Diabetes Update(Bode - Atlanta).pptDiabetes Update(Bode

Diabetes Update(Bode

1. Diabetes Update
Facts, Trends and Observations
Bruce Bode, MD, FACE
Atlanta Diabetes Associates

2. Ultimate Goals Of Diabetes
Treatment
Sustained Normal Blood
Glucose Control
Lowest Incidence of
Hypoglycemia
No Long Term Diabetes
Complications
No Acute Diabetes
Complications

=
=
Best Quality of Life with a
Chronic Disease

3. Relative Risk of Progression of Relative Risk of Progression of
Diabetic ComplicationsDiabetic Complications
DCCT Research Group, N Engl J Med 1993, 329:977-986.
1
3
5
7
9
11
13
15
6 7 8 9 10 11 12
Retinop
Neph
Neurop
R
E
L
A
T
IV
E
R
IS
K
Mean A1C

4. •Gain of 15.3 years of complication free
living compared to conventional
therapy
•Gain of 5.1 years of life compared to
conventional therapy
Lifetime Benefits ofLifetime Benefits of
Intensive Therapy (DCCT)Intensive Therapy (DCCT)
DCCT Study Group, JAMA 1996, 276:1409-1415.

5. DCCTDCCT
•10% reduction in HbA1c
•43% reduced risk of retinopathy
progression
•18% increased risk of severe
hypoglycemia with coma and/or
seizure
DCCT Research Group, N Engl J Med 1993, 329:977-986.

6. *Percent risk reduction per 0.9% decrease in HbA
1C
;

UKPDS. Lancet. 1998;352:837-853.
Lowering A1C Reduces Risk Lowering A1C Reduces Risk
of Complicationsof Complications
R
e
d
u
c
t
i
o
n

i
n

r
i
s
k

(
%
)
*
p=0.029
p=0.0099
p=0.052
p=0.015
p=0.000054
0
-10
-20
-30
-40
-50
-12
-25
-16
-34
-21
Any diabetes-related
endpoint
Microvascular
endpoint
MI
Retinopathy
Albuminuria at 12
years
United Kingdom Prospective Diabetes Study United Kingdom Prospective Diabetes Study
(UKPDS)(UKPDS)

7. New Targets of
Intensive Diabetes Management
Near-normal glycemia
•A1C less than 6.5%
•Post-prandial: <140 mg/dl
Avoid short-term crisis
•Hypoglycemia
•Hyperglycemia
•DKA
Minimize long-term complications
Improve QOL
ADA: Clinical Practice Recommendations, 2001.
AACE and EASD
DCCT Research Group, N Engl J Med 1993, 329:977-986.

8. How Are We Doing?

9. U.S. Diabetes PrevalenceU.S. Diabetes Prevalence
—Diabetes kills 1 American
every 3 minutes
—New case diagnosed every
40 seconds
—More deaths than AIDS
and breast cancer
combined
—Average life expectancy:
15 years less than non-
diabetes population
—Afflicts over 177 million
people worldwide
—300 million afflicted by
2025
18 Million

10. World View
•177 million worldwide
•4th leading cause of death by disease
•India 33 million people with diabetes
•China 23 million people with diabetes
•Population of diabetes will double to triple
by 2025
•One out of every three Americans born
today will develop diabetes
Time magazine December 2003; CDC

11. $92
$109
$138
$40
$47
$54
$132
$156
$192
$0
$40
$80
$120
$160
$200
$240
Direct Indirect Total
2002
2010
2020
Diabetes Care 26:917-932, 2003
Costs Continue to Increase (U.S.)

12. Percentage of Patients With Diabetes
Having A1C
<7%
Harris MI, et al. Diabetes Care. 1999;22:403-408.
0
20
40
60
80
100
Diet aloneOral agents Insulin
US Adults With Diagnosed Diabetes in 1988-94
NHANES III
73
38
26
Whole
population
45
Percent
at goal
Therapy used

13. Lessons from the DCCT and UKPDS:Lessons from the DCCT and UKPDS:
Sustained Intensification of Therapy is DifficultSustained Intensification of Therapy is Difficult

