type 2 diabetes: disease state overview
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Type 2 Diabetes: Disease State Overview. AF2086R0. Suggestions for Slide Deck Use. The following unbranded slides are provided as a disease state library and may be used as background information at the beginning of any promotional program - PowerPoint PPT PresentationTRANSCRIPT
Type 2 Diabetes: Disease State Overview
AF2086R0
Suggestions for Slide Deck Use
• The following unbranded slides are provided as a disease state library and may be used as background information at the beginning of any promotional program
• These slides should always supplement the affirmative deck unless the program is scheduled to be "disease state only"
Diabetes Disease State Overview
• Diabetes: epidemiology/pathophysiology – Prevalence and burden of diabetes
– Core defects of type 2 diabetes
– Complications and costs associated with type 2 diabetes
– Predicting and preventing type 2 diabetes
• Treatment goals and strategies – Improving glycemic control
– Reducing diabetes-related complications
– Treating the whole patient
Every Day in the United States Approximately…
*Patients ages ≥20 years.Centers for Disease Control. National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed March 5, 2009.
66 people lose their eyesight
because of diabetes
66 people lose their eyesight
because of diabetes
128 people begintreatment for end-stagerenal disease (ESRD)
128 people begintreatment for end-stagerenal disease (ESRD)
640 people die fromdiabetes and itscomplications
640 people die fromdiabetes and itscomplications
195 lower-limbamputations are performed
because of diabetes
195 lower-limbamputations are performed
because of diabetes
More than 4000 newcases* of diabetes will be
diagnosed today
More than 4000 newcases* of diabetes will be
diagnosed today
≈23.5 Million (10.7%) Americans 20 Years or Older Have Diabetes (Diagnosed or Undiagnosed)*
*Data is from 2003–2006, projected to year 2007.NIDDK. National Diabetes Statistics. 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.Accessed February 11, 2009.
0
5
10
15
20
25
Age group
2.6
10.8
23.8
20–39 40–59 60+
Perc
enta
ge
*Data is from 2004–2006, projected to year 2007.NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.Accessed February 11, 2009.
0
200,000
400,000
600,000
800,000
1,000,000
Age group20–39 40–59 60+
Num
ber
Adults Diagnosed with Diabetes in the United States*
1.6 million new cases of diabetes were diagnosed in people aged 20 years or older in 2007
Total economic costs of diabetes estimated to be
$174 billion (2007)
281,000
819,000
536,000
Age-adjusted Total Prevalence of Diabetes in the United States by Race/Ethnicity (Age ≥20)
0 2 4 6 8 10 12 14 16 18 20
Non-Hispanic Whites
Hispanic/Latino Americans
Non-Hispanic Blacks
American Indians/Alaska Natives
Percentage
17
12
10
7
NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.Accessed February 11, 2009.
Asian Americans 8
Economic Consequences of Diabetes
Total Annual Cost in 2002: $132 Billion
Disability and early mortality
$40 billion
Diabetes and diabetes supplies$23 billion
Chronic complications$25 billion
$44 billion
General medical conditions
Indirect costs* = $40 billion Direct costs† = $92 billion
Stolar MW et al. JMCP. 2008;14:S1–S19.
*Indirect costs include lost productivity, disability, and premature mortality.†Direct costs include: hospital inpatient care, nursing home care, physician office visits, total home healthcare costs, costs associated with hospice care, and diabetes supplies.
0
1000
2000
3000
4000
5000
6000
7000
0 5 10 15
Annual Medical Expenditures and Length ofTime with Diabetes
Duration of Diabetes (Years)
Cos
t in
2005
(dol
lars
)
Diagnosis of diabetes at age 50
Diagnosis of diabetes at age 65
Adapted from Trogdon JG et al. Diabetes Care. 2008;31:2307–2311.
