Diabetes Care Diabetes Care

THE ALPHABET THE ALPHABET STRATEGYSTRATEGY

• It is estimated that 1.4 million people in the UK It is estimated that 1.4 million people in the UK have diabetes mellitus.have diabetes mellitus.

– Up to 1.25 million have type 2 diabetesUp to 1.25 million have type 2 diabetes– 0.15 million have type 1 diabetes0.15 million have type 1 diabetes

• There may be as many as one million There may be as many as one million undiagnosed cases.undiagnosed cases.

• A new patient is diagnosed with type 2 A new patient is diagnosed with type 2 diabetes every 5 minutes.diabetes every 5 minutes.

UK prevalence of diabetes mellitusUK prevalence of diabetes mellitus

RetinopathyRetinopathyMost common cause of Most common cause of

blindness in people of blindness in people of working ageworking age

NephropathyNephropathy16% of all new patients 16% of all new patients

needing renal replacement needing renal replacement therapytherapy

Erectile DysfunctionErectile DysfunctionMay affect up to 50% of May affect up to 50% of

men with long-men with long-standing diabetesstanding diabetes

Coronary and Coronary and cerebrovascular cerebrovascular

DiseaseDisease2–4 fold increased risk 2–4 fold increased risk

of coronary heart of coronary heart disease and stroke, disease and stroke,

75% have 75% have hypertensionhypertension

Foot ProblemsFoot Problems15% of people with 15% of people with diabetes develop diabetes develop

foot ulcers; 5–15% of foot ulcers; 5–15% of people with diabetic people with diabetic

foot ulcers need foot ulcers need amputationsamputations

The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.

Chronic complications of diabetesChronic complications of diabetes

50% of newly presenting patients with type 2 diabetes already 50% of newly presenting patients with type 2 diabetes already have one or more complications at diagnosis .have one or more complications at diagnosis .

Retinopathy: 21%Retinopathy: 21%

Hypertension: 35%Hypertension: 35%

Stroke or TIA: 1%Stroke or TIA: 1%

Absent foot pulses: 13%Absent foot pulses: 13%

Intermittent Intermittent claudication: 3%claudication: 3%

Ischaemic skin Ischaemic skin changes to feet: 6%changes to feet: 6%

Erectile dysfunction: 20%Erectile dysfunction: 20%

Plasma creatinine Plasma creatinine >120>120mol/l: 3%mol/l: 3%

Myocardial Infarction: 1%Myocardial Infarction: 1%

Abnormal ECG: 18%Abnormal ECG: 18%

UKPDS Group. Diabetes Research 1990;13:1–11.

Complications at diagnosis in the UKPDS

Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721.

Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066.

40

45

50

55

60

65

70

75

80

85

15-19 20-29 30-39 40-49 50-59 60-70

Lif

e e

xpe

cta

nc

y (

yrs

)

Diabetics

NonDiabetics

Age at diagnosis (yrs)

Life expectancy and diabetesLife expectancy and diabetes

Asian

European

Men Women

Age groups

20–39 40–59 60–79 20–39 40–59 60–79

30%

25%

20%

15%

10%

5%

0%

Diabetes in the UK Indo - Asian Diabetes in the UK Indo - Asian communitycommunity

U.K. economic costsU.K. economic costs

Diabetes UK. May 2000.Diabetes UK. May 2000.

Year 2000 projected NHS Year 2000 projected NHS diabetes expenditure ( 9% ) :diabetes expenditure ( 9% ) : £4,878,000,000£4,878,000,000

Equivalent to:Equivalent to:per week £93,807,692 per day £13,401,098 per hour £ 558,379 per minute £ 9,306per second £ 155

50% of Costs are due to premature 50% of Costs are due to premature complicationscomplications

GMS ContractGMS Contract

NICENICE

National National Service Service FrameworkFramework

GuidelinesGuidelines

Increasing Increasing prevalenceprevalence

Evidence baseEvidence base

User User expectationsexpectations

GlycaemiaGlycaemia

LipidsLipids

Blood Blood pressurepressure

LifestyleLifestyle

Multi -Multi -disciplinarydisciplinary

Patient Patient orientedoriented

AuditAuditFeet

Eyes

“ “ Excellence requires that Excellence requires that important, simple things are important, simple things are done right all the time . ”done right all the time . ”

National Service Framework for National Service Framework for Coronary Heart DiseaseCoronary Heart Disease

Patel V, Morrissey JThe Alphabet StrategyBritish Journal of Diabetes &Vascular Disease, 2002: 2: 1: 58-59

The Alphabet StrategyThe Alphabet Strategy

• AAdvicedvice• BBlood pressure lood pressure • CCholesterolholesterol• DDiabetes controliabetes control• EEye examinationye examination• FFeet examinationeet examination• GGuardian drugsuardian drugs• HHeart risk scoreeart risk score

The Alphabet StrategyThe Alphabet Strategy

• AAdvicedvice Smoking , diet , exerciseSmoking , diet , exercise• BBlood pressure lood pressure << 140/80 140/80• CCholesterol holesterol TC ≤ 5, LDL : HDL ≤ 3TC ≤ 5, LDL : HDL ≤ 3• DDiabetes control iabetes control HbA1c ≤ 7%HbA1c ≤ 7%• EEye examination ye examination Annual examinationAnnual examination• FFeet examination eet examination Annual examinationAnnual examination• GGuardian drugs uardian drugs Aspirin, ACEI, statins &c Aspirin, ACEI, statins &c• HHeart risk score eart risk score UKPDS, Framingham UKPDS, Framingham

A is for ...A is for ...

