Dapagliflozin: Clinical practice compared with pre-registration trial data

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1 Dapagifozi: Ciica practice compared ith pre-regitratio tria data ANDREW P MCGOVERN 1-3, NINA DUTTA 1, NEIL MUNRO 1-4, KENNETH WATTERS 1,2,4, MICHAEL FEHER 1,2,4 Abtract Backgroud: Dapagifozi i the firt odium-gucoe cotraporter 2 (SGLT2) ihibitor to be approved i Europe ad repreet a e ca of aget deveoped a ora diabete medicatio. Improved gycaemic cotro ad eight o have bee demotrated i ciica tria but effectivee outide of the tria eviromet ha ot yet bee reported. Method: A ytematic ciica cae ote audit of type 2 diabete patiet iitiated o dapagifozi i a diabete peciait outpatiet cetre of a Lodo teachig hopita. Reut: Of the 96 peope icuded, 42% had a reductio i gycated haemogobi (HbA 1c ) of >1%, 29% had o reductio; 15% had eight o >5kg, 3% had eight o >10kg ad 24% had o eight reductio. Improvemet i HbA 1c, eight, ad bood preure ere coitet ith thoe reported i ciica tria. The rate of dicotiuatio of dapagifozi due to ide effect (22%) a higher tha reported i tria (3-4%), but 52% of peope toeratig dapagifozi ere abe to top or reduce oe or more other diabete medicatio. Cocuio: Dapagifozi i effective at improvig gycaemic cotro. It ao reduce bood preure, reut i eight o, ad reduce the eed for cocomitat diabete medicatio. Hoever, it i ot a e toerated i rea-ord patiet a i participat of ciica tria. Br J Diabete Vac Di 2014;14: Key ord: dapagifozi, rea-ord, SGLT2, type 2 diabete 1 Beta Ce Diabete Cetre, Cheea ad Wetmiter Hopita, Lodo, SW10 9NH, UK 2 Diabete Therapie Evauatio Netork, Cheea, Lodo, SW3 5HW, UK 3 Departmet of Heath Care Maagemet ad Poicy, Uiverity of Surrey Guidford, GU2 7PX, UK 4 Warick Medica Schoo, Warick Uiverity, Covetry, CV4 7AL, UK Addre for correpodece: Dr Michae Feher Beta Ce Diabete Cetre, Cheea ad Wetmiter Hopita, 369 Fuham Road, Lodo, SW10 9NH, UK Te: +44 (0) x8821 E-mai: m.feher@cheet.h.uk Abbreviatio ad acroym BMI body ma idex GLP-1ra gucago-ike peptide-1 receptor agoit GP geera practitioer HbA 1c gycated haemogobi OAD ora atidiabetic drug SEM tadard error of the mea SGLT2 odium gucoe co-traporter 2 UTI uriary tract ifectio Itroductio Dapagifozi i the firt SGLT2 ihibitor drug to gai approva i Europe for the maagemet of type 2 diabete ad a itroduced ito UK ciica practice i December The pre-regitratio ciica tria of dapagifozi have demotrated improvemet i gycaemic cotro he ued a mootherapy 1 ad ith metformi, 2-4 ufoyurea, 5,6 or iui. 7,8 There have ao bee ciicay meaigfu reductio i eight ad bood preure. Hoever, thee ciica tria ere performed o eected patiet group ad therefore the tria reut may ot be matched i rea-ord ciica practice. The Aociatio of Britih Ciica Diabetoogit atioide exeatide audit demotrated a differig rea-ord efficacy profie from that reported i regitratio ciica tria. 9 We hypotheied that routie ue of dapagifozi i ciica practice may vary i efficacy ad ide effect rate from thoe reported i ciica tria. We preet the reut of a phae 4 ciica tudy i the form of treatmet obervatio of type 2 diabete patiet treated ith dapagifozi. Method The deig a a rea-ord, obervatioa, o-radomied ige cetre tudy. The tudy compried of a ytematic ciica audit of ote ad eectroic record from peope ith type 2 diabete ith dapagifozi iitiated i the diabete peciait outpatiet cetre of a Lodo teachig hopita. The record of a peope precribed dapagifozi before 14th May 2014 ere aayed (=122). Peope ith o foo-up data ere excuded (=26). Aoymied data ere coected o patiet demographic, dieae profie, cocurret medicatio, ad outcome. The demographic ad dieae iformatio coected compried patiet age, geder, diabete type ad duratio, rea fuctio, ad baeie meauremet of HbA 1c, eight, BMI, ad bood preure. A recorded ciica meauremet ere take from routie data. Where o baeie meauremet a avaiabe for HbA 1c, eight, or bood preure, the mot recet avaiabe meauremet ithi the precedig three moth a ued. A ma umber of peope had dapagifozi topped by their 138 THE BRITISH JOURNAL OF DIABETES & VASCULAR DISEASE