Annual cost increases with length of time with diabetes
Pathophysiology of Type 2 Diabetes
• Type 2 diabetes results from a progressive insulin secretory defect on the background of insulin resistance1
• Key pathophysiologic mechanisms leading to hyperglycemia in type 2 diabetes
– Insulin resistance2,3
– Beta-cell dysfunction3
1. American Diabetes Association. Diabetes Care. 2009;32:S13–S61. 2. DeFronzo RA. Med Clin North Am. 2004;88:787–835.3. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
Two Defects Contributing to Type 2 Diabetes
1. Buchanan TA. Clin Ther. 2003;25(suppl 2):B32–B46.2. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
Type 2 DiabetesType 2 Diabetes
Beta-cellBeta-cell
InsulinInsulinresistanceresistance
InsulinInsulinresistanceresistance
Beta-cell Beta-cell dysfunctiondysfunction
Beta-cell Beta-cell dysfunctiondysfunction
Muscle tissueMuscle tissue
Adipose tissueAdipose tissue
Obesity (visceral)1Obesity (visceral)1
PancreasPancreas
Obesity (visceral)2Obesity (visceral)2
LiverLiver
Natural Progression of Insulin Resistance in Patients with Type 2 Diabetes1,2
Normal glycemia
Insulin resistance rises, leading to
beta cells working overtime to secrete
more insulin
Beta cells are unable to produce the insulin needed to compensate for the increased
level of insulin resistance, causing glucose levels to rise, leading to type 2 diabetes*
*Type 2 diabetes is diagnosed when FPG is ≥126 mg/dL.3
Adapted from International Diabetes Center, Minneapolis, MN.1
Insulin resistanceInsulin production & secretion/ Beta-cell functionFasting plasma glucose
1. Bergenstal RM et al. Endocrinology. 4th ed. Philadelphia, PA: WB Saunders Company;2001:821–835. 2. Ramlo-Halsted BA, Edelman SV. Clin Diab. 2000;18:80–85. 3. American Diabetes Association. Diabetes Care. 2008;31(suppl1):S12–S54.
DiabeticRetinopathy
Leading causeof blindnessin adults
DiabeticNephropathy
Major cause of kidney failure
CardiovascularDisease
Stroke
DiabeticNeuropathy
Major cause of lower extremity amputations
CV Disease & Stroke account for ~65% of deaths in T2D patients
Type 2 Diabetes Associated with Serious Complications
CV = cardiovascular.National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of Health, 2005.
Prevalence of Multiple Complications Among People with Type 2 Diabetes
No complications42.1%
2 complications10.3%
3 complications6.7%
4 or more complications
7.6%
1 complication33.3%
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at: http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
*In NHANES, “chronic kidney disease" refers to people with microalbuminuria (albumin:creatinine ratio >30 µg/mg).†In the NHANES analysis, "foot problems" includes foot/toe amputations, foot lesions, and numbness in the feet.‡"Eye damage" includes a positive response by NHANES participants to the question, "Have you been told diabetes has affected your eyes/had retinopathy?" Retinopathy is damage to the eye's retina. In NHANES, people without diagnosed diabetes were not asked this question, therefore, prevalence information for nondiabetics is not available.CHD = coronary heart disease; CHF = congestive heart failure.
9.8 9.5 9.17.9
6.6
27.8
22.9
18.9
1.8 1.7 2.1 1.1 1.8
6.1
10
0
10
20
30
Heart attack Chest pain CHD CHF Stroke Chronic kidneydisease
Foot problems Eye damage
Perc
enta
ge w
ith c
ompl
icat
ions
Diagnosed diabetes
Normal blood sugar levels
Prevalence of Macrovascular and Microvascular Complications of Diabetes
Macrovascular Microvascular
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at: http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 9, 2009.
*† ‡
Prevalence of Diabetic Retinopathy
*95% CI: 38.8%–41.7%†95% CI: 7.4%–9.1%‡Diabetic retinopathy defined as a retinal vascular disorder characterized by signs of retinal ischemia and/or signs of increased retinal vascular permeability. Retinopathy severity level ≥14 retinopathy and/or macular edema.§Vision threatening retinopathy defined as severe retinopathy and/or diabetic macular edema. Retinopathy severity level ≥50 and/or macular edema.Kempen JH et al. Arch Ophthalmol. 2004;122:552–563.
0
10
20
30
40
50
Diabetic retinopathy Vision-threateningretinopathy
8.2%†
40.3%*
‡
§
Prev
alen
ce o
f ret
inop
athy
in
dia
betic
s ag
e ≥4
0 ye
ars
(%)
Number of Cases with ESRD Due to Diabetic Nephropathy Is Increasing in the United States
1991 19921990 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 0
10
20
30
40
50
Num
ber o
f cas
es
(thou
sand
s)
Year
Diabetes is the leading cause of ESRD
ESRD = end-stage renal disease.CDC. Morbidity and Mortality Weekly Report. 2005;54(43)1097–1100.
CV Risk in Patients with Diabetes and No Prior MI Is Similar to Risk in Nondiabetics with Prior MI
Schramm TK et al. Circulation. 2008; 117:1945–1954.
