T1D incidence is rising 3-5% per year
70
Incidence /100,000/ yr
in children aged 0-14
60
Finland
50
Sweden
40
30
Colorado
20
Germany
10
0
1950
1960
1970
1980
1990
2000
Early stage
• TRIGR - cow’s milk elimination
Late stage
Ongoing Prevention Trials
• TrialNet – oral insulin
• NIP
- omega-3 nutritional supplementation
• PrePoint Study – oral insulin in high risk subjects
• TrialNet – oral GAD – in development
• TrialNet – anti-CD3, anti CD20, anti CTLA-4
Mean HbA1c in BDC patients by age
diabetes
> 1 year
BDC duration
HbA1c by Age
9.4
HbA1c
9.2
9
8.8
8.6
8.4
2000
2002
2004
2006
8.2
8
7.8
7.6
7.4
7.2
<6 yr
n = 150->171
6-12 yr
n = 611->850
13-19 yr
n = 806 -> 1205
Improvement of glycemic control in
Hannover children
Proportion of patients (%)
60
50
2000 n = 468
40
2001 n = 453
2002 n = 469
30
2003 n = 471
20
2004 n = 510
2005 n = 530
10
2006 n = 545
2007 n = 560
0
< 7.5 %
7.5 - 9.0 %
> 9.0 %
Individual yearly median HbA1c
T Danne 2008
Glycemic Control Is Improving in US
Adults with T2D & T1D
NHANES Diabetes Care 2008; 31:81-86
HbA1c has improved post-DCCT, but the
incidence of severe hypoglycemia has
doubled
Bulsara et al.
Diabetes Care 2004
Risk of Hypoglycemia vs. Complications
Severe
hypoglycemi
a /100 p-yrs
Diabetic retinopathy
Nephropathy
Neuropathy
Microalbuminuria
100
RR
15
13
ISPAD ‘07
11
80
9
60
7
5
40
3
20
0
1
6
7
8
9
10
11
adults ADA kids
Skyler JF. DCCT Endocrinol Metab Clin North Am. 1996;25:243-54
12
HbA1c %
Our goal is somewhere there,
but it depends on the patient and on a lot of other things
<8%
<7.5%
<7%
A1c as close to normal as possible
without severe hypoglycemia
Metabolic memory from the first year of DM
predicts later development of background retinopathy
probability for
remaining free of retinopathy
1
0,8
0,6
HbA1c (3-12mo) < 7.5%
(n=112)
0,4
p<0.03
HbA1c (3-12mo) > 7.5%
(n=109)
0,2
0
0
Berlin Retinopathy Study
5
10
15
12.4 14.4
diabetes
duration (years)
Prevalence of Hypertension at Each Year of the EDIC Study
JAMA 2003;290:2159-2167.
Copyright restrictions may apply.
Cumulative incidence of nonfatal MI,
stroke, or death from cardio. disease
Cumulative Incidence of the First Occurrence of Nonfatal
MI, Stroke, or CVD Death
0.12
0.10
0.08
Conventional
treatment
0.06
0.04
Intensive
treatment
0.02
0.00
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Years since entry
No. at Risk
Intensive
705
686
Conventional
721
694
640
118
637
96
N Engl
J Med
2005;
DCCT/EDIC Study Research
Group,
N Engl
J Med353;2643-2653
2005; 353:2643-53.
