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Achieving Good Glycemic Control. Aim. Provide practical guidance on improving diabetes care through highlighting the need to: treat to glucose targets intensively monitor glycemia use a holistic approach to treatment involve experts in diabetes management.

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slide2
Aim

Provide practical guidance on improving diabetes

care through highlighting the need to:

  • treat to glucose targets
  • intensively monitor glycemia
  • use a holistic approach to treatment
  • involve experts in diabetes management
type 2 diabetes a global call to action
Type 2 diabetes accounts for 85–95% of diabetes casesType 2 diabetes: a global call to action

333 million

350

300

250

200

Global prevalence of

diabetes (millions)

150 million

150

100

30 million

50

0

1985

2000

2025

Year

http://www.idf.org/home/

obesity is a key driver of the diabetes epidemic
Obesity is a key driver of the diabetes epidemic
  • 50–65% of the general population are obese or overweight1
  • The risk of developing type 2 diabetes increases with increasing weight2
  • It is estimated that half of all diabetes cases would be eliminated if weight gain could be prevented3

1http://www.idf.org/home/; 2Mokdad AH, et al. JAMA 2003; 289:76–79.

3Knowler WC, et al. N Engl J Med 2002; 346:393–403.

despite falling chd mortality rates diabetes increases the risk of chd
Despite falling CHD mortality rates, diabetes increases the risk of CHD

Factors  CHD deaths

include  smoking, cholesterol, and BP and

changes in treatments

Factors  CHD deaths

include diabetes and obesity

20,000

0

-20,000

Deaths prevented or postponed in 2000

-40,000

-60,000

-80,000

-100,000

Data from England and Wales between 1981 and 2000 in men and women aged 35–84 years

There were 68,230 fewer CHD deaths than expected from baseline mortality rates in 1981

Unal B, et al. Circulation 2004; 109:1101–1107.

individuals with diabetes are at increased risk of cardiovascular mortality
Individuals with diabetes are at increased risk of cardiovascular mortality

Relative risk of death from any cause

Relative risk of CHD death

20

15

Relative risk of death

10

5

0

Diabetes no CHD

CHD no diabetes

Diabetes and CHD

Age-adjusted relative risk of death compared with men with no diabetes or CHD

Lotufo P, et al. Arch Intern Med 2001; 161:242–247.

mortality rate is doubled in individuals with diabetes
Mortality rate is doubled in individuals with diabetes

Control

Diabetes

35

Ratio 2.5

Ratio 2.2

Ratio 2.1

30

25

Mortality rate(deaths per 1,000 patient-years)

20

15

10

5

0

Whitehall

Study

Helsinki

Policemen Study

Paris ProspectiveStudy

Balkau B, et al. Lancet 1997; 350:1680.

type 2 diabetes is associated with serious complications
Type 2 diabetes is associated with serious complications

Stroke

2- to 4-fold increase in

cardiovascular mortality and stroke5

DiabeticRetinopathy

Leading cause

of blindness

in adults1,2

CardiovascularDisease

8/10 individuals with diabetes die from CV events6

Diabetic

Nephropathy

DiabeticNeuropathy

Leading cause of

end-stage renal disease3,4

Leading cause ofnon-traumatic lower extremity amputations7,8

1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al.Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

individuals suffering extreme problems in quality of life
Individuals suffering ‘extreme problems’ in quality of life

Diabetes

General population

10.0

*

7.5

*

Individuals reporting ‘extreme problems’ (%)

*

5.0

2.5

*

*

0

Anxiety/

depression

Self-care

Mobility

Usual

activities

Pain/

discomfort

*Significant versus general population

Williams R, et al. The true costs of type 2 diabetes in the UK. Findings from T2ARDIS and CODE-2 UK, 2002.

Department of Health. Health Survey for England 1996. London: HMSO, 1997.

costs of diabetes are rising
Costs of diabetes are rising

Indirect costs

$132

140

Direct costs

120

$98

$92

100

80

Cost per year (US$ billion)

60

40

$20

20

0

19871

19922

19973

20024

Year

Estimated US costs

1Huse DM, et al. JAMA 1989; 262:2708–2713. 2Javitt JC & Chiang Y-P. In Diabetes in America, 1995; 601–611. NIH Publication No. 95–1468.