ADVICEADVICE

 

• Adherence to diet and medicationAdherence to diet and medication• Smoking cessation, exercise, weight reductionSmoking cessation, exercise, weight reduction• Ensure diabetes education and advise Diabetes UK Ensure diabetes education and advise Diabetes UK

membershipmembership• Stress role of the dietician, podiatrist and diabetes Stress role of the dietician, podiatrist and diabetes

care nursescare nurses• Regular follow-up with comprehensive Annual Regular follow-up with comprehensive Annual

Review is essential. 20% of patients with early Review is essential. 20% of patients with early severe complications will be persistent Diabetes severe complications will be persistent Diabetes Clinic non-attendersClinic non-attenders

• Lifestyle targets: weight reduction > 5% if obese , fat Lifestyle targets: weight reduction > 5% if obese , fat intake < 30% of energy intake , saturated fat < 10% intake < 30% of energy intake , saturated fat < 10% of energy intake , fibre > 15g per 1000 calories, of energy intake , fibre > 15g per 1000 calories, exercise for four hours / week.exercise for four hours / week.

AdviceAdvice

Prevention of progression of IGT to Prevention of progression of IGT to diabetesdiabetes

Finnish Diabetes Prevention Study

Intensive lifestyle intervention reduced progression Intensive lifestyle intervention reduced progression to diabetes by 58%. to diabetes by 58%.

Diabetes Prevention Program

Intensive lifestyle management reduced diabetes by Intensive lifestyle management reduced diabetes by 58%.58%.

Standard lifestyle advice plus metformin reduced Standard lifestyle advice plus metformin reduced diabetes by 31%diabetes by 31%

Incidence of diabetes was 11, 7.8 and 4.8 cases per Incidence of diabetes was 11, 7.8 and 4.8 cases per 100 person years with placebo, metformin and 100 person years with placebo, metformin and intensive lifestyle intervention respectively.intensive lifestyle intervention respectively.

B is for ...B is for ...

BLOOD PRESSUREBLOOD PRESSURE 

UKPDS designUKPDS 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.

AimTo determine whetherTo determine whether intensified blood glucose intensified blood glucose controlcontrol , with either sulphonylurea or insulin , , with either sulphonylurea or insulin , reduces the risk of macrovascular or reduces the risk of macrovascular or microvascular complications in type 2 diabetes. microvascular complications in type 2 diabetes. To determine the effect ofTo determine the effect of aggressive blood aggressive blood pressure control .pressure control .

Study Population3867 newly diagnosed type 2 diabetic patients 3867 newly diagnosed type 2 diabetic patients who were asymptomatic after 3 months of diet ; who were asymptomatic after 3 months of diet ; fasting glucose 6.1–15 mmol/l (110–270 mg/dl) ; fasting glucose 6.1–15 mmol/l (110–270 mg/dl) ; treat for 10 years .treat for 10 years .

UKPDS : diabetes related endpointsUKPDS : diabetes related endpoints

•Diabetes related deathDiabetes related death

•Non fatal myocardial infarction , heart failure Non fatal myocardial infarction , heart failure or anginaor angina

•Non fatal strokeNon fatal stroke

•AmputationAmputation

•Renal failureRenal failure

•Retinal photocoagulation or vitreousRetinal photocoagulation or vitreous haemorrhagehaemorrhage

•Cataract extraction or blind in one eyeCataract extraction or blind in one eye

UKPDS : diabetes-related deathsUKPDS : diabetes-related deaths

0%

5%

10%

15%

20%

0 3 6 9

% o

f pa

tien

ts w

ith e

vent

s%

of p

atie

nts

with

eve

nts

Years from randomisationYears from randomisation

Tight blood pressure control (758)Less tight blood pressure control (390)

Risk reduction32% ( p=0.019 )

UKPDS : microvascular endpointsUKPDS : microvascular endpointsUKPDS : microvascular endpointsUKPDS : microvascular endpoints

0%

5%

10%

15%

20%

25%

0 3 6 9

% p

atie

nts

with

eve

nt%

pa

tient

s w

ith e

vent

Years from randomisationYears from randomisation

Tight Blood Pressure Control (758)

Less Tight Blood Pressure Control (390)

Risk reductionRisk reduction37% ( p=0.0092 )37% ( p=0.0092 )

UKPDS blood pressure control studyUKPDS blood pressure control study

In 1148 type 2 diabetic patients a tight blood pressure In 1148 type 2 diabetic patients a tight blood pressure control policy which achieved blood pressure of 144 / 82 mm control policy which achieved blood pressure of 144 / 82 mm Hg gave reduced risk for :Hg gave reduced risk for :

Any diabetes-related endpoint Any diabetes-related endpoint 24% p=0.004624% p=0.0046

Diabetes-related deaths Diabetes-related deaths 32% p=0.01932% p=0.019

StrokeStroke 44% p=0.01344% p=0.013

Microvascular disease Microvascular disease 37% p=0.009237% p=0.0092Heart failureHeart failure 56% p=0.004356% p=0.0043

Retinopathy progression Retinopathy progression 34% p=0.003834% p=0.0038

Deterioration of vision Deterioration of vision 47% p=0.003647% p=0.0036

Step 1

Younger (e.g.<55yr)and Non-Black

Older (e.g.>55yr)or Black

A or B C or D

A + DMost cases

or B+C

C or B or alpha blocker

Add: C or alpha blocker or ß-blocker or spironolactone or other diuretic or monoxidine

A: ACE Inhibitor or angiotensin receptor blocker B: B-blockerC: Calcium Channel Blocker D: Diuretic

Step 2

Step 3

Step 4Resistant Hypertension

modified fromJ Hum Hypertens 2003:17;81-86

“BHS Guidelines” - 2003

A + DMost cases +

C is for ...C is for ...

