Fifty years of diabetes management in primary care
|
|
- Scot Hunter
- 8 years ago
- Views:
Transcription
1 Fifty years of management in primary care MIKE KIRBY Abstract The incidence of has increased exponentially over the last 50 years, meaning that the management of solely by specialist healthcare professionals is no longer feasible. Since the 1970s, primary and community healthcare professionals have increasingly treated patients with. Advances in equipment and new treatments have further enabled patients to be treated more conveniently and this has enhanced their quality of life. There has also been an evolution in health service strategies for notably growing acknowledgement of the benefits of intensive treatment for patients with type 2, as well as type 1, and the now well-recognised importance of effective shared care programmes between primary and secondary healthcare professionals. Thus, the organisation and delivery of care for patients with has improved dramatically since Key words: shared care, primary care,, history. Introduction Fifty years ago patients with were mostly treated in hospitals by specialists, but the sharp rise in the prevalence of type 2 means that this is no longer practical. Since the 1970s increasing numbers of primary and community healthcare professionals in the UK have assumed responsibility for the routine review, monitoring and management of patients with. There are other reasons for the increased role of primary healthcare professionals in the shared care of contemporary management. New treatments and advances in monitoring and delivery devices have allowed more effective and flexible management strategies. Healthcare professionals are also increasingly aware of the importance of a patient s quality of life, and so attention has become focused on disease management that is more suited to patients lifestyles. Additionally, patients today expect to be actively involved in their treatment, are often Correspondence to: Dr Mike Kirby Director of Hertfordshire Primary Care Research Network (HeartNet), The Surgery, Nevells Road, Letchworth, Hertfordshire, SG6 4TS, UK. Tel: +44 (0) ; Fax: +44 (0) kirbym@globalnet.co.uk Br J Diabetes Vasc Dis 2002;2: Mike Kirby better informed and are less likely to accept advice unquestioningly from healthcare professionals. Hence, care has evolved and new concepts have been introduced. These include intensive therapy for patients with type 2, as well as for those with type 1. It is also appreciated now that is a cardiovascular disease and that a holistic approach to treating patients, including exercise and life-style changes, is essential to improving patients outcomes and well-being. This approach calls for the close involvement of primary care professionals and, therefore, the idea of shared care for patients between primary and secondary healthcare has gained renewed importance over recent years. Therapeutic advances Oral agents In the 1950s, sulphonylureas were the only oral antidiabetic agents for routine clinical use. They were associated with hypoglycaemia and weight gain, and the American University Group Diabetes Program (1970) suggested that sulphonylureas might aggravate cardiovascular complications. Biguanides entered routine use in the early 1960s, and while they did not cause hypoglycaemia or weight gain, the link with lactic acidosis and withdrawal of phenformin in the late 1970s restricted their use until the revival of metformin in the 1980s and 90s. In the 1990s, the alpha-glucosidase inhibitor acarbose, the metiglinides and the glitazones were introduced. Use of VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER
2 Figure 1. Modern self-monitoring of blood glucose (SMBG) meter Figure 2. Historical glass syringe Permission from Science Photo Library Permission from Science Photo Library acarbose was limited by gastrointestinal intolerance: metiglinides have been viewed as little more than short-acting sulphonylureas although there are subtle mechanistic differences; and glitazones are expensive, cause weight gain and fluid retention and are only as second-line agents. 1 However, these drugs offer a useful choice and should be used sooner rather than later. Insulin therapy Fifty years ago insulin therapy consisted of regular insulin and either neutral protamine Hagedorn (NPH) or the (then) recently Lente class of insulins. 2 All were derived from animals and NPH, Lente and Ultralente were chemically modified to be longer-acting than regular (soluble) insulin. Unfortunately injection regimens with these insulins do not reproduce the daily profile of endogenous insulin. In an attempt to match the physiological insulin profile commercially- mixtures of insulins were produced with different durations of action, and latterly short-acting and longacting insulin analogues have appeared. Other notable advances in insulin therapy, include the production of ultra-pure, monocomponent insulin in 1973, and the manufacture of human insulin in the 1980s using recombinant DNA technology. This allowed the mass production of human insulin and insulin analogues, and resulted in the near disappearance of porcine and bovine insulins. Intensive therapy for patients with type 1 and 2 The Diabetes Control and Complications Trial (DCCT) with type 1 and the United Kingdom Prospective Diabetes Study (UKPDS) with type 2 showed the benefits of tight glycaemic control, using early and intensive therapy, with near-normal glycaemic targets. 3,4 Although patients receiving intensive therapy significantly fewer diabetic complications than patients treated conventionally, both studies noted that intensive therapy caused significantly more treatment-related adverse events, particularly hypoglycaemia and weight gain. These side effects have limited the success of intensive therapy, although short- and long-acting insulin analogues have gone some way to addressing these concerns. Advances in monitoring and insulin delivery devices Blood glucose monitoring In the 1950s patients with had to visit their hospital to obtain accurate blood glucose tests. Urine glucose testing was possible at home, using the Benedict s test, but this was inaccurate and only gave positive results with very high glucose concentrations. Self monitoring of blood glucose (SMBG) meters first became in the UK in the 1970s. The early meters required a significant amount of blood. However, more advanced machines with easy-to-use strips and requiring little blood were soon (figure 1). In the 1980s and 1990s computerised SMBG meters were introduced. SMBG has empowered patients, helping them to take a more active part in their management and lead more normal lives. In the clinic, monitoring of glycaemic control has been greatly facilitated since the 1980s with the use of glycated haemoglobin (HbA 1 and HbA 1C ). Insulin delivery systems One drawback of insulin therapy is the need for injections. However, delivery systems have improved significantly over the last 50 years. In the 1950s syringes were made of glass and required rigorous and time-consuming cleaning between injections (figure 2). The needles themselves were large and made injections painful. Injection guns were as early as These were the size of revolvers and patients pulled triggers to insert the needle and inject the insulin. In the 1980s dis- 458 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