Mortality per 100,000 U.S. standard population
CVD incidence in T1D is increasing,
despite declining CVD mortality in the
general population
600
30 (%)
Cumulative incidence of
CAD by 30 yr T1D duration
500
25
400
20
300
15
200
10
100
5
0
T1D cohorts dx:
1950-59
1960
75
65
70
80
60-64 65-70
85
90
0
95
CDC/NCHS, National Vital Statistics System, Mortality
Pabianco G et al. EDC Study , Diabetes 2006 55:1463-9
2000
2005
Think Activity
Encourage daily activity, year-round
Insulin Sensitivity
200%
150%
daily
100%
2-3 x/wk
never
50%
0%
M
G Scheiner 2008
Tu
W
Th
F
Sa
S
Recommended LDL-Cholesterol Concentrations for Pharmacologic
Treatment of Children and Adolescents 10 Years and Older
Patient characteristics
Recommended cutoff points
No other risk factors for
cardiovascular disease
LDL-C levels persistently
>190 mg/dL despite diet Rx
Other risk factors present,
(obesity, hypertension, smoking
family history of premature CVD)
LDL-C levels persistently
>160 mg/dL despite diet Rx
Children with diabetes
mellitus
LDL-C levels ≥130 mg/dL
LDL-C levels ≥100 mg/dL
Daniels SR et al. Pediatrics 2008; 122:198-208.
Changes in Insulin Therapy 1986 - 2007
100
Proportion of patients (%)
Two injections
MDI
CSII
80
60
40
20
0
1986 90
94
n= 339 425
521
T Danne, Hannover, 2008
99
458
03
471
04
05
06
07
510
530
545
589
Insulin Therapy MDI vs. CSII
HbA1c distribution
MDI
CSII
T Danne, Hannover 2006
Improved Nightime Glucose Excursions with STS Glucose Sensor
Garg S et al: Diabetes Care: 2006, 29; 44-50
4
Blinded period
Unblinded period
Time Spent (hours)
*p < 0.0001
8%
Increase*
3
14%
Increase*
9%
Reduction*
2
33%
Reduction*
38%
Reduction*
1
0.33
0.21
0.59
0.40
1.89
2.15
2.99
3.24
2.20
2.01
0
<55
55-80
81-140
141-240
Glucose Range (mg/dl)
241-400
CGM/CSII help those who use it,
not those who just wear it!
STAR 1: 138 CSII patients on CGM for 6 months
HbA1c (%)
10
Before
6 month on CGM
9
8
7
6
100% compliant
Hirsh I. et al, STAR 1, ADA 2007, abstract 90
<60% compliant
Glucose Levels in CL vs. Hybrid Control
Glucose (mg/dl)
300
setpoint
Closed Loop (N=8)
meals
Hybrid CL (N=9)
200
100
0
6A
Noon
6P
MidN
6A
Noon
Plasma Insulin (U/mL)
100
Weinzimer et al. DC 2008;31:934
80
60
40
Closed Loop
20
Hybrid CL
0
0
60
120
Time (min)
180
240
6P
Nasal Exenatide Serum Glucose and Insulin
Serum Glucose
Placebo
600 mcg IN
Serum Glucose (mg/dL)
240
220
200
180
160
140
120
100
80
0
30
60
90
120
150
180
210
240
Time (min)
Exenatide
followed by
breakfast
Blase et al. Diabetes 2008 57: Suupl 1: Abstract 195-OR.
Patients Using Insulin Pumps
& CG sensors
400,000
300,000
Pumps
CG sensors
200,000
100,000
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
0
HSBC Global Research
Dow Jones
Cost Estimates of Intensive Treatment
Annual Cost Estimates*
Pumps
MDI
DCCT 1995
$5,800
$4,000
BDC 2003 2008
$9,400
$11,000
$4,900
$ 7,000
* cost of DKA, hypoglycemia not included
Between 2000 and 2006, Colorado
had a 73 percent increase in the number
Of children living in poverty
Two tracks of diabetes care:
For Haves and Have Nots?
Health care reform, perhaps?
Electronic Medical Record
Patient web portal
- replace ‘log-book’
- empower patient
- interface with provider
- 3rd party reimbursement
Therapy Accessibility & Consumer Electronics Integration
Confidential. Not to be circulated outside of Medtronic
30
Thank you for coming and for active
participation!
Safe travels!
Final versions of slides next week on
www. BarbaraDavisCenter.org
Many thanks to the Speakers, Sponsors and
Staff!
See you back in July 2010!