CHOLESTEROLCHOLESTEROL

 

MRC/BHF Heart Protection Study : MRC/BHF Heart Protection Study : eligibilityeligibility

• Increased CHD risk due to prior disease :Increased CHD risk due to prior disease :• Myocardial infarction or other CHD ;Myocardial infarction or other CHD ;• Occlusive disease of non-coronary arteries ; orOcclusive disease of non-coronary arteries ; or• Diabetes mellitus or treated hypertensionDiabetes mellitus or treated hypertension

• Age 40-80 yearsAge 40-80 years• Total cholesterol >3.5 mmol/l ( >135mg/dl)Total cholesterol >3.5 mmol/l ( >135mg/dl)• Statin or vitamins not considered clearly indicated Statin or vitamins not considered clearly indicated

or contraindicated by patient’s own doctorsor contraindicated by patient’s own doctors

SIMVASTATIN: CAUSE-SPECIFIC MORTALITY

Risk ratio and 95% CISTATIN PLACEBOCause ofdeath (10269) (10267) STATIN better STATIN worse

CHD 577 701

Other vascular 214 242

ALL VASCULAR 791 943(7.7%) (9.2%)

17% SE 4.4reduction(2P<0.0002)

Neoplastic 352 337

Respiratory 93 111

Other medical 76 91

Non-medical 16 21

ALL NON-VASCULAR 537 560(5.2%) (5.5%)

5% SE 5.9reduction

ALL CAUSES 1328 1503(12.9%) (14.6%)

12% SE 3.5reduction(2P<0.001)

0.4 0.6 0.8 1.0 1.2 1.4

SIMVASTATIN: MAJOR VASCULAR EVENTS

Risk ratio and 95% CISTATIN PLACEBOVascular

event (10269) (10267) STATIN betterSTATIN worse

Total CHD 914 1234

Total stroke 456 613

Revascularisation 926 1185

ANY OF ABOVE 2042 2606

(19.9%) (25.4%)

24% SE 2.6reduction

(2P<0.00001)0.4 0.6 0.8 1.0 1.2 1.4

SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASESTATIN worse

Risk ratio and 95% CISTATIN PLACEBOBaselinefeature (10269) (10267) STATIN better STATIN worse

Previous MI 1007 1255

Other CHD (not MI) 452 597

No prior CHD

CVD 182 215

PVD 332 427

Diabetes 279 369

ALL PATIENTS 2042 2606(19.9%) (25.4%)

24% SE 2.6reduction(2P<0.00001)

0.4 0.6 0.8 1.0 1.2 1.4

SIMVASTATIN: VASCULAR EVENT by PRIOR LIPID LEVELS

Risk ratio and 95% CISTATIN PLACEBOBaselinefeature (10269)

(10267)STATIN betterSTATIN worse

LDL (mmol/l)

Het2

2 = 3.0

< 3.0 (116 mg/dl) 602 761 3.0 < 3.5 483 655 3.5 (135 mg/dl) 957 1190

Total cholesterol (mmol/l)

Het2

2 = 0.5

<5.0 (193 mg/dl) 361 476 5.0 < 6.0 746 965 6.0 (232 mg/dl) 935 1165

ALL PATIENTS 2042 2606(19.9%) (25.4%)

24%SE 2.6reduction(2P<0.00001)

0.4 0.6 0.8 1.0 1.2 1.4

HPS : main conclusionsHPS : main conclusions

• After allowance for non-compliance, 40mg daily After allowance for non-compliance, 40mg daily simvastatin safely reduces the risk of heart simvastatin safely reduces the risk of heart attack , of stroke and of revascularisation by at attack , of stroke and of revascularisation by at least one-third .least one-third .

• 5 years of statin treatment typically prevents 5 years of statin treatment typically prevents these “major vascular events” in about :these “major vascular events” in about :

• 100 of every 1000 with previous MI100 of every 1000 with previous MI• 8080 " " " " other CHDother CHD• 70 70 " " " diabetes (age 40+) " diabetes (age 40+)• 70 70 " " " previous stroke " previous stroke• 70 70 " " " other PVD " other PVD

• … … irrespective of cholesterol level, age, sex or irrespective of cholesterol level, age, sex or other treatment .other treatment .

CARDSCollaborative 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

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

Atorvastatin 10mg

Placebo

2838patients

CARDS Design

Placebo

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=0.001127 (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

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

CHD prevention trials with statins in CHD prevention trials with statins in diabetesdiabetes: :

Study Drug Number of

patients

CHD risk redn

Nondiabetics

CHD risk redn

Diabetes

Primary Prevention

CARDS

HPS1 †

Atorvastatin 10mg

Simvastatin 40mg

2838

2912 25%*

37%**

26-33%

Secondary Prevention

CARE2 †† Pravastatin 586 23% 25%

4S3‡

GREACE

Simvastatin

Atorvastatin 24mg

202

313

32% 55%

59%

4S reanalysis4 ‡‡ Simvastatin 483 32% 42%

HPS1 Simvastatin 3051 24%* 12% NSCHD 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

CholesterolCholesterol

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

D is for ...D is for ...

