Introduction To The
Alphabet Strategy And
Evidence Based
Medicine
UK prevalence of diabetes
mellitus
• UK prevalence of diabetes mellitus = 3.54%.
• 2.2 million people in the UK have diabetes :
• 1.9 million ( 87%) have type 2 diabetes.
• 300,000 (13%) have type 1 diabetes.
• There may be as many as one million
undiagnosed cases of type 2 diabetes.
Diabetes UK, 2006
Global prevalence of diabetes 2003
< 2%
2% - 5%
5% - 8%
8% - 11%
11% - 14%
14% - 17%
17% - 20%
>20
Diabetes Atlas second edition, IDF 2003
Chronic complications of diabetes
Retinopathy
Most common cause of
blindness in people
of working age
Nephropathy
16% of all new patients
needing renal replacement
therapy
Erectile Dysfunction
May affect up to 50% of
men with longstanding diabetes
Coronary and
cerebrovascular
Disease
2–4 fold increased risk
of coronary heart
disease and stroke, 75%
have hypertension
Foot Problems
15% of people with
diabetes develop
foot ulcers; 5–15% of
people with diabetic
foot ulcers need
amputations
The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.
Life expectancy (yrs)
Life expectancy and diabetes
Non
Diabetics
85
80
75
Diabetics
70
65
60
55
50
45
40
15-19
20-29
30-39
40-49
50-59
60-70
Age at diagnosis (yrs)
Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721.
Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066.
Diabetes in the UK Indo - Asian
community
30%
Men
Women
25%
Asian
20%
European
15%
10%
5%
0%
20–39
40–59
60–79
20–39
Age groups
40–59
60–79
Cost of diabetes to the NHS
NHS spend on diabetes is :
• 5% of the total budget, or
• £10 million per day.
This is predicted to increase to 10%
of the total budget by 2011.
Diabetes UK, 2004
GMS Contract
Evidence
base
NICE
National
Service
Framework
Guidelines
Increasing
prevalence
User
expectations
Glycaemia
Eyes
Lipids
Patient
oriented
Blood
pressure
Lifestyle
Multi disciplinary
Feet
Audit
Evidence-based medicine
“ The integration of best research
evidence with clinical expertise and
patient values . ”
Sackett DL et al (2000) Evidence Based Medicine
Best research evidence
Clinical expertise
Patient values
Best research evidence
Clinical expertise
Patient values
… within available resources
William of Ockham
(1285-1349)
“ Entia non sunt
multiplicanda praeter
necessitatem ”
“ Entities are not to be
multiplied beyond
necessity ”
K
I
S
S
Keep
It
Simple ,
Stupid
“ Excellence requires that
important, simple things are
done right all the time . ”
National Service Framework for
Coronary Heart Disease
The Alphabet Strategy
• Advice
• Blood pressure
• Cholesterol
• Diabetes control
• Eye examination
• Feet examination
• Guardian drugs
• Heart risk score
The Alphabet Strategy
• Advice
• Blood pressure
• Cholesterol
• Diabetes control
• Eye examination
• Feet examination
• Guardian drugs
• Heart risk score
Smoking , diet , exercise
< 140/80
TC ≤ 4 , LDL : HDL ≤ 2
HbA1c ≤ 7%
Annual examination
Annual examination
Aspirin, ACEI, statins &C
UKPDS, Framingham
Patel V, Morrissey J
The Alphabet Strategy
British Journal of Diabetes &
Vascular Disease, 2002: 2: 1: 58-59
A is for ...
ADVICE
Advice
• Adherence to diet and medication
• Smoking cessation, exercise, weight reduction
• Ensure diabetes education and advise Diabetes UK
•
•
•
membership
Stress role of the dietician, podiatrist and diabetes
care nurses
Regular follow-up with comprehensive Annual
Review is essential. 20% of patients with early severe
complications will be persistent Diabetes Clinic nonattenders
Lifestyle targets: weight reduction > 5% if obese , fat
intake < 30% of energy intake , saturated fat < 10% of
energy intake , fibre > 15g per 1000 calories, exercise
for four hours / week.
B is for ...
BLOOD
PRESSURE
UKPDS 38 : 154/87 versus 144/82
-21
Non significant
MI
-34
Significant
Microvascular endpoint –34%
Significant
Heart failure –35%
-35
-37
Significant
-44 Significant
Stroke –37%
All macrovascular endpoints –44%
Retinal photocoagulation –56%
-56 Significant
Any diabetes-related endpoint –24%
-24
0
-10
-20
Significant
-30
-40
-50
UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703–713
C is for ...
CHOLESTEROL
CHD prevention trials with
statins in diabetes:
Study
Drug
CHD risk redn
Nondiabetics
CHD risk redn
Diabetes
2838
2912
25%*
37%**
26-33%
Number
of
patients
Primary Prevention
CARDS
HPS1 †
Atorvastatin 10mg
Simvastatin 40mg
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% NS
CHD 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
D is for ...
DIABETES
CONTROL
Effect on diabetes complications
of HbA1c% reduction
Study name
DCCT
UKPDS
Kumamoto
Steno-2
HbA1c
 2%
 0.9%
 2%
 1.0%
Retinopathy
 63%
 17-21%
 69%
 58%
Nephropathy
 54
 24-33%
 70%
 61%
Autonomic
neuropathy
 60%
_
_
 63%
CVD
 41%
 16%
_
 53%
Reductions in HbA1c and corresponding reductions in microvascular and
macrovascular complications described in major studies of persons with T1
DM and T2 DM
To summarise . . .
•
•
•
Control blood glucose to prevent
microvascular complications.
Lower cholesterol to prevent
macrovascular complications.
Lower blood pressure to prevent
both.
E is for ...
EYE
EXAMINATION
F is for ...
FEET
EXAMINATION
G is for ...
GUARDIAN
DRUGS
The Alphabet Strategy
• Advice
• Blood pressure
• Cholesterol
• Diabetes control
• Eye examination
• Feet examination
• Guardian drugs
• Heart risk score
Smoking , diet , exercise
< 140/80
TC ≤ 4 , LDL : HDL ≤ 2
HbA1c ≤ 7%
Annual examination
Annual examination
Aspirin, ACEI, statins &C
UKPDS, Framingham