Sharing of DM Management in

HKWC

Dr. WS Chow & Ms. Karen Wong (Med)

Dr. Emily Tse (FM&PHC)

Queen Mary Hospital

DM Joint Clinic• Collaboration between 2 specialties

• To provide quality, continuous and easily accessible specialist service to more complicated patients

• Regular sessions at Family Medicine Clinics

• Jointly formulate the most suitable management plan

Family Physician

(Primary care)

Diabetologist

(Secondary care)

DM JOINT CLINIC

How to choose case?

RAMP AC:

• Poor DM control as judged

by HbA1c and risk

stratification in RAMP

• Oral antidiabetic drug

failure and require insulin

initiation

DM Joint Clinic:

• DM patients with suboptimal

control despite on 2 daily

doses of insulin

• Drug problems eg. insulin

allergy

• Resistant cases that could not

resolve in RAMP AC clinic

Stable case refer back to GOPC

• QMH DM center refer stable DM case to

FMSC/GOPC

• RAMP AC clinic and DM Joint clinic refer

back stable case to FMSC/GOPC

FM Physicians Dietitians Physiotherapists Podiatrists

Clinical

PsychologistsOphthalmologistProsthetics &

Orthotics

Multi-disciplinary Collaboration

Pharmacists

DM nurse

Specialists

Endocrinologists

Cases for Illustration

How patients are handled through

the tier system?

Case 1

• 75/M, ADL independent

• DM for 8 years

• On the following oral anti-DM drugs:

– Metformin 1000mg bd

– Diamicron 160mg bd

• HbA1c 8.1; eGFR 65

� What would be your management to the

patient?

Case 1�Re-emphasize on lifestyle modification

? Further step up the oral drug?

• Suggests to use insulin?

× ‘I don’t want insulin!’

• Consider DPP4 inhibitor?

�Explain its usefulness and limitation

�Patient agrees to use it at cost.

�Put on Januvia 100mg daily

�HbA1c improved to 7.0 in 6 months’ time.

Case 2

• 55/M Retired Policeman

• History of DM for 9 years

• BW 82.8 kg BH1.77 m BMI 26.4 kg/m2

• On the following oral anti-DM drugs:

– Metformin 1000mg bd

– Diamicron 160mg bd

– Januvia 100mg daily

• HbA1c 8.5%; L/RFT normal

� What would be your management to the

patient?

Case 2

• Tackle any lifestyle obstacles

• Advise patient to consider insulin

�Patient agreed with our suggestion

�Referral to RAMP AC clinic made

�Seen with nurse counselling on use of

insulin

�Taught injection technique using pen

�Put on Protaphane 8 units SC Nocte, keep

Metformin, Diamicron and Januvia

Case 2

• HbA1c gradually improved upon adding of

basal insulin and up-titrating the

Protaphane dose to 10 units SC Nocte

- achieved HbA1c down to 6.8%

• Patient was referred back to Family

Medicine Specialist Clinic for follow up

Case 3 • FU GOPC Jan 2016

• M/ 65; retired, living with wife and daughter (just graduated)

• DM 1981 (35 yrs), HT, Hyperlipidaemia,

• Psychotic & dysthymia

• Complicated with CKD, Proteinuria, DR

• BW 72.2 kg BH 1.67 m BMI 25.9 kg/m2

• HbA1c 9.1%; Cr 157 -> 189 (eGFR 31);

• Urine MA 64 -> 215; Urine P/C 296

• On Diamicron 40mg BD; Metformin 250mg BD

• Treatment:

• Off Metformin

• Step up Diamicron 80mg BD

• Refer QMH SOPC

Case 3• 2 weeks later FU DM Centre 26-1-16

• DM Nurse Clinic Assessment

• Psychosocial assessment and DM education

• Review diet, drug compliance; seen dietitian

• Taught SMBG

• Treatment:

• Infection screening: CXR, MSU

• Book elective USG Kidneys

• Prime for insulin, he refused

• Keep Diamcron 80mg BD

Case 3

• Subsequent DM Nurse Clinic FU Feb – Apr 2016

• Complication screening done

• HbA1c 9.1%; Cr 189 -> 194 (eGFR 30);

• 24 hr urine for Protein 2.7g/D

• Discuss for insulin use, patient still refused insulin, claimed for lifestyle change

• Treatment:

• Start (SFI) Linagliptin 5mg QD

• Gradually step up Diamicron to 160mg om 120mg pm

• FU S6 DM SOPC

Case 3

• FU QMH SOPC DM Clinic May 2016

• HbA1c 9.1%-> 8.6% Cr 198 eGFR 30

• BP 101/65 mmHg

• Ankle odema

• Treatment:

• Maximize Diamicron 160mg BD; keep Linagliptin

• Add Lasix

• FU DM Nurse for ambulatory dosage adjustment

Case 3• FU DM Nurse again May 2016

• Reinforced the importance of glycaemic control and benefit of insulin

• Explore barriers for insulin: afraid of pain and needle

• Injection pen and needle shown with dry tapping on skin

• Discuss with patient to find meaning for use of insulin, e.g. better control to prevent deterioration of complications and have good health to enjoy life with family

• Treatment:

• Finally accept insulin injection; taught injection pen technique and competent to handle by himself

• Off Diamicron; keep Linagliptin

• Started on Protaphane (Penfill) 16 units SC OM

Case 4• FU GOPC DM Joint Clinic Nov 2015

• F/56, BMI 22.1, working as OAH assistant, on shift duty

• DM 2011 (5 years), HbA1c 9.5%, L/RFT normal

• Anti-DM drug failure Aug 2015, started on OM

Protaphane with dose stepped up

• Currently on Protaphane (Penfill) 28 units SC OM &

Metformin 1gm BD

• Treatment:

• Declined SFI DPP4 inh or SFI SGLT2 inh due to

financial

• Discuss for BD injections and agree

• Split doses Protaphane (Penfill) 22 / 12 units SC BD,

keep Metformin 1gm BD

• Refer Nurse Clinic QMH for FU

Case 4

• QMH Nurse Clinic first FU Nov 2015

• On shift work: meal time (6am, 1pm, 7pm) or

• (7pm, 4am, 8am)

• Injection before first and third meal

• Poor diet compliance, taking sweet soup/food

• Poor drug compliance, missing pm dose insulin

• Treatment

• Reinforce diet and drug compliance

• Retaught Novopen injection technique

• Discuss with patient for importance of glycaemiccontrol

Case 4

• FU DM Nurse subsequent visits, Dec 2015 to Apr 2016

• Highish Hstx profile, HbA1c 9.5% ->10.2%

• Improved diet and drug compliance

• Treatment:

• Step Protaphane up to 22 / 14 units SC BD

• Change to Mixtard (70/30) 22 / 14 units SC BD

• Step up to Mixtard (70/30) 30 / 16 units SC BD

• Reluctant for multiple doses insulin; add Linagliptin

• HbA1c 10.2% -> 8.5% -> 7.3%

• Back to GOPC FU

Acknowledgement

• Special thanks to Dr. Wendy Tsui (Chief of

service, Department of Family Medicine

and Primary Healthcare, Hong Kong West

Cluster, Hospital Authority) for some of the

slides.