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Additional therapy in association with diet in patients with diabetes mellitus.
Impaired glucose tolerance (IGT)*, in combination with diet and exercise.
*Defined as 2 hour post-glucose load plasma concentration (2HPG) between 7.8 and 11.0 mmol/L (140-200mg/dL) and fasting
values between 6.1-6.9 and 7.0 mmol/L (100-125 mg/dL).
Page 2
Pre Diabetes is
Page 3
Why its important to treat Pre Diabetes
immediately?
Page 4
NHANES: National Health and Nutrition Examination Survey
www.cdc.gov/nchs/products/elec_prods/subject/nhanesii.htm
NHANES: National Health and Nutrition Examination Survey
Janka HU. Fortschr Med 1992;110:637-41
www.cdc.gov/nchs/products/elec_prods/subject/nhanesii.htm
Janka HU. Fortschr Med 1992;110:637-41
Page 5
DECODA: Pre Diabetes is associated with
an increased risk of mortality
DECODA (n=6,817)
3.5
Multivariate hazard ratio
2.5
p=0.001 p<0.001
2.0 p=0.006 p<0.001
1.5
1.0
0.5
0
<6.1 6.16.9 7.0 <7.8 7.811.0 11.1
FPG (mmol/L) 2hPG (mmol/L)
Page 7
Relationship between postprandial plasma
glucose levels and CVD mortality
DECODE
Honolulu 19991 Pacific and
Heart Study Indian Ocean
19877 19992
Page 8
Postprandial hyperglycaemia is associated
with an increased risk of CVD
Singapore National Health Survey 1992 (n=3,568)
ischaemic heart
2.0 disease than those
1.5 with NGT
in each FPG
1.0 category
0.5
0
<5.6 5.66.0 >6.0
FPG level (mmol/L)
Tai ES, et al. Diabetes Care 2004;27:172834.
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IDF Consensus Statement 2007
Page 10
IDF recognises that PPHG increases the
risk of macrovascular complications
Is postmeal hyperglycaemia harmful?
Page 11
Page 12 RTD Pre Diabetes Glucobay
How to help screen pre Diabetes patients?
Page 13
FINDRISC (Finnish Diabetes Risk Score):
Detection of people at high risk for diabetes
A self-administreted one-page
questionnaire
8 questions, with categorized answers
about:
Age
BMI
Waist circumference
Physical activity
Daily consumption of fruits, berries
or vegetable
History of antihypertensive drug
treatment
History of high blood glucose
Family history of diabetes
Recommended in
ESC and EASD Guidelines1
Adapted from: http://www.diabetes.fi/english/risktest/
Jaakko Tuomilehto et al. (2010) Diabetes Prevention in Practice ; 9-18
Page 14
Which glycemic standard should we use to
optimize diabetes management: PPHG, FBG or
HbA1c?
Page 15
DECODE: PPHG is a risk factor
for CVD mortality
Hazard ratio for
CVD-related
mortality
1.0
Known
diabetes
0.8
0.6
0.4
0.2
0
<4.5 4.66.0 6.16.9 7.0 >11.0 10.111.0 7.810.0 6.67.7 3.16.5 3.0
Page 16
DECODE: PPHG is better correlated with
cardiovascular and all-cause mortality than FPG
Hazard ratio
l)
l/
mo
(m
PGP
2-h
FPG (mmol/l)
Page 17
PPG & 2hPG are associated with a greater
risk of CVD events and all-cause mortality
than FPG
CVD mortality All-cause mortality
Cardiovascular All-cause
events mortality
PPG, postprandial plasma glucose; 2hPG, 2h plasma glucose in oral glucose tolerance test; CVD, cardiovascular disease; FPG, fasting plasma glucose.
DECODE/DECODA adjusted for age, sex, cohorts, body mass index, systolic blood pressure, cholesterol, smoking. DECODA also adjusted for 2hPG (FPG model)
and FPG (2hPG model). In San Luigi Gonzaga, four glycemic parameters and A1c were analysed separately as individual predictors.
HR=1 (standard) for known diabetes (DECODE), <6.1 (FPG) and <7.8 mmol/l (2hPG) (DECODA), 3.9-7.2 (FPG) and <10 mmol/l (PPG) (San Luigi Gonzaga).
1.
Figure modified from The DECODE study group. Diabetes Care 2003;26:688-696.
2.
Figure created from Nakagami T, et al. Diabetologia 2004;47:385-94.
3.
Figure created from Cavalot F, et al. Diabetes Care 2011;34:2237-43.
