Microvascular Disease in Type 1 Diabetes

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Microvascular Disease in Type 1 Diabetes Jay S. Skyler, MD, MACP Division of Endocrinology, Diabetes, and Metabolism and Diabetes Research Institute University of Miami Miller School of Medicine

The Course of Type 1 Diabetes 100% Genetic Susceptibility Inciting Event(s) Silent Cell Loss Diabetes Onset Total Diabetes Islet Cell Mass 50% Complications 0% Time (years)

Burden of Diabetes Diabetic Retinopathy #1 Cause of Blindness in Working Age Adults Diabetic Nephropathy #1 Cause of End Stage Renal Disease Diabetic Amputations # 1 Cause of Non-traumatic Lower Extremity Amputations Diabetic Vascular Disease 2-to-6-Fold More Likely to Have Heart Disease National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011 Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

DRS: Cumulative Rates of Severe Visual Loss From Proliferative Diabetic Retinopathy 40 Control Event Rates/100 30 20 10 Treated 0 0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 Follow-up (Months) Ophthalmology 1981;88:583-600

DCCT

A1c During DCCT 11 10 DCCT Intervention Conventional mean A1c 9.1% 9 A1c (%) 8 7 6 5 Intensive mean A1c 7.2% 0 1 2 3 4 5 6 7 8 9 Study Year

DCCT Retinopathy Progression Primary Prevention Cohort 100% Cumulative Incidence (%) 80% 60% 40% 20% 0% p<0.001 0 1 2 3 4 5 6 7 8 9 Years Conventional Group Intensive Group DCCT. NEJM 1993; 329:977

DCCT Retinopathy Progression Secondary Intervention Cohort 100% Cumulative Incidence (%) 80% 60% 40% 20% 0% p<0.001 0 1 2 3 4 5 6 7 8 9 Years Conventional Group Intensive Group DCCT. NEJM 1993; 329:977

DCCT: Microalbuminuria & Macroalbuminuria Primary Prevention Cohort Percentage of Patients 30 25 20 15 10 5 Conventional Intensive Microalbuminuria > 40 mg/24 h Albuminuria 300 mg/24 h P< 0.04 P= 0.4 0 0 1 2 3 4 5 6 7 8 9 Year of Study DCCT (1993) NEJM 329:977-986. 986.

DCCT: Microalbuminuria and Macroalbuminuria Secondary Intervention Cohort Percentage of Patients 50 40 30 20 10 Conventional Intensive Microalbuminuria 40 mg/24 h P= 0.001 P= 0.01 Albuminuria 300 mg/24 h 0 0 1 2 3 4 5 6 7 8 9 Year of Study DCCT (1993) NEJM 329:977-986. 986.

DCCT-EDIC

A1c During DCCT and EDIC 11 DCCT Intervention Conventional mean A1c 9.1% Training EDIC Observation 10 9 Conventional mean A1c 8.2% A1c (%) 8 7 6 Intensive mean A1c 7.2% Intensive mean A1c 8.0% 5 0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 Study year EDIC = Epidemiology of Diabetes Interventions and Complications Nathan DM, et al. N Engl J Med 2005;353;2643 53 53

Distribution of A1c in the Former DCCT Intensive & Conventional Groups During EDIC 14 12 Conventional Intensive A1c (%) 10 8 6 p <.0001.0001.0001.002.04.08.037.59.83 DCCT Closeout 1 2 3 4 5 6 7 8 EDIC year JAMA 2003; 290:2159-2167

HbA1c by DCCT Treatment Group at the end of the DCCT and at Each of the First 10 years of EDIC DCCT-EDICResearch Group, Arch Ophthalmol 2008;126:1707-1715.

Cumulative incidence of further 3-step progression of retinopathy from DCCT closeout to EDIC study year 10 (adjusted for retinopathy level at DCCT end, cohort, entry HbA1c, baseline diabetes duration) DCCT-EDICResearch Group, Arch Ophthalmol 2008;126:1707-1715.

