Introduction To The Alphabet Strategy And Evidence Based Medicine

UK prevalence of diabetes mellitus UK prevalence of diabetes mellitus = 3.54%. UK prevalence of diabetes mellitus = 3.54%. 2.2 million people in the UK have diabetes : 2.2 million people in the UK have diabetes : 1.9 million ( 87%) have type 2 diabetes. 1.9 million ( 87%) have type 2 diabetes. 300,000 (13%) have type 1 diabetes. 300,000 (13%) have type 1 diabetes. There may be as many as one million undiagnosed cases of type 2 diabetes. There may be as many as one million undiagnosed cases of type 2 diabetes. UK prevalence of diabetes mellitus = 3.54%. UK prevalence of diabetes mellitus = 3.54%. 2.2 million people in the UK have diabetes : 2.2 million people in the UK have diabetes : 1.9 million ( 87%) have type 2 diabetes. 1.9 million ( 87%) have type 2 diabetes. 300,000 (13%) have type 1 diabetes. 300,000 (13%) have type 1 diabetes. There may be as many as one million undiagnosed cases of type 2 diabetes. There may be as many as one million undiagnosed cases of type 2 diabetes. Diabetes UK, 2006

Diabetes Atlas second edition, IDF 2003 < 2% 2% - 5% 5% - 8% 8% - 11% 11% - 14% 14% - 17% 17% - 20% >20 Global prevalence of diabetes 2003

Chronic complications of diabetes Retinopathy Most common cause of blindness in people of working age Retinopathy Nephropathy 16% of all new patients needing renal replacement therapy Erectile Dysfunction May affect up to 50% of men with long- standing diabetes Coronary and cerebrovascular Disease 2–4 fold increased risk of coronary heart disease and stroke, 75% have hypertension Foot Problems 15% of people with diabetes develop foot ulcers; 5–15% of people with diabetic foot ulcers need amputations The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.

Life expectancy and diabetes Life expectancy (yrs) Diabetics Non Diabetics Age at diagnosis (yrs) Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721. Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066.

Asian European MenWomen Age groups 20–3940–5960–7920–3940–5960–79 30% 25% 20% 15% 10% 5% 0% Diabetes in the UK Indo - Asian community

Cost of diabetes to the NHS NHS spend on diabetes is : 5% of the total budget, or 5% of the total budget, or £10 million per day. £10 million per day. This is predicted to increase to 10% of the total budget by NHS spend on diabetes is : 5% of the total budget, or 5% of the total budget, or £10 million per day. £10 million per day. This is predicted to increase to 10% of the total budget by Diabetes UK, 2004

NICE GMS Contract National Service Framework Guidelines Evidence base Increasing prevalence User expectations

Lipids Blood pressure Lifestyle Feet GlycaemiaEyes Patient oriented Multi - disciplinary Audit

Evidence-based medicine “ The integration of best research evidence with clinical expertise and patient values. ” Sackett DL et al (2000) Evidence Based Medicine

Best research evidence Clinical expertise Patient values

Best research evidence Clinical expertise Patient values … within available resources

William of Ockham ( ) “ Entia non sunt multiplicanda praeter necessitatem “ Entia non sunt multiplicanda praeter necessitatem ” “ Entities are not to be multiplied beyond necessity ”

KISS

Keep It Simple, Stupid

“ Excellence requires that important, simple things are done right all the time. ” National Service Framework for Coronary Heart Disease

The Alphabet Strategy Advice Advice Blood pressure Blood pressure Cholesterol Cholesterol Diabetes control Diabetes control Eye examination Eye examination Feet examination Feet examination Guardian drugs Guardian drugs Advice Advice Blood pressure Blood pressure Cholesterol Cholesterol Diabetes control Diabetes control Eye examination Eye examination Feet examination Feet examination Guardian drugs Guardian drugs

The Alphabet Strategy AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol Cholesterol TC ≤ 200mg/dl, LDL ≤ 130mg/dl, HDL > 50mg/dl (F) >40 mg/dl (M), TGs 50mg/dl (F) >40 mg/dl (M), TGs <150mg/dl Diabetes control HbA1c ≤ 7% (IFCC ≤ 5.3%) Diabetes control HbA1c ≤ 7% (IFCC ≤ 5.3%) Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, ARB, statins Guardian drugs Aspirin, ACEI, ARB, statins AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol Cholesterol TC ≤ 200mg/dl, LDL ≤ 130mg/dl, HDL > 50mg/dl (F) >40 mg/dl (M), TGs 50mg/dl (F) >40 mg/dl (M), TGs <150mg/dl Diabetes control HbA1c ≤ 7% (IFCC ≤ 5.3%) Diabetes control HbA1c ≤ 7% (IFCC ≤ 5.3%) Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, ARB, statins Guardian drugs Aspirin, ACEI, ARB, statins

The Alphabet Strategy Advice Advice Blood pressure Blood pressure Cholesterol Cholesterol Diabetes control Diabetes control Eye examination Eye examination Feet examination Feet examination Guardian drugs Guardian drugs Heart risk score Heart risk score Advice Advice Blood pressure Blood pressure Cholesterol Cholesterol Diabetes control Diabetes control Eye examination Eye examination Feet examination Feet examination Guardian drugs Guardian drugs Heart risk score Heart risk score

