La información contenida en esta presentación es
confidencial y es propiedad del Dr. Melchor Alpízar
Salazar y del Centro Especializado en Diabetes
Obesidad y Prevención de Enfermedades
Cardiovasculares, S. C.
IFCC Point-of-Care International Symposium
NOVEMBER 2015, CANCÚN, MÉXICO
PoCT Supporting Management of Diabetic
Patients
Melchor Alpízar Salazar, MD, FACECEO of the Center Specialized in Diabetes, Obesity and
Prevention of Cardiovascular Diseases S.C.
CLINICAL HORIZON
People with diabetes(6.4-14 million adults)*
Reversible changesPeople with impaired glucose tolerance.(20-25 million)*
Reversible changesPopulation without diabetes, exposed to risk factors(35-45 million)
POSTPRANDIAL HIPERGLICEMIA
METABOLIC SYNDROME
*ENEC, 1993, ENSANUT 2012
Alpizar, y cols. Manual del Paciente Diabético 3a ed. 2008 .
THE ICEBERG OF
DIABETES
ENDOTHELIAL ALTERATIONSInflamatory endotelial process since birth.
'Fuente: Secretaría de Salud/Dirección General de Información en Salud. Elaborado a partir de la base de datos de defunciones 1979-2008 INEGI/SS
TOP 10 CAUSES OF
DEATH ARE DIABETES
AND IT’S
COMPLICATIONS
Main Causes of Death in people aged 15 to 64, México National
Statistics INEGI 2008.
Barquera S et al. Diabetes in Mexico: cost and management of diabetes and its complications and challenges
for health policy. Barquera et al. Globalization and Health 2013, 9:3
COSTS OF DIABETES IN
MEXICO
ECONOMIC IMPACT OF
METABOLIC SYNDROME, IMSS.
Cardiovascular Disease Diabetes Mellitus
Insulin Resistance
Hiperinsulinism
Bad Nutrition Habits
Tabacco and
Alcohol
Cerebrovascular
Disease (Stroke)
Obesity
Sedentarism
Systemic Arterial
Hypertension
GLUCOSE INTOLERANCE
CKD/ESRD
Bad Stress
Managment
More than 25% of the budget
2006
Alpizar, y cols. Manual del Paciente Diabético 3a ed. 2008.
in 6.9 years,
n=360 (10%) died,
n=209 (5.8%) died
of cardiovascular disease.
Bosnia – Finnish and Swiss Studies
METABOLIC
SYNDROME
Microalbuminuria showed the highest risk of CV disease mortality (RR 2.8;
p=0.002)
Cardiovascular (CV) mortality 12% vs 2.2%
(p<0.001)
Risk of Coronary Artery disease and Stroke 3 times
(p<0.001)
Total Mortality rate 18% vs.
4.6% (p<0.001)
Isomaa, BO, et al. Diabetes Care 2001;24 No 4:683-689.
Inflammation
Hypertension
Dyslipidemia
Type 2 DM
Thrombosis
Arthritis
CVD
↑ Lipoprotein
Lipase↑ Lactate
↑ IL - 6
↑ Leptin
↑ TNF - α
↑ Adipsin
↑ Estrogens↑ PAI-1
↑ Resistin in plasma
↑ FFA ↑ Insulina
↑ Angiotensin
↓ Adiponectin
Adipose Tissue – A Multi-
Endocrine Organ.
↑ Oxidative Stress
↑ Adipocyte
Destruction
↑ IL - 18
↑ IL - 1β↑ IL - 10
Cornier M-A, Dabelea D, Hernandez TL, Lindstrom RC, Steig AJ, Stob NR, et al.
The metabolic syndrome. Endocr Rev. 2008 Dec;29(7):777–822.
↑ VisfatinCANCER
PATHOPHYSIOLOGY OF THE
METABOLIC SYNDROME
Circulation. 2004; 109:433-438
Insulin Resistance Manifestations
C a r d i o v a s c u l a r D i s e a s e
HyperinsulinemiaObesity
H.T.N
Dyslipidemia
Hyperuricemia
Fibrinolysis Alt.
