MAKING BEST PRACTICE EVERYDAY PRACTICE

Best practice in diabetes

Professor Michael Kirby & Jane Diggle

Chair: Fola Omotunde

In association with Diabetes UK

Delivering best practice: 5 Steps / Interactive Case Study

Making Best Practice, Everyday Practice 4th November 2016

Delivering Diabetes Care

in General Practice Professor Mike Kirby

Jane Diggle

Professor Mike Kirby MK has received funding for research, conference attendance, lecturing and advice from the pharmaceutical industry including Astellas, Pfizer, Takeda, Bayer, MSD, BI, Lilly, GSK, AZ and Menarini. Editor PCCJ. Also on several NHS advisory boards including the Prostate cancer Risk Management Programme and the Prostate Cancer advisory Group. Jane Diggle Associate Editor-in-Chief for Diabetes and Primary Care , Board Member of the Primary Care Diabetes Society (PCDS) Committee, the Forum for Injection Technique(FIT) and Associate Member of TREND-UK. Received funding for participation in Advisory Boards, presentations and preparation of educational materials for Boehringer Ingelheim, BMS/Astra Zeneca, Eli Lilly, Janssen, MSD, Takeda, Novo Nordisk and Sanofi.

Disclosures

What are we trying to achieve? ● To alleviate symptoms ● Maintain Quality of Life

● Prevent or slow the progression of complications

Best Practice Diabetes Care

1. Kaplar M, et al. J Nucl Med 2009; 50:1993–1998. 2. Diabetes in the UK. Diabetes UK. Available at http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf. April 2012. Last accessed October 2013. 3. Mealey BL. JADA 2006; 137 (Suppl 10):26S–31S. 4. Tolman KG, et al. Diabetes Care 2007;30(3):734–43.

Microvascular complications Macrovascular complications

Diabetic nephropathy2

Diabetic retinopathy2

Diabetic neuropathy2

Brain and cerebral circulation1

Periodontal disease3

Erectile dysfunction2

Peripheral vascular disease2

Heart disease2

Stroke2

Liver disease4

The complications associated with diabetes

What is Best Practice?

What percentage of people registered with diabetes achieved the NICE defined treatment targets for glucose control, blood pressure and blood

cholesterol?

Type 1 Type 2 and other 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

HbA1c < 58 mmol/mol 28.7 28.1 27.0 27.2 29.4 29.9 66.6 66.5 65.8 64.9 66.8 66.1 Blood Pressure < 140/80* 68.5 68.8 72.2 73.4 76.4 76.4 60.8 61.4 66.6 68.6 73.6 74.2 Cholesterol < 5mmol/L 72.6 72.0 71.1 70.2 71.5 71.3 78.2 78.0 77.4 76.7 77.8 77.5

Meeting all three treatment targets 16.9 16.5 16.5 16.1 18.6 18.9 35.0 35.1 37.4 37.3 41.4 41.0

Percentage of people with diabetes in England and Wales achieving their treatment targets by diabetes type and audit year

* The blood pressure target does not exactly match NICE (<140/80) but was changed to align with the relevant QOF indicator (<140/80) . More information can be found here

What are the challenges?

• Progressive condition requiring treatment intensification.

• Often associated with co-morbidities (polypharmacy – complex regimens)

• Often asymptomatic - difficult to convey the benefits of treating now to reduce

future risks (especially where drugs cause side effects)

• Poor medication adherence

• Encouraged to involve patients in shared decision-making but patient

knowledge may be poor.

• Patient expectations are rising – with ever-expanding choice of therapies.

• Prescribing costs are escalating but pressure to reduce prescribing costs.

• New evidence emerging all the time.

“Clinical guidelines are recommendations on the appropriate treatment and care of people with specific conditions that are based on the best available evidence. They are designed to help healthcare professionals in their work, but do not replace their knowledge and skills.”