DIABETES DIABETES CONTROL CONTROL 

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

UKPDS glucose control studyUKPDS glucose control study

UKPDS : diabetes related endpointsUKPDS : diabetes related endpoints

•Diabetes related deathDiabetes related death

•Non fatal myocardial infarction , heart failure or Non fatal myocardial infarction , heart failure or

anginaangina

•Non fatal strokeNon fatal stroke

•AmputationAmputation

•Renal failureRenal failure

•Retinal photocoagulation or vitreousRetinal photocoagulation or vitreous haemorrhagehaemorrhage

•Cataract extraction or blind in one eyeCataract extraction or blind in one eye

UKPDS : any diabetes related endpointUKPDS : any diabetes related endpoint

0%0%

20%20%

40%40%

60%60%

00 33 66 99 1212 1515

% o

f p

atie

nts

wit

h a

n e

ven

t%

of

pat

ien

ts w

ith

an

eve

nt

Years from randomisationYears from randomisation

Intensive (2729)Intensive (2729)

Conventional (1138)Conventional (1138)

Risk reduction 12%Risk reduction 12%

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

any

dia

bet

es

end

po

ints

MI

mic

ro

vas

cula

rs

Ret

inal

la

ser

cata

ract

Mic

roal

bu

min

uri

a

12%

16%

25%

29%

24%

33%

P=0.029

P=0.052

P=0.0099

P=0.0031

P=0.046

P<0.001

HbAHbA1c1c% 7.0% versus 7.9%% 7.0% versus 7.9%

06

7

8

9

0 3 6 9 12 15

HbA 1

c (%

)

Years from randomisation

Conventional

Intensive

6.2% upper limit of normal range

UKPDS : glycaemic controlUKPDS : glycaemic control

E is for ...E is for ...

EYE SCREENINGEYE SCREENING

Diabetic retinopathyDiabetic retinopathy

• Diabetic retinopathy is the commonest cause of Diabetic retinopathy is the commonest cause of blindness under the age of 65 in the Western blindness under the age of 65 in the Western World.World.

• 21% of Type 2 diabetics have retinopathy at 21% of Type 2 diabetics have retinopathy at diagnosis.diagnosis.

• 1500 new cases of blindness could be prevented 1500 new cases of blindness could be prevented by screening in UK yearly.by screening in UK yearly.

• 20 years after diagnosis 95% with Type 1 diabetes 20 years after diagnosis 95% with Type 1 diabetes have retinopathy ...have retinopathy ...

• ... as do 60% of patients with Type 2 diabetes.... as do 60% of patients with Type 2 diabetes.

Eye screeningEye screening

The Diabetes National Service Framework The Diabetes National Service Framework guarantees :guarantees :

• Screening of 80% of people with diabetes by Screening of 80% of people with diabetes by 20062006

• Rising to 100% by the end of 2007Rising to 100% by the end of 2007

• By digital retinal photographyBy digital retinal photography

• Based on a diabetes registerBased on a diabetes register

F is for ...F is for ...

FOOT SCREENINGFOOT SCREENING

Foot screeningFoot screening

• Annual review essential - by GP, Practice Annual review essential - by GP, Practice Nurse , Diabetes Nurse or , ideally , Nurse , Diabetes Nurse or , ideally , podiatrist .podiatrist .

• Examination should include: inspection , Examination should include: inspection , foot pulses , capillary refill , 10g foot pulses , capillary refill , 10g monofilament testing, vibration sense .monofilament testing, vibration sense .

• If evidence of neuropathy or ischaemia If evidence of neuropathy or ischaemia refer to podiatrist since risk of ulceration is refer to podiatrist since risk of ulceration is high . If ulceration present refer urgently to high . If ulceration present refer urgently to foot at risk clinicfoot at risk clinic . .

G is for ...G is for ...

GUARDIAN DRUGSGUARDIAN DRUGS

Guardian drugsGuardian drugs

Aspirin 75mg od:Aspirin 75mg od:

• Diabetes UK advocates considering aspirin Diabetes UK advocates considering aspirin prophylaxis against cardiovascular events in all prophylaxis against cardiovascular events in all diabetic patients ( >30yrs ) with any of the diabetic patients ( >30yrs ) with any of the following: following:

• Myocardial infarction, angina, hypertension Myocardial infarction, angina, hypertension (>140/80 or on treatment), AF, diabetic retinopathy, (>140/80 or on treatment), AF, diabetic retinopathy, peripheral vascular disease and microalbuminuria.peripheral vascular disease and microalbuminuria.

• Also if : Indo-Asian, obese (BMI > 25), Also if : Indo-Asian, obese (BMI > 25), dyslipidaemia, CHD risk > 15%, FH of CHD, dyslipidaemia, CHD risk > 15%, FH of CHD, smokers.smokers.

