Facts and Fiction about Type 2 Diabetes

Michael L. Parchman, MDMichael L. Parchman, MD

Department of Family & Community Department of Family & Community MedicineMedicine

September 2004September 2004

Complications from Type 2 Diabetes

MicrovascularMicrovascular RetinopathyRetinopathy NeuropathyNeuropathy NephropathyNephropathy Autonomic: gastroparesis, blood pressureAutonomic: gastroparesis, blood pressure

MacrovascularMacrovascular MIMI CVACVA Claudication/PVDClaudication/PVD

Preventing Complications from Type 2 Diabetes

GlucoseGlucose Blood PressureBlood Pressure LipidsLipids What is the Evidence?What is the Evidence?

UKPDS

The only large study of patients with Type 2 DM The only large study of patients with Type 2 DM of new onsetof new onset

20 year study conducted in 23 centers in the U.K.20 year study conducted in 23 centers in the U.K. More than 5,000 patients enrolledMore than 5,000 patients enrolled Primary Aim: determine the effect of intensive Primary Aim: determine the effect of intensive

control of glucose on 21 predetermined end-control of glucose on 21 predetermined end-points.points.

Added a secondary arm to study the effect of Added a secondary arm to study the effect of blood pressure and lipid control.blood pressure and lipid control.

Glucose: Fact or Fiction?

Tight control of blood glucose improves Tight control of blood glucose improves mortality.mortality.

FACT: Tight control of blood glucose did FACT: Tight control of blood glucose did not prevent premature mortalitynot prevent premature mortality

Glucose: Fact or Fiction?

All patients with type 2 diabetes benefit from All patients with type 2 diabetes benefit from treatment with metformin.treatment with metformin.

FACT: In overweight patients, metformin FACT: In overweight patients, metformin decreased mortality related to diabetes or other decreased mortality related to diabetes or other cause (13.5 v. 20.6 events per 1000 pt yrs, NNT cause (13.5 v. 20.6 events per 1000 pt yrs, NNT per year=141) AND diabetes related per year=141) AND diabetes related complications (29.8 v. 43.3 events/1000 pt yrs)complications (29.8 v. 43.3 events/1000 pt yrs)

““Overweight patients with type 2 DM seem to Overweight patients with type 2 DM seem to benefit not so much from the overall control of benefit not so much from the overall control of glucose but rather from taking metformin.”glucose but rather from taking metformin.”

Glucose: Fact or Fiction?

Tight control of blood glucose prevents the onset Tight control of blood glucose prevents the onset of microvascular and macrovascular of microvascular and macrovascular complications.complications.

FACT: Changes in HbA1c produced by intensive FACT: Changes in HbA1c produced by intensive drug treatment did not correlate with drug treatment did not correlate with microvascular or macrovascular outcomes.microvascular or macrovascular outcomes.

FACT: In overweight patients, treatment with FACT: In overweight patients, treatment with insulin or sulfonylureas had no effect on insulin or sulfonylureas had no effect on individual or aggregate microvascular or individual or aggregate microvascular or macrovascular outcomes.macrovascular outcomes.

BP: Fact or Fiction

Tight blood pressure control prevents Tight blood pressure control prevents macrovascular but not microvascular macrovascular but not microvascular complicationscomplications

FACT: Tight control of blood pressure decreased FACT: Tight control of blood pressure decreased likelihood of ALL 21 different endpoints, likelihood of ALL 21 different endpoints, microvascular, macrovascular and mortality.microvascular, macrovascular and mortality.

Control of BP had greater effect on complications Control of BP had greater effect on complications than glucose control (24% v. 12% decreased risk than glucose control (24% v. 12% decreased risk in diabetes related complicationsin diabetes related complications

BP: Fact or Fiction

Diastolic blood pressure is a more important risk Diastolic blood pressure is a more important risk factor for MI and stroke than systolicfactor for MI and stroke than systolic

FACT: Systolic BP is a more important risk FACT: Systolic BP is a more important risk factor for MI and stroke than diasolic.factor for MI and stroke than diasolic.

FACT: Each 10mm Hg reduction in systolic BP FACT: Each 10mm Hg reduction in systolic BP associated with 12% reduction in risk for ANY associated with 12% reduction in risk for ANY complication of diabetescomplication of diabetes

FACT: No lower threshold for any complication FACT: No lower threshold for any complication below which risk no longer decreased.below which risk no longer decreased.

Systolic BP and Incidence Rate of Any DM Complication

How Do We Get This Low?