NICE (2014) Clinical guidelines. NICE, London. Available at: www.nice.org.uk/CG (accessed: 23.05.2014)

NICE Clinical Guidelines – NG28: Type 2 diabetes in adults: management http://www.nice.org.uk/guidance/ng28

New Guidelines for Type 2 diabetes

Meet Margaret

57yrs old - on routine screening found to have diabetes. HbA1c is 72mmol/mol. Mild symptoms

• Polyuria • Recurrent thrush ( 3 episodes over past year)

BMI 32 Kg/m2

BP 155/85 mmHg Cholesterol 5.2mmol/l

• Non HDL Cholesterol 3.4mmol/l ALT 92mmol/l eGFR 68ml/min/1.73m2 ACR 5mg/mmol Family history

• Mother Type 2 diabetes diagnosed at 54yrs when admitted with an MI.

• Father CVA aged 78yrs.

What are the issues?

Margaret’s medical issues

• 57yr old • Mild symptoms • Overweight • Raised BP • Dyslipidaemia • Albuminuria • Abnormal LFT • FH premature CVD

Clinical scenario

• BMI 32 Kg/m2

• BP 155/85mmHg • HbA1c 72 mmol/mol • Cholesterol 5.2mmol/l

– Non HDL Cholesterol 3.4mmol/l

• eGFR 68ml/min/1.73m2

• ALT 92mmol/l • ACR 5mg/mmol

Tackling her CV risk

• QRisk2

• Consider 24 hour ABPM • Need to establish if there are microvascular complication (repeat ACR) as this

will impact BP target • preferred target is ≤ 140/80 • CKD/proteinuria the target is ≤ 130/80

• Lifestyle Interventions (Diet and physical activity including weight

management, alcohol consumption, caffeine & salt intake, smoking cessation advice for smokers, referral to health trainer if appropriate)

• Consider anti-hypertensive therapy: ACE inhibitor first-line.

• Consider Lipid-lowering therapy (if QRisk2 is above 10%) : Atorvastatin 20mg – Aim for a 40% reduction in non-HDL.

Key NICE Updates

• Hypertension CG 127 (August 2011). • Lipid Modification CG 181 (July 2014). • Chronic Kidney Disease CG 182 (July 2014).

• Agree an individualised HbA1c target.

• Where appropriate, aim for the targets on the algorithm.

• Measure HbA1c at 3 or 6 monthly intervals.

• Choose from the full range of oral treatments. – Base treatment choice on effectiveness, safety, tolerability, individual

circumstances, preferences, needs, indications and costs

– If 2 drugs in same class, choose the lowest acquisition cost option.

• SMBG guidance not changed (not routinely unless person is on insulin, on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery, is pregnant or planning to become pregnant or if there is evidence of hypoglycaemic episodes).

Tackling her HbA1c

UKPDS=United Kingdom Prospective Diabetes Study Holman RR et al (2008) N Engl J Med 359: 1577–89 UKPDS Group (1998) Lancet 352: 854–65

Med

ian

HbA

1c (%

)

0 6

7

8

9

UKPDS 1998

Conventional Approach More intensive approach

Holman et al 2008

Drives the “legacy effect”

1997

Difference in HbA1c was lost after first year but those in the initial intensive arm still had lower incidence of any complication 10 years

later (the legacy effect): • 21% reduction in any diabetes-related endpoint (P=0.01) • 33% reduction in myocardial infarction (P=0.005) • 27% reduction in death from any cause (P=0.002)

2007

UKPDS: early, intensive control of hyperglycaemia is important

But tackling lifestyle is a real challenge…….

Lifestyle modification is key

Telling people what to do doesn’t work!

We have to hand over responsibility to the patient, explore their attitudes & beliefs & find more effective ways to support them to make healthier

and less risky lifestyle decisions.