5-ye
ar in
cide
nce
(%)
CV = cardiovascular. For CV death, the hazard ratio was 2.42 in men with diabetes only and 2.44 in men with a prior MI only ( P=0.60). Results for women were 2.45 and 2.62, respectively (P<0.001).
20.124.5
3.5 3.7
34.1
39.8
14.6 15.6
05
1015202530354045
CV death CV death
No diabetes/prior MINo diabetes/no prior MIDiabetes/prior MIDiabetes/no prior MIMen Women
A population study of 3.3 million people
Annual National Cost of Type 2 Diabetes and Related Complications*
$22.9
$57.1
$1.8
$8.4
$0.0
$10.0
$20.0
$30.0
$40.0
$50.0
$60.0
$70.0
Complications alone Diabetes and complications
National total expenditures
National out-of-pocket costs
*Cost estimates in this report were adjusted for inflation to reflect 2006 costs.American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at: http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
Cos
t in
billi
ons
Individual Costs by Complication*
Annual Healthcare Costs
*Cost estimates in this report were adjusted for inflation to reflect 2006 costs.American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at: http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
$ 1785
$ 4687
$ 6062
$ 7806
$ 7932
$ 9002
$ 14,150
$ $ $ $ $ $ $ $ $
$ 153
$ 480
$ 224
$ 448
$ 510
$ 439
$ 574
0 2000 4000 6000 8000 10,000 12,000 14,000 16,000
Heart attack
Chronic kidney disease
CHF
Stroke
CHD
Foot problems
Eye damage Total expenditures
Out-of-pocket costs
Algorithm to Estimate Type 2 Diabetes Risk
Item Points
Fasting glucose level 100–126 mg/dL, yes/no 10
Body mass index (BMI) 25.0–29.9, yes/no 2
BMI ≥30.0, yes/no 5
High-density lipoprotein cholesterol (HDL-C) level <40 mg/dL in men or <50 mg/dL in women, yes/no
5
Parental history of diabetes mellitus, yes/no 3
Triglyceride level ≥150 mg/dL, yes/no 3
Blood pressure ≥130/85 mmHg or receiving treatment, yes/no 2
According to a study in a middle-aged white population, total points ≥25 corresponds to >35% 8-year risk of type 2 diabetes.
Wilson PW et al. Arch Intern Med. 2007;167:1068–1074.
Preventing Development of Type 2 Diabetes
• Screening for prediabetes and asymptomatic type 2 diabetes should be considered in adults who are overweight or obese (BMI ≥25 kg/m2) and have additional risk factors
• In those without risk factors, testing should begin at age 45 years
• If results are normal, testing should be repeated at least every 3 years
• Counseling on lifestyle modification is recommended for patients with impaired fasting glucose or impaired glucose tolerance
– Weight-loss goal of 5%–10% of initial body weight
– Physical activity with moderate intensity for 150 minutes per week
American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61. American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61.
Summary of Diabetes: Epidemiology/Pathophysiology
• Diabetes and diabetes-related complications (eg, heart disease, kidney disease, blindness, amputations) are highly prevalent1
• The pathophysiology of diabetes involves the development of insulin resistance and beta-cell dysfunction2
• Diabetes is strongly correlated with a number of microvascular risk factors and diseases, and is a contributor to macrovascular disease and mortality1
• Routine clinical measures may be used to identify patients at risk of developing type 2 diabetes who may benefit from lifestyle counseling3
1. NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.Accessed February 11, 2009.2. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.3. American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61.
