Type 2 Diabetes:
Disease State Overview
AF2086R0
Suggestions for Slide Deck Use
• The following unbranded slides are provided as a disease state
library and may be used as background information at the
beginning of any promotional program
• These slides should always supplement the affirmative deck
unless the program is scheduled to be "disease state only"
Diabetes Disease State Overview
• Diabetes: epidemiology/pathophysiology
– Prevalence and burden of diabetes
– Core defects of type 2 diabetes
– Complications and costs associated with type 2 diabetes
– Predicting and preventing type 2 diabetes
• Treatment goals and strategies
– Improving glycemic control
– Reducing diabetes-related complications
– Treating the whole patient
Every Day in the United States Approximately…
66 people lose
their eyesight
because of diabetes
128 people begin
treatment for end-stage
renal disease (ESRD)
More than 4000 new
cases* of diabetes will be
diagnosed today
195 lower-limb
amputations are performed
because of diabetes
640 people die from
diabetes and its
complications
*Patients ages ≥20 years.
Centers for Disease Control. National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed March 5, 2009.
≈23.5 Million (10.7%) Americans 20 Years or Older Have
Diabetes (Diagnosed or Undiagnosed)*
25
23.8
Percentage
20
15
10.8
10
5
0
2.6
20–39
40–59
60+
Age group
*Data is from 2003–2006, projected to year 2007.
NIDDK. National Diabetes Statistics. 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.
Accessed February 11, 2009.
Adults Diagnosed with Diabetes in the
United States*
1.6 million new cases of diabetes were diagnosed in people aged
20 years or older in 2007
1,000,000
Total economic costs of
819,000
Number
800,000
600,000
400,000
diabetes estimated to be
$174 billion (2007)
536,000
281,000
200,000
0
20–39
40–59
Age group
60+
*Data is from 2004–2006, projected to year 2007.
NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.
Accessed February 11, 2009.
Age-adjusted Total Prevalence of Diabetes in the United
States by Race/Ethnicity (Age ≥20)
17
American Indians/Alaska Natives
12
Non-Hispanic Blacks
10
Hispanic/Latino Americans
Asian Americans
8
7
Non-Hispanic Whites
0
2
4
6
8 10 12
Percentage
14
16
18
NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.
Accessed February 11, 2009.
20
Economic Consequences of Diabetes
Total Annual Cost in 2002: $132 Billion
Indirect costs* = $40 billion
Disability and early mortality
Direct costs† = $92 billion
$23 billion
$40 billion
$25 billion
Diabetes and diabetes supplies
Chronic complications
$44 billion
General medical conditions
*Indirect costs include lost productivity, disability, and premature mortality.
†Direct costs include: hospital inpatient care, nursing home care, physician office visits, total home healthcare costs, costs associated
with hospice care, and diabetes supplies.
Stolar MW et al. JMCP. 2008;14:S1–S19.
Annual Medical Expenditures and Length of
Time with Diabetes
Annual cost increases with length of time with diabetes
7000
Diagnosis of diabetes at age 50
Diagnosis of diabetes at age 65
Cost in 2005 (dollars)
6000
5000
4000
3000
2000
1000
0
0
5
10
Duration of Diabetes (Years)
Adapted from Trogdon JG et al. Diabetes Care. 2008;31:2307–2311.
