DIABETES WORKSHOP IN GENERAL PRACTICE Dr John Rochford GP Sharnbrook.
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Transcript of DIABETES WORKSHOP IN GENERAL PRACTICE Dr John Rochford GP Sharnbrook.
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 ?