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1
Tackling clinical inertia in Diabetes in
Primary Care?
David Strain,
Diabetes and Vascular Research Centre
University of Exeter Medical School, UK
2
The financial burden of diabetes
The cost of diabetes to the NHS is over £1.5m an hour
or 10% of the NHS budget for England and Wales
This equates to over £25,000 being spent on diabetes every minute
Cost to treat diabetes-related complications is 3 – 4 fold
the cost of prescribing medications
Annual out-patient costs estimated
between £300 and £370 per patient
Annual in-patient care estimated
between £1,800 and £2,500 per patient
Diabetes.co.uk. Cost of Diabetes [accessed September 2018] https://www.diabetes.co.uk/cost-of-diabetes.html
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The Cost of Diabetes in the UK
Expenditure Type 1
Diabetes
Type 2
Diabetes
Total Percent
Diabetes
drugs
£0.344 billion £0.712 billion £1.056 billion 7.8%
Non-diabetes
drugs
£0.281 billion £1.810 billion £2.091 billion 15.2%
Inpatient £1.007 billion £8.038 billion £9.045 billion 65.8%
Outpatient (excluding drugs)
£0.170 billion £1.158 billion £1,328 billion 9.7%
Other (including
social service)
£0.230 billion 1.7%
Total £1.802 billion £11.718 billion £13.750 billion 100%
Kanavos, van den Aardweg and Schurer: Diabetes expenditure, burden of disease and management in 5 EU countries, LSE (Jan 2012)
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Many patients with type 2 diabetes still fail to reach target HbA1c <7%
0
10
20
30
40
50
60
70
80
90
100
HbA1c checked
Met HbA1c target
HbA1c, glycated haemoglobin A1c.
Stone MA, et al. Diabetes Care. 2013;36:2628-38.
Perc
en
t, %
GUIDANCE study 7,597 patients
5
UKPDS
(n=3867)
ADVANCE2
(n=11,140)
ACCORD3
(n=10,251)
VADT4
(n=1791)
Duration of diabetes (years) 0 8 10 11.5
Mean baseline HbA1c (%) 7.1 7.5 8.3 9.4
Mean baseline FPG (mmol/L) 8.0 8.5 9.7 11.4
Mean age (years) 53 66 62 60
Microvascular ± =
Macrovascular = =
Should we treat early?
UKPDS Group. Lancet.1998;352:837–853; ADVANCE Collaborative Group. N Engl J Med. 2008;358:2560–
2572; ACCORD Study Group. N Engl J Med. 2008;358:2545–2559; Duckworth W, et al. N Engl J Med.
2009;360:129–139
Disease progression
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Convincing our patients to the need for early intervention
When should you start servicing the car?
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Diabetes picture in the UK
24,000 people with diabetes die prematurely each year because of ineffective
management
80% of costs of diabetes are attributable to management of avoidable
complications
Only 49% of people with diabetes receive all the basic tests
Only 1 in 5 achieved the recommended levels for blood glucose, blood
pressure and cholesterol
Without these simple checks, there is an increased risk of developing
complications
Department of Health: the management of adult diabetes services in the NHS. 17th report of session 2012–13. Available at
https://www.nao.org.uk/wp-content/uploads/2012/05/121321.pdf. Last accessed October 2017.
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Intensification of glucose-lowering treatment delayed despite OAD
failure
Avoidable glycaemic burden = time remaining on
therapy after exceeding HbA1c target
12.316.5
26.025.9
36.6
51.1
0
10
20
30
40
50
60
Metformin… Sulfonylurea… Combination…
Month
s
7% HbA1c target8% HbA1c target
Met, metformin; OAD, oral antidiabetic drug; SU, sulphonylurea
Brown et al. Diabetes Care 2004;27:1535–40
At insulin initiation, the average patient had:
• 5 years with A1C > 8%
• 10 years with A1C > 7%
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How do we modify CV risk in T2DM?
CV, cardiovascular; T2DM, type 2 diabetes mellitus1. Rydén L et al. Eur Heart J 2013;34:3035–3087; 2. Fox CS et al. Diabetes Care 2015;38:1777–1803; 3. Piepoli MF et al. Eur Heart J 2016;37:2315–2381
Lifestyle modification1–3Platelet inhibition1–3
Blood-pressure control1–3
Multifactorial
Approach
Management of dyslipidaemia1–3
Glycaemic control1–3
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Using digital technology to tackle clinical inertia
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What is Eclipse
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1. Protection of Vulnerable Diabetes Patients.