15
Pathophysiology of Type 2 Diabetes
• Type 2 diabetes results from a progressive insulin secretory defect on
the background of insulin resistance1
• Key pathophysiologic mechanisms leading to hyperglycemia in type 2
diabetes
– Insulin resistance2,3
– Beta-cell dysfunction3
1. American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
2. DeFronzo RA. Med Clin North Am. 2004;88:787–835.
3. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
Two Defects Contributing to Type 2 Diabetes
Obesity (visceral)2
Obesity (visceral)1
Insulin
resistance
Liver
Muscle tissue
Beta-cell
dysfunction
Adipose tissue
Pancreas
Beta-cell
Type 2 Diabetes
1. Buchanan TA. Clin Ther. 2003;25(suppl 2):B32–B46.
2. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
Natural Progression of Insulin Resistance in
Patients with Type 2 Diabetes1,2
Insulin resistance
Normal
glycemia
Insulin resistance
rises, leading to
beta cells working
overtime to secrete
more insulin
Beta cells are unable to produce the insulin
needed to compensate for the increased
level of insulin resistance, causing glucose
levels to rise, leading to type 2 diabetes*
*Type 2 diabetes is diagnosed when FPG is ≥126 mg/dL.3
Adapted from International Diabetes Center, Minneapolis, MN.1
1. Bergenstal RM et al. Endocrinology. 4th ed. Philadelphia, PA: WB Saunders Company;2001:821–835.
2. Ramlo-Halsted BA, Edelman SV. Clin Diab. 2000;18:80–85.
3. American Diabetes Association. Diabetes Care. 2008;31(suppl1):S12–S54.
Type 2 Diabetes
Associated with Serious Complications
Diabetic
Retinopathy
Leading cause
of blindness
in adults
Stroke
CV Disease & Stroke
account for ~65% of
deaths in T2D patients
Cardiovascular
Disease
Diabetic
Nephropathy
Major cause of
kidney failure
Diabetic
Neuropathy
Major cause of lower
extremity amputations
CV = cardiovascular.
National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national
estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of
Health, 2005.
Prevalence of Multiple Complications
Among People with Type 2 Diabetes
4 or more
complications
7.6%
No complications
42.1%
3 complications
6.7%
2 complications
10.3%
1 complication
33.3%
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at:
http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
Prevalence of Macrovascular and Microvascular
Complications of Diabetes
30
27.8
Diagnosed diabetes
Percentage with complications
Normal blood sugar levels
22.9
18.9
20
9.8
9.5
10
1.8
10
9.1
1.7
7.9
2.1
6.6
1.1
6.1
1.8
0
Heart attack
Chest pain
CHD
Macrovascular
CHF
Stroke
Chronic kidney Foot problems† Eye damage‡
disease*
Microvascular
*In NHANES, “chronic kidney disease" refers to people with microalbuminuria (albumin:creatinine ratio >30 µg/mg).
†In the NHANES analysis, "foot problems" includes foot/toe amputations, foot lesions, and numbness in the feet.
‡"Eye damage" includes a positive response by NHANES participants to the question, "Have you been told diabetes has affected your eyes/had retinopathy?"
Retinopathy is damage to the eye's retina. In NHANES, people without diagnosed diabetes were not asked this question, therefore, prevalence information for
nondiabetics is not available.
CHD = coronary heart disease; CHF = congestive heart failure.
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at:
http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 9, 2009.
Prevalence of retinopathy
in diabetics age ≥40 years (%)
Prevalence of Diabetic Retinopathy
50
40.3%*
40
30
20
8.2%†
10
0
Diabetic retinopathy ‡
Vision-threatening
retinopathy §
*95% CI: 38.8%–41.7%
†95% CI: 7.4%–9.1%
‡Diabetic retinopathy defined as a retinal vascular disorder characterized by signs of retinal ischemia and/or signs of increased retinal
vascular permeability. Retinopathy severity level ≥14 retinopathy and/or macular edema.
§Vision threatening retinopathy defined as severe retinopathy and/or diabetic macular edema. Retinopathy severity level ≥50 and/or
macular edema.
Kempen JH et al. Arch Ophthalmol. 2004;122:552–563.
Number of Cases with ESRD Due to Diabetic Nephropathy
Is Increasing in the United States
Diabetes is the leading cause of ESRD
Number of cases
(thousands)
50
40
30
20
10
0
1990
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
ESRD = end-stage renal disease.
CDC. Morbidity and Mortality Weekly Report. 2005;54(43)1097–1100.
CV Risk in Patients with Diabetes and No Prior MI Is
Similar to Risk in Nondiabetics with Prior MI
A population study of 3.3 million people
5-year incidence (%)
Men
45
40
35
30
25
20
15
10
5
0
No diabetes/prior MI
No diabetes/no prior MI
Diabetes/prior MI
Diabetes/no prior MI
Women
39.8
34.1
24.5
20.1
15.6
14.6
3.5
CV death
3.7
CV death
CV = cardiovascular. For CV death, the hazard ratio was 2.42 in men with diabetes only and 2.44 in men with a prior MI only (P=0.60). Results
for women were 2.45 and 2.62, respectively (P<0.001).
Schramm TK et al. Circulation. 2008; 117:1945–1954.
