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Achieving Good Glycemic Control

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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Achieving Good Glycemic Control

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  1. Achieving Good Glycemic Control

  2. 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

  3. Type 2 diabetes accounts for 85–95% of diabetes cases Type 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/

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. 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

  19. Lack of clarity over definition of good glycemic control

  20. Although HbA1c targets are converging, good glycemic control is not reached ?

  21. 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.

  22. Inadequate monitoring of glycemia

  23. 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

  24. 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

  25. 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.

  26. 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

  27. 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.

  28. Complexity of managing hyperglycemia relative to dyslipidemia and hypertension

  29. 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.

  30. What are the priorities in diabetes management? ? Cholesterol? ? ? Glucose? Blood pressure? ?

  31. 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.

  32. 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.

  33. Insufficient involvement of specialist care units

  34. 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

  35. 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.

  36. 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.

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