1. Improving Medical Management of Diabetes
Jay Shubrook DO FACOFP, FAAFP
Associate Professor of Family Medicine
Director, Diabetes Fellowship
Ohio University College of Osteopathic Medicine

2. Diabetes in the US 24 million American with diabetes
90%-95% have type 2
>1 million more per year
57 million Americans have pre-DM
$170 billion dollars
Estimated 25% of adults > 60 y/o have DM
1 in 5 Medicare dollars
CDC Fact Sheet

3. Diabetes in the US Children can have type 2
SEARCH trial
20% of children with DM have type 2 DM
Some have estimated 7% of children and adolescents have pre-DM
CDC predicts people born in 2000
1 in 3 will develop DM
40% risk in at risk populations
50% or 1 in 2 in Hispanic population

4. Natural History of DM-2 Post Meal Glucose Fasting Glucose
350
250
Fasting Glucose
Glucose
150 50
Insulin Resistance
300
Relative
Function
200
The relationship of increased postprandial and fasting glucose levels, insulin resistance, and insulin levels in subjects with type 2 diabetes are illustrated in this figure.
Bergenstal RM, Kendall DM, Franz MJ, Rubenstein AH. Management of type 2 diabetes: a systematic approach to meeting standards of care. II: Oral agents, insulin and management of complications. In Endocrinology, 4th ed, De Groo LJ and Jameson JL, editors. WB Saunders Co, Phila. (Originally published in Type 2 Diabetes BASICS, ©200 International Diabetes Center, Minneapolis). Used with permission.
100
At risk for
Diabetes
Insulin Level
Beta Cell Failure
-10 -5 5 10 15 20 25 30
Years of Diabetes
Bergenstal, ©2000 International Diabetes Center Used with permission.

5. Diabetes is progressive
At diagnosis 50% of functional beta cells lost
UKPDS results
No slowing of progression
Lifestyle or metformin
Typically we start low and go slow
Like the old rheumatoid arthritis treatment algorithms

7. Random PG > 200 + symptoms
2010 Diagnosis of Diabetes and Categories of Increased Risk for Diabetes
NORMAL
IFG or IGT
DIABETES
FPG < 100 mg/dl
IFG
FPG > mg/dl
FPG > 126 mg/dl
2-h PG < 140 mg/dl
IGT
2-h PG > 140 -
199 mg/dl
2-h PG > 200 mg
Random PG > symptoms
A1C
5.7% to 6.4%
≥ 6.5%
ADA, Diabetes Care 33: Suppl. 1, S11-S61, 2010

8. THE INTERNATIONAL EXPERT COMMITTEE. Diabetes Care 2009;32:1327
International Expert Committee Report on A1C in the Diagnosis of Diabetes
6.5%
THE INTERNATIONAL EXPERT COMMITTEE. Diabetes Care 2009;32:1327

9. Conventional treatment
DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA1c and Years of Follow-up 24
Mean HbA1c = 11%
10% 9% 20
Conventional treatment 16
Rate/100 Person-Years 12 8 8% 4 7% 9 8 7 6 5 4 3 2 1
Time During Study (y)
DCCT Research Group. Diabetes 1995;44:

10. Clinical Efficacy of Oral Hypoglycemic Agents
Clinical Efficacy of Oral Hypoglycemic Agents
Class of hypoglycemic agents
Reduction in HbA1c (%)
Reduction in FPG (mg per dl)
Sulfonylureas
Meglitinides
Biguanides
Thiazolidinediones
Alpha-glucosidase inhibitors
DPP-4 inhibitor
0.8 to 2.0
0.5 to 2.0
1.5 to 2.0
0.5 to 1.5
0.7 to 1.0
0.5 to 0.9
60 to 70
65 to 75
50 to 70
25 to 50
35 to 40
20 to 30
Adapted from University Educators MD-PhD

