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Management of Type 2 Diabetes
New Zealand Guidelines Group
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Cost of Type 2 Diabetes
1. Major component of General Practice work requiring an intensive and integrated approach:
2. 2010 prevalence: 195,778 people with type 2 diabetes or 4.4% of New Zealanders
I. 50-64: 8-9%, 65+: 15-16%
II. Number 4 OECD
3. Increased prevalence amongst Māori, Pacific and Indian subcontinent peoples
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Cost of Type 2 Diabetes cont.
4. An additional $3,721 of publicly funded health care for each person with type 2 diabetes per year1
5. Approximately $728 million extra healthcare cost per year
1. Ministry of Health, 2008
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Lead Role for General Practice
Many cases of type 2 diabetes ‘fall’ between General Practice and speciality care:
• Specialty services cannot effectively deal with existing burden
• General Practice have an increasingly important role in management
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Critical Issue: Management of BP
1. BP is measured frequently but BP targets set in clinical guidelines not being consistently met
2. Recent NZ reports indicate 53–78% of people with type 2 diabetes have a BP above 130/80 mm Hg
3. Key reasons are medication adherence by patients and clinical inertia, ie, failure of health practitioners to initiate or intensify treatment when indicated
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Blood pressure management
• Step wise approach: Multiple Medication
• Target BP <130/80 mm Hg
• Evidence suggests BP target <120 mm Hg may be harmful (ACCORD Study)
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Management: microalbuminuria
• People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present
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Critical Issue: Risk of Complications
1. Preventing complications an important aspect of care
2. Every patient with type 2 diabetes should be assessed for risk of diabetes-related complications early in their diabetes care
3. Māori and Pacific – complications develop more frequently and at a younger age
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Focus: Risk of Complications
3. ‘Risk chart’ categorises into low, moderate or high risk for diabetes-related complications:• Two identified risk factors places person at
moderate risk
• Three identified risk factors is assessed as high risk
• An ‘existing’ complication (eg, previous cardiac event) places person at high risk.
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Focus: Risk of Complications
• Two identified risk factors (eg. HbA1c >55 mmol/mol (~ 7%), and eGFR <60 ml/min/1.73m2 is at moderate risk
• Three identified risk factors (eg, HbA1c >55 mmol/mol, eGFR <60 ml/min/1.73m2 plus BP >130/80 mm Hg) is at high risk for complications
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Key Points For General Practice(1)
1. General Practice and Primary Care need to take the lead
2. Identify risk of complications early for intensive intervention
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Key Points (2)
3. Aim for HbA1c 50–55 mmol/mol (~7%)
I. Not too aggressive target 7%(50-55)
II. Accord (2010) – Some evidence increase fatal events with tighter control (6%)
III. Metformin till eGFR < 30
IV. Insulin early rather than late
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Key Points (3)4. BP aim <130/80.
I. Avoid Clinical Inertia
II. Often multiple medication required
III. <120 maybe harmful(Accord)
5. ACEI/ARB with microalbuminuria, whether or not hypertensive
6. Lipid control –
I. Consider satins early: Aim TC<4, TG<1.7
II. CV Guidelines
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Key Points (4)7. Diet/Exercise/Smoking Cessation essential in
management:
I. Diet/Exercise: Additional Benefit compared with most expensive new drugs if intensify diet/exercise.
8. Practice recalls for retinal screening/podiatry review/bloods/medical review
9. Specialist advice as required:
I. Case Conferencing, Phone, E-mail, combined Consults, Outpatients