3 Figure 3. Insulin pens Figure 4. Timeline of evolution in therapies and equipment for management Evolution of management Sulphonylureas first used in UK Lente class of insulins introduced Metformin in UK Monocomponent insulin Insulin Recombinant metiglinides and glitazones glargine human insulin produced 2nd generation in the UK sulphonylureas Glimepiride - 3rd generation Insulin aspart sulphonylurea and lispro Three new classes of OHAs introduced: α-glucosidase inhibitors, Source: OptiPen range 2002 posable plastic syringes became in the UK. Insulin pens were in the 1980s, but were not included on the NHS prescription list until 2000 (figure 3). Not all insulins are yet in pen cartridges, and cartridges are not suitable for patients taking more than one form of insulin. Syringes despite being less convenient remain commonplace. Continuous subcutaneous insulin infusion (CSII) using insulin pumps are unlikely to be used by most patients because they are expensive and require a significant amount of patient education and motivation to monitor glucose concentrations consistently. 5 Injection guns First shared care scheme tried Table 1. Standard 1 SMBG meters introduced in the UK Disposable plastic syringes Computerised SMBG devices Changes to GP contracts for chronic disease management Selected National Service Framework Standards DCCT UKPDS NSF for Diabetes CSII pumps Some insulin pens included on NHS prescription list strategies to reduce the risk of developing type 2 and to reduce the inequalities in the risk of developing type 2 NO mediated anti-aggregation Progression in health service strategies The development of new treatment options and advances in monitoring and delivery equipment were important factors in the evolution of management (figure 4). The growing incidence and burden of type 2 has also contributed to change and has led to the recent development of a National Service Framework (NSF) for to outline expected standards for management. The NSF standards (table 1) were published late last year and their implementation is scheduled to commence by April Preventing and minimising the complications Programmes to prevent are essential. This demands a holistic approach to management through education initiatives that aim to change the lifestyles of at-risk patients. Diabetes is now recognised as a cardiovascular disease, with a focus being on weight reduction, improving diet and increasing physical activity. Indeed, even modest lifestyle changes can help to delay or prevent type 2. 6 The complications of have severe economic consequences, as well as majorly impacting on the lives of patients. The type 2 Diabetes Accounting for a Major Resource Demand In Society (T2ARDIS) study found that hospitalisation of patients with -associated complications accounts for approximately 41% of overall expenditure, compared with only 2% on Standard 2 Standard 3 Standard 4, 5 & 6 Standard 7 strategies to identify people who do not know they have All patients with will receive a service that encourages partnership in decision-making, supports them in managing their and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process All patients with will receive high-quality care, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of. All children will be supported to optimise their physical, psychological, intellectual, educational and social development. All young people with will experience a smooth transition of care from paediatric services to adult services, whether hospital- or community-based agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained healthcare professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER
4 drug therapy. The same study found that early intervention with intensive treatment strategies (as proposed by the UKPDS and DCCT) could cut the cost of by reducing the risk of complications and, therefore, hospitalisation. 7 To reduce the risk of complications of, the recently-published NICE guidelines for the management of type 2 recommended that: Each patient should be set an HbA 1C target of between 6.5% and 7.5%. Weight loss and increased physical activity should be encouraged in those who are overweight or obese. Healthcare professionals should work with individuals to develop beneficial lifestyle changes in combination with ongoing patient education. A combination of clinical and community-based programmes is needed to implement these health service strategies. Moreover, a collaborative team approach to managing, involving a broad range of healthcare professionals, is essential for these strategies to be put into practice successfully. This will include primary care in the community by GPs and by practice and community nurses who will monitor and review patients, secondary care by diabetologists and specialist nurses, as well as frontline emergency staff. The importance of shared care The high incidence of has necessitated a shift in the traditional relationship of specialist physician/patient relationship. GPs and practice nurses now play a pivotal role in care. The scale of the problem was underlined by a UK study examining the epidemiology of type 2 in the community, which found that of 1,122 individuals, 4.5% had previously undiagnosed and 16.7% had impaired glucose tolerance. 8 Shared care has been defined as "the joint participation of hospital consultants and GPs in the planned delivery of care for patients with a chronic condition". 9 However, this definition needs widening for as input from a broader range of healthcare professionals is required (figure 5). 10 The idea of shared care is not new. It was tried as early as 1953, when health visitors provided a link between hospital clinics and general practices, but the concept has subsequently evolved. General practice-based mini-clinics for started to appear in the early 1970s, but it was changes to the UK GP contract in 1990 and the institution of payment for chronic disease management in primary care in 1993 that really brought about the switch in focus. Today, over 90% of GPs claim fees for care. The aims for shared care programmes for should include early diagnosis, the identification and management of risk factors and diabetic complications, advice on diet, effective blood glucose control, prompt and appropriate referral for specialist advice and the continued education and motivation of patients. 