2. Personalised Care for Diabetes.
3. Validated Improvements in Patient Safety
4. Reduced Workload for GPs
5. Reduced Costs for the CCG
6. Reduced burden on Secondary Care
7. Enhanced Education
8. Patient facing portal to empower patients in their own self care
What it delivers
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Using ECLIPSE to tackle clinical inertia
People who are overdue screening identified
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Using ECLIPSE to tackle clinical inertia
High Risk Patients electronically identified
Looking at
flux of
endpoint
data helps
identify
patients
earlier.
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Using ECLIPSE to tackle clinical inertia
Stratification of patients by overall cost (not just medication costs)
Top 20 most expensive
patients in practice of 550
people with diabetes
A&E, Accident & Emergency department; APC, admitted patient care; F, female; M, male; OP, Out Patient attendance
Data used by permission of Caldicott Guardian, Litcham surgery
18−65 years
66−75 years
76−85 years
>85 years
<18 years
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Using ECLIPSE to tackle clinical inertia: Implementation of Actions
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Using the database in the UK
9% less admissions
17% less out patient appointments
8% less A&E Admissions
10% less Emergency Admissions
We have the potential to identify
predictors and contributory elements
An internal audit compared practices that regularly use ECLIPSE vs. those
who have installed the system but rarely use it
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Saving money
Improving quality of life costs money
No medication saves lives
• They just delay death
Only ways to save money are
• Spend less time in hospital
• Spend more time at work (paying tax)
• Dying!
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Engaged care translates to reduced patient costs through better outcomes
Year ending 2012/13 2013/14 2014/15
Prescription costs* +11.2% +5.7% -16.6%
Unplanned admission
costs-52% -88% -57.7%
Referral costs -86.1% -72% N/A **
Total cost per 1000
patients-0.7% -5.2% -19.7%
* includes all prescriptions for co-morbidities in addition to diabetes related
treatment costs
** No referrals to specialists were recorded in this year.
Strain WD EASD P1698 2016
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Summary
Early intensification of therapy reduces progression of diabetes
An individualized approach is required based on the predominant features of the disease.
For those with Pre-existing heart failure SGLT-2i may have an advantage
For those with proven atherosclerotic disease GLP-1-RA may be of use
For all, the most important consideration in choosing the drugs that the people will take…
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Diabetes in the elderly
David Strain,
Diabetes and Vascular Research Centre
University of Exeter Medical School, UK
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Prevalence of hypoglycaemia more frequent in older adults
Retrospective data suggests
12.8% of patients aged over 70 years
vs. 10.1% aged 60–69 years
vs. 9% aged under 60 years
Prospective data however…
39% of elderly patients treated with SU-treated
64% treated with insulin for >5 years
36% expenditure increase in patients experiencing hypoglycaemia2
45–70% increased risk of fall-related fracture in relation to hypoglycaemia in people >65 years2
1. McCoy RG et al. Diabetes Care 2012;35:1897–901; 2. Johnston SS et al. Diabet Obes Metab 2012;14:634–43
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Longevity
• Will they benefit from treatment?
• Cholesterol (statin) therapy takes months(years) to give benefit
• Stopping smoking takes minutes to benefit physiology, but QALY benefit…?
• Glycaemic control alone take years (decades) to improve outcomes
1. Heart Protection Study Collaborative Group. Lancet 2011;378:2013–20; 2. UKPDS 33. Lancet 1998;352:837–53; 3. Holman et al. N Engl J Med 2008;359:1577–89; 4. Bain et al. J R Soc Med 1992;85:80–2.QALY=quality-adjusted life year
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Individualising treatment for older adults in a clinical trial
At baseline, an individualised 24−week HbA1c target was defined by the investigator for
each of the 278 older adults
• Mean age 74.8 SD (4.12), range 70−97 years
Target was based on clinical judgment, taking into account:
• Age of the patient
• Baseline HbA1c value
• Frailty status
• Comorbidities
HbA1c, glycated haemoglobin;; SD, standard deviation
In this elderly cohort (70+ years old, mean age 75), the mean individualised HbA1c
targets set by the investigators were around 7.0% for both treatment groups,
0.9% (range –4.4 to –0.1) lower than the mean baseline HbA1c of 7.9%
Strain et al. Lancet 2013;382:409‒16
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Predictors of investigator-defined treatment targets in
the intention-to-treat population
CovariateEffect size per unit change in covariate
p value
Categorical Variables
Age (<75 vs ≥75 years) -0.036 0.5
Frailty status (No vs Yes) 0.169 0.07
Sex (Female vs Male) 0.119 0.025
Continuous Variables
Screening HbA1c (%) 0.536 <0.0001
Duration of diabetes (years) -0.001 0.7600
Target setting = frailty status (No or Yes) + age (<75 or ≥75) + sex + duration of diabetes + screening HbA1c
*For categorical covariates the estimate is the difference between the adjusted means of comparison-reference in the corresponding category.