Diabetes Disease State Overview
• Diabetes: epidemiology/pathophysiology – Prevalence and burden of diabetes
– Core defects of type 2 diabetes
– Complications and cost associated with type 2 diabetes
– Predicting and preventing type 2 diabetes
• Treatment goals and strategies – Improving glycemic control
– Reducing diabetes-related complications
– Treating the whole patient
Criteria for the Diagnosis of Diabetes Mellitus: ADA Standards of Medical Care, 2009
• FPG 126 mg/dL (7.0 mmol/L)– Fasting is defined as no caloric intake for at least 8 hours
OR• Symptoms of hyperglycemia plus casual plasma glucose concentration
200 mg/dL (11.1 mmol/L)– Casual is defined as any time of day without regard to time since last meal– The classic symptoms of hyperglycemia include polyuria, polydipsia, and
unexplained weight loss
OR• 2-h plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT
– The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water
ADA = American Diabetes Association; OGTT = oral glucose tolerance test, WHO = World Health Organization.American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
ADA = American Diabetes Association; OGTT = oral glucose tolerance test, WHO = World Health Organization.American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
Recommendations for Early Pharmacologic Treatment from AACE and ADA
• To reduce the risk of serious disease-related complications,1,2 AACE recommends
– Target A1C goal of ≤6.5%2
– Earlier intervention with appropriate therapies and persistent titration to achieve goal2
• ADA recommends3
– Target A1C goal of <7% “for most patients”
– Achieving and maintaining glycemic goals and changing interventions when therapeutic goals are not being met
AACE = American Association of Clinical Endocrinologists.1. Stratton IM et al. BMJ. 2000;321:405–412.2. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):4–68.3. American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
United Kingdom Prospective Diabetes Study (UKPDS)
Conventional MonotherapiesUnable to Maintain Glycemic Control Over Time
Med
ian
A1C
(%)
Time from randomization (years)
Glibenclamide (glyburide)
Conventional*
Insulin
MET
0
6
7
8
10
0 3 6
9
9 12 15
ADA Goal
AACE Goal
FPG = fasting plasma glucose; MET = metformin.*Conventional therapy defined as dietary advice given at 3-month intervals where FPG was targeted at best levels feasible in clinical practice. If FPG exceeded 270 mg/dL, patients were re-randomized to receive nonintensive MET, chlorpropamide, glibenclamide, or insulin. If FPG exceeded 270 mg/dL again, those on SU would have MET added. If FPG exceeded 270 mg/dL after this, insulin was substituted.
Adapted from UK Prospective Diabetes Study (UKPDS 34) Group. Lancet. 1998;352:854–865.
Patients reaching glycemic target
Glycemic Targets Are Not Being Achieved Worldwide
DICE = Diabetes in Canada Evaluation; NHANES = National Health and Nutrition Examination Surveys; RECAP-DM = Real-life Effectiveness and Care Patterns of Diabetes Management.1. Harris SB et al. Diabetes Res Clin Pract. 2005;70:90–97. 2. Ong et al. Ann Epidemol. 2008;18:222–229. 3. Guisasola et al. Diabetes Obes Metab. 2008;10:8–15.
UNITED STATES (NHANES)2
HbA1c <7%
57%
43%
EUROPE(RECAP-DM)3
HbA1c <6.5%
74%
CANADA(DICE)1
HbA1c <7%
51%
49% 26%
Patients not reaching glycemic target
Length of time between first monotherapy(A1C >8.0%) and switch/addition in therapy*
*May include uptitration. Based on a prospective, population-based study using retrospective observational data.Brown JB et al. Diabetes Care. 2004;27:1535–1540.
Months
26.5
35.1
0 6 12 18 24 30 36
MET Only
SU Only
Patients Remain on Monotherapy >2 Years After First A1C >8.0%*
Risk of CV Events or Death Increased with HbA1c Level (EPIC-Norfolk)
Age
-adj
uste
d re
lativ
e ris
k (9
5% C
I)
Khaw KT et al. Ann Intern Med 2004; 141:413–420.
Men
0
1
2
3
4
5
6
7
8
CHD events CVD events All-causemortality
CHD events CVD events All-causemortality
Women
5–5.4% 5.5–5.9% 7%6.5–6.9%6.0–6.4%HbA1c level:
P0.001 for linear trend across HbA1c categories for all endpoints.CHD = coronary heart disease; CI = confidence interval; CVD = cardiovascular disease; EPIC-Norfolk = European prospective investigation into cancer in Norfolk.
1.56
2.002.13
3.44
7.07
1.231.56
1.79
3.03
5.01
1.251.57
1.80
3.49 3.38
0.96 1.04
2.29
3.06
4.73
0.890.98
1.63
2.37
7.96
1.021.28
1.61 1.70
6.91
Multifactorial Approach: Strategies for Reducing Diabetic Complications—Treating the Whole Patient
• Strategies for reducing microvascular complications
– Routine screening for diabetes
– Optimized glycemic control
– Optimized BP control
• Strategies for reducing macrovascular complications
– Optimized glycemic control
– Treatment of hypertension and other established cardiovascular risk factors in diabetic and possibly prediabetic subjects*
– Lipid control*
– Antiplatelet therapy*
*For appropriate patient population based on treatment guidelines.American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
*For appropriate patient population based on treatment guidelines.American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Stratton IM et al. BMJ. 2000;321:405–412.
