t1d incidence is rising 3-5% per year incidence /100,000/ yr in children aged 0-14
TRANSCRIPT
0
10
20
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40
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70
1950 1960 1970 1980 1990 2000
Finland
Sweden
Colorado
Germany
T1D incidence is rising 3-5% per year
Incidence /100,000/ yr in children aged 0-14
Ongoing Prevention Trials
• TRIGR - cow’s milk elimination
• NIP - omega-3 nutritional supplementation • PrePoint Study – oral insulin in high risk subjects
• TrialNet – oral insulin • TrialNet – oral GAD – in development
• TrialNet – anti-CD3, anti CD20, anti CTLA-4
Lat
e L
ate
stag
est
age
Ear
ly s
tage
Ear
ly s
tage
BDC HbA1c by Age
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
9
9.2
9.4
<6 yr 6-12 yr 13-19 yr
HbA1c
2000200220042006
Mean HbA1c in BDC patients by age diabetes duration > 1 year
n = 150->171 n = 611->850 n = 806 -> 1205
Improvement of glycemic control in Hannover children
0
10
20
30
40
50
60
< 7.5 % 7.5 - 9.0 % > 9.0 %
2000 n = 468
2001 n = 453
2002 n = 469
2003 n = 471
2004 n = 510
2005 n = 530
2006 n = 545
2007 n = 560
Proportion of patients (%)
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
Skyler JF. DCCT Endocrinol Metab Clin North Am. 1996;25:243-54
RR
HbA1c %7 8 9 10 11 12
Diabetic retinopathyNephropathyNeuropathyMicroalbuminuria
15
13
11
9
7
5
3
1
Severe hypoglycemia /100 p-yrs
0
20
40
60
80
100
6
ISPAD ‘07
adults ADA kids
<7.5% <7%<8%
Our goal is somewhere there, but it depends on the patient and on a lot of other things
A1c as close to normal as possible
without severe hypoglycemia
0 5 10 150
0,2
0,4
0,6
0,8
1
14.4
HbA1c (3-12mo) < 7.5%(n=112)
12.4
HbA1c (3-12mo) > 7.5%(n=109)
p<0.03
diabetes duration (years)
pro
ba
bili
ty fo
rre
ma
inin
g fr
ee
of r
etin
opa
thy
Metabolic memory from the first year of DM predicts later development of background retinopathy
Berlin Retinopathy Study
Copyright restrictions may apply.
Prevalence of Hypertension at Each Year of the EDIC Study
JAMA 2003;290:2159-2167.
Cumulative Incidence of the First Occurrence of Nonfatal MI, Stroke, or CVD Death
0.00
0.02
0.04
0.06
0.08
0.10
0.12
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Years since entry
Cu
mu
lati
ve i
nci
den
ce o
f n
on
fata
l M
I,
stro
ke,
or
dea
th f
rom
car
dio
. d
isea
se
Conventional treatment
Intensive treatment
DCCT/EDIC Study Research Group, N Engl J Med 2005; 353:2643-53.
Intensive 705 686 640 118
Conventional 721 694 637 96
No. at Risk
N Engl J Med 2005; 353;2643-2653
0
100
200
300
400
500
600
1960 65 70 75 80 85 90 95 2000 2005
0
5
10
15
20
25
30
T1D cohorts dx: 1950-59 60-64 65-70
CVD incidence in T1D is increasing, despite declining CVD mortality in the
general population
Mort
ality
per
100,0
00 U
.S.
sta
nd
ard
p
op
ula
tion
Cumulative incidence of CAD by 30 yr T1D duration
(%)
CDC/NCHS, National Vital Statistics System, MortalityPabianco G et al. EDC Study , Diabetes 2006 55:1463-9
Think ActivityThink ActivityEncourage daily activity, year-round
0%
50%
100%
150%
200%
M Tu W Th F Sa S
Insulin S
ensit
ivit
y
daily
2-3 x/ wk
never
G Scheiner 2008
Patient characteristics Recommended cutoff points
No other risk factors forcardiovascular disease
LDL-C levels persistently >190 mg/dL despite diet Rx
Other risk factors present,(obesity, hypertension, smokingfamily history of premature CVD)
LDL-C levels persistently >160 mg/dL despite diet Rx
Children with diabetes mellitus
LDL-C levels ≥130 mg/dLLDL-C levels ≥100 mg/dL
Daniels SR et al. Daniels SR et al. PediatricsPediatrics 2008; 2008; 122:198-208122:198-208..
Recommended LDL-Cholesterol Concentrations for Pharmacologic Recommended LDL-Cholesterol Concentrations for Pharmacologic Treatment of Children and Adolescents 10 Years and OlderTreatment of Children and Adolescents 10 Years and Older
Changes in Insulin Therapy 1986 - 2007
T Danne, Hannover, 2008
n= 339 425 521 458 471 510 530 545
0
20
40
60
80
100
1986 90 94 99 03 04 05 06
Proportion of patients (%)
07 589
Two injectionsMDICSII
Insulin Therapy MDI vs. CSIIHbA1c distribution
T Danne, Hannover 2006
MDICSII
Improved Nightime Glucose Excursions with STS Glucose SensorGarg S et al: Diabetes Care: 2006, 29; 44-50
Blinded periodUnblinded period
0.33 0.59 1.89 2.99 2.200.21 0.40 2.15 3.24 2.010
1
2
3
4
<55 55-80 81-140 141-240 241-400
Glucose Range (mg/dl)
Tim
e S
pen
t (h
ou
rs)
38%Reduction*
14%Increase* 9%
Reduction*
33%Reduction*
8%Increase**p < 0.0001
CGM/CSII help those who use it, not those who just wear it!
STAR 1: 138 CSII patients on CGM for 6 months
6
7
8
9
10
100% compliant <60% compliant
Before 6 month on CGM
Hirsh I. et al, STAR 1, ADA 2007, abstract 90
HbA1c (%)
Glucose Levels in CL vs. Hybrid Control
6A Noon 6P MidN 6A Noon 6P0
100
200
300Closed Loop (N=8)
meals
setpoint
Hybrid CL (N=9)
Glu
cose
(mg
/dl)
0 60 120 180 2400
20
40
60
80
100
Closed Loop
Hybrid CL
Time (min)
Pla
sma
Insu
lin
(
U/m
L)
Weinzimer et al. DC 2008;31:934
Nasal Exenatide Serum Glucose and InsulinNasal Exenatide Serum Glucose and Insulin
0 30 60 90 120 150 180 210 24080
100
120
140
160
180
200
220
240 Placebo600 mcg IN
Serum Glucose
Exenatidefollowed bybreakfast
Time (min)
Ser
um G
luco
se (m
g/dL
)
Blase et al. Blase et al. Diabetes Diabetes 2008 57: Suupl 1: Abstract 195-OR.2008 57: Suupl 1: Abstract 195-OR.
0
100,000
200,000
300,000
400,000
Pumps
CG sensors
Patients Using Insulin PumpsPatients Using Insulin Pumps& CG sensors& CG sensors
HSBC Global Research
Dow Jones
Cost Estimates of Intensive Treatment
Annual Cost Estimates*
DCCT 1995 BDC 2003 2008
Pumps $5,800 $9,400 $11,000
MDI $4,000 $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?
Patient web portal- replace ‘log-book’ - empower patient- interface with provider- 3rd party reimbursement
Electronic Medical Record
30
Therapy Accessibility & Consumer Electronics Integration
Confidential. Not to be circulated outside of Medtronic
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!