Annual National Cost of Type 2 Diabetes and
Related Complications*
$70.0
Cost in billions
$60.0
$50.0
National total expenditures
$57.1
National out-of-pocket costs
$40.0
$30.0
$22.9
$20.0
$10.0
$8.4
$1.8
$0.0
Complications alone
Diabetes and complications
*Cost estimates in this report were adjusted for inflation to reflect 2006 costs.
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at:
http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
Individual Costs by Complication*
$ 1785
Eye damage
Total expenditures
Out-of-pocket costs
$ 480
$ 4687
Foot problems
$ 153
$ 6062
CHD
$ 224
$ 7806
Stroke
$ 448
$ 7932
CHF
$ 510
$ 9002
Chronic kidney disease
$ 439
$ 14,150
Heart attack
$ 574
$0
$ 2000
$ 4000
$ 6000
$ 8000
$ 10,000
Annual Healthcare Costs
$ 12,000
$ 14,000
*Cost estimates in this report were adjusted for inflation to reflect 2006 costs.
American Association of Clinical Endocrinologists. State of Diabetes Complications in America Report. Available at:
http://www.aace.com/newsroom/press/2007/images/DiabetesComplicationsReport_FINAL.pdf. Accessed March 5, 2009.
$ 16,000
Algorithm to Estimate Type 2 Diabetes Risk
Item
Points
Fasting glucose level 100–126 mg/dL, yes/no
10
Body mass index (BMI) 25.0–29.9, yes/no
2
BMI ≥30.0, yes/no
5
High-density lipoprotein cholesterol (HDL-C) level <40 mg/dL in
men or <50 mg/dL in women, yes/no
5
Parental history of diabetes mellitus, yes/no
3
Triglyceride level ≥150 mg/dL, yes/no
3
Blood pressure ≥130/85 mmHg or receiving treatment, yes/no
2
According to a study in a middle-aged white population, total points ≥25
corresponds to >35% 8-year risk of type 2 diabetes.
Wilson PW et al. Arch Intern Med. 2007;167:1068–1074.
Preventing Development of Type 2 Diabetes
•
Screening for prediabetes and asymptomatic type 2 diabetes should be
considered in adults who are overweight or obese (BMI ≥25 kg/m2) and have
additional risk factors
•
In those without risk factors, testing should begin at age 45 years
•
If results are normal, testing should be repeated at least every 3 years
•
Counseling on lifestyle modification is recommended for patients with
impaired fasting glucose or impaired glucose tolerance
– Weight-loss goal of 5%–10% of initial body weight
– Physical activity with moderate intensity for 150 minutes per week
American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61.
Summary of Diabetes:
Epidemiology/Pathophysiology
• Diabetes and diabetes-related complications (eg, heart disease,
kidney disease, blindness, amputations) are highly prevalent1
• The pathophysiology of diabetes involves the development of
insulin resistance and beta-cell dysfunction2
• Diabetes is strongly correlated with a number of microvascular
risk factors and diseases, and is a contributor to
macrovascular disease and mortality1
• Routine clinical measures may be used to identify patients at
risk of developing type 2 diabetes who may benefit from
lifestyle counseling3
1. NIDDK. National Diabetes Statistics. November 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/#y_people.
Accessed February 11, 2009.
2. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
3. American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13–S61.
Diabetes Disease State Overview
• Diabetes: epidemiology/pathophysiology
– Prevalence and burden of diabetes
– Core defects of type 2 diabetes
– Complications and cost associated with type 2 diabetes
– Predicting and preventing type 2 diabetes
• Treatment goals and strategies
– Improving glycemic control
– Reducing diabetes-related complications
– Treating the whole patient
Criteria for the Diagnosis of Diabetes Mellitus:
ADA Standards of Medical Care, 2009
•
FPG 126 mg/dL (7.0 mmol/L)
– Fasting is defined as no caloric intake for at least 8 hours
•
OR
Symptoms of hyperglycemia plus casual plasma glucose concentration
200 mg/dL (11.1 mmol/L)
– Casual is defined as any time of day without regard to time since last meal
– The classic symptoms of hyperglycemia include polyuria, polydipsia, and
unexplained weight loss
•
OR
2-h plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT
– The test should be performed as described by WHO, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water
ADA = American Diabetes Association; OGTT = oral glucose tolerance test, WHO = World Health Organization.