2 Tabe 1 Chage i outcome meaure at fia foo-up viit i patiet ith type 2 diabete treated ith dapagifozi Outcome meaure (uit) (%) Mea baeie Mea chage from 95% cofidece vaue (SEM) baeie (SEM) iterva HbA 1c (%) 79 (82) 9.51 (0.19) (0.23) to HbA 1c (mmo/mo) 79 (82) 80.4 (2.1) -9.2 (2.5) to -4.2 Weight (kg) 88 (92) 94.3 (2.6) -2.2 (0.5) -3.2 to -1.2 Sytoic BP (mmhg) 68 (71) 135 (2) -3.9 (2.3) -8.5 to 0.8 Diatoic BP (mmhg) 68 (71) 78 (1) -3.9 (1.3) -6.5 to -1.2 GP ad there a o documeted reao for thi dicotiuatio i the ecodary care ote. I thee cae the GP a cotacted for additioa iformatio ad aked about ay drug reated advere effect. Where peope topped takig dapagifozi, data from ubequet viit ere excuded from the aayi here. A coected data ere ee checked ad apparety aomaou vaue ere rechecked i the ciica record. Statitica aaye To evauate chage i the outcome parameter of HbA 1c, eight, ad bood preure over time, patiet foo-up data ere grouped by three moth period; 0-3, 4-6, 7-9, ad moth. The media chage i each outcome parameter a cacuated for each three moth group. Where peope atteded more tha oe foo-up appoitmet i a ige three moth period, the at appoitmet data a ued. We performed a iear regreio aayi to idetify predictor of reductio i HbA 1c, eight, ad bood preure i peope takig dapagifozi. Peope ho faied to tart dapagifozi or ho topped takig it durig the foo-up period ere excuded. Chage from baeie for the outcome meaure of HbA 1c, eight, ad bood preure ere cacuated. We aume a igificace eve of p <0.05 ad report mode performace uig R-quare ad adjuted R-quare vaue. The aayi a udertake uig SPSS verio Ethica coideratio Thi tudy a deiged a a ciica audit of routie practice for the purpoe of improvig patiet maagemet ad a uch did ot require ethic committee revie. 10 Reut A peope (=122) ho had bee precribed dapagifozi ere iitiay icuded for aayi. Three peope ere excuded a their ote ere uavaiabe. Four peope ere excuded a they faied to atted ay foo-up appoitmet. Oe pero a excuded a they had type 1 diabete iitiay midiagoed a type 2, ad dapagifozi a the topped. Fourtee peope ere excuded becaue they ere ot yet due to atted fooup ad four ere excuded becaue they choe ot to tart takig dapagifozi. The majority of participat had compete data (a iitia vaue ad foo-up meauremet) o HbA 1c (=79; 82%), eight (=88; 92%), ad bood preure (=68; 71%). Thoe ith icompete data for a outcome meaure ere excuded from the aayi of that outcome meaure. The icuded cohort (=96) atteded oe or more fooup appoitmet ad compried 43% ome, mea age 58.9 (rage 31-85) year, ith a mea duratio of type 2 diabete of 15.1 (rage 1-37) year. The mea eight of the cohort a 94.7 (rage ) kg ad BMI 33.7 (rage 22-52) kg/m 2. The mea duratio of foo-up a 152 (rage 7-431; tadard deviatio 115) day. The hortet duratio of foo-up a a urget appoitmet requeted becaue the patiet had deveoped a idepread rah. Dapagifozi a topped at thi viit. The mea umber of foo-up appoitmet icuded a 1.57 (rage 1-4). Efficacy Of the icuded peope, 72 (75%) had foo-up ithi the firt three moth of tartig dapagifozi, 50 (52%) at 4-6 moth, 22 (23%) at 7-9 moth, ad 12 (13%) at moth. Average chage at the foo-up viit are ho i Tabe 1. Seve peope had o repoe to dapagifozi ith o improvemet i HbA 1c ad o eight reductio (Tabe 2). The HbA 1c repoe a utaied (Figure 1). Weight ad bood preure cotiued to improve durig the year of foo-up (Figure 2). Of thoe peope ho toerated dapagifozi through the foo -up period, 36 (52%) ere abe to top or reduce oe or more other diabete medicatio, herea 18 (26%) patiet had medicatio Tabe 2 Repoe to dapagifozi treatmet i patiet ith type 2 diabete ( rea-ord data ) Outcome meaure (%) Repoe % HbA 1c reductio 79 (82) No repoe 29 Reductio < 1% 29 Reductio > 1% 42 Weight o 88 (92) No repoe 24 Weight o < 5kg 58 Weight o > 5kg ad <10kg 15 Weight o > 10kg 3 Sytoic BP (mmhg) 68 (71) No repoe 43 reductio Reductio < 5mmHg 16 Reductio > 5mmHg 41 Diatoic BP (mmhg) 68 (71) No repoe 40 reductio Reductio < 5mmHg 12 Reductio > 5mmHg 48 VOLUME 14 ISSUE 4 OCTOBER/NOVEMBER/DECEMBER

3 Figure 1. Chage over time i HbA 1c i patiet ith type 2 diabete fooig iitiatio of dapagifozi Chage from baeie (mmo/mo) HbA1c chage Time (day) Chage from baeie (uit - ee key) Figure 2. Chage over time i eight ad bood preure i patiet ith type 2 diabete fooig iitiatio of dapagifozi Sytoic BP chage (mmhg) Diatoic BP chage (mmhg) Weight chage (kg) Time (day) Tabe 3 Chage i cocurret diabete medicatio durig the foo-up period i patiet ho toerated dapagifozi Cocurret medicatio type (%) Doe decreaed Medicatio topped Doe icreaed Medicatio tarted Tota 69 (100) 17* 21* 10* 3 OAD 69 (100) 7* 9* 2* 1 GLP-1ra 33 (48) Iui 36 (52) 9* *Icude patiet ith chage to >1 medicatio. Tabe 4 Ciica predictor of chage i HbA 1c i patiet takig dapagifozi (=79) Ciica Coefficiet (95% p characteritic cofidece imit) vaue Age (year) ( to 0.009) Femae ( to ) Diabete duratio (year) ( to 0.034) BMI (kg/m 2 ) ( to 0.037) Baeie HbA 1c (%) ( to ) <0.001 Mode R-quare 0.459, adjuted R-quare doe icreaed or a additioa medicatio added (Tabe 3). Higher HbA 1c at baeie a aociated ith a greater reductio i HbA 1c hit takig dapagifozi (Tabe 4). Reductio i HbA 1c a idepedet of age, geder, duratio of diabete. Higher BMI at baeie a aociated ith greater eight o (Tabe 5). Baeie eight a ot aociated ith the degree of eight o (reut ot ho). Weight o a idepedet of age, geder, duratio of dieae, ad baeie HbA 1c. Higher Tabe 5 Ciica predictor of eight chage i patiet takig dapagifozi (=88) (kg) Ciica Coefficiet (95% p characteritic cofidece imit) vaue Age (year) ( to 0.052) Femae ( to 0.328) Diabete duratio (year) ( to 0.065) BMI (kg/m 2 ) ( to ) Baeie HbA 1c (%) ( to 0.079) Mode R-quare 0.072, adjuted R-quare baeie bood preure a aociated ith a greater reductio i both ytoic ad diatoic bood preure (Tabe 6 ad 7). Oder age a eaky aociated ith a greater reductio i diatoic bood preure. Advere effect Advere effect ere recorded for 36 (38%) peope. Icreaed urie fo (octuria ad poyuria) a the mot commo advere 140 THE BRITISH JOURNAL OF DIABETES & VASCULAR DISEASE

4 Tabe 6 Ciica predictor of reductio i ytoic bood preure (mmhg) i patiet takig dapagifozi (=68) Tabe 7 Ciica predictor of reductio i diatoic bood preure (mmhg) i patiet takig dapagifozi (=68) Ciica Coefficiet (95% p characteritic cofidece imit) vaue Age (year) ( to 0.066) Femae ( to 6.401) Diabete duratio (year) ( to 0.248) BMI (kg/m 2 ) ( to 0.090) Baeie HbA 1c (%) ( to 0.358) Baeie ytoic BP (mmhg) ( to ) <0.001 Mode R-quare 0.261, adjuted R-quare Ciica Coefficiet (95% p characteritic cofidece imit) vaue Age (year) ( to ) Femae ( to 1.665) Diabete duratio (year) ( to 0.368) BMI (kg/m 