Optimum Care in Type 2 Diabetes: Does One Size Fit All?

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Transcript Optimum Care in Type 2 Diabetes: Does One Size Fit All?

Optimum Care in Type 2 Diabetes: Does One Size Fit All?

James LaSalle on behalf of the

Global Partnership for Effective Diabetes Management

This slideset was developed in 2009 with support from GlaxoSmithKline

Need to individualize patient care

"Good glycaemic control continues to have an essential role in type 2 diabetes management... However, having reviewed the evidence, we recognise that individualising targets and/or treatment according to patient type is paramount.

For example, while early intervention is preferred wherever appropriate, certain high risk groups may not respond to overly intensive glucose-lowering regimens such as that utilised in ACCORD."

Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Patient groups requiring special consideration

• Newly diagnosed individuals with type 2 diabetes, but no complications – Overweight or obese adults – Lean adults • Individuals with a history of poor glycemic control – No complications – History of CVD • Individuals at risk of hypoglycemia Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Case study: Newly-diagnosed adults, no complications, overweight/obese

      HbA 1c > 6.5% BMI > 25 kg/m 2 Typically > 30 years of age Mild symptoms or asymptomatic Diagnosis before emergence of complications No associated comorbidities e.g. hypertension, dyslipidemia Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Stepwise approach: delays control and leaves patients at risk of complications

10 Diet and exercise OAD monotherapy OAD monotherapy uptitration OAD combination OAD + basal insulin OAD + multiple daily insulin injections 9 8 7 6

OAD = oral antidiabetic

Mean Duration of diabetes

1. Adapted from Del Prato S,

et al

.

Int J Clin Pract

2. Stratton IM,

et al. BMJ

2005;

59:

1345 –1355. 2000;

321:

405 –412.

Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

Early, intensive intervention: reach glycemic goals and reduce the risk of complications

10 Diet and exercise OAD monotherapy 9 OAD combination 8 7 6

OAD = oral antidiabetic

OAD uptitration OAD + basal insulin OAD + multiple daily insulin injections Mean Duration of diabetes

1. Adapted from Del Prato S,

et al

.

Int J Clin Pract

2. Stratton IM,

et al. BMJ

2005;

59:

1345 –1355. 2000;

321:

405 –412.

Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

Newly diagnosed adults, no complications, overweight/obese

Practical guidance: glycemic targets

GOAL: HOW: Bottom of target range (HbA 1c modest hyperglycemia (HbA 1c 6.5

–7%), even in patients with < 7.5%) Aim for HbA 1c as close to normal as can safely be achieved without causing hypoglycemia or marked weight gain If HbA 1c < 7.5%, consider agents not associated with hypoglycemia that address the underlying pathophysiology of diabetes Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Newly diagnosed adults, no complications, overweight/obese

Practical guidance: other considerations

• As for all people with type 2 diabetes, diet and exercise should be continually reinforced • Overweight and obese patients are at increased risk of CVD, pay particular attention to managing

all

CV risk factors

Glycemic control

=

Lipid-lowering

=

Antihypertensives

Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Case study:

newly diagnosed adults, no complications, lean       HbA 1c > 6.5% BMI < 25 kg/m 2 Typically > 30 years of age Mild symptoms or asymptomatic Diagnosis before emergence of complications No associated comorbidities, e.g. hypertension, dyslipidemia Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Lean patients may have a greater degree of

-cell dysfunction

• Most individuals with type 2 diabetes are overweight or obese but this varies across the world

South-East Asia* < 40% of T2D are obese North America almost 90% of T2D are obese

• In lean patients,  -cell dysfunction is often more marked compared with overweight/obese individuals – Particularly in some non-western populations – LADA may also be more prevalent in lean patients Brunetti P.

Int J Clin Pract

2007;

61:

3 –9.

Newly diagnosed adults, no complications, lean

Practical guidance: glycemic targets

GOAL: HOW: Bottom of target range (HbA 1c modest hyperglycemia (HbA 1c 6.5

–7%), even in patients with < 7.5%) Aim for HbA 1c as close to normal as can safely be achieved without causing hypoglycemia or marked weight gain Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Newly diagnosed adults, no complications, lean

Practical guidance: other considerations

• Increased likelihood of β-cell dysfunction, therefore early therapy should include agents that support β-cell function • Despite lower CV risk, lean individuals should still be educated about maintaining a healthy lifestyle to prevent weight gain 

-cell dysfunction

• Since LADA may be present, consider testing for autoantibodies, where possible  Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Case study:

history of inadequate glycemic control, no complications    Likely to be older than newly diagnosed individuals No complications and a longer duration of diabetes with inadequate glycemic control (HbA 1c > 7.5%) ≥ 1 year No associated comorbidities, e.g. hypertension, dyslipidemia Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Level of care in patients with type 2 diabetes and sustained hyperglycemia

1.0

0.9

0.8

0.7

After 2 years, 11% of patients had still not received appropriate care* 0.6

0.5

0.4

0.3

0.2

0.1

After 12 months, 25% of patients had not received appropriate care* After 6 months, 41% of patients had not received appropriate care* 0 0 10 20 30 40 Months of sustained hyperglycemia

*Appropriate care defined as medication intensification or HbA 1c test result ≤ 7%.

