Diabetes Update for registrarsPART 1- Type 2 Diabetes-an overview

C McNamara

Learning objectives:

Understand progressive nature of DM Aim for early diagnosis & patient empowerment –

(better self-management) Screen for complications (and treat if +ve) Optimise function (ie. keep patients well and

informed) Understand treatments, how to uptitrate and move

to insulin where necessary Understand the difference between Type 1 & Type 2

DM

Progressive Decline of B Cell Function in UKPDS

0

20

40

60

80

100

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Years

B C

ell

Fu

nc

tio

n %

““Insulin Insulin Resistance Resistance

unchanged”unchanged”

““50% of patients 50% of patients need insulin after need insulin after

6 years6 years””

DiagnosisDiagnosis

Progressive Decline of Progressive Decline of B Cell Function in UKPDSB Cell Function in UKPDS

0

20

40

60

80

100

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Years

B C

ell

Fu

nc

tio

n %

““Insulin Insulin Resistance Resistance unchangedunchanged””

““50% of patients 50% of patients need insulin after need insulin after

6 years6 years””

DiagnosisDiagnosis

Type 2 Diabetes

A growing epidemic

Approximately 200,000 in New Zealand

and 25,000 plus in WDHB. 5% in European NZ 10-13% in Maori and Pacific Island people.

A growing epidemicApproximately 180,000 in New Zealandand 20,000 plus in WDHB.

Risk factors for Type 2 Diabetes

Ethnicity- twice as common in Maori, Pacific Island and Indian (South-East Asian)

Positive family history Obesity and sedentary life-style Mainly occurs at age>50y BUT THE OBESITY

EPIDEMIC IS MAKING TYPE 2 DIABETES COMMON IN KIDS.

Evidence of other vascular risk factors

What to do following a screening test for

type 2 diabetes Result Action

HbA1c ≥ 50mmol/mol and, if measured, Fasting glucose ≥7.0 mmol/L Or Random blood glucose ≥11.1mmol/L

No further tests required Diabetes is confirmed

Symptomatic

What to do following a screening test for type 2

diabetes Result Action

HbA1c ≥ 50mmol/mol and, if measured, Fasting glucose ≥7.0 mmol/L Or Random blood glucose ≥11.1mmol/L

Repeat HbA1c or a fasting plasma glucose

Two results above the diagnostic cut-offs, on separate occasions are required for the diagnosis of diabetes*

asymptomatic

Prediabetes?

Result Action

HbA1c 41-49 mmol/mol and, if measured, Fasting glucose 6.1–6.9 mmol/L

Advise on diet and lifestyle Redo test in 6-12 m

Results indicate ‘pre-diabetes’ or impaired fasting glucose

asymptomatic

HbA1c reporting (% to mmol/mol)

NPS

Prevention and early detectionLifestyle Education and support:(see www.nzssd.org.nz)

•Self Management education(DSME)•Smoking cessation•Dietary advice•Exercise/Green RX•Family support •Psychological support•Dental Health•Diabetes NZ Support Groups

DIAGNOSIS(HbA1c>50mmol/mol)

(see www.nzssd.org.nz for guidelines)

WEIGHT

Target BMI <28(or 5-10% weight loss)

Dietitian

Refer: Consider bariatric surgery if BMI > 35

LIPIDS

Target TG <1.7; LDL < 2Total <4; HDL>1 Statin Combine withezetimibe or nicotinicacid if predominately hypercholesterolaemia

Combine with fibrate if predominately hypertriglyceridaemia

CV Risk >15%:consider aspirin, statinand antihypertensive

Refer: If not attaining targets despite dietician and maximal therapy

GLYCAEMIC CONTROL

Target 50 –60mmol/mol (but individualise) Metformin (caution if eGFR < 40 and stop if eGFR<30) Add Sulphonylureas (or pioglitazone or gliptin if not tolerated) See useful tips

Insulin (see Insulin initiation algorithm)

Refer: If unable to initiate insulin or target not reached within 3 - 4months

RENAL FUNCTION

Micro/ macro albumniuria or low eGFR for age ACEI or ARB initially targetting BP

Consider Intrinsic renal disease or raised BP if not improving and no retinopathyRefer: •eGFR < 60 and age <50years•eGFR < 40 •20% reduction eGFR over 3 months Progressive increase in ACR on therapy•BP target not achieved with multiple agents

