Management of Type 2 Diabetes

1. Management of Type 2 Diabetes New Zealand Guidelines Group

3. Cost of Type 2 Diabetes • Major component of General Practice work requiring an intensive and integrated approach: • 2010 prevalence: 195,778 people with type 2 diabetes or 4.4% of New Zealanders • 50-64: 8-9%, 65+: 15-16% • Number 4 OECD • Increased prevalence amongst Māori, Pacific and Indian subcontinent peoples

4. Cost of Type 2 Diabetes cont. • An additional $3,721 of publicly funded health care for each person with type 2 diabetes per year1 • Approximately $728 million extra healthcare cost per year 1. Ministry of Health, 2008

5. 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

6. Critical Issue: Management of BP BP is measured frequently but BP targets set in clinical guidelines not being consistently met Recent NZ reports indicate 53–78% of people with type 2 diabetes have a BP above 130/80 mm Hg Key reasons are medication adherence by patients and clinical inertia, ie, failure of health practitioners to initiate or intensify treatment when indicated

7. 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)

8. Management: microalbuminuria • People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present

9. Critical Issue: Risk of Complications 1.Preventing complications an important aspect of care • Every patient with type 2 diabetes should be assessed for risk of diabetes-related complications early in their diabetes care • Māori and Pacific – complications develop more frequently and at a younger age

10. 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.

11. 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

12. Key Points For General Practice(1) 1. General Practice and Primary Care need to take the lead • Identify risk of complications early for intensive intervention

13. Key Points (2) • Aim for HbA1c 50–55 mmol/mol (~7%) • Not too aggressive target 7%(50-55) • Accord (2010) – Some evidence increase fatal events with tighter control (6%) • Metformin till eGFR < 30 • Insulin early rather than late

14. Key Points (3) • BP aim <130/80. • Avoid Clinical Inertia • Often multiple medication required • <120 maybe harmful(Accord) • ACEI/ARB with microalbuminuria, whether or not hypertensive • Lipid control – • Consider satins early: Aim TC<4, TG<1.7 • CV Guidelines

15. Key Points (4) • Diet/Exercise/Smoking Cessation essential in management: • Diet/Exercise: Additional Benefit compared with most expensive new drugs if intensify diet/exercise. • Practice recalls for retinal screening/podiatry review/bloods/medical review • Specialist advice as required: • Case Conferencing, Phone, E-mail, combined Consults, Outpatients