10 The advantages of such initiatives are that they allow the flexible treatment of patients in familiar surroundings and provide a complete treatment approach rather than simply setting glycaemic targets. Potential disadvantages are that no single professional takes Figure 5. Algorithm of shared care schemes in the UK Optometrist Chiropodist Dietician Patient groups (e.g. DUK) Hospital centre Diabetes specialist nurse PATIENT GP and PCT District register Diabetologist and team (Figure 3.1 in Shared care for. Gatling, Hill and Kirby) Ophthalmologist and other specialists full responsibility and those in primary care are generally less accustomed to performing routine follow-up than those in outpatient settings. Additionally, primary care centres may lack the appropriate personnel, and staff may lack the expertise/specialist education to give optimal care. Several studies have investigated the efficacy of shared care for These concluded that good organisational structures for primary care clinics is essential, and it is important that GPs and practice nurses feel supported, and that care is truly shared between primary and secondary care, not simply shifted. A meta-analysis of the effectiveness of care in general practice found that well-organised practices, with computerised central recall and prompts for GPs and patients, achieved standards of care that were similar to or better than hospital care. The authors noted, however, that unstructured primary care is associated with poorer glycaemic control and greater mortality than hospital care. 11 A recent study found that 80% of practices now feel adequately supported and that most have good organisational practices. However, the same study found that more work needs to be done to ensure seamless care across the primary secondary care interface, and suggested the establishment of shared treatment protocols. 12 Similar findings and suggestions were reported by Greenhalgh in her systematic review of shared care programmes, finding them effective only if the system includes a register for patient monitoring, protected time for care, a practice nurse with some experience, a written protocol agreed with the local consultant diabetologist and a system for auditing standards of care. 13 Conclusions The increasing incidence of means that its effective management has become a priority for healthcare professionals and has led to most people with now being treated in general practice rather than hospital outpatient clinics. Advances in equipment and treatments over the last 50 years 460 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
5 Key messages Over the last 50 years the increasing prevalence of has necessitated a switch in focus from secondary to primary care disease management New therapeutic agents and advances in monitoring and delivery systems have also allowed this evolution in management The benefits of early and intensive therapy for patients with type 1 and type 2 are increasingly recognised Diabetes is now appreciated as a cardiovascular disease, as is the importance of risk factor management, especially blood pressure control and lipid management The benefits of a collaborative team approach and sharing of care for patients with between primary and secondary care is widely acknowledged Shared treatment protocols, good organisational structures and auditing are essential to ensure seamless care across the primary secondary care interface have also contributed to this evolution in management and the application of new concepts. These include the increasing recognition of the benefits of intensive therapy for patients with type 2, as well as those with type 1 disease. Additionally, the importance of shared care for is now recognised, as is the need for organisational structures that ensure these programmes are implemented and managed effectively. Diabetes management has changed markedly since 1952 and the next 50 years also promises to see innovative treatments, strategies, and perhaps a cure, for. Editor s note Mike Kirby epitomises the new face of primary care commitment to shared care management. His career has enveloped a wealth of experience within hospital and general practice, enabling a clear perspective on the evolution of current organisational structures for care. References 1. Gale E. Lessons from the glitazones: a story of drug development. Lancet 2001;357: Owens DR, Zinman B, Bolli GB. Insulins today and beyond. Lancet 2001;358: UK Prospective Diabetes Study (UKPDS) Group 33. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2. Lancet 1998;352: Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of on the development and progression of long-term complications in insulin-dependent mellitus. N Engl J Med 1993;329: Rosenstock J. Insulin therapy: Optimising control in type 1 and type 2. Clin Cornerstone 2001;4: Narayan KM, Bowman BA, Engelgau ME. Prevention of type 2. BMJ 2001;323: Type 2 Diabetes Accounting for a Major Resource Demand In Society. Diabetes UK Ref Type: Electronic Citation. 8. Williams DRR, Wareham NJ, Wareham NJ et al. Undiagnosed glucose intolerance in the community: the Isle of Ely project. Diabet Med 1995;12: Hickman M, Drummond N, Grimshaw J. The operation of shared care for chronic disease. Health Bull 1994;52: Gatling W, Hill R, Kirby M. The shared care concept. Shared care for. Oxford: Isis Medical Media Ltd, 1999: Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials. BMJ 1998;317: Pierce M, Agarwal G, Ridout D. A survey of care in general practice in England and Wales. Br J Gen Pract 2000;50: Greenhalgh PM. Shared care for. A systematic review. 67, The Royal College of General Practitioners. Ref Type: Report. VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER
SHORT CLINICAL GUIDELINE SCOPE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SHORT CLINICAL GUIDELINE SCOPE 1 Guideline title Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes 1.1 Short title Type 2
More informationPrescribing for Diabetes in England - An Update: 2002-2008 An analysis of volume, expenditure and trends
Prescribing for Diabetes in England - An Update: 2002-2008 An analysis of volume, expenditure and trends June 2009 diabetes Health Intelligence YHPHO YORKSHIRE & HUMBER PUBLIC HEALTH OBSERVATORY Diabetes
More information4. Does your PCT provide structured education programmes for people with type 2 diabetes?
PCT Prescribing Report Drugs used in Type 2 Diabetes Discussion Points 1. Does your PCT have a strategy for prevention of type 2 diabetes? Does your PCT provide the sort of intensive multifactorial lifestyle
More informationClinical and cost-effectiveness of continuous subcutaneous insulin infusion therapy in diabetes.
