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Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos.

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Presentation on theme: "Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos."— Presentation transcript:

1 Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos Tzoulis Romilla Jones, Emma Prescott, Dr Farrukh Shah The Whittington Hospital NHS Trust, London

2 Diabetes affects 366 million people worldwide Predicted to affect 552 million people by 2030 Diabetes caused 4.6 million deaths in 2011 Every 10 seconds a person dies from diabetes-related causes Every 10 seconds two people develop diabetes Greatest number of people with diabetes are between 40 to 59 years of age 78,000 children develop type 1 diabetes each year The Diabetes Epidemic International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF,

3 The Top 10 International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF,

4 Diabetes Prevalence International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF,

5 The Top 10 by Prevalence International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF,

6 USD ($) 465 billion spent on healthcare for diabetes 11% of all healthcare spending is for diabetes USD ($) 1,274 is spent on diabetes care per person with diabetes Healthcare Expenditure (2011) International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF,

7 Diabetes prevalence ~20% (age, chelation therapy) Aetiology and risk factors: Transfusional iron overload Poor chelation therapy, poor compliance, advanced age of onset Altered β-cell insulin secretion Autoimmunity Insulin resistance secondary to liver disease HCV infection Global epidemic – type 1/type 2 diabetes Diabetes in β-Thalassaemia Major

8 Annual oral glucose tolerance tests (OGTT) from puberty or from age 10 years if there is a positive family history Prompt treatment of hyperglycaemia Intensification of iron chelation therapy Early Diagnosis of Diabetes Thalassaemia International Federation. Guidelines for the Clinical Management of Thalassaemia. 2nd Revised Edition Available at: United Kingdom Thalassaemia Society. Standards for the Clinical Care of Children and Adults with Thalassaemia in the UK. 2nd Edition Available at:

9 Diagnosis of Diabetes CategoryPlasma Glucose (mmol/l) Fasting2h Post-Glucose Load Diabetes mellitus Impaired glucose tolerance (IGT)< – 11.0 Impaired fasting glycaemia (IFG) 6.1 – 6.9 (WHO) 5.6 – 6.9 (ADA) < 7.8 Not diabetic or glucose intolerant 6.0 (WHO) 5.6 (ADA) < 7.8 CategoryPlasma Glucose (mg/dl) Fasting2h Post-Glucose Load Diabetes mellitus Impaired glucose tolerance (IGT)< – 199 Impaired fasting glycaemia (IFG) 110 – 125 (WHO) 100 – 125 (ADA) < 140 Not diabetic or glucose intolerant< 110 (WHO) < 100 (ADA) < 140

10 Prevention, detection and management of complications Microvascular & Macrovascular Aim of Treatment Background retinopathy Proliferative retinopathy Kidney glomerulus Glomerular sclerosis Neuropathic foot ulcer Ischaemia

11 Risk for death among people with diabetes twice that of people of similar age but without diabetes In 2004, heart disease noted on 68% of diabetes-related death certificates among people aged 65 years or older (USA) In 2004, stroke noted on 16% of diabetes related death certificates among people aged 65 years or older (USA) Mortality in Diabetes Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011

12 Muscle Glucose (G) Carbohydrate Glucose DIGESTIVEENZYMES Insulin (I) I I I I I I G G G G I G G I I G Sulphonylureas Meglitinides GLP-1 analogues DPP-IV inhibitors Metformin Acarbose Metformin Glitazone GLP-1 Liver Pancreas Adipose tissue Antidiabetic Drugs

13 Insulin ± oral agents Oral combination Oral monotherapy Diet & exercise Metformin Sulphonylureas Gliptins GLP-1 analogues Stepwise Management of Diabetes

14 Physiological insulin regimen 24 hour insulin and glucose profile in non-diabetic persons Insulin Therapy

15 BreakfastLunchDinnerBedtime Insulin (Rapid) Insulin (Basal) Basal-Bolus Insulin Regimen e.g. Insulin aspart (Novorapid) + insulin glargine (Lantus)

16 To calculate rapid insulin dose given with a meal: Take capillary blood glucose before eating If >7 mmol/l, calculate insulin correction dose Estimate carbohydrate content of food 10g carbohydrate = 1 Carbohydrate Portion (CP) Calculate food insulin using 1 – 3 units for each CP Remember to adjust for all other factors that may affect glycaemic control (exercise, illness, alcohol etc) Give insulin (correction dose + food insulin) Insulin Dose Adjusting

17 Aims: Provide high quality diabetes, endocrine and haematology care Optimise metabolic control Support patient self-management Support partnership working between specialist teams and between patients and clinicians Provide education, training and research opportunities Whittington Joint Diabetes Thalassaemia Clinic

18 Patients seen jointly: Consultant Diabetologist (Dr Maria Barnard) Consultant Haematologist (Dr Farrukh Shah) Diabetes Specialist Nurse (Romilla Jones) Haematology Specialist Nurse (Emma Prescott) Senior Diabetes Dietitian Clinical Psychologist Access to Whittington type 1 diabetes structured education courses (WINDFAL) Whittington Joint Diabetes Thalassaemia Clinic