P.C.O.S
b Cell Failure
IGT
DM 2
Endothelial
Dysfunction
Accelerated
Atheroesclerosis
INSULIN RESISTANCE
BETA CELL PROGRESSIVE DETERIORATION
Heine R et. Al. Diabetologia, may 2002.
PATHOPHYSIOLOGY OF
TYPE 2 DIABETESNormoglycemia Impaired glucose
tolerance Type 2 Diabetes
PANCREATIC RESERVE
0-5y 6-15y >15y
Diet +
Systematic Exercise
Oral Hypoglycemic
agentsInsulin
Systematic
Exercise
Diet +
Systematic Exercise
Diet +
Systematic Exercise
+Insulin or
Oral Hypoglycemic agents
(with reserve)
Insulin Resistance
appears 15-20 before
DM onset.
To compensate there is
a metabolic state of
hyperinsulinemia.
Glucose levels are above
normal, but not in DM
range.
High risk for coronary artery
disease. With obesity,
dyslipidemia and HTN.
Normal to High
Insulin secretion but
not enough to break
insulin resistance
and avoid high
levels of blood
glucose
Insulin reserve slowly
decreases, adn
persistant high levels
of glucose.
Insulin deficiency and
waisting.
Some diabetic patients
develop close to
complete loss of insulin
secretion.
These patients are
usually malnurished with
metabolic discontrol.
Diet +
Systematic Exercise
Oral Hypoglycemic
agents
HbA1c
<6.5%HbA1c
>6.5%
Microalbuminuria > 30
mg
Alb/Creat Ratio >
300mg/g
Diabetic Nephropathy is not adequatly
treated in the Comprehensive treatment of
Diabetes.
In USA most of the comorbidities
remain low in the last 20 years.
Diabetic Nephropathy remains the
same for the last 20 years.
Studies and intents to treat are
limited.
The REASON may be lack of work
regarding comprehensive treatment
with an Endocrine-Nephrologist
approach.
Changes in Diabetes-Related Complications in the United States, 1990–2010N Engl J Med 2014
EVERY PATIENT IS
DIFFERENT: PERSONALIZED
TREATMENT!
BEGINNING:
Patient with an
early diagnosis
of T2DM
Mechanisms of
Diabetic
Nephropathy
Progression are
Unknown
-Final Result:
Renal
Replacement
Treatment
Study the mechanisms responsable for the progression of
renal disease in diabetic patients.
1) Improved prognosis.
2) Treatment of evidence-based medicine.
RECAP….
Growing Obesity and T2DM epidemia.
High treatment related health costs, which are not sustainable.
Lack of adequate Prevention models.
Neglect of vulnerable populations in Mexico.
IT´S CHEAPER TO PREVENT THAN COVER EXPRENSIVE HEALTH COSTS
RELATED TO COMPLICATIONS ACCORDING TO THE NATURAL COURSE
OF THE DISEASE!!
KEY TREATMENT
Helps lower blood pressure levels
Improves lipid profiles
Increases insulin sensitivity
Lowers risk of thrombosis
Lowers inflamatory markers
Lowers risk of Cardiovascular Disease.
LOSS OF 30% VISCERAL FAT
Food portions and plate
size increase over time
A study analized food portions and
plate sizes in 52 paintings of the “Last
Supper” finding an increase over the
millennium.
Wansink, B & C.S. The largest Last Supper: depictions of food portions and plate size increased over the millennium. International
Journal of Obesity. March 23, 2010
www.drpinna.com
Willett WC et al. Am J Clin Nutr 1995; 61(6): 14025-65
Baron RB en: Papadakis MA et al. Current Medical… 2013
Include physical activity, and
share good food, and great
moments.
