > 7.5%DCCT-EDICIntensiveEDCConventionalUS2HbA1c > 7.0%1. Calvert M, et al. BMJ 2009; 338:b1870.2. DCCT/EDIC Study Research Group. Arch Intern Med 2009; 169:1307–1316.
14Managing hyperglycemia in type 1 diabetes The Global Partnership recommends:Aim for as good glycemic control as possible while minimizing the risk of hypoglycemiaEnsure regular and appropriate monitoring for complicationsAschner P, et al. Int J Clin Pract 2009: in press.
16Intensive insulin therapy using a basal-bolus approach: considered best treatment in T1DM Intensive insulin therapy using a basal-bolus approach, whether as multiple daily injections or pump therapy, is considered best treatment for individuals with T1DM regardless of ageProvides greater glycemic control, reduces risk of complications, preserves β-cell function (DCCT)1-3Choice of insulin/mode of delivery should be guided by factors such as:hypoglycemia, age, lifestyle, general health, motivation, ability for self-management and diet, availability/accessibility1. DCCT Research Study Group. N Engl J Med 1993; 329:977– DCCT/EDIC Research Study Group. N Engl J Med 2005; 353:2643–2653.3. DCCT Research Study Group. Ann Intern Med 1998; 128:517–523.
17Duration of T1DM (years) DCCT: C-peptide levels decrease with increasing duration of T1DM0.10.20.30.40.50.6Basal C-peptideStimulated C-peptideC-peptide (nmol/L)123456789101112131415Duration of T1DM (years)Mean ± SEM basal (solid) and stimulated (stripes) C-peptide levels shown for 610 patients, mean age 25 years (range 13–39 years). C-peptide levels measured following meal challengeReproduced with permission from DCCT Research Study Group. J Clin Endocrinol Metab 1987; 65:30–36.
20Incidence of severe hypoglycemia is reduced with CSII StudySevere hypoglycemia rate ratioWeight (%)SMD (95% CI)Bode (poor control)Bode (good control)KadermanManiatisRizviLittonLinkeschovaBruttomessoRudolph, HirschPlotnikCohenHunger-DatheWeintrobWeinzimerMcMahonSiegel-CzarkowskiAlemzadehMack-FoggSciaffiniRodriguesLeporeHoogmaOverall (l 2 = 84.2%, P = 0.00)5.844.665.113.343.262.195.235.075.875.132.045.753.046.035.602.173.585.403.615.615.73100.005.55 (3.57, 8.61)10.50 (4.24, 26.01)6.47 (3.09, 13.55)1.29 (0.31, 5.42)8.00 (1.84, 34.79)5.75 (0.72, 45.97)13.92 (6.95, 27.86)3.44 (1.62, 7.33)3.81 (2.49, 5.84)2.18 (1.05, 4.52)4.69 (0.52, 41.98)3.62 (2.23, 5.85)3.00 (0.62, 14.44)2.11 (1.50, 2.96)2.89 (1.67, 4.98)7.07 (0.87, 57.46)2.51 (0.67, 9.47)2.09 (1.12, 3.92)1.25 (0.34, 4.65)35.41 (29.94, 57.15)3.50 (2.04, 6.01)2.50 (1.53, 4.08)4.19 (2.86, 6.13)0.51.02.05.01025Favors MDIFavors CSIIPickup JC & Sutton AJ. Diabet Med 2008; 25:765–774.Reprinted by permission of John Wiley & Sons, Inc.
21Aschner P, et al. Int J Clin Pract 2009: in press. Initiation of insulinThe Global Partnership recommends:Initiate basal-bolus regimen as early as possibleProvide all patients with a structured educational programme at initiation of insulin and thereafterAschner P, et al. Int J Clin Pract 2009: in press.
