Current Evidence and Best Practice in the Management …€¦ · Current Evidence and Best Practice in the Management of Diabetes ... acarbose, Gliptins, ... Current Evidence and

Current Evidence and Best Practice in the Management of Diabetes

Ganesh ArunagirinathanConsultant Physician

Western General HospitalEdinburgh

Diabetes mellitus

• Coined by the Greek Physician Aretaeus-Diabetes meaning siphon

• Mellitus meaning Honey in Latin

• Group of metabolic diseases characterised by high glucose levels in blood (hyperglycemia)

• Defects in insulin secretion or insulin action or both

• Long term damage, dysfunction and failure of various organs

Classification of Diabetes

• T2 Diabetes Mellitus

• T1 Diabetes Mellitus

• Gestational Diabetes Mellitus

• Monogenic Diabetes

• Secondary diabetes- pancreas, hormonal/endocrine including steroids

• Rare & related to syndromes

UK-Diabetes data (Facts & Figures, Diabetes UK 2015)

• More than 1 in 16• 4 Million in UK (90% T2DM, 10% T1DM)• 56% Men, 44% Women• I person is newly diagnosed every 2 minutes

• Undiagnosed 549000• Impaired Glucose Tolerance prevalence 5.9%

• Scotland 271,312

Ethnicity

• South Asians upto 6 times higher risk of diabetes than Caucassians

• Black African/Carribean have upto 5 times higher risk

• Children of Asian origin are 8.9 times & black African origin 5.8 times more likely to have T2DM than Caucassian children

Children & Diabetes(DUK)

• Prevalence of T1DM - 22.8/100,000

• Peak age of onset is 9 to 14

• 95% T1DM

• 1.9% T2DM

• 2.73% Monogenic & others

Gestational DM

• 5% of all pregnancies in UK

• 7.5% T1DM, 5% T2DM

• Manifest in the 2nd or 3rd trimester

• 7 fold higher risk of diabetes in later life

• Children born to women with GDM are usually overweight & have 6 times higher risk of T2DM later in life

HbA1C

Glycosylated Haemoglobin Marker of glucose control

DCCT to IFCC conversion

Burden of the disease

• T1DM• By age 20, life expectancy reduced by 11 years in

men and 14 years in women

• T2DM• Life expectancy reduced by 6 years around age 50

• 10% of NHS budget spent on diabetes(1 million an hour)

Diabetes Control &Complications Trial(DCCT) T1DM

• 1983-1993

• US & Canada

• Age 13-39

• T1DM between 1 to 15 years from diagnosis, no or minimal retinopathy

• 1441

DM diagnostic criteria

DCCT- EDIC 30 year MACE follow upLegacy effect-Metabolic memory

Diabetes Care 2016

United Kingdom prospective Diabetes Study (UKPDS) T2DM

• 1977 to 1997

• 23 UK centres

• 5102 patients with median follow up of 10 years

• Intensive vs conventional glucose control

UKPDS Summary

• There is a direct relationship between the risk of complications of diabetes and glycaemia over time

• No threshold of glycaemia was observed for a substantive change in risk for any of the clinical outcomes examined

• The lower the glycaemia the lower the risk for complications

• The rate of increase of risk for microvasculardisease with hyperglycaemia is greater than that for macrovascular disease

UKPDS

0

2 0

4 0

6 0

8 0

0 5 6 7 8 9 1 0 1 1

Myocardial

infarction

Microvascular

disease

Updated mean HbA1c (%)

Incid

ence p

er

1000 p

atient-

years

UKPDSIntensive (SU/Ins) vs. Conventional glucose control

HR (95%CI)

UKPDS

BP 154/87 vs 144/82

Risk for macrovascular disease

• Hypertension

• Dyslipidaemia

• Insulin resistance

• Obesity

• Smoking

• Higher HbA1C

• Synergistic interaction of above factors

Pathophysiology

• Similar to non-diabetic population

• More extensive, diffuse, aggressive, distal & multivessel involvement

• Higher rate of hypertension(50%) and dyslipidaemia(30%) at diagnosis

• HbA1C is an independent risk factor for vascular disease

MRFITStamler J et al, Diabetes Care 1993

“Diabetes is Coronary Artery disease equivalent”

MRFIT study- Haffner SM et al, NEJM 1998

Statins- Metaanalysis CTT collaborators, Mar 2012, Lancet

STATINS sign 116

• 1mmol/L reduction in LDL = 21% reduction in risk of CVD

• CARDS study- Benefit noted irrespective of baseline cholesterol concentration

• Simvastatin 40mg or atorvastatin 10mg daily for T2DM over 40 years (consider in T1DM)

• Statin should be recommended in <40 age group with higher risk eg microalbuminuria

• In established CVD/ACS, atorvastatin 80mg/day

Smoking- Nurses Health Study

Management of T1DM

• Structured education- Carbohydrate counting and insulin dose adjusting

• DAFNE (Diet Adjustment For Normal Eating)

• Insulin pumps- special features like low glucose suspend etc.

