The InnovatorsDiabetes: How Sweet It Isn’t!R. Keith Campbell, RPh, CDEFosberg Distinguished Professor of Pharmacy Department of PharmacotherapyCollege of Pharmacy
Diabetes Facts:Scary but True…
• Over 6.8% of U.S. Population has diabetes• 20.8 million people with diabetes in the U.S.• 1 of every 3 babies born today will develop
diabetes in his/her lifetime• 1 in every 5 dollars spent on health care
is for diabetes: $134 billion/year
Diabetes Facts:Scary but True…
• Fastest growing segments of the populationare people 30-39 years old and adolescentsdeveloping type 2 diabetes
• Diabetes in Washington State affects 1.3 million patients/family; kills 4000/year; is a factorin 67,000 hospitalizations & accountsfor > $1 Billion just in hospitalizations
• Number of diabetes patients will doublein the world within 10 years
Status of Diabetes Management• Majority of patients with type 2 diabetes have
only fair to poor metabolic control§ Fasting serum glucose levels of ≥ 200 mg/dL § HbA1c levels of > 9%
• Postprandial blood glucose levels average~300 mg/dL
• < 2% of American adults with diabetesreceive optimal quality of care
Beckles GLA et al. Diabetes Care. 1998;21:1432-1438.American Diabetes Association. Diabetes Care. 1998;21(Suppl 1).Colwell JA. Ann Intern Med. 1996;124(1pt2):131-135.Abraira C et al. Diabetes Care. 1992;15:1560-1571.Klein R et al. Am J Epidemiol. 1987;126:415-428.Cowie CC et al. Diabetes in America. 2nd ed.
Diabetes Healthcare System ProblemsManaged Care Places Barriers to Optimal Care
• Greater than 90% of patients are seenonly by primary care physicians
• 70% of patients receive no diabetes education
• 70% of patients do not receive annualeye exams
• Less than half of all patients performSMBG appropriately
Harris MI et al. Ann Intern Med 1996 Jan 1;124(1 Pt 2):117-22
ADA Standards of Care• Physician Visits 2-4 per year• HbA1c Measurement 2-4 per year• Fasting Glucose Measurement / (SMBG) 4-6 per year/daily• Foot Exams Every Visit• Aspirin Daily• Urine Protein Measurements Yearly• Blood Pressure As needed to achieve goals
• Lipid Levels As needed to achieve goals• Dilated Pupil Eye Exam Yearly• Flu and Pneumovax As needed
Prevalence of GlucoseIntolerance in the United States
0
5
10
15
20
25
30
35
40
45
50
0 20-44 45-54 55-64 65-74
Age
% o
f Pop
ulat
ion
Diabetes
Undiagnosed diabetes
Impaired glucose tolerance
Kenny SJ et al. In: Diabetes in America. 2nd ed. 1995;chap 4.
Patients with diabetes are impacted by many groups and health care providers including:
Physicians
Nurses
RD’s
Pharmacists
Eye docs
Podiatrists
Physician Assistants
Dermatologists
The Amer. Diabetes Assoc.
Managed care organizations
Government & private health care programs
AADE
Center For Disease Control
The NIH
State diabetes control projects
Pharmaceutical manufacturers
Universities’ research and education programs
Local hospital patient support groups
Other diabetes patients
Insulin Resistance
• A core defect in type 2 diabetes- 92% of patients with type 2 diabeteshave insulin resistance
• Definition: Impaired response to thephysiological effects of insulin
• Deterioration of the beta cell over time
Haffner SM et al. Diabetes Care 1999;22:562-568.Consensus Development Conference of the American
Diabetes Association. Diabetes Care 1998;21:310-314.
The Metabolic Syndromeof Insulin Resistance
EndothelialDysfunction Systemic
InflammationComplex
DyslipidemiaInc TG, sdLDL
Dec HDL
InsulinResistance
Type 2Diabetes
AtherosclerosisDisorderedFibrinolysis
Hypertension VisceralObesity
Adapted from the Consensus Development Conference of theAmerican Diabetes Association. Diabetes Care 1998;21:310-314.
Pradhan AD et al. JAMA 2001;286:327-334.
© International Diabetes Center. From Kendall D, Bergenstal R.
