Diabetes Care Improvement Packages. Role of Primary Care

Diabetes Care Improvement Packages. Role of Primary Care Dr Jeremy Krebs Clinical Leader and Endocrinologist Wellington Hospital

Diabetes Mellitus How big is the problem? Diabetes Care Improvement Packages Does hyperglycaemia matter? Management Goals Insulin

New Zealand Virtual Diabetes Register end-2005 to end-2012 latest data 250000 200000 150000 100000 Increase is in both genders, also across all ethnicities 50000 0 2005 2006 2007 2008 2009 2010 2011 2012

Rate (Base=Practice enrolled population) New Zealand Diabetes Prevalance Rate as of 31 Dec 2006 European/Other Mäori Pacific people Indian 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age group

Direct same-scale comparison of prevalence curves 2005 and 2011

VDR 2012: major points Diagnosed diabetes prevalence at December 2012 is 225,731, an increase of 8.5% above December 2011 (17,600, 50 per day). All DHBs showed increases from 3-13%. Peak prevalence in Pacific and Asian groups is now at 45% in older adults. In Maori is now at 35% in older adults. The majority of diabetes (69%) is still within the European/Other community.

Traditional Model of Diabetes Care Gestational DM Secondary Care Type 1 Paediatrics Primary Care Type 2 Access to specialist advice / services Limited input to overall population Disparities in Access / Care Information sharing

How can we improve diabetes care? What? (Primary and Secondary Care) Improved Communication Improved Sharing of Data Improved Two-way Flow of Patients How Shared Care Combined Community Clinics More Multi-Disciplinary Approach Acceleration of therapy in primary care

Diabetes Care Improvement Plan Prevent and slow progression of diabetic complications, especially heart disease, renal failure, impaired vision and lower limb amputations Reduce disparities between different population groups Reduced frequency of diabetes-related presentations to hospital emergency departments Reduce rates of hospital admission for diabetes and related complications Prevent or delay the onset of diabetes

The CCDHB model s key components Combined Primary and Secondary Diabetes Clinical Network Practice population management Performance measures Collaborative case service in priority practices Workforce development Nurse practice partnership Self Management Groups Hospital specialist service focused on complex, Type 1, paediatric, gestational and renal diabetes

Key Goals Get quality services to the population that need it Foster patient self management Maximise the skills and confidence of the workforce

Traditional Model of Diabetes Care Gestational DM Secondary Care Type 1 Paediatrics Primary Care Type 2 Access to specialist advice / services Limited input to overall population Disparities in Access / Care Information sharing

New Model for Diabetes Management in the Wellington Region Practice Outreach Primary Care Practice Practice Practice Secondary Care Gestational DM Type 1 Paediatrics Practice Practice Self Management Groups Practice Clinical Network Practice Practice Practice

Relative risk HbA1c and Risk of Diabetes Related Complications 17 15 13 Retinopathy Nephropathy Neuropathy Microalbuminuria 11 9 7 5 3 1 Target HbA1c <7% 6 7 8 9 10 11 12 HbA1c (%) Skyler JS. Endocrinol Metab Clin 1996;25:243 254.

Incidence per 1,000 patient-years Incidence rates of MI and microvascular endpoints by mean HbA 1c (UKPDS) 80 60 Microvascular disease 40 Myocardial infarction 20 0 0 5 6 7 8 9 10 11 Updated mean HbA 1c (%) Study population: white, Asian Indian, and Afro-Caribbean UKPDS patients (n = 4,585) Adjusted for age, sex, and ethnic group Error bars = 95% CI Adapted from Stratton IM, et al. Br Med J 2000; 321:405 412.

