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The Science Behind Intensive Management

The Science Behind Intensive Management. Objective Review the benefits of Intensive Diabetes Management over the use of Conventional Therapy Key Points The ADA has high standards for glucose control Clinical benefits of Intensive Diabetes Management over Conventional Therapy are:

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The Science Behind Intensive Management

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  1. The Science Behind Intensive Management

  2. Objective Review the benefits of Intensive Diabetes Management over the use of Conventional Therapy Key Points • The ADA has high standards for glucose control • Clinical benefits of Intensive Diabetes Management over Conventional Therapy are: • Reduction in A1C • Reduction in microvascular & macrovascular complications • Benefits of Intensive Diabetes Management in Type 2 patients • Concerns about Intensive Management without insulin pumps

  3. Intensive Diabetes Management Requires a Treat-to-Target Approach Blood Glucose Targets Recommended By: ADA AACE AAFP A1C (%) <7 ≤6.5 — Fasting/preprandial glucose (mg/dL) 90-130 <110 80-120 Postprandial glucose (mg/dL) <180 <140* <180 Bedtime glucose (mg/dL) — 100-140 100-140 3 AM glucose (mg/dL) — — 70-110 *2 hours after the start of eating. American Association of Clinical Endocrinologists (AACE). Endocr Pract. 2007;13(suppl 1):3-68. American Academy of Family Physicians (AAFP). Self-monitoring of blood glucose (SMBG) monograph. Available at: http://www.aafp.org/PreBuilt/smbgmonograph_pated-eng.pdf. American Diabetes Association (ADA). Diabetes Care. 2008;31(suppl 1):S5-S11.

  4. Diabetes Control and Complications Trial (DCCT): Intensive Treatment Reduced the Risks of Microvascular Complications in Patients with Type 1 Diabetes by 35%-90% Intensively treated patients achieved a mean A1C of 7.3%, compared with 9.1% for conventionally treated patients Writing Team for Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA. 2002;287(19):2563-2569. Figure adapted from DCCT Research Group. N Engl J Med. 1993;329:977-986. Reused with permission.

  5. DCCT Results: A1C and Relative Risk of Diabetic Complications Average US A1C range: 7.8% - 8.6% Skyler, J. Endo Met Cl N Am, 1996; 25:.243- 254 Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986. Endocrine Practice 2002, 8 (supp 1), pg. 7. AACE recommends less than or equal to 6.5 HbA1c. Minshall M, Roze S, Palmer A, et al. Clin Ther. 2005;27:940–950.

  6. Epidemiology of Diabetes Interventions and Complications (EDIC) Study: Benefits of Intensive Treatment Were Still Significant, 4 Years After Completion of DCCT Writing Team for Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA. 2002;287(19):2563-2569. Figure adapted from DCCT Research Group. N Engl J Med. 1993;329:977-986.

  7. Intensive Treatment Was Associated with Decreased Risk for Cardiovascular Events in EDIC After a mean follow-up of 17 years, intensive insulin therapy was associated with a 42% reduction in cardiovascular events compared to conventional treatment (P = 0.02) Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med. 2005;353:2643-2653.

  8. Intensive Treatment Was Associated with Decreased Risk for Diabetes-Related Complications in Type 2 Patients In 3,867 patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS), intensive control of blood glucose was associated with a decreased risk for complications Intensive management achieved significantly lower median A1C levels compared to conventional treatment* *Median follow-up in the UKPDS study was 10 years UKPDS Group. Lancet. 1998;352:837-853.

  9. Epidemiologic Analysis of UKPDS Data Each 1% reduction in A1C was associated with a significant reduction in the risk of macrovascular and microvascular complications. Stratton IM, Adler AI, Neil HA, et al. BMJ. 2000;321:405-412.

  10. Insulin Therapy Does Not Seem to Cause Obesity in Patients with Type 2 Diabetes • Patients treated with insulin  less weight gain • Compared with no therapy and oral agents Adapted from Looker et al; Diabetes Care 2001; 24(11): 1917-1922

  11. Breaking Glucose Toxicity with Type 2 Diabetes: Case Study of 55 Year Old Woman • Frequent administration of analog insulin (every 2 hours for 11 days) • Notable reduction in glucose toxicity & insulin requirements Raine, CH et,al. J Natl Med Assoc 1999;91:410-413

  12. Improving Insulin Sensitivity with Type 2 Diabetes: Case Study of 55 Year Old Woman • Frequent administration of analog insulin (every 2 hours for 11 days) • Notable improvement in severe insulin resistance Raine, CH et,al. J Natl Med Assoc 1999;91:410-413

  13. Concern About Hypoglycemia is a Key Barrier to Intensive Management Rate of Severe Hypoglycaemia in DCCT (per 100 patient-years) Intensive group Conventional group P value 61.2 18.2 <0.001 Severe hypoglycaemia* 16.3 5.4 <0.001 Coma or seizure *Defined as episodes in which patient required assistance and had documented blood glucose <50 mg/dL. Despite the risk of hypoglycaemia, intensive management is recommended for most patients with diabetes given the proven benefits: reduction of long-term complications of diabetes DCCT Research Group. Diabetes Care. 1995;18:1415-1427.

  14. Intensive Management: CSII is Superior to MDI • More effective in reducing A1C • Significantly reduces hypoglycaemia • Improves quality of life Bruttomesso D, et al. Diabet Med. 2002;19(8):628-634. Bell DSH, et al. Endocr Pract. 2000;6(5):357-360. Rudolph DS, et al. Endocr Pract. 2002;8(6):401-405. Chantelau E, et al. Diabetologia. 1989;32(7):421-426. Boland EA, et al. Diabetes Care. 1999;22(11):1779-1784. Maniatis AK, et al. Pediatrics. 2001;107(2):351-356. Litton J, et al. J Pediatr. 2002;141(4):490-495. Rudolph JW, Hirsch IB. Endocrine Practice. 2002; 8:401 – 405. Bode,BW, Steed RD, Davidson PC. Diabetes Care. 1996;19:324-7; Boland EA, Grey M, Oesterle A, et al. Diabetes Care. 1999; 22:1779 – 84; Peyrot M, Rubin R. Diabetes Care. 2005;28:53–58. Raskin P, Bode BW, Marks JB, et al. Diabetes Care. 2003; 26: 2598-2603.

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