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Diabetes Care

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SUDIPTO on Nov 15, 2009 Says :

comprehensive basic coverage,liked it,getting it for a patient education meeting,thanks.

Abdul on Oct 25, 2009 Says :

EXCELLENT SLIDES

Dr.Krishna murthy V.S. on Apr 21, 2009 Says :

Very interesting. I prefer to know more about the disease than statistics. But still it is quite absorbing. Thanks for the presentation.

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Notes

Show Notes

Slide 1 :

Diabetes Care THE ALPHABET STRATEGY

Slide 2 :

It is estimated that 1.4 million people in the UK have diabetes mellitus. Up to 1.25 million have type 2 diabetes 0.15 million have type 1 diabetes There may be as many as one million undiagnosed cases. A new patient is diagnosed with type 2 diabetes every 5 minutes. UK prevalence of diabetes mellitus

Slide 3 :

Retinopathy Most common cause of blindness in people of working age Nephropathy 16% of all new patients needing renal replacement therapy Erectile Dysfunction May affect up to 50% of men with long-standing diabetes Coronary and cerebrovascular Disease 2–4 fold increased risk of coronary heart disease and stroke, 75% have hypertension Foot Problems 15% of people with diabetes develop foot ulcers; 5–15% of people with diabetic foot ulcers need amputations The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000. Chronic complications of diabetes

Slide 4 :

50% of newly presenting patients with type 2 diabetes already have one or more complications at diagnosis . Retinopathy: 21% Hypertension: 35% Stroke or TIA: 1% Absent foot pulses: 13% Intermittent claudication: 3% Ischaemic skin changes to feet: 6% Erectile dysfunction: 20% Plasma creatinine >120?mol/l: 3% Myocardial Infarction: 1% Abnormal ECG: 18% UKPDS Group. Diabetes Research 1990;13:1–11. Complications at diagnosis in the UKPDS

Slide 5 :

Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721. Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066. Life expectancy and diabetes

Slide 6 :

Diabetes in the UK Indo - Asian community

Slide 7 :

U.K. economic costs Diabetes UK. May 2000. Year 2000 projected NHS diabetes expenditure ( 9% ) : £4,878,000,000 Equivalent to: per week £93,807,692 per day £13,401,098 per hour £ 558,379 per minute £ 9,306 per second £ 155 50% of Costs are due to premature complications

Slide 8 :

Slide 9 :

GMS Contract NICE National Service Framework Guidelines Increasing prevalence Evidence base User expectations

Slide 10 :

Glycaemia Lipids Blood pressure Lifestyle Multi -disciplinary Patient oriented Audit Feet Eyes

Slide 11 :

“ Excellence requires that important, simple things are done right all the time . ” National Service Framework for Coronary Heart Disease

Slide 12 :

Patel V, Morrissey J The Alphabet Strategy British Journal of Diabetes & Vascular Disease, 2002: 2: 1: 58-59

Slide 13 :

The Alphabet Strategy Advice Blood pressure Cholesterol Diabetes control Eye examination Feet examination Guardian drugs Heart risk score

Slide 14 :

The Alphabet Strategy Advice Smoking , diet , exercise Blood pressure < 140/80 Cholesterol TC = 5, LDL : HDL = 3 Diabetes control HbA1c = 7% Eye examination Annual examination Feet examination Annual examination Guardian drugs Aspirin, ACEI, statins &c Heart risk score UKPDS, Framingham

Slide 15 :

A is for ... ADVICE

Slide 16 :

Adherence to diet and medication Smoking cessation, exercise, weight reduction Ensure diabetes education and advise Diabetes UK membership Stress role of the dietician, podiatrist and diabetes care nurses Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non-attenders Lifestyle targets: weight reduction > 5% if obese , fat intake < 30% of energy intake , saturated fat < 10% of energy intake , fibre > 15g per 1000 calories, exercise for four hours / week. Advice

Slide 17 :

Slide 18 :

Prevention of progression of IGT to diabetes Finnish Diabetes Prevention Study Intensive lifestyle intervention reduced progression to diabetes by 58%. Diabetes Prevention Program Intensive lifestyle management reduced diabetes by 58%. Standard lifestyle advice plus metformin reduced diabetes by 31% Incidence of diabetes was 11, 7.8 and 4.8 cases per 100 person years with placebo, metformin and intensive lifestyle intervention respectively.

