Diabetes Complications

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Managing Diabetes: It

Managing Diabetes: It’ ’s Not Easy But s Not Easy But It’ It ’s Worth It s Worth It

The National Diabetes Education Program

Changing the Way Diabetes is Treated

W. Lee Ball, Jr., OD, FAAO The National Diabetes Education Program

wwwYourDiabetesInfo.org · 1-888-693-NDEP

A joint program of NIH and CDC

Presenter Disclosures Presenter Disclosures

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(1) The following personal financial relationships with The following personal financial relationships with commercial interests relevant to this presentation commercial interests relevant to this presentation existed during the past 12 months:

existed during the past 12 months:

W. Lee Ball, Jr., OD, FAAO

No relationships to disclose

What is Diabetes?

Diabetes is a group of diseases resulting from Diabetes is a group of diseases resulting from problems with insulin production, insulin action, problems with insulin production, insulin action, or both

or both

Diabetes can lead to serious health problems and Diabetes can lead to serious health problems and premature death

premature death

About 24 million Americans have diabetes About 24 million Americans have diabetes

NIDDK, National Diabetes Statistics 2007.

www.diabetes.niddk.nih.gov/dm/pubs/statistics/

Common Types of Diabetes Common Types of Diabetes

Type 1 diabetes Type 1 diabetes

• • 5% to 10% of diagnosed cases of 5% to 10% of diagnosed cases of diabetes

diabetes Type 2 diabetes Type 2 diabetes

• • 90% to 95% diagnosed cases of diabetes 90% to 95% diagnosed cases of diabetes

Common Types of Diabetes Common Types of Diabetes

• • Gestational Diabetes occurs during Gestational Diabetes occurs during pregnancy

pregnancy

• • 5 to 10 % of women with gestational diabetes are found to 5 to 10 % of women with gestational diabetes are found to have type 2 diabetes

have type 2 diabetes

• • Increased lifelong risk for mother and child for developing Increased lifelong risk for mother and child for developing type 2 diabetes

type 2 diabetes

• • 40 40- -60 % women with gestational diabetes will develop 60 % women with gestational diabetes will develop diabetes in the next 5 to 10 years

diabetes in the next 5 to 10 years

Risk Factors for Diabetes Risk Factors for Diabetes

• • Age 45 and older Age 45 and older

• • Overweight (BMI Overweight (BMI ≥ ≥ 25) 25)

• • Hypertension Hypertension

• • Abnormal lipid levels Abnormal lipid levels

• • Family history of diabetes Family history of diabetes

• • Race/ethnicity Race/ethnicity

• • History of gestational diabetes History of gestational diabetes

American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.

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Risk Factors for Diabetes Risk Factors for Diabetes

• History of vascular disease

• Signs of insulin resistance – (such as PCOS or acanthosis

nigricans)

• IGT or IFG on previous test

• Inactive lifestyle

American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.

Diabetes and Cardiovascular Disease Diabetes and Cardiovascular Disease

• • Cardiovascular disease is the leading cause of Cardiovascular disease is the leading cause of death for people with diabetes

death for people with diabetes

• • In adults with diabetes: In adults with diabetes:

– – 68% die of heart disease or stroke 68% die of heart disease or stroke –

– the risk for stroke is two to four times higher the risk for stroke is two to four times higher – – 75% have high blood pressure 75% have high blood pressure

– – smoking doubles the risk for heart disease smoking doubles the risk for heart disease

Diabetes Complications Diabetes Complications

• •Diabetes is the leading cause of: Diabetes is the leading cause of:

–

– kidney failure kidney failure –

– new cases of adult blindness new cases of adult blindness –

– nontraumatic lower nontraumatic lower- -limb amputations limb amputations

• •In adults with diabetes: In adults with diabetes:

– – the risk of periodontal (gum) disease is two to three the risk of periodontal (gum) disease is two to three times higher

times higher –

– 60 to 70 % have mild to severe nervous system 60 to 70 % have mild to severe nervous system damage

damage

Diabetes Control and Complications Diabetes Control and Complications

Trial (DCCT) Trial (DCCT)

Compared effects of two diabetes treatment Compared effects of two diabetes treatment regimens

regimens – – standard therapy and intensive standard therapy and intensive control

control – – on the complications of diabetes on the complications of diabetes in people with type 1 diabetes

in people with type 1 diabetes

DCCT. New England Journal of Medicine, 329(14), September 30, 1993.

