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Managing T2DM is easy Background Replaces all existing T2 guidelines except: Foot care (CG10 2004) Pregnancy (CG63 2008) Quick reference guide is short and easy to digest All diabetes practitioners need to read Should be available in all DM clinics for reference Caveats Does not consider many newer drugs DPP-IV Detemir Exenatide only briefly touched on Doesn’t include data from the latest type 2 studies UKPDS 80 and 81 ADVANCE, ACCORD Patient education Should be offered to all at diagnosis Ideally structured group education in accordance with DoH guidance Individual education to same standard where group sessions are inappropriate Annual reinforcement and review Current position locally BANES - DESMOND Wiltshire – X-PERT Somerset - DESMOND Dietary advice General advice Include high fibre, low GI CHO Include low fat dairy and oily fish Control saturated fats and trans fatty acids Discourage ‘diabetic’ foods Action Provide individualised and ongoing advice from a healthcare professional with expertise and competencies in nutrition Initial target weight loss 5-10% Assessment of glycaemic control General target HbA1c 6.5%, but individualise Demonstrate how any reduction benefits future health Simple clinic demonstration Complications 7 9 11 13 HbA1c Assessment of glycaemic control Check 2-6 monthly until stable, then 6 monthly Seek specialist advice if HbA1c result discrepant or invalid Self monitoring HBGM should be available: To those on insulin To those on OHAs capable of causing hypos To assess changes in BGs resulting from medication change To monitor during intercurrent illness To ensure safety during activities eg driving Self monitoring (2) Discuss purpose, interpretation and how to act on HBGM Only initiate at diagnosis as an integral part of self-management education Assess at least annually in a structured way Equipment Technique Understanding and utilisation Blood glucose-lowering therapy HbA1c >= 6.5% after trial of lifestyle Metformin (with active dose titration) Notes on Metformin Step up over several weeks to avoid GI upset Try SR MFN if GI s/e Review dose if Cr >130 or eGFR <45 Stop if Cr >150 or eGFR <30 Caution where there is a risk of sudden deterioration in renal function Blood glucose-lowering therapy HbA1c >= 6.5% after trial of lifestyle Metformin (with active dose titration) HbA1c <6.5% HbA1c >= 6.5% Monitor for deterioration Metformin + Sulphonylurea (with active dose titration) Notes on SUs Prescribe cheap version (avoiding glibenclamide) Educate patient about risk of hypos, particularly if has renal impairment Consider rapid-acting secretagogue for patients with erratic lifestyles Offer once-daily if concordance is a problem Blood glucose-lowering therapy HbA1c >= 6.5% after trial of lifestyle Metformin (with active dose titration) HbA1c <6.5% HbA1c >= 6.5% Monitor for deterioration Metformin + Sulphonylurea (with active dose titration) HbA1c <7.5% HbA1c >= 7.5% Monitor for deterioration Blood glucose-lowering therapy (2) HbA1c >= 7.5% Add TZD or insulin (with active dose titration) HbA1c >= 7.5% HbA1c <7.5% Monitor for deterioration Insulin + Metformin + Sulphonylurea (with active dose titration) HbA1c >= 7.5% HbA1c <7.5% Monitor for deterioration Intensify insulin regimen Notes on glitazones Warn patient about significant oedema Do not initiate or continue if evidence of heart failure or at higher risk of fracture Select drug based on most up-to-date advice from regulatory authorities, cost and safety Consider pio with insulin if high doses ineffective Exenatide Consider if BMI >35 (adjust for ethic group) Patient had specific psychological, biochemical or physical problems arising from high body weight HbA1c ≥ 7.5% after MFN and SU Would otherwise be starting high cost Rx (TZD or insulin) Continue if ≥1% reduction of HbA1c at 6 months ≥ 5% reduction weight at 1 year Insulin Initiate with a structured program employing active dose titration Structured education Continuing telephone support Frequent self-monitoring Dose titration to target Dietary understanding Management of hypoglycaemia Management of acute changes in glucose control Support from appropriately trained HCP Insulin (2) Preferably begin with NPH insulin (OD or BD) Consider glargine if Patient requires assistance to administer insulin Recurrent hypos BD basal insulin plus OHAs would otherwise be needed Consider BD pre-mixed human insulin if HbA1c >9% Consider BD pre-mixed analogues when Injection immediately pre meal is preferred Hypos are a problem Marked postprandial glucose excursions UKPDS – post trial monitoring Background 20 year study (1977 – 1997) Main results published 1998 Revolutionised our Rx of T2D 10 post trial surveillance just published at EASD UKPDS 80 & 81 (NEJM 2008 359) UKPDS - Glucose Interventional Trial Dietary Randomisation Trial end Run-in 1977-1991 1997 744 2,729 Diet failure Intensive Intensive FPG >15 mmol/l with sulfonylurea/insulin P 5,102 1,138 (411 overweight) Newly-diagnosed 4209 Conventional Conventional type 2 diabetes with diet P 149 342 (all overweight) Diet satisfactory Intensive Intensive FPG <6 mmol/l with metformin Mean age 54 years (IQR 48–60) Change in HbA1c over time cross-sectional, median values 9 Conventional 8 HbA1c (%) Intensive 7 6.2% upper limit of normal range 6 0 0 3 6 9 12 15 Years from randomisation Myocardial Infarction and Microvascular Disease 80 60 Microvascular 1000 patient-years disease Incidence per 40 Myocardial infarction 20 0 0 5 6 7 8 9 10 11 Updated mean HbA1c (%) UKPDS 35. BMJ 2000; 321: 405-12 Microvascular Endpoints (cumulative) renal failure or death, vitreous haemorrhage or photocoagulation 346 of 3867 patients (9%) 30% Conventional % of patients with an event Intensive p=0.0099 20% 10% Risk reduction 25% 0% (95% CI: 7% to 40%) 0 3 6 9 12 15 Years from randomisation UKPDS Group. Lancet. 