3American Diabetes Association. Diabetes Care 1998; 21:296–309. 4American Diabetes Association. Diabetes Care 2003; 26:917–932.

hospitalizations account for the majority of the costs of managing type 2 diabetes
Hospitalizations account for the majority of the costs of managing type 2 diabetes

Ambulatory care 18%

Antidiabetic drugs 7%

Other drugs 21%

Hospitalizations

55%

= €29 billion/year

Jönsson B. Diabetologia 2002; 45 (Suppl.):S5–S12.

lowering hba 1c reduces the risk of complications
Lowering HbA1c reduces the risk of complications

Deaths related to diabetes

21%

HbA1c

Microvascular complications

37%

1%

Myocardial infarction

14%

Stratton IM, et al. BMJ 2000; 321:405–412.

risk of complications decreases as hba 1c decreases
Risk of complications decreases as HbA1c decreases

80

Microvascular complications

NormalHbA1clevels

60

Incidence per1,000 patient-years

40

Myocardial infarction

20

0

0

5

6

7

8

9

10

11

Updated mean HbA1c (%)

Stratton IM, et al. BMJ 2000; 321:405–412.

diabetes management guidelines hba 1c
Diabetes management guidelines: HbA1c

APPG (Asia Pacific)7

HbA1c< 6.5%

CDA (Canada)4

HbA1c 7%

NICE (UK)5

HbA1c 6.5–7.5%

Australia8

HbA1c 7%

ADA (US)1

HbA1c < 7%

IDF (Europe)3

HbA1c 6.5%

AACE (US)2

HbA1c 6.5%

ALAD (Latin America)6

HbA1c <6–7%

1American Diabetes Association. Diabetes Care 2004; 27 (Suppl. 1):S15–S34. 2American Association of Clinical Endocrinologists. Endocr Pract 2002; 8 (Suppl. 1):40–82.

3European Diabetes Policy Group. Diabet Med 1999; 16:716–730. 4Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl. 2):S1–S152.

5National Institute for Clinical Excellence. 2002. Available at: http://www.nice.org.uk. 6ALAD. Rev Asoc Lat Diab 2000; Suppl. 1.

7Asian-Pacific Policy Group. Practical Targets and Treatments (3rd Edition). 8NSW Health Department. 1996.

diabetes management guidelines a sense of urgency
Diabetes management guidelines: a sense of urgency

“... the results of the UKPDS mandate that treatment of type 2 diabetes include aggressive efforts to lower blood glucose levels as close to normal as possible”

“Diabetes must be… diagnosed earlier.And once diagnosed, all types of diabetes must then be managed much more aggressively”

HbA1c

American Diabetes Association1

Canadian Diabetes Association2

1American Diabetes Association. Diabetes Care 2003; 26:S28–S32.

2Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl. 2):S1–S152.

two thirds of individuals do not achieve target hba 1c
Two thirds of individuals do not achieve target HbA1c

Saydah SH, et al. JAMA 2004; 291:335–342.

Liebl A, et al.Diabetologia 2002; 45:S23–S28.

proportion of individuals reaching target hba 1c is not improving over time
Proportion of individuals reaching target HbA1c is not improving over time

NHANES (1988–1994)

60

NHANES (1999–2000)

48%

50

44%

37%

36%

40

34%

29%

Individuals achieving goals (%)

30

20

7%

5%

10

0

HbA1c

< 7.0%

BP

< 130/80

mmHg

Total

cholesterol

< 200 mg/dL

Good

control*

*Individuals achieving goals for HbA1c, blood pressure and total cholesterol

Saydah SH, et al. JAMA 2004; 291:335–342.

barriers to achieving good glycemic control
Barriers to achieving good glycemic control

Lack of clarity over definition of good glycemic control

Inadequate monitoring of glycemia

Complexity of managing hyperglycemia relative to dyslipidemia and hypertension

Insufficient involvement of specialistcare units

what is good glycemic control
What is good glycemic control?

