Type 2 Diabetes. Tabinda Dugal GP Day 4/05/16

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1 Type 2 Diabetes Tabinda Dugal GP Day 4/05/16

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3 Diabetes Diabetes.a growing health crisis in Britain 869m per year 10% of NHS budget

4 Projections.. 5 million by 2025 Youngest patient?

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6 T2DM Type 2 diabetes is a chronic metabolic condition characterised by insulin resistance (that is, the body's inability to effectively use insulin) insufficient pancreatic insulin production, resulting in high blood glucose levels (hyperglycaemia)

7 T2DM Type 2 diabetes is commonly associated with obesity, Physical inactivity, Raised blood pressure, Disturbed blood lipid levels A tendency to develop thrombosis, and therefore is recognised to have an increased cardiovascular risk

8 T2DM It is associated with long-term microvascular and macrovascular complications, together with reduced quality of life and life expectancy.

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10 NICE 2015 Monitor blood pressure every 1 2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmhg (below 130/80 mmhg if there is kidney, eye or cerebrovascular damage)

11 NICE 2015 Involve adults with type 2 diabetes in decisions about their individual HbA1c target. 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. [new 2015] 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. [new 2015] Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless: the person is on insulin or there is evidence of hypoglycaemic episodes or the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery orthe person is pregnant, or is planning to become pregnant.

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21 % of Subjects n = 404 We Are NOT At Goal % 7% GOAL Survey 12.4% 7.8% 17.0% 25.8% 37.0% 37.2% >8% A1C >10% >9% >8% 7-8% <7% Only 7% of adults with diabetes in NHANES attained: A1C level <7% Blood pressure <130/80 mm Hg Total cholesterol <200 mg/dl Adults aged years with previously diagnosed diabetes who participated in the interview and examination components of the National Health Examination Survey (NHANES), Saydah SH et al. JAMA. 2004;291:

22 Many patients are still failing to meet their treatment targets UNCONTROLLED 35% of people nationally OVERWEIGHT 90% of adults with type 2 diabetes are not meeting their treatment target of an HbA 1c of 58 mmol/mol (7.5%) 1 with type 2 diabetes are overweight or obese 2 How does this compare to your local figures? 1. Diabetes UK (2015) State of the Nation: Challenges for 2015 and Beyond (England). Available at: State-of-the-nation-challenges-for-2015-and-beyond/ (accessed ) 2. Public Health England (2014) Adult obesity and type 2 diabetes. Available at: (accessed )

23 Renal Handling of Glucose (180 L/day) (900 mg/l)=162 g/day Glucose SGLT2 S1 90% S3 SGLT1 10% No Glucose

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26 Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes Bernard Zinman, M.D., Christoph Wanner, M.D., John M. Lachin, Sc.D., David Fitchett, M.D., Erich Bluhmki, Ph.D., Stefan Hantel, Ph.D., Michaela Mattheus, Dipl. Biomath., Theresa Devins, Dr.P.H., Odd Erik Johansen, M.D., Ph.D., Hans J. Woerle, M.D., Uli C. Broedl, M.D., and Silvio E. Inzucchi, M.D., for the EMPA-REG OUTCOME Investigators

27 EMPA-REG CONCLUSIONS Patients with type 2 diabetes at high risk for cardiovascular events who received empagliflozin, as compared with placebo, had a lower rate of the primary composite cardiovascular outcome and of death from any cause when the study drug was added to standard care. (Funded by Boehringer Ingelheim and Eli Lilly; EMPA-REG OUTCOME ClinicalTrials.gov number, NCT )

28 Number of patients <6 <6 Number of patients Type 2 HbA 1c levels when initiating insulin therapy Average HbA 1c is 10.1% Average HbA 1c is 10.4% Basal Only Basal Bolus Patients with HbA 1c recorded:19533 Patients with HbA 1c recorded: ,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, ,400 1,200 1, Level of HbA 1c control Level of HbA 1c control Source: CSD Patient Data, MAT to May 2013

29 < <6 12+ Number of patients Number of patients Type 2 HbA 1c control levels in UK patients on insulin Average HbA 1c is 8.8% Average HbA 1c is 8.8% Basal Only 39% of patients have HbA 1c >9%: 44,166 Basal Bolus 39% of patients have HbA 1c >9%: 95,676 25,000 20,000 15,000 10,000 40,000 33,000 30,000 25,000 20,000 15,000 5,000 10,000 5, Level of HbA 1c control Level of HbA 1c control Source: CSD Patient Data, MAT to May 2013

30 Effects of Meals and Snacks Dietary fiber Targets of grams/day Can be difficult to achieve Improves postprandial numbers for some Soluble fiber can lower cholesterol numbers Increases satiety Alcohol Can cause hypoglycemia, especially when taken without carbohydrates Don t forget, it s a source of calories Moderate intake associated with improved heart health

31 Effects of Physical Activity on Glucose Immediate effects Metabolism During and several hours after exercise Delayed effects 4 12 hours after exercise Long-lasting effects Improves insulin sensitivity Implications for glucose monitoring

32 Hypoglycemia Treatment Options Frequent Decrease medication Usually sulfonylurea or insulin Special problems associated with SU Intermittent Due to too little food Adjust food Decrease insulin dose if on insulin Due to too much physical activity Add carbs for extra fuel Decrease insulin dose if on insulin

33 Hyperglycemia Treatment Options Reduce food portions and/or carbohydrates Add in aerobic physical activity Resistance exercise adds benefit also Increase medication effect Dosage, timing Add new medication

34 Listening to Your Patient Collect the information Thank them for bringing it in Ask what they think about their numbers Look for barriers to checking glucoses Ask if you could share some of your thoughts on their numbers Give a brief interpretation Using AHH, emphasize average glucose goal and A1C Decide, with the patient, about an approach to take Changing food, activity, medication Discuss follow-up

35 The Basics Just Say AHH A1C and average blood glucose On target? (Do they know their target?) Hypoglycemia (<4 mmol/dl) Fasting or postprandial? Frequent or intermittent? Symptoms? Hyperglycemia (>fasting/postprandial target) Fasting or postprandial? Frequent or intermittent?

36 Weight loss 13% wt loss 0.6gm from pancreas Reversal of diabetes

37 New Diagnosis and control "Prompted by the case of a newly diagnosed diabetic lady who experienced a deterioration of vision after rapid lowering of her blood sugar, in Cornwall we have reviewed the advice regarding management of diabetes in newly diagnosed type 2 diabetic people having significant hyperglycaemia and whose retinopathy status is unknown.

38 Case Through regular GP/Diabetes updates we have disseminated advice to our colleagues in primary care that newly diagnosed type 2 diabetics should be offered diabetic retinopathy screening as soon as possible, and importantly, not to initiate rapid improvement in glycaemic control until the retinopathy status is known to be mild (R1) Our screening service operates from some 70 sites throughout Cornwall and, in practice, we can usually offer a screening appointment within one week for such patients. Patients with sight threatening retinopathy (R2 or R3) are fast-tracked for further assessment and treatment in the hospital eye service and with careful liaison with Primary Care Practitioners and where appropriate our diabetologists regarding glycaemic management.

39 Case In general, our diabetologists recommend lowering of blood sugar 0.5% or 6 mmol/mol every six months and a combination of insulin and metformin is frequently advised to achieve predicted control. It should also be recognised that some medications, e.g. sulphonylureas and/or SGLT2 blockers should be avoided as they have the potential to lead to a poweful, sudden reduction of blood sugar with adverse effects on preexisting retinopathy."

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