Slide 19 :

B is for ... BLOOD PRESSURE

Slide 20 :

UKPDS design Adapted from UK Prospective Diabetes Study (UKPDS) Group Lancet 1998;352:837-853; Turner R et al Ann Intern Med 1996;124(1 pt 2):136-145. Aim To determine whether intensified blood glucose control , with either sulphonylurea or insulin , reduces the risk of macrovascular or microvascular complications in type 2 diabetes. To determine the effect of aggressive blood pressure control . Study Population 3867 newly diagnosed type 2 diabetic patients who were asymptomatic after 3 months of diet ; fasting glucose 6.1–15 mmol/l (110–270 mg/dl) ; treat for 10 years .

Slide 21 :

UKPDS : diabetes related endpoints Diabetes related death Non fatal myocardial infarction , heart failure or angina Non fatal stroke Amputation Renal failure Retinal photocoagulation or vitreous haemorrhage Cataract extraction or blind in one eye

Slide 22 :

UKPDS : diabetes-related deaths 0% 5% 10% 15% 20% 0 3 6 9 % of patients with events Years from randomisation Tight blood pressure control (758) Less tight blood pressure control (390) Risk reduction32% ( p=0.019 )

Slide 23 :

UKPDS : microvascular endpoints Risk reduction37% ( p=0.0092 )

Slide 24 :

UKPDS blood pressure control study In 1148 type 2 diabetic patients a tight blood pressure control policy which achieved blood pressure of 144 / 82 mm Hg gave reduced risk for : Any diabetes-related endpoint 24% p=0.0046 Diabetes-related deaths 32% p=0.019 Stroke 44% p=0.013 Microvascular disease 37% p=0.0092Heart failure 56% p=0.0043 Retinopathy progression 34% p=0.0038 Deterioration of vision 47% p=0.0036

Slide 25 :

Slide 26 :

C is for ... CHOLESTEROL

Slide 27 :

MRC/BHF Heart Protection Study : eligibility Increased CHD risk due to prior disease : Myocardial infarction or other CHD ; Occlusive disease of non-coronary arteries ; or Diabetes mellitus or treated hypertension Age 40-80 years Total cholesterol >3.5 mmol/l ( >135mg/dl) Statin or vitamins not considered clearly indicated or contraindicated by patient’s own doctors

Slide 28 :

SIMVASTATIN: CAUSE-SPECIFIC MORTALITY

Slide 29 :

SIMVASTATIN: MAJOR VASCULAR EVENTS

Slide 30 :

SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE STATIN worse

Slide 31 :

SIMVASTATIN: VASCULAR EVENT by PRIOR LIPID LEVELS

Slide 32 :

HPS : main conclusions After allowance for non-compliance, 40mg daily simvastatin safely reduces the risk of heart attack , of stroke and of revascularisation by at least one-third . 5 years of statin treatment typically prevents these “major vascular events” in about : 100 of every 1000 with previous MI 80 " " other CHD 70 " " diabetes (age 40+) 70 " " previous stroke 70 " " other PVD … irrespective of cholesterol level, age, sex or other treatment .

Slide 33 :

CARDS Collaborative Atorvastatin Diabetes Study Helen Colhoun, John Betteridge, Paul Durrington, Graham Hitman, Andrew Neil, Shona Livingstone, Margaret Thomason, Michael Mackness, Valentine Menys, John Fuller on behalf of the CARDS Investigators Presented at ADA 2004

Slide 34 :

Primary prevention diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy) CARDS Design Placebo

Slide 35 :

