Presentation on theme: "Improving Medical Management of Diabetes"— Presentation transcript:
1 Improving Medical Management of Diabetes Jay Shubrook DO FACOFP, FAAFPAssociate Professor of Family MedicineDirector, Diabetes FellowshipOhio University College of Osteopathic Medicine
2 Diabetes in the US 24 million American with diabetes 90%-95% have type 2>1 million more per year57 million Americans have pre-DM$170 billion dollarsEstimated 25% of adults > 60 y/o have DM1 in 5 Medicare dollarsCDC Fact Sheet
3 Diabetes in the US Children can have type 2 SEARCH trial20% of children with DM have type 2 DMSome have estimated 7% of children and adolescents have pre-DMCDC predicts people born in 20001 in 3 will develop DM40% risk in at risk populations50% or 1 in 2 in Hispanic population
5 Diabetes is progressive At diagnosis 50% of functional beta cells lostUKPDS resultsNo slowing of progressionLifestyle or metforminTypically we start low and go slowLike the old rheumatoid arthritis treatment algorithms
7 Random PG > 200 + symptoms 2010 Diagnosis of Diabetes and Categories of Increased Risk for DiabetesNORMALIFG or IGTDIABETESFPG < 100 mg/dlIFGFPG > mg/dlFPG > 126 mg/dl2-h PG < 140 mg/dlIGT2-h PG > 140 -199 mg/dl2-h PG > 200 mgRandom PG > symptomsA1C5.7% 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 Diabetes6.5%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-up24Mean HbA1c = 11%10%9%20Conventional treatment16Rate/100 Person-Years1288%47%987654321Time During Study (y)DCCT Research Group. Diabetes 1995;44:
10 Clinical Efficacy of Oral Hypoglycemic Agents Clinical Efficacy of Oral Hypoglycemic AgentsClass of hypoglycemic agentsReduction in HbA1c (%)Reduction in FPG (mg per dl)SulfonylureasMeglitinidesBiguanidesThiazolidinedionesAlpha-glucosidase inhibitorsDPP-4 inhibitor0.8 to 2.00.5 to 2.01.5 to 2.00.5 to 1.50.7 to 1.00.5 to 0.960 to 7065 to 7550 to 7025 to 5035 to 4020 to 30Adapted from University Educators MD-PhD
11 Probability of events of non-fatal myocardial infarction with intensive glucose-lowering vs. standard treatmentRay et al, Lancet 2009; 373: 1765–72
13 UKPDS: 10 yr Follow up HbA1c difference disappeared Outcome reduction with intensive controlAny DM end point % p= 0.04Myocardial infarction 15% p=0.01Death overall 13% p=0.005If on metforminMI % p=0.005Death 27% p=0.002
14 Intensive Glycemic Control in Diabetes: Implications of ACCORD, ADVANCE and VADT A1C targets for diabetesLowering A1C to < 7% has been shown to significantly reduce the risk of microvascular complications in both type 1 and type 2 diabetesControlled trials of more intensive glycemic control have not shown a decrease in CVD mortalityLong-term follow-up suggests that A1C < 7% in the years following diagnosis is associated with a reduction in CVD riskUntil more evidence becomes available, the general A1C target of < 7% appears reasonableA 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 CareIf metformin started with in 3 months of diagnosisWorked for twice as long12% vs 21% failure rate per yearBrown JB . Secondary Failure of Metformin Monotherapy in Clinical Practice.Diabetes Care March 2010
16 Tips to get controlLifestyle should be used in all patients but only as part of the treatmentStart aggressively and back offAssume each medication will improve HgA1c 1%Never substitute medsAlways add new agent firstTitrate to get controlThen stop first agentAsk the patient what they wantShots may be better than more pillsDevelop a plan that prevents hypoglycemia