UKPDS: Improving HbA 1c Control Reduced Diabetes-Related Complications EVERY 1% reduction in HbA 1c Relative Risk N=3642 Diabetesrelated deaths REDUCED RISK (P<0.0001) 1% Myocardial infarctions Microvascular complications Amputations or deaths from peripheral vascular disorders UKPDF=United Kingdom Prospective Diabetes Study. Data adjusted for age, sex, and ethnic group, expressed for white men aged 50 54 years at diagnosis and with mean duration of diabetes of 10 years. Stratton IM et al. UKPDS 35. BMJ 2000;321:405 412. 14

Figure 4:Legacy Effect of Earlier Glucose Control After median 8.5 years post-trial follow-up Aggregate Endpoint 1997 2007 Any diabetes related endpoint RRR: 12% 9% P: 0.029 0.040 Microvascular disease RRR: 25% 24% P: 0.0099 0.001 Myocardial infarction RRR: 16% 15% P: 0.052 0.014 All-cause mortality RRR: 6% 13% P: 0.44 0.007 RRR = Relative Risk Reduction, P = Log Rank

Cumulative incidence of death (%) Steno-2 Post Trial: Mortality of any cause 70 Log-rank P=0.015 60 50 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Years of follow-up Numbers at risk Conventional Intensive 80 80 80 78 77 75 69 72 63 65 51 62 43 57 30 39 Gaede et al. NEJM 2008

Cumulative incidence of CVD events (%) Steno-2 Post Trial: Any CVD events Cumulative incidence of patients with a major CVD event during follow-up 70 60 Log-rank P=0.0002 50 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Years of follow-up Numbers at risk Conventional Intensive 80 80 70 72 60 65 46 61 38 56 29 50 25 47 14 31 Gaede et al. NEJM 2008

Number of patients with type 2 diabetes and microalbuminuria needed to treat for 13 years to prevent one... Death 5 patients Cardiovascular death Major cardiovascular event Progression to nephropathy Dialysis Laser treatment 8 patients 3 patients 5 patients 16 patients 7 patients (from Gaede et al 2008 Steno 2, 13 year study)

Recent Trials of Glycaemic Control Advance, Accord 10 year post diagnosis, middle age Despite intensive HBA1c management have failed to show CVD benefit

Accord The Action to Control Cardiovascular Risk in Diabetes Study Group N=10,000 1/3 already on insulin 1/3 prevalent CVD events Age 62 Diabetes for 10 years HbA1c 8.3 Strategy of (ultra) intensive glycaemic control aiming for HbA1c 6 (achieved 6.3)

Accord The mean difference during the trial was 1.1%

Accord June 2008 Primary Outcome: First occurrence of nonfatal MI, stroke or death from Cardiovascular cause 352 vs 371 events HR 0.9 (0.78-1.04, p=0.16)

Intensive N (%) Standard N (%) HR (95% CI) P Primary 352 (6.86) 371 (7.23) 0.90 (0.78-1.04) 0.16 Secondary Mortality 257 (5.01) 203 (3.96) 1.22 (1.01-1.46) 0.04 Nonfatal MI 186 (3.63) 235 (4.59) 0.76 (0.62-0.92) 0.004 Nonfatal Stroke 67 (1.31) 61 (1.19) 1.06 (0.75-1.50) 0.74 CVD Death 135 (2.63) 94 (1.83) 1.35 (1.04-1.76) 0.02 CHF 152 (2.96) 124 (2.42) 1.18 (0.93-1.49) 0.17

% of Participants 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 1st 2nd 3rd 4th 5th 6th Year Postrandomization Intensive Standard

Treatment Targets NZ Primary Care Handbook 2012

Adults, % Less than 50% of Adults With Type 2 Diabetes Have Achieved HbA 1c Goals 60 US Population NHANES III (1988 1994) (n=1204) NHANES 1999 2000 (n=370) 50 44.3 48.2 40 30 37.0 35.8 29.0 33.9 20 10 5.2 7.3 0 HbA 1c level <7% Blood pressure <130/80 mmhg Total cholesterol <200 mg/dl Achieved all 3 treatment goals CV Risk Factors NHANES=National Health and Nutrition Examination Survey of a US population. Adapted from Saydah SH et al. JAMA. 2004;291:335 342. 13

Glycaemic Control Target HbA1c 48-58 mmol/mol (6.5-7.5%) Management Strategy Diet and Lifestyle Oral Hypoglycaemics Monotherapy Combination therapy Insulin

HbA 1c (%) Natural History of Type 2 Diabetes 9 cross-sectional, median values 8 Conventional 7 Intensive 6 0 6.2% upper limit of normal range 0 3 6 9 12 15 Years from randomisation