DCCT EDIC
(Type 1)
UKPDS (Type 2),
Insulin Group
DCCT/EDIC Research Group. New Engl J Med 2000; 342:381-389
Steffes M et al. Diabetes 2001; 50 (suppl 2):A63
UK Prospective Diabetes Study Group (UKPDS) 33
Lancet 1998; 352:837-853
4
6
8
10
9.0
8.1
7.3
7.9
06.5+ 4+ 6 yrs
DCCT EDIC
0
6
7
8
0 2 4 6 8 10 yrs
A1C (%)
Normal
Baseline
A1C (%)

14. Relationship between % BG in
Target and A1C Level
Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21:2.
Within Target
Above Target
Below Target
33%
18%
49%
A1C = 7%
A1C = 8.5%
46%
12%
42%
A1C = 8%
41%
14%
45%

15. Primary Objectives of Effective Primary Objectives of Effective
ManagementManagement
A1C
%
SBP
mm Hg
LDL
mg/dL
45505560657075808590
9
Diagnosis
8
7
130
100
145
140
Patient Age
Reduction
of both
micro- and
macro-
vascular
event
rates
…by 75%!
lGæde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O.
Multifactorial intervention and cardiovascular disease in patients with
type 2 diabetes. N Engl J Med. 2003;348:383-393.

16. How is diabetes currently
being treated?

17. Roper Starch Worldwide
•“Gold Standard” market research study of
diabetes patients 18 years and older
•Self reported information
•Conducted annually in the U.S.
•N= 6,000
Roper Starch Worldwide, 2002

18. PROGRESSION TO INSULIN USE (US)
Among Type 2 diabetic patients sampled
Prior Therapy Prior Therapy Prior Therapy
43% no prior therapy 51% exclusive pills 66% no prior therapy
41% exclusive pills 14% insulin 18% diet/no med
5% diet to pills 13% pills to insulin 8% insulin

Average time on pills
before moving to
insulin
= 4.9 years
Average time on diet
before moving to
pills
= 3.2 years
Average time on pills
before moving to
insulin
= 5.6 years
Exclusive Insulin
15%
Dual Insulin/Pill
13%
Exclusive Pills
63%
To tal Type 2 patients
Roper Starch Worldwide, 2002

19. Trends Among Insulin Injectors
Intensive
Therapy
46%
Pump
Therapy
Multiple Daily
Injections
2001
Conventional
54%
Intensive
Therapy
57%
Pump
Therapy
Multiple Daily
Injections2002
Conventional
%
Roper Starch Worldwide, 2002
20%
37%
43%
31%
15%

20. ADA Physician Reported Treatment Choices
Based on aggregate responses (N=213)
23% Conventional (1-2 shots/day)
57% Intensive(3 or more shots/day)
20% Insulin Pump Therapy
Insulin Treated Patients
ADA 2003, Physician Survey, Medtronic MiniMed

21. 26,500
43,000
81,000
162,000
200,000
0
50,000
100,000
150,000
200,000
'95 '97 '99 2001 2003
Total Patients Using Insulin Pumps
Estimated figures for 2003

22. Other Possible Contributions to
Intensive Management
PATIENT ATTITUDES AND
BEHAVIORS

23. DEMOGRAPHICS (US)
By education and income
%
EDUCATION
High School or less College
Roper Starch Worldwide, 2002
%
INCOME LEVEL
< $35K$35K - $75K > $100K

24. HCPs Frequently Visited By Patients
TYPE 1
%
TYPE 2
%
Roper Starch Worldwide, 2002
“What type of healthcare professional do you normally
visit for your diabetes care?”

25. Most Feel That They Are In Good Control
Needs improvement
Good control
Roper Starch Worldwide, 2002
“Are you satisfied with your diabetes control?”
8119
US
% incidence
within total
sample

26. Most Patients Are Satisfied With Their Health
86
7172
0
20
40
60
80
100
US
Satisfied with overall healthT1T2
Roper Starch Worldwide, 2002

27. Self-Reported A1C Results
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
4.1-5.05.1-6.06.1-7.07.1-8.08.1-9.09.1-10.010.1-
11.0
Over
11.0
Don't
Know
T1
T2
Roper Starch Worldwide, 2002

28. Summary
Diabetes prevalence and costs continue to grow
Lower treatment targets will likely drive the adoption of more
intensive management
The use of intensive insulin management continues to grow
with a notable increase in insulin pump use
A potential barrier to intensive management is patient’s lack
of awareness and perception of good control