Cumulative incidence of proliferative retinopathy or worse from DCCT closeout to EDIC study year 10 (adjusted for retinopathy level at DCCT end, cohort, entry HbA1c, baseline diabetes duration) DCCT-EDICResearch Group, Arch Ophthalmol 2008;126:1707-1715.

Clinic vs Real-world Data: Incidence of Proliferative Retinopathy (DCCT-EDIC/EDC) Cumulative Incidence (%) 20 18 15 13 10 8 5 3 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes Duration (years) DCCT Conventional therapy EDC DCCT Intensive therapy Cumulative incidence of proliferative retinopathy or worse DCCT/EDIC Research Group. Arch Intern Med 2009;69:1307 16 16

Prevalence of Diabetic Retinopathy in Type 1 Diabetes Wisconsin Epidemiological Study of Diabetic Retinopathy: WESDR Prevalence (%) 100 80 60 40 20 Any Retinopathy Proliferative Retinopathy 0 5 10 15 20 25 30 35 40 45 50 Duration of Diabetes (years) Klein R, et al, Arch Ophthalmol.. 1984;102:520-526. 526.

Cumulative Incidence of Severe Retinopathy in Childhood T1D According To Long-Term Glycemia 80 Cumulative Proportion (%) 60 40 20 Linkoping HbA1c < 7.6% HbA1c 7.6 8.5% HbA1c 8.6 9.5% HbA1c 9.6% ** 0 0 10 20 30 40 Duration of Diabetes (years) Nordwall et al. Ped Diab 2009;10:168-76

Cumulative Incidence of Laser-Rx Rx d d DR in T1D with Onset Age < 15 Years, According To Year of Onset 70 Linkoping Cumulative Proportion (%) 60 50 40 30 20 10 1976 1980 1971 1975 1966 1970 1961 1965 Overall p = 0.006 0 0 1981 1985 5 10 15 20 25 30 35 Duration of Diabetes (years) Nordwall et al. Diabetologia 2004;47:1266-74 74

Retinopathy Diabetes is leading cause of new cases of blindness among adults ages 20 74 years Of people with diabetes aged 40 years, 4.2 million (28.5%) had diabetic retinopathy in 2005 2008 655,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss (15.7% of those with retinopathy) National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011 Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

Cumulative Incidence of New Microalbuminuria > 40 mg/24 h During EDIC Cumulative Incidence (%) 20 15 10 5 57% risk reduction p <.0001 Conventional Intensive 0 1-2 3-4 5-6 7-8 EDIC Year JAMA 2003; 290:2159-2167 2167

Cumulative Incidence of New Clinical Albuminuria > 300 mg/24 h During EDIC Cumulative Incidence (%) 12 10 8 6 4 2 84% risk reduction p <.0001 Conventional Intensive 0 1-2 3-4 5-6 7-8 EDIC Year JAMA 2003; 290:2159-2167 2167

Estimated GFR over Time DCCT/EDIC Research Group. N Engl J Med 2011;365:2366-2376

Cumulative Incidence of an Impaired Glomerular Filtration Rate, According to Treatment Group. DCCT/EDIC Research Group. N Engl J Med 2011;365:2366-2376

Impaired GFR Can Develop Without Albuminuria Cumulative Incidence Albuminuria Status 100 15 90 80 10 70 60 50 5 40 30 20 0 0 5 10 15 20 Time from randomization (years) 10 0 Normo Micro Macro Molitch M et al, Diabetes Care 2010

Glycemic Control Prevents Albuminuria de Boer IH et al, Arch Int Med 2011

Microalbuminuria Can Regress de Boer IH et al, Arch Int Med 2011

Clinic vs Real-world Data: Incidence of Nephropathy (DCCT-EDIC/EDC) Cumulative incidence, % 20 18 15 13 10 8 5 3 0 DCCT Conventional therapy EDC DCCT Intensive therapy 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes duration, years Nephropathy defined as albumin excretion rate 300 mg/24 h, serum Cr 2 mg/dl, dialysis or renal transplant DCCT/EDIC Research Group. Arch Intern Med 2009; 169:1307 1316. 1316.

