Diabetes Update

Facts, Trends and Observations

Bruce Bode, MD, FACE

Atlanta Diabetes Associates
 Ultimate Goals Of Diabetes
Treatment

Sustained Normal Blood No Long Term Diabetes

Glucose Control = Complications

No Acute Diabetes
Lowest Incidence of Complications
Hypoglycemia =

Best Quality of Life with a

Chronic Disease
Relative Risk of Progression of
Diabetic Complications

15

13
11 Retinop

9
Neph
7
RELATIVE

5 Neurop

3
RISK

1
6 7 8 9 10 11 12

Mean A1C
DCCT Research Group, N Engl J Med 1993,
329:977-986.
Lifetime Benefits of
Intensive Therapy (DCCT)

• Gain of 15.3 years of complication free

living compared to conventional
therapy
• Gain of 5.1 years of life compared to
conventional therapy

DCCT Study Group, JAMA 1996, 276:1409-1415.

DCCT
• 10% reduction in HbA1c

• 43% reduced risk of retinopathy

progression
• 18% increased risk of severe
hypoglycemia with coma and/or
seizure

DCCT Research Group, N Engl J Med 1993,

329:977-986.
 Lowering A1C Reduces Risk
of Complications
United Kingdom Prospective Diabetes Study
(UKPDS)
Reduction in risk (%)*

0 Any diabetes-related
endpoint
-12
-10 -16 Microvascular
p=0.029
endpoint
p=0.052 -21
-20 -25
p=0.015 MI
p=0.0099
-34 Retinopathy
-30
p=0.000054

-40 Albuminuria at 12
years

-50

*Percent risk reduction per 0.9% decrease in HbA1C ; UKPDS. Lancet. 1998;352:837-853.
 New Targets of
Intensive Diabetes Management
Near-normal glycemia
• A1C less than 6.5%
• Post-prandial: <140 mg/dl
Avoid short-term crisis
• Hypoglycemia
• Hyperglycemia
• DKA
Minimize long-term complications
Improve QOL
ADA: Clinical Practice Recommendations, 2001.
AACE and EASD
DCCT Research Group, N Engl J Med 1993, 329:977-986.
How Are We Doing?
U.S. Diabetes Prevalence
— Diabetes kills 1 American
every 3 minutes

18 Million — New case diagnosed every

40 seconds
— More deaths than AIDS
and breast cancer
combined
— Average life expectancy:
15 years less than non-
diabetes population
— Afflicts over 177 million
people worldwide
— 300 million afflicted by
2025
 World View
• 177 million worldwide
• 4th leading cause of death by disease
• India 33 million people with diabetes
• China 23 million people with diabetes
• Population of diabetes will double to triple by
2025
• One out of every three Americans born today
will develop diabetes

Time magazine December

2003; CDC
Costs Continue to Increase (U.S.)
$240
$192
$200
$156
$160 $138
$132
$109 2002
$120
$92 2010
$80 2020
$54
$47
$40
$40

$0
Direct Indirect Total

Diabetes Care 26:917-932, 2003

 Percentage of Patients With Diabetes
Having A1C <7%
US Adults With Diagnosed Diabetes in 1988-94
NHANES III
Percent 100
at goal
80 73

60
45
38
40
26
20

0
Diet alone Oral agents Insulin Whole
Therapy used population

Harris MI, et al. Diabetes Care. 1999;22:403-408.

Lessons from the DCCT and UKPDS:
Sustained Intensification of Therapy is Difficult

DCCT EDIC UKPDS (Type 2),

(Type 1) Insulin Group
10
8
9.0

8.1
8 7.9
7.3 A1C (%)
A1C (%)
7
Baseline
6

6 Normal

4 0
0 6.5 +4 + 6 yrs 0 2 4 6 8 10 yrs

DCCT EDIC

DCCT/EDIC Research Group. New Engl J Med 2000; 342:381-389

Steffes M et al. Diabetes 2001; 50 (suppl 2):A63
UK Prospective Diabetes Study Group (UKPDS) 33
Lancet 1998; 352:837-853
 Relationship between % BG in
Target and A1C Level

33% 41% 45%

49%
18% 14%

A1C = 7% A1C = 8%

46% 42%
Within Target 12%
Above Target
Below Target

A1C = 8.5%
Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21:2.
 Primary Objectives of Effective
Management
lGæde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O.
A1C Diagnosis Multifactorial intervention and cardiovascular disease in patients with
% 9 type 2 diabetes. N Engl J Med. 2003;348:383-393.

