3/6/17

1

PreventingaChronicDiseasebyManagementofPrediabetes

EdenM.MillerD.O.&KevinT.MillerD.O.

Disclosures

EdenM.Miller,D.O.•  EliLilly• NovoNordisk• AstraZeneca•  Jenssen• AbboA• Omnipod• BehringerIngelheim

KevinT.Miller,D.O.•  Ihavenothingtodisclose

3/6/17

2

WhatisPrediabetes?• A1c>5.7%butlessthan6.5%

• AnA1cbetween6.0%-6.5%hasa5yearriskofbetween25%-50%ofdevelopingdiabetes

• ThosewithA1c>6.0%shouldhaveaggressiveintervenSon.

• FPGfrom100mg/dlto125mg/dl

• 2hPPG75-gOGTT140mg/dlto199mg/dl

Whoshouldbescreened?

• AdultswithBMI>25orAsianAmericans>23• HighriskEthnicGroups(AfricanAmerican,LaSno,NaSveAmerican,AsianAmericanorPacificIslanders)• Allpeopleaged45orolder• FamilyhistoryofType2DM(FirstDegreeRelaSve)• WomenwithdxofPCOSorGestaSonalDiabetes• PaSentswithdxofCVD,orHTN• PhysicalInacSvity,otherdysmetaboliccondiSons(HDL<35orTG>250)oracanthosisnigricans• Score5orhigheronDiabetesRiskTest

3/6/17

3

EpidemiologyofPrediabetesinUS•  In2012,86millionpeopleintheU.S.hadPrediabetes• 29millionhavediagnosisofT2DM• 1.4millionnewpaSentsdiagnosedeveryyear• OrderofprevalencebasedonethnicityNaSveAmerican15.9%AfricanAmerican13.2%Hispanic12.8%Asians9.0%Caucasian7.6%

CostofDiabetesManagement• $322Billioncostdiagnoseddiabetes$244Billionindirectcare:43%InpaSenthospitalcare18%PrescripSonmedicaSonforcomplicaSons12%AnSdiabeScagentsandsupplies9%Officevisits1in5HealthCaredollarsspentofDM40%increasefrom2007-2012

• Expenditureforpeoplewithdiabetesis2.3SmeshigherthanpaSentswithout.

3/6/17

4

TheEconomicBurdenofElevatedBloodGlucoseLevelsin2012:DiagnosedandUndiagnosedDiabetes,GestationalDiabetes

Mellitus,andPrediabetesTimothyM.Dall1⇑,WenyaYang2,PragnaHalder2,BoPang2,Marjan

Massoudi3,NeilWintfeld3,AprilP.Semilla1,JerryFranz3&PaulF.Hogan2

•  2007,researchersfoundthatoverfiveyears,thecostofprediabetesincreased74percent(to$44billion)whilethecostofundiagnoseddiabetesroseastaggering82percent(to$33billion).•  $244billionfordiagnoseddiabetes,$33billionforundiagnoseddiabetes,$44billionforprediabetes,and$1.3billionforGDM•  Prediabetescosts$510annuallyperperson(medicalcostsonly);undiagnoseddiabetes,$4,030;anddiagnoseddiabetes,$10,970.ThecostofGDMpercaseaveraged$5,800inhigherdeliverycostsandothercostsduringthenewborn’sfirstyearoflife.ThiscostincreasedasthepaSentagedatSmeofdiagnosis.

Conclusion

ThesestaSsScsunderscoretheimportanceoffindingwaystoreducetheburdenof

prediabetesanddiabetesthroughprevenSonandtreatment.

3/6/17

5

ImprovedIdentiRicationofatRiskPopulation•  AmpleEvidencethatDM2geneScbasis•  70%riskMonoZygoScTwinsvs.20-30%DizygoScTwins•  40%riskifoneparentand70%if2parentshaveDM

•  Over65GeneScmarkersidenSfiedthatincreasetheriskof

developingT2DM

•  Theyanoncodingvariantgenesandonlyincreaseriskby10-30%•  NotEnoughconclusiveevidenceexistsyettobeabletopredictT2DM

usinggeneSctesSng.•  BestPredic+onmodelsinclude:age,obesity,sedentary,lowfiber/

highfatdiet,family/culturalhistory,gestaSonalDM,elevatedfasSngglucose.HTN,dyslipidemia,andcertainmedicaSons(HCTZ,BetaBlockers,andStaSns)

•  FINRISKStudyhasshowthegreatestpredictordevelopingT2DM

LimitationsofPrediabetesDiagnosis

• NoGuaranteeindividualwilldevelopdisease

• DiagnosScCriteriaarenot100%sensiSveorspecific

• AsaresultliAleresearchonpharmacologicevidenceforprimaryprevenSonsince

“atriskpopulaSonisdifficulttobecertain”

3/6/17

6

ICD-10codesfor“Prediabetes”

• R73.0AbnormalGlucose• R73.01ImpairedFasSngGlucose• R73.02ImpairedGlucoseTolerance• R73.03Prediabetes• R73.09OtherAbn.GlucoseincludingA1c• R73.9HyperglycemiaUnspecified• E88.81MetabolicSyndrome/InsulinResistant• E66.Obesity

EvidenceBasedRisk-Reduction• 7%-10%weightloss

• 150minutesmoderateexerciseperweek

• IncreasedFiber,lowerSaturatedFat,IncreasedFruitandVegetablediet(MediterraneanDiet)

• Results40-70%relaSveriskreducSon

3/6/17

7

PharmacologicalIntervention

• Menormin(strongestevidencebasedbutlesscosteffecSvethanlifestyle,31-70%relaSveriskreducSon)

• AlphaGlucosidaseinhibitors

• PiogliSzone(72%riskreducSon-DeFranzo)

• Orlistat

Whatcanwedoinourcommunities?

3/6/17

8

PrediabetesPrimaryCareWorkRlow

PrediabetesRiskTest

3/6/17

9

PatientEducationPamphlet

PatientEducationPamphlet

3/6/17

10

PatientEducationHandout

PatientEducationHandout

3/6/17

11

CommunityResourceBooklet

AllMaterialsCanBeFoundForFreeAt:

www.cohealthcouncil/diabetes-clinical

3/6/17

12

InformationObtained

• AmericanDiabetesAssociaSon• NaSonalInsStuteofHealth• CentersforDisease• UptoDate• DiabetesCare