THE CHANGE EQUATION (Gleicher – Beckard & Harris 1987)

Dissatisfaction x Vision x First Steps > Resistance to change

To change behaviour a person has to: • be dissatisfied with their current situation (D) • want to change it (V) • know how to make the first step towards this (F) • feel confident in their ability to make the change.

Metformin

+

Sulphonylurea

+

Insulin

• Thiazolidinediones (Glitazones)

• DPP4-inhibitors

• SGLT2-inhibitors

• GLP-1 RA’s

• New insulin Strengths

• Biosimilar Insulin

But ultimately most people will need blood glucose lowering drugs…

Metformin

Metformin

• Mechanisms of action – ↓ hepatic glucose production, ↑ gut glucose uptake, ↑ GLP-1, alters bile acids and microbiome.

• NICE - First-line unless contraindications • Build dose – start low, go slow, aim for 1g twice daily • No hypoglycaemia, weight neutral; CVD benefit (UKPDS) • GI side effects – allow to settle; trial Metformin MR • Consensus - Reduce dose if eGFR <45; stop if <30 • Stop therapy temporarily if fluid depletion eg vomiting diarrhoea • B12 deficiency - ? significance

Available in combination with other oral drugs to reduce pill burden/cost McCreight, Bailey and Pearson Diabetologia 2016; 59: 426-35 Inzucchi et al Diabetes Care 2015; 38: 140-49

“I feel well thanks”

“Metformin gave me a bit of diarrhoea”

“I want to do something about my weight”

4 months later …..

HbA1c is 65mmol/mol

Margaret is on maximum tolerated metformin (Metformin MR 1g daily)

What next?

• Revisit lifestyle – scope to make more changes?

• Offer structured education. • Check medication

adherence!

What next after metformin?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

Agree a target and aim for HbA1c of 53mmol/mol (7%).

What next after metformin?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

DPP-4 inhibitors

• Sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin • Glucose-dependent ↑ insulin secretion and ↓ glucagon secretion • Low risk of hypoglycaemia. • Weight neutral. • Excreted by kidney apart from linagliptin – may reqwuire dose adjustment

according to eGFR. • CVD safety studies

– sitagliptin – no HF (TECOS) – saxagliptin (SAVOR TIMI) and alogliptin (EXAMINE) – possible ↑ heart

failure hospitalisations • Well tolerated; possible risk pancreatitis

Scirica et al. N Engl J Med 2013;369:1317-26. White et al. N Engl J Med 2013;369:1327-35. Inzucchi et al Diabetes Care 2015; 38: 140-49

Causes of Mortality in Patients With Diabetes

UK/DIA/00315 | February 2016

Heart failure and T2D share risk factors Independent risk factors for developing heart failure or T2D1–5

*Synthesised based on data from 2 clinical studies – see notes page for details Please see notes page for references 28

People with diabetes have a 2–3-fold higher risk of developing heart failure8

Diabetes increases the risk of all-cause mortality and cardiovascular death in the heart failure setting9*

Age,4,6 ethnicity,4,6 family history,4,6 obesity,2–4 fat distribution,4,7

hypertension,3 smoking3

T2D is an independent

risk factor for heart failure1

Heart failure is an independent

risk factor for T2D1,2

UK/DIA/00315 | February 2016

0.8 -

0.6 -

0.4 -

0.2 -

1.0 -

0.0 - 0 2 4 6 8 10 12

Varela-Roman A et al. Eur J Heart Failure 2005;7:859

Poorer HF survival with diabetes than without diabetes

Kaplan–Meier survival curves of HF patients hospitalised with LVEF ≥50% (n=498) and <50% (n=754)

1.0 -

0.8 -

0.6 -

0.4 -

0.2 -

0.0 - 0 2 4 6 8 10 12

Surv

iva

l pro

por

tion

Time (years)

p=0.0322 RR=1.41

p<0.0001 RR=1.73

LVEF ≥50% LVEF <50%

Diabetes No diabetes Diabetes No diabetes

Diabetes worsens heart failure prognosis Approximately 1 in 5 patients with HF have type 2 diabetes

UK/DIA/00315 | February 2016

The presence of diabetes increases the risk of hospitalisation or death in patients with heart failure

Aguilar D, et al. Am J Cardiol. 2010;105:373–377.

