Transcript Diabetes Update(Bode - Atlanta)

Diabetes Update
Facts, Trends and Observations
Bruce Bode, MD, FACE
Atlanta Diabetes Associates
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
Relative Risk of Progression of
Diabetic Complications
15
RELATIVE RISK
13
Retinop
11
9
Neph
7
Neurop
5
3
1
6
7
8
9
10
11
12
Mean A1C
DCCT Research Group, N Engl J Med 1993, 329:977-986.
Lifetime Benefits of
Intensive Therapy (DCCT)
• Gain of 15.3 years of 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.
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.
Lowering A1C Reduces Risk
of Complications
Reduction in risk (%)*
United Kingdom Prospective Diabetes Study
(UKPDS)
0
-10
-20
Any diabetesrelated endpoint
-12
p=0.052 -21
-25
p=0.0099
-30
Microvascular
endpoint
-16
p=0.029
MI
p=0.015
-34
Retinopathy
p=0.000054
-40
Albuminuria at 12
years
-50
*Percent risk reduction per 0.9% decrease in HbA1C; UKPDS. Lancet. 1998;352:837-853.
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.
How Are We Doing?
U.S. Diabetes Prevalence
— Diabetes kills 1 American
every 3 minutes
18 Million
— New case diagnosed every
40 seconds
— More deaths than AIDS
and breast cancer
combined
— Average life expectancy:
15 years less than nondiabetes population
— Afflicts over 177 million
people worldwide
— 300 million afflicted by
2025
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
Costs Continue to Increase (U.S.)
$240
$192
$200
$156
$160
$138
$132
$109
$120
2002
2010
2020
$92
$80
$40
$40
$47
$54
$0
Direct
Indirect
Diabetes Care 26:917-932, 2003
Total
Percentage of Patients With Diabetes
Having A1C <7%
US Adults With Diagnosed Diabetes in 1988-94
NHANES III
Percent
at goal
100
80
73
60
45
38
40
26
20
0
Diet alone
Oral agents
Therapy used
Harris MI, et al. Diabetes Care. 1999;22:403-408.
Insulin
Whole
population
Lessons from the DCCT and UKPDS:
Sustained Intensification of Therapy is Difficult
DCCT
(Type 1)
EDIC
UKPDS (Type 2),
Insulin Group
10
8
9.0
7.9
8
8.1
A1C (%)
7.3
A1C (%)
7
Baseline
6
6
4
Normal
0
0
6.5
DCCT
+4
+ 6 yrs
EDIC
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
0
2
4
6
8
10 yrs
Relationship between % BG in
Target and A1C Level
33%
18%
41%
49%
14%
A1C = 7%
A1C = 8%
46%
Within Target
Above Target
45%
42%
12%
Below Target
A1C = 8.5%
Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21:2.
Primary Objectives of Effective
Management
A1C
%
9
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
8
7
Reduction
of both
micro- and
macrovascular
event
rates
…by 75%!
SBP
mm Hg
145
130
LDL
mg/dL
140
100
45
50
55
60
65
70
Patient Age
75
80
85
90
How is diabetes currently
being treated?
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
PROGRESSION TO INSULIN USE (US)
Among Type 2 diabetic patients sampled
Total Type 2 patients
Exclusive Insulin
15%
Prior Therapy
43% no prior therapy
41% exclusive pills
5% diet to pills
Dual Insulin/Pill
13%
Exclusive Pills
63%
Prior Therapy
Prior Therapy
51% exclusive pills
14% insulin
13% pills to insulin
66% no prior therapy
18% diet/no med
8% insulin
Average time on pills
before moving to
insulin
Average time on pills
before moving to
insulin
= 4.9 years
= 5.6 years
Average time on diet
before moving to
pills
=
3.2 years
Roper Starch Worldwide, 2002
Trends Among Insulin Injectors
Pump
Therapy
Conventional
15%
54%
Intensive
Therapy
31%
46%
%
2001
Multiple Daily
Injections
Conventional
Pump
Therapy
20%
43%
37%
2002
Multiple Daily
Injections
Roper Starch Worldwide, 2002
Intensive
Therapy
57%
ADA Physician Reported Treatment Choices
Based on aggregate responses (N=213)
Insulin Treated Patients
57%
20%
23%
23% Conventional (1-2 shots/day)
57% Intensive(3 or more shots/day)
20% Insulin Pump Therapy
ADA 2003, Physician Survey, Medtronic MiniMed
Total Patients Using Insulin Pumps
200,000
200,000
Estimated figures for 2003
162,000
150,000
81,000
100,000
43,000
50,000
26,500
0
'95
'97
'99
2001
2003
Other Possible Contributions to
Intensive Management
PATIENT ATTITUDES AND
BEHAVIORS
DEMOGRAPHICS (US)
By education and income
EDUCATION
%
T1
T2
High School or less
47
50
College
51
48
INCOME LEVEL
% incidence within total sample
< $35K
T1
T2
%
32
54
$35K - $75K
> $100K
37
19
26
% incidence within total sample
Roper Starch Worldwide, 2002
9
HCPs Frequently Visited By Patients
“What type of healthcare professional do you normally
visit for your diabetes care?”
%
%
100
100
TYPE 2
TYPE 1
80
80
60
60
40
40
20
20
0
0
Endos
GPs
Roper Starch Worldwide, 2002
Nurses
Endos
GPs
Nurses
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
Most Patients Are Satisfied With Their Health
Satisfied with overall health
T1
T2
100
86
80
71
72
60
40
20
0
US
Roper Starch Worldwide, 2002
Self-Reported A1C Results
50%
45%
40%
35%
30%
25%
20%
T1
T2
15%
10%
5%
0%
4.1-5.0
5.1-6.0
6.1-7.0
7.1-8.0
8.1-9.0 9.1-10.0
10.111.0
Over
11.0
Don't
Know
Roper Starch Worldwide, 2002
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