Objective Review the benefits of Intensive Diabetes Management over the use of Conventional Therapy Key Points • The ADA has high standards for glucose control • Clinical benefits of Intensive Diabetes Management over Conventional Therapy are: • Reduction in A1C • Reduction in microvascular & macrovascular complications • Benefits of Intensive Diabetes Management in Type 2 patients • Concerns about Intensive Management without insulin pumps
Intensive Diabetes Management Requires a Treat-to-Target Approach Blood Glucose Targets Recommended By: ADA AACE AAFP A1C (%) <7 ≤6.5 — Fasting/preprandial glucose (mg/dL) 90-130 <110 80-120 Postprandial glucose (mg/dL) <180 <140* <180 Bedtime glucose (mg/dL) — 100-140 100-140 3 AM glucose (mg/dL) — — 70-110 *2 hours after the start of eating. American Association of Clinical Endocrinologists (AACE). Endocr Pract. 2007;13(suppl 1):3-68. American Academy of Family Physicians (AAFP). Self-monitoring of blood glucose (SMBG) monograph. Available at: http://www.aafp.org/PreBuilt/smbgmonograph_pated-eng.pdf. American Diabetes Association (ADA). Diabetes Care. 2008;31(suppl 1):S5-S11.
Diabetes Control and Complications Trial (DCCT): Intensive Treatment Reduced the Risks of Microvascular Complications in Patients with Type 1 Diabetes by 35%-90% Intensively treated patients achieved a mean A1C of 7.3%, compared with 9.1% for conventionally treated patients Writing Team for Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA. 2002;287(19):2563-2569. Figure adapted from DCCT Research Group. N Engl J Med. 1993;329:977-986. Reused with permission.
DCCT Results: A1C and Relative Risk of Diabetic Complications Average US A1C range: 7.8% - 8.6% Skyler, J. Endo Met Cl N Am, 1996; 25:.243- 254 Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986. Endocrine Practice 2002, 8 (supp 1), pg. 7. AACE recommends less than or equal to 6.5 HbA1c. Minshall M, Roze S, Palmer A, et al. Clin Ther. 2005;27:940–950.
Epidemiology of Diabetes Interventions and Complications (EDIC) Study: Benefits of Intensive Treatment Were Still Significant, 4 Years After Completion of DCCT Writing Team for Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA. 2002;287(19):2563-2569. Figure adapted from DCCT Research Group. N Engl J Med. 1993;329:977-986.
Intensive Treatment Was Associated with Decreased Risk for Cardiovascular Events in EDIC After a mean follow-up of 17 years, intensive insulin therapy was associated with a 42% reduction in cardiovascular events compared to conventional treatment (P = 0.02) Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med. 2005;353:2643-2653.
Intensive Treatment Was Associated with Decreased Risk for Diabetes-Related Complications in Type 2 Patients In 3,867 patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS), intensive control of blood glucose was associated with a decreased risk for complications Intensive management achieved significantly lower median A1C levels compared to conventional treatment* *Median follow-up in the UKPDS study was 10 years UKPDS Group. Lancet. 1998;352:837-853.
Epidemiologic Analysis of UKPDS Data Each 1% reduction in A1C was associated with a significant reduction in the risk of macrovascular and microvascular complications. Stratton IM, Adler AI, Neil HA, et al. BMJ. 2000;321:405-412.
Insulin Therapy Does Not Seem to Cause Obesity in Patients with Type 2 Diabetes • Patients treated with insulin less weight gain • Compared with no therapy and oral agents Adapted from Looker et al; Diabetes Care 2001; 24(11): 1917-1922
Breaking Glucose Toxicity with Type 2 Diabetes: Case Study of 55 Year Old Woman • Frequent administration of analog insulin (every 2 hours for 11 days) • Notable reduction in glucose toxicity & insulin requirements Raine, CH et,al. J Natl Med Assoc 1999;91:410-413
Improving Insulin Sensitivity with Type 2 Diabetes: Case Study of 55 Year Old Woman • Frequent administration of analog insulin (every 2 hours for 11 days) • Notable improvement in severe insulin resistance Raine, CH et,al. J Natl Med Assoc 1999;91:410-413
Concern About Hypoglycemia is a Key Barrier to Intensive Management Rate of Severe Hypoglycaemia in DCCT (per 100 patient-years) Intensive group Conventional group P value 61.2 18.2 <0.001 Severe hypoglycaemia* 16.3 5.4 <0.001 Coma or seizure *Defined as episodes in which patient required assistance and had documented blood glucose <50 mg/dL. Despite the risk of hypoglycaemia, intensive management is recommended for most patients with diabetes given the proven benefits: reduction of long-term complications of diabetes DCCT Research Group. Diabetes Care. 1995;18:1415-1427.
Intensive Management: CSII is Superior to MDI • More effective in reducing A1C • Significantly reduces hypoglycaemia • Improves quality of life Bruttomesso D, et al. Diabet Med. 2002;19(8):628-634. Bell DSH, et al. Endocr Pract. 2000;6(5):357-360. Rudolph DS, et al. Endocr Pract. 2002;8(6):401-405. Chantelau E, et al. Diabetologia. 1989;32(7):421-426. Boland EA, et al. Diabetes Care. 1999;22(11):1779-1784. Maniatis AK, et al. Pediatrics. 2001;107(2):351-356. Litton J, et al. J Pediatr. 2002;141(4):490-495. Rudolph JW, Hirsch IB. Endocrine Practice. 2002; 8:401 – 405. Bode,BW, Steed RD, Davidson PC. Diabetes Care. 1996;19:324-7; Boland EA, Grey M, Oesterle A, et al. Diabetes Care. 1999; 22:1779 – 84; Peyrot M, Rubin R. Diabetes Care. 2005;28:53–58. Raskin P, Bode BW, Marks JB, et al. Diabetes Care. 2003; 26: 2598-2603.