Diabetes Nick Pendleton

Diabetes (part one of two)

• Relevance to General Practice and wider health economy

• Diabetes - Type 2 and in pregnancy

• What guidance is available to help identify and manage risk of DM?

Diabetes

• Example patients

• Diabetes and Driving

• What’s new or on the way?

Diabetes in the UK• Currently £9.8 billion of NHS budget is spent on

patients with Diabetes

NHS spending on diabetes 'to reach £16.9 billion by 2035‘

• 17% of entire NHS budget!

• 79% of diabetes spend is on treating complications from DiabetesFrom Impact Diabetes report published in Journal of Diabetes Medicine -

April 2012

Why?• Numbers of people at risk of DM are

increasing

• The numbers of people developing diabetes are increasing

• More people with DM are being identified

• Expensive new medications

• Complications of diabetes are significant and costly to treat

RISK FACTORS FOR DEVELOPING TYPE 2 DIABETES

• PMH - Hypertension, IHD, Stroke• Being overweight/High BMI• Waist Circumference eg. > 37 inches in men• PCOS, Gestational DM or baby over 10 lbs• Ethnicity (African-Caribbean, Black African, Chinese or South Asian )

• 1st degree relative with DM• Severe Mental Illness treated with

Medication (schizophrenia, bipolar disorder or depression)

http://www.diabetes.org.uk/Guide-to-diabetes/What-is-diabetes/Know-your-risk-of-Type-2-diabetes/Diabetes-risk-factors /

What is happening in the body in Type 2 Diabetes?

NORMAL INSULIN RESPONSE

INSULIN

• Insulin is required for glucose to enter cells of muscle, fat and liver so that it can be stored and used for energy

• It also stops fat being used as an energy source by inhibiting glucagon

Insulin response +120 mins

GLUCOSE LEVELS

Insulin response Lean v Obese (non-DM)

Development of Diabetes• People with Type 2 DM produce insulin but

can not use it properly – Insulin resistance• At first they produce more insulin to make up

for this• With time, sustained high levels of insulin

trigger pancreatic Beta-cell death • As time passes the pancreas cannot keep up

and glucose levels begin to rise• Capacity to produce insulin diminishes

Complications of Diabetes

• A high glucose level in the blood is toxic and causes damage to tissues and organs:

• K• N• I• V• E• S

Complications of Diabetes

• A high glucose level in the blood is toxic and causes damage to tissues and organs:

• Kidneys• Nerves• Infections• Vascular• Eyes• Skin

Complications of Diabetes

• Kidney – nephropathy• Neuromuscular – peripheral neuropathy,

mononeuritis, amyotrophy• Infective – UTIs, TB• Vascular –

coronary/cerebrovascular/peripheral artery disease

• Eye – cataracts, retinopathy• Skin – lipohypertrophy/lipoatrophy,

necrobiosis lipoidica

Necrobiosis Lipoidica

http://www.patient.co.uk/doctor/necrobiosis-lipoidica-pro

The effect of Diabetes on Kidneys

• Renal atherosclerosis• UTIs• Diabetic nephropathy - diffuse or nodular

(Kimmelstiel-Wilson lesion). • High levels of blood glucose cause the kidneys

to work harder and filter more blood• Over time this damages the glomeruli and

associated capillaries which then become leaky

eGFR

Late intervention

No intervention

Dialysis

Early intervention

Time from Diagnosis of Diabetes

Diabetic Nephropathy

• Early stages cause an elevated glomerular filtration rate with enlarged kidneys but the principal feature of diabetic nephropathy is proteinuria.

• Proteinuria develops insidiously, starting as intermittent microalbuminuria

• Progresses to constant proteinuria and occasionally nephrotic syndrome.

Monitoring and Detection

• All Diabetics - recall and annual review• Measure urinary ACR or albumin

concentration annually. Use a first morning urine sample when possible.

• Repeat if abnormal (and not due to UTI) within a maximum of 3-4 months.

• Measure serum creatinine and estimated glomerular filtration rate (eGFR) annually

Preventing Diabetic Nephropathy

• Tight blood glucose control to HbA1c< 48 mmol/l (6.5%)

• Tight blood pressure control to <140/80)

• 5 ways to lower BP - lose weight, eat less salt, avoid alcohol, avoid tobacco, and get regular exercise

• BP target is <130/80 if already have nephropathy, eye or vascular complications (NICE Clinical Pathway)

• ACE inhibitors (even if not hypertensive)• A2RBs (but not both together)

HbA1cTo Monitor Control of Diabetes

What is HbA1c?

