Changes in Diabetes-Related Complications in the United States
Abstract & Commentary
By Jeff Unger, MD, ABFP, FACE
Medical Director, Unger Primary Care Medicine Group, Rancho Cucamonga, CA
Dr. Unger is on the speaker’s bureau for Janssen Pharmaceuticals, Novo Nordisk and Valeritas; is an advisory board member for Janssen, Sanofi-Aventis, Novo Nordisk, Halozyme, and Abbott; is a consultant for Novo Nordisk, Sanofi-Aventis, Valeritas, and Dance Pharmaceuticals. He also received research grants from Boehringer Ingelheim, Novo Nordisk, GSK, Eli Lilly, Johnson and Johnson, Pfizer, Sanofi-Aventis, Takeda, and Merck.
Synopsis: In diabetes-related complications in the United States from 1990-2010, the incidence of myocardial infarctions and death has decreased by 68%, stroke and amputation has declined by 50%, while end-stage renal disease has declined by 28%.
Source: Gregg EW, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med 2014; 370:1514-1523.
The authors used several population-based data sets to determine the incidence of lower-extremity amputation, end-stage renal disease, acute myocardial infarction (MI), stroke, and death from hyperglycemic crisis from 1990-2000. The data for the diabetes cohort were compared with age-matched controls within the non-diabetic population. The incident rates of all five complications declined from 1990-2010 in the diabetes population with the largest risk reduction observed in MI (-67.8%). Death from hyperglycemic crisis decreased -64.4%, while stroke and amputation declined -52.7% and -51.4%, respectively. End-stage renal disease decreased -28%. Interestingly, the rates of reduction for these comorbidities were significantly greater in the diabetes cohort than among adults without diabetes. Despite the observed improvement in long-term diabetes complications incidence, a large burden for clinicians persists. During the study period, the number diagnosed with diabetes tripled from 6.5 million to 20.7 million.
Let the celebration begin! Finally, patients with diabetes have cause to rejoice. Maybe, just maybe they can live their lives without having to worry about losing a toe or having an acute MI while attending their grandchild’s 2nd birthday party at the pizza parlor. Before we put away those blood glucose meters, we should ask ourselves a few insightful questions related to the future of diabetes care.
First, who is responsible for the improvement in long-term outcomes? The American Association of Clinical Endocrinologists (AACE) were quick to confirm to their members that this paper validated its own published comprehensive approach to diabetes management.2 However, 90% of patients with diabetes are managed not by endocrinologists, but by primary care providers (PCPs), the vast majority of whom have never seen, read, or discussed the AACE or ADA guidelines for diabetes management. Perhaps PCPs and mid-level practitioners have become more ambitious and proficient in screening patients for diabetes. PCPs are introducing and titrating basal insulin sooner during the course of treatment. PCPs are being forced to intensively manage more patients with diabetes, as access to endocrine specialists is often difficult.
Second, new and novel drugs are being utilized to treat patients with diabetes. We are now focusing on getting patients to their prescribed target, while minimizing one’s risk of weight gain and hypoglycemia. Thus, the use of GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors, and even disposable insulin delivery devices (patch pumps) have provided patients with safe, painless, and effective pharmaceutical agents.
I recently participated in a needs assessment for a CME provider and asked 300 PCPs how they choose a second-line therapy following metformin. More than 70% of the respondents said they simply reach into the sample cabinet and pull out the first drug that touches their hand. If this is the case, PCPs should be provided with additional training related to the disease mechanisms of type 2 diabetes. Type 2 diabetes results from eight specific defects. As such, we should be prescribing medications and promoting lifestyle interventions that could potentially reverse each of these defects. Managing diabetes should not be a crap shoot. We should employ "smart pharma bombs" in a pre-emptive attack to salvage the beta cell.
Third, 72 million Americans have prediabetes and 30% of these patients will progress to clinical diabetes every 3 years. We must place more emphasis on disease prevention as well as on racial disparities, health care accessibility, and means by which we can improve our management of obesity.
Diabetes is not going away anytime soon. In fact, by the year 2050, 30% of adults in the United States will have clinical diabetes. Enjoy the good news while you can.
- American Diabetes Association. Fast Facts. Data and Statistics about Diabetes. http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/FastFacts%20March%202013.pdf. Accessed May 4, 2014.
- Handelsman Y, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2011;17(Suppl 2):1-53.
- Garber AJ, et al. American Association of Clinical Endocrinologists’ comprehensive diabetes management algorithm 2013 consensus statement-executive summary. Endocr Pract 2013;19:536-557.
- American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(Suppl 1): S14-S80.