1998;352:837-853 Myocardial Infarction (cumulative) fatal or non fatal myocardial infarction, sudden death 573 of 3867 patients (15%) 30% Conventional % of patients with an event Intensive p=0.052 20% 10% Risk reduction 16% 0% (95% CI: 0% to 29%) 0 3 6 9 12 15 Years from randomisation UKPDS 10 year post trial surveillance just published at EASD UKPDS 80 & 81 (NEJM 2008 359) Post-Trial Monitoring: Patients 1997 2002 2007 # in survivor cohort # with final year data 2,118 Clinic Questionnaire 1,010 Sulfonylurea/Insulin Sulfonylurea/Insulin P 880 Clinic Questionnaire 379 Conventional Conventional P 279 Clinic Questionnaire 136 Metformin Metformin Mean age Mortality 44% (1,852) 62±8 years Lost-to-follow-up 3.5% (146) Post-Trial Changes in HbA1c UKPDS results Mean (95%CI) presented Microvascular Disease Hazard Ratio (photocoagulation, vitreous haemorrhage, renal failure) Intensive (SU/Ins) vs. Conventional glucose control HR (95%CI) Myocardial Infarction Hazard Ratio (fatal or non-fatal myocardial infarction or sudden death) Intensive (SU/Ins) vs. Conventional glucose control HR (95%CI) Legacy Effect of Earlier Glucose Control After median 8.5 years post-trial follow-up Aggregate Endpoint 1997 2007 Any diabetes related endpoint RRR: 12% 9% P: 0.029 0.040 Microvascular disease RRR: 25% 24% P: 0.0099 0.001 Myocardial infarction RRR: 16% 15% P: 0.052 0.014 All-cause mortality RRR: 6% 13% P: 0.44 0.007 RRR = Relative Risk Reduction, P = Log Rank Conclusions of glucose intervention trial • Despite an early loss of glycaemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up • A continued benefit after metformin therapy was evident among overweight patients. • ‘Metabolic memory’ NICE 2008 Blood pressure Targets <130/80 if kidney, eye or cerebrovascular damage Otherwise <140/80 If BP above target repeat within 1 month if >150/90 2 months otherwise Once treated, monitor 1-2 monthly until consistently below target Then 4-6 monthly BP treatment Lifestyle advice ACE inhibitor Add CCB or diuretic Add other drug Add alpha blocker, beta blocker or K- sparing diuretic UKPDS Blood Pressure Interventional Trial 5,102 Randomisation Trial end UKPDS patients 1987-1991 1997 759 Tight control Tight control ACEI or ß-blocker 1,148 BP ≥160/90 mm Hg P or ≥150/80 on Rx Mean age 390 56±8 years Less-tight control Less-tight control No ACEI or ß-blocker Myocardial Infarction and Microvascular 50 Disease per 1000 person years 40 Adjusted incidence Myocardial infarction 30 20 10 Microvascular endpoints 0 0 110 120 130 140 150 160 170 Updated mean systolic blood pressure (mm Hg) UKPDS 35. BMJ 2000; 321: 405-12 Microvascular endpoints 25% Less Tight Blood Pressure Control (390) Tight Blood Pressure Control (758) % patients with event 20% 15% 10% 5% risk reduction 0% 37% p=0.0092 0 3 6 9 Years from randomisation Myocardial Infarction 25% Less Tight Blood Pressure Control (390) Tight Blood Pressure Control (758) % of patients with event 20% 15% 10% 5% risk reduction 0% 21% p=0.13 0 3 6 9 Years from randomisation Post-Trial Monitoring: Patients 1997 2002 2007 # in survivor cohort # with final year data 592 Clinic Questionnaire 250 Tight control Tight control P 292 Clinic Questionnaire 126 Less-tight control Less-tight control Mean age Mortality 51% (584) 63±8 years Lost-to-follow-up 2.0% (23) Post-Trials Changes in Blood Pressure UKPDS results presented Mean (95%CI) Microvascular Disease Hazard Ratio (photocoagulation, vitreous haemorrhage, renal failure) Less-tight vs. Tight blood pressure control HR (95%CI) Myocardial Infarction Hazard Ratios (fatal or non-fatal myocardial infarction or sudden death) Less-tight vs. Tight blood pressure control Conclusions of BP intervention trial • The benefits of previously improved blood-pressure control were not sustained when between-group differences in blood pressure were lost • Early improvement in blood-pressure control in patients with both type 2 diabetes and hypertension was associated with a reduced risk of complications, but it appears that good blood pressure control must be continued if the benefits are to be maintained NICE 2008 Nephropathy Annual monitoring ACR on early morning urine Serum creatinine and eGFR Abnormal ACR (exclude UTI and proteinuria) Repeat test twice within 3-4 months Microalbuminuria confirmed if >1 test abnormal Action ACE inhibitor to maximum tolerated dose Maintain BP <130/80 When is it not nephropathy? No significant or progressive retinopathy BP particularly high or resistant to Rx Heavy proteinuria (ACR>100) when previously normal Significant haematuria GFR rapidly worsened Patient systemically unwell Retinopathy Important to screen at diagnosis Discuss reasons for attending to formal screening programme Retinal screening programme compliant with guidance Neuropathy NICE 2008 - Conclusions Useful document, but incomplete wrt hypoglycaemic therapies Please ensure all patients referred for education Important emphasis on early control BP target controversial Nothing radical wrt complications
"Management of Type Diabetes NICE miocardial infarction"