PROTOCOL Clinical and cost-effectiveness of continuous subcutaneous insulin infusion therapy in diabetes. A. This the revised protocol (April 2002) B. Review team Contact for correspondence: Dr Jill Colquitt
More informationJill Malcolm, Karen Moir
Evaluation of Fife- DICE: Type 2 diabetes insulin conversion Article points 1. Fife-DICE is an insulin conversion group education programme. 2. People with greater than 7.5% on maximum oral therapy are
More informationSelf-Monitoring Of Blood Glucose (SMBG)
Self-Monitoring Of Blood Glucose (SMBG) Aim(s) and objective(s) It is important is to ensure that people with Diabetes are given the opportunity to self monitor their blood glucose appropriately as an
More informationScottish Medicines Consortium
Scottish Medicines Consortium insulin glulisine for subcutaneous injection 100 units/ml (Apidra ) No. (298/06) Sanofi Aventis 4 August 2006 The Scottish Medicines Consortium (SMC) has completed its assessment
More informationAre insulin analogs worth their cost in type 2 diabetes?
Keystone, Colorado 2012 Are insulin analogs worth their cost in type 2 diabetes? Dr. Amanda Adler Consultant Physician, Institute of Metabolic Sciences Addenbrooke s Hospital, Cambridge Chair, Technology
More informationCochrane Quality and Productivity topics
Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus NICE has developed the Cochrane Quality and Productivity (QP) topics to help the NHS identify practices
More informationGlycaemic Control in Adults with Type 1 Diabetes
Glycaemic Control in Adults with Type 1 Diabetes Aim(s) and objective(s) This document aims to provide guidance on good clinical practice in managing glycaemic control in adult patients with Type 1 Diabetes
More informationInsulin initiation in type 2 diabetes: Experience and insights
Insulin initiation in type 2 diabetes: Experience and insights Joan Everett A diagnosis of type 2 diabetes can be devastating for the individual and their family. Furthermore, many people with diabetes
More informationDiabetes Subcommittee of PTAC meeting. held 18 June 2008. (minutes for web publishing)
Diabetes Subcommittee of PTAC meeting held 18 June 2008 (minutes for web publishing) Diabetes Subcommittee minutes are published in accordance with the Terms of Reference for the Pharmacology and Therapeutics
More informationImproving access to insulin pump therapy: The role of the Insulin Pump Network
Article Improving access to insulin pump therapy: The role of the Insulin Pump Network Peter Hammond Citation: Hammond, P (2013) Improving access to insulin pump therapy: The role of the Insulin Pump Network.
More informationTrends in Prescribing of Drugs for Type 2 Diabetes in General Practice in England (Chart 1) Other intermediate and long-acting insulins
Type 2 Diabetes Type 2 diabetes is the most common form of diabetes, accounting for 90 95% of cases. 1 Charts 1 and 2 reflect the effect of increasing prevalence on prescribing and costs of products used
More informationPrior Authorization Guideline
Prior Authorization Guideline Guideline: PC (CO) - Insulin Delivery Systems Therapeutic Class: Hormones and Synthetic Substitutes Therapeutic Sub-Class: Insulin Delivery Systems Client: CO Approval Date:
More informationInsulin Pump Therapy for Type 1 Diabetes
Insulin Pump Therapy for Type 1 Diabetes Aim(s) and objective(s) This guideline has been developed to describe which patients with Type 1 Diabetes should be referred for assessment for insulin pump therapy
More informationStandard 7. Key practice points. What the quality statement means for each audience
Standard 7 When insulin is required it should be initiated by trained health care professionals within a structured programme that, whenever possible, includes education in dose titration for the person
More informationHumulin R (U500) insulin: Prescribing Guidance
Leeds Humulin R (U500) insulin: Prescribing Guidance Amber Drug Level 2 We have started your patient on Humulin R (U500) insulin for the treatment of diabetic patients with marked insulin resistance requiring
More informationThese competences are designed to reflect what you are doing in your current practice and to help you identify any learning needs you may have.
DIABETES COMPETENCES FOR COMMUNITY NURSES This document has been developed in conjunction with the Diabetes Link Nurses and Diabetes Nurse Specialists working in, and for, Lothian Health Board. These competences
More informationPolicy For The Adjustment Of Insulin Dose For Patients With Diabetes By Diabetes Specialist Dietitians And Cystic Fibrosis Dietitians In NHS Grampian
Policy For The Adjustment Of Insulin Dose For Patients With Diabetes By Diabetes Specialist Dietitians And Cystic Fibrosis Dietitians In NHS Grampian Co-ordinators: Advanced Dietitian (Diabetes) Consultation
More informationPrescribing for Diabetes. England 2005-06 to 2013-14
Prescribing for Diabetes England 2005-06 to 2013-14 Published 12 August 2014 We are the trusted national provider of high-quality information, data and IT systems for health and social care. www.hscic.gov.uk
More informationSubmission by the Irish Pharmacy Union to the Department of Health on the Scope for Private Health Insurance to incorporate Additional Primary Care
Submission by the Irish Pharmacy Union to the Department of Health on the Scope for Private Health Insurance to incorporate Additional Primary Care Services January 2015 1 IPU Submission to the Department
More informationDiabetes and insulin therapy in older people
Hendra p 19-23 21/03/2005 14:58 Page 1 Diabetes and insulin therapy in older people TIMOTHY J HENDRA Abstract Concerns about hypoglycaemia, plus lack of evidence of benefit, contributed to underutilisation
More informationWorkshop A Tara Kadis
Workshop A Tara Kadis Considerations/barriers in decision making about insulin verses GLP-1 use in people with type 2 diabetes Which Insulin regimes should we consider? Diabetes is a progressive multi-system
More informationHealth Technology Appraisal- Continuous subcutaneous insulin infusion for the treatment of diabetes (review)
Health Technology Appraisal- Continuous subcutaneous insulin infusion for the treatment of diabetes (review) Submission on behalf of British Dietetic Association (BDA) Following consultation with the BDA
More informationThe table below logs the history of the steps in development of the document.
