Type 2 Diabetes Mellitus

1. Type 2 Diabetes Mellitus FOR GPST2 DR BECKY LUND

3. Bolton prevalence – 6.2% - highest in those practices with more patients that are elderly and/or of SE Asian origin (Community Orientation)

4. Overview of NICE guidelines • Who should we test for diabetes? • How do we diagnose diabetes? • When should we not use HbA1c? • What are the targets for . . . • BP • Lipids • HbA1c

6. Overview of NICE guidelines • What lifestyle advice should we give? • How should we treat hypertension in T2DM? • What are the recommendations for lipid control in T2DM? • primary and secondary prevention

10. BM monitoring NICE recommend only offer SMBG in adults if:  the person is on insulin or  there is evidence of hypoglycaemic episodes or  the person is on oral medication that may increase their risk of hypoglycaemia while driving/operating machinery or  the person is pregnant, or is planning to become pregnant or  the person is starting treatment with oral or intravenous corticosteroids.

12. Priorities for care • Can you order these according to importance for improved outcomes in T2DM? • BP control • Glycaemic control • Lipid control • Microvascular screening • Smoking cessation

13. Priorities for care • Answer . . . • Smoking cessation • BP control • Lipid control • Glycaemic control • Microvascular screening

14. QOF on Diabetes 2017/18 • rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care. • 86 points available for diabetes (large proportion of total) 1 2 3 4 5

15. 6 7 8 9 10 11

16. Diabetes Drugs Can you name 7 drug classes, with examples of each?

17. Diabetes Drugs • Biguanides – metformin • Sulphonylureas / ‘SUs’ – gliclazide, glimepiride • Thiazolidinediones – pioglitazone • Meglitinide - repaglinide • DPP-4 inhibitors / ‘gliptins’ – sitagliptin, alogliptin, linagliptin • SGLTs inhibitors / ‘gliflozins’ – canagliflozin, dapagliflozin, empagliflozin • GLP-1 analogues – exenatide, liraglutide, lixisenatide

18. Diabetes Drugs Can you explain their modes of action?

19. Diabetes Drugs • Metformin - acts mainly by reducing gluconeogenesis and increasing peripheral utilisation of glucose • SUs – directly stimulate insulin secretion from B cells • Pioglitazone – increase whole body insulin sensitivity at molecular level • Rapaglinide - directly stimulate insulin secretion from B cells • ‘gliptins’ – delay activation of GLP1 prolonging its effects • ‘gliflozins’ – inhibit renal glucose reabsorption, insulin independent action • GLP-1 analogues – mimic GLP-1 which increases insulin secretion after meals, reduces gastric emptying and increases satiety.

20. Diabetes Drugs Important factors to consider when prescribing • Risk of hypoglycaemia • Effect on weight • Side effects • Use in renal impairment • CV impact • Cost

24. GLP-1 mimetics For people on triple therapy, with metformin and two other oral antidiabetic drugs, consider combination treatment with metformin, a sulfonylurea, and a GLP-1 mimetic for: • Adults, BMI ≥ 35 kg/m2 AND specific psychological or other medical problems associated with obesity, or  • Adults, BMI < 35 kg/m2 AND insulin therapy would have significant occupational implications, or weight loss would benefit other significant obesity-related comorbidities.  GLP-1 mimetic therapy should only be continued if the person has had a beneficial metabolic response = a reduction of at least 11 mmol/mol in HbA1c and a weight loss of at least 3% of initial body weight in 6 months.

27. BREAK

28. Explaining to patients • Pre-diabetes - multiple terms (studies have found that patients favour ‘borderline diabetes’, coded as ‘At risk of diabetes’), ‘Golden Opportunity’ • T2DM - https://www.youtube.com/watch?v=JA81IEAQMR0 - Patient UK description - ‘Normally the amount of sugar in the bloodstream is controlled by the hormone insulin from the pancreas. In people with diabetes there is not enough insulin or the insulin doesn’t work properly. If the sugar level remains poorly controlled this can lead to various problems including eye, feet and kidney problems, and there is an increased risk of developing heart disease or stroke.’ • Lifestyle advice Use motivational interviewing rather than confrontational questions, non-judgemental, use patients ICE, avoid jargon, show empathy

29. Case 1 • 30yr old, male, farmer presents TATT asking for repeat TFTs. Snores and has longstanding nasal congestion. • PMH: subclinical hypothyroidism, mild sleep disordered breathing – advised by sleep clinic to lose weight • O/E Weight 165kg, BMI 50, BP 160/100

30. Bloods – • HbA1c 55 • ALT 58 • Triglycerides 2.3 • Folate low BP 170/110 Epworth Sleepiness Scale 12/24 (mild daytime sleepiness)