Clinical Inertia 10 9 Metformin monotherapy (n=513 episodes) Sulfonylurea monotherapy (n=3394 episodes) 35 b 27 b months months 9.1 8.8 HbA 1c, % 8 7 8.2 7.6 7.7 7.1 ADA goal EASD goal 6 0 First HbA 1c on Treatment Best HbA 1c on Treatment a US Physicians; 1994 2002 b Mean number of months that elapsed until a new or additional treatment was started. c Monotherapy switched to another agent or additional agent added. Brown JB et al. Diabetes Care. 2004;27:1535 1540; American Diabetes Association. Diabetes Care. 2007;30(suppl 1):S4 S41; Nathan DM et al. Diabetologia. 2006 Aug;49(8):1711 21. Last HbA 1c before Switch or Addition c ADA=American Diabetes Association. EASD=European Association for the Study of Diabetes. 11

Traditional Type 2 Diabetes Management: A Treat-to-Fail Approach Published Conceptual Approach Mean HbA 1c of patients 10 Diet and exercise OAD monotherapy OAD up-titration OAD combination OAD plus basal insulin OAD plus multiple daily insulin injections HbA 1c, % 9 8 7 6 Time Duration of Diabetes OAD=oral anti-hyperglycaemic drug. Adapted from Campbell IW. Need for intensive, early glycaemic control in patients with type 2 diabetes. Br J Cardiol. 2000;7(10):625 631. Del Prato S et al. Int J Clin Pract. 2005;59:1345 1355. 12

The Therapeutic Challenge in Managing Type 2 Diabetes We need treatments that: Additive to traditional treatments Can be used in presence of complications (eg kidney failure, heart disease) Acceptable to patients Minimise rather than worsen complications of diabetes (preferably) not increase weight (ideally) not cause hypos

Pathogenesis of Type 2 Diabetes: Insulin Resistance and -cell dysfunction Genetic Susceptibility Obesity, Sedentary Lifestyle Insulin Resistance -cell Dysfunction glucose uptake hepatic glucose production impaired insulin secretion Type 2 Diabetes De Fronzo J. Diabetes 1998; 37:667 687.

Major Targeted Sites of Oral Drug Classes Liver Pancreas Impaired insulin secretion Sulfonylureas GLP-1 mimetics DPP-4 inhibitors Muscle and fat Hepatic glucose overproduction Biguanides TZDs GLP-1 mimetics DPP-4 inhibitors Glucose level Gut Glucose absorption α-glucosidase inhibitors Biguanides Insulin resistance TZDs Biguanides DPP-4=dipeptidyl peptidase 4; TZDs=thiazolidinediones. Buse JB et al. In: Williams Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders; 2003:1427 1483; DeFronzo RA. Ann Intern Med. 1999;131:281 303; Inzucchi SE. JAMA 2002;287:360-372; Porte D et al. Clin Invest Med. 1995;18:247 254. 15

Type 2 Diabetes Algorithm Diet and Lifestyle No hypos Oral agent But weight gain, heart Good evidence failure, fractures, But weight gain, bladder cancer.?ihd hypos risk Oral agent No hypos But GI side effects Metformin Weight neutral Oral agent No hypos Weight loss No hypos But Injectable SU Glitazone Acarbose DPPIV Ant GLP-1 Agon Insulin

Insulin Therapy Pro s Feel Better More energy Less infections Better HbA1c Flexibility Microvascular? Macrovascular Con s Injections Weight gain More hypo s Driving issues Needle phobias

Risk of developing hypoglycaemia/complications (%) Trade off of Intensifying Insulin therapy 100 90 80 70 Hypoglycaemia Complications 60 50 40 30 20 10 0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 HbA1C DCCT Research Group. N Engl J Med 1993;329:977 986

Insulin and Type 2 Diabetes: The Who? Anyone! Poor glycaemic control (HbA1c >60 mmol/mol) Symptoms of hyperglycaemia But consider: Is it realistic Self inject? Risk of hypoglycaemia Age and Co-morbidities

Progressive Decline in Insulin Secretion Glucose (mg/dl) Relative function (%) 350 300 250 200 150 100 50 250 200 150 100 50 0 Obesity IFG Diabetes Clinical diagnosis Postprandial glucose Uncontrolled hyperglycemia Fasting glucose Insulin resistance Insulin secretion -10-5 0 5 10 15 20 25 30 Years of diabetes Adapted from Burger HG, et al. 2001. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. In Endocrinology. 4 th ed. Edited by LJ DeGroot and JL Jameson. Philadelphia: W.B. Saunders Co., 2001. Originally published in Type 2 Diabetes BASICS. International Diabetes Center, Minneapolis, 2000.