• Grossly under-implementedGrossly under-implemented: 23% in UK, 20% in 23% in UK, 20% in USAUSA. ( But 83% at George Eliot ! ). ( But 83% at George Eliot ! )

ACE-inhibitorsACE-inhibitors have a special role in preventing have a special role in preventing diabetes complications (HOPE and Micro-HOPE) :diabetes complications (HOPE and Micro-HOPE) :

There is now a cardiovascular disease prevention There is now a cardiovascular disease prevention licence for ramipril 10 mg daily in normo-tensive licence for ramipril 10 mg daily in normo-tensive diabetic patients > 55 years with these risk factors :diabetic patients > 55 years with these risk factors :

• Controlled hypertension Controlled hypertension

• Cholesterol > 5.2 mmol/l or HDL < 0.9 mmol/lCholesterol > 5.2 mmol/l or HDL < 0.9 mmol/l

• Currently smoking Currently smoking

• Micro-albuminuria.Micro-albuminuria.

Guardian drugsGuardian drugs

HOPE: Heart Outcomes HOPE: Heart Outcomes Prevention Evaluation Study: Prevention Evaluation Study:

Micro-HOPE sub studyMicro-HOPE sub study

HOPE: Heart Outcomes HOPE: Heart Outcomes Prevention Evaluation Study: Prevention Evaluation Study:

Micro-HOPE sub studyMicro-HOPE sub study

Effects of ramipril on Effects of ramipril on cardiovascular and cardiovascular and

microvascular outcomes in microvascular outcomes in people with diabetes mellituspeople with diabetes mellitus

Lancet 2000; 355: 253 - 59

HOPE : MI rate -HOPE : MI rate -ramipril vs placebo in diabeticsramipril vs placebo in diabetics

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0 500 1000 1500 2000

Days of Follow-up

Kap

lan-

Mei

er R

ates

ramipril Placebo

RRR = 22% (6 - 36) p= 0.01

HOPE : stroke rate - HOPE : stroke rate - ramipril vs placebo in diabeticsramipril vs placebo in diabetics

0.00

0.02

0.04

0.06

0.08

0 500 1000 1500 2000

Days of Follow-up

Kap

lan

-Mei

er R

ates

ramipril Placebo

RRR = 33% (10 - 50) p=0.0074

HOPE : CV death - HOPE : CV death - ramipril vs placebo in diabeticsramipril vs placebo in diabetics

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0 500 1000 1500 2000

Days of Follow-up

Ka

pla

n-M

eie

r R

ate

s ramipril Placebo

RRR = 37% (21 - 51) p=0.0001

HOPE : main conclusionsHOPE : main conclusionsHOPE : main conclusionsHOPE : main conclusions

• In people with diabetes at risk for cardiovascular In people with diabetes at risk for cardiovascular disease, addition of ramipril to other effective disease, addition of ramipril to other effective therapies significantly reduces:therapies significantly reduces:

• CV death, strokes and myocardial infarctionCV death, strokes and myocardial infarctionTotal mortalityTotal mortalityRevascularisationRevascularisationDiabetic nephropathyDiabetic nephropathy

• The benefit is independent of the effect on BP The benefit is independent of the effect on BP ( 2.47/1 ) ( 2.47/1 )

• The incidence of cough was 7%The incidence of cough was 7%

LIFE : losartan LIFE : losartan intervention for intervention for

endpoint reduction in endpoint reduction in hypertension studyhypertension study

LIFE : losartan LIFE : losartan intervention for intervention for

endpoint reduction in endpoint reduction in hypertension studyhypertension study

Lancet 2002 ; 359 : 995 - 1003

LIFE : total mortality – diabetes subgroup

Study Month

0 6 12 18 24 30 36 42 48 54 60 66

Pro

po

rtio

n o

f p

atie

nts

, %24

20

16

12

8

4

0

RRR = 39%; p=0·002

Losartan

Atenolol

LIFE : LIFE : new onset diabetes by new onset diabetes by treatment grouptreatment group

Study Month

0 6 12 18 24 30 36 42 48 54 60 660

2

4

6

8

10

Pro

po

rtio

n o

f p

atie

nts

, %

AtenololLosartan

Compared with atenolol-based, losartan-based Compared with atenolol-based, losartan-based antihypertensive therapy was associated with:antihypertensive therapy was associated with:

• less cardiovascular morbidity and mortality less cardiovascular morbidity and mortality (13%)(13%)

• less stroke (25%)less stroke (25%)

• less new diabetes (25%)less new diabetes (25%)

• better tolerability with significantly fewer better tolerability with significantly fewer discontinuations for adverse events discontinuations for adverse events

… … for similar blood pressure reduction .for similar blood pressure reduction .

LIFE : main conclusionsLIFE : main conclusionsLIFE : main conclusionsLIFE : main conclusions

H is for ...H is for ...

HEART DISEASE RISKHEART DISEASE RISK

POEM 400 : heart disease risk score

23.9

31.2

23.7

0

5

10

15

20

25

30

35

Absolute 10 year risk %

T0 Tadj Tfu

UKPDS 10 year absolute CHD risk

UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p<0.001

n=315

Pulling it all together : the Steno 2 Study

Pulling it all together : the Steno 2 Study

Multifactorial Multifactorial intervention in high-risk intervention in high-risk individuals with type 2 individuals with type 2

diabetesdiabetes

Gaede P et al (2003) N Eng J Med 348:5 p383

Steno-2 : objectiveSteno-2 : objective

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

Steno-2 : study populationSteno-2 : study population

• 160 patients with T2D and 160 patients with T2D and microalbuminuriamicroalbuminuria