Paediatric Insulin Pumps Version: 0.4 Committee Approved by: Clinical Cabinet Date Approved 5 February 2014 Author: Responsible Directorate: Janet Wilson Strategy and Commissioning (Children s) Date issued:
More informationDiabetes: Factsheet. Tower Hamlets Joint Strategic Needs Assessment 2010-2011. Executive Summary. Recommendations
Diabetes: Factsheet Tower Hamlets Joint Strategic Needs Assessment 2010-2011 Executive Summary Diabetes is a long term condition that affects 11,859 people in Tower Hamlets, as a result of high levels
More informationPrescribing for Diabetes, England 2005-06 to 2012-13
Prescribing for Diabetes, England 2005-06 to 2012-13 Published 13 August 2013 This product is relevant to members of the public and other stakeholders to support the understanding of primary care prescribing
More informationGlobal Guideline for Type 2 Diabetes
INTERNATIONAL DIABETES FEDERATION, 2005 Clinical Guidelines Task Force Global Guideline for Type 2 Diabetes Chapter 10: Glucose control: insulin therapy Copyright All rights reserved. No part of this publication
More informationMy Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started. Combination Therapy
My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started Combination Therapy How Can Combination Therapy Help My Type 2 Diabetes? When you have type 2 diabetes,
More informationUnderstanding diabetes Do the recent trials help?
Understanding diabetes Do the recent trials help? Dr Geoffrey Robb Consultant Physician and Diabetologist CMO RGA UK Services and Partnership Assurance AMUS 25 th March 2010 The security of experience.
More informationSample Service Specifications
Sample Service Specifications SSS 1: Care of people with diabetes as part of essential services Service Description Certain aspects of diabetes care fall within the essential services element of the community
More informationLead Clinician(S) (DATE) Approved by Diabetes Directorate on: Approved by Medicines Safety Group on: This guideline should not be used after end of:
Guideline for members of the diabetes team and dietetic department for advising on insulin dose adjustment and teaching the skills of insulin dose adjustment to adults with type 1 or type 2 diabetes mellitus
More informationBritish Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Self-Monitoring of Blood Glucose in Type 2 Diabetes
British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Self-Monitoring of Blood Glucose in Type 2 Diabetes Introduction Self-monitoring of blood glucose (SMBG) is in widespread use among
More informationType 2 Diabetes workshop notes
Group 1 notes Abi / Nicole Type 2 Diabetes workshop notes 4.1 Population The group discussed the following sub groups that may need addressing: Men-as they tend to die earlier compared with women, their
More informationBritni Hebert, MD PGY-1
Britni Hebert, MD PGY-1 Importance of Diabetes treatment Types of treatment Comparison of treatment/article Review Summary Example cases 1 out of 13 Americans have diabetes Complications include blindness,
More informationType 2 diabetes is a progressive. status
Type 2 diabetes is a progressive disease: its treatment the current status Associate Professor Jonathan Shaw Why is type 2 diabetes so hard to treat? How to choose the right glucose-lowering g drug? Page
More informationINSULIN PRODUCTS. Jack DeRuiter
INSULIN PRODUCTS Jack DeRuiter The number and types of insulin preparations available in the United States is constantly changing, thus students should refer to recent drug resources for a current list
More informationDiabetes. C:\Documents and Settings\wiscs\Local Settings\Temp\Diabetes May02revised.doc Page 1 of 12
Diabetes Introduction The attached paper is adapted from the initial background paper on Diabetes presented to the Capital and Coast District Health Board Community and Public Health Advisory Committee
More informationINSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT
INSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT APIRADEE SRIWIJITKAMOL DIVISION OF ENDOCRINOLOGY AND METABOLISM DEPARTMENT OF MEDICINE FACULTY OF MEDICINE SIRIRAJ HOSPITOL QUESTION 1 1. ท านเคยเป นแพทย
More informationReview of diabetes care in London Health and Environment Committee
The London Assembly s Health and Environment Committee intends to review diabetes care in London. Aim of review The purpose of this review is for the Committee to understand the extent of diabetes prevalence
More informationEveryday Practice: Diabetes Mellitus
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 20, NO. 5, 2007 245 Everyday Practice: Diabetes Mellitus Insulin therapy for patients with type 2 diabetes mellitus NISHA R. S., E. BHATIA INTRODUCTION India
More informationPresent and Future of Insulin Therapy: Research Rationale for New Insulins
Present and Future of Insulin Therapy: Research Rationale for New Insulins Current insulin analogues represent an important advance over human insulins, but clinically important limitations of these agents
More informationInsulin myths and facts
london medicines evaluation network Insulin myths and facts Statement 1 Insulin is the last resort for patients with Type 2 diabetes After initial metformin and sulfonylurea therapy, NICE and SIGN suggest
More informationGuideline for the Administration of Insulin by Nursing Staff
Guideline for the Administration of Insulin by Nursing Staff Aims and objectives In Lanarkshire the number of people with Diabetes on insulin treatment is growing, as both the population ages and people
More informationTraditionally, patients newly