FOOT CARE NEUROPATHY

Annual foot check

Refer Podiatrist for at risk/high risk foot:Previous amputation, ulcers or Charcot footPeripheral arterial diseasePeripheral neuropathy Foot deformity,significant callous formation orpreulcerative lesions

Refer to High risk Foot clinic and/or relevant speciality:Active ulcerationSuspected CharcotNon-responsive painful peripheral neuropathyUrgent admission:Severe or spreading infectionCritical limb ischaemia

BLOOD PRESSURE

Target usually < 130/80(but individualise)

ACEI or ARB Add calcium channel blocker (CCB), thiazide diuretic orchlorthalidone Add another thiazide diuretic or CCB Add one of: alpha, beta blocker or potassium sparing diuretic Add another of above Refer:BP targets not reached on multiple agents Associated diabetes nephropathy

EYE CARE 2 yearly retinal screening if no retinopathy

1 yearly retinal check for those with retinopathy (especially if poor glycaemic control)

(First trimester retinal screening in pregnant diabetes patients)

Refer Ophthalmology:Acute changes in vision

Type 2 Diabetes AlgorithmNorthern Region Diabetes Clinical Network - 2012

Aim to reduce complications and morbidity. 3 monthly evaluation of BP, HbA1C, lipids, ACR, creatinine, eGFR then lipids 12 monthly once controlled

Referral at diagnosis:

•Severe hyperglycaemia ie glucose > 25mmol/l or ketonuria (urgent)•Intercurrent severe illness (urgent)•Complications of diabetes at diagnosis (semi-urgent)•Pregnant or gestational diabetes diagnosed (semi-urgent)•Type 2 adults < 30 years old (semi-urgent)

TTyyppee 22 ddiiaabbeetteess ((SSEEEE AAllggoorriitthhmm))

PPaarrtt ooff ““mmeettaabboolliicc ssyynnddrroommee””

• Vascular Disease

• Hypertension

• Proteinuria

• Raised lipids

• Obesity (apples vs pears)

Insulin Resistance

Be sure of Type of Diabetes

Consider autoimmune diabetes (adult Type 1) if slimmer, younger, history of autoimmune disease.

GAD Ab positive

SET TARGET for each patient

HbA1c target depends on age, co-morbidities, diabetes duration, e.g.: 50-55 (6.7-7.2%) for younger fitter

55-64 (7.2 – 8.0%) in others with vascular co-morbidities, especially over 70 yrs

LDL cholesterol to 2.5 or better (TG <3.0)

BP 130/80

Next step after Metformin

Diet & Exercise

Metformin

Sulphonylureae.g. Glipizide

Gliclazide

Glitazoneeg. Pioglitazone

Incretinse.g.

Sitagliptin Byetta

Liraglutide

Insulin

INCRETINSa) Sitagliptin (Januvia) DPPIV inhibitor

GLP is a gut hormone from the ileum which is reduced in type 2 diabetes. Restoring GLP levels leads to:

insulin from ß cell − Glucagon from α cell Gastric emptying; − Appetite

Sitagliptin is a DPPIV inhibitor which inhibits the enzyme that breaks down GLP and therefore increases GLP levels

ProsPros: Cons:Cons: Once/day and tablet form No hypogylcaemia Weight neutral HbA1c 0.5-1.0% on average

COST Limited experience

so far

b) GLP-agonists

Given by S.C. injection once or twice daily, possibly soon once weekly e.g. Exanatide B.D., Liraglutide once daily

ProsPros: Cons:Cons:

HbA1c 1.0-1.5% Weight loss No hypoglycaemia B.P. May preserve ß cell As good as insulin in

some studies

COST S.C. injection Nausea

(usually wears off)

Checklist for Pre-insulin assessmentChecklist for Pre-insulin assessment Maximum tablets Maximum tablets

do they take them?do they take them? at the right times?at the right times?

Physical activity-Physical activity- can it be increased?can it be increased?

Food- Food- Carbs/calsCarbs/cals

Blood Monitoring-to look for patterns and understandBlood Monitoring-to look for patterns and understand how lifestyle affects blood glucosehow lifestyle affects blood glucose

UnderstandUnderstand diabetes ‘risks’diabetes ‘risks’ HbA1cHbA1c blood glucose targetsblood glucose targets