DIABETES WORKSHOP IN GENERAL PRACTICE

Dr John Rochford

GP Sharnbrook

Bedford Diabetes Survey

• 1962 : 1,000 citizens ,

• 4% clinistix + -> oral GTT, 25%intolerant

• 240 randomised Tolbutamide / placebo

• 5% per annumm → Diabetes

• 20 world diabetes experts – < 7.8 m mol : diabetes absent– > 11.1 m mol : diabetes present

Diabetes Classification

• 1936 Ainsworth– Insulin Dependent Diabetes IDDM– Non Insulin Dependent Diabetes NIDD

• Type I or Type II

• 1997 : Type 1, 2, 3, 4, 5, 6,

UK epidemiology

• England 2008– 2.5 million 4% ♂ 3% ♀; 90 % type 2– Prevalence doubled 1991 → 2003

• North Bedfordshire – 1994 7,000– 2008 3.5 % 14,643

• Sharnbrook Surgery– 1986 70 [1.2%]– 2008 192 [3.4%]

Why do we treat ?

• ↓ life expectancy by 15 years

80% die of macrovascular disease

• ↑ healthcare costs by *3

• ↓ HbA1c of 1% – ↓ Fatal MI 17 %– ↓ CVA risk 37 %

Two trials• DCCT

– 1,441 Type 1 patients , USA – Intensive [pump] v conventional treatment– ↓ retinopathy 70%, ↓ neuropathy 64%– ↓ cardiac + pvd 41 %, ↑ hypos *3 ↑ weight

• UKPDS– 5,000 new Type 2 patients, UK– Intensive DM treatment [ eye 25 %, renal 33%]

– Intensive BP control ↓ macrovascular death

Complications

• Macro vascular– Cardiac– Cerebro-vascular– Peripheral Vascular Disease

• Micro Vascular– Retinal– Renal– Impotence– Peripheral neuropathy

Drug treatments BNF 6.1

• Sulphonylureas ↑ insulin release• Biguanides ↑ periph glucose utilisatn ↓ hepatic glucose production• Glitazones ↓ insulin resistance• Incretins ↑ insulin reponse to oral

glucose• Alpha glucosidase delays starch absorpn• Insulin moves glucose into cells

Metformin

• Doses 500 mg , 850 mg , SR , max 2g /d

• .s/e : nausea , vomiting, diarrhoea, wt

• .c/I : liver , CCF,

renal creat > 150 / eGFR <30

Sulphonylurea

• Gliclizide , Glimepramide, Glipizide

• Glibenclamide, Chlorpropamide

• Prandial Glucose Regulators – Repaglanide , Nateglinide

• s/e Hypo, weight

• c/I severe liver / renal impairment

Glitazones

• [troglitazone] Pioglitazone , Rosiglitazone

• Triple therapy

• s/e weight, fluid retention, fractures, GI, lipids,

• c/i CCF, vascular disease, liver disease

Incretins

• Incretin effect– ↓ glucose load in blood– ↓ liver gluconeogenesis– ↓ gastric emptying

• GLP1 agonist [glucose like peptide]

• DPP4 inhibitor [DiPeptidyl Peptidase 4]

Exanatide

• Hospital initiation only at present• BMI > 35 , HbA1c > 7.5• 5-10 mcg daily sc [60 doses] ac• Can add to Metformin / Sulphonylurea• ↓ weight, ↓ HbA1c by 1%

• s/e Nausea , dizzy, h/a, apetite, [pancreatitis]

• c/i renal disease, glitazones, insulin

Sitagliptin / Vandagliptin

• Single daily dose 100mg mg

• Can add to Metformin / sulphonylurea

• s/e GI disturbance, oedema , urti,

• c/i severe renal disease

Insulin

• Currently only in hospital in North Beds

• blood glucose testing

• Intensive lifestyle review

• Weight gain

• Insulin treated Type 2

• Insulin regimes + dose adjustment – 10 / 10 / 15 // 25– 25 / 30

Combination therapies

• Underweight BMI < 20– Sulphonylurea – 2nd line Insulin

• Normal / over wt 20 – 25 / 25-35– Metformin– 2nd line Sulphonylurea– 3rd line [sitagliptin]– 4th line Glitazone / [Exanetide]– 5th line Insulin