Adjusted HR 1.68 95% CI: 1.26–2.25; p < 0.01

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

HF

hosp

italis

atio

n or

HF

dea

th

0 12 24 36 48 Months

No diabetes

Diabetes

Number of patients at risk 285 702

234 613

193 559

121 366

47 136

UK/DIA/00315 | February 2016

Life expectancy is reduced by 12 years in diabetes patients* with previous CV disease

In this case, CV disease is represented by MI or stroke *60 years of age The Emerging Risk Factors Collaboration. JAMA. 2015;314:52. 31

60 End of life yrs

-6 yrs

-12 yrs

No diabetes

Diabetes

Diabetes + MI

33

CV = cardiovascular; DPP-4 = dipeptidyl peptidase-4; CAD = coronary artery disease; CVD = cardiovascular disease; PAD = peripheral artery disease; ACS = acute coronary syndrome; EXAMINE = Examination of Cardiovascular Outcomes: Alogliptin vs Standard of Care in Patients With Type 2 Diabetes Mellitus and Acute Coronary Syndrome; SAVOR-TIMI 53 = Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus Trial-Thrombolysis in Myocardial Infarction 53; TECOS = Trial Evaluating Cardiovascular Outcomes With Sitagliptin; CARMELINA = Cardiovascular and Renal Microvascular Outcome Study With Linagliptin in Patients With Type 2 Diabetes Mellitus at High Vascular Risk. 1. White W et al. N Engl J Med. 2013;369:1327–1335. 2. Scirica BM et al. N Engl J Med. 2013;369:1317–1326. 3. Bethel MA et al. Diabetes Obes Metab. 2015; 17:395–402. 4. Green JB et al. N Engl J Med. 2015 Jun 8.[Epub ahead of print]. 5. CARMELINA: Cardiovascular and renal microvascular outcome study with linagliptin in patients with type 2 diabetes mellitus at high vascular risk. ClinicalTrials.gov web site. http://clinicaltrials.gov/ct2/show/ NCT01703298. Accessed September 12, 2014.

Baseline Risk of Patient Populations Enrolled in CV Safety Trials of DPP-4 Inhibitors

Vildagliptin does not have an ongoing CV safety trial

Linagliptin CARMELINA (N=8,300)5

Pre-existing CVD + albuminuria or impaired renal function End Jan 2018

Sitagliptin TECOS (N=14,671)3,4

Pre-existing CVD Presented Jun 2015

Alogliptin EXAMINE (N=5,380)1

ACS within 15–90 days

Presented Sept 2013

Saxagliptin SAVOR-TIMI 53 (N=16,492)2

Pre-existing CVD or multiple risk factors for CVD

Presented Sept 2013

Risk Factors Stable CAD-CVD-PAD Post ACS patients

The Truth Is Not So Sweet

Cardiovascular safety of diabetes drugs

• The goal of marely lowering blood glucose levels in diabetes is too simplistic

• With respect to CVD it appears important how you lower blood sugar as well as how much

• Diabetes drugs, even within the same “class” may yield dramatically different CV outcomes

35

EXAMINE = Examination of Cardiovascular Outcomes: Alogliptin vs Standard of Care in Patients With Type 2 Diabetes Mellitus and Acute Coronary Syndrome; SAVOR-TIMI 53 = Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus Trial-Thrombolysis in Myocardial Infarction 53; TECOS = Trial Evaluating Cardiovascular Outcomes With Sitagliptin. CV = cardiovascular; MI = myocardial infarction; UA = unstable angina. 1. White WB et al. N Engl J Med. 2013;369:1327–1335. 2. Scirica BM et al. N Engl J Med 2013;369:1317–1326. 3. Green JB et al. Am Heart J. 2013;166:983–989.e7. 4. Bethel MA et al. Diabetes Obes Metab. 2015; 10.1111/dom.12441. 5. Green JB et al. New Engl J Med 2015 Jun 8.[Epub ahead of print].