17 ADA Consensus Statement for the Management of Type 2 Diabetes STEP 1At diagnosis: Lifestyle + METIf A1C ≥7%STEP 2Tier 1: Well-validated core therapies*ORTier 2: Less-well-validated therapies*Lifestyle + MET + SFULifestyle + MET + Basal InsulinLifestyle + MET + GLP-1 AgonistLifestyle + MET + PIOLifestyle + MET + PIO + SFULifestyle + MET + Basal InsulinCHF, chronic heart failure MET, metformin PIO, pioglitazone SFU, sulfonylureaSTEP 3Lifestyle + MET + Intensive Insulin*Validation based on clinical trials and clinical judgment.Adapted from Nathan DM, et al. Diabetes Care. 2008;31(1):
20 Glucose control for special populations Children with type 1A1c <8% and limit hypoglycemiaGlucose variability may be importantChildren with type 2No guidelinesSame goals as adultsOlder adultsBased upon life expectancyTime to benefit for glucose vs. BP and lipids
21 ADA – Summary of Recommendations for Adults with Diabetes GoalsGlycemic control:A1C* < 7%Preprandial BG 90 – 130 mg/dlPeak postprandial BG <180 mg/dlBlood Pressure: < 130/80 mm HgLipids:LDL < 100 mg/dlTriglycerides <150 mg/dlHDL > 40 mg/dlADA. Diabetes Care, 2010.
22 Risk Reduction of Diabetes-Related End Points with Tight BP Control Diabetes-related Mortality*Microvascular End Points‡Myocardial InfarctionStroke†102030405021Risk Reduction (%)323744* 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 individualsSecondary prevention (75–162 mg/day):Use aspirin therapy as a secondary prevention strategy in those with diabetes with a history of CVDADA Clinical Practice Recommendations, Diabetes Care, January 2010
25 Multifactorial intervention and CVD in type 2 diabetes: STENO 2 1110Conventional therapy987Glycated hemoglobin (%)Intensive therapy65412345687910111213Follow-up time (years)Gaede P, et al. N Engl J Med 2008;358:580–91.
26 STENO 2 - Risk of Death from Any Cause 80706050Conventional therapy40Cumulative Incidence of death (%)p = 0.023020Intensive therapyFigure 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.10Follow-up time (years)12345687910111213No. at riskIntensiveConventionalGaede P, et al. N Engl J Med 2008;358:580–91.
27 ADA – Summary of Recommendations for Adults with Diabetes GoalsGlycemic control:A1C* < 7%Preprandial BG 90 – 130 mg/dlPeak postprandial BG <180 mg/dlBlood Pressure: < 130/80 mm HgLipids:LDL < 100 mg/dlTriglycerides <150 mg/dlHDL > 40 mg/dlADA. Diabetes Care, 2010.
28 Managing DiabetesMost psychologically and behavior mod. challenging disease to manage95% of care is self-careOffice visits have 3 agendas:PatientPhysicianInsurerCultural and social influences are strong
29 Results: T2DM Survey Adults HGM 11Records 9Oral meds 8Foot care 6Oral care 8Problem sol 13Ob. supplies 11Support groups 13Sch. Med appts 988 minutesCommon needsMeal planning 21Shopping 23Exercise 32Preparing meals 54Stress manage 16146 minutesTotal minutes3 hours and 54 minutes!!Shubrook et al. In press
30 Keys to Managing Diabetes Address the 3 agendasBuild efficiencies into your careMeasure your care (others already are)Celebrate small successesFocus on the positiveDispel myths- be an accurate sourceWork as a team and re-enforce messages
31 Glucose monitoringGlucose measurement should match the intensity of treatmentRare checks if no meds3-7 checks per week on insulin sensitizers onlyIf on insulin:FSG for each time injecting insulinAVOID sliding scale insulin loneaAVOID 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 diseaseStart low and go slow does not workAssume 1% reduction in A1c for each medicationGuidelines exist to help direct treatmentRemember the 3 agendasThis is the patient’s disease process not yoursIt will be a lifetime so pace yourself as well