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Diabetes Update

Diabetes Update. Facts, Trends and Observations. Bruce Bode, MD, FACE Atlanta Diabetes Associates. Ultimate Goals Of Diabetes Treatment. No Long Term Diabetes Complications No Acute Diabetes Complications. Sustained Normal Blood Glucose Control Lowest Incidence of Hypoglycemia. =. =.

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Diabetes Update

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

  2. Ultimate Goals Of Diabetes Treatment No Long Term Diabetes Complications No Acute Diabetes Complications Sustained Normal Blood Glucose Control Lowest Incidence of Hypoglycemia = = Best Quality of Life with a Chronic Disease

  3. Relative Risk of Progression of Diabetic Complications RELATIVERISK Mean A1C • DCCT Research Group, N Engl J Med 1993, 329:977-986.

  4. Lifetime Benefits ofIntensive Therapy (DCCT) • Gain of15.3 yearsof complication free living compared to conventional therapy • Gain of 5.1 years of life compared to conventional therapy • DCCT Study Group, JAMA 1996,276:1409-1415.

  5. DCCT • 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. Lowering A1C Reduces Risk of Complications United Kingdom Prospective Diabetes Study (UKPDS) 0 -10 -20 -30 -40 -50 Any diabetes-related endpoint Microvascular endpoint MI Retinopathy Albuminuria at 12 years -12 -16 p=0.029 p=0.052 -21 -25 Reduction in risk (%)* p=0.015 p=0.0099 -34 p=0.000054 *Percent risk reduction per 0.9% decrease in HbA1C;UKPDS. Lancet. 1998;352:837-853.

  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 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. Costs Continue to Increase (U.S.) Diabetes Care 26:917-932, 2003

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

  13. Lessons from the DCCT and UKPDS:Sustained Intensification of Therapy is Difficult DCCT EDIC (Type 1) UKPDS (Type 2),Insulin Group 10 8 9.0 8.1 7.9 8 A1C (%) 7.3 A1C (%) 7 Baseline 6 6 Normal 4 0 0 6.5 + 4 + 6 yrs 0 2 4 6 8 10 yrs EDIC DCCT 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

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

  15. Primary Objectives of Effective Management 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. Diagnosis A1C % 9 8 7 Reduction of both micro- and macro- vascular event rates …by 75%! SBP mm Hg 145 130 LDL mg/dL 140 100 45 50 55 60 65 75 80 85 90 70 Patient Age

  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. Average time on pills before moving to insulin = 4.9 years Average time on pills before moving to insulin =5.6 years Average time on diet before moving to pills = 3.2 years PROGRESSION TO INSULIN USE (US)Among Type 2 diabetic patients sampled Prior TherapyPrior TherapyPrior 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 Roper Starch Worldwide, 2002

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

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

  21. 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 INCOME LEVEL < $35K $35K - $75K > $100K % Roper Starch Worldwide, 2002

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

  25. Most Feel That They Are In Good Control “Are you satisfied with your diabetes control?” Needs improvement Good control % incidence within total sample 19 81 US Roper Starch Worldwide, 2002

  26. Most Patients Are Satisfied With Their Health Roper Starch Worldwide, 2002

  27. Self-Reported A1C Results 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

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