DPP4 EXAMINE, SAVOR-TIMI 53, and TECOS CV Safety Trials

Median Duration of Follow-up

SAVOR- TIMI 532

TECOS3–5

EXAMINE1

6.5–8.0

CV death, Nonfatal MI,

Nonfatal stroke, or UA req. hospitalization

Randomization Year 3 Year 2 Year 1

CV death, Nonfatal MI, or Nonfatal stroke

CV death, Nonfatal MI, or Nonfatal stroke

Saxagliptin

Alogliptin

Placebo

Placebo

6.5–12.0

6.5–11.0

HbA1c Range, % Primary End point Duration of Treatment (as part of usual care)

R

R

R

Sitagliptin

Placebo

Heart failure • Insulin, induces sodium retention and thiazolidinediones

increase the risk of heart failure.

• Increase in the risk of admission to hospital for heart failure in patients treated with the dipeptidylpeptidase-4 (DPP4) inhibitor, saxagliptin, compared with placebo. (SAVOR TIMI- 53)

• There was also a trend toward an increased risk of heart-failure events among type 2 diabetic patients treated with alogliptin (Nesina, Takeda) in the EXAMINE study.

• TECOS: No CVD Risks or Heart Failure With Sitagliptin in High-Risk Diabetic Patients

What next after metformin?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

SGLT-2 inhibitors • Sodium-glucose co-transporter 2 inhibitors – reduce reabsorption glucose in

kidney; lose up to 80g glucose daily • Insulin independent – use at any stage • Weight reduction (2kg+), BP benefits (2-4/1-2mmHg) • Empagliflozin positive CVD study (EMPA-REG); others awaited • Less effective when eGFR <60 (canagliflozin, empagliflozin can continue

lower dose to eGFR 45) • Caution with loop diuretic; fluid depletion, elderly • Increased fungal and urinary infections • Emerging euglycaemic DKA risk – rare

– Must warn patients (partners/other professionals) – Ensure practice systems to test for ketones – PCDS statement

• Increased toe amputations (canagliflozin)

Inzucchi et al Diabetes Care 2015; 38: 140-49

UK/DIA/00282b | October 2015

Primary outcome: 3-point MACE

HR 0.86 (95.02% CI 0.74, 0.99)

p=0.04*

Cumulative incidence function. MACE, Major Adverse Cardiovascular Event; HR, hazard ratio: RRR: Relative risk reduction; ARR: Absolute risk reduction. * Two-sided tests for superiority were conducted (statistical significance was indicated if p≤0.0498) RRR: 14%; ARR: 1.6% (CER – EER): Incidence of 3P-MACE: 10.5% (empagliflozin) vs. 12.1% (placebo). CER: Control event rate; EER: Experimental event rate. Zinman B et al. N Engl J Med 2015 DOI: 10.1056/NEJMoa1504720

UK/DIA/00282b | October 2015

CV death

HR 0.62 (95% CI 0.49, 0.77)

p<0.001

RRR: 38%; ARR: 2.2%. (CER – EER) Rates of CV death: 3.7% (empagliflozin) vs. 5.9% (placebo) Cumulative incidence function HR, hazard ratio. Indicated with 95% confidence intervals; RRR: Relative risk reduction; ARR; Absolute risk reduction; CER: Control Event Rate; EER: Experimental Event rate. Zinman et al N Engl J Med 2015; doi: 10.1056/NEJMoa15047201

