DIABETES WORKSHOP IN GENERAL PRACTICE

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DIABETES WORKSHOP IN GENERAL PRACTICE

• Dr John Rochford
• GP Sharnbrook

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Bedford Diabetes Survey

• 1962 1,000 citizens ,
• 4 clinistix -gt oral GTT, 25intolerant
• 240 randomised Tolbutamide / placebo
• 5 per annumm ? Diabetes
• 20 world diabetes experts
• lt 7.8 m mol diabetes absent
• gt 11.1 m mol diabetes present

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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,

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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

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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

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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

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Complications

• Macro vascular
• Cardiac
• Cerebro-vascular
• Peripheral Vascular Disease
• Micro Vascular
• Retinal
• Renal
• Impotence
• Peripheral neuropathy

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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

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Metformin

• Doses 500 mg , 850 mg , SR , max 2g /d
• .s/e nausea , vomiting, diarrhoea, wt
• .c/I liver , CCF,
• renal creat gt 150 / eGFR lt30

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Sulphonylurea

• Gliclizide , Glimepramide, Glipizide
• Glibenclamide, Chlorpropamide
• Prandial Glucose Regulators
• Repaglanide , Nateglinide
• s/e Hypo, weight
• c/I severe liver / renal impairment

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Glitazones

• troglitazone Pioglitazone , Rosiglitazone
• Triple therapy
• s/e weight, fluid retention, fractures, GI,
  lipids,
• c/i CCF, vascular disease, liver disease

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Incretins

• Incretin effect
• ? glucose load in blood
• ? liver gluconeogenesis
• ? gastric emptying
• GLP1 agonist glucose like peptide
• DPP4 inhibitor DiPeptidyl Peptidase 4

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Exanatide

• Hospital initiation only at present
• BMI gt 35 , HbA1c gt 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

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Sitagliptin / Vandagliptin

• Single daily dose 100mg mg
• Can add to Metformin / sulphonylurea
• s/e GI disturbance, oedema , urti,
• c/i severe renal disease

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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

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Combination therapies

• Underweight BMI lt 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

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Combination therapies

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

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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

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Hypoglycaemia

• Definition
• Severe hypo
• Symptoms
• adrenergic
• neuroglycopenic
• Management
• Oral treatment
• Glucagon

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B G T S

• Testing frequency
• Insulin
• Tablets
• Diet alone
• Urine testing

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Glucose Targets HbA1c

• QoF 10.0 7.5
• Old 7.0
• NICE 6.5

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Cholesterol

• Cholesterol measurement
• Diet
• Drug therapy
• Monitoring HDL LDL

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Cholesterol Targets

• QoF
• total 5.0 LDL 3.0
• NICE
• total 4.0 LDL 2.0

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Hypertension

• Blood Pressure below
• Q o F 150/90
• Conventional 140/80
• Renal disease 130/80
• Proteinuria gt100g 120/80

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Hypertension

• Lifestyle
• Weight
• Waist circumference
• Sodium
• BP Measurement in surgery / at home

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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

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Kidney Disease

• Classification
• Stage 1 eGFR gt90 ml/min/1.73m2
• . 2 60 - 89
• . 3a 45 - 59
• . 3b 30 44
• . 4 15 29
• . 5 lt 15

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Microalbuminuria testing

• ACR albumen / creatinine ratio
• Male gt 2.5
• Female gt 3.5
• Confirm by 2 of 3 pos EMU
• Avoid
• Smoking
• Non steroidals
• Excess weight
• Lack of exercise

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Microalbuminuria management

• ACE / A2RB
• Aspirin 75 mg
• B P target lt 130/80
• Diabetes control optimised HbA1c lt 6.5

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Ongoing care

• Retest every 12 months
• if MAU , re test every 6 months
• Refer
• eGFR lt30 , CKD stage 4 / 5
• ACR gt 70

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CKD without diabetes

• Routinely request eGFR with creatinine
• eGFR lt 60 retest in 2/52
• Test ACR on EMU preferable to PCR,
• Re test ACR if gt 30
• Dont test for protein with sticks
• If ACR 30 70 dip test for haematuria

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CKD without diabetes What next

• ACR 30 70 no haematuria
• BP lt 140/90 ACE / A2
• Statins
• Aspirin
• FBC to see if Hb lt 11.0 if it is refer

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CKD without diabetes Refer

• ACR gt 70 / haematuria , renal u/s
• Rapid decline of eGFR
• gt 5 ml / yr
• gt 10 ml in 5 yrs
• On 4 hypertension drugs
• CKD stage 4 or 5

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Managing the patients

• Running the clinic
• Call recall system
• Blood tests
• Seeing the patients
• Eye Screening
• New patients
• Follow up after diagnosis
• Education - DESMOND

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Metabolic syndrome

• Global prev 16 UK 25
• International Diabetes Federation
• Central obesity waist gt 94 M / 80 F
• Plus two of the following
• fast glu gt 5.5,
• TG gt 1.7,
• HDL chol lt 1.03 M / 1.29 F
• BP gt 130/85
• Management wt loss, diet, exercise, BP, lipids

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Pregnancy

• Pre pregnancy counselling
• Smoking folic acid 5mg
• Diabetes control optimised
• Gestational diabetes
• Drugs
• Metformin and insulin ok
• Stop statins , ACE/A2

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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 ?