Managing diabetes in the post-guideline world. Dr Helen Snell Nurse Practitioner PhD, FCNA(NZ)

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1 Managing diabetes in the post-guideline world Dr Helen Snell Nurse Practitioner PhD, FCNA(NZ)

2 Overview Pathogenesis of T2DM Aims of treatment The place of glycaemic control Strategies to improve glycaemic control Individualising targets Models of care

3 Pathogenesis of T2DM Genetic susceptibility, lifestyle, diet etc. Insulin resistance Increased hepatic glucose output Decreased peripheral utilisation T2DM

4 HOMA (%) HbA1C (%) Beta cell function and glycaemic control in T2DM As beta cell function declines glycaemic control worsens Diet/conv Rx (n=376) Metformin (n=159) SU/intensive (n=511) Diet/conv Rx (n=297) Metformin (n=251) SU/intensive (n=695) Years Years UKPDS 16 Diabetes (1995) 44:1249

5 Pathogenesis of T2DM Genetic susceptibility, lifestyle, diet etc. Insulin resistance Increased hepatic glucose output Decreased peripheral utilisation Beta-cell dysfunction Decreased insulin secretion T2DM

6 T2DM is a progressive disease

7 Overview Pathogenesis of T2DM Aims of treatment The place of glycaemic control Strategies to improve glycaemic control Individualising targets

8 Evolution of T2DM care Management of symptoms Glycaemic control Intensive glycaemic control Multifactorial approach Guidelines & targets Individualising care Prevention

9 United Kingdom Prospective Diabetes Study Intensive vs conventional control RR p Relative Risk & 95% CI Any diabetes related endpoint Diabetes related deaths All cause mortality Myocardial infarction Stroke Microvascular Favours intensive Favours conventional

10 For each 1% reduction in HbA1c 21% All DM-related endpoints 37% Retinopathy 35% Nephropathy 43% Amputations 21% Diabetes related death 14% Fatal/non-fatal MI 12% Fatal/non-fatal stroke UKPDS 35 BMJ (2000) 321:405

11 Metabolic legacy effect: glycaemic control Aggregate endpoint All DM-related endpoints Microvascular disease MI All-cause mortality RRR: P-value: RRR: P-value: RRR: P-value: RRR: P-value: 12% % % % % % % % P-values calculated with log-rank test RRR = relative risk reduction Holman et al. NEJM (2008) 359:1577

12 Multifactorial approach 85 CVD events in 35 conventional patients (44%) versus 33 CVD events in 19 intensive patients (24%) Conventional Intensive Hazard ratio 0.47 (0.24 to 0.73); p= Gæde et al. NEJM (2003) 348:383

13 Overview Pathogenesis of T2DM Aims of treatment The place of glycaemic control Strategies to improve glycaemic control Individualising targets

14 Glycaemic control algorithms Diagnosis Tier 1: Well-validated core therapies Add basal insulin most effective No Lifestyle intervention + metformin HbA 1c 7% Add sulphonylurea least expensive Yes* Add glitazone no hypoglycaemia At diagnosis: Lifestyle + metformin Lifestyle and metformin + basal insulin Lifestyle and metformin + sulphonylurea Step 1 Step 2 Step 3 Lifestyle and metformin + intensive insulin No HbA 1c 7% Yes* No HbA 1c 7% Yes* No HbA 1c 7% Yes* Tier 2: Less well-validated studies Intensify insulin Add glitazone Add basal insulin Add sulphonylurea No HbA 1c 7% Yes* No Add basal or intensify insulin Intensive insulin + metformin ± glitazone HbA 1c 7% Yes* Lifestyle & metformin + pioglitazone No hypoglycaemia Oedema/CHF Bone loss Lifestyle and metformin + GLP-1 agonist No hypoglycaemia Weight loss Nausea/vomiting Lifestyle and metformin + pioglitazone + sulphonylurea Lifestyle and metformin + basal insulin Nathan et al. Diabetes Care (2006) 29:1963 Nathan et al. Diabetes Care (2008) 31:1