2 ) ( to ) Baeie HbA 1c (%) ( to 0.279) Baeie diatoic BP (mmhg) ( to ) Mode R-quare 0.146, adjuted R-quare effect (occurrig i 17 peope) fooed by geita cadidiai (10), potura hypoteio (3), UTI (3), dypepia (2), thirt (2), dry mouth (2), rah (2), erectie dyfuctio (1), fatigue (1), back pai (1), papitatio (1), ad uriary icotiece (1). The pero reportig uriary icotiece had a previou hitory of icotiece hich retured hit takig dapagifozi. The to peope reportig rah had deveoped a idepread erythematou rah ith aociated pruritu ithi the firt three day of takig dapagifozi eceitatig dicotiuatio. Oe pero a admitted to hopita ith a cofirmed E. coi UTI ad bacteraemia hit takig dapagifozi. Thi pero had a hitory of mutipe UTI athough oe had previouy required hopita admiio. Thi ugget a hitory of recurret UTI may imit the ue of thi drug. Toerabiity A tota of 27 (28%) peope topped takig dapagifozi durig the foo-up period. Four peope ere advied to top becaue of deterioratio i their rea fuctio (three of thee had a improvemet i gucoe cotro prior to toppig), to becaue they fet it added to a aready arge pi burde (hich may be improved i future by fixed doe combiatio) ad 21 becaue of advere effect. The mot commo advere effect eadig to dicotiuatio of dapagifozi a geita cadidiai (4 of 10 peope affected). Mot peope ith reported poyuria (6 of 8) eected to cotiue takig dapagifozi. Simiary, mot peope ith octuria (8 of 9) eected to cotiue. Dicuio Thi tudy of rea-ord data demotrate that dapagifozi i effective at reducig HbA 1c ith 42% of the peope ho toerated dapagifozi achievig a reductio i HbA 1c >1%. Sigificat reductio i eight ad bood preure ere ao cofirmed i our tudy. The ciica repoe to dapagifozi a idepedet of age ad duratio of diabete ad the greatet improvemet i HbA 1c a ee i thoe ith the pooret cotro at baeie. Simiary the greatet reductio i eight ad bood preure a ee i thoe ith the highet BMI ad bood preure at baeie. BMI ad ot baeie eight a aociated ith eight o, hich ugget that the degree of obeity i the predictor of eight o. A coiderabe umber coud either reduce or top other ora therapie or iui, there may be additioa cot beefit from a pharmaco-ecoomic perpective. Dapagifozi improve gycaemic cotro by prevetig gucoe reuptake by SGLT2 i the proxima tubue of the kidey. 11,12 Ihibitio of SGLT2 prevet rea reaborptio of Tabe 8 Outcome i ciica tria compared ith rea-ord data i patiet ith type 2 diabete treated ith dapagifozi Rea-ord data Ferraii Baiey Strojek Widig (Curret tudy) et a. 1 et a. 2 et a. 6 et a. 7 Duratio of foo-up (eek) 22 (mea) Cocomitat therapy Variou Noe Metformi Gimepiride Iui Participat demographic Tota participat () Mea age (year) Mea duratio of diabete (year) Mea BMI (kg/m 2 ) Outcome (mea) HbA 1c chage (%) Weight chage (kg) Sytoic BP chage (mmhg) Diatoic BP chage (mmhg) VOLUME 14 ISSUE 4 OCTOBER/NOVEMBER/DECEMBER

5 gucoe. The reutig gucouria ao promote eight o. 4 The actio i idepedet of iui ecretio ad iui actio ad doe ot predipoe to hypogycaemia. 3 Ihibitio of SGLT2 ca promote uriary odium o 13,14 hich, aog ith eight reductio ad a omotic diurei, may be repoibe i part for the bood preure oerig effect oberved. 