Overview and update of modern type 2 Diabetes philosophy and management. Dr Steve Stanaway Consultant Endocrinologist BCU

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1 Overview and update of modern type 2 Diabetes philosophy and management Dr Steve Stanaway Consultant Endocrinologist BCU

2 Diabetes economics 2009: 2.6M adults with DM in UK (90% type 2) 2025: est. > 4M adults with DM 2006: 3.6% prevalence 2011: 5.5% prevalence NaDIA 2012: 17.9% Wrexham in-patients have DM (>90% T2DM) : BNF DM section = highest cost + highest rising cost in primary care England Diabetes costs currently = 25k per minute in England and Wales = 10% NHS budget Costs estimated to hit 16.5% (1 sixth) NHS budget by 2035

3 Diabetes economics Figures published Jan Figures in BILLIONS of pounds Area Type 1 Type 2 Total % costs Diab drugs % Non-diab drugs % In patient % Out patient (non drugs) % Other/social % Total %

4 The Cost of Complications Combined micro and macrovascular complications DOUBLE the likelihood of need for a carer TRIPLE the patient s personal financial costs QUADRUPLE social services costs QUINTRUPLE NHS costs

5 Prevention is better for an expensive life limiting disease especially when there is (almost) no cure. BUT to prevent you have to know what the cause actually is!

6

7 Insulin Prevalence resistance of Type and Prevalence 2 diabetes of (%) T2DM (%) IR and Type 2 DM increase with BMI Male Female <18.5 or under to to to 40 Over >40 40 BMI BMI (kg/m 2 ) Adapted from Department of Health. Health Survey for England London: The Department of Health.

8 INTERHEART Study Standardised, case-control study of acute myocardial infarction (AMI) in 52 countries To determine strength of association between various risk factors and Acute MI 15,142 cases and 14,820 controls 9 risk factors studied Yusuf S, et al. Lancet 2004; 364:

9 9 risk factors 90.4% of risk of AMI Current or former smoking History of diabetes History of hypertension Abdominal obesity Combined psychosocial stressors Irregular consumption of fruits and vegetables No alcohol intake Avoidance of regular exercise Raised plasma lipids Yusuf S, et al. Lancet 2004; 364:

10 INTERHEART: summary of results Yusuf S, et al. Lancet 2004; 364:

11 Visceral Fat and Glycaemia (mmol/l) Glucose ,2 Area (pmol/l) Nonobese Obese low visceral AT Obese high visceral AT ,2 1,2 1,2 Insulin 1,2 1,2 Area 1,2 1,2 1,2 1,2 1, Time (min) 1 significantly different from nonobese 2 significantly different from obese with low visceral AT levels Time (min) From Pouliot MC et al. Diabetes (1992) 41:

12 visceral fat CVD risk Triglycerides HDL-cholesterol 60 (mg/dl) 4 (mg/dl) Nonobese Obese 30 Nonobese Obese Low visceral AT High visceral AT Low visceral AT High visceral AT Adapted from Pouliot MC et al. Diabetes (1992) 41:

13 HPS: Effect of HDL-cholesterol levels CHD event rate Placebo Simvastatin 16.4% 13.5% 10.5% 10.3% 8.2% 9.0% 7.3% 0.9 < < 0.9 No type 2 diabetes Type 2 diabetes 12.9% HDL- chol (mmol/l) Adapted from The Lancet 361 June 14, 2003 (web)

14 T2DM and CV Risk Grouping MI +MI Non-diabetic subjects Subjects with type 2 diabetes -MI +MI 7 year incidence of cardiovascular events (%) MI +MI -MI +MI -MI +MI 10 -MI +MI 5 0 MI Haffner SM et al. N Engl J Med 1998;339: Stroke CV deaths

15 Mechanistic Thinking Genetic factors Environmental factors Insulin Resistance T2DM Endo Procoagulation dysfuncton BP/lipids glucose CV events Microangiopathic disease

16 Shared Predictors for T2DM and CVD CVD FHx high FPG high TG low HDL high BP high LDL insulin resistance low grade inflammation smoking T2DM FHx high FPG high TG low HDL high BP high small dense LDL insulin resistance low grade inflammation

17 Type 2 Diabetes: a suggested definition An obesity and lifestyle related state of [high likelihood of] premature cardiovascular death associated with chronic hyperglycaemia and also with blindness and renal failure. (based on; Fisher, 2001)

18 Lifestyle HbA1c > 6.5% Metformin (1) HbA1c > 6.5% Metformin + SU (2) HbA1c > 7.5% MF + SU + Pio (3) Or MF + SU + gliptin Or MF + SU + GLP-1 analogue (4)* HbA1c > 7.5% MF + SU + Insulin (no alternatives) (5)* HbA1c > 7.5% Intensified Insulin regime* 1. Can start with SU if weight low/mf CI d/rapid response needed or with Sitagliptin if MF and SU not suitable Use SR metformin if GI upset with standard prep 2. Use RAIS instead of SU if lifestyle erratic Use Pio or gliptins 2 nd line if hypos a problem. 3. Avoid Pio if fluid retention or high fracture risk or haematuria/suspicion of bladder cancer or specific high body weight issues 4. Use GLP-1 if BMI >35 and causing problems with psych/metab/physical health or if <35 and insulin not acceptable or weight loss desirable GLP-1 analogue must be stopped if HbAic not reduce by 1% AND weight by 3% after 6 months 5. Insulin should not be delayed if control very poor and or other serious complications are developing eg severe eye disease *For these stages referral to secondary care would be increasingly appropriate although earlier referral or discussion for specific complex glycaemia-related problems may be considered

19 Alone MF SU MF+SU Pio MF+Pio Ins Notes Pio Exen bd X ** **Basal insulins only Exen o/w X * * X X * = when triple therapy regimes not suitable Lira X X *** *** levemir only can be added in Lyxy X ** **Basal insulins only and insulin + MF Sita Vilda X X X Saxa X X X Lina**** X X X ****No dose adjust for renal Ins X Dapagli X X X NICE due April 2013

20 Referral Urgency Deterioration into apparent insulin dependent state New foot ulcer or Charcot changes Pre pregnancy planning/confirmed pregnancy Major diabetic complications management Worsening renal function requiring major meds management* Loss of hypo awareness Severe painful diabetic neuropathy not responding to standard NICE Guideline 87 treatments Inconsistent NICE BP target achievement (proven on 24/24 recording) despite use of and compliance with three therapies or more (Severe patient pressure in the absence of the above) *Investigate renal impairment in usual way. Refer to renal team independently as appropriate

21 Primary Prevention Lipid management Notes: High risk if have any of Low risk High risk < 40 > 40 Nil Statin Statin if 10 yr risk > 20%* Statin BMI > 25, BP > 140/80, high ACR, smoker, CVD, FHx prem CVD, high risk lipid profile *Calculate 10 yr risk using UKPDS risk engine Statins generic where possible equivalent to Simva 40mg Aim for TC = 4 or LDL = 2 If targets not met Increase statin to 80mg or consider stronger statin or statin + ezetimibe Re-check at 1-3 months

22

23

24 Summary Diabetes (especially type 2) is on the rise and extraordinarily expensive T 2 Diabetes and Heart Disease are often the same condition based around insulin resistant state Preventing T2DM essential and MUST be a good investment Eat at the Frying Pan!

25 ACONCAGUA 2014

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