National Programs to promotethe use of bicycles
Mexico City and 86 other mexicancities promote the massive use of bikes:
Promote a greater use of bicycles in Mexico,
Fight obesity and climat change(global warming).
Strengthen family ties and building happier and healthiercities.
Montes R. El D.F. pone a pedalear a otras 86 ciudades. En: Periódico El Universal, Viernes 27 de Agosto de 2010
Control parameters
and Diagnostic
Tools
Page 23
Increased pressure to improve patient’s follow-up and results
Diabetes is a growing
epidemic all around
the world!
Ensure glycemic
control and renal
function.
Find undiagnosed
patients as soon
as possible
Identify pre-
diabetics to reduce
risk of progression
Page 24
It serves as a marker for estimating average
glucose levels over the previous 8-12 weeks.
It has been validated to use for diagnosis of
DM and for follow-up patients.
Microvascular
complications
(nephropathy, blindness)*
Amputation or peripheral
artery disease*
Stroke**
Deaths related
to DM*21%
37%
12%
43%
Acute MI*14%
* p<0.0001
** p=0.035
1%
HbA1c
Stratton IM et al. BMJ 2000; 321: 405–412.
Better glycemic control equals
less complications
Capillary Glucometer
9PM 6PM3PM12PM9AM6AM3AM
Glu
co
se
( m
g/d
L)
100
40
200
300
400
Glucose sensor
A1C = 8.0%
Glucose average
Glucometers suggest good
glycemic control
Courtesy of CEDOPEC
Glu
co
se
( m
g/d
L)
100
40
200
300
400
Glucose sensor
A1C = 8.0%
Glucose average
9PM 6PM3PM12PM9AM6AM3AM
A1C = 6.5%
Cortesía CEDOPEC
HbA1c suggests the need to adjust treatment and safe therapeutic intervention
INDIVIDUALIZED
TREATMENT
Endocrine Practice Vol 19 N°2 March/April2015
DCA VantageTM Analyzer
• Reproducibility: coefficient of
variation= 3.39%
• Linearity, correlation
coefficient= 0.9955
Page 30
+ =
Precise Information &
Decision Making
Improves Patients Results
Immediate HbA1c results during the visit has demostrated a better
glycemic control in patients with type 1 and type 2 diabetes. 1, 2
HbA1c measurement during a doctor’s visit –
showes improvement in care efficiency and
patient results.
Results in minutes
Convenient, Cost-effective Testing Procedure
No phlebotomy; only 1 μL of fingerstick blood
needed
No requirement for patient fasting, dietary
changes, or glucose beverage ingestion before
testing
No sample or reagent preparation
Simple, four-step test process does not require
a lab technician
No need for expensive external laboratory tests
Advantages of in-clinic
DCA HbA1c testing
Fast and Flexible Results Reporting
HbA1c results are available to Diabeter
physicians in just 6 minutes
Dual HbA1c reporting in mmol/mol and %
HbA1c
DCA HbA1c test is NGSP certi ed, traceable to
IFCC reference materials and test methods
and is CLIA-waived in the US
Advantages of in-clinic
DCA HbA1c testing
DCA Vantage
Certificate of
Traceability
Effective Patient Management
Actionable results at the time of the
Diabeter patient visit
Clinical studies show that face-to-face
testing along with direct physician-to- patient
guidance signi cantly improves patient
compliance3.
DCA Vantage Analyzer HbA1c patient-
trending graphs can be used to track a
patient’s progression
Advantages of in-clinic
DCA HbA1c testing
Page 36
MOST COMMON CAUSES OF INACCURACY
•Low erythrocyte half-life
•Acute blood loss
•Renal insufficiency, pregnancy and anemia.