11. Probability of events of non-fatal myocardial infarction with intensive glucose-lowering vs. standard treatment
Ray et al, Lancet 2009; 373: 1765–72

13. UKPDS: 10 yr Follow up HbA1c difference disappeared
Outcome reduction with intensive control
Any DM end point % p= 0.04
Myocardial infarction 15% p=0.01
Death overall 13% p=0.005
If on metformin
MI % p=0.005
Death 27% p=0.002

14. Intensive Glycemic Control in Diabetes: Implications of ACCORD, ADVANCE and VADT
A1C targets for diabetes
Lowering A1C to < 7% has been shown to significantly reduce the risk of microvascular complications in both type 1 and type 2 diabetes
Controlled trials of more intensive glycemic control have not shown a decrease in CVD mortality
Long-term follow-up suggests that A1C < 7% in the years following diagnosis is associated with a reduction in CVD risk
Until more evidence becomes available, the general A1C target of < 7% appears reasonable
A position statement of the ADA and a scientific statement of the ACC and the AHA. Diabetes Care 32; 2009;

15. Early treatment=greater success
March 2010 Diabetes Care
If metformin started with in 3 months of diagnosis
Worked for twice as long
12% vs 21% failure rate per year
Brown JB . Secondary Failure of Metformin Monotherapy in Clinical Practice.
Diabetes Care March 2010

16. Tips to get control
Lifestyle should be used in all patients but only as part of the treatment
Start aggressively and back off
Assume each medication will improve HgA1c 1%
Never substitute meds
Always add new agent first
Titrate to get control
Then stop first agent
Ask the patient what they want
Shots may be better than more pills
Develop a plan that prevents hypoglycemia

17. ADA Consensus Statement for the Management of Type 2 Diabetes
STEP 1
At diagnosis: Lifestyle + MET
If A1C ≥7%
STEP 2
Tier 1: Well-validated core therapies* OR
Tier 2: Less-well-validated therapies*
Lifestyle + MET + SFU
Lifestyle + MET + Basal Insulin
Lifestyle + MET + GLP-1 Agonist
Lifestyle + MET + PIO
Lifestyle + MET + PIO + SFU
Lifestyle + MET + Basal Insulin
CHF, chronic heart failure MET, metformin PIO, pioglitazone SFU, sulfonylurea
STEP 3
Lifestyle + MET + Intensive Insulin
*Validation based on clinical trials and clinical judgment.
Adapted from Nathan DM, et al. Diabetes Care. 2008;31(1):

18. AACE Guidelines

19. What about special populations?

20. Glucose control for special populations
Children with type 1
A1c <8% and limit hypoglycemia
Glucose variability may be important
Children with type 2
No guidelines
Same goals as adults
Older adults
Based upon life expectancy
Time to benefit for glucose vs. BP and lipids

21. ADA – Summary of Recommendations for Adults with Diabetes
Goals
Glycemic control:
A1C* < 7%
Preprandial BG 90 – 130 mg/dl
Peak postprandial BG <180 mg/dl
Blood Pressure: < 130/80 mm Hg
Lipids:
LDL < 100 mg/dl
Triglycerides <150 mg/dl
HDL > 40 mg/dl
ADA. Diabetes Care, 2010.

22. Risk Reduction of Diabetes-Related End Points with Tight BP Control
Diabetes-related Mortality*
Microvascular End Points‡
Myocardial Infarction
Stroke† 10 20 30 40 50 21
Risk Reduction (%) 32 37 44
* Death due to MI, sudden death, stroke, peripheral vascular disease, renal disease, hyperglycemia, or hypoglycemia. † Fatal or nonfatal.
‡ Retinopathy requiring photocoagulation, vitreous hemorrhage and fatal or nonfatal renal failure.
Mean BP : 144/82 mm Hg (tight BP control) vs /87 mm Hg (less tight BP control).
UK Prospective Diabetes Study Group. BMJ. 1998;317:

23. Lipid lowering: Heart Protection Study
LDL lowering resulted in 22% reduction in CVD events across all categories of LDL