For continuous covariates the estimate is the change in adjusted means per unit. HbA1c=glycosylated hemoglobin A1c.
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Strain WD et al. Aging 2017 March
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Frailty assessment pathway in diabetes
ABPI, ankle-brachial pressure index; GP, general practitioner; IADL, instrumental activities of daily living; PVD, peripheral vascular disease; SPPB, short physical performance battery
Strain WD et al. Diabet Med. 2018;35:838–845
Patient-related symptoms / concernsFalls
Mobility change
Post-hospital decrease in IADL
Weight loss/fatigue
Primary care
Diabetes specialist/geriatrician
Opportunity for referral
Assessment procedures
• Clinical review
• 4m gait speed
• Get Up and Go Test
• Electronic Frailty Index or
similar tool
Confirm or exclude presence
of frailty
Assessment procedures
• Clinical review
• Fried score
• Frail score
• SPPB
• Grip strength
• 4m gait speed
• Diagnosis of sarcopaenia (dexa scan)
• Evaluate and/or exclude peripheral
neuropathy (monofilament or vibration perception)
• Structured history/ABPI with hand-held
Doppler ultrasound for PVD and referral for
further assessment if required
• Comprehensive assessment of
functional status
• Confirmation of frailty diagnosis
• Review of glycaemic goals
• Exclude vascular and
neuropathic causes of mobility
impairment
Initial management plan
Promote positive lifestyle intervention with regular exercise
Nutritional assessment and exclude vitamin D deficiency
Review glucose control and medications according to functional
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Normal range for TUAG
Age Group Time in Seconds (95% Confidence Interval)
60 – 69 years 8.1 (7.1 – 9.0)
70 – 79 years 9.2 (8.2 – 10.2)
80 – 99 years 11.3 (10.0 – 12.7)
Group Time in Seconds
Community Dwelling Frail Older Adults > 14 associated with high fall risk
Multimorbid patient > 30 predictive of requiring assistive
device for ambulation and being
dependent in ADLs
Values highly predictive of severe frailty
Bohannon RW. Journal of Geriatric Physical Therapy, 2006;29(2):64-8.Shumway-Cook A, Phys Ther. 2000;80:896-903.
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New UK assessment protocol: simplified frailty assessment
Patient type Examples of patient features
Healthy• Few coexisting chronic illnesses
• Cognitive and functional status intact
Complex
or
intermediate
• Multiple coexisting chronic illnesses
• >2 activities of daily living impairments
• Mild-to-moderate cognitive impairment
Very complex
or
in poor health
• Long-term condition
• End-stage chronic illnesses
• Moderate-to-severe cognitive impairment
• >2 activities of daily living dependencies
Strain WD et al. Diabet Med. 2018;35:838–845
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Treatment targets
Patient characteristics Targets Interventions
The fit older adult with diabetes 58 mmol/mol (7.5%)Avoid initiating new agents that may cause hypoglycaemia or
exaggerate weight loss
Moderate-to-severe frailty 64 mmol/mol (8.0%)
DPP-4 inhibitors and longer acting insulins have demonstrated
safety. TZDs may increase risk of heart failure. SGLT-2i may
provide additional benefit in people with heart failure but also
exacerbate symptoms of diabetes
Very severe frailty 70 mmol/mol (8.5%)
DPP-4 inhibitors renally appropriate dose for those only mildly away
from target. Consider long-acting analogue insulins to achieve
target with minimal fluctuation and lower risk of hypoglycaemia.
