CEPNDiabetes Part 1

 

Facilitator notes:

1. Introductions 1.30-1.35

2. Introduce website 1.30-1.40 www.barnetccg.nhs.uk/CEPN

If possible have computer on and website up to show attendees; the plan is to upload materials from MCLG meetings under resource section in future. All MCLG dates will be on calendar

3. Thumbnail sketch case and learning outcomes hoped from today’s session 1.40-1.45

Learning outcomes:

• Recognise risk factors for pre diabetes and diabetes.

• Understand how to screen and the limitations of HbA1c.

• Learn about how to manage pre diabetes and new diagnosis of diabetes.

• Discover what resources and services are available.

• Think about what advice to give. How can we keep this consistent between disciplines? How can we motivate patients to make changes.

• Role of lifestyle and medication• Long-term risks of pre diabetes

4. Divide into small groups – read the case and discuss the questions:1.45-2.15

Mr Kipling is 49 years old. He is of South Indian heritage but he was born in the UK. He works as an IT specialist and spends much of his time at a desk. He is married to Melissa and has two children; Candy aged 10 who has asthma, and Dex age 14. He does not smoke or drink much alcohol but has a poor diet. He usually misses breakfast but tends to snack throughout the day often missing meals but filling up with crisps or cheese sticks. He likes chewy seed nut bars and drinks several cups of coffee a day, which he always has with a biscuit. He has a large meal in the evening when he gets home from work, usually after 8pm. He particularly likes rice and pasta

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and has this with almost every meal. This is usually a take away as his wife works in the evenings at an Adult Education College teaching art.

He does not do any formal exercise but he does like to walk the dog in the morning and evening.

Both his parents are still alive. He has two older siblings. His eldest sister is a fitness freak. His middle brother had an MI last year and was diagnosed with diabetes at the time. His mum has type two diabetes, which is well controlled on oral medication. She had gestational diabetes when pregnant with both her sons. His father is well but has hypertension that is well controlled. He does not take any regular medication and hardly ever goes to the doctor, as it is so difficult to get an appointment. However about 4 months ago, he did see his GP for an itch over his scrotal skin and foreskin. He was diagnosed with thrush which he thought he might have picked up from his wife. His GP prescribed Canesten Cream, which did the job.

Unfortunately his symptoms returned a few weeks after stopping treatment so Mr Kipling bought some Canesten Cream OTC. He has been using the cream and nearly finished the tube but this time the symptoms seem to be persisting.

Today he has popped in see the pharmacist to collect his daughter’s asthma medication. He asks Mr Dossett the pharmacist for another tube of Canesten. Mr Dossett recalls having previously issued a prescription and sold Mr Kipling Canesten.  He is concerned and asks Mr Kipling a few questions about his symptoms.

Mr Kipling says he feels well; he does not report any weight loss, thirst, or polyuria. He does admit to feeling tired and getting up in the night to pee. Mr Dossett asks Mr Kipling if he would mind being weighed and having his blood pressure, waist and blood sugar measured.This reveals: 

BG: 11mmolBP: 144/86Weight: 85Height: 160BMI: 33.2Waist Circumference: 106cm Stop for discussion at this point:

a) What risk factor would alert you to have concern about a patient being at high risk of diabetes and in your role what can you do when you encounter such a patient? Do you find discussing such risk with patients easy?

b) What would you advise him? Discuss according to your discipline.

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(Note: Get participants to discuss the details of the life style advice they would like Mr Kipling to make ie not just “he needs healthy eating advice ” but “could suggest no biscuit with his tea”, “reduce carbohydrate eg pasta intake” etc. Hopefully this will lead to sharing of current up-to-date dietary advice – which will be consolidated at plenary with input from dietician).

c) How can we empower Mr Kipling to make changes?

d) What do the group think would be best practice for Mr Dossett regarding communication with Mr Kipling’s GP practice?

.Return to the case:Mr Dossett advises Mr Kipling to see his GP as he is concerned that Mr Kipling may have diabetes. He then sees his GP, Dr Legume who requests some blood tests.

Fasting glucose 6.6 HbA1c 46Total Cholesterol 6.7Trigs 1.8LDL 3.1HDL 1.9Ratio  3.5Creat 58Na+140Urea 6K+ 4eGFR 92Alb 38Bil 11ALT 31AST 91GGT 27Microalbumin ratio 2.3

Discuss the results.·     Is the diagnosis clear?currently classified as "high risk of diabetes". Is the HbA1c reliable enough? What

else could we do? What about GTT? Would the result change management?·     What else do you want to know?GGT; Fasting blood sugar. ·     What do you now advise Mr Kipling?Medication? Diet advice? Carbohydrates. Portion size. Exericse, 10min brisk,

raise heart rate. ·     What is your approach to managing him? Do you think drugs have a place?

discussion about the place of drugs in pre diabetes·     What about follow up?  Who, when, where?

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·     Do you know what services are available or other resources he could use or that you could direct him towards?  