Primary/secondary care interface Nurse-led management of newly diagnosed type 2 diabetes Joan Everett and David Kerr Article points 1The diagnosis of diabetes can have a profound psychological impact upon
More informationtrends in the treatment of Diabetes type 2 - New classes of antidiabetic drugs. IAIM, 2015; 2(4): 223-
Review Article Pharmacological trends in the treatment of Diabetes type 2 - New classes of antidiabetic Silvia Mihailova 1*, Antoaneta Tsvetkova 1, Anna Todorova 2 1 Assistant Pharmacist, Education and
More informationCOST ANALYSIS OF ANTIDIABETIC DRUGS FOR DIABETES MELLITUS OUTPATIENT IN KODYA YOGYAKARTA HOSPITAL
Malaysian Journal of Pharmaceutical Sciences, Vol. 5, No. 1, 19 23 (2007) COST ANALYSIS OF ANTIDIABETIC DRUGS FOR DIABETES MELLITUS OUTPATIENT IN KODYA YOGYAKARTA HOSPITAL TRI MURTI ANDAYANI* AND IKE IMANINGSIH
More informationAlert. Patient safety alert. Actions that can make anticoagulant therapy safer. 28 March 2007. Action for the NHS and the independent sector
Patient safety alert 18 Alert 28 March 2007 Immediate action Action Update Information request Ref: NPSA/2007/18 4 Actions that can make anticoagulant therapy safer Anticoagulants are one of the classes
More informationPrimary prevention of chronic kidney disease: managing diabetes mellitus to reduce the risk of progression to CKD
Primary prevention of chronic kidney disease: managing diabetes mellitus to reduce the risk of progression to CKD Date written: July 2012 Author: Kate Wiggins, Graeme Turner, David Johnson GUIDELINES We
More informationInsulin therapy in various type 1 diabetes patients workshop
Insulin therapy in various type 1 diabetes patients workshop Bruce H.R. Wolffenbuttel, MD PhD Dept of Endocrinology, UMC Groningen website: www.umcg.net & www.gmed.nl Twitter: @bhrw Case no. 1 Male of
More informationSection 5: Type 2 Diabetes
SECTION OVERVIEW Definition and Symptoms Blood Glucose Monitoring Healthy Eating Physical Activity Oral Medication Insulin Sharps Disposal Definition and Symptoms Type 2 diabetes is occurring more frequently
More informationTherapy Insulin Practical guide to Health Care Providers Quick Reference F Diabetes Mellitus in Type 2
Ministry of Health, Malaysia 2010 First published March 2011 Perkhidmatan Diabetes dan Endokrinologi Kementerian Kesihatan Malaysia Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus Quick
More informationInsulin Dependent Diabetes Trust
Insulin Dependent Diabetes Trust Type 2 and You Issue 4 - July 2010 Registered Company Number 3148360 Registered Charity No 1058284 Welcome to the fourth issue of Type 2 and You. In this issue we look
More informationMaking the case for insulin pump therapy
T Ulahannan*, NN Myint, KF Lonnen Introduction Previously used economic models of continuous subcutaneous insulin infusion (CSII/insulin pump therapy) projected long-term costs and outcomes compared to
More informationWhat is DIABETES? Gwen Hall Diabetes Specialist Nurse, Community Diabetes Services Portsmouth, Primary Care Team.
What is DIABETES? By: Gwen Hall Diabetes Specialist Nurse, Community Diabetes Services Portsmouth, Primary Care Team. WHAT IS DIABETES? What is diabetes? In simple terms diabetes prevents your body converting
More informationIMPROVED METABOLIC CONTROL WITH A FAVORABLE WEIGHT PROFILE IN PATIENTS WITH TYPE 2 DIABETES TREATED WITH INSULIN GLARGINE (LANTUS ) IN CLINICAL
464 IMPROVED METABOLIC CONTROL WITH A FAVORABLE WEIGHT PROFILE IN PATIENTS WITH TYPE 2 DIABETES TREATED WITH INSULIN GLARGINE (LANTUS ) IN CLINICAL PRACTICE STEPHAN A SCHREIBER AND ANIKA RUßMAN ABSTRACT
More informationDiagnosis, classification and prevention of diabetes
Diagnosis, classification and prevention of diabetes Section 1 1 of 4 Curriculum Module II 1 Diagnosis, classification and presentation of diabetes Slide 2 of 48 Polyurea Definition of diabetes Slide 3
More informationPrior Authorization Guideline
Prior Authorization Guideline Guideline: PC - Apidra, Levemir Therapeutic Class: Hormones and Synthetic Substitutes Therapeutic Sub-Class: Antidiabetic Agents Client: CA, CO, NV, OK, OR, WA and AZ Approval
More informationHSE Transformation Programme. to enable people live healthier and more fulfilled lives. Easy Access-public confidence- staff pride
HSE Transformation Programme. to enable people live healthier and more fulfilled lives Easy Access-public confidence- staff pride The Health Service Executive 4.1 Chronic Illness Framework July 2008 1
More informationNATIONAL INSTITUTE FOR CLINICAL EXCELLENCE. Final Appraisal Determination. Patient-education models for diabetes
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE 1 Guidance 1.1 It is recommended that structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as
More informationNational Assembly for Wales: Health and Social Care Committee
2 Ashtree Court, Woodsy Close Cardiff Gate Business Park Cardiff CF23 8RW Tel: 029 2073 0310 wales@rpharms.com www.rpharms.com 18 th October 2011 Submission to: Call for Evidence: Response from: National
More informationDiabetes Complications
Managing Diabetes: It s s Not Easy But It s s Worth It Presenter Disclosures W. Lee Ball, Jr., OD, FAAO (1) The following personal financial relationships with commercial interests relevant to this presentation
More informationSecond- and Third-Line Approaches for Type 2 Diabetes Workgroup: Topic Brief
Second- and Third-Line Approaches for Type 2 Diabetes Workgroup: Topic Brief March 7, 2016 Session Objective: The objective of this workshop is to assess the value of undertaking comparative effectiveness
More informationUnderstanding and Managing Type 2 Diabetes