American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
Recommendations for Early Pharmacologic
Treatment from AACE and ADA
• To reduce the risk of serious disease-related complications,1,2
AACE recommends
– Target A1C goal of ≤6.5%2
– Earlier intervention with appropriate therapies and persistent
titration to achieve goal2
• ADA recommends3
– Target A1C goal of <7% “for most patients”
– Achieving and maintaining glycemic goals and changing
interventions when therapeutic goals are not being met
AACE = American Association of Clinical Endocrinologists.
1. Stratton IM et al. BMJ. 2000;321:405–412.
2. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):4–68.
3. American Diabetes Association. Diabetes Care. 2009;32:S13–S61.
Conventional Monotherapies
Unable to Maintain Glycemic Control Over Time
United Kingdom Prospective Diabetes Study (UKPDS)
10
Conventional*
Median A1C (%)
9
Insulin
Glibenclamide (glyburide)
8
MET
ADA Goal
7
AACE Goal
6
0
0
3
6
9
12
Time from randomization (years)
15
FPG = fasting plasma glucose; MET = metformin.
*Conventional therapy defined as dietary advice given at 3-month intervals where FPG was targeted at best levels feasible in clinical practice.
If FPG exceeded 270 mg/dL, patients were re-randomized to receive nonintensive MET, chlorpropamide, glibenclamide, or insulin. If FPG
exceeded 270 mg/dL again, those on SU would have MET added. If FPG exceeded 270 mg/dL after this, insulin was substituted.
Adapted from UK Prospective Diabetes Study (UKPDS 34) Group. Lancet. 1998;352:854–865.
Glycemic Targets Are Not Being
Achieved Worldwide
CANADA
(DICE)1
UNITED STATES
(NHANES)2
EUROPE
(RECAP-DM)3
HbA1c <7%
HbA1c <7%
HbA1c <6.5%
51%
57%
49%

Patients reaching glycemic target
43%

26%
74%

Patients not reaching glycemic target
DICE = Diabetes in Canada Evaluation; NHANES = National Health and Nutrition Examination Surveys; RECAP-DM = Real-life
Effectiveness and Care Patterns of Diabetes Management.
1. Harris SB et al. Diabetes Res Clin Pract. 2005;70:90–97.
2. Ong et al. Ann Epidemol. 2008;18:222–229.
3. Guisasola et al. Diabetes Obes Metab. 2008;10:8–15.
Patients Remain on Monotherapy
>2 Years After First A1C >8.0%*
Length of time between first monotherapy
(A1C >8.0%) and switch/addition in therapy*
SU Only
35.1
MET Only
26.5
0
6
12
18
24
Months
*May include uptitration.
Based on a prospective, population-based study using retrospective observational data.
Brown JB et al. Diabetes Care. 2004;27:1535–1540.
30
36
Risk of CV Events or Death Increased with HbA1c Level
(EPIC-Norfolk)
5–5.4%
HbA1c level:
6.0–6.4%
7%
6.5–6.9%
Men
8
Age-adjusted relative risk (95% CI)
5.5–5.9%
Women
7.96
7.07
7
6.91
6
5.01
5
4
3.49
3.44
2.00
3.06
2.13
1.56
1
0
3.38
3.03
3
2
4.73
CHD events
2.37
2.29
1.56
1.79
1.23
CVD events
1.57
1.80
1.25
1.63
0.96 1.04
All-cause
mortality
CHD events
0.89
0.98
CVD events
1.02
1.28
1.61 1.70
All-cause
mortality
P0.001 for linear trend across HbA1c categories for all endpoints.
CHD = coronary heart disease; CI = confidence interval; CVD = cardiovascular disease; EPIC-Norfolk = European prospective investigation
into cancer in Norfolk.
Khaw KT et al. Ann Intern Med 2004; 141:413–420.
Multifactorial Approach: Strategies for Reducing Diabetic
Complications—Treating the Whole Patient
• Strategies for reducing microvascular complications
– Routine screening for diabetes
– Optimized glycemic control
– Optimized BP control
• Strategies for reducing macrovascular complications
– Optimized glycemic control
– Treatment of hypertension and other established cardiovascular risk
factors in diabetic and possibly prediabetic subjects*
– Lipid control*
– Antiplatelet therapy*
*For appropriate patient population based on treatment guidelines.