22Adjusting insulin dosages: practical barriers facing individuals with T1DM Patients must adjust insulin doses in response to many factors to minimize risk of hypo- or hyperglycemia:carbohydrate intake, lifestyle, exercise, intercurrent illnessModification of insulin dosages based on diet and exercise should be considered an essential part of patient educationadapted to local diet and lifestylePatients may not know the effect of factors such as exercise or alcohol on glucose levels and need for appropriate adjustment of insulin therapy64% of patients with T1DM do not achieve recommended physical activity levels due to barriers such as fear of hypoglycaemia1,21. Brazeau AS, et al. Diabetes Care 2008; 31:2108– Plotnikoff RC, et al. Med Sci Sports Exerc 2006; 38:1526–1534.
23Modification of insulin dosages based on diet and exercise: DTTP study HbA1cSevere hypoglycemia100.70.690.5Severe hypoglycemic episodes (events per patient-year)HbA1c (%)80.470.30.260.15Baseline1 yearMean difference: –0.7% (95% CI –0.9 to –0.6%, P < )Mean difference: −0.21 events per patient-year (95% CI −0.32 to −0.11, P = )Dusseldorf Diabetes Treatment and Teaching Programme (DTTP): N = 9,583.Samann A, et al. Diabetologia 2005; 48:1965–1970.
24Precipitating causes of DKA Precipitating factorPercentage of casesInfection28–43%Omission/reduction of insulin dose13–45%First presentation of diabetes10–20%Myocardial infarction1%No cause identified<40%Wallace TM & Matthews DR. QJM 2004; 97:773–780.Reprinted by permission of Oxford University Press.
25Self-monitoring blood glucose (SMBG): a fundamental aspect of insulin therapy SMBG is so fundamental that insulin therapy should always comprise insulin therapy plus SMBGDespite clear benefits, up to 64% of patients do not regularly self-monitor1Barriers include patient motivation, psychological barriers, cost, socioeconomic status, educationPatients should receive appropriate training in SMBG when insulin therapy is initiated and periodically thereafter1. DCCT/EDIC Research Study Group. Arch Intern Med 2009; 169:1307–1316.
26SMBG ≥ 3-times per day associated with better glycemic control in T1DM 9.5Estimated HbA1c (%)9.08.58.07.57.0No utilizationLess thandailyDailyAt least3x dailyAdjusted HbA1c by strip use (average strips per day)Reproduced from Karter AJ, et al. Am J Med 2001; 111:1–9.Copyright 2001 with permission from Elsevier.
27Treatment time (months) JDRF study: Sustained HbA1c lowering in T1DM patients with HbA1c >7.0% using CGMHbA1c (%)Treatment time (months)JDRF CGM Study Group. Diabetes Care 2009; 32: 2047–2049.
28Treatment time (months) JDRF study: Maintained HbA1c with less hypoglycemia in T1DM patients with HbA1c < 7.0% using CGMHbA1c (%)Treatment time (months)JDRF CGM Study Group. Diabetes Care 2009; 32: 2047–2049.
29Self-monitoring of blood glucose The Global Partnership recommends:Ensure that self-monitoring is universally adopted as an integral part of insulin therapyAschner P, et al. Int J Clin Pract 2009: in press.
30Hypoglycemia: can affect many aspects of care in T1DM In DCCT, severe hypoglycemia three times higher with intensive vs conventional therapy1,2Almost one-third of patients who experience severe hypoglycemia have a second episode within 4 months2Almost half of severe hypoglycemic episodes occur at night1Risk factors include strict glycemic control, prior episode of severe hypoglycemia, longer duration of diabetes, autonomic neuropathy, hypoglycemia unawarenessIn the DCCT, intensively treated patients with greater residual β-cell function had a significantly lower rate of hypoglycemia vs those with less/no residual β-cell function31. DCCT Research Study Group. Am J Med 1991; 90:450– DCCT Research Group. Diabetes 1997; 46:271– Steffes M, et al. Diabetes Care 2003; 26:832–836.
31DCCT: Risk of severe hypoglycemia versus HbA1c in intensive and conventional groups 1008060Rate per 100 years4020IntensiveConventional56789111121314HbA1c(%)duringstudyN = 1,441DCCT Research Study Group. Diabetes 1997; 46:271–286.Copyright 1997 American Diabetes Association. Reprinted with permission from The American Diabetes Association.