Educate carers and relatives regarding risk of hypoglycaemia
DPP-4, Dipeptidyl peptidase-4; NPH, neutral protamine Hagedorn; SGLT-2i, sodium-glucose co-transporter-2 inhibitor; TZD, thiazolidinedione
Strain WD et al. Diabet Med. 2018;35:838–845
30
ADA/EASD 2018 consensus for glucose-lowering medication in T2D
*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by
region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If
no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i
relatively cheaper
To avoid clinical inertia reassess and
modify treatment regularly
(3–6 months)
Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#
If HbA1c above target If HbA1c above targetIf HbA1c above target
GLP-1RA
TZD
DPP-4i
OR
OR
SGLT-2i†
DPP-4i
GLP-1RA
OR
OR
SGLT-2i†
TZD
OR
SGLT-2i†
TZD
OR
If HbA1c above target
SGLT-2i† TZDGLP-1RADPP-4i
Compelling need to minimise hypoglycaemia
Continue with addition of other agents as outlined above
If HbA1c above target
If HbA1c above target
DPP-4 inhibitors in elderly patients
have been demonstrated to have a
complication rate comparable with
younger patients
Not particularly potent
Relatively well tolerated
31
ADA/EASD 2018 consensus for glucose-lowering medication in T2D
*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by
region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If
no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i
relatively cheaper
To avoid clinical inertia reassess and
modify treatment regularly
(3–6 months)
Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#
If HbA1c above target If HbA1c above targetIf HbA1c above target
GLP-1RA
TZD
DPP-4i
OR
OR
SGLT-2i†
DPP-4i
GLP-1RA
OR
OR
SGLT-2i†
TZD
OR
SGLT-2i†
TZD
OR
If HbA1c above target
SGLT-2i† TZDGLP-1RADPP-4i
Compelling need to minimise hypoglycaemia
Continue with addition of other agents as outlined above
If HbA1c above target
If HbA1c above target
GLP1-RA
May reduce risk of stroke more than
alternative glucose lowering
methods (Semaglutide)
Associated with weight loss
Unknown effect on those with
sarcopaenia
32
ADA/EASD 2018 consensus for glucose-lowering medication in T2D
*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by
region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If
no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i
relatively cheaper
To avoid clinical inertia reassess and
modify treatment regularly
(3–6 months)
Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#
If HbA1c above target If HbA1c above targetIf HbA1c above target
GLP-1RA
TZD
DPP-4i
OR
OR
SGLT-2i†
DPP-4i
GLP-1RA
OR
OR
SGLT-2i†
TZD
OR
SGLT-2i†
TZD
OR
If HbA1c above target
SGLT-2i† TZDGLP-1RADPP-4i
Compelling need to minimise hypoglycaemia
Continue with addition of other agents as outlined above
If HbA1c above target
If HbA1c above target
SGLT2-I
May be associated with higher stroke
risk (Empagliflozin)
Reduce hospitalisations and delay
death from heart failure (Empagliflozin
& Canagliflozin)
Associated with weight loss
Unknown effect on those with
sarcopaenia
May exacerbate symptoms of
diabetes
33
ADA/EASD 2018 consensus for glucose-lowering medication in T2D
*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by
region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If
no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i
relatively cheaper
To avoid clinical inertia reassess and
modify treatment regularly
(3–6 months)
Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#
If HbA1c above target If HbA1c above targetIf HbA1c above target
GLP-1RA
TZD
DPP-4i
OR
OR
SGLT-2i†
DPP-4i
GLP-1RA
OR
OR
SGLT-2i†
TZD
OR
SGLT-2i†
TZD
OR
If HbA1c above target
SGLT-2i† TZDGLP-1RADPP-4i
Compelling need to minimise hypoglycaemia
Continue with addition of other agents as outlined above
If HbA1c above target
If HbA1c above target
TZD
Associated with fluid retention
(c.f. heart failure)
Reduces stroke risk (pioglitazone)
Increased fracture risk
May be associated with bladder
cancer
Unknown effect on those with
sarcopaenia
Degludec / glargine U300<glargine U100 / detemir<NPH insulin
34
ADA/EASD 2018 consensus for glucose-lowering medication in T2DTo avoid
clinical inertia reassess and
modify treatment regularly
(3–6 months)
Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#
If HbA1c above target If HbA1c above targetIf HbA1c above target
GLP-1RA
TZD
DPP-4i
OR
OR
SGLT-2i†
DPP-4i
GLP-1RA
OR
OR
SGLT-2i†
TZD
OR
SGLT-2i†
TZD
OR
If HbA1c above target
SGLT-2i† TZDGLP-1RADPP-4i
Compelling need to minimise hypoglycaemia
Continue with addition of other agents as outlined above
If HbA1c above target
If HbA1c above target
Insulins should be considered in order
In CF low dose insulin protects against
sarcopaenia
?Effect in frailty
*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by
region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If
no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i
relatively cheaper
Degludec / glargine U300<glargine U100 / detemir<NPH insulin
35
De-escalation thresholds
Patient characteristics Threshold Suggested interventions
The fit older adult with diabetes 53 mmol/mol (7.0%)
Evaluate long-acting sulphonylurea and insulin therapy that may
cause hypoglycaemia. Consider appropriate dosage in setting of
renal function
Moderate-to-severe frailty 58 mmol/mol (7.5%)
Discontinue any sulphonylurea if HbA1c below threshold. Avoid
TZDs due to risk of heart failure. Cautious use of insulin and
metformin mindful of renal function
Very severe frailty 64 mmol/mol (8.0%)
Withdraw sulphonylureas and short-acting insulins due to risk of
hypoglycaemia. Review suitability of NPH insulin – consider
analogues with lower risk of hypoglycaemia. Therapies that
promote weight loss may exacerbate sarcopaenia
NPH, neutral protamine Hagedorn; TZD, thiazolidinedione
Strain WD et al. Diabet Med. 2018;35:838–845
36
NICE quality standards. October 2018
3
Table 1: New indicators added to the NICE indicator menu NICE ID Indicator wording Evidence base Rationale
Diabetes
NM157 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months.