American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Improved Glycemic Control Has Been Shown to Help
Reduce the Risk of Complications
According to the United Kingdom Prospective Diabetes
Study (UKPDS) 35, every 1% decrease in A1C resulted in:
21%
37%
Decrease
in risk of
microvascular
complications
(P<0.0001)
Stratton IM et al. BMJ. 2000;321:405–412.
Decrease
in risk of any
diabetes-related
endpoint
(P<0.0001)
UKPDS:
Long-Term Intensive Glucose Control in Type 2 Diabetes
•
•
•
•
Multicenter, randomized study with 10-year follow-up1
– One of the longest and largest type 2 diabetes trials ever conducted2
– 4209 patients newly diagnosed with type 2 diabetes1
Study Design
– After a 3-month run-in period, patients with FPG >108 mg/dL but <270 mg/dL
were randomized to receive either intensive therapy (SU or insulin or, if more
than 120% of ideal body weight, MET) or conventional therapy (diet only)1
Primary study objective
– To determine whether long-term improved glycemic control was able to sustain
risk reductions in microvascular complications, and if intensive therapy had a
long-term effect on macrovascular outcomes1
Primary outcome
– Prespecified aggregate clinical outcomes were any diabetes-related endpoint,
diabetes-related death, death from any cause, myocardial infarction, stroke,
peripheral vascular disease, and microvascular disease1
FPG = fasting plasma glucose.
1. Holman et al. N Engl J Med. 2008;359:1577–1589.
2. Lawton J et al. Br J Gen Pract. 2003;53:394–398.
Sustained Intensive Glycemic Control Can Reduce
Diabetes-Related Complications
Risk Reductions for Intensive-Therapy Regimens at 10-Year Follow-up
SUinsulin
MET
SUinsulin
MET
SUinsulin
MET
SUinsulin
MET
-9%
-16%
-21%
-13%
-15%
-24%
-27%
-33%
•
Any diabetes-related
endpoint
Microvascular
disease
Myocardial
infarction
Death from
any cause
(P = 0.04 for SU-insulin;
P = 0.01 for MET)
(P = 0.001 for SU-insulin;
P = 0.31 for MET)
(P = 0.01 for SU-insulin;
P = 0.005 for MET)
(P = 0.007 for SU-insulin;
P = 0.002 for MET)
Long-term intensive glycemic control is associated with a significantly decreased
risk of MI or death from any cause, in addition to known risk reductions in
microvascular disease
Holman et al. N Engl J Med. 2008;359:1577–1589.
Treating the Whole Patient: Statin Therapy in Patients
with Diabetes Reduced CV Risk (CARDS)
Relative CV Risk Reduction 37% (95% CI: –52 to –17)
Cumulative hazard (%)
15
P = 0.001
Placebo
127 CV events*
10
Atorvastatin
83 CV events*
5
0
Placebo
0
1
2
3
1410
1351
1306
1022
651
305
1361
1074
694
328
1428
1392
Atorvastatin
*CV events included stroke.
CARDS = Collaborative Atorvastatin Diabetes Study.
Colhoun HM et al. Lancet. 2004;364:685–696.
4
4.75
Years
Treating the Whole Patient: Patients Reaching Intensive
Treatment Goals at 7.8 Years* (Steno-2)
80
P<0.001
70
P = 0.19
60
Patients (%)
50
Intensive
therapy (n = 80)†
Conventional
therapy (n = 80)‡
P = 0.21
P = 0.001
40
30
20
P = 0.06
10
0
A1C
<6.5%
Cholesterol
<175 mg/dL
Triglycerides
<150 mg/dL
Systolic BP
<130 mmHg
Diastolic BP
<80 mmHg
*Mean.
†Intensive treatment included stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia,
hypertension, dyslipidemia, and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin.
‡Conventional treatment was based on the Danish Medical Association guidelines.
Gæde et al. N Engl J Med. 2003;348:383–393.
Treating the Whole Patient: Intensive Therapy Reduced
Composite Macrovascular Endpoints (Steno-2)
Primary composite endpoint* (%)
60
Conventional therapy
50
HR† = 0.47
(95% CI, 0.24-0.73)
40
53%
30
20
Intensive therapy
10
0
0
12
24
36
48
60
Months of Follow-up
72
84
96
*Composite endpoint of death from cardiovascular causes, nonfatal myocardial infarction, coronary-artery bypass grafting, percutaneous
coronary intervention, nonfatal stroke, amputation, or surgery for peripheral atherosclerotic artery disease, P=0.007; †Unadjusted HR.