The Global Partnership recommends:

Aim for good glycemic control = HbA1c < 6.5%*

< 6.5%

*Or fasting/preprandial plasma glucose < 110 mg/dL (6.0 mmol/L) where assessment of HbA1c is not possible

Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

frequent monitoring of glycemia is important
Frequent monitoring of glycemia is important
  • Cornerstone of diabetes care
  • Ensures best possible glycemic control by:
    • assessing efficacy of therapy
    • guiding adjustments in diabetes care regimen, including diet, exercise and medications
who should monitor glycemia
Who should monitor glycemia?

PatientSelf-monitoring of blood glucose

+

Healthcare professionalsRegular monitoring of HbA1c

Diabetes care team

Combined synergistic efforts of team are crucial to ensure effective monitoring of glycemic control

self monitoring of blood glucose smbg

Not Monitored (37%)

Regular SMBG Performers (21%)

Irregular SMBG Performers (42%)

Self-monitoring of blood glucose (SMBG)
  • Regular SMBG increases the proportion of individuals achieving their glycemic targets
  • Individuals should monitor postprandial glucose as part of their SMBG schedule
  • Regular discussion of results with diabetes care team is essential

HbA1c 8.0

HbA1c > 8.0

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Blonde L, et al. Diabetes Care 2002; 25:245–246.

hba 1c monitoring
HbA1c monitoring
  • HbA1c measures glycemia over preceding 2–3 months
  • Regular assessment of HbA1c can lead to more proactive management of diabetes
  • Two consecutive measurements of HbA1c 7.0% should lead to a review of the treatment algorithm
how often should hba 1c be monitored
How often should HbA1cbe monitored?

The Global Partnership recommends:

Monitor HbA1c every 3 months in addition to regular glucose self-monitoring

Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

influence of multiple risk factors and diabetes on cvd mortality
Influence of multiple risk factors and diabetes on CVD mortality

No diabetes

140

Diabetes

120

100

Age-adjusted CVD death rate per10,000 person-years

80

60

40

20

0

None

One only

Two only

All three

Number of risk factors*

*Serum cholesterol > 200 mg/dL, smoking, systolic blood pressure > 120 mmHg

Stamler J, et al. Diabetes Care 1993; 16:434–444.

what are the priorities in diabetes management
What are the priorities in diabetes management?

?

Cholesterol?

?

?

Glucose?

Blood pressure?

?

fewer individuals achieve goals for hba 1c versus lipids and blood pressure
Fewer individuals achieve goals for HbA1c versus lipids and blood pressure

80

72%

72%

70

58%

60

46%

50

Individuals achieving

treatment goals (%)

40

30

15%

20

10

0

HbA1c

< 6.5%

Total

cholesterol

< 175 mg/dL

Triglycerides

< 150 mg/dL

Systolic BP

< 130 mmHg

Diastolic BP

< 80 mmHg

Gaede P, et al. N Engl J Med 2003; 348:383–393.

should glycemia be given more or less priority versus lipids and blood pressure
Should glycemia be given more or less priority versus lipids and blood pressure?

The Global Partnership recommends:

Aggressively manage hyperglycemia, dyslipidemia and hypertension with the same intensity to obtain the best patient outcome

SBP

FPG

TC

DBP

TGs

=

=

Glycemic control

Lipid-lowering

Antihypertensive

HbA1c

HDL

ABPM

LDL

Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

type 2 diabetes is a complex disorder
Type 2 diabetes is a complex disorder
  • Management of type 2 diabetes needs considerable expertise in order to:
    • match medication to individual ‘phenotype’
    • manage complex drug regimens
    • provide strong support for patient education
specialist input leads to better outcomes in type 2 diabetes
Specialist input leads to better outcomes in type 2 diabetes

In the Verona Diabetes Study, individuals attending a specialist diabetes center had a substantially improved chance of survival compared with those seen only by family physicians

17%

Verlato G, et al. Diabetes Care 1996; 19:211–213.

how can expertise be best utilized in diabetes management
How can expertise be best utilized in diabetes management?

The Global Partnership recommends:

Refer all newly diagnosed patients to a unit specializing in diabetes care where possible

Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.