Accomplishing Good Glycemic Control

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Accomplishing Good Glycemic Control

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Aim Provide pragmatic direction on enhancing diabetes mind through highlighting the need to: treat to glucose targets seriously screen glycemia utilize an all encompassing way to deal with treatment include specialists in diabetes administration

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Type 2 diabetes represents 85–95% of diabetes cases Type 2 diabetes: a worldwide invitation to take action 333 million 350 300 250 200 Global predominance of diabetes (millions) 150 million 150 100 30 million 50 0 1985 2000 2025 Year http://www.idf.org/home/

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Obesity is a key driver of the diabetes pandemic 50–65% of the overall public are large or overweight 1 The danger of creating sort 2 diabetes increments with expanding weight 2 It is evaluated that half of all diabetes cases would be dispensed with if weight pick up could be forestalled 3 1 http://www.idf.org/home/; 2 Mokdad AH, et al . JAMA 2003; 289:76–79. 3 Knowler WC, et al . N Engl J Med 2002; 346:393–403.

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Despite falling CHD death rates, diabetes expands the danger of CHD Factors  CHD passings incorporate  smoking, cholesterol, and BP and changes in medications Factors  CHD passings incorporate diabetes and weight 20,000 0 - 20,000 Deaths anticipated or put off in 2000 - 40,000 - 60,000 - 80,000 - 100,000 Data from England and Wales somewhere around 1981 and 2000 in men and ladies matured 35–84 years There were 68,230 less CHD passings than anticipated from benchmark death rates in 1981 Unal B, et al. Flow 2004; 109:1101–1107.

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Individuals with diabetes are at expanded danger of cardiovascular mortality Relative danger of death from any cause Relative danger of CHD demise 20 15 Relative danger of death 10 5 0 Diabetes no CHD no Diabetes and CHD Age-balanced relative danger of death contrasted and men with no diabetes or CHD Lotufo P, et al. Curve Intern Med 2001; 161:242–247.

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Mortality rate is multiplied in people with diabetes Control Diabetes 35 Ratio 2.5 Ratio 2.2 Ratio 2.1 30 25 Mortality rate (passings per 1,000 patient-years) 20 15 10 5 0 Whitehall Study Helsinki Policemen Study Paris Prospective Study Balkau B, et al. Lancet 1997; 350:1680.

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Type 2 diabetes is connected with genuine complexities Stroke 2-to 4-overlay increment in cardiovascular mortality and stroke 5 Diabetic Retinopathy Leading reason for visual impairment in grown-ups 1,2 Cardiovascular Disease 8/10 people with diabetes bite the dust from CV occasions 6 Diabetic Nephropathy Diabetic Neuropathy Leading reason for end-arrange renal malady 3,4 Leading reason for non-traumatic lower furthest point removals 7,8 1 UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2 Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3 The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4 Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5 Kannel WB, et al. Am Heart J 1990; 120:672–676. 6 Gray RP & Yudkin JS. Cardiovascular sickness in diabetes mellitus. In Textbook of Diabetes second Edition, 1997. Blackwell Sciences. 7 King's Fund. Considering the consequence . The genuine effect of non-insulin subordinate diabetes. London: British Diabetic Association, 1996. 8 Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

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Individuals enduring 'outrageous issues' in personal satisfaction Diabetes General populace 10.0 * 7.5 * Individuals reporting 'extraordinary issues' (%) * 5.0 2.5 * 0 Anxiety/sadness Self-mind Mobility Usual exercises Pain/inconvenience *Significant versus overall public Williams R, et al . The genuine expenses of sort 2 diabetes in the UK. Discoveries from T 2 ARDIS and CODE-2 UK, 2002. Branch of Health. Wellbeing Survey for England 1996. London: HMSO, 1997.

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Costs of diabetes are rising Indirect expenses $132 140 Direct costs 120 $98 $92 100 80 Cost for every year (US$ billion) 60 40 $20 20 0 1987 1 1992 2 1997 3 2002 4 Year Estimated US costs 1 Huse DM, et al . JAMA 1989; 262:2708–2713. 2 Javitt JC & Chiang Y-P. In Diabetes in America , 1995; 601–611. NIH Publication No. 95–1468. 3 American Diabetes Association. Diabetes Care 1998; 21:296–309. 4 American Diabetes Association. Diabetes Care 2003; 26:917–932.

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Hospitalizations represent most of the expenses of overseeing sort 2 diabetes Ambulatory care 18% Antidiabetic drugs 7% Other medications 21% Hospitalizations 55% = €29 billion/year Jönsson B. Diabetologia 2002; 45 (Suppl.):S5–S12.

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Lowering HbA 1c decreases the danger of confusions Deaths identified with diabetes 21% HbA 1c Microvascular entanglements 37% 1% Myocardial localized necrosis 14% Stratton IM, et al . BMJ 2000; 321:405–412.

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Risk of confusions reductions as HbA 1c diminishes 80 Microvascular difficulties Normal HbA 1c levels 60 Incidence for each 1,000 patient-years 40 Myocardial localized necrosis 20 0 5 6 7 8 9 10 11 Updated mean HbA 1c (%) Stratton IM, et al . BMJ 2000; 321:405–412.