Improved Glycemic Control Has Been Shown to Help Reduce the Risk of Complications
According to the United Kingdom Prospective DiabetesStudy (UKPDS) 35, every 1% decrease in A1C resulted in:
Decrease in risk of any
diabetes-related endpoint
(P<0.0001)
21%
Decrease in risk of
microvascularcomplications
(P<0.0001)
37%
UKPDS: Long-Term Intensive Glucose Control in Type 2 Diabetes
• Multicenter, randomized study with 10-year follow-up1
– One of the longest and largest type 2 diabetes trials ever conducted2
– 4209 patients newly diagnosed with type 2 diabetes1
• Study Design– After a 3-month run-in period, patients with FPG >108 mg/dL but <270 mg/dL
were randomized to receive either intensive therapy (SU or insulin or, if more than 120% of ideal body weight, MET) or conventional therapy (diet only)1
• Primary study objective– To determine whether long-term improved glycemic control was able to sustain
risk reductions in microvascular complications, and if intensive therapy had a long-term effect on macrovascular outcomes1
• Primary outcome– Prespecified aggregate clinical outcomes were any diabetes-related endpoint,
diabetes-related death, death from any cause, myocardial infarction, stroke, peripheral vascular disease, and microvascular disease1
FPG = fasting plasma glucose.1. Holman et al. N Engl J Med. 2008;359:1577–1589.2. Lawton J et al. Br J Gen Pract. 2003;53:394–398.
Sustained Intensive Glycemic Control Can Reduce Diabetes-Related Complications
• Long-term intensive glycemic control is associated with a significantly decreased risk of MI or death from any cause, in addition to known risk reductions in microvascular disease
Any diabetes-relatedendpoint
(P = 0.04 for SU-insulin;P = 0.01 for MET)
Microvasculardisease
(P = 0.001 for SU-insulin;P = 0.31 for MET)
Myocardialinfarction
(P = 0.01 for SU-insulin;P = 0.005 for MET)
Death fromany cause
(P = 0.007 for SU-insulin;P = 0.002 for MET)
SU-insulin
METSU-
insulinMET
SU-insulin
METSU-
insulinMET
-21%-24%
-15%-13%
-16%
-33%
-27%
-9%
Holman et al. N Engl J Med. 2008;359:1577–1589.
Risk Reductions for Intensive-Therapy Regimens at 10-Year Follow-up
Treating the Whole Patient: Statin Therapy in Patients with Diabetes Reduced CV Risk (CARDS)
Relative CV Risk Reduction 37% (95% CI: –52 to –17)
Years
328
305
694
651
1074
1022
1361
1306
1392
1351
Atorvastatin
Placebo
1428
1410
Placebo127 CV events*
Atorvastatin83 CV events*
Cum
ulat
ive
haza
rd (%
)
0
5
10
15
0 1 2 3 4 4.75
P = 0.001
*CV events included stroke.CARDS = Collaborative Atorvastatin Diabetes Study.Colhoun HM et al. Lancet. 2004;364:685–696.
Treating the Whole Patient: Patients Reaching Intensive Treatment Goals at 7.8 Years* (Steno-2)
Intensivetherapy (n = 80)†
Conventionaltherapy (n = 80)‡
A1C<6.5%
Patie
nts
(%)
20
30
40
50
60
70
10
80
Cholesterol<175 mg/dL
Triglycerides<150 mg/dL
Systolic BP<130 mmHg
Diastolic BP<80 mmHg
P = 0.06
P<0.001
P = 0.19
P = 0.001
P = 0.21
0
*Mean.†Intensive treatment included stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipidemia, and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin.‡Conventional treatment was based on the Danish Medical Association guidelines.Gæde et al. N Engl J Med. 2003;348:383–393.
Treating the Whole Patient: Intensive Therapy Reduced Composite Macrovascular Endpoints (Steno-2)
Prim
ary
com
posi
te e
ndpo
int*
(%)
0
0 3612
966048 847224
60
30
40
20
10
50
Intensive therapy
Conventional therapy
HR† = 0.47 (95% CI, 0.24-0.73)
53%
Months of Follow-up
*Composite endpoint of death from cardiovascular causes, nonfatal myocardial infarction, coronary-artery bypass grafting, percutaneous coronary intervention, nonfatal stroke, amputation, or surgery for peripheral atherosclerotic artery disease, P=0.007; †Unadjusted HR.CI = confidence interval; HR = hazard ratio.Gæde et al. N Engl J Med. 2003;348:383–393.
*Composite endpoint of death from cardiovascular causes, nonfatal myocardial infarction, coronary-artery bypass grafting, percutaneous coronary intervention, nonfatal stroke, amputation, or surgery for peripheral atherosclerotic artery disease, P=0.007; †Unadjusted HR.CI = confidence interval; HR = hazard ratio.Gæde et al. N Engl J Med. 2003;348:383–393.