19 Complete full diabetes annual review once a year Address the 9 Key Care Processes for diabetes: [1] Glycaemic control [2] Blood pressure [3] Serum cholesterol [4] Serum creatinine [5] Urinary albumin [6] Weight [7] Diabetic foot examination [8] Smoking status assessment [9] Retinal screening Whittington Joint Diabetes Thalassaemia Clinic

20 MeasureTarget Fructosamine (umol/l) HbA1c (%) < 322 (< 299) < 7.0 (< 6.5) Capillary blood glucose (mmol/l) Pre-prandial Post-prandial (2 h) 4 – 7 5 – 8 Blood pressure (mmHg) - with nephropathy < 130 / 80 < 125 / 75 Total cholesterol (mmol/l)< 4.0 LDL cholesterol (mmol/l)< 2.0 Triglycerides (mmol/l)< 1.7 Smoking statusNon-smoker Body mass index (kg/m 2 )20 – 25 ExerciseDaily Aspirin (75 mg) if > 50 y of age or CV riskDaily

21 Whittington Joint Diabetes Thalassaemia Clinic Clinic Population Description Gender - Female Male 59% 41% Age*39 years (28 – 59y) Ethnic origin Greek Cypriot / Greek South Asian (Indian, Pakistani, Bangladeshi) 36% 64% Ferritin at first appointment*1827 ug/l ( ug/l) Diabetes duration*13 years (<1 – 29y) Age at diagnosis*21 years (10 – 40y) BMI*24.8 kg/m 2 Treatment – insulin73% Treatment – oral antidiabetic drugs only14% Treatment – diet control only14% *median values

22 Performance: Joint Clinic vs. National Audit for England Care ProcessPerformance of Key Care Processes Joint Clinic ( ) National Diabetes Audit ( ) Fructosamine (HbA1c)97.5%91.1% Serum cholesterol91.1%89.9% Serum creatinine100%91.2% Urinary albuminuria91.1%62.7% Weight / Body mass index97.5%88.8% Blood pressure (BP)80.4%93.7% Foot assessment89.2%77.1% Smoking status89.2%86.5%

23 Target achievement: Joint Clinic vs. National Audit for England TargetPercentage of patients achieving treatment target Joint Clinic ( ) National Diabetes Audit ( ) Fructosamine < 345 umol/l (HbA1c < 7.5%) 72.7%62.9% BP < 135/75 mmHg57.9%30.1% Total cholesterol < 5.0 mmol/l82.1%78.0%

24 Metabolic improvement in Joint Clinic ParameterFirst appointment1 year follow-upChange Fructosamine344 umol/l319 umol/l-25 umol/l BP122/70 mmHg124/77 mmHg+2/7 mmHg Total cholesterol3.8 mmol/l3.5 mmol/l-0.3 mmol/l 33% of patients achieved reduction in ferritin of >10% 23% were on antihypertensive agents 23% were on lipid lowering agents 32% on antiplatelet/anticoagulant agents

25 Diabetic Complications in Patients Attending Joint Clinic Diabetic complicationPrevalence in patients attending Joint Clinic Microalbuminuria13.6% Diabetic retinopathy13.6% 1 microvascular complication22.7% Charcot neuroarthropathy4.5% Cataracts9.1% Macrovascular complications0 Diabetic emergencies0

26 Endocrinopathies in Patients Attending Joint Clinic EndocrinopathyPrevalence in patients attending Joint Clinic Hypogonadism - Hypogonadotrophic hypogonadism - Primary hypogonadism 86% 59% 27% Hypothyroidism18% Hypoparathyroidism23% Osteopenia14% Osteoporosis55% Glucocorticoid deficiency0 Growth hormone deficiency0

27 Joint Diabetes Thalassaemia Clinic effective at providing high quality care in the most complex patients 41% patients diagnosed with diabetes <19 years of age Early effective iron chelation is critical Be aware of diabetic complications (microvascular) Optimise glycaemic control Modify cardiovascular risk Whittington Joint Diabetes Thalassaemia Clinic - Discussion

28 Patients with diabetes and thalassaemia have complex medical care needs Psychological impact – treatment burden, impact on daily life, feeling of difference, dependence and anxiety Partnership working of the Joint Diabetes Thalassaemia Clinic: Patients have easy access to senior specialist clinicians Continuity of care Supported by multidisciplinary team Working together with the patient and each other Supporting self-management Diabetes and Thalassaemia - Conclusions

29 Patients receive training in carbohydrate counting and insulin dose adjustment Patients access type 1 diabetes structured education Significant educational opportunities for healthcare professionals and staff in training Managing diabetes is one of the greatest challenges a person with thalassaemia can face. Joint Diabetes Thalassaemia Clinic enables our patients to effectively manage their physical and psychological long-term health Diabetes and Thalassaemia - Conclusions


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