UK/DIA/00282b | October 2015

Hospitalisation for heart failure

HR 0.65 (95% CI 0.50, 0.85)

p=0.002

Cumulative incidence function. HR, hazard ratio; RRR: Relative risk reduction; ARR: Absolute risk reduction; CER: Control Event Rate; EER: Experimental Event rate. RRR: 35%; ARR: 1.4% (CER – EER). Incidence of HHF: 2.7% (empagliflozin) vs. 4.1% (placebo) Zinman B et al. N Engl J Med 2015 DOI: 10.1056/NEJMoa1504720

UK/DIA/00282b | October 2015

All-cause mortality

HR 0.68 (95% CI 0.57, 0.82)

p<0.001

Kaplan-Meier estimate. HR, hazard ratio; RRR: Relative risk reduction; ARR: Absolute risk reduction. CER: Control Event Rate; EER: Experimental Event rate. RRR: 32%; ARR: 2.6% (CER – EER). Incidence of All-cause mortality: 5.7% (empagliflozin) vs. 8.3% (placebo) Zinman B et al. N Engl J Med 2015 DOI: 10.1056/NEJMoa1504720

Empagliflozin modulates several factors related to CV risk

Adapted from Inzucchi SE,Zinman, B, Wanner, C et al. Diab Vasc Dis Res 2015;12:90-100 45

BP Arterial stiffness

Glucose Insulin

Albuminuria

Uric acid

Other

↑LDL-C ↑HDL-C

Triglycerides

Oxidative stress

Sympathetic nervous system

activity

Weight Visceral adiposity

What next after metformin?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

Thiazoledinediones - Pioglitazone

• Increases insulin sensitivity • Pioglitazone – start 15mg; can increase to 45mg daily • No hypoglycaemia; durable action • Weight gain, fluid retention, peripheral oedema and heart failure • Bladder cancer possibly increased – avoid if undiagnosed

haematuria/previous bladder cancer • Increased fracture risk especially in women • Possible decreased CVD (PROactive study) • Not restricted in renal disease • May improve LFTs – possible benefits in NAFLD

Inzucchi et al Diabetes Care 2015; 38: 140-49 Tuccori et al BMJ 2016;352:i1541 Charbonnel et al Diabetes care 2004; 27: 1647-1653

What next after metformin?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

Sulphonylureas and meglitinides

• Increase insulin secretion • Effective at reducing HbA1c; long-term experience; ↓ microvascular risks

(UKPDS) • Significant hypoglycaemia risks (monitoring/ driving). • Weight gain; low durability • Meglitinides – ‘prandial glucose regulators’ - complex dosing, still significant

hypoglycaemia risk

Inzucchi et al Diabetes Care 2015; 38: 140-49

What would you do next for Margaret?

Metformin

Sulphonylurea DPP-4 inhibitor Pioglitazone SGLT-2 inhibitor

?

And later…..

Metformin

Sulphonylurea

DPP-4 inhibitor

Pioglitazone

SGLT-s inhibitor

GLP-1 agonist

Insulin

LEADER trial: Primary Outcome

15

10

20

5

0

0 6 12 18 24 30 36 42 48 54

Placebo Liraglutide

Pat

ient

s w

ith a

n ev

ent (

%)

Months since randomisation

Hazard ratio, 0.87 (95% CI, 0.78–0.97) P<0.001 for noninferiority P=0.01 for superiority

First occurrence of CV death, nonfatal myocardial infarction, or nonfatal stroke in the time-to-event analysis in patients with type 2 diabetes and high CV risk.

Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial

Adapted from: Marso SP et al., NEJM 2016

LEADER trial: Death from Cardiovascular Causes

15

10

20

5

0

0 6 12 18 24 30 36 42 48 54

Placebo Liraglutide

Pat

ient

s w

ith a

n ev

ent (

%)

Months since randomisation

Hazard ratio, 0.78 (95% CI, 0.66–0.93) P=0.007

Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial

Adapted from: Marso SP et al., NEJM 2016

Results of the sodium-glucose-lithium transporter 2 (SGLT-2) inhibitor empagliflozin trial (EMPA-REGS) 11

AND The results of the glucagon-like peptide-1 (GLP-1) agonist liraglutide (LEADER-6) 12 trial showed reduced CVD events and mortality !! Will lead to the order of different classes of hypoglycaemic therapy in the pathway being rearranged.