15 Metabolic legacy effect: a word on metformin Aggregate endpoint All DM-related endpoints Microvascular disease MI All-cause mortality RRR: P-value: RRR: P-value: RRR: P-value: RRR: P-value: 32% % % % % % % % P-values calculated with log-rank test RRR = relative risk reduction Holman et al. NEJM (2008) 359:1577

16 Diabetes is a progressive disease

17 Glycaemic control algorithms Diagnosis Tier 1: Well-validated core therapies Add basal insulin most effective No Lifestyle intervention + metformin HbA 1c 7% Add sulphonylurea least expensive Yes* Add glitazone no hypoglycaemia At diagnosis: Lifestyle + metformin Lifestyle and metformin + basal insulin Lifestyle and metformin + sulphonylurea Step 1 Step 2 Step 3 Lifestyle and metformin + intensive insulin No HbA 1c 7% Yes* No HbA 1c 7% Yes* No HbA 1c 7% Yes* Tier 2: Less well-validated studies Intensify insulin Add glitazone Add basal insulin Add sulphonylurea No HbA 1c 7% Yes* No Add basal or intensify insulin Intensive insulin + metformin ± glitazone HbA 1c 7% Yes* Lifestyle & metformin + pioglitazone No hypoglycaemia Oedema/CHF Bone loss Lifestyle and metformin + GLP-1 agonist No hypoglycaemia Weight loss Nausea/vomiting Lifestyle and metformin + pioglitazone + sulphonylurea Lifestyle and metformin + basal insulin Nathan et al. Diabetes Care (2006) 29:1963 Nathan et al. Diabetes Care (2008) 31:1

18 Overview Pathogenesis of T2DM Aims of treatment The place of glycaemic control Strategies to improve glycaemic control Individualising targets

19 The lower the better? What HbA1c?

20 What HbA1c? ACCORD (7.5% vs 6.4%) Terminated early due to excess deaths in intensive group Advance (7.3% vs 6.5%) No reduction of CV events Both n=10,000-11,000

21 ACCORD vs Advance ACCORD Advance High risk CVD population High risk CVD population 10 year Hx 8 year Hx Age 62 Age kg 78 kg Baseline HbA1c 8.1% Baseline HbA1c 7.5% Intensive group 6.4% vs 7.5% Intensive group 6.5% vs 7.3% Most intensive on 3 OHA and insulin Most intensive on MF and SU

22 Cause of excess mortality in ACCORD?

23 A way forward Multifactorial approach Smoking, BP, lipids, diet etc. & glycaemic control Set targets Work to meet those targets Individualise targets

24 A way forward

25 Prediabetes Government Society Healthcare providers Personal

26 NZGG guidance

27 Identification of patients at risk of diabetes complications Aim in treating diabetes is to: Treat symptoms Prevent complications Microvascular Macrovascular Safely

28 Annual review Microvascular: HbA1c Urinary ACR Retinal screening Foot examination Macrovascular: Height & weight BP Lipids Pedal pulses Bloods including LFT & egfr Agree a management plan

29 Identification of patients at risk of diabetes complications Patients with existing complications Angina or previous cardiac event Previous stroke or TIA Peripheral vascular disease Previous amputation/ulcer Severe retinopathy or moderate maculopathy egfr <45 ml/min/1.73m 2 or ACR>30 mg/mmol

30 Identification of patients at risk of diabetes complications

31 Identification of patients at risk of diabetes complications Aim in identifying early is to facilitate more CVD Risk Assessment CVD Risk Assessment for people with type 2 diabetes in New Zealand Age: 66 Duration of Diabetes: 10 years Sex: Male Female Smoker: Never smoked Total Cholesterol: 4.0 mmol/l HDL: 1.2 mmol/l Albuminuria: Normo Micro Macro 13/ 08/ :05 intensive intervention Systolic BP: 120 mmhg HbA1c 8.0 mmol/mol % Ethnicity: Eu ropean BP lowering medication: Yes No Unknown Calculate Reset and follow-up NZ CVD calculator: 5 year CVD 18.4 % Risk: 5 year MI Risk: 8.1 % Copy Pr int

