Professional Documents
Culture Documents
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About JDRF
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Tight Glycemic Control is the
Recommended Standard of Care
American Diabetes Association (ADA) (ADA, 2006.)
› Glycemic control is fundamental to the management of diabetes
› The HbA1c (A1c) goal for patients in general is an A1c goal of <7%
› The goal of therapy is to achieve an A1c as close to normal as possible
(representing normal fasting and postprandial glucose concentrations) in
the absence of hypoglycemia
American Association of Clinical Endocrinologists (AACE) (AACE, 2002)
› A1c level of 6.5% or less
› The threat of hypoglycemia can often be minimized with more frequent
blood glucose monitoring
American Geriatrics Society Panel for Improving Care for Elders with
Diabetes (Brown et al., 2003)
› A1c <7% for those with “good functional status”
› 8% for frail older adults, those with life expectancies less than 5 years
and in whom the risks of tight control outweigh the benefits
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Hemoglobin A1c Levels are Elevated in the
United States and Appear to Have Plateaued
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Hyperglycemia Causes Complications
in Type 1 and Type 2 Diabetes
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There are Common Pathways in
Diabetes Complications
Peripheral & Autonomic Neuropathy
Glucose
Polyol
Pathway
Hexosamine
AGE Formation Pathway
Cellular
Oxidative ROS
Dysfunction
Stress
ROS Vascular
Nephropathy
Damage
Cell
Damage Retinopathy
Hypoglycemia
› Is a real obstacle to tight glycemic control (Report from
the American Diabetes Association Workgroup on Hypoglycemia, 2005, Cryer et al.,
2003)
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Significant Glycemic Variability is Found
in both Type 1 and Type 2 Diabetes
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Variability May Exacerbate Complications Pathways
Monnier et al.(2006):
› Type 2 Patients – Mean Age 63.6
› Mean A1c – 9.6%
› Acute Glucose Swings Activate Oxidative Stress
Pathways
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Tight Glycemic Control Improves Outcomes for all
People with Diabetes – the Young and the Elderly
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Better Glycemic Control Increases Survival for
People with Diabetes on Dialysis
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Better Glycemic Control Reduces Hospitalization
Time for Elderly People with Diabetes and CHF
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Better Glycemic Control Prevents the Progression
of Retinopathy in Elderly People with Diabetes
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Better Glycemic Control Improves Cognitive
Function in Elderly People with Diabetes
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New Technologies Hold Potential to
Improve Control
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New Technologies Provide Additional Information
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JDRF Plans Prospective Studies in Elderly
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Potential JDRF Studies will Examine
Diabetes Outcomes in Over 65 patients
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References
American Diabetes Association. Standards of medical care in diabetes -2006. Diabetes Care. 2006; 29
Suppl 1:S4-42.
Bailey T., Kaplan R., Schwartz S. Reduction in A1c with Real-Time Continuous Glucose Monitoring:
Interim Results from a 12-Week Clinical Study. ADA Late breaking Abstract 1-LB. 2006 Annual
Scientific Sessions.
Ben-Ami H, Nagachandran P, Mendelson A et al. Drug-induced hypoglycemic coma in 102 diabetic
patients. Arch Intern Med 1999; 159: 281–284.
Bhatia V, Wilding GE, Dhindsa G, Bhatia R, Garg RK, Bonner AJ, Dhindsa S. Association of poor
glycemic control with prolonged hospital stay in patients with diabetes admitted with
exacerbation of congestive heart failure. Endocr Pract. 2004; 10: 467-71.
Bode BW, Schwartz S, Stubbs HA, Block JE. Glycemic characteristics in continuously monitored
patients with type 1 and type 2 diabetes: normative values. Diabetes Care. 2005; 28: 2361-6.
Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American
Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving
the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003; 51(5 Suppl
Guidelines): S265-80.
Brownlee M. Biochemistry and molecular cell biology of diabetic complications. Nature. 2001; 414:
813-20.