11 Zinman B et al Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015 ; 373 : 2117 – 28 . 12 Marso SP et al . Liraglutide and

cardiovascular outcomes in type 2 diabetes . N Engl J Med 2016 ; DOI: 10.1056/NEJMoa1603827.

Diabetes

Individualisation is the key!

Factors to be taken into consideration when selecting an appropriate drug

? Therapy for diabetes

Age Occupation

Hobbies

Sex

Past medical history (e.g. haematuria/

cancer)

Renal function

Fasting

Live alone / nutrition

Driving

Liver function

BMI / body

weight

Fracture risk

? Therapy for

diabetes

ADA/EASD position statement: Intensiveness of glucose lowering should be individualised

ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes. Inzucchi SE et al (2015) Diabetes Care 38: 140–9

Few/mild

Few/mild

Usually not modifiable

Potentially modifiable

More stringent HbA1c 7% Less stringent

Risks potentially associated with hypoglycaemia and other drug adverse events Disease duration Life expectancy Important comorbidities Established vascular complications Patient attitude and expected treatment efforts Resources and support system Readily available Limited

Less motivated, non-adherent, poor self-care capacities

Severe

Severe

Short

Long-standing

High

Highly motivated, adherent, excellent self-care capacities

Absent

Absent

Long

Newly diagnosed

Low

Patient/disease features

Current glycaemic control

Frail elderly control often too tight

Younger and early disease often not tight

enough

Glycaemic control

• When caring for older people with type 2 diabetes, consider their broader health and social care needs.

• They are more likely to have co-existing conditions (dementia, mobility &

sensory problems) and are likely to be on more medications. • Their ability to benefit from risk-reduction interventions in the longer term

may be reduced. • Much of the evidence base used to inform guidelines has been generated

from studies involving younger adults (under 70 years).

• Avoidance of hypoglycaemia should take priority.

• Relax HbA1c targets (worth auditing this – especially for those in care homes or living alone)

Older People

Clinical inertia

Retrospective Cohort Study 2 2004-2011 n= 81,573 In those with HbA1c >7% it took: • 1.6 years before a second oral agent was added. • >6.9 years before a third oral agent was added.

• HbA1c typically reached 8.7 – 9.7% (71.6 - 82.5mmol/mol) before insulin was

initiated.

“Clinical inertia may be defined as a failure to initiate or intensify treatment in a timely manner in people with diabetes whose health is likely to improve with this intensification” 1

1. Strain WD, et al. Diabetes Research and Clinical Practice 105. 2014;302–312. 2. Khunti K, et al. Diabetes Care 2013;36:3411–7

In conclusion….. 5 Key Messages

1. Guidelines are not absolutes (we need to individualise targets and treatment).

Ref. Page 56 of NG28

2. Diabetes management is not just about blood glucose.

EVERY 1% reduction in HbA1c

REDUCED RISK*

1%

UKPDS Lancet 1998; 352: 837–853.

Deaths from diabetes

Heart attacks

Microvascular complications

Peripheral vascular disorders

*p<0.0001

Lessons from UKPDS: better control means fewer complications

3. We need to encourage and support patients to self-manage and be actively involved in treatment decisions through education and motivational approaches.

4. We all need to be properly trained

Now, chuck out your uni books, pop this on and everything will be just like the good old days……

http://www.trend-uk.org/documents/TREND_4th%20edn_V9.pdf

Six SMART Steps to Insulin Safety

5. You can’t do an annual diabetes review in 10 minutes!

• Consider skill mix (HCA) • Share results with patient prior to the consultation • Encourage patient to consider what issues they want to discuss

and what they need more information about and focus on that.