insulins_and_insulin_delivery

1. New Insulins
and
Insulin Delivery Systems
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
Part 1

2. Methods For Managing Persons with
Diabetes
Take Diabetes out of the equation.
Control glucose!!!

3. Undiagnosed
diabetes
~5.2 million
Prevalence of Glycemic Abnormalities
in the United States
Additional
25 -35 million
with Prediabetes
Diagnosed
type 2 diabetes
~12 million
Diagnosed
type 1 diabetes
~1.0 million
Centers for Disease Control. Available at: http://www.cdc.gov/diabetes/pubs/estimates.htm;
Harris MI. In: National Diabetes Data Group. Diabetes in America. 2nd ed. Bethesda, Md:
NIDDK; 1995:15-36; U.S. Census Bureau Statistical Abstract of the U.S.; 2001
US Population: 275 Million in 2000
3

4. Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care. 2001;24(Suppl 1):S5-S20.
FPG
126 mg/dL
100 mg/dL
7.0 mmol/L
5.6 mmol/L
Prediabetes
Normal
2-Hour PG on OGTT
200 mg/dL
140 mg/dL
11.1 mmol/L
7.8 mmol/L
Diabetes Mellitus
Impaired Glucose
Tolerance
Normal
Diabetes Mellitus
Diagnostic Criteria Associated
with Glucose Abnormalities

5. Relative Risk of Progression of
Diabetes Complications (DCCT)
DCCT Research Group, N Engl J Med 1993, 329:977-986.
1
3
5
7
9
11
13
15
6 7 8 9 10 11 12
Retinop
Neph
Neurop
RELATIVE
RISK
Mean A1C

6. l Gain of 15.3 years of complication free
living compared to conventional therapy
l Gain of 5.1 years of life compared to
conventional therapy
Lifetime Benefits of
Intensive Therapy (DCCT)
DCCT Study Group, JAMA 1996, 276:1409-1415.

7. Effect of A1C On Complications in the UKPDS
Study
A1C
Stratton IM et al. BMJ 2000;321:405
0
10
20
30
40
50
60
Myocardial Infarction Microvasc Disease
5.5%
6.5%
7.5%
8.5%
9.5%
10.5%

8. Lessons from the DCCT and UKPDS:
Sustained Intensification of Therapy is Difficult
DCCT EDIC
(Type 1)
UKPDS (Type 2),
Insulin Group
DCCT/EDIC Research Group. New Engl J Med 2000; 342:381-389
Steffes M et al. Diabetes 2001; 50 (suppl 2):A63
UK Prospective Diabetes Study Group (UKPDS) 33
Lancet 1998; 352:837-853
4
6
8
10
9.0
8.1
7.3
7.9
0 6.5 + 4 + 6 yrs
DCCT EDIC
0
6
7
8
0 2 4 6 8 10 yrs
A1C (%)
Normal
Baseline
A1C (%)

9. Specific Goals in Management of Diabetes
l Fasting < 110 mg/dL
l Post-meal < 140 mg/dL
l A1C < 6.5%
l Blood Pressure < 130/80
l LDL < 100 mg/dL; HDL > 45 mg/dL
l Triglycerides < 150 mg/dL

10. Primary Objectives of Effective
Management
A1C
%
SBP
mm Hg
LDL
mg/dL
45 50 55 60 65 70 75 80 85 90
9
Diagnosis
8
7
130
100
145
140
Patient Age
Reduction
of both
micro- and macro-
vascular
event
rates
…by 75%!
lGæde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O. Multifactorial
intervention and cardiovascular disease in patients with type 2 diabetes. N Engl
J Med. 2003;348:383-393.

11. 0
2
4
6
8
10
12
14
16
<150 150-175 175-200 200-225 225-50 >250
Average Post-operative glucose (mg/dl)
Mortality
Cardiac-related mortality
Noncardiac-related mortality
Mortality of DM Patients Undergoing CABG
Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

12. 0
5
10
15
20
25
30
35
40
45
0 50 100 150 200 250
Days after inclusion
Cumulative
%
Mortality
(in
hospital
death)
P=0.000
9
P=0.026
BG<110
110<BG<150
BG>150
Surgical ICU Mortality
Effect of Average BG
Van den Berghe et al (Crit Care Med 2003; 31:359-366)

13. 0
5
10
15
20
25
30
35
40
45
80-99 100-
119
120-
139
140-
159
160-
179
180-
199
200-
249
250-
299
>300
Average ICU glucose (mg/dl)
Mortality
%
Hyperglycemia and Hospital Mortality
1826 consecutive ICU patients 10/99 thru 4/02, Stamford CT
Krinsley JS: Mayo Clin Proc 78: 1471-1478, 2003