Brownlee M, Hirsch IB. Glycemic variability: a hemoglobin A1c-independent risk factor for diabetic
Complications. JAMA. 2006; 295: 1707-8.
Cryer P, Davis SN, and Shamoon, H.,. Hypoglycemia in Diabetes, Diabetes Care. 2003; 26: 1902-12.
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References
Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of
diabetes on the development and progression of long-term complications in insulin-dependent
diabetes mellitus. N Engl J Med 1993; 329: 977-986.
Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications
Research Group. Retinopathy and nephropathy in patients with type 1 diabetes four years after a
trial of intensive therapy. N Engl J Med 2000; 342: 381-389.
DMICC HbA1c, Diabetes and Public Health December 12, 2005 Summary Minutes.
http://www.niddk.nih.gov/federal/dmicc/2005/12-12-05/summary.pdf
Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and
postoperative infectious complications. Arch Surg. 2006; 141: 375-80.
Garg S., Zisser H., Jovanovic L. Improvement in Glucose Excursions Using a Seven-Day Continuous
Glucose Sensor: Managing the Extremes. Abstract Number: 393-P. ADA Annual Scientific
Sessions. 2006.
Garg S, Zisser H, Schwartz S, et. al. Improvement in Glycemic Excursions With a Transcutaneous,
Real-Time Continuous Glucose Sensor: A randomized controlled trial, Diabetes Care. 2006; 29:
44-50.
Gradman TJ, Laws A, Thompson LW, Reaven GM: Verbal learning and/or memory improves with
glycemic control in older subjects with non-insulin dependent diabetes mellitus. J Am Geriatr
Soc. 1993; 41: 1305-12.
Kennedy RL et al. “Accidents in patients with insulin-treated diabetes: increased risk of low-impact
falls but not motor vehicle crashes- a prospective register-based study.” J Trauma. 2002; 52:
660-6.
Meneilly GS, Cheung E, Tessier D, Yakura C, Tuokko H: The effect of improved glycemic control on
cognitive functions in the elderly patient with diabetes. J Gerontol. 1993; 48: M117-21.
Meneilly GS, Cheung E, Tuokko H. Altered responses to hypoglycemia of healthy elderly people. J
Clin Endocrinol Metab. 1994; 78: 1341-8.
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References
Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP, Colette C. Activation of oxidative stress by
acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type
2 diabetes. JAMA. 2006; 295: 1681-7.
Morisaki N, Watanabe S, Kobayashi J, Kanzaki T, Takahashi K, Yokote K, Tezuka M, Tashiro J,
Inadera H, Saito Y, et al. Diabetic control and progression of retinopathy in elderly patients: five-
year follow-up study. J Am Geriatr Soc. 1994; 42: 142-5.
Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B;
Diabetes Control and Complications Trial/Epidemiology of Diabetes. Interventions and
Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and
cardiovascular disease in patients with type 1 diabetes N Engl J Med. 2005; 353: 2643-53.
Oomichi T, Emoto M, Tabata T, Morioka T, Tsujimoto Y, Tahara H, Shoji T, Nishizawa Y. Impact of
glycemic control on survival of diabetic patients on chronic regular hemodialysis: a 7-year
observational study. Diabetes Care. 2006; 29: 1496-500.
Presentations at the 9-05 EASD meeting in Athens, Greece and the 11-05 Diabetes Technology
Meeting in San Francisco.
Report from the American Diabetes Association Workgroup on Hypoglycemia, 2005. Diabetes Care
28: 1245-9.
The American Association of Clinical Endocrinologists Medical Guidelines for the Management of
Diabetes Mellitus:The AACE System of Intensive Diabetes Self-Management—2002 Update.
Endocrine Practice. 2002; Vol. 8 (Suppl. 1).
UKPDS Group. Intensive blood glucose control with sulphonylureas or insulin compared with
conventional treatment and risk for complications in patients with type 2 diabetes. Lancet. 1998;
352: 837-853.
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