Insulin Therapy: The What?? Once daily intermediate acting insulin? Twice daily intermediate acting insulin? Mixed insulins? Basal bolus regimen? Regular or analogue Little evidence to support one over another in Type 2.

How to Decide on What? Pattern of hyperglycaemia Fasting vs Post-prandial Morning vs Evening What will the patient do? Inject once or several times per day? Willing to test glucose levels? Able to interpret result and modify insulin?

Role of Self Monitoring of Blood Glucose Type 2 DM on lifestyle alone/metformin Useful intermittently to establish effect of food/exercise on glycaemia Useful to examine pattern of glucose elevation to aid commencement of further treatment Type 2 DM on oral hypoglycaemic agents As above, plus Monitoring for hypoglycaemia Type 1 DM and Type 2 on insulin Needed to rationally adjust insulin doses, plus Factors above 53

7:10 9:20 12:00 2:10 6:45 8:35 11:00 7:00 9:15 12:30 2:20 7:15 9:20 11:41 6:45 9:00 12:00 2:10 7:30 9:45 11:40 0 0 0 0 0 0 0 0 0 83 159 134 203 103 178 102 93 201 136 123 156 237 142 90 147 93 138 132 201 173 Glucose Focused Testing Examples Actionable information for informed decision-making Pattern Testing Multi-point BG profiles for a specific duration to use pattern analysis to identify problem areas for remediation. Paired Testing Testing to explore cause and effect BG variance related to life events or activities, such as food, lifestyle, and current medication. Supports patient self-learning and engagement. Adjustment Testing BG testing to support activities to determine dose adjustment. 4/4/07 4/5/07 4/6/07 0 0 0 0 0 0 0 00 0 0 00 0 0 0 0 0 0 0 0 x x x x x x x x x x x x x x x x x x x x x 54

Types of Insulin Basal Insulins Isophane (Protophane, Humulin N) Analogs (Glargine, Detimir) Bolus Insulins Actrapid, Humulin R Analogs (Novorapid, Humalog, Apidra) Mixed Insulins Penmix 30/70, Humalog Mix 25 and 50

Insulin comparisons

To normalise blood glucose both FPG and PPG must be reduced % contribution to HbA 1c 100 80 60 40 20 0 70% 30% 50% 45% 40% 50% 55% 60% 30% 70% <7.3 7.3 8.4 8.5 9.2 9.3 10.2 >10.2 HbA 1c range (%) Most insulin is initiated when HbA 1c >8.5% PPG FPG Adapted from Monnier L et al. Diabetes Care 2003;26:881 5

Success Comes From Using the Most Appropriate Tools

What about the oral agents? Continue or Stop? Metformin Good evidence to continue Glitazones Some evidence but increased risk of heart failure Sulphonylureas Often continue in short-term No real benefit to continue in the long-term?

Most Commonly Add in once daily intermediate or long acting insulin (NPH insulin or Glargine). Evening if FPG>6mmol/L Morning if hyperglycaemia mostly later in day May need to look at twice daily insulin Wean off sulphonylurea

Insulin Therapy: The When? Poor Glycaemic control: HbA1c > 53mmol/mol (7.0%) despite maximal tolerated oral therapy? Symptomatic

Insulin Therapy: The When? Prepare patient in advance. Progressive disease. Likely to be needed at some stage. Don t use insulin as a threat! If you don t exercise you will need insulin. When the patient is ready! Optimised diet and lifestyle Optimised oral hypoglycaemics Compliance Home glucose monitoring

Insulin Therapy: Summary Why? Who? What? When? DCCT and UKPDS. Reduced complications All with Type 1 diabetes Anyone with Type 2 diabetes, but Anything goes. Start with once daily NPH insulin (protophane/humulin N) or Glargine. Continue Metformin. Consider when HbA1c > 53 mmol/mol (7.0%) despite optimal other care When the patient is ready