Treatment effect on the primary endpoint 21 (1.5%) 24 (1.7%) 51 (3.6%) 83 (5.8%) Atorva* 48% (11- 69) 39 (2.8%) Stroke 31% (16- 59) 34 (2.4%) Coronary revascularisation 36% (9- 55) 77 (5.5%) Acute coronary events 37% (17- 52) p=0.001 127 (9.0%) Primary endpoint** Hazard Ratio Risk Reduction (CI) Placebo* Event * N (% randomised) .2 .4 .6 .8 1 1.2 Favours Atorvastatin Favours Placebo ** Fatal MI, other acute CHD death, non fatal MI, unstable angina, CABG, fatal stroke, non fatal stroke

Slide 36 :

29% (-5-52)p=0.40 43 (6.1) 60 (8.4) Trig. < 1.7 44% (18-62) 40 (5.5) 67 (9.6) Trig. = 1.7 38% (9-58) 44 (6.1) 66 (9.5) LDL-C = 3.06 47 (6.4) 36 (5.2) 39 (5.6) Atorva** 41% (11-61) 62 (8.4) HDL-C = 1.35 35% (5-55) p=0.71 65 (9.6) HDL-C < 1.35 37% (6-58) p=0.96 61 (8.5) LDL-C < 3.06 Hazard Ratio Risk Reduction (CI) Placebo** Subgroup* * units in mmol/L ** N (% of randomised) Treatment effect onthe primary endpoint by lipid levels .2 .4 .6 .8 1 1.2 Favours Atorvastatin Favours Placebo

Slide 37 :

CHD prevention trials with statins in diabetes: CHD Endpoints: †HPS = first major vascular event; ††CARE = absolute risk of coronary events; ** CARDS: Acute Coronary Events ‡4S = major CHD events; ‡‡4S reanalysis = major coronary events. Cohorts: *HPS = risk reduction for the entire cohort (nondiabetics and patients with diabetes). Footnote: NS = results not statistically significant. 1. HPS Collaborative Group. Lancet. 2002;360:7-22. 2. Goldberg RB, Mellies MJ, Sacks FM, et al. Circulation. 1998;98:2513-2519. 3. Pyörälä K, Pedersen TR, Kjekshus J, et al. Diabetes Care. 1997;20:614-620. 4. Haffner SM, Alexander CM, Cook TJ, et al. Arch Intern Med. 1999;159:2661-2667. CARDS Study ADA 2004. GREACE Study

Slide 38 :

Cholesterol Treat all diabetes patients with statins! (evidence if total cholesterol greater than 3.5 mmol/l) Alphabet target : total cholesterol <4.0 LDL <2 HDL = 1.0: GMS target : total cholesterol <5.0

Slide 39 :

D is for ... DIABETES CONTROL

Slide 40 :

Does intensive glucose control reduce the risk of diabetes complications ? UKPDS glucose control study

Slide 41 :

Slide 42 :

UKPDS : any diabetes related endpoint

Slide 43 :

HbA1c% 7.0% versus 7.9%

Slide 44 :

UKPDS : glycaemic control

Slide 45 :

E is for ... EYE SCREENING

Slide 46 :

Slide 47 :

Diabetic retinopathy Diabetic retinopathy is the commonest cause of blindness under the age of 65 in the Western World. 21% of Type 2 diabetics have retinopathy at diagnosis. 1500 new cases of blindness could be prevented by screening in UK yearly. 20 years after diagnosis 95% with Type 1 diabetes have retinopathy ... ... as do 60% of patients with Type 2 diabetes.

Slide 48 :

Eye screening The Diabetes National Service Framework guarantees : Screening of 80% of people with diabetes by 2006 Rising to 100% by the end of 2007 By digital retinal photography Based on a diabetes register

Slide 49 :

F is for ... FOOT SCREENING

Slide 50 :

Slide 51 :

Foot screening Annual review essential - by GP, Practice Nurse , Diabetes Nurse or , ideally , podiatrist . Examination should include: inspection , foot pulses , capillary refill , 10g monofilament testing, vibration sense . If evidence of neuropathy or ischaemia refer to podiatrist since risk of ulceration is high . If ulceration present refer urgently to foot at risk clinic .