Glucose control is key to preventing or delaying complications of diabetes Any sustained lowering of blood glucose helps, even if the person has a history of poor control

DCCT Findings

DCCT Findings DCCT Findings

Lowering blood glucose reduced risk of:

• • Eye disease by 76% Eye disease by 76%

• • Kidney disease by 50% Kidney disease by 50%

• • Nerve disease by 60% Nerve disease by 60%

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United Kingdom Prospective Diabetes United Kingdom Prospective Diabetes

Study (UKPDS) Study (UKPDS)

20 Year Clinical Trial 20 Year Clinical Trial

Looked at intensive management of blood Looked at intensive management of blood glucose levels and long term risk

glucose levels and long term risk- -factors for factors for diabetes complications in type 2 diabetes diabetes complications in type 2 diabetes

UKPDS. BMJ. 2000; 321:405-412.

Mirrored the findings of DCCT in people with type 2 diabetes—better glucose control reduced development of microvascular complications Demonstrated the need for management of high blood pressure and cholesterol as well as blood glucose levels (the ABCs of diabetes)

UKPDS Findings

UKPDS. BMJ. 2000; 321:405-412.

UKPDS Findings UKPDS Findings

Stratton IM, et al. BMJ. 2000;321:405-412.

P <.0001 P = .035 P = .021 P = .0001

Risk reduction with 1% decline in annual mean A1C

Micro- vascular Disease

37%

PVD

43%

Stroke MI

14% 12%

Heart Failure Cataract

Extraction

16% 19%

0%

15%

30%

45%

Epidemiology of Diabetes Interventions and Epidemiology of Diabetes Interventions and

Complications Study (EDIC) Complications Study (EDIC) Ongoing Observational study Ongoing Observational study DCCT participants (type 1 diabetes) DCCT participants (type 1 diabetes) Looked at risk factors for long

Looked at risk factors for long- -term incidence term incidence of cardiovascular disease

of cardiovascular disease

DCCT/EDIC N Engl J Med 2005: 353:2643-2653.

Participants continue to benefit years later from period of intense glucose control

Years after intensive therapy:

• Lasting benefits for eye, nerve, and kidney disease

• Reduces CVD events by more than half

EDIC Findings: Intensive Therapy and Diabetes Complications

Cumulative IncidenceCumulative Incidence

Years from Study Entry

Years from Study Entry

EDIC Findings: Cardiovascular Events

Cumulative Incidence of Any Event Cumulative Incidence of Any Event

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Risk reduction 42%

95% CI: 9% to 63%

P = 0.02 P = 0.02

0.120.12 0.10 0.10

0.080.08

0.06 0.06

0.04 0.04

0.02 0.02

0.00 0.00

Conventional Conventional

Intensive Intensive

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UKPDS 10 yr Follow

UKPDS 10 yr Follow- -Up Study Up Study- - insulin/sulfonylurea group insulin/sulfonylurea group

Differences in A1C between intensive & standard

Differences in A1C between intensive & standard glycemic glycemic control control treatment groups were lost after one year

treatment groups were lost after one year

Relative risk reductions at 10 yr in intensive insulin/sulfonylu Relative risk reductions at 10 yr in intensive insulin/sulfonylurea rea

group:

• • 9% for any diabetes end point (P=0.04) 9% for any diabetes end point (P=0.04)

• • 24% microvascular 24% microvascular disease (P=0.001) disease (P=0.001)

• • 15% myocardial infarction (P=0.01) 15% myocardial infarction (P=0.01)

• • 13% death from any cause (P=0.007) 13% death from any cause (P=0.007)

N Engl J Med 2008; 359

UKPDS 10 yr Follow

UKPDS 10 yr Follow- -Up Study Up Study- - metformin

metformin group group

Differences in A1C between intensive & standard Differences in A1C between intensive & standard

glycemic

glycemic control treatment groups were lost after one control treatment groups were lost after one year year

