Diese Präsentation wurde erfolgreich gemeldet.
Die SlideShare-Präsentation wird heruntergeladen. ×
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Nächste SlideShare
UKPDS
UKPDS
Wird geladen in …3
×

Hier ansehen

1 von 16 Anzeige
Anzeige

Weitere Verwandte Inhalte

Diashows für Sie (20)

Ähnlich wie DCCT (20)

Anzeige

Aktuellste (20)

Anzeige

DCCT

  1. 1. DCCT OVMC LANDMARK TRIALS SERIES The Diabetes Control and Complications Trial (DCCT). “The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus.” New England Journal of Medicine.1993; 329:977-986
  2. 2. The Diabetes Control and Complications Trial (DCCT) Summarized by: Maria Morkos, MD; Laxmi Suthar, MD
  3. 3. BACKGROUND  Insulin dependent diabetes mellitus causes much morbidity and mortality, including many long term microvascular and neurological complications  Up until this study it was unclear if tight glycemic control could decrease or prevent such complications
  4. 4. CLINICAL QUESTION How would intensive diabetes management compare with conventional therapy in regards to the development and progression of early vascular and neurologic complications of IDDM? retinopathy nephropathyneuropathy
  5. 5. DESIGN  Analysis: intention to treat; chi-square test, Wilcoxon rank-sum test  Randomized, unblinded, multicenter design (29 centers in United States)  N= 1441  Group 1: 726 primary prevention  Group 2: 715 secondary intervention  Participants in each group were randomized to either conventional or intensive treatment  Median follow-up: 6.5 years  Outcomes: microvascular complications (neuropathy, nephropathy, retinopathy)
  6. 6. POPULATION Inclusion Criteria  13-39 years old  T1DM defined by C-peptide deficiency  Primary prevention group  T1DM 1-5 years  No retinopathy  Urinary albumin excretion <40 mg/24 hours  Secondary intervention group  T1DM 1-15 years  Mild-moderate non-proliferative retinopathy Exclusion Criteria  Hypertension  Hyperlipidemia  Severe diabetic complications
  7. 7. INTERVENTIONS  Intensive therapy  >3 insulin injections/day, or use of an insulin pump  Goal pre-prandial blood glucose 70-120; goal post-prandial <180  Goal A1c <6.05%  Conventional therapy  1-2 daily insulin injections  Adjustments to insulin only to avoid sx of hypo/hyperglycemia or ketonuria
  8. 8. RESULTS  In primary prevention group, intensive insulin therapy (compared to conventional therapy) reduced adjusted mean relative risk of developing  retinopathy by 76%  microalbuminuria by 34%  clinical neuropathy by 69%  In secondary intervention group, intensive insulin therapy (compared to conventional tx) reduced adjusted mean relative risk of worsened  retinopathy by 54%  microalbuminuria by 43%  clinical neuropathy by 57%
  9. 9. RESULTS  Mean blood glucoses were  155+/-30 mg/dL in intensive tx group  231 +/- 55 mg/dL in conventional tx group  Hypoglycemia 3x higher in intensive group  Increased weight gain in intensive group  No differences in macrovascular events  No difference in mortality
  10. 10. CRITICISMS  Follow-period (6.5 years) was too short to evaluate for macrovascular outcomes  Did not look at patients with severe microvascular complications  Limited age range  Excluded pts with HTN and HLD (?applicability)  Types of insulin were not standardized  Unblinded trial
  11. 11. BOTTOM LINE In Type 1 diabetics, intensive therapy with insulin slows progression of microvascular complications (nephropathy, neuropathy, and retinopathy)
  12. 12. DISCUSSION QUESTIONS  What were the two arms of the study, in general terms?  What outcomes/endpoints did the study look at?  What were two negative outcomes in the intensive therapy group?  What were two outcomes that did not differ between the two groups (intensive and conventional therapy groups)?
  13. 13. DISCUSSION ANSWERS  What were the two arms of the study, in general terms?  ANSWER: primary prevention (early T1DM) and secondary intervention (more progressed T1DM)  What outcomes/endpoints did the study look at?  ANSWER: microvascular complications (retinopathy/nephropathy/neuropathy)  What were two negative outcomes in the intensive therapy group?  ANSWER: higher risk of hypoglycemia and weight gain  What were two outcomes that did not differ between the two groups (intensive and conventional therapy groups)?  ANSWER: macrovascular events and mortality
  14. 14. BOARD-LIKE QUESTION 57 yo M with a history of DM and CAD is evaluated for b/l burning sensation in his feet for the last 6 months. The sensation worsens at night. His A1c’s were <7% for the last two years but previously were 8-9% (prior to switching to insulin two years ago). Medications are regular insulin, NPH insulin, aspirin, metoprolol, atorvastatin, and lisinopril. PE findings are compatible with distal polyneuropathy. Labs including CBC are wnl. (Adapted from MKSAP) QUESTION Which of the following is the most appropriate management of this patient’s neuropathy? A. Amitriptyline B. Duloxetine C. Nerve conduction study D. Vitamin B12 measurement
  15. 15. BOARD-LIKE QUESTION Educational Objective: Manage diabetic neuropathy Key Point: - Damage to small nerve fibers leads to pain/numbness/burning/tingling; damage to large nerve fibers leads to abnormal vibration sensation and proprioception. - Amitriptyline in a patient like this one with CAD increases the risk for arrhythmias, heart block, and sudden death. - NCS not necessary in classic stocking- glove distribution; B12 measurement unnecessary since labs are wnl. QUESTION Which of the following is the most appropriate management of this patient’s neuropathy? A. Amitriptyline B. Duloxetine C. Nerve conduction study D. Vitamin B12 measurement
  16. 16. REFERENCES  The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus (1993). New England Journal of Medicine, 329:977- 986. doi 10.1056/NEJM199309303291401

×