Timeline forUtilization of Therapies
Glucose
Relative Function
050
100150200250
-10 -5 0 5 10 15 20 25 30
50100150200250300350
Years of Diabetes
Insulin Resistance
Insulin Level
Fasting Glucose
Beta cell failure
Post Meal Glucose
At riskfor Diabetes
Lifestyle InsulinMetformin, TZD, AGI, Incretins
SUMeglitinide
Priorities of Care for Adults with Diabetes
© 2005 International Diabetes Center. All rights reserved.
Hemoglobin A1C Target < 7.0%
SMBGPre 70-140 mg/dLPost <160 mg/dL
(~ 50% of readings)Combination RxInsulin therapy
Insulin sensitizers
Annual Lipid ProfileLDL < 100HDL > 40
Trigs < 150
Statin FibrateNiacin TZD Ezetimibe
Combination Rx
Blood Pressure(every visit)
Dx and Rx = 130/80
ACEI or Thiazidebased-Rx
Combo therapy
Annual ScreeningNephropathy
Microalbumin screening
RetinopathyDilated retinal exam
NeuropathyNeuro and foot exam
Sexual heath
Hospital care Gestational DM
Foot careDental care
Immunizations
CVD RiskASA, Tobacco, ACEI/ARB, Statin
Diagnosis and PreventionPrediabetes (IFG -IGT) - Metabolic Syndrome
HypertensionGlucoseInsulin resistance
Microvascular Complications
Other Essentialsof CareLipids
Diabetes Self-Management SkillsLifestyle• Patient education• BG monitoring• Medical nutrition• Physical activity
Behavioral Health• Emotional assessmentdistress, depression, complications
• Support needsfamily, peers, medical
Diabetes = Cardiovascular Disease
• Up to 70 % of diabetes patients diefrom heart disease or stroke
• Diabetes is a cardiovascular risk factor• Diabetes treatment must include treatment
of blood pressure, blood fats, blood sugarand coagulation factors
Treating the Metabolic Syndrome
• Stop smoking• Eat less• Exercise more• Take magnesium• Take aspirin• Take an ace inhibitor or an arb• Take a statin• Take pioglitazone, metformin
to reduce insulin resistance
Matching Pharmacologyto Pathophysiology
↑HepaticGlucose Output
↓PeripheralGlucose Uptake
Glucose Influx
↓InsulinSecretionHyperglycemia
Biguanides(TZD)
Insulin TZD(Biguanides)
Insulin
SulfonylureasMeglitinides
Insulin
AGIIncretins
www.PDC-USA.com
PDC Technosphere™/Insulin
• Fastest onset of anyinsulin-mimics firstphase insulin release
• Highest bioavailability(40-50%)
• Initial studies suggestless variable absorption
Generex: Buccal Insulin Delivery
• Oral-Lyn: Absorbed directlyvia the oral mucosa
• Aminopeptidase inhibitorsmay need to be added
FDA Approved CGM Devices
Device GlucoWatch CGMs Gold Guardian 1
Invasive? No? Yes Yes
Real-time/Retrospective? Real-time Retrospective Real-time
Frequency of Data?Every 10 minutes
up to 13 hoursEvery 5 minutes up
to 72 hours Alarm only
Alarm?• Low, high
• Pending lowNo Low, high
Investigational Devices
Device Navigator DesCom Guardian RealTime
Invasive? Yes Yes Yes
Real-time/Retrospective? Real-time Real-time Real-time
Frequency of Data? Every minute Every 5minutes
Every 5minutes
Alarm?Low, high
Pending low/highLow, high
Pending low/highLow, high
FreeStyle Navigator™ Continuous Glucose Monitor
TransmitterSensor/Sensor Mount
Receiver
Investigational Device
Experimental but Promising New Medications to Treat Diabetes
• Ruboxistaurin (Arxxant) preventseye and kidney disease
• Rimonabant (Acomplia) inhibits theeffects of cannabis and results in weightloss, smoking cessation and improvedinsulin resistance
• Adiponectin type products
Diabetes and WSU• The Diabetes Initiative• Educational programs from Pharmacy,
Nursing, Extension, FSHN and others• Clinical research from Pharmacy, Nursing,
FSHN, Health Care Policy Administrationand other departments
• Basic science research from Biochemistry,Veterinary Medicine, Pharmacy
Conclusions
Questions and comments
Thank you so much for your timeand attention; it is much appreciated.
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