 Discuss the results – Suraiya’s answers

i. Q:Is the diagnosis clear? A: Is diagnosis clear i.e pre-diabetes? Can he have diabetes already but not shown in his blood result?

ii. Q: What else do you want to know?A: Should the patient start on statin?

iii. Q: What do you advise Mr Kipling?A: healthy diet; refer to diabetes dietitianContinue with physical activitiesExplain that losing 5–10% of their weight in 1 year is a realistic initial target that would help reduce their risk of type 2 diabetes and also lead to other, significant health benefits.

iv. Q: What is your approach to managing him? Do you think drugs have a place? How would you motivate him?A: see how motivated he is before considering Metformin A: would you consider Orlistat?.

v. Q:What about follow up?  Who, when, where?A:Refer to pre-diabetes group asap.Reassess his weight and BMI at least in one year (diabetes pathway NICE) – would you wait that long though?

vi. Q: What services are available or other resources he could use or you could direct him towards? A: Refer to dietitian for weight management.- may be discussion about if this exists!! Exercise programme

5. Plenary 2.15-2.50 (incl with dietician talk)

Share learning from small groupsSuggest dietician gives 5-10min talk (ideally backed up with written material that can be sent out later/put on website)

6. Information Giving & Close 2.50-3.00

CLCH will hopefully be able tell group about the new service starting April 2016 (maybe more info at 2nd session). Written material/website link if ready

Education available (Eli Lilly)

Advise next session back pain - RMS, one after is part 2 diabetes

Please ensure signed register and please complete evaluation sheet   

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Websites

Primary Care Diabetes Societywww.pcd society .org/

Diabetes UK – Care. Connect. Campaign. - Diabetes UK https://www. diabetes .org. uk /

Choose MyPlatewww. choosemyplate .gov/

https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-2185604173

(above link should be printed as used as a hand out

http://www.nice.org.uk/guidance/ng28/resources/patient-decision-aid-2187281197 patient decision aid

http://www.nice.org.uk/guidance/ng3/chapter/1-recommendations Nice recommendations in pregnancy

The following are extracts form the current updated 2015 NICE guidelines:

Repeat blood pressure measurements within:

• 1 month if blood pressure is higher than 150/90 mmHg

• 2 months if blood pressure is higher than 140/80 mmHg

2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage.

If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:

• quality-controlled plasma glucose profiles

• total glycated haemoglobin estimation (if abnormal haemoglobins)

• fructosamine estimation.

Involve adults with type 2 diabetes in decisions about their individual HbA1c target.

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Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life.

Offer lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target

For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).

For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:

• Reinforce advice about diet, lifestyle and adherence to drug treatment and

• Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and

• Intensify drug treatment.

Consider relaxing the target HbA1c level (see recommendations 1.6.7 and 1.6.8) on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:

• Who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy

• For whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job

• For whom intensive management would not be appropriate, for example, people with significant comorbidities.

in January 2011 the World Health Organization (WHO) recommended that glycated haemoglobin (HbA1c) could be used as an alternative to standard glucose measures to diagnose type 2 diabetes among non-pregnant adults.

HbA1c levels of 48 mmol/mol (6.5%) or above indicate that someone has type 2 diabetes.

• but there is no fixed point to indicate when someone has 'pre-diabetes'. A UK expert group has also recommended HbA1c for diagnosis of diabetes according to the WHO criteria. The group also recommended an HbA1c of 42−47 mmol/mol (6.0–6.5%) to classify someone as being at high risk of diabetes (John et al. 2012).

• The titles of the two, complementary pieces of guidance were changed to reflect a move away from describing 'pre-diabetes' as a separate condition.

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However, their overall range and scope remains the same. In January 2011, the World Health Organization (WHO) recommended that glycated haemoglobin (HbA1c) could be used as an alternative to standard glucose measures to diagnose type 2 diabetes among non-pregnant adults.

HbA1c levels of 48 mmol/mol (6.5%) or above indicate that someone has type 2 diabetes. However, WHO did not provide specific guidance on HbA1c criteria for people at increased risk of type 2 diabetes (WHO 2011).

A report from a UK expert group on the implementation of the WHO guidance recommends using HbA1c values between 42 and 47 mmol/mol (6.0–6.4%) to indicate that a person is at high risk of type 2 diabetes. The group also recognised that there is a continuum of risk across a range of subdiabetic HbA1c levels – and that people with an HbA1c below 42 mmol/mol (6.0%) may also be at risk (John et al. 2012).

Encourage the following to have a risk assessment:

• All eligible adults aged 40 and above, except pregnant women

• People aged 25–39 of South Asian, Chinese, African-Caribbean, black African and other high-risk black and minority ethnic groups, except pregnant women

• Adults with conditions that increase the risk of type 2 diabetes.

• For people with a moderate risk (a high risk score, but with a fasting plasma glucose less than 5.5 mmol/l or HbA1c of less than 42 mmol/mol [6.0%]):

• Tell the person that they are currently at moderate risk, and their risks could increase in the future. Explain that it is possible to reduce the risk. Briefly discuss their particular risk factors, identify which ones can be modified and discuss how they can achieve this by changing their lifestyle.