24. Antiplatelet Agents in Diabetes, 2010
Primary Prevention (75–162 mg/day):
Type 1 or type 2 diabetes at increased CV risk (10 yr risk > 10%), men > 50 yr or women >60 yr who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria)
There is not sufficient evidence to recommend aspirin for primary prevention in lower risk individuals
Secondary prevention (75–162 mg/day):
Use aspirin therapy as a secondary prevention strategy in those with diabetes with a history of CVD
ADA Clinical Practice Recommendations, Diabetes Care, January 2010

25. Multifactorial intervention and CVD in type 2 diabetes: STENO 211 10
Conventional therapy 9 8 7
Glycated hemoglobin (%)
Intensive therapy 6 5 4 1 2 3 4 5 6 8 7 9 10 11 12 13
Follow-up time (years)
Gaede P, et al. N Engl J Med 2008;358:580–91.

26. STENO 2 - Risk of Death from Any Cause80 70 60 50
Conventional therapy 40
Cumulative Incidence of death (%)
p = 0.02 30 20
Intensive therapy
Figure 3. Kaplan-Meier Estimates of the Risk of Death from Any Cause and from Cardiovascular Causes and the Number of Cardiovascular Events, According to Treatment Group. Panel A shows the cumulative incidence of the risk of death from any cause (the study's primary end point) during the 13.3-year study period. Panel B shows the cumulative incidence of a secondary composite end point of cardiovascular events, including death from cardiovascular causes, nonfatal stroke, nonfatal myocardial infarction, coronary-artery bypass grafting (CABG), percutaneous coronary intervention (PCI), revascularization for peripheral atherosclerotic artery disease, and amputation; Panel C shows the number of events for each component of the composite end point. In Panels A and B, the I bars represent standard errors. 10
Follow-up time (years) 1 2 3 4 5 6 8 7 9 10 11 12 13
No. at risk
Intensive
Conventional
Gaede P, et al. N Engl J Med 2008;358:580–91.

27. ADA – Summary of Recommendations for Adults with Diabetes
Goals
Glycemic control:
A1C* < 7%
Preprandial BG 90 – 130 mg/dl
Peak postprandial BG <180 mg/dl
Blood Pressure: < 130/80 mm Hg
Lipids:
LDL < 100 mg/dl
Triglycerides <150 mg/dl
HDL > 40 mg/dl
ADA. Diabetes Care, 2010.

28. Managing Diabetes
Most psychologically and behavior mod. challenging disease to manage
95% of care is self-care
Office visits have 3 agendas:
Patient
Physician
Insurer
Cultural and social influences are strong

29. Results: T2DM Survey Adults
HGM 11
Records 9
Oral meds 8
Foot care 6
Oral care 8
Problem sol 13
Ob. supplies 11
Support groups 13
Sch. Med appts 9
88 minutes
Common needs
Meal planning 21
Shopping 23
Exercise 32
Preparing meals 54
Stress manage 16
146 minutes
Total minutes
3 hours and 54 minutes!!
Shubrook et al. In press

30. Keys to Managing Diabetes
Address the 3 agendas
Build efficiencies into your care
Measure your care (others already are)
Celebrate small successes
Focus on the positive
Dispel myths- be an accurate source
Work as a team and re-enforce messages

31. Glucose monitoring
Glucose measurement should match the intensity of treatment
Rare checks if no meds
3-7 checks per week on insulin sensitizers only
If on insulin:
FSG for each time injecting insulin
AVOID sliding scale insulin lonea
AVOID insulin that have variable absorption

32. Summary Diabetes is common and will get more common
Early aggressive treatment may be our best bet at preventing burden of disease
Start low and go slow does not work
Assume 1% reduction in A1c for each medication
Guidelines exist to help direct treatment
Remember the 3 agendas
This is the patient’s disease process not yours
It will be a lifetime so pace yourself as well