• 80 allocated to conventional treatment80 allocated to conventional treatment

• 80 allocated to intensive treatment80 allocated to intensive treatment

• Mean age 55.1 yearsMean age 55.1 years

• Mean follow-up 7.8 yearsMean follow-up 7.8 years

Steno-2 vs Alphabet Strategy : Steno-2 vs Alphabet Strategy : targetstargets

Steno-2 Steno-2 intensive cohortintensive cohort

Alphabet Alphabet StrategyStrategy

AAdvicedvice StandardStandard StandardStandard

BBlood Pressurelood Pressure 130 / 80 (140 / 85)130 / 80 (140 / 85) 140 / 80140 / 80

CCholesterolholesterol 4.54.5 5.05.0

DDiabetes Control : HbA1c%iabetes Control : HbA1c% 6.56.5 7.07.0

EEyesyes AnnuallyAnnually AnnuallyAnnually

FFeeteet AnnuallyAnnually AnnuallyAnnually

GGuardians : aspirinuardians : aspirin AllAll MostMost

ACEI / AIIAACEI / AIIA AllAll MostMost

HHeart diseaseeart disease EventsEvents UKPDS riskUKPDS risk

Steno-2 intensive cohort : resultsSteno-2 intensive cohort : results

TargetTarget %%Systolic BP =< 130Systolic BP =< 130 5454

Diastolic BP =< 80Diastolic BP =< 80 7070

Total cholesterol =< 4.5Total cholesterol =< 4.5 7272

HbA1c% =< 6.5HbA1c% =< 6.5 1515

Aspirin useAspirin use 8787

Statin useStatin use 8585

ACEI useACEI use 7979

AIIA useAIIA use 2828

Steno-2 : CVD event reductionSteno-2 : CVD event reduction

EventEvent ConventionalConventional IntensiveIntensive

Cardiovascular DeathCardiovascular Death 77 77

MI : non-fatalMI : non-fatal 1717 55

CABGCABG 1010 55

PCIPCI 55 00

Stroke : non-fatalStroke : non-fatal 2020 33

AmputationsAmputations 1414 77

Revascularisation for PVDRevascularisation for PVD 1212 66

85 events in 35 85 events in 35 patientspatients

33 events in 33 events in 19 patients19 patients

Steno-2 : CVD event reductionSteno-2 : CVD event reduction

Conventionalintensive

0

2

4

6

8

10

12

14

16

18

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Steno-2 : conclusionSteno-2 : conclusion

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

The Alphabet StrategyThe Alphabet Strategy• Health care professional talkHealth care professional talk• Patient / carer talkPatient / carer talk• ““Diabetes Care 4 U” postersDiabetes Care 4 U” posters• ““Diabetes and your medication” bookletDiabetes and your medication” booklet• Patient held recordPatient held record• Audit toolsAudit tools• Clinic letter templateClinic letter template• Antenatal clinic templateAntenatal clinic template• Young persons clinic templateYoung persons clinic template• ABC guidelines ABC guidelines • Website: abcdiabetescare.org.ukWebsite: abcdiabetescare.org.uk

AdviceDiet : Maintaining a healthy diet and preventing or reducing overweight willhelp you control your diabetes

Exercise : Regular exercise will help to maintain an optimum weight and will benefit all members of the family

Smoking : It is widely accepted that smoking causes heart and lung disease. Most diabetic complications are worsened by smoking

Weight control : There is a greater risk of Developing diabetes and heart disease with increasing waist circumference

Finnish Diabetes StudyThis study was conducted to determine the

effects of a programme of changes in lifestyle in patients with ‘Pre’ diabetes

Lifestyle changes included

•Weight reduction greater than 5% (if needed)•Fat intake less than 30% of calorie intake•Saturated fat less than 10% of calorie intake•Fibre intake greater than 15grams/ 1000 calories•Exercise greater than 4 hours per week (brisk walking)

Carrying out this programme resulted in less diabetes by 58%

Are you eating healthy foods?How often do you exercise?

Do you smoke?Do you know your target weight?

Blood Pressure140 / 80

Very good control of blood pressure is required!

Raised blood pressure can increase all complications of diabetes

It is important that it is checked regularly

Tablets maybe taken to control blood pressure

You may need to change what you eat and exercise more

UK Prospective Diabetes StudyUK Prospective Diabetes StudyBlood Pressure Control Study

Aggressive blood pressurecontrol reduces the risk of

most complications inDiabetes

It’s as simple as that!

Remember your target is 140/80 Have you hit the bulls-eye?

Target :

Ret

ino

path

y p

rog

ress

ion

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

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ease

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ion

24%

32%

56%44%

37%34%

47%

P=0.004

P=0.019

P=0.004

P=0.013

P=0.009P=0.004

P=0.004

Ret

ino

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ion

-70%

-60%

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24%

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56%44%

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P=0.004

P=0.019

P=0.004

P=0.013

P=0.009P=0.004

P=0.004

Any diabetes 0

10

20

30

40

50

60

problemHeartFailure

Stroke

CholesterolThis is the amount of fat in blood

Some blood fats are necessary to provide important energy sources

Too much fat can cause you to beoverweight, making it much more difficult to control your diabetes

It can also cause heart problems

How much fat does your blood contain?

The optimal target for blood cholesterol level is

LESS THAN 5

1 2 3 4 5 600

20

40

60

80

100

Riskreduction

55%

Simvastatin

Number of years on

Pro

port

ion

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rt p

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)

1 2 3 4 5 600

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Riskreduction

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Placebo

Number of years on simvastatin

Pro

port

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rt p

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s (%

)

SCANDINAVIAN SIMVASTATINSURVIVAL STUDY

This study showed that long-term simvastatin (cholesterol lowering drug) therapy reduces chances of dying and heart problemsin patients with diabetes

Do you know what your level is?Are you on target?

