Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos

Diabetes and Thalassaemia

3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Limassol, 24 – 26 October 2012

Dr Maria Barnard & Dr Ploutarchos TzoulisRomilla Jones, Emma Prescott, Dr Farrukh Shah

The Whittington Hospital NHS Trust, London

● Diabetes affects 366 million people worldwide

● Predicted to affect 552 million people by 2030

● Diabetes caused 4.6 million deaths in 2011

● Every 10 seconds a person dies from diabetes-related causes

● Every 10 seconds two people develop diabetes

● Greatest number of people with diabetes are between 40 to 59 years of age

● 78,000 children develop type 1 diabetes each year

The Diabetes Epidemic

International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

The Top 10


Diabetes Prevalence


The Top 10 by Prevalence


● USD ($) 465 billion spent on healthcare for diabetes

● 11% of all healthcare spending is for diabetes

● USD ($) 1,274 is spent on diabetes care per person with diabetes

Healthcare Expenditure (2011)


● Diabetes prevalence ~20% (age, chelation therapy)

● Aetiology and risk factors:

Transfusional iron overload

Poor chelation therapy, poor compliance, advanced age of onset

Altered β-cell insulin secretion

Autoimmunity

Insulin resistance secondary to liver disease

HCV infection

Global epidemic – type 1/type 2 diabetes

Diabetes in β-Thalassaemia Major

● Annual oral glucose tolerance tests (OGTT) from puberty or from age 10 years if there is a positive family history

Prompt treatment of hyperglycaemia

Intensification of iron chelation therapy

Early Diagnosis of Diabetes

Thalassaemia International Federation. Guidelines for the Clinical Management of Thalassaemia. 2nd Revised Edition 2008. Available at: http://www.thalassaemia.org.cy/publications.html

United Kingdom Thalassaemia Society. Standards for the Clinical Care of Children and Adults with Thalassaemia in the UK. 2nd Edition 2008. Available at: http://www.ukts.org/pdf.html

http://www.thalassaemia.org.cy/publications.html

http://www.ukts.org/pdf.html

Diagnosis of DiabetesCategory Plasma Glucose (mmol/l)

Fasting 2h Post-Glucose Load

Diabetes mellitus ≥ 7.0 ≥ 11.1

Impaired glucose tolerance (IGT) < 7.0 7.8 – 11.0

Impaired fasting glycaemia (IFG) 6.1 – 6.9 (WHO)5.6 – 6.9 (ADA)

< 7.8< 7.8

Not diabetic or glucose intolerant ≤ 6.0 (WHO)≤ 5.6 (ADA)

< 7.8

Category Plasma Glucose (mg/dl)

Fasting 2h Post-Glucose Load

Diabetes mellitus ≥ 126 ≥ 200

Impaired glucose tolerance (IGT) < 126 140 – 199

Impaired fasting glycaemia (IFG) 110 – 125 (WHO)100 – 125 (ADA)

< 140< 140

Not diabetic or glucose intolerant < 110 (WHO)< 100 (ADA)

< 140

● Prevention, detection and management of complications

● Microvascular & Macrovascular

Aim of Treatment

Background retinopathy

Proliferative retinopathy

Kidney glomerulus

Glomerular sclerosis

Neuropathic foot ulcer

Ischaemia

● Risk for death among people with diabetes twice that of people of similar age but without diabetes

● In 2004, heart disease noted on 68% of diabetes-related death certificates among people aged 65 years or older (USA)

● In 2004, stroke noted on 16% of diabetes related death certificates among people aged 65 years or older (USA)

Mortality in Diabetes

Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011

Muscle

Glucose (G)

Carbohydrate

Glucose

DIGESTIVE ENZYMES

Insulin(I)

I

I

I

I

I

I

G

G

G

GI

G

G

I

IG

SulphonylureasMeglitinidesGLP-1 analogues DPP-IV inhibitors

Metformin

Acarbose

Metformin

Glitazone

Glitazone

Glitazone

GLP-1

Liver

Pancreas

Adipose tissue

Antidiabetic Drugs

Insulin ± oral agents

Oral combination

Oral monotherapy

Diet & exerciseMetformin

Sulphonylureas

Gliptins

GLP-1 analogues

Stepwise Management of Diabetes

● Physiological insulin regimen

24 hour insulin and glucose profile in non-diabetic persons

Insulin Therapy

Breakfast Lunch Dinner Bedtime

Insulin (Rapid)

Insulin (Rapid)

Insulin (Rapid)

Insulin (Basal)

Basal-Bolus Insulin Regimen

e.g. Insulin aspart (Novorapid) + insulin glargine (Lantus)

● To calculate rapid insulin dose given with a meal:

Take capillary blood glucose before eating

If >7 mmol/l, calculate insulin correction dose

Estimate carbohydrate content of food

10g carbohydrate = 1 Carbohydrate Portion (CP)

Calculate food insulin using 1 – 3 units for each CP

● Remember to adjust for all other factors that may affect glycaemic control (exercise, illness, alcohol etc)

● Give insulin (correction dose + food insulin)

Insulin Dose Adjusting

● Aims:

Provide high quality diabetes, endocrine and haematology care

Optimise metabolic control

Support patient self-management

Support partnership working between specialist teams and between patients and clinicians

Provide education, training and research opportunities

Whittington Joint Diabetes Thalassaemia Clinic

● Patients seen jointly:

● Consultant Diabetologist (Dr Maria Barnard)

● Consultant Haematologist (Dr Farrukh Shah)

● Diabetes Specialist Nurse (Romilla Jones)

● Haematology Specialist Nurse (Emma Prescott)

● Senior Diabetes Dietitian

● Clinical Psychologist

● Access to Whittington type 1 diabetes structured education courses (WINDFAL)


● Complete full diabetes annual review once a year

● Address the 9 Key Care Processes for diabetes:

[1] Glycaemic control

[2] Blood pressure

[3] Serum cholesterol

[4] Serum creatinine

[5] Urinary albumin

[6] Weight

[7] Diabetic foot examination

[8] Smoking status assessment

[9] Retinal screening



Measure Target

Fructosamine (umol/l) HbA1c (%)

< 322 (< 299) < 7.0 (< 6.5)

Capillary blood glucose (mmol/l) Pre-prandial Post-prandial (2 h)

4 – 75 – 8

Blood pressure (mmHg) - with nephropathy

< 130 / 80< 125 / 75

Total cholesterol (mmol/l) < 4.0

LDL cholesterol (mmol/l) < 2.0

Triglycerides (mmol/l) < 1.7

Smoking status Non-smoker

Body mass index (kg/m2) 20 – 25

Exercise Daily

Aspirin (75 mg) if > 50 y of age or CV risk Daily


Clinic Population Description

Gender - Female Male

59%41%

Age* 39 years (28 – 59y)

Ethnic origin Greek Cypriot / Greek South Asian (Indian, Pakistani, Bangladeshi)

36%64%

Ferritin at first appointment* 1827 ug/l (600-6143ug/l)

Diabetes duration* 13 years (<1 – 29y)

Age at diagnosis* 21 years (10 – 40y)

BMI* 24.8 kg/m2

Treatment – insulin 73%

Treatment – oral antidiabetic drugs only 14%

Treatment – diet control only 14%

*median values

Performance: Joint Clinic vs. National Audit for England

Care Process Performance of Key Care Processes

Joint Clinic(2005-2009)

National Diabetes Audit (2007-2008)

Fructosamine (HbA1c) 97.5% 91.1%

Serum cholesterol 91.1% 89.9%

Serum creatinine 100% 91.2%

Urinary albuminuria 91.1% 62.7%

Weight / Body mass index 97.5% 88.8%

Blood pressure (BP) 80.4% 93.7%

Foot assessment 89.2% 77.1%

Smoking status 89.2% 86.5%

Target achievement: Joint Clinic vs. National Audit for England

Target Percentage of patients achieving treatment target

Joint Clinic(2005-2009)

National Diabetes Audit (2007-2008)

Fructosamine < 345 umol/l(HbA1c < 7.5%)

72.7% 62.9%

BP < 135/75 mmHg 57.9% 30.1%

Total cholesterol < 5.0 mmol/l 82.1% 78.0%

Metabolic improvement in Joint Clinic

Parameter First appointment 1 year follow-up Change

Fructosamine 344 umol/l 319 umol/l -25 umol/l

BP 122/70 mmHg 124/77 mmHg +2/7 mmHg

Total cholesterol 3.8 mmol/l 3.5 mmol/l -0.3 mmol/l

● 33% of patients achieved reduction in ferritin of >10%

● 23% were on antihypertensive agents

● 23% were on lipid lowering agents

● 32% on antiplatelet/anticoagulant agents

Diabetic Complications in Patients Attending Joint Clinic

Diabetic complication Prevalence in patients attending Joint Clinic

Microalbuminuria 13.6%

Diabetic retinopathy 13.6%

≥1 microvascular complication 22.7%

Charcot neuroarthropathy 4.5%

Cataracts 9.1%

Macrovascular complications 0

Diabetic emergencies 0

Endocrinopathies in Patients Attending Joint Clinic

Endocrinopathy Prevalence in patients attending Joint Clinic

Hypogonadism - Hypogonadotrophic hypogonadism - Primary hypogonadism

86%59%27%

Hypothyroidism 18%

Hypoparathyroidism 23%

Osteopenia 14%

Osteoporosis 55%

Glucocorticoid deficiency 0

Growth hormone deficiency 0

● Joint Diabetes Thalassaemia Clinic effective at providing high quality care in the most complex patients

● 41% patients diagnosed with diabetes <19 years of age

Early effective iron chelation is critical

● Be aware of diabetic complications (microvascular)

● Optimise glycaemic control

● Modify cardiovascular risk

Whittington Joint Diabetes Thalassaemia Clinic - Discussion

● Patients with diabetes and thalassaemia have complex medical care needs

● Psychological impact – treatment burden, impact on daily life, feeling of difference, dependence and anxiety

● Partnership working of the Joint Diabetes Thalassaemia Clinic:

Patients have easy access to senior specialist clinicians

Continuity of care

Supported by multidisciplinary team

Working together with the patient and each other

Supporting self-management

Diabetes and Thalassaemia -Conclusions

● Patients receive training in carbohydrate counting and insulin dose adjustment

● Patients access type 1 diabetes structured education

● Significant educational opportunities for healthcare professionals and staff in training

● Managing diabetes is one of the greatest challenges a person with thalassaemia can face.

● Joint Diabetes Thalassaemia Clinic enables our patients to effectively manage their physical and psychological long-term health

Diabetes and Thalassaemia -Conclusions

Documents

Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos