a conversation among aace, acp, endocrine society and ada ... · aace: member of the national board...
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A Conversation among AACE, ACP, Endocrine Society and ADA Regarding Diabetes Guidelines
Guillermo E. Umpierrez, MD, CDE, FACP, FACEProfessor of Medicine
Director, Clinical Research Diabetes & Metabolism CenterEmory University School of Medicine
Director, Diabetes & Endocrinology SectionGrady Health System
AACE: Member of the National Board of Directors, Chair of Diabetes Disease State Network, Chair of Diabetes Clinical Practice Guideline Committee
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External Industry Relationships *
Company Name(s) Role
Equity, stock, or options in biomedical industry
companies or publishers
BMJ Open Diabetes Research & Care
Editor-in-Chief
Industry funds to Emory University for my
research
Merck, Sanofi,Novo NordiskAstra Zeneca
Insulcloud, Dexcom
Principal Investigator -Initiated Research Projects
IndustryAdvisory/Consultant
activities
2018 - 2019Dr. Guillermo Umpierrez, MD, CDE, FACE, FACPPersonal/Professional Financial Relationships with Industry/publishers
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2009 Algorithm
2009 AACE/ACE Algorithm:
• A1C Goal and glucose monitoring recommendations
• Treatment: mono- dual - triple therapy of 8 major FDA approved antidiabetic agents with complementary mechanisms of action
• Prioritized choices of medications according to:• safety, • risk of hypoglycemia, • efficacy, • simplicity, • anticipated degree of patient adherence,• cost of medications.
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2019 Algorithm
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Effects of intensive glucose control on microvascular outcomes in patients with diabetes
Skyler J. Endocrinol Metab Clin North Am. 1996;25:243DCCT Research Group. N Engl J Med. 1993;329:977
A1C and Microvascular Complications: DCCT
Re
lati
ve
Ris
k
Retinopathy
Nephropathy
Neuropathy
Microalbuminuria
A1C (%)
15
13
11
9
7
5
3
1
6 7 8 9 10 11 12
UKPDS: Risk Reductions With
Intensive Therapy (Median HbA1c = 7.0%)
% R
isk
Red
ucti
on
-50 -46
-12
-25
-29
-24
-33
-16
-45
-40
-35
-30
-25
-20
-15
-10
-5
0 Any Diabetes
Related Endpoint
Microvascular Endpoints Laser Rx Cataract Albuminuria Myocardial
Infarction Sudden Death
P = 0.029
P = 0.0031
P = 0.046
P = 0.000054
P = 0.052
P < 0.047
P = 0.0099
UKPDS Group. Lancet 1998;352:837-853.
DCCT: Type 1 Diabetes UKPDS: Type 2 Diabetes
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Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes
Zoungas et al. Lancet Diabetes Endocrinol 2017; 5: 431–37
Meta-analysis: ACCORD, ADVANCE, UKPDS, and VADT with 27049 participants.
The relative risk was reduced by 20% for kidney events (hazard ratio 0·80, 95% CI 0·72 to 0·88; p<0·0001) and by 13% for eye events (0·87, 0·76 to 1·00; p=0·04), but was not reduced for nerve events (0·98, 0·87 to 1·09; p=0·68)
Kidney Outcome
Eye Outcome
Nerve Outcome
Intensive glucose control, if safely achieved (avoiding hypoglycemia and adverse events) reduces microvascular complications
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2019 Algorithm
Medications with higher hypoglycemia risk and adverse events
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A1
C <
7%
Metformin Sulfonylurea Insulin
Years of Therapy Years of Therapy Years of Therapy
Most patients on traditional therapies will fail to monotherapy and require another agent(s) to maintain glycemic control
UKPDS: 4075 patients with newly diagnosed T2D, age 25-65 years, average BG 11.5 mmol/L (9.0-14.4 mmol/l), HbA1c 9.1% (7.5-10.7%) and BMI 29 (6) kg/m2. Follow up at 3, 6 and 9 years after enrollment
Glycemic Control Declines Over Time With Monotherapy
Turner RC et al. JAMA. 1999;281:2005
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Diet & exercise
OAD monotherapy
OAD up-titration
OAD combination
OAD plusinsulin
OAD plusMDI insulin
Monotherapy
Early combination therapy
Traditional Management vs Early Combination Therapy in T2D
Bianchi et al. Drugs. 2017 Mar;77(3):247-264; Phung et al. Diabetes Obes Metab. 2014;16:410–7; Haak et al, Diabetes Obes Metab. 2012;14:565–74; Blonde et al. Moon et al, Korean J Intern Med 2017 Nov;32(6):974-983.; Blonde L et al, Adv Ther.2018 Jul;35(7):939-965. Ross et al. Diabetes Obes Metab. 2015;17:136–44; Blonde L. T Adv Ther. 2012;29:1–13; Hadjadj et al, Diabetes Care. 2016;39:1718–28
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2019 Algorithm
Cardio-renal-obesity protection
When Cost Is a Major Issue
- Metformin
- Sulfonylureas
- Thiazolidinedione
- Human insulin
Hypoglyce-miaavoidance
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Individualized Treatment
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EFFICACY
(Lowering HgA1c)
SAFETY
(Hypoglycemia Prevention)
Evolution of Clinical Recommendations for the
Management of Type 2 Diabetes
Cardiovascular Disease Prevention
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2009 Algorithm
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2009 Algorithm