• HbA most common Hb molecule• HBA1c is glycosylated HbA• Amount of glycosylation depends of

prevailing Glucose levels• Blood cells last 120 days• Measuring HbA1c gives measure of

glucose levels in last 4 months

HbA1c

Controlled diabetes, not much glucose, not much glycosylated haemoglobin

Uncontrolled diabetes, more glucose, much more glycosylated haemoglobin

Low HbA1c High HbA1c

QOF Target

HbA1c < 59 mmol/l (7.5%)

Diet and lifestyle advice for Diabetics:http://www.patient.co.uk/doctor/Diabetes-Diet-and-Exercise.htm

There appears to be a good correlation between glucose levels, Hba1c levels and clinical outcomes

Development of retinopathy

DIAGNOSING TYPE 2 DIABETES

What are the possible ways Diabetes can be diagnosed?

Diagnosing Type 2• Screening• New patient check (urine) • >40s campaign• Private health check• Used someone else’s BM machine• Pre-op clinic• HbA1c or serum glucose fasting or random• Incidental abnormal blood glucose result • Incidental glycosuria• Symptoms present• Investigating symptoms• Identified during pregnancy• Oral glucose tolerance test

Hba1c for Diagnosis

WHO Report 2011http://www.who.int/diabetes/publications/report-hba1c_2011.pdf

• HbA1c can be used if the test is stringently quality controlled and its results can be internationally referenced

• And there are no conditions present which preclude its accurate measurement.

What are the advantages of using HbA1c?

• Patient doesn’t need to fast• Can be performed any time of day• Plasma glucose is variable• Don’t need to do an OGTT (inconvenient)• Can be used for screening

HbA1C testing

HbA1c > 48 indicate diabetes is present

• If symptomatic diagnosis can be made at this point

• If asymptomatic test needs to be repeated between 2 – 4 weeks

When should HbA1c not be used?

• ALL children and young people • Patients of any age suspected of having Type 1

diabetes• Patients with symptoms of diabetes for less

than 2 months • Patients at high diabetes risk who are acutely

ill (e.g. those requiring hospital admission)

When should HbA1c not be used?

• Patients taking medication that may cause rapid glucose rise e.g. steroids, antipsychotics

• Patients with acute pancreatic damage, including pancreatic surgery

• In pregnancy• Presence of genetic, haematologic and illness-

related factors that influence HbA1c and its measurement

HbA1c is affected by:

• Erythropoiesis (RBC production)

• Increased HbA1c: iron, vitamin B12 deficiency, decreased erythropoiesis.

• Decreased HbA1c: administration of erythropoietin, iron, vitamin B12,

• reticulocytosis, chronic liver disease.

HbA1c is affected by:

• Altered Haemoglobin• Genetic or chemical alterations in

haemoglobin: haemoglobinopathies,• HbF, methaemoglobin, may increase or

decrease HbA1c.

HbA1c is affected by:

• Glycation• Increased HbA1c: alcoholism, chronic renal

failure, decreased intraerythrocyte pH.• Decreased HbA1c: aspirin, vitamin C and E,

certain haemoglobinopathies, increased intra-erythrocyte pH.

• Variable HbA1c: genetic determinants.

HbA1c is affected by:

• Erythrocyte destruction• Increased HbA1c: increased erythrocyte life

span: Splenectomy.• Decreased A1c: decreased erythrocyte life

span: haemoglobinopathies,• splenomegaly, rheumatoid arthritis or drugs

such as antiretrovirals, ribavirin and dapsone.

HbA1c is affected by:

• Assays (the tests)

• Increased HbA1c: hyperbilirubinaemia, carbamylated haemoglobin,

• alcoholism, large doses of aspirin, chronic opiate use.

• Variable HbA1c: haemoglobinopathies.• Decreased HbA1c: hypertriglyceridaemia.