Page 18
PPG contributes to HbA1c
Relative contribution of PPG to HbA1c
(n=164)2
PPG FPG
PPG can occur even when overall metabolic 100
control appears to be adequate as
assessed by HbA1c1 80
Contribution
60
The relative contribution of PPG to overall
(%)
glycaemia increases as HbA1c decreases1,2
40
Target HbA1c will not be reached without bringing down postprandial hyperglycaemia
1.
2011 Guideline For Management of Postmeal Glucose In Diabetes. Available at: http://www.idf.org/.
2.
Figure modified from Woerle HJ, et al. Diab Res Clin Pract 2007;77:280-5.
Page 19
Emerging evidence associates mealtime
glucose spikes and risk of CVD and
mortality
DECODE, 1999 1
High 2-hour post-load blood glucose is
associated with increased risk of death,
independent of FPG
Pacific and Indian Ocean, 1999 2
Isolated 2-hour hyperglycemia doubles
the risk of mortality
Funagata Diabetes Study, 1999 3
IGT, but not IFG, is a risk factor for CVD
Whitehall, Paris, Helsinki Study, 1998 4
Men in upper 2.5% of 2-hour post-meal
glucose distribution had significantly
higher CHD mortality
The Rancho-Bernardo Study, 1998 5
2-hour post-challenge hyperglycemia
more than doubles the risk of fatal CVD
and heart disease in older adults
Diabetes Intervention Study, 1996 6
Post-meal, but not fasting glucose, is
associated with CHD
1. DECODE Study Group. Lancet 1999;354:61721. 2. Shaw JE et al. Diabetologia 1999;42:10504
3. Tominaga M et al. Diabetes Care 1999;22:9204. 4. Balkau B et al. Diabetes Care 1998;21:3607
5. Barrett-Connor E et al. Diabetes Care 1998;21:12369. 6. Hanefeld M et al. Diabetologia 1996;39:157783
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What drugs prevent the onset of T2DM?
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ESC/ EASD Guideline 2013
pharmacotherapies that can delay
progression to DM in people with IGT
ESC Essential Messages, 2013
Acarbose is recommended
as a pharmacological option
to prevent the onset of type
2 diabetes when lifestyle
modification alone has not
achieved the desired weight
loss and/or improved
glucose tolerance goals
Page 23
Chinese Prevention Study acarbose reduces the
risk of progression from IGT to type 2 diabetes
Reduction in the
risk of type 2
11.6 ~29% 77% 88% diabetes
12
10
Annual incidence
8.2
of diabetes (%)
8
6
4.1
4
2.0
2
0
Control Diet + exercise Metformin + Acarbose +
Diet + exercise Diet + exercise
p=0.0928 p=0.0002 p=0.0001
vs. control vs. control vs. control
Yang W, et al. Chin J Endocrinol Metab 2001;17:1316
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Glucobay has better efficacy than Metformin
Placebo (n=31)
HbA1c (%)
Metformin (n=31)
Glucobay (n=29)
Screening 0 6 12 18 24
Treatment Period (weeks)
Page 25
Acarbose reduces PPHG
Dysglycaemia,
without acarbose
Intestinal glucose resorption
Dysglycaemia,
Without acarbose
Blood glucose
with acarbose
0 1 2 3 4 0 1 2 3 4
Hours Hours
Page 30
Acarbose has favourable efficacy and tolerability
profiles in Asian patients with type 2 diabetes
China1 Taiwan2
(N=2,480) (N=1,558)
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STOP NIDDM
Development of Cardiovascular
Cardiovascular risk2 Blood
diabetes1 risk 2
pressure2
Page 32
STOP-NIDDM and MeRIA provide positive
evidence for controlling PPHG with acarbose*
Relative risk reduction (%) (vs
placebo)
Page 33
STOP-NIDDM acarbose reduces
CV risk in individuals with IGT
STOP
Chiasson JL, et al. JAMA 2003;290:48694 NIDDM
Page 34
MeRIA7 acarbose reduces CV risk
in type 2 diabetes patients
Page 35
Glucobay has long term efficacy
8
11.1
7 2 h PP
6 8.4
Fasting
5
5.6
0 1 2 3 4 5
Treatment Period (years)
1 mmol/L = 18.02 mg/dl)
Mertes G. Diab Res Clin Pract 2001;52:193204.
Page 36
Acarbose has a good safety profile
Long-term safety profile established1,2
Page 37
Acarbose the only therapy shown to significantly
reduce the incidence of CV events in a population
with IGT
Page 38
Thank you!
Page 39