Download - Rapid E clinical guidance in the management of Type 2 diabetes New Zealand Guidelines Group
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Rapid E clinical guidance in the management of Type 2 diabetes
New Zealand Guidelines Group
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Introduction to guidance
• Developed for use in primary care
• Addresses 3 identified priority areas:
I. Early identification of patients at high risk of diabetes-related complications
II. Better management of raised blood pressure and microalbuminuria
III. Improved glycaemic control (including insulin initiation)
Draws on SIGN guideline 116 Management of Diabetes 2010 www.sign.ac.uk
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1. Early identification of risk
• Risk of diabetes-related complications varies from patient to patient
• Aim is to prevent complications, especially targeting those at high risk
• Patients with existing complications (eye, foot, kidney or cardiovascular disease) are high risk and should be managed intensively
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2.Management: BP & microalbuminuria
• BP is measured frequently but BP targets set in clinical guidelines are not being consistently met
• Recent NZ reports indicate 53 ̶ 78% of people with type 2 diabetes have a BP above 130/80 mm Hg
• Key reasons are medication adherence by patients and clinical inertia ie, failure of health practitioners to initiate or intensify treatment when indicated
• The guidance assists stepwise intensification of treatment as appropriate to individual patients
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Blood pressure management
• Target BP <130/80 mm Hg
• Evidence suggests BP target <120 mm Hg may be harmful (Accord 2010)
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Management: microalbuminuria
• People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present
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More on renal disease
•Māori, Pacific Island and South Asian peoples are at higher risk of renal complications
•More frequent monitoring of renal status is indicated
• Any evidence of renal disease based on decreasing eGFR should be treated with urgency
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3. Glycaemic control.
• Good glycaemic control is difficult to maintain over time as the condition progresses
• More intensive treatment is required over time to meet the treatment target
• Good glycaemic control has a clear benefit on microvascular outcomes and if started early enough, on long-term macrovascular outcomes
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Management of glycaemic control
• Target HbA1c 50 ̶ 55 mmol/mol (7%) or as individually agreed
• Any reduction in HbA1c is beneficial
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When to consider insulin therapy
Consider if:
•unsatisfactory glycaemic control (measured HbA1c does not meet or closely approach agreed target) or
•signs & symptoms of hyperglycaemia
AND
Management has included:•diet, physical exercise and behavioural strategies•review of medication adherence & dose optimisation.
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When to consider insulin therapy cont.
• Also seriously consider insulin therapy if the person has an HbA1c >65 mmol/L
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Key Points For General Practice
1. General Practice and Primary Care need to take the lead
2. Identify risk of complications early for intensive intervention
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Key Points (2)
3. Aim for HbA1c 50–55 mmol/mol (~7%)
I. Don’t be too aggressive. 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
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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
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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, E-mail, combined Consults, Outpatients
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Guidelines
1.Available on line2.Published Nov 2011 with new CV Handbook