32 CVD Risk Assessment 13/ 08/ :06 CVD Risk Assessment 13/ 08/ :06 CVD Risk Assessment for people with type 2 diabetes in New Zealand CVD Risk Assessment for people with type 2 diabetes in New Zealand Age: 66 Total Cholesterol: 4.0 mmol/l Age: 66 Total Cholesterol: 4.0 mmol/l Duration of Diabetes: 10 years HDL: 1.2 mmol/l Duration of Diabetes: 10 years HDL: 1.2 mmol/l Sex: Male Female Smoker: Never smoked Albuminuria: Normo Micro Macro Sex: Male Female Smoker: Never smoked Albuminuria: Normo Micro Macro Systolic BP: 120 mmhg HbA1c 8.0 mmol/mol % BP lowering medication: Yes No Unknown Systolic BP: 120 mmhg HbA1c 8.0 mmol/mol % BP lowering medication: Yes No Unknown Ethnicity: Eu ropean Calculate Reset Ethnicity: Eu ropean Calculate Reset 5 year CVD Risk: 21.7 % 5 year CVD Risk: 31.6 % 5 year MI Risk: 9.6 % Copy Pr int 5 year MI Risk: 14.5 % Copy Pr int

33 Management of hypertension and microalbuminuria Treatment of hypertension requires follow-up to monitor progress Not fire & forget ACEI or ARB should be started in the presence of albuminuria irrespective of the BP Elevated ACR on 2 out of 3 occasions in the absence of infection or contamination Aim to maximise the dose as BP allows Care in women of childbearing age

34 Management of lipids NZGG does not provide guidance other than targets TG <1.7 mmol/l TC <4.0 mmol/l Other guidelines differ (e.g. NICE, ADA etc.) A practical approach CV risk >15%

35

36 Diabetes care in 2020

37 Diabetes care demand Diabetes has no boundaries Increasing prevalence ,364,065: 237, ,666,547: 322,081 Appropriate expertise is required Differing expertise according to complexity

38 National Diabetes Nursing Knowledge & Skills Framework

39 The pyramid or spectrum of diabetes Complex e.g. Renal Ulcers/amputations Very high CV risk Severe hypoglycaemia/pumps Complicated e.g. Severe eye disease Early kidney disease Hypoglycaemia Pregnancy Challenging for patient & team Diabetic control Type 1 diabetes Young people Conventional but not for person with diabetes Type 2 diabetes (C) PL Drury April 2010

40 Pyramid getting bigger Life expectancy increasing Complexity increasing QoL improving Prevention of advancing complications Laser Rx ACE/BP Lipid Rx/Asp Podiatry Retinal screening ACR testing Podiatry CV risk Rx Get Checked (C) PL Drury April 2010

41 Recommendations Prevention & health promotion Service delivery Primary health care Acute & specialist services Retinal screening Renal services Information technology Targeted workforce development People with diabetes Quality improvement & assurance National oversight & monitoring

42 Diabetes workforce service review model of care capacity of PHC co-ordinated interdisciplinary services Efficient interface b/w general practice & community based prevention & management services, & specialist services access to & effectiveness of specialist services for specific problems Right person, right place, right time Clinical partnerships & collaborative MDT practice environments service quality guidelines, registers, recall

43 Supporting active self-care

44 Self care Lifestyle changes & maintenance Self-care for minor illness Managing long term conditions Options for self-care Self-management training in generic skills Self-management training in condition specific care

45 Perceived role expectations Nurses Discuss health concerns Translate treatment instructions Navigate through the complexities of self-care Doctors Making a diagnosis Treating Prescribing Ultimate decision maker

46 Different & complementary focus Doctors primary focus - clinical problems & solutions Medical assessment Address clinical issues & determine interventions? behaviour Nurses primary focus on functional health response Nursing assessment of presenting problems Behaviour & capability Consideration for context & complexities of life Plan interventions & implementation strategies

47 Implications for practice & models of care Ensure the synergistic utilisation of the full range of health care professionals across the health care continuum & in partnership with people with diabetes Clinical partnerships - acknowledge & maximise the different but complementary knowledge, skills & interpersonal styles to ensure people with diabetes receive a comprehensive package of care that is responsive to all of their needs Where-ever care is provided, clinical expertise is most effective when combined with attention to the person, mutuality & respect

48

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