FAT

BLOOD

SERUM

D i a b e t e s C o n t r o lB l o o d g l u c o s e n e e d s t o b e k e p t w i t h i n

a c o n t r o l l e d r a n g e

4 – 7T h i s c a n b e h e l p e d b y r e g u l a r b l o o d g l u c o s e m o n i t o r i n g a t h o m e a n d k e e p i n g a n a c c u r a t e w r i t t e n r e c o r d . B r i n g i t t o c l i n i c !

W h a t i s H b A 1 c % ?

T h i s v a l u e t e l l s y o u t h e a m o u n t o f g l u c o s e s t i c k i n g t o y o u r b l o o d o v e r t h e l a s t 6 0 d a y sI t r e f l e c t s h o w w e l l y o u r d i a b e t e s h a s b e e n c o n t r o l l e d

T h e a i m i s t o h a v e a v a l u e o f l e s s t h a n 7 . 0 %W h a t d r u g s h e l p t o c o n t r o l d i a b e t e s ?

M e t f o r m i n , G l i c l a z i d e , G l i m e p i r i d e , P i o g l i t a z o n e , R o s i g l i t a z o n e , I n s u l i n a n d

m a n y o t h e r d r u g s

U K P r o s p e c t i v e D i a b e t e s G l u c o s e C o n t r o l S t u d y

T h e U K P D s t u d y s h o w s t h a t g o o dT h e U K P D s t u d y s h o w s t h a t g o o dg l u c o s e c o n t r o l c a n d e c r e a s e t h e g l u c o s e c o n t r o l c a n d e c r e a s e t h e

r i s k s o f :r i s k s o f :

H e a r t a t t a c k b y 1 6 %C a t a r a c t b y 2 4 %K i d n e y p r o b l e m s b y 3 3 %

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-

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A r e y o u i n c o n t r o l o f y o u r d i a b e t e s ?W h a t i s y o u r H b A 1 c % ?

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B l o o d P r e s s u r e

R i s k o f D i a b e t e s C o m p l i c a t i o n s

I n c r e a s i n g

E y e sH o w y o u r e y e s w o r k

Y o u r e y e h a s a l e n s a n d a n o p e n i n g a t t h e f r o n t , w h i c h a d j u s t t o b r i n g o b j e c t s i n t o f o c u s o n t h e r e t i n a a t t h e b a c k o f t h e e y e .

T h e r e t i n a i s m a d e u p o f d e l i c a t e t i s s u e t h a t i s s e n s i t i v e t o l i g h t r a t h e r l i k e t h e f i l m i n a c a m e r a .

A t t h e c e n t r e o f t h e r e t i n a i s t h e m a c u l a , w h i c h i s a s m a l l a r e a a b o u t t h e s i z e o f a p i n h e a d . I t i s v i t a l b e c a u s e i t e n a b l e s y o u t o s e e f i n e d e t a i l .

W h e n w a s t h e l a s t t i m e y o u h a d y o u r e y e s c h e c k e d ?

I s D i a b e t e s s l o w l y s t e a l i n g y o u r v i s i o n ?

• A p e r s o n w i t h d i a b e t e s c a n h a v e e y e d i s e a s e a n d n o t e v e n k n o w i t u n t i l s e r i o u s , i r r e v e r s i b l e v i s i o n l o s s h a s o c c u r r e d

• T h e o n l y w a y t o d i a g n o s e e a r l y s i g n s o f d i a b e t i c e y e d i s e a s e i s t h r o u g h a d i l a t e d e y e e x a m a t l e a s t o n c e a y e a r

D I A B E T I C E Y E D I S E A S ED i a b e t i c E y e D i s e a s e ( D i a b e t i c r e t i n o p a t h y ) i s t h e c o m m o n e s t c a u s e o f b l i n d n e s s u n d e r t h e a g e o f 6 5 i n t h e W e s t e r n W o r l d3 7 % o f d i a b e t e s p a t i e n t s h a v e r e t i n o p a t h y a t d i a g n o s i s o f d i a b e t e s1 5 0 0 n e w c a s e s o f b l i n d n e s s c o u l d b e p r e v e n t e d b y y e a r l y s c r e e n i n g i n U K 2 0 y e a r s a f t e r d i a g n o s i s 9 5 % w i t h T y p e 1 d i a b e t e s h a v e r e t i n o p a t h y2 0 y e a r s a f t e r d i a g n o s i s 6 0 % o f p a t i e n t s w i t h T y p e 2 d i a b e t e s h a v e r e t i n o p a t h y L a s e r t r e a t m e n t c a n s a v e e y e s i g h t g e t t i n g w o r s e i n 9 0 % o f p a t i e n t s

N o r m a l r e t i n a D i a b e t i c R e t i n o p a t h y

M a c u l a O p t i c D i s c F a t t y H a e m o r r h a g eD e p o s i t s

F e e t• D u r i n g a l i f e t i m e , y o u r f e e t m a y w a l k t h e e q u i v a l e n t o f f o u r

t i m e s a r o u n d t h e w o r l d ! • T o e n s u r e t h a t t h e y c o n t i n u e t h e i r t r i p t h r o u g h l i f e w i t h o u t

c o m p l a i n t , i t p a y s t o l o o k a f t e r y o u r f e e t !