The Alphabet Strategy AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Diabetes control HbA1c ≤ 7% Diabetes control HbA1c ≤ 7% Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, statins &C Guardian drugs Aspirin, ACEI, statins &C Heart risk score UKPDS, Framingham Heart risk score UKPDS, Framingham AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Diabetes control HbA1c ≤ 7% Diabetes control HbA1c ≤ 7% Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, statins &C Guardian drugs Aspirin, ACEI, statins &C Heart risk score UKPDS, Framingham Heart risk score UKPDS, Framingham

Patel V, Morrissey J The Alphabet Strategy British Journal of Diabetes & Vascular Disease, 2002: 2: 1: Patel V, Morrissey J The Alphabet Strategy British Journal of Diabetes & Vascular Disease, 2002: 2: 1: 58-59

A is for... ADVICE ADVICE

AdviceAdvice Adherence to diet and medication Adherence to diet and medication Smoking cessation, exercise, weight reduction Smoking cessation, exercise, weight reduction Ensure diabetes education and advise Diabetes UK membership Ensure diabetes education and advise Diabetes UK membership Stress role of the dietician, podiatrist and diabetes care nurses Stress role of the dietician, podiatrist and diabetes care nurses Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non- attenders Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non- attenders Lifestyle targets: weight reduction > 5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week. Lifestyle targets: weight reduction > 5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week. Adherence to diet and medication Adherence to diet and medication Smoking cessation, exercise, weight reduction Smoking cessation, exercise, weight reduction Ensure diabetes education and advise Diabetes UK membership Ensure diabetes education and advise Diabetes UK membership Stress role of the dietician, podiatrist and diabetes care nurses Stress role of the dietician, podiatrist and diabetes care nurses Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non- attenders Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non- attenders Lifestyle targets: weight reduction > 5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week. Lifestyle targets: weight reduction > 5% if obese, fat intake 15g per 1000 calories, exercise for four hours / week.

B is for... BLOOD PRESSURE BLOOD PRESSURE

UKPDS 38 : 154/87 versus 144/82 UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703–713 MI Microvascular endpoint –34% Heart failure –35% Stroke –37% All macrovascular endpoints –44% Retinal photocoagulation –56% Any diabetes-related endpoint –24% % Reduction in risk -24 Significant -34 Significant -21 Non significant -44 Significant -56 Significant -37 Significant -35 Significant

C is for... CHOLESTEROL CHOLESTEROL

CHD prevention trials with statins in diabetes : StudyDrugNumber of patients CHD risk red n Nondiabetics CHD risk red n Diabetes Primary Prevention CARDS HPS 1 † Atorvastatin 10mg Simvastatin 40mg %* 37%** 26-33% Secondary Prevention CARE 2 †† Pravastatin58623%25% 4S 3‡ GREACE Simvastatin Atorvastatin 24mg %55% 59% 4S reanalysis 4 ‡‡ Simvastatin48332%42% HPS 1 Simvastatin305124%*12% NS CHD Endpoints: † HPS = first major vascular event; †† CARE = absolute risk of coronary events; ** CARDS: Acute Coronary Events ‡ 4S = major CHD events; ‡‡ 4S reanalysis = major coronary events. Cohorts: *HPS = risk reduction for the entire cohort (nondiabetics and patients with diabetes). Footnote: NS = results not statistically significant. 1. HPS Collaborative Group. Lancet. 2002;360: Goldberg RB, Mellies MJ, Sacks FM, et al. Circulation. 1998;98: Pyörälä K, Pedersen TR, Kjekshus J, et al. Diabetes Care. 1997;20: Haffner SM, Alexander CM, Cook TJ, et al. Arch Intern Med. 1999;159: CARDS Study ADA GREACE Study

D is for... DIABETES CONTROL DIABETES CONTROL

Study nameDCCTUKPDSKumamotoSteno-2 HbA1c  2%  0.9%  2%  1.0% Retinopathy  63%  17-21%  69%  58% Nephropathy  54  24-33%  70%  61% Autonomic neuropathy  60% __  63% CVD  41%  16% _  53% Reductions in HbA1c and corresponding reductions in microvascular and macrovascular complications described in major studies of persons with T1 DM and T2 DM Effect on diabetes complications of HbA1c% reduction

To summarise... Control blood glucose to prevent microvascular complications. Control blood glucose to prevent microvascular complications. Lower cholesterol to prevent macrovascular complications. Lower cholesterol to prevent macrovascular complications. Lower blood pressure to prevent both. Lower blood pressure to prevent both.

E is for... EYE EXAMINATION

F is for... FEET EXAMINATION

G is for... GUARDIAN DRUGS

The Alphabet Strategy AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Diabetes control HbA1c ≤ 7% Diabetes control HbA1c ≤ 7% Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, statins &C Guardian drugs Aspirin, ACEI, statins &C Heart risk score UKPDS, Framingham Heart risk score UKPDS, Framingham AdviceSmoking, diet, exercise AdviceSmoking, diet, exercise Blood pressure < 140/80 Blood pressure < 140/80 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Cholesterol TC ≤ 4, LDL : HDL ≤ 2 Diabetes control HbA1c ≤ 7% Diabetes control HbA1c ≤ 7% Eye examination Annual examination Eye examination Annual examination Feet examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, statins &C Guardian drugs Aspirin, ACEI, statins &C Heart risk score UKPDS, Framingham Heart risk score UKPDS, Framingham

Thank you for listening !