Combination therapies

• Obese BMI > 35– Metformin– 2nd line Sulphonylurea– 3rd line [exanetide / sitagliptin] glitazone– 4th line Intensive lifestyle review– 5th line insulin

Annual cost of drugs £

• Metformin 2g / day 17• Gliclazide 320mg 35• Rosiglitazone 16 mg 482• Pioglitazone 45 mg 482• Glargine insulin 25 u 237• Sitagliptin 100 mg 434• Vidagliptin 100mg 414• Exanatide 20 mcg 830

Hypoglycaemia

• Definition

• Severe hypo

• Symptoms – adrenergic– neuroglycopenic

• Management– Oral treatment– Glucagon

B G T S

• Testing frequency– Insulin– Tablets– Diet alone

• Urine testing

Glucose Targets : HbA1c

• QoF 10.0 % 7.5 %

• Old 7.0 %

• NICE 6.5 %

Cholesterol

• Cholesterol measurement

• Diet

• Drug therapy

• Monitoring HDL + LDL

Cholesterol Targets

• QoF

– total 5.0 LDL 3.0

• NICE– total 4.0 LDL 2.0

Hypertension

• Blood Pressure below

– Q o F 150/90

– Conventional 140/80

– Renal disease 130/80

– Proteinuria >100g 120/80

Hypertension

• Lifestyle – Weight

– Waist circumference

– Sodium

– BP Measurement in surgery / at home

Hypertension

• A B C D– A ACE inhibitors A2RB– B [ A2 blocker ]– C Calcium antagonists– D Diuretics

• Other drugs – Beta or Alpha blockers – Centrally acting [ moxonidine , clonidine, methyl dopa]– Spironolactone

Kidney Disease

• Classification – Stage 1 eGFR >90

ml/min/1.73m2

– . 2 60 - 89– . 3a 45 - 59 – . 3b 30 – 44– . 4 15 – 29– . 5 < 15

Microalbuminuria testing• ACR [albumen / creatinine ratio ]

– Male > 2.5– Female > 3.5– Confirm by 2 of 3 pos EMU

• Avoid– Smoking– Non steroidals– Excess weight – Lack of exercise

Microalbuminuria management• ACE / A2RB

• Aspirin 75 mg

• B P target < 130/80

• Diabetes control optimised HbA1c < 6.5

Ongoing care

• Retest every 12 months

• if MAU +, re test every 6 months

• Refer– eGFR <30 , CKD stage 4 / 5– ACR > 70

CKD without diabetes

• Routinely request eGFR with creatinine

• eGFR < 60 retest in 2/52

• Test ACR on EMU preferable to PCR,

• Re test ACR if > 30

• Don’t test for protein with sticks

• If ACR 30 – 70 dip test for haematuria

CKD without diabetes – What next

• ACR 30 – 70 + no haematuria

– BP < 140/90 ACE / A2– Statins– Aspirin– FBC to see if Hb < 11.0 if it is refer

CKD without diabetes – Refer

• ACR > 70 / haematuria +, [renal u/s]

• Rapid decline of eGFR – > 5 ml / yr– > 10 ml in 5 yrs

• On 4+ hypertension drugs

• CKD stage 4 or 5

Managing the patients

• Running the clinic – Call + recall system– Blood tests– Seeing the patients

• Eye Screening • New patients

– Follow up after diagnosis– Education - DESMOND

Metabolic syndrome

• Global prev 16 % UK 25 %• International Diabetes Federation

– Central obesity [ waist > 94 M / 80 F ]– Plus two of the following

• fast glu > 5.5, • TG > 1.7, • HDL chol < 1.03 M / 1.29 F• BP > 130/85

• Management [wt loss, diet, exercise, BP, lipids]

Pregnancy

• Pre pregnancy counselling – Smoking folic acid 5mg– Diabetes control optimised

• Gestational diabetes

• Drugs– Metformin and insulin ok– Stop statins , ACE/A2

New local horizons

• Can we make local care more effective ?

• Do we need to send so many patients to the hospital ?

• Do we need local Diabetes champions / GPwSI ?