550% of type 2 diabetes patients have complications at the time of diagnosis MICROVASCULARMACROVASCULARRetinopathy, glaucoma or cataractsCerebrovascular diseaseCoronary heart diseaseNephropathyIn the UKPDS, 50% of patients had a diabetes-related complication at diagnosis.1Neuropathy affects around 70% of those with diabetes at the time of diagnosis, leading to 55,000–60,000 amputations in the US each year.2Retinopathy, glaucoma or cataracts occur in around 10% of people after 15 years of diabetes. Blindness affects around 2%.2Nephropathy is the leading cause of end-stage renal disease.2Coronary heart disease (CHD) affects 7.5–20% of all people with diabetes over 45 years of age in the US. The risk of CHD is two to four times higher than for those without diabetes.2Cerebrovascular disease: the risk of stroke is two to four times higher in people with diabetes. Fifteen percent of people with type 2 diabetes die from stroke.2The risk of peripheral vascular disease is four to eight times higher in people with type 2 diabetes.21. UKPDS Group. UKPDS 33. Lancet 1998; 352:837–853.2. World Health Organization/International Diabetes Federation. The economics of diabetes and diabetes care: a report of the Diabetes Health Economics Study Group (WHO).Peripheral vascular diseaseNeuropathyUKPDS Group. UKPDS 33. Lancet 1998; 352:837–853.
7Atherosclerosis in Diabetes ~80% of all diabetic mortality75% from coronary atherosclerosis25% from cerebral or peripheral vascular disease>75% of all hospitalizations for diabetic complicationsNational Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995.
11Dyslipidemia/lipid management Statin therapy should be added to lifestyletherapy, regardless of baseline lipid levels, for diabetic patients:with overt CVD (A)without CVD who are over the age of 40 and have one or more other CVD risk factors. (A)American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54.
12Dyslipidemia/lipid management For lower-risk patients than those specified above (e.g., without overt CVD and under the age of 40).Statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains 100 mg/dl or in those with multiple CVD risk factors (E).American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54.
13Dyslipidemia/lipid management In individuals without overt CVD, the primary goal is an LDL cholesterol 100 mg/dl . (A)In individuals with overt CVD, a lower LDL cholesterol goal of 70 mg/dl. (E)If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 40% from baseline is an alternative therapeutic goal. (A)American Diabetes Association. Diabetes Care 2008; 31 (Suppl. 1):S12–S54.
14Percentage of Thai diabetic patients who may need lipid lowering agents NCEP III targetNew 2005 ADA lipid targetAllAge >40No need for lipid lowering agents132.71.4Need for lipid lowering agents8797.398.6
19Tier 1:Glucose lowering intervensions HbA1cAdvantageDisadvSulphonylurea1-2%Rapidly effectiveWeight gain, HypoglycemiaMetforminWeight neutralGI side effect, C/I in renal failureInsulin%No dose limit, rapidly effect, improve lipidLifestyleBroad benefitsInsufficiency within 1st yr
20Tier 2:Glucose lowering intervensions HbA1cAdvantageDisadvTZDs%PIO:Improve lipid profile, decrease MIFlueid retension, CHF, Fracture, weight gain, potential increase MI (Rosi)GLP 10.5-2%Weight lossTwo injection a day, GI side effect, long term safety not established
21Other interventions Disadv HbA1c Advan Glinide 0.5-1.5% Rapidly effectiveWeight gain, Hypoglycemia, 3-times a dayAcrabose%Weight neutralGI side effect, 3-times a dayDDP IV inhibitorlong term safety not established
23Tier 2: Less well-validated therapies Life style intervention + MetforminAdd Pioglitazone or GLP-1Met+SU+Pio or Met+Basal insulinIntensive insulin treatment+metformin
