1. Diabetes for the AKT September 2013

2. We reproduce below our feedback from AKT 16 which sadly continues to apply in AKT 17. Please re-read! “In the last feedback, we noted that diagnosis of diabetes appeared to have improved. However, in AKT 16 there were again difficulties in interpreting test results. It is very likely that similar items will appear in subsequent tests. We would suggest that candidates carefully review this aspect of diabetes care which will become even more significant in daily work as the prevalence of diabetes increases. “ AKT feedback Jan 2013

3. Diagnosis according to…

4. NICE CKS guidelines for diagnosis… Fasting Plamsa Glucose = or > 7.0 mmol/l – On 1 occasion if symptommatic (polyuria, polydipsia and weight loss) – On 2 occasions if asymptommatic 2 hr plasma glucose = or > 11.1 mmol/l after 75 g oral glucose load (i.e. OGTT) OGTT considered “gold standard” – OGTT > fasting plasma glucose > random plasma glucose

5. WHO (via Map of Medicine)… HbA1C = or > 48 mmol/mol (6.5%) or… As above: OGTT, fasting plasma glucose and random plasma glucose (= or > 11.1 mmol/l) Perform an OGTT if – Fasting plasma glucose 6.1 – 6.9 mmol/l – Random plasma glucose 6.1 – 11 mmol/l So, how to intepret OGTT results…

6. A Fasting plasma glucose 7.8 mmol/l up to (but not incl.) 11.1 mmol/l – IMPAIRED GLUCOSE TOLERANCE Fasting plasma glucose 6.1 – 6.9 mmol/l AND 2 hr OGTT plasma venous glucose < 7.8 mmol/l – IMPAIRED FASTING GLYCAEMIA

7. Gestational Diabetes SIGN guideline At booking – Assess for risk factors – If risk factors present for HbA1C or a fasting glucose Risk factors for gestational diabetes are defined as:[16] BMI more than 30 kg/m?. Previous macrosomic baby weighing 4.5 kg or more. Previous gestational diabetes. Family history of diabetes (first-degree relative with diabetes). Family origin with a high prevalence of diabetes, including South Asian, Black Caribbean and Middle Eastern. All women with risk factors should have an OGTT at 24-28 weeks

8. Type 2 Diabetes Management NICE CG87, piorities: NICE CG87 – Offer structured education to every person at time of diagnosis – Individualised dietary advice – Target HbA1C = 6.5 (48), avoid pursuing less than this and tailor to individual patient – Offer self-monitoring…only as an integral part of their self-management education (??) – When starting insulin use a structured programme

9. Simple?

10. Blood glucose lowering therapy If HbA1C >/= 6.5 (48) after trial of lifestyle  METFORMIN, unless; – NOT over-weight – Metformin not tolerated/Cied – Hyperglycaemic symps requiring rapid control Essentially step 1: – Mostly METFORMIN or occasionally SULFONYLUREA

11. Blood glucose lowering therapy con Step 2 kicks in if HbA1C >/= 6.5 (48) : – If on METFORMIN add in SULFONYLUREA – If on SULFONYLUREA add in METFORMIN – However, just to make things more complicated… If on METFORMIN and worried about hypos (i.e. you do not want to, or unable to, use SULFONYLUREA) – Add in DPP-4 INHIBITOR (gliptins) or THIAZOLIDINEDIONE (Pioglitazone) If on SULFONYLUREA and cannot have METFORMIN – Add in DPP-4 INHIBITOR or THIAZOLIDINEDIONE

12. So far then… STEP 1 – METFORMIN or SULFONYLUREA STEP 2 – METFORMIN + either SULFONLYUREA or DPP-4 INHIBITOR or THIAZOLIDINEDIONE – SULFONYLUREA + either DPP-4 INHIBITOR OR THIAZOLIDINEDIONE

