optimum care in type 2 diabetes: does one size fit all? james lasalle on behalf of the global...

Optimum Care in Type 2 Diabetes: Does One Size Fit All?

James LaSalle on behalf of the

Global Partnership for Effective Diabetes Management

This slideset was developed in 2009 with support from GlaxoSmithKline

Need to individualize patient care

"Good glycaemic control continues to have an essential role in type 2 diabetes management...

However, having reviewed the evidence, we recognise that individualising targets and/or treatment according

to patient type is paramount.

For example, while early intervention is preferred wherever appropriate, certain high risk groups may not respond to overly intensive glucose-lowering regimens

such as that utilised in ACCORD."

Del Prato S, et al. Int J Clin Pract 2009; in press.

Patient groups requiring special consideration

• Newly diagnosed individuals with type 2 diabetes, but no complications

– Overweight or obese adults– Lean adults

• Individuals with a history of poor glycemic control

– No complications– History of CVD

• Individuals at risk of hypoglycemia


Case study: Newly-diagnosed adults, nocomplications, overweight/obese

HbA1c > 6.5%

BMI > 25 kg/m2

Typically > 30 years of age

Mild symptoms or asymptomatic

Diagnosis before emergence of complications

No associated comorbidities e.g. hypertension,

dyslipidemia


Stepwise approach: delays control and leaves patients at risk of complications

OAD = oral antidiabetic

1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355. 2. Stratton IM, et al. BMJ 2000; 321:405–412.

Duration of diabetes

Hb

A1c

(%

)1

7

6

9

8

10

Diet andexercise

OADmonotherapy

OAD combination

OAD +basal insulin

OAD monotherapy

uptitration

OAD + multiple daily

insulin injections

Mean

Complications2

Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

Early, intensive intervention: reach glycemic goals and reduce the risk of complications

Duration of diabetes

Complications2

Diet andexercise

OAD monotherapy

OAD combination

OAD uptitration

OAD + basal insulin

OAD + multipledaily insulin

injections

Mean

OAD = oral antidiabetic

Hb

A1c

(%

)1

7

6

9

8

10

1. Adapted from Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355. 2. Stratton IM, et al. BMJ 2000; 321:405–412.

Copyright 2005 Blackwell Publishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.

Newly diagnosed adults, nocomplications, overweight/obese

Practical guidance: glycemic targets

GOAL: Bottom of target range (HbA1c 6.5–7%), even in patients with modest hyperglycemia (HbA1c < 7.5%)

HOW: Aim for HbA1c as close to normal as can safely be achieved without causing hypoglycemia or marked weight gain

If HbA1c < 7.5%, consider agents not associated with hypoglycemia that address the underlying pathophysiology

of diabetes


Newly diagnosed adults, nocomplications, overweight/obese

Practical guidance: other considerations

• As for all people with type 2 diabetes, diet and exercise should be continually reinforced

• Overweight and obese patients are at increased risk of CVD, pay particular attention to managing all CV risk factors

=Glycemic control Lipid-lowering Antihypertensives=HbA1c

FPG TC

LDLHDL

TGs SBP DBP

ABPM Del Prato S, et al. Int J Clin Pract 2009; in press.

Case study: newly diagnosed adults, no complications, lean

HbA1c > 6.5%

BMI < 25 kg/m2

Typically > 30 years of age

Mild symptoms or asymptomatic

Diagnosis before emergence of complications

No associated comorbidities, e.g. hypertension,

dyslipidemia


Lean patients may have a greater degree of -cell dysfunction

• Most individuals with type 2 diabetes are overweight or obese but this varies across the world

North America almost 90% of T2D are obese

South-East Asia* < 40% of T2D are obese

• In lean patients, -cell dysfunction is often more marked compared with overweight/obese individuals

– Particularly in some non-western populations

– LADA may also be more prevalent in lean patients

Brunetti P. Int J Clin Pract 2007; 61:3–9.

Newly diagnosed adults, nocomplications, lean


GOAL: Bottom of target range (HbA1c 6.5–7%), even in patients with modest hyperglycemia (HbA1c < 7.5%)

HOW: Aim for HbA1c as close to normal as can safely be achieved without causing hypoglycemia or marked weight gain


Newly diagnosed adults, nocomplications, lean


• Increased likelihood of β-cell dysfunction, therefore early therapy should include agents that support β-cell function

• Despite lower CV risk, lean individuals should still be educated about maintaining a healthy lifestyle to prevent weight gain

• Since LADA may be present, consider testing for autoantibodies, where possible

-celldysfunction


Case study: history of inadequate glycemic control, no complications

Likely to be older than newly diagnosed individuals

No complications and a longer duration of diabetes with inadequate glycemic control (HbA1c > 7.5%) ≥ 1 year

No associated comorbidities, e.g. hypertension, dyslipidemia


Level of care in patients with type 2 diabetes and sustained hyperglycemia

Lafata JE, et al. Diabetes Care 2009; 32:1447–1452.