CI = confidence interval; HR = hazard ratio.
Gæde et al. N Engl J Med. 2003;348:383–393.
Treating the Whole Patient: a 5.5-Year* Follow-up (Steno-2)
Intensive Therapy Sustains Cardiovascular Benefits
80
HR 0.41
(95% CI, 0.25 to 0.67; P<0.001)
Cumulative Incidence of Any
Cardiovascular Event† (%)
70
60
Conventional therapy
59%
50
40
30
Intensive therapy
20
10
0
0
1
2
3
4
5
6
7
8
Years of Follow-up
9
10
11
12
13
*Mean. †Secondary composite endpoint of cardiovascular events, including death from cardiovascular causes, nonfatal stroke, nonfatal
myocardial infarction, coronary-artery bypass grafting, percutaneous coronary intervention, revascularization for peripheral
atherosclerotic artery disease, and amputation.
Gæde et al. N Engl J Med. 2008;358:580–591.
Management of Type 2 Diabetes
•
Type 2 diabetes requires a multifactorial approach for the management of
glucose levels, blood pressure, and lipids to reduce complications1
•
Recommendations for type 2 diabetes:
Lifestyle
Modification
Hypertension
ADA/EASD1
Target
<130/80
mmHg
ACE/AACE2
Target
<130/80
mmHg
Dyslipidemia:
LDL
Dyslipidemia:
HDL
HbA1c Goal
Target LDL
<100 mg/dL
Target HDL >40
mg/dL in men,
>50 mg/dL in
women
<7%
Target HDL >40
mg/dL in men,
>50 mg/dL in
women
≤6.5%
(<70 mg/dL for highrisk patients*)
Target LDL
<100 mg/dL
(<70 mg/dL for highrisk patients*)
Combination
therapy within
3 mo if not at
HbA1c goal
*High risk patients are those with acute coronary syndromes or previous cardiovascular events.
AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; ADA = American Diabetes
Association; EASD = European Association for the Study of Diabetes; HDL = high-density lipoprotein; LDL = low-density lipoprotein.
1. ADA Standards of Medical Care in Diabetes – 2009. Diabetes Care. 2009;32:S13–S61.
2. American Association of Clinical Endocrinologists. Endocrine Practice. 2007;13(suppl 1):3–68.
Summary of Treatment Goals and Strategies
• Glycemic control is fundamental to the management of diabetes1
• The UKPDS demonstrated significant risk reductions in microvascular
complications in type 2 diabetes with more intensive glycemic control.
The benefit of A1C–lowering to reduce CVD in type 2 diabetes is
supported by UKPDS data2
• There is a need to treat the whole patient, including management of
hyperglycemia, CV risk factors and other comorbidities. This is key in
reducing diabetes-related complications3
1. AACE. Endocr Pract. 2007;13(suppl 1):4–68.
2. Stratton IM et al. BMJ. 2000;321:405–412.
3. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Conclusions:
Management of Type 2 Diabetes
• Diabetes is a major clinical problem
– Pathophysiology involves insulin resistance and beta-cell
dysfunction1
• Diabetes is correlated with increased risk of microvascular and
macrovascular diseases and events
– Microvascular complications are predominately driven by
hyperglycemia2,3
– Macrovascular complications are multifactorial and complex4
1. Kahn SE. J Clin Endocrinol Metab. 2001;86:4047–4058.
2. AACE. Endocr Pract. 2007;13(suppl 1):4–68.
3. Stratton IM et al. BMJ. 2000;321:405–412.
4. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54.
Conclusions:
Management of Type 2 Diabetes (cont)
• A1C reduction has been shown to reduce the risk of microvascular
complications and may contribute to risk reduction of macrovascular
endpoints1
• Early intervention is needed to get A1C to goal (diet and exercise
should always be recommended)2
• It is challenging to maintain A1C control over time with traditional
monotherapies3
• AACE and ADA* guidelines recommends use of combination therapy
to achieve and sustain glycemic goals2,4
*ADA guidelines recommend that a second medication should be added within 3 months if patients are not at goal.
1. Stratton IM et al. BMJ. 2000;321:405–412; 2. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12–S54; 3. UKPDS. Lancet.
1998;352:854–865; 4. AACE. Endocr Pract. 2007;13(suppl 1):4–68.