FRUCTOSAMINE TEST

• Alternative test if HbA1C cannot be used

• Gives a measure of diabetic control in last 14-21 days

NICE PUBLIC HEALTH GUIDANCE (PH38)July 2012

WHO did not give any guidance about how to manage those at risk…

• Preventing type 2 diabetes: risk identification and interventions for individuals at high risk

• HbA1c 42-47 = high risk of developing DM

• http://publications.nice.org.uk/preventing-type-2-diabetes-risk-identification-and-interventions-for-individuals-at-high-risk-ph38/recommendations

Recommendations• Identify people at risk• Offer testing• Stratify people into high, moderate & low risk

• High = 42-47, mod = 39-41, low/normal <38• Match intervention to the risk• High risk – intensive structured lifestyle

management programme and reassess annually (Health Trainer)

• Lower risk – brief intervention: tell the patient, advocate healthy lifestyle, test 3 yearly

NICE Guidelines & Pathways

Link to clinical pathways:http://pathways.nice.org.uk/pathways/diabetes

• CG 87 is an update of CG 66 (2008) and is about managing Type 2 DM and includes newer agents (published 2009)

• On the way by 2015...• Diabetes in Children (Type 1 and 2)• Diabetes in Pregnancy• Diabetes in Adults – Type 1• Diabetes in Adults – Type 2

Mrs Rachelle Patel, 2628 weeks pregnantAttends practice based-midwife led clinicFound to have glucose in urine

• Next initial steps...• Complications if diabetes not detected and

treated• Follow up after delivery?

Mrs Rachelle Patel, 26• Oral Glucose Tolerance Test

• This should be offered as a screening tool to women at risk:

• FH DM in 1st degree relative• Previous Gestational Diabetes Mellitus• BMI > 30• Previous macrosomic baby > 4.5 kg• Family origin with a high prevalence of diabetes

(South Asian, black Caribbean and Middle Eastern)

Mrs Rachelle Patel, 26

If undetected/untreated risks are:• Macrosomia, difficult delivery, neonatal

hypoglycaemia, respiratory distress syndrome, increased perinatal mortality

Follow up:• OGTT at 6-8 weeks after delivery• Increased chance of developing Diabetes• If OGTT normal Annual HbA1C

Daryl Duncan, 37, Mechanic• I think I’ve got Diabetes Dr!

• Lost 1 stone in weight in 3-4 weeks• Feels exhausted• Really thirsty• Passing a lot of urine

• Initial management in the surgery?

Daryl Duncan, 37• Urine Dipstick 3+ Glucose, 2+ Ketones• Finger prick BM 26• Pulse rate 101 bpm, BP 118/70• Looks pale but alert• Admission?• Newly diagnosed type 1 DM• HbA1c and serum glucose in under 40s as still

could have Type 1• Established on insulin and followed up by Diabetes

Centre and in GP Practice

MODYMaturity Onset Diabetes of the Young

• Rare 1-2% of UK popn• Different to Type 1 and 2• Familial, Single Gene Mutation• Typically diagnosed in late childhood,

adolescence, or early adulthood• 90% of people with MODY may have

been misdiagnosed as Type 1 or 2

MODYMaturity Onset Diabetes

of the Young

MODYMaturity Onset Diabetes of the Young

Key features• Being diagnosed with diabetes under the

age of 25• Having a parent with diabetes, with

diabetes in two or more generations• Not necessarily needing insulin

MODY: Why is it Important?

• There are different types of MODY each needing a different treatment approach

• The different types of MODY progress in different ways

• As it is genetic there are implications for other family members

MODYMaturity Onset Diabetes of the Young

• HNF1 –alpha: 70% of cases, decreased insulin prodn, treated with sulphonylureas

• HNF4 –alpha: large birthweight, neonatal hypoglycaemia, sulphonylureas and then insulin

• HNF1 –beta: Diabetes assoc with gout, renal cysts and uterine abnormalities

• Glucokinase: Cannot recognise blood sugar levels, levels increase

DIABETES AND DRIVING

QUIZ

1. A newly diagnosed diet-controlled Type 2 diabetic who drives a car (Group 1) must inform the DVLA of the diagnosis

No – unless having hypos with impaired awareness, or disabling hypos, or have other complications of diabetes eg impaired vision

