What s the Goal? Individualizing Glycemic Targets Matthew Freeby M.D. December 3 rd, 2016
Diabetes Mellitus: Complications and Co-Morbid Conditions Retinopathy Between 2005-2008, 28.5% of patients with diabetes 40 years and older diagnosed with diabetic retinopathy Nephropathy In 2011, 44% of all new cases of kidney failure were diabetes-related Neuropathy / Amputations In 2011, 60% of nontraumatic lower-limb amputations were diabetes-related CVD Death Rates 1.7 times higher in patients with diabetes than without diabetes Stroke Risk 2-4 times more likely in diabetes than without diabetes American Diabetes Association, Fact Sheet 2014 Zoungas S & Patel A. Annals NYAS. 2010 2
Case - Mr. Jones 58 year old male with past medical history HTN, hyperlipidemia, T2DM. Diabetes Medications include: Metformin 1000 mg BID Glipizide 10 mg BID
Question #1: Mr. Jones What do you recommend as Mr. Jones target A1C? A. Less than 6% B. Less than 7% C. Less than 7.5% D. Less than 8%
Case - Mr. Smith 63 year old male with T2DM, HTN, hyperlipidemia, obesity and CAD in clinic receiving diabetes care. Current Diabetes Medications: Metformin 1g BID Sitagliptin 100 mg daily Glargine insulin 30 units nightly
Question #2: Mr. Smith What do you recommend as Mr. Smith s target A1C? A. Less than 6% B. Less than 7% C. Less than 7.5% D. Less than 8%
Case - Ms. Watson 83 year old female with past medical history moderate cognitive impairment, HTN, hyperlipidemia, T2DM. Diabetes Medications include: Metformin 1000 mg BID Empagliflozin 10 mg daily Repaglinide 1 mg TID
Question #3: Ms. Watson What do you recommend as Ms. Watson s target A1C? A. Less than 6% B. Less than 7% C. Less than 7.5% D. Less than 8%
Glycemic Control in the United States: 1999-2010 Percent of US by A1C Increment A1C < 7% > 7% <7%% 44.2% 52.5% > 7% <7%% 1999-2002 2007-2010 Ali MK et al. NEJM 2013 9
Glycemic Control in the United States: 1999-2010 Percent of US by A1C Increment A1C > 9% 18.9% 12.7% 1999-2002 2007-2010 Ali MK et al. NEJM 2013 10
A1C and Microvascular Complication Risk Skyler, JS. Endocrine Met Clin North Am. 1996 11
Microvascular Complications: New or Worsening Microalbuminuria Boussageon et al. BMJ. 2001 12
UKPDS: Risk of Myocardial Infarction and Microvascular Disease UKPDS Recruited 5102 newly diagnosed T2DM subjects, 25-65 years of age between 1977 and 1991 23 centers in England, Scotland and Northern Ireland Targeted conventional (7.9%) vs. intensive (7%) treatment Adjusted incidence per 1000 person years (%) Myocardial infarction Microvascular disease 5 6 7 8 9 10 11 Hemoglobin A1C (%) Stratton IM, et al. BMJ 2000.
ACCORD: Intensive vs. Standard Glucose Management Design and Methods T2DM, ages 40-79 years with CVD or at least 2 risk factors Randomized 10,251 subjects targeting intensive <6% vs. standard 7-7.9% ACCORD Study Group. NEJM 2008
ACCORD: Intensive Glucose Management Increased Mortality Results Primary Endpoint: Non-fatal MI, Stroke and death from CV causes was non-significant Secondary Endpoint: Increased mortality in intensively treated (HR 1.22, p=0.04) P=0.04 ACCORD Study Group. NEJM 2008
Effect of Intensive Glucose Lowering Treatment in T2DM: Meta-Analysis Probability of All-Cause Mortality Ray et al. The Lancet. 2009
Effect of Intensive Glucose Lowering Treatment in T2DM: Meta-Analysis Probability of hypoglycemia Boussageon et al. BMJ. 2001
ADA Guidelines for Glycemic Control: 2016 Glycemic Targets Goals Hemoglobin A1C < 7.0%* Pre-prandial plasma glucose 80-130 mg/dl* Peak postprandial plasma glucose < 180 mg/dl* American Diabetes Association. Diabetes Care. 2016
ADA Recommendations: Non-Pregnant Adults with Diabetes *Goals Should Be Individualized Based on: Duration of diabetes Individual patient considerations Co-morbid Conditions Known CVD or advanced complications (A1C < 7.5%) Hypoglycemia unawareness Age & Health Status (<7.5 to 8.5%) American Diabetes Association. Diabetes Care. 2016
Diabetes Goals in Older Adults: A Consensus Report by the ADA and AGS Health Status A1C Goal Healthy (Few coexisting chronic illnesses, intact cognitive and functional status) < 7.5% Intermediate (Multiple coexisting chronic illnesses or 2+ instrumental ADL impairments or mild/moderate cognitive impairment) < 8.0% Very Complex (Long-term care, endstate chronic illness or moderate-severe cognitive impairment) < 8.5% Kirkman MS, et al. Diabetes Care and JAGS. 2012
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