1. T2DM: NICE Guidelines Dr Nemanja Stojanović Consultant Endocrinologist Queen’s Hospital, Romford

2. The Talk Diabetes: Definition/ Classification A few cases NICE Guidelines New Developments

3. Definition –Fasting plasma glucose 7mmol/l- 2 occasions –2 h plasma glucose or random glucose of 11.1 mmol/l

4. Case1: What is Your Next Question ? Is there family history of Diabetes? She should be referred and genetic counselling offered

5. DM Classification Type 1 DM Type 2 DM GDM ? Double Diabetes Type 1.5 LADA Other subtypes

6. Genetic Diabetes MODY HNF-4α (1) Glucokinase (2) HNF-1α (3) IPF1 (4) HNF-1β (5) Neuro D1 (6) Neonatal Diabetes Mitochondrial DNA defects Genetic defects of insulin action

7. Drug Induced Steroids Pentamidine T4 β blockers Dizoxide Nicotinic Acid Thiazides α Interferon

8. Other Forms of DM ENDOCRINOPATHIES Acromegaly Cushing’s Disease Glucagonoma Hyperthyroidism Somatostatinoma Aldosteronoma Pheochromocytoma Others Exocrine Pancreas Cystic Fibrosis Hemochromatosis Haemosiderosis Cancer Trauma/ surgery Pancreatitis

9. NICE May 08 Patient centred care Good communication is essential Support the care with evidence based medical information Allow patient is to reach informed decisions about their care

10. Self Monitoring Offer it only as a part of integral care Discuss the purpose Insulin treatment OHA’s: to provide information on hypoglycaemia To assess changes in glucose control resulting from medications and lifestyle change To monitor glucose during intercurrent illness To ensure safety during activities, including driving.

11. Education Meet the national criteria laid down by DoH Meet the local cultural, linguistic, cognitive and literacy needs Provide appropriate resources to support the educators, who should be properly trained and allowed time to develop and maintain their skills.

12. Diet General advice for healthy eating: -Include high-fibre, low-glycaemic index sources of carbohydrate -Include low-fat dairy products and oily fish -Control the intake of foods containing saturated fats and trans fatty acids

13. HbA1c Target: 6.5% Discuss with the patient appropriate levels, set individual A1c targets Escalate treatment when HbA1c is> 7.5%

14. Metformin Start over several weeks Consider SR if GI side effects Stop if Cr> 150umol/l or GFR< 30ml/min In patient with moderate liver impairment /cardiac dysfunction discuss with the patient risk vs benefit

15. Start low cost (not glibenclamide) when indicated Educate about the risk of hypoglycaemia PPGs Sulphonylureas

16. Glitazones Warn about significant oedema and tell the person what to do if it happens Do not start if evidence of LVF or high risk of fracture When selecting a glitazone take into account most up-to-date advice, safety and cost issues

17. HbA1c> 7.5% BMI (Caucasian)> 35 Has specific psychological, biochemical or physical problems arising from high body weight Would otherwise be starting TZD or insulin. Continue if of 1% in A1c over 6 months and BW of 5% over 12 months Exenatide

18. Acarbose If unable to tolerate other medications

19. Insulin If HbA1c> 7.5% Structured programme Start once or twice daily NPH with SU + metformin Injection devices/ sharps

20. Glargine Patients who need help injecting BD insulin otherwise needed Significant hypoglycaemia including nocturnal hypos

21. Biphasic Insulin HbA1c > 9.0%. Biphasic Analogues -Immediate injection before the meals is preferred -Problems with hypos -Postprandial hyperglycaemia is a problem

22. Blood Pressure Target 140/80 mmHg If macro/ microvascular damage: retinopathy, nephropathy, cerebrovascular disease: 130/80 mmHg Monitor for SE of therapy

23. Blood Pressure Monitor annually in normotensive patients without renal disease BP above the target: -Repeat within a month if > 150/90mmHg -Repeat within 2 months if > 140/80mmHg - Repeat within 2 months if > 130/80mmHg & eye, kidney or cerebrovascular disease