Slide 52 :

G is for ... GUARDIAN DRUGS

Slide 53 :

Guardian drugs Aspirin 75mg od: Diabetes UK advocates considering aspirin prophylaxis against cardiovascular events in all diabetic patients ( >30yrs ) with any of the following: Myocardial infarction, angina, hypertension (>140/80 or on treatment), AF, diabetic retinopathy, peripheral vascular disease and microalbuminuria. Also if : Indo-Asian, obese (BMI > 25), dyslipidaemia, CHD risk > 15%, FH of CHD, smokers. Grossly under-implemented: 23% in UK, 20% in USA. ( But 83% at George Eliot ! )

Slide 54 :

ACE-inhibitors have a special role in preventing diabetes complications (HOPE and Micro-HOPE) : There is now a cardiovascular disease prevention licence for ramipril 10 mg daily in normo-tensive diabetic patients > 55 years with these risk factors : Controlled hypertension Cholesterol > 5.2 mmol/l or HDL < 0.9 mmol/l Currently smoking Micro-albuminuria. Guardian drugs

Slide 55 :

HOPE: Heart Outcomes Prevention Evaluation Study: Micro-HOPE sub study Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus Lancet 2000; 355: 253 - 59

Slide 56 :

HOPE : MI rate -ramipril vs placebo in diabetics

Slide 57 :

HOPE : stroke rate - ramipril vs placebo in diabetics

Slide 58 :

HOPE : CV death - ramipril vs placebo in diabetics

Slide 59 :

HOPE : main conclusions In people with diabetes at risk for cardiovascular disease, addition of ramipril to other effective therapies significantly reduces: CV death, strokes and myocardial infarctionTotal mortalityRevascularisationDiabetic nephropathy The benefit is independent of the effect on BP ( 2.47/1 ) The incidence of cough was 7%

Slide 60 :

LIFE : losartan intervention for endpoint reduction in hypertension study Lancet 2002 ; 359 : 995 - 1003

Slide 61 :

LIFE : total mortality – diabetes subgroup

Slide 62 :

LIFE : new onset diabetes by treatment group Study Month 0 6 12 18 24 30 36 42 48 54 60 66 0 2 4 6 8 10 Proportion of patients, % Atenolol Losartan

Slide 63 :

Compared with atenolol-based, losartan-based antihypertensive therapy was associated with: less cardiovascular morbidity and mortality (13%) less stroke (25%) less new diabetes (25%) better tolerability with significantly fewer discontinuations for adverse events … for similar blood pressure reduction . LIFE : main conclusions

Slide 64 :

H is for ... HEART DISEASE RISK

Slide 65 :

Slide 66 :

Slide 67 :

POEM 400 : heart disease risk score UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p<0.001 n=315

Slide 68 :

Pulling it all together : the Steno 2 Study Multifactorial intervention in high-risk individuals with type 2 diabetes Gaede P et al (2003) N Eng J Med 348:5 p383

Slide 69 :

Slide 70 :

Steno-2 : objective To compare the effect of a targeted , intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for cardiovascular disease in patients with type 2 diabetes and microalbuminuria.

Slide 71 :

Steno-2 : study population 160 patients with T2D and microalbuminuria 80 allocated to conventional treatment 80 allocated to intensive treatment Mean age 55.1 years Mean follow-up 7.8 years

Slide 72 :

Steno-2 vs Alphabet Strategy : targets

Slide 73 :

Steno-2 intensive cohort : results

Slide 74 :

Steno-2 : CVD event reduction

Slide 75 :

Steno-2 : CVD event reduction

Slide 76 :

Steno-2 : conclusion “ A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”

Slide 77 :

The Alphabet Strategy Health care professional talk Patient / carer talk “Diabetes Care 4 U” posters “Diabetes and your medication” booklet Patient held record Audit tools Clinic letter template Antenatal clinic template Young persons clinic template ABC guidelines Website: abcdiabetescare.org.uk

Slide 78 :

Slide 79 :

Slide 80 :

Thank you for listening !

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