recent recommendations for the treatment of type 2 diabetes idf vs easd ada vs french a consensus?...
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Recent recommendationsRecent recommendationsfor the treatment of type 2 diabetesfor the treatment of type 2 diabetes
IDFIDF vs EASD ADA vs vs EASD ADA vs FrenchFrench A consensus?A consensus?
S. HALIMIS. HALIMI
•President of the French Guidelines HASPresident of the French Guidelines HAS•Vice President ALFEDIAMVice President ALFEDIAM•Vice President MGSDVice President MGSD
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Percentage of diabetes among major CV and renal diseases
•European DialysisEuropean Dialysis
• and Transplantation Associationand Transplantation Association
6060
2020
4040
3030
5050
1010
Dia
bet
ic
Dia
bet
ic P
atie
nts
Pat
ien
ts (%
)(%
)
00
AmputationsAmputations
50%
Diabetes prevalence 3–5%Diabetes prevalence 3–5%
Myocardial InfarctionMyocardial InfarctionFemaleFemale MaleMale
25%25%33%33%
38%38%36%36%
GERGER FRFRUSUS GERGER FRFR
25%25%25%25%
USUS AustriaAustria
29%29%
StrokeStroke
30%30%27%27%
EUREUR
EDTA*EDTA* JapanJapan
ESRDESRD
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http://www.idf.org
Diabetes is expected to cause 3.8 million deaths worldwide in 2007, about 6% of total global mortality, about the same as HIV/AIDS. Using World Health Organization (WHO) figures on years of life lost per person dying of diabetes, this translates into more than 25 million years of life lost each year.
Diabetes is expected to cause 3.8 million deaths worldwide in 2007, about 6% of total global mortality, about the same as HIV/AIDS. Using World Health Organization (WHO) figures on years of life lost per person dying of diabetes, this translates into more than 25 million years of life lost each year.
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BP recommendations
• ADA EASDADA EASD– Goal: < 130/80 mmHgGoal: < 130/80 mmHg– Goal: < 125/75 mmHg if proteinuriaGoal: < 125/75 mmHg if proteinuria– Goal > to the drug utilizedGoal > to the drug utilized
• IDF IDF – goal <130/80 in Diabetic nephropathygoal <130/80 in Diabetic nephropathy– goal <140/80 in other Type 2 DMgoal <140/80 in other Type 2 DM– Probably more realisticProbably more realistic
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Microvascular Complications
UKPDSUKPDS 7575
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ACE Sartans BBBB I Ca
Insuffisance cardiaque
Nephropathy in DT2
Microalbuminuria
Proteinuria
HVG
DT 2 + HTA
Which Antihypertensive drugs ADA EASD French IDF guidelinesIDF guidelines
DiurTzd Anti-
aldost
VDVDCentralCentral
High CV risk
High CV risk
2ary 2ary prevention
prevention
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Prév. 2aireou mal rénale
ou > 10 ans AD+ 2 FR
avec 0 FRavec 0 FRsans micro Angsans micro Ang
< 5 ans d’AD< 5 ans d’AD
Number of RF
LDL-C (g/l)
+ 1 seul FR
< 10 ans AD+ 2 FR
1.9 160160 100100130130
Type 2 DiabetesType 2 Diabetes
French recommendations 2006French recommendations 2006ADA GuidelinesIDF 95 mg/dlIDF 95 mg/dl
CV prevention
STATINSSTATINSVery low risk Very low risk
Low risk Low risk
Medium RiskMedium Risk
High risk High risk ++
2 ary prevention2 ary prevention
Stop Soking
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Guidelines
Blood Glucose Control
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Microangiopathy and threshold: retinopathy
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CV complication and glucose tolerance
0
5
10
15
20
25
30
Normal Intolérance glucose Diabète nondiagnostiqué
débutant
Diabète établi
Normal Intolérance glucose Diabète non diagnostiqué débutant Diabète établi
3174 subjects (30-74 years) 2nd NHANES 1976 - 1980-1990 (% CV death during the follow-up according to glycemic status )
Prof. Serge HALIMI
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Myocardial Infarction
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Why new recommendations ?Why new recommendations ?
UKDS trial revisited regarding UKDS trial revisited regarding
the design and the conclusionsthe design and the conclusions
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Usual strategyUsual strategy
DIet and physical activity
One OAD
Combination of several OADs
Insulin + OADs
Insulin
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Adapted from UKPDS 16. Diabetes 1995;44:1249–58
Years from diagnosis
Bet
a-ce
ll f
un
ctio
n (
%)
–10 –8 –6 –4 –2 0 2 46
100
80
60
40
20
0
Beginning of the disease
––1212
How to improve InsSensitivity
How to preventB cell failure
UKPDS worsening of Insulin secretion
Diagnosis
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UKPDS : Worsening of Glycated Hb in both groups
(1) U.K. Prospective Diabetes Study Group. Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; Vol 352 : 837-853.
06
7
8
9
0 3 6 9 12 15Years after randomization
« Conventional »
« Intensive »
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Why new recommendations ?Why new recommendations ?TThe UKPDS trial Revisited : regarding the design and the he UKPDS trial Revisited : regarding the design and the
conclusions conclusions
• Constant worsening of HbA1c in UKPDS in both Constant worsening of HbA1c in UKPDS in both groupsgroups
• Natural history of the disease (unavoidable) or Natural history of the disease (unavoidable) or consequence of the design of the trial…old consequence of the design of the trial…old strategies !strategies !