I t i s i m p o r t a n t t h a t y o u e x a m i n e y o u r f e e t r e g u l a r l y . Y o u s h o u l da l s o f e e l i n s i d e a l l s h o e s f o r a n y s e a m s o r s t i t c h i n g w h i c h c o u l d r u b t h e f o o t a n d l e a d t o p r o b l e m s . I t i s i m p o r t a n t t h a t y o u r e c e i v e r e g u l a r f o o t a d v i c e o r t r e a t m e n t .

P e o p l e s u f f e r i n g f r o m d i a b e t e s c a n o f t e n e x p e r i e n c e l o s s o f s e n s a t i o n i n t h e i r f e e t . E v e n t h e s m a l l e s t i n j u r y c a n l e a d t o i n f e c t i o n , w h i c h i f

n o t t r e a t e d p r o m p t l y , m a y l e a d t o s e r i o u s c o m p l i c a t i o n s .

F o o t P r o b l e m s

1 5 % o f p a t i e n t s w i t h d i a b e t e s w i l l d e v e l o p f o o t u l c e r s d u e t o n e r v e d a m a g e a n d r e d u c e d b l o o d f l o w

F o o t u l c e r s c o m e b e f o r e 8 5 % o f a m p u t a t i o n s i n p e o p l e w i t h d i a b e t e s . F o o t u l c e r s a r e t h e c o m m o n e s t c a u s e o f a m p u t a t i o n i n t h e U K

L i v e r p o o l D i a b e t e s C l i n i c : F o o t P r o t e c t i o n P r o g r a m m e

W h e n p a t i e n t s w i t h d i a b e t e s a n d f o o t d e f o r m i t i e s a t t e n d e d r e g u l a r c l i n i c s w i t h a t r a i n e d p o d i a t r i s t a n d f o o t e d u c a t i o n , i t w a s f o u n d t h a t

A t 2 y e a r s u l c e r a t i o n w a s r e d u c e d t o 2 . 4 % c o m p a r e d w i t h 3 . 5 % A m p u t a t i o n w a s r e d u c e d b y 3 t i m e s

W h e n w a s t h e l a s t t i m e y o u h a d y o u r f e e t c h e c k e d ?

Guardian Drugs

30

25

20

15

10

5

0Any cardiovascular Heart Attack

problem

- 14%

-29%

ASPIRIN

Diabetes UK recommends taking aspirin to prevent against heart problems in all diabetes patients (greater than 30yrs) with any of the following:

Heart attack, angina, high blood pressure, eye problems, blood vessel diseases and kidney problems

Also if: Indo - Asian, overweight, high cholesterol, Heart Disease risk greater than 15%, family history, history of heart disease, smokers

ACE -inhibitors are drugs that have a special role in preventing diabetic complications.The HOPE study showed that one ace inhibitor, ‘Ramipril’ reduced:

The names of these drugs end in ‘PRIL’

Do you know if you are taking any of the guardian drugs?

ACE INHIBITORS

% D

ecre

ase

in E

vent

s

Heart Disease Stroke Kidney Eye disease

What are Guardian Drugs?Guardian drugs are given to protect you from further diabetes

complications

D i a b e t e s C a r e 4 U !W e l c o m e t o D i a b e t e s C a r e 4 U ! H e r e y o u w i l l f i n d p o s t e r s p a c k e d f u l l o f i n f o r m a t i o n a n d i n n o v a t i v e i d e a s t o e n s u r e y o u h a v e g r e a t D i a b e t e s

C a r e ! B e f o r e y o u e n t e r i n t o t h e u n i q u e e x p e r i e n c e l e t u s g o o v e r t h e p r o b l e m s o f d i a b e t e s .

D I A B E T I C E Y E D I S E A S EM o s t c o m m o n c a u s e o f

b l i n d n e s s i n p e o p l e o fw o r k i n g a g e

H E A R T a n d B L O O D V E S S E L S2 t o 4 f o l d i n c r e a s e d r i s k o f

h e a r t d i s e a s e a n d s t r o k e7 5 % h a v e h y p e r t e n s i o n

D I A B E T I C K I D N E Y D I S E A S E

2 0 % o f a l l n e w p a t i e n t s n e e d i n g r e n a l d i a l y s i s t h e r a p y h a v e d i a b e t e s

F O O T P R O B L E M S1 5 % o f p e o p l e w i t h d i a b e t e s d e v e l o p f o o t

u l c e r ; 5 - 1 5 % o f t h e s e n e e d a m p u t a t i o n

I f y o u t h i n k a n y a r e a o f y o u r c a r e n e e d s t o b e a d d r e s s e d p l e a s e m a k e a n o t e a n d d i s c u s s t h i s w i t h y o u r D i a b e t e s C a r e T e a m .

E n j o y t h e P o s t e r s !

S t r o k e

E y e D i s e a s e

H e a r t D i s e a s e

H i g h B l o o d P r e s s u r e

K i d n e y D i s e a s e

R e m e m b e r w i t h g o o d c a r e a l l

c o m p l i c a t i o n s c a n b e r e d u c e d

o r e v e n p r e v e n t e d !

P a i n o r l o s s o f t h e l o w e r l e g s d u e t o i m p a i r e d b l o o d f l o w

P e r i p h e r a l N e u r o p a t h y( n e r v e d i s e a s e )

Thank you for Thank you for listening !listening !