15 Peope ho experieced poyuria or octuria ere ikey to cotiue to take the aget, athough evera advere effect ere oberved eadig to 22% of the cohort dicotiuig dapagifozi therapy. The gycouria iduced by dapagifozi ca potetiay ead to UTI ad geita ifectio, predomiaty cadidiai 12,16 - the advere effect mot ikey to ead to dicotiuatio. Compario ith pre-regitratio tria reut Our patiet cohort a a imiar i age to peope icuded i ciica tria, athough the mea duratio of diabete a oger tha that of tria participat (Tabe 8). The effectivee of dapagifozi, depite the oger duratio of diabete, i our tudy a imiar to that reported i ciica tria of imiar duratio (Tabe 8). I pre-regitratio tria patiet takig dapagifozi 10mg ige aget therapy, geita ifectio ere reported i 9.7%, UTI i 8.1%, octuria i 1.6%, hypoteio i 1.1%, ad ay advere evet eadig to dicotiuatio i 4.3%. 1 I patiet takig cocurret metformi ad dapagifozi (10mg), geita ifectio ere reported i 8.8%, UTI i 8.1%, ad ay advere evet eadig to dicotiuatio i 3.0%. 2 I patiet takig cocurret iui ad dapagifozi (10mg), poyuria a reported i 8.3%, ad ay advere effect eadig to dicotiuatio i 4.2%. By cotrat, the curret tudy had ighty higher rate of geita ifectio (10.4%) ad potura hypoteio (3.1%), ad higher rate of icreaed urie fo (poyuria/octuria) (17.7%) tha reported i thee tria. The mot ubtatia dicrepacy a the rate of dicotiuatio due to ide effect hich e foud to be 22%. Limitatio of thi rea-ord tudy Uig routiey coected data to ae the prevaece of ideeffect i ikey to ead to ome uderetimatio of their frequecy, a mior ide effect may ot be reported i ciic. Hoever major advere evet or effect that ead to patiet atig to dicotiue dapagifozi are amot certaiy documeted. The routiey coected data ao had ome miig vaue for the outcome meaure of HbA 1c, eight, ad bood preure. We caot determie retropectivey if there a a bia toard miig data i a particuar ubpopuatio athough e upect that miig data are moty radom. Our rea-ord data are cofouded by chage to other medicatio ad there i o cotro group for compario. Hoever the geera tred oberved durig the foo-up period a toard e cocomitat medicatio, uggetig that the beeficia effect ee i thi group of patiet are moty attributabe to dapagifozi. The iear regreio aayi of factor aociated ith HbA 1c, Key meage I a rea ord ettig: Dapagifozi repoder had a marked reductio i gucoe, eight ad BP The greatet beefit occurred i thoe ith the pooret gucoe cotro, highet BMI ad BP Icreaed urie fo (poyuria ad octuria) a the mot commo ide effect athough geita cadidiai a mot ikey to ead to dicotiuatio eight, ad bood preure chage i imited by ma ampe ize ad heterokedacity i both outcome meaure. The higher variabiity i HbA 1c, eight, ad bood preure chage ith higher iitia vaue i ikey to be a itriic property of the data. Cocuio The rea-ord data preeted here may have greater geeraiabiity to ciica practice, tha data from ciica tria a patiet ith mutipe co-morbiditie or o mutipe ora atidiabetic aget ere icuded i the popuatio aayed ad are uuay excuded from ciica tria. Thi tudy ooked at a popuatio of patiet ith diabete referred for peciait maagemet i ecodary care ad therefore may ot be appicabe to a patiet i the primary care ettig. Thee data cofirm that dapagifozi i effective for ue i ciica practice but ciicia houd accout for a higher eve of itoerace to the ide effect of dapagifozi i ciica practice tha that hich i reported i ciica tria. I thoe ho toerated dapagifozi, the commoy cutered metaboic rik factor of poor gycaemic cotro, obeity, ad hyperteio ere a igificaty improved. There a ao a reductio i the ue of other ora atidiabetic aget ad iui i thi popuatio. Cofict of iteret AMcG ad ND ere fuded by the Diabete Therapie Evauatio Netork. NM, KW, ad MF receive fiacia upport for reearch, peaker meetig, ad coutacy from MSD, Merck, BMS, AtraZeeca, Pfizer, Novo, Ei-Liy, ad Saofi-Aveti. AMcG, ND, NM, KW, ad MF rote the maucript. AMcG ad ND coected ad aayed the data. Referece 1. Ferraii E, Ramo SJ, Saai A, et a. Dapagifozi