Treating the Whole Patient: a 5.5-Year* Follow-up (Steno-2) Intensive Therapy Sustains Cardiovascular Benefits
Cum
ulat
ive
Inci
denc
e of
Any
C
ardi
ovas
cula
r Eve
nt† (
%)
0
0 1
60
30
40
20
10
50
Intensive therapy
Conventional therapy
Years of Follow-up
*Mean. †Secondary composite endpoint of cardiovascular events, including death from cardiovascular causes, nonfatal stroke, nonfatal myocardial infarction, coronary-artery bypass grafting, percutaneous coronary intervention, revascularization for peripheral atherosclerotic artery disease, and amputation.Gæde et al. N Engl J Med. 2008;358:580–591.
*Mean. †Secondary composite endpoint of cardiovascular events, including death from cardiovascular causes, nonfatal stroke, nonfatal myocardial infarction, coronary-artery bypass grafting, percutaneous coronary intervention, revascularization for peripheral atherosclerotic artery disease, and amputation.Gæde et al. N Engl J Med. 2008;358:580–591.
2 3 4 5 6 7 8 9 10 11 12 13
70
80
HR 0.41(95% CI, 0.25 to 0.67; P<0.001)
59%
*High risk patients are those with acute coronary syndromes or previous cardiovascular events.AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; ADA = American Diabetes Association; EASD = European Association for the Study of Diabetes; HDL = high-density lipoprotein; LDL = low-density lipoprotein. 1. ADA Standards of Medical Care in Diabetes – 2009. Diabetes Care. 2009;32:S13–S61.2. American Association of Clinical Endocrinologists. Endocrine Practice. 2007;13(suppl 1):3–68.
Management of Type 2 Diabetes
• Type 2 diabetes requires a multifactorial approach for the management of glucose levels, blood pressure, and lipids to reduce complications1
• Recommendations for type 2 diabetes:
Lifestyle Modification
HypertensionDyslipidemia:
LDLDyslipidemia:
HDLHbA1c Goal
Combination therapy within 3 mo if not at HbA1c goal
ADA/EASD1 Target <130/80 mmHg
Target LDL <100 mg/dL
(<70 mg/dL for high-risk patients*)
Target HDL >40 mg/dL in men, >50 mg/dL in
women<7%
ACE/AACE2 Target<130/80 mmHg
Target LDL <100 mg/dL
(<70 mg/dL for high-risk patients*)
Target HDL >40 mg/dL in men, >50 mg/dL in
women≤6.5%
Summary of Treatment Goals and Strategies
• Glycemic control is fundamental to the management of diabetes1
• The UKPDS demonstrated significant risk reductions in microvascular complications in type 2 diabetes with more intensive glycemic control. The benefit of A1C–lowering to reduce CVD in type 2 diabetes is supported by UKPDS data2
• There is a need to treat the whole patient, including management of hyperglycemia, CV risk factors and other comorbidities. This is key in reducing diabetes-related complications3
1. AACE. Endocr Pract. 2007;13(suppl 1):4–68. 2. Stratton IM et al. BMJ. 2000;321:405–412.3. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Conclusions:Management of Type 2 Diabetes
• Diabetes is a major clinical problem
– Pathophysiology involves insulin resistance and beta-cell dysfunction1
• Diabetes is correlated with increased risk of microvascular and macrovascular diseases and events
– Microvascular complications are predominately driven by hyperglycemia2,3
– Macrovascular complications are multifactorial and complex4
1. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.2. AACE. Endocr Pract. 2007;13(suppl 1):4–68. 3. Stratton IM et al. BMJ. 2000;321:405–412.4. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Conclusions:Management of Type 2 Diabetes (cont)
• A1C reduction has been shown to reduce the risk of microvascular complications and may contribute to risk reduction of macrovascular endpoints1
• Early intervention is needed to get A1C to goal (diet and exercise should always be recommended)2
• It is challenging to maintain A1C control over time with traditional monotherapies3
• AACE and ADA* guidelines recommends use of combination therapy to achieve and sustain glycemic goals2,4
*ADA guidelines recommend that a second medication should be added within 3 months if patients are not at goal.1. Stratton IM et al. BMJ. 2000;321:405–412; 2. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54; 3. UKPDS. Lancet. 1998;352:854–865; 4. AACE. Endocr Pract. 2007;13(suppl 1):4–68.