*Appropriate care defined as medication intensification or HbA1c test result ≤ 7%.

0 10 20 30 40 50 600

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Months of sustained hyperglycemia

Pro

po

rtio

n o

f p

atie

nts

rec

eivi

ng

app

rop

riat

e ca

re

After 2 years,

11% of patients had still not received appropriate care*

After 12 months,

25% of patients had not received appropriate care*

After 6 months,

41% of patients had not received appropriate care*

Copyright 2009 American Diabetes Association. Reprinted with permission from The American Diabetes Association.

History of inadequate glycemic control, no complications


GOAL: Target near-normal HbA1c

HOW: Aim for a more gradual reduction in HbA1c versus newly diagnosed individuals

Reassess potential reasons for inadequate glycemic control, e.g.• overly conservative management, e.g. delay in introducing

combination therapy• inadequate adherence to antidiabetic regimens• inappropriate choice of agents (e.g. agents that do not address

the underlying pathophysiology)


Challenges in increasing adherence

Patient adherence to therapy

62% took tablets correctly in

relation to food

20% regularly forgot to take

their tablets

5% omitted tablets if their blood

glucose was too high

2% omitted tablets if their blood

glucose was too low

Browne DL, et al. Diabet Med 2000; 17:528–531.

Challenges in improving patient understanding

35% recalled receiving advice

about their medication

15% knew the mechanism of

action of their therapy

10% taking sulfonylureas knew

that they could cause hypoglycemia

20% taking metformin knew it

could cause gastrointestinal side effects

Patient knowledge of oral antidiabetic agents

Browne DL, et al. Diabet Med 2000; 17:528–531.

History of inadequate glycemic control, no complications


• Implement structured educational programs to motivate individuals with type 2 diabetes to assume a more active role in managing their condition

“I don’t need to take my tablets – I don’t feel ill”

“Complications only occur in patients who take insulin”


Case study: history of inadequate glycemic control and cardiovascular disease

Known history of CVD

Likely to have large pill burden and restrictions on choice of therapy due to comorbidities


History of inadequate glycemic control and cardiovascular disease


GOAL: Guidance as for patients with a history of inadequate glycemic control but no complications, i.e. target near-normal HbA1c

HOW: Take particular care to avoid hypoglycemia

Adopt less stringent glycemic targets and aim for a more gradual reduction in HbA1c


History of inadequate glycemic control and cardiovascular disease


• CV risk management should be intensified in these individuals

• Be vigilant for contraindications and other limitations concerning choice of agents and possible drug interactions


Case study: individuals at risk of hypoglycemia

Previous symptoms of hypoglycemia

Particularly wide daily glucose fluctuations

Individuals such as the elderly who often have impaired creatinine clearance, and irregular lifestyles/eating patterns increasing susceptibility to hypoglycemia

– Especially when taking hypoglycemic agents such as insulin and sulfonylureas


Increased risk of hypoglycemia with intensive glycemic control: ACCORD

0

5

10

15

20

Requiring

medical

assistance

Requiring any

assistance

Hyp

og

lyce

mia

(%

)

Intensive

Standard

*P < 0.001

*

*

Gerstein HC, et al. N Engl J Med 2008; 358:2545–2559.

16.2%

5.1%3.5%

10.5%

Individuals at risk of hypoglycemia


WHAT: Targets should be individualized according to the risk of hypoglycemia, e.g.

• history of severe or frequent hypoglycemia• kidney function• age of patient• previous CV events


Individuals at risk of hypoglycemia


• Educate patients on being alert to possible hypoglycemia, to increase awareness and responsiveness to symptoms of hypoglycemia

• Counseling particularly vulnerable patients such as the elderly on increased risk of hypoglycemia with irregular lifestyles/eating patterns and encourage compliance to prescribed regimens

• Emphasize the importance of regular self-monitoring of glucose where appropriate


Summary: one size does not fit all

• Good glycemic control, including early intervention, remains the cornerstone of diabetes care

• However, strategies to achieve glycemic targets

should always ensure patient safety• Treatment should be individualized to the

patient


optimum care in type 2 diabetes: does one size fit all? james lasalle on behalf of the global...

Documents

risk of complications

int j clin pract

prato s

lean hba

complications overweight

emergence of complications

complications likely

overweightobese hba