mootherapy i type 2 diabetic patiet ith iadequate gycemic cotro by diet ad exercie: a radomized, doube-bid, pacebo-cotroed, phae 3 tria. Diabete Care 2010;33: Baiey CJ, Gro JL, Pieter A, et a. Effect of dapagifozi i patiet ith type 2 diabete ho have iadequate gycaemic cotro ith metformi: a radomied, doube-bid, pacebo-cotroed tria. Lacet 2010; 375: Baiey CJ, Gro JL, Heicke D, et a. Dapagifozi add-o to metformi i type 2 diabete iadequatey cotroed ith metformi: a radomized, doube-bid, pacebo-cotroed 102-eek tria. BMC Medicie 2013;11: THE BRITISH JOURNAL OF DIABETES & VASCULAR DISEASE

6 4. Strojek K, Yoo KH, Hruba V, et a. Dapagifozi added to gimepiride i patiet ith type 2 diabete meitu utai gycemic cotro ad eight o over 48 eek: a radomized, doube-bid, parae-group, pacebo-cotroed tria. Diabete Ther 2014;5: Nauck MA, De Prato S, Meier JJ, et a. Dapagifozi veru gipizide a add-o therapy i patiet ith type 2 diabete ho have iadequate gycemic cotro ith metformi: a radomized, 52-eek, doube-bid, active-cotroed oiferiority tria. Diabete Care 2011;34: Strojek K, Yoo KH, Hruba V, et a. Effect of dapagifozi i patiet ith type 2 diabete ho have iadequate gycaemic cotro ith gimepiride: a radomized, 24-eek, doube-bid, pacebo-cotroed tria. Diabete Obe Metab 2011;13: Widig JP, Norood P, T'Joe C, et a. A tudy of dapagifozi i patiet ith type 2 diabete receivig high doe of iui pu iui eitizer: appicabiity of a ove iui-idepedet treatmet. Diabete Care 2009;32: Widig JP, Woo V, Soer NG, et a. Log-term efficacy of dapagifozi i patiet ith type 2 diabete meitu receivig high doe of iui: a radomized tria. A Iter Med 2012;156: Thog KY, Joe B, Sukumar N, et a. Safety, efficacy ad toerabiity of exeatide i combiatio ith iui i the Aociatio of Britih Ciica Diabetoogit atioide exeatide audit. Diabete Obe Metab 2011; 13: Natioa Reearch Ethic Service. Defiig Reearch Avaiabe from: pdf. 11. Fujita Y, Iagaki N. Rea odium gucoe cotraporter 2 ihibitor a a ove therapeutic approach to treatmet of type 2 diabete: Ciica data ad mechaim of actio. J Diabete Ivetig 2014;5: Rahmoue H, Thompo PW, Ward JM, et a. Gucoe traporter i huma rea proxima tubuar ce ioated from the urie of patiet ith o-iui-depedet diabete. Diabete 2005;54: Komoroki B, Vachharajai N, Feg Y, et a. Dapagifozi, a ove, eective SGLT2 ihibitor, improved gycemic cotro over 2 eek i patiet ith type 2 diabete meitu. Ci Pharmaco Ther 2009;85: Tahrai AA, Barett AH. Dapagifozi: a odium gucoe cotraporter 2 ihibitor i deveopmet for type 2 diabete. Diabete Therapy 2010;1: Ptazyka A, Hardy E, Joho E, et a. Effect of dapagifozi o cardiovacuar rik factor. Potgrad Med 2013;125: Poker GL. Dapagifozi: a revie of it ue i type 2 diabete meitu. Drug 2012;72: Dapagifozi (Forxiga) Natioide Audit No Lauched! ABCD auched a atioide audit of dapagifozi i the UK. Thi audit i particuary importat ith dapagifozi beig the firt of a e ca of drug for diabete, the SGLT2 ihibitor. We have a chace to ae rea ciica efficacy ad afety of thi e type of treatmet by pooig our experiece atioide Doe your cetre ue dapagifozi (Forxiga)? If ye, REGISTER YOUR CENTRE! by cotactig abcd.audit@diabetoogit.org.uk you are abe to aaye your oca data eaiy you are ivited to eter your patiet data ito the oie too o N3 (the NHS ecure etork) the data i be automaticay added to the atioa data i aoymied form e ca provide eay-to-compete paper proforma for ue i ciic if preferred Peae remember: - the more data, the more compete our udertadig of thi e treatmet i be - a cotributor i be ited i pubicatio ariig from data ubmiio VOLUME 14 ISSUE 4 OCTOBER/NOVEMBER/DECEMBER