Diabetes Update

Diabetes UpdateFacts, Trends and Observations

Bruce Bode, MD, FACE

Atlanta Diabetes Associates

Ultimate Goals Of Diabetes Treatment

Sustained Normal BloodGlucose Control

Lowest Incidence of Hypoglycemia

No Long Term DiabetesComplications

No Acute DiabetesComplications

=

=

Best Quality of Life with a Chronic Disease

Relative Risk of Progression of Relative Risk of Progression of Diabetic ComplicationsDiabetic Complications

DCCT Research Group, N Engl J Med 1993, 329:977-986.

1

3

5

7

9

11

13

15

6 7 8 9 10 11 12

Retinop

Neph

Neurop

RELA

TIV

E

RIS

K

Mean A1C

• Gain of 15.3 years of complication free living compared to conventional therapy

• Gain of 5.1 years of life compared to conventional therapy

Lifetime Benefits ofLifetime Benefits ofIntensive Therapy (DCCT)Intensive Therapy (DCCT)

DCCT Study Group, JAMA 1996, 276:1409-1415.

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 Med 1993, 329:977-986.

*Percent risk reduction per 0.9% decrease in HbA1C; UKPDS. Lancet. 1998;352:837-853.

Lowering A1C Reduces Risk Lowering A1C Reduces Risk of Complicationsof Complications

Red

ucti

on

in

ris

k (

%)*

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-related endpoint

Microvascular endpoint

MI

Retinopathy

Albuminuria at 12 years

United Kingdom Prospective Diabetes Study United Kingdom Prospective Diabetes Study (UKPDS)(UKPDS)

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 complicationsImprove QOL

ADA: Clinical Practice Recommendations, 2001.AACE and EASDDCCT Research Group, N Engl J Med 1993, 329:977-986.

How Are We Doing?

U.S. Diabetes PrevalenceU.S. Diabetes Prevalence

— Diabetes kills 1 American every 3 minutes

— New case diagnosed every 40 seconds

— More deaths than AIDS and 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

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

$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.)

Percentage of Patients With DiabetesHaving A1C <7%

Harris MI, et al. Diabetes Care. 1999;22:403-408.

0

20

40

60

80

100

Diet alone Oral agents Insulin

US Adults With Diagnosed Diabetes in 1988-94NHANES III

73

38

26

Wholepopulation

45

Percent at goal

Therapy used

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 Med 2000; 342:381-389Steffes M et al. Diabetes 2001; 50 (suppl 2):A63UK Prospective Diabetes Study Group (UKPDS) 33Lancet 1998; 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 (%)

Relationship between % BG in Target 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%

Primary Objectives of Effective Primary 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 event rates

…by 75%!

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.

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

Prior Therapy Prior Therapy Prior Therapy43% no prior therapy 51% exclusive pills 66% no prior therapy41% exclusive pills 14% insulin 18% diet/no med 5% diet to pills 13% pills to insulin 8% insulin

Average time on pills before moving to

insulin

= 4.9 years

Average time on diet before moving to

pills

= 3.2 years

Average time on pills before moving to

insulin

= 5.6 years

Exclusive Insulin15%

Dual Insulin/P ill13%

Exclusive P ills63%

T o tal T yp e 2 p a tien ts


Trends Among Insulin Injectors

IntensiveTherapy

46%

PumpTherapy

Multiple Daily Injections2001

Conventional

54%

IntensiveTherapy

57%

PumpTherapy

Multiple Daily Injections2002

Conventional

%


20%

37%43%

31%

15%

ADA Physician Reported Treatment ChoicesBased on aggregate responses (N=213)

23% Conventional (1-2 shots/day)57% Intensive(3 or more shots/day)20% Insulin Pump Therapy

Insulin Treated Patients

ADA 2003, Physician Survey, Medtronic MiniMed

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

Other Possible Contributions to Intensive Management

PATIENT ATTITUDES AND BEHAVIORS

DEMOGRAPHICS (US) By education and income

%

EDUCATION

High School or less College


%

INCOME LEVEL

< $35K $35K - $75K > $100K

HCPs Frequently Visited By Patients

TYPE 1

%

TYPE 2

%


“What type of healthcare professional do you normally visit for your diabetes care?”

Most Feel That They Are In Good Control

Needs improvement

Good control


“Are you satisfied with your diabetes control?”

8119

US

% incidence within total

sample

Most Patients Are Satisfied With Their Health

86

7172

0

20

40

60

80

100

US

Satisfied with overall health T1 T2


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

Over11.0

Don'tKnow

T1T2


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

Diabetes Update

Health & Medicine

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