• Offer them a brief intervention to help them change their lifestyle: give information about services that use evidence-based behaviour-change techniques that could help them change, bearing in mind their risk profile. Services cited could include walking programmes, slimming clubs or structured weight-loss programmes.

• Discuss whether they would like to join a structured weight-loss programme. Explain that this would involve an individual assessment and tailored advice about diet, physical activity and behaviour change. Let them know which local programmes offer this support – and where to find them.

• For people confirmed as being at high risk (a high risk score and fasting plasma glucose of 5.5–6.9 mmol/l or HbA1c of 42–47 mmol/mol [6.0–6.4%]):

• Tell the person they are currently at high risk but that this does not necessarily mean they will progress to type 2 diabetes. Explain that the

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risk can be reduced. Briefly discuss their particular risk factors, identify which ones can be modified and discuss how they can achieve this by changing their lifestyle.

• Offer them a referral to a local, evidence-based, quality-assured intensive lifestyle-change programme(see recommendations 8, 9 and 10). In addition, give them details of where to obtain independent advice from health professionals.

•• For people with possible type 2 diabetes(fasting plasma glucose of, 7.0 mmol/l or

above, or HbA1c of 48 mmol/mol [6.5%] or above, but no symptoms of type 2 diabetes):

• Carry out a second blood test. If type 2 diabetes is confirmed, treat this in accordance with NICE guidance on type 2 diabetes. Ensure blood testing conforms to national quality specifications.

If type 2 diabetes is not confirmed, offer them a referral to a local, quality-assured, intensive lifestyle-change programme (see recommendations 8, 9 and 10).

Risk factors for type 2 diabetes

Impaired glucose regulation signifies that someone has impaired glucose tolerance, impaired fasting glucose or raised glycated haemoglobin (HbA1c) or any combination of these conditions. In each case, their blood glucose levels are above normal but not high enough for a diagnosis of type 2 diabetes.

Not everyone with impaired glucose regulation progresses to diabetes. However, people with a high blood glucose reading are at greater risk. The more additional risk factors a person has (see People at risk above), the more likely they are to progress to type 2 diabetes (Diabetes UK 2011).

Progression rates also vary between individuals and for different populations, according to a range of other factors. These include:

• ethnicity

• age

• BMI

• co-morbidities

• genetics

• level of deprivation in the area where someone lives.

Blood tests

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The oral glucose tolerance test has been regarded as the standard diagnostic tool for type 2 diabetes. The person being tested has to fast overnight before having blood taken. They are tested over a period of 2 hours early the next morning, before and after consuming a glucose load. The test is time-consuming, for both the person being tested and the health professional (Eborall et al. 2012).

The World Health Organization (WHO) now recommends using the glycated haemoglobin blood test (HbA1c) to diagnose diabetes in most people. This is provided that quality specifications are met and assays are standardised according to international reference values. These requirements are met in the UK. For the HbA1c test, 48 mmol/mol (6.5%) and higher indicates type 2 diabetes (WHO 2011).

WHO does not provide guidance on the HbA1c level that would indicate if someone is at high risk of diabetes. Rather, it states that clinicians should consider the individual's personal risk and provide advice and monitor them accordingly (WHO 2011). However, an expert group in the UK has suggested that HbA1c values between 42–47 mmol/mol (6.0–6.4%) indicate a high risk – while conceding that people with HbA1c values lower than 42 mmol/mol (6.0%) may still be at risk (John et al. 2012).

Progression-rate estimates are based on evidence from the oral glucose tolerance test 2-hour blood glucose values. However, a recent UK study found that the incidence of type 2 diabetes over a 3-year period was 15 times higher among participants with an HbA1c between 42–47 mmol/mol (6.0–6.4%) at the beginning of the study, compared with those with a baseline HbA1c less than 31 mmol/mol (5.0%) (Chamnan et al. 2011).

People with impaired glucose tolerance or elevated HbA1c may have a greater risk of developing type 2 diabetes and cardiovascular disease compared to those with impaired fasting glucose. People with both impaired fasting glucose and impaired glucose tolerance, or an HbA1c of 42 mmol/mol (6.0%), are at an even greater risk of developing diabetes (WHO 2006; The DECODE Study Group 2001). Other risk factors, such as an increased BMI and waist circumference, can more than double the chances (Lindström et al. 2008).

Validated risk-assessment tools, based on multiple factors, can be used to identify people with undiagnosed type 2 diabetes or those at risk. FINDRISC, a self-assessment questionnaire developed in Finland, is the most widely used and validated. It uses weighted scores from eight categories to calculate an overall risk score (Lindström and Tuomilehto 2003). A risk assessment score has been developed from FINDRISC by Leicester University and University Hospitals of Leicester NHS Trust. This has been validated for use in a multi-ethnic population in the UK (Gray et al. 2010). It is now available as the Diabetes Risk Score, from the Diabetes UK website.

Other risk-assessment tools, such as the Cambridge diabetes risk score, Leicester practice score and the QDiabetes risk calculator, take account of data routinely collected in primary care.

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