UKPDS: Over 60% of UKPDS: Over 60% of patients in “tight” BP patients in “tight” BP control group requires control group requires 3 or more drugs3 or more drugs2 2

(“tight” = mean BP (“tight” = mean BP 144/82)144/82)

Lipids: Fact or Fiction

Patients with type 2 diabetes and no history Patients with type 2 diabetes and no history of CVD should have an LDL level of <130of CVD should have an LDL level of <130

FACT: Heart Protection Study*FACT: Heart Protection Study* T2DM over age 40T2DM over age 40 Total Cholesterol over 135Total Cholesterol over 135 LDL reduction of 30% associated with LDL reduction of 30% associated with

25% reduction in first major coronary 25% reduction in first major coronary event, event, regardless of baseline LDL levelregardless of baseline LDL level

How Low Can We Go?

Grundy et al. Circulation 2004;110:227. July 13, 2004

Adult Treatment Panel III Guidelines as of July 13, 2004

Diabetes AND CHDDiabetes AND CHD

LDL goal of less than 70 mg/dlLDL goal of less than 70 mg/dl

Diabetes Without CHDDiabetes Without CHD

LDL goal of less than 100 mg/dlLDL goal of less than 100 mg/dl

Grundy et al. Circulation 2004;110:227. July 13, 2004

Heart Protection Study*

“…“…statin therapy should now be statin therapy should now be considered routinely for all diabetic considered routinely for all diabetic patients at sufficiently high risk for such patients at sufficiently high risk for such major vascular events, irrespective of their major vascular events, irrespective of their initial cholesterol concentrations.”initial cholesterol concentrations.”

*Lancet 2003;361:2005-2016

Evidence: Know your “A,B,Cs”

““A”:A”: A1c A1c less than 7.0less than 7.0

““B”:B”: Blood Pressure Blood Pressure less than 130/80less than 130/80

““C”:C”: Cholesterol: Cholesterol: LDL less than 100 mg/dl; LDL less than 100 mg/dl; OR 30% reduction in LDL with a statin if over OR 30% reduction in LDL with a statin if over

age 40 & total cholesterol>135 mg/dlage 40 & total cholesterol>135 mg/dl

The “5-minute” Diabetes Visit

PPressureressure LLipidsipids AAspirinspirin GGlucoselucose UUrine proteinrine protein EEyesyes FFeeteet

ADA Target: BP < 130/80

P: Blood Pressure

L: Lipid Control

LDL < 100LDL < 100 TG < 150TG < 150 HDL > 40 men; HDL > 40 men;

>50 women>50 women If over 40, and total If over 40, and total

Cholesterol >135:Cholesterol >135: Use statin to reduce Use statin to reduce

LDL by 30% LDL by 30% regardless of baseline regardless of baseline LDL levelLDL level

A: Aspirin, 75-162 mg/day

Recommended for all patients with T2DMRecommended for all patients with T2DM US Physician’s Health StudyUS Physician’s Health Study

a reduction in myocardial infarction from 10.1% a reduction in myocardial infarction from 10.1% (placebo) to 4.0% (aspirin),(placebo) to 4.0% (aspirin),

Early Treatment Diabetic Retinopathy Study Early Treatment Diabetic Retinopathy Study For those on ASA: relative risk 0.72 for myocardial For those on ASA: relative risk 0.72 for myocardial

infarction in the first 5 years infarction in the first 5 years Hypertension Optimal Treatment (HOT) Trial Hypertension Optimal Treatment (HOT) Trial

Aspirin significantly reduced cardiovascular events Aspirin significantly reduced cardiovascular events by 15% and myocardial infarction by 36% by 15% and myocardial infarction by 36%

G: Glucose Testing

If < 7.0: A1c testing twice each year, at If < 7.0: A1c testing twice each year, at least 3 months apartleast 3 months apart

If > 7.0; every 3 monthsIf > 7.0; every 3 months

ADA Target: A1c < 7.0%

U: Urine Protein

Annual screening urine micro-albuminAnnual screening urine micro-albumin

Detection of nephropathyDetection of nephropathy

Begin ACEI to slow progression of Begin ACEI to slow progression of nepthropathynepthropathy

E: Eyes

Annual dilated eye Annual dilated eye exam or at frequency exam or at frequency recommended by eye recommended by eye specialist after initial specialist after initial examexam

Screening for Retinopathy:Vijan S, et al JAMA 2000;238:889-896

Risk GroupRisk Group

Risk of Any Risk of Any RetinopathyRetinopathy

No ScreeningNo Screening Annual Annual ScreeningScreening

High (age 45y; High (age 45y; A1c 11%A1c 11%

86.186.1 22.422.4 10.110.1

Moderate (age Moderate (age 65 y; A1c 9%65 y; A1c 9%

49.449.4 2.72.7 1.21.2

Low (age 75y; Low (age 75y; Ac1 7%Ac1 7%

35.635.6 0.80.8 0.30.3

Risk of Blindness, %

F: Feet

Visual inspection at every visitVisual inspection at every visit Comprehensive exam once each year with Comprehensive exam once each year with

monofilament, tuning fork, palpation and monofilament, tuning fork, palpation and visual examinationvisual examination