Management of Type 2 Diabetes New Zealand Guidelines Group

Cost of Type 2 Diabetes 1. Major component of General Practice work requiring an intensive and integrated approach: prevalence: 195,778 people with type 2 diabetes or 4.4% of New Zealanders I : 8-9%, 65+: 15-16% II. Number 4 OECD 3. Increased prevalence amongst Māori, Pacific and Indian subcontinent peoples

Cost of Type 2 Diabetes cont. 4. An additional $3,721 of publicly funded health care for each person with type 2 diabetes per year 1 5. Approximately $728 million extra healthcare cost per year 1. Ministry of Health, 2008

Lead Role for General Practice Many cases of type 2 diabetes ‘fall’ between General Practice and speciality care: Specialty services cannot effectively deal with existing burden General Practice have an increasingly important role in management

Critical Issue: Management of BP 1. BP is measured frequently but BP targets set in clinical guidelines not being consistently met 2. Recent NZ reports indicate 53–78% of people with type 2 diabetes have a BP above 130/80 mm Hg 3. Key reasons are medication adherence by patients and clinical inertia, ie, failure of health practitioners to initiate or intensify treatment when indicated

Blood pressure management Step wise approach: Multiple Medication Target BP <130/80 mm Hg Evidence suggests BP target <120 mm Hg may be harmful (ACCORD Study)

Management: microalbuminuria People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present

Critical Issue: Risk of Complications 1. Preventing complications an important aspect of care 2. Every patient with type 2 diabetes should be assessed for risk of diabetes-related complications early in their diabetes care 3. Māori and Pacific – complications develop more frequently and at a younger age

Focus: Risk of Complications 3. ‘Risk chart’ categorises into low, moderate or high risk for diabetes-related complications: Two identified risk factors places person at moderate risk Three identified risk factors is assessed as high risk An ‘existing’ complication (eg, previous cardiac event) places person at high risk.

Focus: Risk of Complications Two identified risk factors (eg. HbA1c >55 mmol/mol (~ 7%), and eGFR <60 ml/min/1.73m 2 is at moderate risk Three identified risk factors (eg, HbA1c >55 mmol/mol, eGFR 130/80 mm Hg) is at high risk for complications

Key Points For General Practice(1 ) 1. General Practice and Primary Care need to take the lead 2. Identify risk of complications early for intensive intervention

Key Points (2) 3. Aim for HbA1c 50–55 mmol/mol (~7%) I. Not too aggressive target 7%(50-55) II. Accord (2010) – Some evidence increase fatal events with tighter control (6%) III. Metformin till eGFR < 30 IV. Insulin early rather than late

Key Points (3) 4. BP aim <130/80. I. Avoid Clinical Inertia II. Often multiple medication required III. <120 maybe harmful(Accord) 5. ACEI/ARB with microalbuminuria, whether or not hypertensive 6. Lipid control – I. Consider satins early: Aim TC<4, TG<1.7 II. CV Guidelines

Key Points (4) 7. Diet/Exercise/Smoking Cessation essential in management: I. Diet/Exercise: Additional Benefit compared with most expensive new drugs if intensify diet/exercise. 8. Practice recalls for retinal screening/ podiatry review/bloods/medical review 9. Specialist advice as required: I. Case Conferencing, Phone, , combined Consults, Outpatients