8
7
Reduction
SBP
of both
mm Hg
micro- and
145 macro-
130 vascular
LDL event
mg/dL rates
…by 75%!
140
100
45 50 55 60 65 70 75 80 85 90
Patient Age
How is diabetes currently
being treated?
 Roper Starch Worldwide

• “Gold Standard” market research study of

diabetes patients 18 years and older

• Self reported information

• Conducted annually in the U.S.

• N= 6,000
Roper Starch Worldwide, 2002
PROGRESSION TO INSULIN USE (US)
Among Type 2 diabetic patients sampled

T o t a l T y p e 2 p a t i e n t s

E x c l u s i v e D I nu s a ul lI in n s u lE i n x / c P l ui l ls i v e P i l l s
1 5 % 1 3 % 6 3 %

Prior Therapy Prior Therapy Prior Therapy

43% no prior therapy 51% exclusive pills 66% no prior therapy
41% exclusive pills 14% insulin 18% diet/no med
5% diet to pills 13% pills to insulin 8% insulin

Average time on pills Average time on pills Average time on diet

before moving to before moving to before moving to
insulin insulin pills

= 4.9 years = 5.6 years = 3.2 years

Roper Starch Worldwide, 2002

 Trends Among Insulin Injectors

Conventional Pump
Therapy

15%
54% Intensive
31% Therapy
46%
Multiple Daily
%
2001 Injections
Pump
Conventional Therapy

20%
Intensi
43% ve
37%
Therap
y
57%
Multiple Daily
2002 Injections

Roper Starch Worldwide, 2002

ADA Physician Reported Treatment Choices
Based on aggregate responses (N=213)

Insulin Treated
Patients

23% Conventional (1-2

shots/day)
57% Intensive(3 or more
shots/day) ADA 2003, Physician Survey, Medtronic
20% Insulin Pump Therapy MiniMed
Total Patients Using Insulin Pumps
200,000

200,000 Estimated figures for 2003

162,000

150,000

100,000 81,000

43,000
50,000 26,500

0
'95 '97 '99 2001 2003
Other Possible Contributions to
Intensive Management

PATIENT ATTITUDES AND

BEHAVIORS
 DEMOGRAPHICS (US)
By education and income

EDUCATION
%
High School or College
less

INCOME LEVEL
< $35K - >
$35K $75K $100K
%

Roper Starch Worldwide, 2002

 HCPs Frequently Visited By Patients
“What type of healthcare professional do you normally
visit for your diabetes care?”
% %

TYPE 1 TYPE 2

Roper Starch Worldwide, 2002

Most Feel That They Are In Good Control

“Are you satisfied with your diabetes control?”

Needs
improvement
Good control
% incidence
within total
sample

19 81

US

Roper Starch Worldwide, 2002

Most Patients Are Satisfied With Their Health

Satisfied with overall health T1 T2

100
86
80 71
72

60

40

20

0
US

Roper Starch Worldwide, 2002

Self-Reported A1C Results

50%
45%
40%
35%
30%
25% T1
20% T2
15%
10%
5%
0%
4.1-5.0 5.1-6.0 6.1-7.0 7.1-8.0 8.1-9.0 9.1-10.0 10.1- Over Don't
11.0 11.0 Know

Roper Starch Worldwide, 2002

 Summary
Diabetes prevalence and costs continue to
grow
Lower treatment targets will likely drive the
adoption of more intensive management
The use of intensive insulin management
continues to grow with a notable increase in
insulin pump use
A potential barrier to intensive
management is patient’s lack of awareness
and perception of good control