Advantages of in-clinic DCA
HbA1c testing
HbA1c testing on the DCA Vantage Analyzer is integral to the
success of the Diabetes care program, which is helping people
with diabetes to:
• Reduce and stabilize their long-term blood glucose levels
• Lower their risk of long-term complications
• Minimize the frequency and duration of their visits to hospital
• Self-monitor their condition with support via cost-effective e-
communication
HbA1c Comparison
DCA VANTAGE COVANCE USA
MASCULIN 9.90% 8.80%
MASCULIN 10.40% 9.70%
FEMENIN 8.30% 8.70%
MASCULIN 7.10% 6.80%
MASCULIN 9.20% 9.40%
FEMENIN 7.70% 7.90%
Alpizar y cols. Cedopec 2015.
DCA VANTAGE QUINTILES USA
MASCULIN 9.20% 9%
MASCULIN 10.80% 10.60%
MASCULIN 7.10% 7.50%
MASCULIN 7.70% 7.90%
FEMENIN 7.10% 7.20%
FEMENIN 8.90% 9.10%
FEMENIN 8.90% 9.20%
FEMENIN 6.80% 8%
HbA1c Comparison
Page 40
New Solutions Should
Improve These
Pressures
Simple and convenient tests
can improve diagnosis
We need precise
results to monitor levels of
HbA1c
Precise results
which are on time to adjust
treatment regimens
Find undiagnosed
patients as soon as possible
Ensure glycemic
control to avoid complications
Identify pre-diabetics to
reduce risk of progression
Easy to UseHigh Quality
Lab
POOR GLYCEMIC CONTROL
DISCONTROLED HYPERTENTION
-Great predictor of
mortality and CV
events
-If the GFR < 30
ml/min/1.73 m2,
there is a greater
risk of death.
7.3% of patients have
microalbuminuria when
diagnosed with DM.
Monitoring Frecuency
(Numb. times/year)
according to GFR and
albuminuria category
Pesistant Albuminuria Category.
Description and Range
Ca
teg
orí
as
TF
G (
ml/m
in/1
-73
m2)
Des
cri
pc
ión
y R
an
go
A1 A2 A3
<30 mg/g
<3 mg/mmol
<30-300 mg/g
<3-30 mg/mmol
>300 mg/g
>30 mg/mmol
G1
G2
G3
a
G
3b
G4
G5
≥90
60-89
45-59
30-44
15-29
<15
1
1
1
2
2
2
2
3 3
3
3
3
4+
4+ 4+ 4+
AACE/ACE Diabetes Guidelines, Endocr Pract. 2015;21(Suppl 1)
Chronic Renal Disease avoids the adecuate kidney
function, it presents secondary to diseases like
Diabetes and Hypertention, representing 60% of
patients with chronic dyalisis.
ADA has stated a
preference for the A/C
ratio for screening EKD.
State of Mexico:
Diabetes Care Units
NEED TO EMPHASIZE ON RENAL
PREVENTION!!!
CONCLUSIONS
• PoCT is a practical tool used in the clinician´s office, to
assess diabetic patient´s glycemic control, side by side
with patient, explain the best therapeutic approach and
adjust the treatment regimen.
• PoCT has been found to have a positive impact on he
process of care in the patients with diabetes.
• Studies have also described an improvement in patient
sartisfaction and glycemic control as a result of the
immediate feedback of PoCT
Page 45
CERTIFIED ISO9001-2008 AS AN INVESTIGATIONAL CENTER
Ensure glycemic
control with HbA1c
Identify patients
with Diabetes at
an early stage and
it’s emerging
complications.
Identify patients
with Metabolic
Syndrome and
reduce risks.
Diabetes is a growing epidemic worldwide. Our
Misíon in CEDOPEC S,C.: PREVENTION
“Hospitals are the most expensive hotels
in the world. Fewer and shorter hospital
visits help make the care we provide
significantly more cost-effective”
Dr. Henk-Jank Asnstoot
Thank you for your
attention!
Dr. Melchor Alpízar Salazar
CEDOPEC
Tels. 52(55)52824343 ext 201 y 219
Directo: 55204589
Email: [email protected]
www.cedopec.com