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Management of Type 2 Diabetes
New Zealand Guidelines Group
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
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
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
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
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)
Management: microalbuminuria
• People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present
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
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.
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
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
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
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
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