Diabetes Update Facts Trends and Observations Bruce Bode

Diabetes Update Facts, Trends and Observations Bruce Bode, MD, FACE Atlanta Diabetes Associates

Ultimate Goals Of Diabetes Treatment Sustained Normal Blood Glucose Control Lowest Incidence of Hypoglycemia = No Long Term Diabetes Complications = No Acute Diabetes Complications Best Quality of Life with a Chronic Disease

RELATIVE RISK Relative Risk of Progression of Diabetic Complications Mean A 1 C DCCT Research Group, N Engl J Med 1993, 329: 977986.

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 Hb. A 1 c • 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: 977986.

Lowering A 1 C Reduces Risk of Complications Reduction in risk (%)* United Kingdom Prospective Diabetes Study (UKPDS) Any diabetes-related endpoint 0 -10 -20 -12 p=0. 052 -21 -25 p=0. 0099 -30 Microvascular endpoint -16 p=0. 029 MI p=0. 015 -34 Retinopathy p=0. 000054 -40 Albuminuria at 12 years -50 *Percent risk reduction per 0. 9% decrease in Hb. A 1 C; UKPDS. Lancet. 1998; 352: 837 -853.

New Targets of Intensive Diabetes Management Near-normal glycemia • A 1 C 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 nondiabetes population — Afflicts over 177 million people worldwide — 300 million afflicted by 2025

World View • • • 177 million worldwide 4 th 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. ) Diabetes Care 26: 917 -932, 2003

Percentage of Patients With Diabetes Having A 1 C <7% US Adults With Diagnosed Diabetes in 1988 -94 NHANES III Percent at goal 100 80 73 60 45 38 40 26 20 0 Diet alone Oral agents Therapy used Harris MI, et al. Diabetes Care. 1999; 22: 403 -408. Insulin Whole population

Lessons from the DCCT and UKPDS: Sustained Intensification of Therapy is Difficult DCCT (Type 1) EDIC UKPDS (Type 2), Insulin Group 10 8 9. 0 7. 9 8 8. 1 A 1 C (%) 7. 3 A 1 C (%) 7 Baseline 6 6 4 Normal 0 0 6. 5 DCCT +4 + 6 yrs EDIC DCCT/EDIC Research Group. New Engl J Med 2000; 342: 381 -389 Steffes M et al. Diabetes 2001; 50 (suppl 2): A 63 UK Prospective Diabetes Study Group (UKPDS) 33 Lancet 1998; 352: 837 -853 0 2 4 6 8 10 yrs

Relationship between % BG in Target and A 1 C Level 33% 18% 41% 49% 14% A 1 C = 7% A 1 C = 8% 46% Within Target 45% 42% 12% Above Target Below Target A 1 C = 8. 5% Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21: 2.

Primary Objectives of Effective Management A 1 C % 9 l. Gæde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003; 348: 383 -393. Diagnosis 8 7 Reduction of both micro- and macrovascular event rates …by 75%! SBP mm Hg 145 130 LDL mg/d. L 140 100 45 50 55 60 65 70 75 Patient Age 80 85 90

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 Prior Therapy 43% no prior therapy 41% exclusive pills 5% diet to pills Prior Therapy 51% exclusive pills 14% insulin 13% pills to insulin Average time on pills before moving to insulin = 4. 9 years = 5. 6 years Prior Therapy 66% no prior therapy 18% diet/no med 8% insulin Average time on diet before moving to pills = 3. 2 years Roper Starch Worldwide, 2002

Trends Among Insulin Injectors Conventional 54% Pump Therapy 15% Intensive Therapy 31% 46% % 2001 Multiple Daily Injections Conventional 43% 2002 Pump Therapy 20% 37% Intensiv e Therapy 57% Multiple Daily 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 Mini. Med

Total Patients Using Insulin Pumps Estimated figures for 2003

Other Possible Contributions to Intensive Management PATIENT ATTITUDES AND BEHAVIORS

DEMOGRAPHICS (US) By education and income EDUCATION % High School or less College INCOME LEVEL < $35 K % Roper Starch Worldwide, 2002 $35 K - $75 K > $100 K

HCPs Frequently Visited By Patients “What type of healthcare professional do you normally visit for your diabetes care? ” % % TYPE 1 Roper Starch Worldwide, 2002 TYPE 2

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 Roper Starch Worldwide, 2002

Self-Reported A 1 C Results 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