• Threshold 7 - 8% for treatment adaptation Threshold 7 - 8% for treatment adaptation (i.e. (i.e. addition of drugs or new regimens)addition of drugs or new regimens) for preventing this for preventing this worsening ?worsening ?
• Deleterious effects of Glucotoxicity Deleterious effects of Glucotoxicity – on Insulin secretionon Insulin secretion– on Insulin resistanceon Insulin resistance– and vascular complicationsand vascular complications
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Pivotal role of 3-4 HbA1c measurements/year
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7% 8% 7% 8%
64%
75%
Easier is the obstacle (fence) lower jumps the horse
19%19%
43%43%
Probability next > 8%
Probability next > 7%
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ConsequencesConsequences
RHD 1 OAD 2 OAD Insulin
8 %
6 %
7 %
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3 dimensions
• Metformin as early and as often as possible– Low cost– No hypoglycemia – BW benefit (alone or + OADs or Insulin)– CV prevention ?
• More OADs synergistic associations– Early– Lower thresholds for reinforcement
• New drugs (GTZ)– when well adapted to the patient and – metabolic profile– New target on pathogenesis of T2DM– Allowing for Tritherapy
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Why new recommendations ?Why new recommendations ? 2006 consensus 2006 consensus
August 2006August 2006
EASD ADAEASD ADA
IDFIDF
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HbA1c Goals HbA1c Goals IDFIDF EASD ADA EASD ADA FrenchFrench guidelines guidelines
Similarities and subtle disagreementsSimilarities and subtle disagreementsEASD ADA 2006 EASD ADA 2006 consensusconsensus
• Try to achieve « near normal glycemia» mainly at the very beginning of the disease
• Goal 7%7% HbA1c for a large majority of type 2 DM patients
• Proposed for all type 2 DM
• Only achieved in 1/3 patients in Europe
IDF GuidelinesIDF Guidelines• Goals range 6-7.5% • Progression from pre-diabetic impaired
glucose tolerance to type 2 diabetes has recently become a target for early intervention with pharmacological agents.
French Guidelines
• Consistent with ADA EASD IDF.• ~ 48% French cohort (ENTRED)
have 7% HbA1c or less• 25% ≤ 6.5%
• Consistent• However the upper limit of the normal
value for HbA1c is 6,1% (+2DS) and not 7%
• For some patients 6.5% HbA1c even 6% would be the goal
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EASD ADA Consensus
?
Metformin
Metformin
Metformin
Metformin
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Health policy messageHealth policy message 7% 7% for a large majority of patientsfor a large majority of patients
vs < 50% (France< 50% (France))
How to improve type 2 diabetes management for the next 10 years ?
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French Guidelines
Lifestyle intervention
> 6.5%> 6.5%
Metformin SU
> 6.5%> 6.5%
No hypo Higher HbA1c rapid action
Metformin
66-6.5%6.5%
No hypo
Metformin
Add SUAdd GTZ
No hypoFast action
few expansive
Add GTZ Metformin
SU
Fast action few expansive
Infrequent association
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From 2 OADs to Tritherapy or Insulin
Call to actionCall to action > 7% > 7%
Metformin SUGTZ
No hypo
Metformin
Fast action few expansive
Fast action few expansive
Infrequent association
GTZ SU
Insulin + OADsTritherapyMet + GTZ + Su
Call to actionCall to action
≥≥ 8%8%
Intensive Insulin + Metf± GTZ
Call to action Call to action
> 7%> 7%
1 OAD > 6.5%
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For a better management of Type 2 DM
1 OAD : Metformin max dose
Lifestyle Combination
2 OADs
TritherapyMetf+SU+GT
Z
Insulin + OADs
Lifestyle
1 OAD2 OADs
Insulin
7
8
6.5
6
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< 6.5%< 6.5% 6.5 % 6.5 % → 8%→ 8%French guidelines 1998French guidelines 199820062006
3 categories of patients 3 categories of patients
Early diagnosed and treatedHyperglycemia = ModerateHyperglycemia = Recent Compliance = GoodMotivation = GoodAvailable = Ther. Resources and therapeutic education
6 – 6.5 %6 – 6.5 %
Late diagnosis or treated More marked hyperglycemiaPoor compliancePoor MotivationFew or no Therapeutic education-tools
7 %7 %
Elderly diabeticsLate appearanceHard contextFew therapeutic resourcesNo valuable glycemicbenefit
>7 % to >7 % to 8%8%
Both Goals and Message to avoid deterioration Both Goals and Message to avoid deterioration
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ConclusionConclusionEarly Strong Strict Treatment
• Recommendations are intended to GPs and patientsRecommendations are intended to GPs and patients– Early diagnosis – “don’t consider as minor” slightly elevated HbA1c – Pivotal role of Glycated Hemoglobin – Don’t tolerate deterioration > 3-6 months
• Be strict on the goals as often as possibleBe strict on the goals as often as possible • CombineCombine OADs as soon as possible OADs as soon as possible• Don’t delay the use of insulininsulin• Don’t present it as a threatthreat but as an alternativealternative
treatment• SafetySafety : : consider the benefit/risk of new OADs• CostCost: consider the cost of old and new classes: consider the cost of old and new classes• French guidelines close to IDF but strict +++ Vs ADA-EASDFrench guidelines close to IDF but strict +++ Vs ADA-EASD