MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM Diabetes Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association.

Présentation au sujet: "MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM Diabetes Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association."— Transcription de la présentation:

1 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association Belge du Diabète DR. KRZENTOWSKI - MARS 2004

2 Diabetes Estimates and Projection
1994 2000 2010 Type 1 11.5 million 18.1 million 23.7 million Type 2 98.9 million 157.3 million 215.6 million TOTAL 110.4 million 175.4 million 239.3 million

3 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1990 No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

4 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

5 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

6 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

7 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1995 No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

8 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2000;23: DR. KRZENTOWSKI - MARS 2004

9 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1999 No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., Diabetes Care 2001;24:412. DR. KRZENTOWSKI - MARS 2004

10 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2000 No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., J Am Med Assoc 2001;286:10. DR. KRZENTOWSKI - MARS 2004

11 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2001 No Data <4% %-6% %-8% %-10% >10% Source: Mokdad et al., J Am Med Assoc 2001;286:10. DR. KRZENTOWSKI - MARS 2004

12 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
DR. KRZENTOWSKI - MARS 2004

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14 Diabète de type 1 Cell. Temps Hérédité Environnement Auto-immunité
100 % Environnement Auto-immunité Cell. 10 % 0 % Temps

15 Diabète de type 2 HEREDITE  Pro. Ins./Ins. Glucotoxicité Cell.B M
Foie ADIP Stockage Utilisation R. INS. ENVIRONNEMENT

16 126 mg / dl

17 Classification ADA 1997 TYPE 1 TYPE 2 GESTATIONNEL AUTRES OMS

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19 Un petit diabète ? 20 ans de diabète de type 2
MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM Un petit diabète ? 20 ans de diabète de type 2 55 ans de diabète de type 1 met dieet gecontroleerde DM2 (HbA1c 7.4%) : blind door prol.RP, NI, CVA, voetwonden, hartdecompensatie DR. KRZENTOWSKI - MARS 2004

20 Reduction in life expectancy in type 2 diabetes
MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM Reduction in life expectancy in type 2 diabetes Age at Diagnostis Marks & Krall 1971 Goodkin 1975 Panzram & Zabel-Langhennig 1981 10 / 15 (17) 27 - 15 – 19 16 – 17 23 20 – 29 12 – 14 16 30 – 39 10 – 11 11 40 – 49 8 – 9 10 7 – 8 50 – 59 6 – 7 6 5 – 6 60 – 69 4 – 5 5 3 – 4 70 + 3 Reduction in life expectancy in type 2 diabetes A survey of three observational studies in this area shows that a diagnosis of type 2 diabetes is associated with significant loss of life expectancy. Patients diagnosed in middle age have most to lose, with a potential loss of 5–8 years of life. Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes. Diabetologia 1987;30: DR. KRZENTOWSKI - MARS 2004

21 MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM
DR. KRZENTOWSKI - MARS 2004

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23 OBESITY BP LDL Sedentarity HDL Smoking

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25 Reduction du Risque des Complications chez les Patients Diabétiques
Amélioration du contrôle glycémique :  12 à 76 % de réduction des complications. Amélioration du contrôle de la tension artérielle :  24 à 56 % des risques des complications. Amélioration du contrôle des lipides :  33 à 62 % de réduction des complications.

26 Risk reductions from intervention studies in type 2 diabetes
Clinical Outcomes UKPDS Metformine n = 753 UKPDS SU/Ins n = 3867 Captopril Atenolol n = 1148 HOT Felodipine Aspirin n = 1501 4S Simvastatine n = 202 HOPE Ramipril n = 3577 Diabetes-related deaths (%) 42 10 32 67 36 37 All-cause mortality (%) 6 18 43 24 All MI (%) 39 16 21 51 55 22 Fatal MI (%) 50 28 - All stroke (%) 41 (+) 11 44 30 62 33 Fatal stroke (%) 25 (+) 17 58 Follow-up (years) 10.7 8.4 3.8 5.4 4.5

27 Clinical outcomes for metformin in the UKPDS Myocardial infarction
MULTIPLE RISK FACTOR MANAGEMENT AND SOLUTIONS TO THE COMPLIANCE PROBLEM Clinical outcomes for metformin in the UKPDS Myocardial infarction Diabetes deaths Stroke Clinical outcomes for metformin in the UKPDS Clinical outcomes for heart attacks and strokes are worthy of special consideration, as these are the two key cardiovascular complications which influence long-term survival in patients with type 2 diabetes. UK Prospective Diabetes Study Group. Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:  42%  39%  41% Median dose = 2550 mg/day DR. KRZENTOWSKI - MARS 2004