Diabetes and Driving

2. A car driving gestational diabetic on insulin for less than 3 months does not need to notify the DVLA

Correct- unless they have problems with hypos/severe hypos/hypo unawareness

Diabetes and Driving

3. A Bus-driver (Group 2) started on Gliclazide for control of type 2 Diabetes must notify the DVLA

• Yes – and must be aware of hypos, must regularly monitor blood sugar twice daily and related to driving, must show they understand the risks of hypos. 1,2 or 3 year licence issued

Diabetes and Driving

4. A Taxi Driver who has been started on Insulin must monitor her blood sugar at the start of the journey and every 2 hours

• Yes and Must inform DVLA• And must have hypo awareness

Diabetes and Driving

5. An HGV driver on insulin must present 3 months of blood glucose readings to a Consultant Diabetologist annually

Correct - and the Consultant completes a report for the DVLA

Diabetes and Driving

6. A car driver who has impaired awareness of hypoglycaemia must stop driving

Yes – until it can be demonstrated that hypo awareness has been regained as evidenced by GP or Consultant report (how?)

DVLA GUIDANCE

https://www.gov.uk/current-medical-guidelines-dvla-guidance-for-professionals

What’s New?

DIABETES RESEARCH

A Vaccine for Type 1 DM

• Researchers funded by Diabetes UK are currently conducting a multi-centre trial of a vaccine which they hope will trigger an immune response to protect against Type 1 diabetes.

https://www.diabetes.org.uk/Research/Research-round-up/Research-spotlight/Research-spotlight-a-vaccine-for-Type-1-diabetes/

Low-Calorie Liquid Diets

Can an intensive course of low calorie liquids put Type 2 Diabetes into remission?

• What will the diet used in this study consist of?• The diet used in this study will last for between 8

and 20 weeks and consist of approximately 800 calories a day. This will be comprised of four diet soups or shakes per day providing all essential vitamins and minerals, plus ample fluids. https://www.diabetes.org.uk/Research/Research-round-up/Research-spotlight/Research-spotlight-low-calorie-liquid-diet/

An Artificial Pancreas

• Measures blood glucose levels on a minute-to-minute basis using a continuous glucose monitor (CGM)

• Transmits data to an insulin pump

• The pump calculates and releases the required amount of insulin

https://www.diabetes.org.uk/Research/Research-round-up/Research-spotlight/Research-spotlight-the-artificial-pancreas/

Length of Sleep and DM Risk

• American Teenagers• Length of Sleep and Insulin Resistance• (Cells unable to respond to insulin leading to higher glucose levels in the blood)

• Insulin resistance is a risk for developing DM

• Teenagers who slept less had more Insulin Resistance

• Small study with limitations and confounding factors

Matthews KA, Dahl RE, Owens JP et al. Sleep duration and insulin resistance in healthy black and white adolescents. Sleep.

Short Bursts of Activity and DM Risk

Imperial College and University College London examined data from 20,000 commuters

• People who walk to work are 40% less likely to have diabetes than those who drive and 17% less likely to be hypertensive

• Cyclists have 50% lower risk than driversAm J Prev Med. 2013 Sep;45(3):282-8. doi: 10.1016/j.amepre.2013.04.012

LSE, Harvard & Stanford Meta-analysis

• 305 trials, 339,274 people• Exercise v Drugs• Mortality Outcomes• Physical activity is potentially as effective

as many drug interventions in secondary prevention of coronary heart disease, stroke, heart failure, and pre-diabetes

http://www.bmj.com/content/347/bmj.f5577

LSE, Harvard & Stanford Meta-analysis

• 305 trials, 339,274 people• Exercise v Drugs• Mortality Outcomes• Physical activity is potentially as effective

as many drug interventions in secondary prevention of coronary heart disease, stroke, heart failure, and pre-diabetes

http://www.bmj.com/content/347/bmj.f5577

Britons getting fatter despite

consuming fewer calories

• Britons are consuming 600 fewer calories a day by healthy eating choices but are actually getting fatter because of sedentary jobs and a lack of exercise

Institute of Fiscal Studies 2013 (Daily Telegraph - June 17 2013)

Diabetes Part 2

Medications for Diabetes

• There will be a second session on Diabetes later in the programme exploring prescribing for Diabetes including Insulin.

Upcoming Sessions

• 9th December 2014: COPD (Michaela Bowden)

• 6th January 2015: Lower Limb Orthopaedic Conditions (Dr Khawer Ayoub)

• 20th January 2015: Asthma (Michaela Bowden)