24Recent diabetic trials 1. UKPDS 10 yrs Follow upGlycemic control and macrovascular complication2. ADVANCETight glycemic control (HbA1c<6.5) reduce complicationsMicrovascularMacrovascular3.ACCORDTight glycemic control (HbA1c<6.0) reduce complications1. N Engl J Med 2008;359:1-132. N Engl J Med 2008;358:3.N Engl J Med 2008;358:
25Summerize the studies on glycemic control and complications UKPDS1ADVANCE2ACCORD3OnsetNewly810Prior CVD3235TargetFPG(mg/%)108vs270HbA1c(%)6.5 vs 7-86.0 vs 7-8F/U(yr)53.51. N Engl J Med 2008;359:1-132. N Engl J Med 2008;358:3.N Engl J Med 2008;358:
26Summerize the studies on glycemic control and complications UKPDS1ADVANCE2ACCORD3HbA1c (%)6.4 vs 7.06.5 vs 7.5MicrovasBetterSameCVDWorstSudden death1. N Engl J Med 2008;359:1-132. N Engl J Med 2008;358:3.N Engl J Med 2008;358:
27Glycemic control and complications 1. UKPDS 10 yrs Follow upMicrovascular(~6yrs) YesMacrovascular Yes2. ADVANCE (HbA1c<6.5) F/U 5 yearMicrovascular YesMacrovascular No3.ACCORD (HbA1c<6.0) F/U 3.4 yrsMacrovascular No(worst)1. N Engl J Med 2008;359:1-132. N Engl J Med 2008;358:3.N Engl J Med 2008;358:
28A1C Goals For Clinical Practice 10.09.5DISCUSSION POINTS:Although there is evidence that we have better tools to more aggressively treat diabetes, recent population data show that A1C levels are often in excess of 8 or 9%. This is far above the current AACE target goal A1C (less than 6.5) and the ADA target goal A1C (less than 7%)…Click 1: Percent of patients >8% arrow appearsRecent publications based on data collected in the late 1990s through 2000 found approximately 40 to over 50% of patients with diabetes have an A1C >8%.Click 2: Percent of patients >9.5% arrow appearsApproximately 20 to over 40% of patients fall well within the “red” range where patients show very poor glycemic control (A1C 9.5%).Click 3: Insulin user arrow appearsEven patients with type 2 diabetes who commit to insulin therapy fail to reach glycemic goals much of the time. Approximately 30% of patients using insulin in a recent survey of patients with type 2 diabetes had an A1C less than 8%.SLIDE BACKGROUND:NHANES/BRFSS data from two US population-based cross-sectional surveys:NHANES III: National Health and Nutrition Examination Survey, (total people NHANES III surveyed = 16,705)N=1026 from NHANES III participants with self-reported diagnosis of diabetesBRFSS: Behavioral Risk Factors Surveillance System, 1995 (total people BRFSS surveyed = 103,929)N=3059 from BRFSS participants with self-reported diagnosis of diabetesSubjects were aged 18-75, with a self-reported diabetes diagnosis, median A1C=7.5%Data from these two surveys were analyzed separatelyRef: Saaddine_21417AnnInternMed2002_p565,568Harmel et al study was noncomparative, multicenter, epidemiologic survey of type 2 patients from 9 community care clinics in western US ( )Subjects (N=602) were aged years, using oral antidiabetic medications or insulin or both, mean A1C = 8.2%Ref: Harmel_21416EndocrPract2002_p185,187,1899.0~70% have A1C > 7 %Thailand Diabetic Registry.A1C (%)8.58.07.57.0ADA Target< 7?6.5ADVANCE TargetADA 2006: “The HbA1c goal for the individual patient is an HbA1c as close to normal (<6%) as possible without significant hypoglycemia”< 6.56.0XACCORD Target?5.5
39Lipid treatment (LDL target) Without CVDAge<40 LDL <100 mg/dlAge>40Cholesterol ≥135: Start StatinAim 30-40% reduction and LDL<100
40Lipid treatment (LDL target) With CVDCholesterol ≥135: Start StatinAim 30-40% reduction and LDL<70
41Percentage of Thai diabetic patients who may need lipid lowering agents NCEP III targetNew 2005 ADA lipid targetAllAge >40No need for lipid lowering agents132.71.4Need for lipid lowering agents8797.398.6