1. managing type-2 diabetes in primary care in south camden - a focus on insulin conversion

2. Questions you want answering 2 minutes managing type-2 diabetes in primary care

3. Support materials General Whittington guidelines South camden guidelines – a local version RCN booklet Handouts All the material is on the website http://knerve.com/diabetes Email support xxxxxx Virtual referrals Dr Hurel:

4. Why do we need to take on diabetes?

8. WHAT DO OUR LOCAL GUIDELINES SAY? Screening General education Controlling risk factors Smoking BP Cholesterol Lowering glucose diet orals insulin Managing complications

9. General Message 1 Drug company focus on product A versus product B is misguided The basic drugs work fairly well – failures in care are rarely about choosing the right treatment The main problem is not giving an appropriate amount of simple but effective treatment

10. General Message 2 Effort on improving vascular risk factor control saves more lives than glucose control Glucose control is important too

11. Vascular Risk Factor Control Smoking - …….. BP – if mean of last 3 over 135/75 then needs more treatment now Lipids – if raised then needs more Aspirin - consider for all if CHD risk>15%

12. Simple step ladders e.g. lipids Diet only Simvastatin 20mg Simvastatin 40mg Atorvastatin 40mg Atorvastatin 40mg & Ezetemibe10mg If not controlled then test every 3 months If shows not controlled then move to next step If controlled then test annually

13. Insulin Who What How Adjusting

14. Usual slides on starting insulin here

15. Head on trials comparing regimens

16. Just reported 1 st year results of a 3 year trial No systematic difference between any – more effect always associated with more side effects Commentary stresses need to control CVS risk factors rather than glucose (the UKPDS message) NEJM 21 September 2007

17. Three Way Randomisation 700 T2DM on OAD Add twice daily biphasic insulin * Add once (or twice) daily basal insulin * Add thrice daily prandial insulin * Randomisation visit One year * progress to more intensive insulin regimen only if clinically necessary † stop sulphonylurea if taken Glycaemic target: HbA 1c ≤6.5% R Add midday prandial insulin if glycaemic target not met † Add prandial insulin if glycaemic target not met † Add basal insulin if glycaemic target not met † Two years Three years

18. Choice is a trade off: different insulin regimens vary but lower HbA1c associated with more adverse effects Conclusion: start low and go slow