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Improving Patient Outcomes: Insights From Recent Clinical Trials in Diabetes

Improving Patient Outcomes: Insights From Recent Clinical Trials in Diabetes. Largest cause of morbidity and mortality Risk of CVD increased 2- to 4-fold Higher case fatality vs. non diabetic individuals Reduced survival post–MI, post–CABG, and particularly post–PTCA

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Improving Patient Outcomes: Insights From Recent Clinical Trials in Diabetes

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  1. Improving Patient Outcomes:Insights From Recent Clinical Trials in Diabetes

  2. Largest cause of morbidity and mortality Risk of CVD increased 2- to 4-fold Higher case fatality vs. non diabetic individuals Reduced survival post–MI, post–CABG, and particularly post–PTCA Risk of stroke and peripheral vascular disease substantially increased Impact of Type 2 Diabetes on Macrovascular Disease Betteridge DJ. Acta Diabetol. 1999;36:S25-S29. Nesto R. Acta Diabetol. 2001;38:S3-S8.

  3. The Black Box Diabetic dyslipidemia Procoagulant state Insulin resistance/ hyperinsulinemia Glycation and advanced glycation of proteins “Glycoxidation” and oxidation Hormone-, growth factor-, and cytokine-enhanced SMC proliferation and foam cell formation Atherosclerosis in Type 2 Diabetes Bierman E. Arterioscler Thromb.1992;12:647-656.

  4. Type 2 Diabetes Is a Vascular Disease • Hyperglycemia is just 1 risk factor among many for CVD • Intensive blood glucose control can reduce microvascular, but not macrovascular, complications of diabetes • CVD risk reduction should involve appropriate management of all major modifiable risk factors De Backer G, et al. Eur Heart J. 2003;24:1601-1610. Holman R. Acta Diabetol. 2001;38:S9-S14.

  5. 20 Less tight control Tight control 10 0 UKPDS: Benefits of Tight BP Control inType 2 Diabetes Population: 1148 patients, mean age 56 y; mean BP at entry, 160/94 mm Hg Treatment: Tight control (aim < 150/85) vs less tight (aim < 180/105); captopril vs atenolol regimen; mean BP during follow-up 144/82 vs 154/87 mm Hg (P < 0.0001) RRR: 24% diabetes-related end points 32% diabetes-related deaths 37% microvascular end points Stroke RRR = 44% (95% CI,11-65%) Patients with events (%) P = 0.013 0 1 2 3 4 5 6 7 8 9 Years from randomization Adapted from UKPDS Group. BMJ. 1998;317:703-713.

  6. UKPDS: Strong Association Between SBP and Microvascular End Points and MI Incidence of microvascular end points and MI by updated mean SBP Adjusted for age, sex, and ethnic group Expressed for white men, 50-54 y at baseline and with mean diabetes duration of10 y 50 MI Microvascular end points 40 30 Adjusted incidence per 1000 patient-years (%) 20 10 0 110 120 130 140 150 160 170 Updated mean SBP (mm Hg) Adapted from Adler AI, et al. BMJ. 2000;321:412-419.

  7. Diabetic Dyslipidemia Compared with nondiabetic individuals, patients with diabetic dyslipidemia may have: • Elevated plasma triglyceride levels • Decreased plasma HDL-C levels • Relatively normal plasma LDL-C levels • Relatively high proportion of small, dense LDL-C American Diabetes Association. Diabetes Care. 2004;27:S68-S71.

  8. UKPDS: Risk Factors for CAD in Type 2 Diabetes • LDL-C • HDL-C • TGs • HbA1c • SBP • Fasting plasma glucose • Smoking status Turner RC, et al. BMJ. 1998;316:823-828.

  9. CHD Prevention Trials With Statins in Patients With Diabetes: Subgroup Analyses CHD risk reduction CHD risk reductionStudy Drug Nondiabetics Diabetics Primary Prevention HPS1† Simvastatin 25%* 26% Secondary Prevention CARE2†† Pravastatin 23% 25% 4S3‡ Simvastatin 32% 55% 4S reanalysis4‡‡ Simvastatin 32% 42% HPS1† Simvastatin 24%* 12% NS CHD end points: †HPS = first major vascular event; ††CARE = absolute risk of 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;360:7-22. 2. Goldberg RB, Mellies MJ, Sacks FM, et al. Circulation. 1998;98:2513-2519. 3. Pyörälä K, Pedersen TR, Kjekshus J, et al. Diabetes Care. 1997;20:614-620. 4. Haffner SM, Alexander CM, Cook TJ, et al. Arch Intern Med. 1999;159:2661-2667.