31. Bolton CCGIsolated ALT rise pathway

32. Given education on T2DM & lifestyle advice, • Added to screening registers and coded • Commenced metformin and ramipril • ECG, rpt U&Es & BP in 2wks, also hand in urine for ACR • Rpt LFTs in 4wks & 3mnths • Referred to weight management service • Some improvement with intranasal steroid 

33. How do you start metformin? • Ensure U&Es checked (avoid is eGFR <30, review if eGFR < 45 – increased risk lactic acidosis) • Ensure LFTs checked (withdraw if tissue hypoxia likely) • GI upset • Gradual uptitration – e.g. 500mg OD for wk 1, 500mg BD for week 2, 1g in the morning and 500mg at night for week 3, 1g BD for week 4 • GA / iodine-containing contrast • Pregnancy / breastfeeding • Sick day rules

34. What are your own feelings about overweight and obesity? How might your attitude, as well as societal attitudes, influence your care of patients who are overweight? • What are the social implications of obesity? • How do you approach this topic with patients? Fitness to Practice Maintaining an ethical approach

35. Case 2 • 49yr old Asian male attends for Diabetic Annual Review • HbA1c 79 • Current treatment alogliptin 25mg OD, metformin SR 2g OD, dapagliflozin 10mg OD, glimepiride 5mg OD – forgets at times! • Never smoked, no alcohol • BP 138/86, BMI 29.4, QRISK 12 • Self monitors BMs before breakfast/evening meal– although often forgets! Experiencing symptoms of polyuria and polydipsia, urine dip NAD. Recent consultations – angina, GORD

36. Orlistat • Pancreatic lipase inhibitor that inhibits triglyceride digestion and reduces fat absorption • Licensed for: • Obese with a BMI ≥ 30 kg/m2, or • Overweight with a BMI ≥ 28 kg/m2 with associated risk factors. • Treatment should only continue beyond 3 months if the person has lost at least 5% of their body weight. • There is no restriction on how long orlistat may be prescribed - expert opinion is that, after 12 months, a decision to continue treatment should be taken on an individual basis, weighing up the benefits, costs, and risks for that person. • Orlistat 120 mg should be taken immediately before, during, or up to 1 hour after each main meal (up to a maximum of three times a day). The dose should be omitted if a meal is missed, or if the meal contains little or no fat. • Very rarely (< 1/10,000) hepatitis and cholelithiasis have been reported • Absorption of fat-soluble vitamins may be – ensure plenty of fruit and veg and consider OTC multivitamin supplement.

37. Case 3 • 46yr old lady • struggled with her weight for many years, despite numerous diets, she has never managed to achieve sustained weight loss and is obese with a BMI of 36. • PMH: hypertension, hyperlipidaemia, and T2DM (diagnosed three years ago) • Annual checks have identified background retinopathy but no evidence of nephropathy or neuropathy. • Six months ago she was started on insulin by the diabetes specialist team as her glycaemic control was poor on maximal oral hypoglycaemic therapy and she was due to undergo a cholecystectomy. • Her glycaemic control has deteriorated further since starting insulin. Her HbA1c has increased from 91 to 102. • The practice nurse has been unable to check this result against the patient’s home monitoring record because Mrs Jones has not been testing her blood glucose levels but monitoring her urine glucose instead. When her urine test is negative she has been omitting her insulin dose. • You note that her blood pressure, cholesterol and triglycerides are elevated and that her weight has increased by a further 3 kg over the last six months.

38. How would an awareness of social and psychological factors help the management of this patient? • How would you explain to Mrs Jones the importance of managing her blood glucose, blood pressure, lipids and weight? • What other factors may affect the validity of the Hba1c value?

39. Divorced, single parent to two young children, also looks after her elderly parents and holds down a full-time job at a local bank. • She admits that she has not been prioritising her diabetes, she resents being on insulin and has also been forgetting to take her oral medications. • Fear of having a hypoglycaemic episode. She has been eating larger amounts of carbohydrate regularly to run high blood glucose levels as she had one ‘hypo’ several months ago which frightened her. • She has stopped driving since then and this is making life more stressful.

40. Urgent referral to the diabetes clinical team • Time is spent teaching her how to test and manage her blood glucose, given targets to aim for and an agreement is reached regarding the number of blood glucose measurements and insulin injections per day. • Her obesity is discussed, it is evident she has developed a number of eating behaviours that have contributed to her weight gain. She agrees to enrol on a structured education programme for type 2 diabetes and to be referred to the psychology service for support to change her eating behaviours. • GLP-1 agonist therapy is initiated to assist weight loss and insulin is down-titrated.  • Six months later, she has lost 12kg and is reaching glycaemic, lipid and blood pressure targets. She remains on the GLP-1 agonist and no longer requires insulin.

41. Other areas not covered by this session • Insulin in T2DM • Gestational diabetes • Ramadan & Diabetes • DKA and sick day rules • Driving and diabetes

42. Thank you!