Diabetes in Primary Care

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Diabetes in Primary Care

• VTS 23/3/11

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Types of diabetes and related conditions

• Type 1 (5-15)
• Type 2
• Pre-diabetes (IFG, IGT, GD)
• Secondary diabetes

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Epidemiology

• One million diagnosed diabetics in England (2)
• 1 in 20 people age gt 65
• 1 in 5 people age gt 85
• Increasing prevalence Type 2 DM increased from
  2.8 in 1996 to 4.3 in 2005
• 40-60 patients per General Practitioner
• 41 NHS funding for Type 2 spent on inpatient
  care for complications
• Most diagnosed after 40 with peak onset age 60

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What are the problems in diabetes?

• Mortality from CHD 5 times higher
• Mortality from CVA 3 times higher
• Leading cause of renal failure
• Leading cause of blindness in working age
• Second commonest cause of lower limb amputation

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Aims of diabetes care

• Identify those with DM and related conditions
• Improve quality of service for diabetic patients
• Tackle variations in care
• Make best practice the norm
• Reach communities at greatest risk
• Reduce complication rates
• Eliminate discrimination

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Challenges in dealing with diabetes

• Increasing numbers
• Morbidity
• Medical resource usage
• Cost
• Changing lifestyle
• Improving outcome

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Risk factors for Type 2 diabetes

• Age
• Obesity (80) esp truncal
• Physical inactivity activity increases insulin
  sensitivity
• Genetic factors
• Ethnicity

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Finding Type 2 diabetes

• 50 diabetes undiagnosed i.e. 1 million
• Onset of diabetes may be 7-12 years before
  clinical recognition
• 25 have evidence of microvascular complications
  at clinical diagnosis
• Value of population screening has not been
  established
• Early interventions of diet lifestyle amongst
  at-risk groups is preventative and worthwhile
• Focus on at-risk populations - who could you
  screen in practice how?

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At risk populations for Type 2 DM

• All with cardiovascular disease
• Those with BMI gt 30
• Skin sepsis especially if recurrent
• Thrush especially if recurrent
• Those with ve FH of Type 2 DM
• Ethnic groups especially at certain ages
• Annual review of those with pre-diabetes

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Identifying diabetes in practice

• Protocols/prompts/reminders
• New patient screening
• All within CV care system
• NHS screening checks
• Registers systematic monitoring of at-risk
  patients

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Diagnostic Criteria for Type 2 DM(WHO)

• If symptoms of hyperglycaemia a single fasting
  plasma gt7 or a single random plasma glucose gt11.1
  or
• If asymptomatic fasting glucose gt7 on two
  separate occasions

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Management Type 2 DM

• Education/diet/lifestyle
• Smoking
• Monitor control blood sugar
• Control hypertension lt 140/80 (lt130/80 if end
  organ damage)
• Manage lipids
• Monitor for renal damage
• Monitor for retinopathy
• Feet
• Depression
• Monitor for neuropathy
• ED
• Autonomic

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Monitoring

• HBA1c Glycated HbA1c
• Measure of integrated blood glucose control over
  preceding 3/12 but with extra weighting for 1/12
  prior to sampling
• NICE target 6.5
• QOF target moving to 7.5
• HbA1c will become a diagnostic test
• Role of self-monitoring
• 20 can do this with combination
  diet/lifestyle/exercise
• The rest will need lifestyle modification mono
  or multiple therapies including insulin

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Medication

• Metformin
• Starting point for most patients
• Reduces cardiovascular mortality compared with
  other hypoglycaemic agents
• Helpful with weight
• Review dose of metformin if creatinine gt130 or
  eGFR lt45
• Stop metformin if creatinine gt150 or eGFR lt30
• Temporarily withdraw with tissue hypoxia
• For 3 days after iodine containing contrast
  medium
• 2 days before GA

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However..

• Natural trend of disease is of deteriorating beta
  cell function
• 50 of those on monotherapy require additions at
  3 years
• 50 of patients with chronic illness do not take
  medications as prescribed
• Achieving sustaining long term lifestyle change
  is difficult over time non-medication Rx
  becomes ineffective

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Medications

• Sulphonylureas
• Thiazolidinediones pioglitazone
• Post-prandial glucose modifiers
• DPP-4 inhibitors - gliptins
• GLP-1 mimetics exenatide, liraglutide
• Orlistat
• Insulin regime?