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Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos Tzoulis Romilla Jones, Emma Prescott, Dr Farrukh Shah The Whittington Hospital NHS Trust, London

Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

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Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos Tzoulis Romilla Jones, Emma Prescott, Dr Farrukh Shah The Whittington Hospital NHS Trust, London. The Diabetes Epidemic. - PowerPoint PPT Presentation

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Page 1: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Diabetes and Thalassaemia3rd Pan-European Conference on

Haemoglobinopathies & Rare AnaemiasLimassol, 24 – 26 October 2012

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

The Whittington Hospital NHS Trust, London

Page 2: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 3: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

The Top 10

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

Page 4: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Diabetes Prevalence

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

Page 5: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

The Top 10 by Prevalence

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

Page 6: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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)

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

Page 7: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 8: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 9: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Diagnosis of DiabetesCategory Plasma Glucose (mmol/l)

Fasting 2h Post-Glucose LoadDiabetes 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

Page 10: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● Prevention, detection and management of complications

● Microvascular & Macrovascular

Aim of Treatment

Background retinopathy

Proliferative retinopathy

Kidney glomerulus

Glomerular sclerosis

Neuropathic foot ulcer

Ischaemia

Page 11: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 12: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

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

Page 13: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Insulin ± oral agents

Oral combination

Oral monotherapy

Diet & exerciseMetformin

Sulphonylureas

Gliptins

GLP-1 analogues

Stepwise Management of Diabetes

Page 14: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● Physiological insulin regimen

24 hour insulin and glucose profile in non-diabetic persons

Insulin Therapy

Page 15: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Breakfast Lunch Dinner Bedtime

Insulin (Rapid)

Insulin (Rapid)

Insulin (Rapid)

Insulin (Basal)

Basal-Bolus Insulin Regimene.g. Insulin aspart (Novorapid) + insulin glargine (Lantus)

Page 16: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 17: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 18: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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)

Whittington Joint Diabetes Thalassaemia Clinic

Page 19: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Whittington Joint Diabetes Thalassaemia Clinic

Page 20: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Whittington Joint Diabetes Thalassaemia Clinic

Measure TargetFructosamine (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

Page 21: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Whittington Joint Diabetes Thalassaemia Clinic

Clinic Population DescriptionGender - 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

Page 22: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Performance: Joint Clinic vs. National Audit for England

Care Process Performance of Key Care ProcessesJoint 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%

Page 23: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Target achievement: Joint Clinic vs. National Audit for England

Target Percentage of patients achieving treatment targetJoint 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%

Page 24: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

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

Page 25: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

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

Page 26: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

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

Page 27: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 28: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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

Page 29: Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

● 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