1. DIABETES WORKSHOP IN GENERAL PRACTICE Dr John Rochford GP Sharnbrook

2. 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

3. 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,

4. 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%] –2008192 [3.4%]

5. 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 %

6. 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

7. Complications Macro vascular –Cardiac –Cerebro-vascular –Peripheral Vascular Disease Micro Vascular –Retinal –Renal –Impotence –Peripheral neuropathy

8. 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

9. 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

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

11. Glitazones [troglitazone] Pioglitazone, Rosiglitazone Triple therapy s/e weight, fluid retention, fractures, GI, lipids, c/i CCF, vascular disease, liver disease

12. Incretins Incretin effect –↓ glucose load in blood –↓ liver gluconeogenesis –↓ gastric emptying GLP1 agonist [glucose like peptide] DPP4 inhibitor [DiPeptidyl Peptidase 4]

13. 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

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

15. 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

16. Combination therapies Underweight BMI < 20 –Sulphonylurea – 2 nd line Insulin Normal / over wt 20 – 25 / 25-35 –Metformin –2 nd line Sulphonylurea –3 rd line [sitagliptin] –4 th line Glitazone / [Exanetide] –5 th line Insulin

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

18. Annual cost of drugs £ Metformin 2g / day 17 Gliclazide 320mg 35 Rosiglitazone16 mg 482 Pioglitazone 45 mg482 Glargine insulin 25 u237 Sitagliptin 100 mg434 Vidagliptin100mg414 Exanatide20 mcg830

19. Hypoglycaemia Definition Severe hypo Symptoms –adrenergic –neuroglycopenic Management –Oral treatment –Glucagon

20. B G T S Testing frequency –Insulin –Tablets –Diet alone Urine testing

22. Glucose Targets : HbA1c QoF 10.0 % 7.5 % Old 7.0 % NICE 6.5 %

23. Cholesterol Cholesterol measurement Diet Drug therapy Monitoring HDL + LDL

24. Cholesterol Targets QoF –total 5.0 LDL 3.0 NICE – total 4.0 LDL 2.0

25. Hypertension Blood Pressure below –Q o F150/90 –Conventional 140/80 –Renal disease130/80 –Proteinuria >100g 120/80

26. Hypertension Lifestyle –Weight –Waist circumference –Sodium –BP Measurement in surgery / at home

27. 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

28. Kidney Disease Classification –Stage 1 eGFR >90ml/min/1.73m 2 –. 260 - 89 –.3a45 - 59 –.3b30 – 44 –.415 – 29 –.5< 15

29. 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

30. Microalbuminuria management ACE / A2RB Aspirin 75 mg B P target < 130/80 Diabetes control optimised HbA1c < 6.5

31. Ongoing care Retest every 12 months if MAU +, re test every 6 months Refer –eGFR <30, CKD stage 4 / 5 –ACR > 70

32. 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

33. 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

34. 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

35. Managing the patients Running the clinic –Call + recall system –Blood tests –Seeing the patients Eye Screening New patients –Follow up after diagnosis –Education - DESMOND

36. 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]

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

38. 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 ?