Cumulative Incidence of the First of Any of the Predefined CVD Outcomes Cumulative Incidence of Any Predefined CV Outcome 0.12 0.10 0.08 0.06 0.04 0.02 Risk reduction 42% 95% CI: 9 639 Log-rank p=0.016 Conventional treatment Intensive treatment 0.00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 No. at Risk Years Since Entry Intensive 705 683 629 113 Conventional 714 688 618 92 Nathan DM, et al. N Engl J Med 2005;353;2643 53 53

Cumulative Incidence of the First Occurrence of Non-fatal MI, Stroke, or Death from CVD Cumulative Incidence of Non-fatal MI, Stroke, or Death from CVD 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Risk reduction 57% 95% CI: 12 79 Log-rank p=0.018 Conventional treatment Intensive treatment 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 No. at Risk Years Since Entry Intensive 705 686 640 118 Conventional 721 694 637 96 Nathan DM, et al. N Engl J Med 2005;353;2643 53 53

Clinic vs Real-world Data: Incidence of CVD (DCCT-EDIC/EDC) Cumulative incidence, % 20 18 15 13 10 8 5 3 0 DCCT Conventional therapy EDC DCCT Intensive therapy 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes duration, years CVD was defined as: non-fatal myocardial infarction or stroke, CVD death, subclinical MI,, angina, angioplasty or coronary artery bypass DCCT/EDIC Research Group. Arch Intern Med 2009; 169:1307 1316. 1316.

DCCT: Absolute Risk of Severe Hypoglycemia by Mean A1c 120 Rate of severe Hypoglycemia (per 100 patient-years) 100 80 60 40 20 DCCT: 1986 to 1993 0 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 Glycosylated Hemoglobin (%) DCCT. N Engl J Med 1993;329:977-86

Two Eras of Diabetes Management 120 Rate of severe Hypoglycemia (per 100 patient-years) 100 80 60 40 20 JDRF CGM Study Control Group 2006-2007 2007 DCCT: 1986 to 1993 0 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 Glycosylated Hemoglobin (%) DCCT. N Engl J Med 1993;329:977-86 JDRF. N Engl J Med 2008;359:1464-76

What was different? Insulin Analogs!!

Ideal Basal/Bolus Insulin Absorption Pattern

Impact of Continuous Glucose Monitoring on Rate of Severe Hypoglycemia Compared to DCCT Rate of severe Hypoglycemia (per 100 patient-years) 120 100 80 60 40 20 0 Age 25 years with A1C < 7.0% Age 8-148 years with A1C < 7.0 % Age 15-24 years with A1C < 7.0% Age 25 years with A1C 7.0% Age 15-24 years with A1C 7.0% Age 8-148 years with A1C 7.0% 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 Glycosylated Hemoglobin (%) JDRF. N Engl J Med 2008;359:1464-76

Modern Approaches Can Achieve Meticulous Control Without Much Risk

Burden of Diabetes Diabetic Retinopathy #1 Cause of Blindness in Working Age Adults Diabetic Nephropathy #1 Cause of End Stage Renal Disease Diabetic Amputations # 1 Cause of Non-traumatic Lower Extremity Amputations Diabetic Vascular Disease 2-to-6-Fold More Likely to Have Heart Disease National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011 Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

Cumulative CAD Mortality In T1D 60 Males Cumulative Mortality (%) 45 30 15 Females Joslin T1D Cohorts Framingham Cohorts 0 20 30 40 50 60 Attained Age (years) Krolewski et al. Am J Cardiol 1987; 59:750 755. 755.

Relative Mortality In T1D With and Without Proteinuria 125 100 Women with proteinuria Men with proteinuria Relative Mortality 75 50 Women without proteinuria Men without proteinuria 25 0 0 20 40 60 80 Age (years) Borch-Johnsen et al Diabetologia 1985; 28: 590-596. 596.

Relative Mortality From CVD In T1D With and Without Proteinuria 60 50 With proteinuria Without proteinuria Relative Mortality 40 30 20 10 10 20 30 40 50 Diabetes Duration (years) Borch-Johnsen et al BMJ 1987; 294: 1651-1654. 1654.