13. Step 3 By now using 2 drugs and aiming for HbA1C < 7.5 (59) (note up until now 6.5) Possibilities: – METFORMIN + SULFONLYUREA + DPP-4 INHIBITOR or THIAZOLIDINEDIONE – METFORMIN + DPP-4 INHIBITOR + THIAZOLIDINEDIONE – METFORMIN + THIAZOLIDINEDIONE + DPP-4 INHBITOR – SULFONYLUREA + DPP-4 INHIBITOR + THIAZOLIDINEDIONE – SULFONYLUREA + THIAZOLIDINEDIONE + DPP-4 INHBITOR The final meds you can add at this point are GLP-1 agonists (i.e. Exenatide, Liraglutide) – NICE guidance only states to use EXENATIDE in combination with METFORMIN + SULFONYLUREA

14. Insulin Insulin is mentioned in Step 3 – presumption seems to be that most patients would prefer to stick to oral meds though: “Consider adding sitagliptin or a thiazolidinedione instead of insulin if insulin is unacceptable (because of employment, social, recreational or other personal issues, or obesity)” INSULIN + METFORMIN + SULFONYLUREA

15. Metformin Titrate up over several weeks to avoid GI side effects Consider MR version if side effects occur REVIEW metformin if: – creat > 130 or if eGFR < 45 – STOP metformin if creat > 150 or if eGFR < 30

16. Sulfonylureas Prescribe low cost sulfonylurea i.e. gliclazide Educate patient about risk of hypos especially if concurrent renal impairment The main CI is patients at risk of hypos or if hypos would make occupation difficult

17. Thiozolidedinione Pioglitazone Continue gliptin ONLY if HbA1C reduction of >/= 0.5 points (5.5) by 6 months Contra-indications: – Heart failure (or a history of it, all stages) – Hepatic impairment (ALT > 2,5 times upper limit normal or “liver disease”) – A risk, or history, of bladder cancer or uninvestigated visible blood in urine Avoid in women at high risk of fractures Monitoring: – Baseline LFTS and then every 2 Vs 6 months for first year and then annually

18. Gliptins Sitagliptin, Vildagliptin, Saxagliptin Contra-indications; – Renal impairment eGFR < 50 – Hepatic impairment (does not appear to apply to Sitagliptin – check BNF, but would req monitoring) – Pregnancy and breastfeeding – Use cautiously in patients aged 75 and over Risk of Pancreatitis – warn patient Continue gliptin ONLY if HbA1C reduction of >/= 0.5 (5.5) points by 6 months

19. ExenatideExenatide (GLP-1 agonists) Contra-indications: – GI disease (IBD, gastroparesis) – Renal impairment eGFR < 30 – Pregnancy and breast feeding – Acute/chronic pancreatitis or a history of those, warn patients re risk and symps of pancreatitis Continue Exenatide only if the person has a reduction in HbA1c of ≥ 1.0 (11) percentage point and ≥ 3% of initial body weight in 6 months

20. Blood Pressure Target < 140/80 unless – Renal, eye or cerebrovascular damage when target should be < 130/80

21. Lipid control Consider patients with diabetes to be at high CV risk unless ALL the following apply: – Normal BMI – Normal BP – Non-smoker – No microalbuminuria – No personal or FHx of cardiovascular disease – Normal lipid profile In reality nearly all patients with have at least one of these!

22. Lipid control < 40 + “CV risk profile seems to be particularly poor” = statin (simva 40mg) >/= 40 and no CV risk factors = assess CVD risk – If < 20% no statin – If >/= 20% = statin (Simva 40mg) >/= 40 + CV risk factor = statin (Simva 40mg) If trigs > 4.5 – consider fibrate Target: TC < 4 or LDL < 2

23. Aspirin? MRHA: “Aspirin is not licensed for the primary prevention of vascular events. If aspirin is used in primary prevention, the balance of benefits and risks should be considered for each individual, particularly the presence of risk factors for vascular disease (including conditions such as diabetes) and the risk of gastrointestinal bleeding”

24. Renal problems Assess at diagnosis and then annually (creatinine,eGFR and ACR) Diabetic nephropathy = persistent albuminuria Albuminuria – albumin/creatinine ratio first pass urine morning sample Abnormal ACR (microalbuminuria) – >/= 2.5 men – >/= 3.5 women – If abnormal repeat x 2 within 3-4 months

25. Renal Problems Raised ACR = ACEi or A2RB (with usual precautions) Aim for BP < 130/80

26. Diabetes and Driving Specifications in detail can be found herehere