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Diabetes administration rules: HbA 1c APPG (Asia Pacific) 7 HbA 1c < 6.5% CDA (Canada) 4 HbA 1c  7% NICE (UK) 5 HbA 1c 6.5–7.5% Australia 8 HbA 1c  7% ADA (US) 1 HbA 1c < 7% IDF (Europe) 3 HbA 1c  6.5% AACE (US) 2 HbA 1c  6.5% ALAD (Latin America) 6 HbA 1c < 6 – 7% 1 American Diabetes Association. Diabetes Care 2004; 27 (Suppl. 1):S15–S34. 2 American Association of Clinical Endocrinologists. Endocr Pract 2002; 8 (Suppl. 1):40–82. 3 European Diabetes Policy Group. Diabet Med 1999; 16:716–730. 4 Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl. 2):S1–S152. 5 National Institute for Clinical Excellence. 2002. Accessible at: http://www.nice.org.uk. 6 ALAD. Rev Asoc Lat Diab 2000; Suppl. 1. 7 Asian-Pacific Policy Group. Viable Targets and Treatments (third Edition). 8 NSW Health Department. 1996.

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Diabetes administration rules: a feeling of direness "... the consequences of the UKPDS order that treatment of sort 2 diabetes incorporate forceful endeavors to lower blood glucose levels as near ordinary as could be expected under the circumstances" "Diabetes must be… analyzed prior. What's more, once analyzed, a wide range of diabetes should then be overseen substantially more forcefully" HbA 1c American Diabetes Association 1 Canadian Diabetes Association 2 1 American Diabetes Association. Diabetes Care 2003; 26:S28–S32. 2 Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl. 2):S1–S152.

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66% of people don't accomplish target HbA 1c Saydah SH, et al. JAMA 2004; 291:335–342. Liebl An, et al. Diabetologia 2002; 45:S23–S28.

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Proportion of people achieving target HbA 1c is not enhancing after some time NHANES (1988–1994) 60 NHANES (1999–2000) 48% 50 44% 37% 36% 40 34% 29% Individuals accomplishing objectives (%) 30 20 7% 5% 10 0 HbA 1c < 7.0% BP < 130/80 mmHg Total cholesterol < 200 mg/dL Good control* *Individuals accomplishing objectives for HbA 1c , circulatory strain and aggregate cholesterol Saydah SH, et al. JAMA 2004; 291:335–342.

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Barriers to accomplishing great glycemic control Lack of clarity over meaning of good glycemic control Inadequate observing of glycemia Complexity of overseeing hyperglycemia with respect to dyslipidemia and hypertension Insufficient association of master care units

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Lack of clarity over meaning of good glycemic control

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Although HbA 1c targets are focalizing, great glycemic control is not came to ?

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What is great glycemic control? The Global Partnership prescribes: Aim for good glycemic control = HbA 1c < 6.5%* < 6.5% *Or fasting/preprandial plasma glucose < 110 mg/dL (6.0 mmol/L) where appraisal of HbA 1c is unrealistic Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

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Inadequate checking of glycemia

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Frequent observing of glycemia is vital Cornerstone of diabetes care Ensures most ideal glycemic control by: surveying viability of treatment managing conformities in diabetes mind regimen, including eating routine, practice and pharmaceuticals

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Who ought to screen glycemia? Persistent Self-observing of blood glucose + Healthcare experts Regular checking of HbA 1c Diabetes mind group Combined synergistic endeavors of group are urgent to guarantee powerful observing of glycemic control

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Not Monitored (37%) Regular SMBG Performers (21%) Irregular SMBG Performers (42%) Self-observing of blood glucose (SMBG) Regular SMBG expands the extent of people accomplishing their glycemic targets Individuals ought to screen postprandial glucose as a component of their SMBG plan Regular discourse of results with diabetes mind group is key HbA 1c  8.0 HbA 1c > 8.0 90% 80% 70% 60% half 40% 30% 20% 10% 0% Blonde L, et al . Diabetes Care 2002; 25:245–246.

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HbA 1c observing HbA 1c measures glycemia over going before 2–3 months Regular appraisal of HbA 1c can prompt to more proactive administration of diabetes Two back to back estimations of HbA 1c  7.0% ought to prompt to a survey of the treatment calculation

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How frequently ought to HbA 1c be checked? The Global Partnership prescribes: Monitor HbA 1c at regular intervals notwithstanding normal glucose self-checking Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

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Complexity of overseeing hyperglycemia in respect to dyslipidemia and hypertension

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Influence of numerous hazard components and diabetes on CVD mortality No diabetes 140 Diabetes 120 100 Age-balanced CVD demise rate per 10,000 man years 80 60 40 20 0 None One just Two just All three Number of hazard factors* *Serum cholesterol > 200 mg/dL, smoking, systolic pulse > 120 mmHg Stamler J, et al. Diabetes Care 1993; 16:434–444.

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What are the needs in diabetes administration? ? Cholesterol? ? ? Glucose? Bloo

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