Relative risk reductions at 10 yr in intensive Relative risk reductions at 10 yr in intensive

metformin metformin group: group:

• • 21% for any diabetes end point (P=0.01) 21% for any diabetes end point (P=0.01)

• • 33% myocardial infarction (P=0.005) 33% myocardial infarction (P=0.005)

• • 21% death from any cause (P=0.002) 21% death from any cause (P=0.002)

UKPDS 10 yr Follow

UKPDS 10 yr Follow- -Up Study Up Study- - Blood Blood Pressure findings

Pressure findings

Between group differences lost within 2 yrs Between group differences lost within 2 yrs Significant relative risk reductions in tight control Significant relative risk reductions in tight control

group were

group were not not maintained maintained

Benefits of BP control do not extend beyond Benefits of BP control do not extend beyond

intensive therapy period & ongoing intensive therapy period & ongoing treatment is essential

treatment is essential

Recent Clinical Trial Findings:

Intensive glucose control in type 2 diabetes:

• • lowers risk of new or worsening microvascular lowers risk of new or worsening microvascular complications (ADVANCE)

complications (ADVANCE)

• • was associated with increased mortality in patients was associated with increased mortality in patients with longstanding DM and known CVD

with longstanding DM and known CVD (ACCORD)

(ACCORD)

• • increases risk of severe hypoglycemia (ADVANCE, increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT)

ACCORD and VADT)

ACCORD: N Engl J Med 2008; 358(24):2545-59 ADVANCE: N Engl J Med 2008; 358 (24): 2560-72 VADT: J Diabetes Complications 2003; 17 (6): 314-22

Key points of recent findings:

• • Intensive glucose control in newly diagnosed type 1 or Intensive glucose control in newly diagnosed type 1 or type 2 diabetes has benefits during intensive therapy type 2 diabetes has benefits during intensive therapy AND a legacy effect for later micro

AND a legacy effect for later micro- - and and macrovascular macrovascular benefits

benefits

• • Optimal glucose management should start as early as Optimal glucose management should start as early as possible & continue as long as possible

possible & continue as long as possible

• • While the A1C goal for the general population is <7%, While the A1C goal for the general population is <7%, treatment must be individualized.

treatment must be individualized.

SEARCH SEARCH

For Diabetes in Youth Study For Diabetes in Youth Study

Observational study funded by CDC and NIH Observational study funded by CDC and NIH Physician

Physician- -diagnosed diabetes in youth ages 0 diagnosed diabetes in youth ages 0- -19 19 Data will help researchers better understand and treat Data will help researchers better understand and treat diabetes in young people

diabetes in young people

(SEARCH). Diabetes Care 2006 29(8): 1891-6.

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SEARCH Findings SEARCH Findings

Determine prevalence and correlates of selected CVD risk Determine prevalence and correlates of selected CVD risk factors among youth with diabetes

factors among youth with diabetes

21% of young people with diabetes had at least two CVD 21% of young people with diabetes had at least two CVD risk factors

risk factors

Prevalence of CVD risk factors was higher among youth Prevalence of CVD risk factors was higher among youth aged 10

aged 10- -19 years and among girls 19 years and among girls

SEARCH Findings SEARCH Findings

In young people with type 2 diabetes:

• • 92% had at least two CVD risk factors 92% had at least two CVD risk factors In young people with type 1 diabetes:

In young people with type 1 diabetes:

• • 14% had at least two CVD risk factors 14% had at least two CVD risk factors

National Diabetes Education Program

National Diabetes Education Program Materials Materials Diabetes Control: Patient Materials Diabetes Control: Patient Materials

Diabetes Control:

Health Care Professionals

Health Care Professionals NDEP Websites NDEP Websites

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The U.S. Department of Health and Human Services’ National Diabetes Education Program is jointly sponsored by the National

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The National Diabetes Education Program

wwwYourDiabetesInfo.org · 1-888-693-NDEP

A joint program of NIH and CDC

Thank You!

W. Lee Ball, Jr., OD, FAAO

[email protected]