VEA Bringing Learning to Life Program Support Notes Understanding and Managing Type 2 Diabetes Professional Development 32mins Teacher Notes by Anne Hill, Nurse Educator Produced by VEA Pty Ltd Commissioning
More informationInsulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults
Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults Stock # 45-11647 Revised 10/28/10 Glycemic Goals 1,2 Individualize goal based on patient risk factors A1c 6%
More informationGuidance for Industry Diabetes Mellitus Evaluating Cardiovascular Risk in New Antidiabetic Therapies to Treat Type 2 Diabetes
Guidance for Industry Diabetes Mellitus Evaluating Cardiovascular Risk in New Antidiabetic Therapies to Treat Type 2 Diabetes U.S. Department of Health and Human Services Food and Drug Administration Center
More informationInsulin T Y P E 1 T Y P E 2
T Y P E 1 T Y P E 2 INSULIN There are many different insulins for many different situations and lifestyles. This section should help you and your doctor decide which insulin or insulins are best for you.
More informationWhat the quality statement means for each audience
Standard 17 All patients with type 1 diabetes should have access to an experienced multidisciplinary team, including expertise in insulin pumps and continuous glucose monitoring (CGMS) when required. Key
More informationThe Economic Impact and Cost-Effectiveness of Glucose Monitoring
The Economic Impact and Cost-Effectiveness of Glucose Monitoring William H. Herman, MD, MPH Stefan S. Fajans/GlaxoSmithKline Professor of Diabetes Professor of Internal Medicine and Epidemiology University
More informationINSULIN ALGORITHM FOR TYPE 2 DIABETES MELLITUS IN CHILDREN 1 AND ADULTS
Publication # 45-11647 Targets*
More informationInsulin Safety. The safe use of insulin and you. Patient Information Booklet
Insulin Safety The safe use of insulin and you The Right insulin The Right dose The Right way The Right time Hypoglycaemia Diabetes Patient Information Booklet Adapted from the National Patient Safety
More informationAn Overview of Medicare Covered Diabetes Supplies and Services
News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside
More informationEvaluation of: The Local Enhanced Service provision of for Managing Diabetes Injectable Therapies
Evaluation of: The Local Enhanced Service provision of for Managing Diabetes Injectable Therapies Two CCGs have asked the WSYBCSU to evaluate the current Local Enhanced Service (LES) provision in this
More informationTake a moment Confer with your neighbour And try to solve the following word picture puzzle slides.
Take a moment Confer with your neighbour And try to solve the following word picture puzzle slides. Example: = Head Over Heels Take a moment Confer with your neighbour And try to solve the following word
More informationCLASS OBJECTIVES. Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies
Insulins CLASS OBJECTIVES Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies INVENTION OF INSULIN 1921 The first stills used to make insulin
More informationWhen and how to start insulin: strategies for success in type 2 diabetes
1 When and how to start insulin: strategies for success in type diabetes Treatment of type diabetes in 199: with each step treatment gets more complex Bruce H.R. Wolffenbuttel, MD PhD Professor of Endocrinology
More informationNational Diabetes Inpatient Audit
National Diabetes Inpatient Audit 2013 We are the trusted source of authoritative data and information relating to health and care. www.hscic.gov.uk enquiries@hscic.gov.uk Prepared in collaboration with:
More informationUniversity of Warwick institutional repository: http://go.warwick.ac.uk/wrap
University of Warwick institutional repository: http://go.warwick.ac.uk/wrap This paper is made available online in accordance with publisher policies. Please scroll down to view the document itself. Please
More informationType 2 Diabetes. Management and Medication. HELPLINE: 01604 622837 www.iddtinternational.org
I N D E P E N D E N T D I A B E T E S T R U S T Type 2 Diabetes Management and Medication A charity supporting and listening to people who live with diabetes HELPLINE: 01604 622837 www.iddtinternational.org
More informationUCB. Certolizumab pegol (CIMZIA ) for the treatment of Rheumatoid Arthritis PATIENT ACCESS SCHEME (PAS) SUBMISSION TO NICE
UCB Certolizumab pegol (CIMZIA ) for the treatment of Rheumatoid Arthritis PATIENT ACCESS SCHEME (PAS) SUBMISSION TO NICE July 23 d 2009 1 Executive summary UCB have proposed a patient access scheme (PAS)
More informationCASE B1. Newly Diagnosed T2DM in Patient with Prior MI
Newly Diagnosed T2DM in Patient with Prior MI 1 Our case involves a gentleman with acute myocardial infarction who is newly discovered to have type 2 diabetes. 2 One question is whether anti-hyperglycemic
More informationInsulin Therapy and Patient Choice - Study Update
Insulin study series: The Wessex Starting Insulin Study: practicalities of initiating insulin Jill Rodgers Article points The delivery system used for initiation of insulin therapy varied according to
More informationINSULINThere are. T y p e 1 T y p e 2. many different insulins for
T y p e 1 T y p e 2 INSULINThere are many different insulins for Characteristics The three characteristics of insulin are: Onset. The length of time before insulin reaches the bloodstream and begins lowering
More informationECONOMIC COSTS OF PHYSICAL INACTIVITY
ECONOMIC COSTS OF PHYSICAL INACTIVITY This fact sheet highlights the prevalence and health-consequences of physical inactivity and summarises some of the key facts and figures on the economic costs of
More informationThis information explains the advice about type 2 diabetes in adults that is set out in NICE guideline NG28.