24. Patients Not at High CVS Risk Normal weight BP< 140/80mmHg off treatment Normal ACR/ AER Non smokers Do not have high risk lipid profile No PMH of CVH No FH of CVD DO NOT HAVE ANY OF THESE

25. Effect of reduction of LDL by 1mmol/l by any means on coronary death and non-fatal MI: meta-analysis of 58 trials Law MR BMJ 2003, 326: 1423-9

26. Equivalent Doses Dose LDL Reduction % Atorvastatin + 1039 Simvastatin 20-4035-41 Pravastatin 4034 Rosuvastatin 5-1039-45 Fluvastatin 40-8025-35 Ezetamibe 10 16-18 (12-21c) + max dose decreases the LDL by additional 20%

27. Nephropathy Assess annually: ACR, Cr High ACR: repeat 2x within 3-4 months Treat with ACE/ ARB Aim for BP< 130/80mmHg

28. Suspect Intrinsic Renal Disease No retinopathy BP resistant to treatment Proteinuria in the face of previously normal ACR Rapid decline in ACR Haematuria Systemically ill patient

29. Eye Screening Annually Discuss the benefits Tropicamide and Driving

30. Referral to Ophthalmologist Maculopathy Unexplained loss of VA Pre-proliferative retinopathy

31. Studies/ Recommendations that followed the Guideline

32. ADVANCE 11140 patients: 5 years Intensive glycaemic control (A1c 6.5%) vs Conventional (A1c 7.3%) Intensive group: gliclazide MR 30 to 120 mg daily and other hypoglycamic agents including insulin N Engl J Med 2008;10.1056/NEJMoa0802987

33. ADVANCE Primary Endpoints Composite of macro and microvascular events considered jointly and separately Macro: CVD death, non fatal CVA & MI Micro:new or worsening nephropathy ; doubling of the serum creatinine; the need for dialysis; death due to renal causes; worsening of retinopathy N Engl J Med 2008;10.1056/NEJMoa0802987

34. ADVANCE Conclusion The main contributor to the 10% relative reduction in the primary outcome found with intensive control as compared with standard control was a 21% relative reduction in the risk of new or worsening nephropathy More modest but significant reduction in microalbuminura

35. ACCORD Trial 10,251 patients Intensive glycaemic control and CVS outcomes Primary outcomes : CVD death, Non fatal CVA & MI Intensive Treatment: HbA1c< 6% Conventional Treatment HbA1c 7-7.9 Death rates begin to separate after 1 year….. N Engl J Med 2008;10.1056/NEJMoa0802743

36. ACCORD Intensive (%)Conventional(%) n 51285123 Hypoglycaemia 538 (10.5)179 (3.5) Weight gain> 10kg 1399 (27.8)713 (14.1) CVD Death135 (2.6)94 (1.8) Non fatal MI186 (3.6)235 (4.6) Non fatal CVA67 (1.3)61 (1.2) Any Death257 (5)203 (4) N Engl J Med 2008;10.1056/NEJMoa0802743

37. HbA1c and Screening for T2DM <6% 6.1-6.5% 6.5-6.9% >7% JCEM,2008; 93: 2447-53

38. Fasting Plasma Glucose and CVA/ Vascular Events: NOMAS 3298 participants 572 patients with DM DM patients: 338 elevated FPG > 7mmol/l In elevated FPG: CVA HR 2.7(95 CI: 2.0- 3.8) Those with DM and normal FPG were not at increased risk Dia Care 2008; 31:1132- 37

39. Conclusion A1c 6.5% ( ? 7.5%) BP 130/80mmHg (140/8o mmHg) Cholesterol 4mmol/l LDL 2mmol/l Triglycerides 4.5mmol/l Eyes, Kidneys, Nerves: Screen annually

40. EndoDiabetes.com