28 STENO II Study Multifactorial intervention and cardiovascular
disease in patients with type 2 diabetes. P. Gaede et al. N.E.J.M. 348 (5) : , 2003

29 315 type 2 diabetic patients with microalbuminuria
160 randomised Intensive Conventional 12 deceased 7 CVD 2 cancer 3 other 15 deceased 7 CHD 5 cancer 3 other Mean follow up 7.8 years 67 patients 63 patients

30 Treatment objectives Conventional Intensive 1993-99 2000-01
Systolic BP (mmHg) < 160 < 135 < 140 < 130 HbA1c (%) < 7.5 < 6.5 Cholesterol (mmol/l) < 4.9 < 4.5 Tryglycerides (mmol/l) < 2.2 < 2.0 < 1.7 ACE-I independent of BP No Yes Aspririn Known ischemia Inferior limb Arteriopathy No peripheral or central ischemic disease yes

31 Intensive Intervention Modalities
Dietary < 30 % calorie intake as fat < 10 % calorie intake as saturated fat Vitamin supplements Vit C 250 mg/d D-alpha-tocopherol 100 mg/d Folate 400 g/d Chromium 100 g/d Exercise 30 minutes brisk walk 3 to 5 days/week

32 Intensive Intervention Modalities (Ctd)
Smoking cessation ACE-I (captopril 50 mg x 2/d) or AT-II if contraindication Statine and/or fibrate Aspirin (150 mg/d) OAD, mixed schema (bedtime NPH) or intensive insulin Follow up every 3 months

33 Number of Patients reaching the Objectives (%)
Intensive Conventional HbA1c < 6.5 % 15 % < 5 % Cholesterol < 4.5 mmol/l 75 % 25 % Triglycérides < 1.7 mmol/l 60 % 45 % Systolic BP < 130 mmHg 47 % 20 % Diastolic BP < 80 mmhg

34 Estimated differences between Groups at the End of the Study
Added benefit of intensive treatment at the end of the study : Systolic BP : - 11 mmHg Total cholesterol : mmol/l LDL : mmol/l HbA1c : %

35 Results Primary objective :
Cardiovascular events (death, MI, CABG, PTCA, percutaneous angioplasty, peripheral vascular surgery) 24 % vs 44 % Adjusted relative risk : 0.45 (0.23 – 0.91) NNT in 7.8 years to prevent ONE accident : 5 Secondary objectives : Nephropathy : RR 0.39 (0.17 – 0.87) Retinopathy : RR 0.42 (0.21 – 0.86) Autonomic neuropathy : RR 0.37 (0.18 – 0.79) Peripheral neuropathy : RR 1.09 (0.54 – 2.22)

36 Conclusion A multifactorial approach targeting multiple risk factors at once in microalbuminuric type 2 diabetic patients Results in a reduction of cardiovascular and microvascular events by approximately 50 %

37 Prévention primaire du diabète de type 2
Etudes Nombres Interventions Durée (ans) Résultats MALMO 6 956 (260 IGT) Lifestyle 5 RR Diabetes 0.37 DA QING (530 IGT) 6  Diabetes – 42 % FINNISH 522 IGT 4  Diabetes – 58 % DPP 3 234 (IGT ; IFG) Lifestyle and Metformine 3  Diabetes – 31 % TRIPOD 266 (Previous gestational diabetes) TrogIitazone 2.5  Diabetes : Placebo 12,1 % Troglitazone 5,4 STOP-NIDDM 1 429 IGT Acarbose RR Diabetes 0.75 XENDOS 3 304 Obèses (21 % IGT) Orlistat  Diabetes – 37 %

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41 Traitement du diabète ADO : Biguanide Acarbose Sulfonylurées Glinides
H R P Q ADO : Biguanide Acarbose Sulfonylurées Glinides Glitazones

42 Traitement du diabète INSULINE : Rapides Retards Mélanges Analogues E
C A T I O N H R P Q INSULINE : Rapides Retards Mélanges Analogues

43 And on the belgian field…