32Incidence of hypoglycemia in the DCCT 14.0Rate of hypoglycemia ± SE per 100 participant-years*12.010.08.06.04.02.0UndetectableMinimalBaseline-onlySustainedStimulated C-peptide group*Both treatment groups (intensive and conventional therapy). Undetectable 0.03 nmol/L; minimal 0.04–0.20 nmol/L; baseline-only (> 0.2 nmol/L at baseline, < 0.2 nmol/L thereafter); sustained (> 0.2 nmol/L at baseline and 1 year later). Rates were compared (horizontally) between stimulated C-peptide groups. Rates between all groups were significantly different (P < 0.05), except comparison between minimal and baseline-only groupSteffes M, et al. Diabetes Care 2003; 26:832–836.Copyright 2003 American Diabetes Association. Reprinted with permission from The American Diabetes Association.
33Effect of impaired awareness of hypoglycemia in T1DM NormalImpaired1002.5Subjects (%)802.0601.5Number of events per year401.0200.50.0PercentageEventsGeddes J, et al. Diabetic Med 2008; 25:501–504.
34Aschner P, et al. Int J Clin Pract 2009: in press. HypoglycemiaThe Global Partnership recommends:Provide education about prevention, recognition and treatment of hypoglycemia at initiation of insulin therapy and thereafterAschner P, et al. Int J Clin Pract 2009: in press.
41Depressive symptoms significantly related to HbA1c in T1DM Significant positive relationship between BDI score and HbA1c (r = 0.44, P < 0.02)HbA1c (%)12111098765101520Beck Depression Inventory (BDI) scoreBDI score ≥16 indicates possible clinical depressionReproduced with permission from Van Tilburg MA, et al. Psychosom Med 2001; 63:551–555.
42Disordered eating behavior associated with higher risk of retinopathy & nephropathy in young women with T1DMDisordered-eating status at baselineDiabetic retinopathy at follow-up*Abnormal urinary albumin excretion at follow-upHighly disordered86% (6/7)43% (3/7)Moderately disordered43% (6/14)20% (3/15)Nondisordered24% (12/50)18% (9/50)Values are % (n with complications/total n)Mean age at baseline (±SD): 15±2 years (range 12–18)Rydall AC, et al. N Engl J Med 1997; 336:1849–1854.Copyright 1997 Massachusetts Medical Society. All rights reserved.
43Psychological aspects of type 1 diabetes The Global Partnership recommends:Explore psychological issues associated with type 1 diabetes and treat/refer, as appropriateAschner P, et al. Int J Clin Pract 2009: in press.
45A multidisciplinary approach to care Many complexities involved in treating patients with T1DMAdopting a team approach that involves a broad range of disciplines is essentialWhere possible, team should include: patient, diabetes specialist, primary care physician, nurse, dietitian, podiatrist and psychologist/psychiatrist, as well as family and friends.All members of the team should work together to ensure continuity of careAschner P, et al. Int J Clin Pract 2009: in press.
46A team approach to diabetes care The Global Partnership recommends:Adopt a multidisciplinary team approach with shared goals and recommendationsAschner P, et al. Int J Clin Pract 2009: in press.
47Practical recommendations for the management of adults with T1DM Aim for as good glycemic control as possible while minimizing the risk of hypoglycemiaEnsure regular and appropriate monitoring for complicationsInitiate basal-bolus regimen as early as possibleProvide all patients with a structured educational programme at initiation of insulin and thereafterEnsure that self-monitoring is universally adopted as an integral part of insulin therapyAschner P, et al. Int J Clin Pract 2009: in press.
48Practical recommendations for the management of adults with T1DM Provide education about prevention, recognition and treatment of hypoglycaemia at initiation of insulin therapy and thereafterManage all CV risk factorsExplore psychological issues associated with T1DM and treat/refer, as appropriateAdopt a multidisciplinary team approach with shared goals and recommendationsAschner P, et al. Int J Clin Pract 2009: in press.