NICE NG17 recommendations 1.6.6 and 1.6.7
NICE NG28 recommendations 1.6.8 and 1.6.9
The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to enable patients with little comorbidity to benefit from tighter glycaemic control whilst aiming to encourage the personalisation of care for people with moderate or severe frailty.
NM158 The percentage of patients with diabetes with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months.
NICE NG17 recommendation 1.6.7
NICE NG28 recommendation 1.6.9
The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to reduce complications and improve quality of life for people with moderate or severe frailty.
NM159 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less.
NICE NG17 recommendation 1.3.18
NICE NG28 recommendations 1.4.3, 1.4.5 and 1.4.6
This indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. A focus on people without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit.
NM142 The percentage of patients with type 1 diabetes who are aged over 40 years currently treated with a statin.
NICE CG181 recommendation 1.3.24
This indicator aims to reduce cardiovascular risk and prevent future cardiovascular events.
NM160 The percentage of patients aged 25–84 years, with a diagnosis of type 2 diabetes, without moderate or severe frailty, not currently treated with a statin, who have had a consultation for a cardiovascular risk assessment using a risk assessment tool
NICE CG181 recommendation 1.1.8.
NICE QS100 statement 1.
A focus on CVD risk assessment in people with diabetes without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets through individualised, patient-centred care.
Recognises Frailty as a priority for assessment and different treatments
NICE quality standards. October 2018
https://www.nice.org.uk/Media/Default/Standards-and-indicators/indicators-general-practice.pdf (accessed 26/10/18)
37
NICE quality standards. October 2018
NICE quality standards. October 2018
3
Table 1: New indicators added to the NICE indicator menu NICE ID Indicator wording Evidence base Rationale
Diabetes
NM157 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months.
NICE NG17 recommendations 1.6.6 and 1.6.7
NICE NG28 recommendations 1.6.8 and 1.6.9
The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to enable patients with little comorbidity to benefit from tighter glycaemic control whilst aiming to encourage the personalisation of care for people with moderate or severe frailty.
NM158 The percentage of patients with diabetes with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months.
NICE NG17 recommendation 1.6.7
NICE NG28 recommendation 1.6.9
The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to reduce complications and improve quality of life for people with moderate or severe frailty.
NM159 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less.
NICE NG17 recommendation 1.3.18
NICE NG28 recommendations 1.4.3, 1.4.5 and 1.4.6
This indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. A focus on people without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit.
NM142 The percentage of patients with type 1 diabetes who are aged over 40 years currently treated with a statin.
NICE CG181 recommendation 1.3.24
This indicator aims to reduce cardiovascular risk and prevent future cardiovascular events.
NM160 The percentage of patients aged 25–84 years, with a diagnosis of type 2 diabetes, without moderate or severe frailty, not currently treated with a statin, who have had a consultation for a cardiovascular risk assessment using a risk assessment tool
NICE CG181 recommendation 1.1.8.
NICE QS100 statement 1.
A focus on CVD risk assessment in people with diabetes without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets through individualised, patient-centred care.
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Take Home messages
● Managing elderly patients is complicated by
– Multiple Co-morbidities,
– Increased risk from the complications of treatment
– Reduced life expectancy, therefore reduced return
● Treatment should focus on reducing risk of side effects and improving symptoms
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Thank you for your attention