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Dr Simon Robertson

Cystic Fibrosis Related Diabetes (CFRD)- Problems with diagnosis – Using Continuous Glucose Monitoring (CGM) and risk/ benefit of treatment. Dr Simon Robertson. Background. What is Diabetes? Insufficient insulin to control blood glucose levels

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Dr Simon Robertson

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  1. Cystic Fibrosis Related Diabetes (CFRD)- Problems with diagnosis – Using Continuous Glucose Monitoring (CGM)and risk/ benefit of treatment Dr Simon Robertson

  2. Background • What is Diabetes? • Insufficient insulin to control blood glucose levels • Type 1 (younger onset, destruction of insulin producing cells in pancreas)> inject insulin • Type 2 (Older onset/ obesity- resistance to the action of insulin)> change diet/ tablets/ insulin • What is CFRD? • Slow insulin release + insulin resistance • not enough Insulin made at wrong time

  3. Who gets CFRD? • Pancreatic insufficient (95%) • Currently diagnosed in 2- 5% by 10yr old • 43% by age 30yr (4-9% increase p.a.) • We look when: • Deterioration in lung function/ worse chest infections (esp teenage girls) • Nutritional decline- weight/ poor growth • NG feeds • steroids • pregnancy • Symptoms of drinking lots and weeing lots

  4. When to diagnose CFRD SCREENING

  5. Normal Blood glucose 3.5 to 7mmol/l More than 8= increased bacterial growth, damage to proteins, poor cell repair Oral Glucose Tolerance Test>8mmol= deterioration likely HbA1c>48mmol/l (6.5%) 1-3h post meal/ on continuous feeds Continuous Glucose Monitoring CGM CFRD if >10% time BG>7.5mmol/lOr 2x more than 11mmol a day Impaired if <1x11mmol + >10% >7.5mmol Check age 10y + 14+ as suspected When do we diagnose CFRD?

  6. Freestyle Libre/ Medtronic Ipro Ipro Check x4 finger pricks/day Problems with needle anxiety

  7. Oral Glucose Tolerance Test

  8. CFRD Treatment • Insulin injections- Either/ or • Just long acting insulin • Quick acting Insulin with each meal + long acting (Basal bolus/ multi-dose regime) • Doses adjusted for carbohydrate eaten and corrected for high BG • Continue CF diet, adjust insulin for that • No evidence Tablets for type 2 diabetes do work • Current trial looking at low glycaemic index diet

  9. Better Weight/ growth More energy, better muscles Maintain lung function Fewer infections/ less hospital/ other treatments BENEFIT Finger prick tests (x4-8/ day)(minimise) Injections x1-7/day (minimise) Risk of low BG (minimise) Changes to diet COST Balance or Minimising the Cost

  10. In Practice how do we make the diagnosis/ decide treatment? • At risk/ symptoms- checked each clinic • Annual review screen (HbA1c >6.5%, OGTT 2h Blood Glucose>11mmol/l, fasting BG>7mmol/l) • BG profile (2h post meal BG levels) • Continuous Glucose Monitoring (CGM)- costly/ not on tariff/ not yet in national guidelines • How high is high enough to out balance treatment?

  11. How high is high enough to out balance PRO treatment? • We don’t know- • Ongoing trials to identify pre- diabetes • ?Treat with Multi dose insulin • ?Treat with 0.2-0.3units/kg long acting insulin • ?Treatment to prevent any blood glucose levels >10 or maybe >8.5mmol/l on CGM

  12. Paediatric diabetes Team • Consultants: Simon Robertson/ Katie Mallam • Paed Diabetes Specialist Nurses: • On call(0800-2100) via switchboard. Daytime 01872 254567 • Anita England/ Michelle Skews/ Pip Ali/ Becky Luke/ Shelagh Newman • Adult diabetes Doctors: Steve Creely, Duncan Browne, Tabinda Dugal, “Dr Chells” (Chellamuthu) each cover a patch of Cornwall

  13. Where to get more info? • CF Foundation 70 page document • CF Trust document- 2004 • Royal Brompton Hospital 2017 guideline • https://www.rbht.nhs.uk/care-children-cystic-fibrosis-cystic-fibrosis-related-diabetes • Clinic- monitoring/ diabetes reviews • Once diagnosed- 4 clinics/year, + Diabetes specialist nurses/ diabetes complication screening

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