50 60

Lafata JE,

et al

.

Diabetes Care

2009;

32:

1447 – 1452.

Copyright 2009 American Diabetes Association. Reprinted with permission from The American Diabetes Association.

History of inadequate glycemic control, no complications

Practical guidance: glycemic targets

GOAL: HOW: Target near-normal HbA 1c Aim for a more gradual reduction in HbA 1c diagnosed individuals versus newly Reassess potential reasons for inadequate glycemic control, e.g.

• overly conservative management, e.g. delay in introducing combination therapy • inadequate adherence to antidiabetic regimens • inappropriate choice of agents (e.g. agents that do not address the underlying pathophysiology) Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Challenges in increasing adherence

Patient adherence to therapy 62% took tablets correctly in relation to food 20% regularly forgot to take their tablets 5% omitted tablets if their blood glucose was too high 2% omitted tablets if their blood glucose was too low

Browne DL,

et al. Diabet Med

2000;

17:

528 –531.

Challenges in improving patient understanding

Patient knowledge of oral antidiabetic agents 35% recalled receiving advice about their medication 15% knew the mechanism of action of their therapy 10% taking sulfonylureas knew that they could cause hypoglycemia 20% taking metformin knew it could cause gastrointestinal side effects

Browne DL,

et al. Diabet Med

2000;

17:

528 –531.

History of inadequate glycemic control, no complications

Practical guidance: other considerations

• Implement structured educational programs to motivate individuals with type 2 diabetes to assume a more active role in managing their condition

“I don’t need to take my tablets – I don’t feel ill” “Complications only occur in patients who take insulin”

Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Case study: history of inadequate glycemic control and cardiovascular disease   Known history of CVD Likely to have large pill burden and restrictions on choice of therapy due to comorbidities Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

History of inadequate glycemic control and cardiovascular disease

Practical guidance: glycemic targets

GOAL: HOW: Guidance as for patients with a history of inadequate glycemic control but no complications, i.e. target near-normal HbA 1c Take particular care to avoid hypoglycemia Adopt less stringent glycemic targets and aim for a more gradual reduction in HbA 1c Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

History of inadequate glycemic control and cardiovascular disease

Practical guidance: other considerations

• CV risk management should be intensified in these individuals • Be vigilant for contraindications and other limitations concerning choice of agents and possible drug interactions Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Case study: individuals at risk of hypoglycemia

   Previous symptoms of hypoglycemia Particularly wide daily glucose fluctuations Individuals such as the elderly who often have impaired creatinine clearance, and irregular lifestyles/eating patterns increasing susceptibility to hypoglycemia – Especially when taking hypoglycemic agents such as insulin and sulfonylureas Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Increased risk of hypoglycemia with intensive glycemic control: ACCORD

*P

< 0.001

20 15 10 5 0

*

16.2%

*

10.5% 5.1% 3.5% Requiring medical assistance Requiring any assistance Intensive Standard

Gerstein HC,

et al

.

N Engl J Med

2008;

358:

2545 –2559.

Individuals at risk of hypoglycemia

Practical guidance: glycemic targets

WHAT: Targets should be individualized according to the risk of hypoglycemia, e.g.

• history of severe or frequent hypoglycemia • kidney function • age of patient • previous CV events Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Individuals at risk of hypoglycemia

Practical guidance: other considerations

• Educate patients on being alert to possible hypoglycemia, to increase awareness and responsiveness to symptoms of hypoglycemia • Counseling particularly vulnerable patients such as the elderly on increased risk of hypoglycemia with irregular lifestyles/eating patterns and encourage compliance to prescribed regimens • Emphasize the importance of regular self-monitoring of glucose where appropriate Del Prato S,

et al

.

Int J Clin Pract

2009; in press.

Summary: one size does not fit all

• Good glycemic control, including early intervention, remains the cornerstone of diabetes care • However, strategies to achieve glycemic targets should always ensure patient safety • Treatment should be individualized to the patient Del Prato S,

et al

.

Int J Clin Pract

2009; in press.