Information for the public Published: 2 December 2015 nice.org.uk About this information NICE guidelines provide advice on the care and support that should be offered to people who use health and care
More informationInsulin pump therapy aiming for better blood glucose control in people with type 1 diabetes
Insulin pump therapy aiming for better blood glucose control in people with type 1 diabetes The Guy s and St Thomas NHS Foundation Trust insulin pump service is provided by a multidisciplinary team consisting
More informationSuccessfully starting insulin therapy in Primary Care
Successfully starting insulin therapy in Primary Care May 2014 Lorna Bingham Nurse Practitioner Candidate Endocrine, Diabetes & Research Centre Capital and Coast District Health Board lorna.bingham@ccdhb.org.nz
More informationWHAT CAN I DO TO REDUCE MY RISK OF DEVELOPING THE COMPLICATIONS OF TYPE 1 DIABETES?
Christian In better control with his pump since 2012 WHAT CAN I DO TO REDUCE MY RISK OF DEVELOPING THE COMPLICATIONS OF TYPE 1 DIABETES? Many people with Type 1 diabetes worry about potential long-term
More informationType 2 Diabetes. What is diabetes? Understanding blood glucose and insulin. What is Type 2 diabetes? Page 1 of 5
Page 1 of 5 Type 2 Diabetes Type 2 diabetes occurs mainly in people aged over 40. The 'first-line' treatment is diet, weight control and physical activity. If the blood glucose level remains high despite
More informationThe management of adult diabetes services in the NHS: progress review
Report by the Comptroller and Auditor General Department of Health and NHS England The management of adult diabetes services in the NHS: progress review HC 489 SESSION 2015-16 21 OCTOBER 2015 Our vision
More informationService Specification Template Department of Health, updated June 2015
Service Specification Template Department of Health, updated June 2015 Service Specification No. : 2 Service: Commissioner Lead: Provider Lead: Period: Anti-coagulation monitoring Date of Review: 31 st
More informationAn estimated 280 Australians develop diabetes every day. It is Australia s fastest-growing chronic disease.
Diabetes and insulin Summary Even with the help of your doctor and diabetes nurse educator, it may take a while to find the right insulin dose to reduce your blood glucose to your target levels. Insulin
More informationMeasuring and Improving the Quality of Diabetes care in General Practice. Dr M Grixti. Dr C Scalpello, Dr C Mercieca, Dr P Mangion, Dr T O Sullivan
Measuring and Improving the Quality of Diabetes care in General Practice Dr M Grixti. Dr C Scalpello, Dr C Mercieca, Dr P Mangion, Dr T O Sullivan Outline of presentation Statistics Diabetes care,as the
More informationInsulin switch & Algorithms Rotorua GP CME June 2011. Kingsley Nirmalaraj FRACP Endocrinologist BOPDHB
Insulin switch & Algorithms Rotorua GP CME June 2011 Kingsley Nirmalaraj FRACP Endocrinologist BOPDHB Goal of workshop Insulin switching make the necessary move Ensure participants are confident with Recognising
More informationCHAPTER V DISCUSSION. normal life provided they keep their diabetes under control. Life style modifications
CHAPTER V DISCUSSION Background Diabetes mellitus is a chronic condition but people with diabetes can lead a normal life provided they keep their diabetes under control. Life style modifications (LSM)
More informationGuideline for Insulin Therapeutic Review in patients with Type 2 Diabetes
Diabetes Sans Frontières Guideline for Insulin Therapeutic Review in patients with Type 2 Diabetes 1. Introduction This guideline has been developed in order to support practices to undertake insulin therapeutic
More informationTreating Patients with PRE-DIABETES David Doriguzzi, PA-C First Valley Medical Group. Learning Objectives. Background. CAPA 2015 Annual Conference
Treating Patients with PRE-DIABETES David Doriguzzi, PA-C First Valley Medical Group Learning Objectives To accurately make the diagnosis of pre-diabetes/metabolic syndrome To understand the prevalence
More informationINJEX Self Study Program Part 1
INJEX Self Study Program Part 1 What is Diabetes? Diabetes is a disease in which the body does not produce or properly use insulin. Diabetes is a disorder of metabolism -- the way our bodies use digested
More informationInsulin Pump Therapy during Pregnancy and Birth
Approvals: Specialist Group: Miss F Ashworth, Dr I Gallen, Dr J Ahmed Maternity Guidelines Group: V1 Dec 2012 Directorate Board: V1 Jan 2013 Clinical Guidelines Subgroup: July 2011 MSLC: V1 Nov 2012 Equality
More information