  10. Greek Atorvastatin and CHD Evaluation (GREACE) Study Population: 1600 CHD patients (344 women) Design: Randomized, open, 3-year study, atorvastatin (10-80 mg) vs usual care Atorvastatin titrated to achieve NCEP goal of LDL <2.6 mmol/L (< 100 mg/dL); mean dose, 24 mg/d Usual care group 14% lipid-lowering drugs Lipid changes: LDL-C  46%; non–HDL-C  44%; TGs  31% HDL-C  7% (absolute LDL-C  2.1 mmol/L [81 mg/dL]) Primary end points: Death, nonfatal MI, unstable angina, CHF, stroke, and revascularization Athyros VG, et al. Curr Med Res Opin. 2002;18:220-228.

  11. GREACE: Risk Reduction With Atorvastatin in Diabetic Cohort Risk reduction in composite primary end point: Diabetes 0.42 n = 313 (20%) P < 0.0001 All patients 0.49 n = 1297 P < 0.0001 0 Atorvastatin Usual care Athyros VG, et al. Curr Med Res Opin. 2002;18:220-228.

  12. CARDS:Collaborative AtoRvastatin Diabetes Study Patient Population • Type 2 diabetics (40-75 y) • No prior MI or CVD • Other risk factors + • Lipid profile: • LDL-C  4.14 mmol/L (160 mg/dL) • TGs  6.78 mmol/L (600 mg/dL) • Collaboration in the UK with Diabetes UK, NHS R&D, and Pfizer d/b PBO 2838Patients Atorvastatin 10 mg Min 4 y • Primary End Point • Time to major CV event • (CHD death, nonfatal MI, • revascularization, CABG, stroke) Colhoun HM, et al. Diabet Med. 2002;19:201-211.

  13. Placebo n (%) Atorvastatin n (%) Mean age (years) < 60 529 (37.5%) 558 (39.1%) 60-70 708 (50.2%) 703 (49.2%) > 70 173 (12.3%) 167 (11.7%) Women 453 (32.1%) 456 (31.9%) White ethnicity 1326 (94.0%) 1350 (94.5%) BMI kg/m2 (SD) 28.8 (3.5) 28.7 (3.6) Obese (BMI > 30 kg/m2) 537 (38.1%) 515 (36.1%) CARDS Patient Baseline Characteristics 61.8 61.5 http://www.cardstrial.org/healthcare/slideresources.asp. Accessed June 8, 2004.

  14. CARDS Patient Baseline Characteristics PlaceboMean (SD)or n (%) AtorvastatinMean (SD)or n (%) BP SBP (mm Hg) 144 (16.1) 144 (15.9) DBP (mm Hg) 83 (8.4) 83 (8.5) 940 (67) 956 (67) On BP drug Smoking 323 (22.9%) 308 (21.6%) Current Ex-smoker 601 (42.7%) 622 (43.6%) Never 485 (34.4%) 498 (34.9%) http://www.cardstrial.org/healthcare/slideresources.asp. Accessed June 8, 2004.

  15. CARDS Patient Baseline Lipids* PlaceboMedian (IQR) AtorvastatinMedian (IQR) Total cholesterol (mmol/L) (mg/dL) 5.4 (4.8-5.9)207 (185-229) 5.4 (4.8-5.9)207 (186-228) LDL-C (mmol/L) (mg/dL) 3.1 (2.6-3.6)118 (100-137) 3.1 (2.6-3.6)119 (100-138) HDL-C (mmol/L) (mg/dL) 1.4 (1.2-1.6)53 (46-61) 1.3 (1.2-1.6)52 (45-60) *Subject to final verification. http://www.cardstrial.org/healthcare/slideresources.asp. Accessed June 8, 2004.

  16. CARDS: Stopped Early Due to Significant Benefit of Atorvastatin Treatment • In June 2003, the independent Steering Committee stopped the trial after only 2 years because the magnitude of benefit for the primary end point exceeded the prespecified stopping rule • Preliminary results of the CARDS trial showed a significant reduction in MI, stroke, and other coronary events in patients treated with atorvastatin • CARDS became the second atorvastatin trial to end early because of observed treatment benefit (ASCOT-LLA was the first)

  17. AHA Prevention Conference VI Diabetes and Vascular Disease Goals of Therapy Glycemia HbA1c < 7% (ADA) BP < 130/85 (JNC VI) < 130/80 (ADA) LDL-C < 2.6 mmol/L (100 mg/dL) (NCEP) HDL-C < 1 mmol/L (< 40 mg/dL) Raise HDL (no goal) TGs 2.2-5.6 mmol/L (200-499 mg/dL) Non–HDL-C < 3.4 mmol/L (130 mg/dL) BMI > 25 kg/m2 Lose 10% body wt (OEI) Physical activity Exercise (ADA) Cigarettes Stop Prothrombotic state Low-dose aspirin (ADA) Grundy SM, et al. Circulation. 2002;105:2231-2239.

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