Cumulative Incidence CVD In T1D With and Without Proteinuria 40 Cumulative Incidence of Coronary Heart Disease (%) 30 20 10 2 4 6 Years After Onset of Proteinuria Jensen et al. Diabetologia 1987; 30:144-148. 148.

Diabetic Nephropathy and Mortality in Patients with Type 1 Diabetes 1.00 The FinnDiane Study 0.98 Normoalbuminuria Adjusted Survival (%) 0.96 0.94 0.92 Microalbuminuria 0.90 Macroalbuminuria 0.88 0 2 4 6 8 10 Duration of follow-up (years) Groop et al. Diabetes 2009; 58, 1651-1658 1658

Diabetic Nephropathy and Mortality in Patients with Type 1 Diabetes The FinnDiane Study Groop et al. Diabetes 2009; 58, 1651-1658 1658

Pittsburgh EDC 20-yr Mortality Risk in T1D Related to Renal Disease Unadjusted Survival (%) 1.0 0.8 0.6 0.4 0.2 0.0 Normal MA ON ESRD 0.0 4.0 8.0 12.0 16.0 20.0 24.0 Duration of follow-up (years) (%) Orchard et al. Diabetologia 2010;53:2312-19 19

Pittsburgh EDC 20-yr Mortality Risk in T1D Related to Renal Disease 40.0 Adjusted Hazard Ratio SMR 30.0 20.0 10.0 0.0 Normoalbuminuria Microalbuminuria Overt Nephropathy ESRD Orchard et al. Diabetologia 2010;53:2312-19 19

Prevalence of Microalbuminuria in Children with T1D, in Relation to Mean Lifetime HbA 1 c Amin R, et al. BMJ 2008;336:697-701 701

Cumulative Incidence of Overt Nephropathy In Childhood T1D According To Long-Term Glycemic Control 50 Linkoping 40 Cumulative Proportion (%) 30 20 10 HbA1c <7.6% HbA1c 7.6 8.5% HbA1c 8.6 9.5% HbA1c 9.6% *** 0 0 10 20 30 40 Duration of Diabetes (years) Nordwall et al. Ped Diab 2009; 10: 168-176. 176.

Incidence Rate of End-stage Renal Disease According To Time Period of Diagnosis of Type 1 Diabetes 10 Finland Incidence Rate, Cases Per 1000 Patients (years) 9 8 7 6 5 4 3 2 1 0 * * * Period of Diagnosis of Type 1 Diabetes 1965-1969 1969 1970-1974 1974 1975-1979 1979 1980-1999 1999 * 1-5 6-10 11-15 15 16-20 21-25 25 26-30 31-35 35 Years After Diagnosis of Type 1 Diabetes Finne, P. et al. JAMA 2005;294:1782-1787. 1787.

Cumulative incidence of diabetic nephropathy in type 1 diabetes Denmark Cumulative incidence (%) 50 40 30 20 10 0 0 10 20 30 40 Duration of diabetes (years) 1965 1969 (n = 113) 1970 1974 ( 1974 (n n = 130) 1975 1979 ( 1979 (n n = 113) 1979 1984 ( 1984 (n n = 244) Hovind et al. Diabetes Care 2003;26:1258 1264 1264

Cumulative Incidence of Nephropathy Among Patients In Whom T1D Began Before Age 15 Years, According To Year of Onset 50 Linkoping Overall p<0.001 Cumulative Proportion (%) 40 30 20 10 1971 1975 1961 1965 1966 1970 0 1976 1980 1981 1985 0 5 10 15 20 25 30 35 Duration of Diabetes (years) Nordwall et al. Diabetologia 2004; 47:1266-1274. 1274.

All-Cause Mortality In T1D By Diagnosis Cohort - Pittsburgh 1.0 1975-1980 1980 Cumulative Survival 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Diabetes Duration At Death 1970-1975 1975 1965-1969 1969 1960-1964 1964 1950-1959 1959 0 10 20 30 40 50 Pambianco et al Diabetes 2006; 55:1463-1469. 1469.

Modern Approaches Can Reduce Risk of Complications

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