diabetes update(bode - atlanta)
TRANSCRIPT
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Diabetes UpdateFacts, Trends and Observations
Bruce Bode, MD, FACE
Atlanta Diabetes Associates
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Ultimate Goals Of DiabetesTreatment
Sustained Normal Blood
Glucose Control
Lowest Incidence ofHypoglycemia
No Long Term Diabetes
Complications
No Acute DiabetesComplications
=
=
Best Quality of Life with aChronic Disease
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Relative Risk of Progression ofRelative Risk of Progression of
Diabetic ComplicationsDiabetic Complications
DCCT Research Group, N Engl J Med1993,329:977-986.
1
3
5
7
9
11
13
15
6 7 8 9 10 11 12
Retinop
Neph
Neurop
RE
LATIVE
RISK
Mean A1C
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Gain of15.3 yearsof complication freeliving compared to conventionaltherapy
Gain of5.1 years of life compared toconventional therapy
Lifetime Benefits ofLifetime Benefits ofIntensive Therapy (DCCT)Intensive Therapy (DCCT)
DCCT Study Group,JAMA 1996,276:1409-1415.
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DCCTDCCT
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 Med1993,329:977-986.
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*Percent risk reduction per 0.9% decrease in HbA1C ;UKPDS. Lancet. 1998;352:837-853.
Lowering A1C Reduces RiskLowering A1C Reduces Risk
of Complicationsof Complications
Reduc
tionin
risk(%)*
p=0.029
p=0.0099
p=0.052
p=0.015
p=0.000054
0
-10
-20
-30
-40
-50
-12
-25
-16
-34
-21
Any diabetes-relatedendpoint
Microvascularendpoint
MI
Retinopathy
Albuminuria at 12years
United Kingdom Prospective Diabetes StudyUnited Kingdom Prospective Diabetes Study(UKPDS)(UKPDS)
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New Targets of
Intensive Diabetes Management
Near-normal glycemia
A1C less than 6.5%
Post-prandial:
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How Are We Doing?
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U.S. Diabetes PrevalenceU.S. Diabetes Prevalence
Diabetes kills 1 Americanevery 3 minutes
New case diagnosed every
40 seconds
More deaths than AIDSand 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
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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 December2003; CDC
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$92
$109
$138
$40$47
$54
$132
$156
$192
$0
$40
$80
$120
$160
$200
$240
Direct Indirect Total
2002
2010
2020
Diabetes Care 26:917-932, 2003
Costs Continue to Increase (U.S.)
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Percentage of Patients With Diabetes
Having A1C
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Lessons from the DCCT and UKPDS:Lessons from the DCCT and UKPDS:
Sustained Intensification of Therapy is DifficultSustained Intensification of Therapy is Difficult
DCCT EDIC
(Type 1)UKPDS (Type 2),
Insulin Group
DCCT/EDIC Research Group. New Engl J Med2000; 342:381-389
Steffes M et al. Diabetes 2001; 50 (suppl 2):A63UK Prospective Diabetes Study Group (UKPDS) 33
Lancet1998; 352:837-853
4
6
8
10
9.0
8.1
7.3
7.9
0 6.5 + 4 + 6 yrs
DCCT EDIC
0
6
7
8
0 2 4 6 8 10 yrs
A1C (%)
Normal
Baseline
A1C (%)
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Relationship between % BG inTarget and A1C Level
Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21:2.
Within Target
Above Target
Below Target
33%
18%49%
A1C = 7%
A1C = 8.5%
46%
12%
42%
A1C = 8%
41%
14%
45%
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Primary Objectives of EffectivePrimary Objectives of Effective
ManagementManagement
A1C%
SBPmm Hg
LDLmg/dL
45 50 55 60 65 70 75 80 85 90
9
Diagnosis
8
7
130
100
145
140
Patient Age
Reduction
of both
micro- and
macro-
vascular
eventrates
by 75%!
lGde 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.
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How is diabetes currently
being treated?
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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
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PROGRESSION TO INSULIN USE (US)Among Type 2 diabetic patients sampled
Prior Therapy Prior Therapy Prior Therapy43% 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
Average time on pillsbefore moving to
insulin
= 4.9 years
Average time on dietbefore moving to
pills
= 3.2years
Average time on pillsbefore moving to
insulin
=5.6years
E x c l u s i v
1 5 %
D u a l I n s
1 3 %
E x c l u s i v
6 3 %
T o t a l T y p e
Roper Starch Worldwide, 2002
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Trends Among Insulin Injectors
IntensiveTherapy
46%
PumpTherapy
Multiple DailyInjections2001
Conventional
54%
Intensive
Therapy
57%
PumpTherapy
Multiple DailyInjections2002
Conventional
%
Roper Starch Worldwide, 2002
20%
37%
43%
31%
15%
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ADA Physician Reported Treatment Choices
Based on aggregate responses (N=213)
23% Conventional (1-2shots/day)
57% Intensive(3 or more
shots/day)20% Insulin Pump Therapy
Insulin TreatedPatients
ADA 2003, Physician Survey, MedtronicMiniMed
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26,500
43,000
81,000
162,000
200,000
0
50,000
100,000
150,000
200,000
'95 '97 '99 2001 2003
Total Patients Using Insulin Pumps
Estimated figures for 2003
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Other Possible Contributions to
Intensive Management
PATIENT ATTITUDES AND
BEHAVIORS
DEMOGRAPHICS (US)
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DEMOGRAPHICS (US)
By education and income
%
EDUCATION
High School orless
College
Roper Starch Worldwide, 2002
%
INCOME LEVEL
$100K
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HCPs Frequently Visited By Patients
TYPE 1
%
TYPE 2
%
Roper Starch Worldwide, 2002
What type of healthcare professional do you normally
visit for your diabetes care?
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Most Feel That They Are In Good Control
Needsimprovement
Good control
Roper Starch Worldwide, 2002
Are you satisfied with your diabetes control?
8119
US
% incidencewithin total
sample
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Most Patients Are Satisfied With Their Health
86
7172
0
20
40
60
80
100
US
Satisfied with overall health T1 T2
Roper Starch Worldwide, 2002
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Self-Reported A1C Results
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
4.1-5.0 5.1-6.0 6.1-7.0 7.1-8.0 8.1-9.0 9.1-10.0 10.1-
11.0
Over
11.0
Don't
Know
T1
T2
Roper Starch Worldwide, 2002
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Summary
Diabetes prevalence and costs continue togrow
Lower treatment targets will likely drive the
adoption of more intensive management
The use of intensive insulin managementcontinues to grow with a notable increase in
insulin pump useA potential barrier to intensivemanagement is patients lack of awareness
and perception of good control