• Monitoring devices- Continuous glucose monitor, Flash sensors

Insulin pens and regimens

Pumps, sensors and data

SIGN 116- Psychosocial• Regular assessment of a broad range of psychological and

behavioural problems in children and adults with type 1 diabetes is recommended

• In children this should include eating disorders, behavioural, emotional and family functioning problems

• In adults this should include anxiety, depression and eating disorders

• Children and adults with type 1 and type 2 diabetes should be offered psychological interventions (including motivational interviewing, goal setting skills and CBT) to improve glycaemic control in the short and medium term.

Acute complications

• Hypoglycemia

• DKA

• HHS

Hypoglycemia treatments

T2DM

• Diet

• Lifestyle

• Oral meds- metformin, sulphonylureas, pioglitazone, acarbose, Gliptins, SGLT2 inhibitors

• Injectable- GLP1 analogues(daily, weekly)

• Insulins

• Weight management and bariatric surgery

DESMOND

• Diabetes Education and Self Management for Ongoing and Newly Diagnosed patients with Type 2 Diabetes

• Within the 1st year of diagnosis

Bariatric surgery

• Interventions –individualised lifestyle, pharmacological and surgical- should be offered SIGN 116

• Body Mass Index above 35 with diabetes or other comorbidities

• Benefit in reversing T2DM or reducing medication requirements

Bariatric surgery

Retinal photography

Slit lamp biomicroscopy

Diabetic Retinopathy images

Optimal Coherence Tomography (OCT)

Normal Macular oedema

EDIC Retinopathy progression

Risk factors for Diabetic Retinopathy

Duration of disease- severity

Poor glycaemic control

Renal disease – risk factor for onset and progression

Hypertension-linked to PDR & established risk factor for macular oedema

Dyslipidaemia associated with hard exudates

Pregnancy, puberty, smoking, obesity

Retinopathy prevention & treatment

• Tight glycaemiccontrol

• BP, weight, lifestyle

• Lipids- fenofibratesuseful

• Smoking cessation

• Pre-pregnancy counselling- screen during each trimester

Scatter photocoagulation to peripheral retina

Focal laser photocoagulation for Clinically Significant Macular Oedema

Macular Grid laser for diffuse macular neovascularisation/ leak

Pars plana Vitrectomy for fibrovascularproliferation, severe retinal disease not amenable to laser

Structure of a kidney and nephron

Management of nephropathy

• ACEI/ARB- withhold if dehydration, contrast

• BP- as low as tolerable; 130/80 & below

• Glucose

Statins-

• May preserve renal function over time and reduce microalbuminuria

• Reduce albuminuria even if EGFR <30ml/mt

• avoid fibrates in CKD- 4 & 5

• Smoking cessation

• Avoid nephrotoxics eg NSAIDs

• Hb – check from CKD-3

• Refer to Nephrology if rapid decline in EGFR, Blood in dipstik, CKD 4 ,5 OR atypical presentation

Peripheral nerve anatomy

Clinical presentation of Diabetic NeuropathiesPickup J, Williams G, Textbook of Diabetes Vol 1, 1997

Diabetic Neuropathy

• Varied

• Silent, non-specific or mimic other diseases

• Diagnosed by exclusion

• Grossly under diagnosed

• Complications are equal in type 1 and type 2 DM

• Symptomatic Autonomic neuropathy has 25-50% mortality in 5 to 10 years

Evidence for achieving good glycemiccontrol

• DCCT- 50% reduction in neuropathy over 5 years with intensive insulin therapy

• UKPDS -“Legacy Effect”- despite worsening control later neuropathic symptoms improved

• EDIC study confims Legacy Effect

• STENO trial showed 0.32 reduction in ODDs ratio for development of autonomic neuropathy with treatment of all metabolic comorbidities

Diabetic foot ulcers

• 1.7 to 3.3% in <50 yrs; 5 to 10% in >50 yrs

• 50% annual risk in those with previous ulcers

• Lifetime risk of getting diabetic foot ulcer is 25%

• Amputation performed in 3 per 1000 diabetics

Risk factors for Diabetic foot ulcers

• Neuropathy as such does not cause ulcers

• Callus, deformity & high foot pressures

• Ill fitting shoes

• Foot trauma

• Combination with ischaemia

• Retinopathy, CKD & dialysis

• Previous ulcers

Foot ulcers

Peripheral Vascular Disease

Osteomyelitis

Charcot foot

Aircast, scotch cast, Total Contact Cast, Removable Cast walker

SIGN 116

• Running-style, cushion soled trainers should be used by those with foot disease

• Custom-built footwear or orthotic insoles should be used to reduce callus severity and ulcer recurrence

• Active foot disease to be referred to MD footcare Team

• Cardiovascular risk management should be addressed for anyone with foot disease

Pregnancy planning

• GDM Prevalence 19.8%

• GDM 171300

• Preconception contraception

• Need HbA1C to be very well controlled ideally below 53mmol/mol

• Folic acid 5mg daily upto 12 weeks

• STOP ACE inhibitors/ARBs/Statins

Older people with diabetes

• Diet- minimal restriction in care homes

• Nutritional assessment and individual advice

• Risk of dehydraion/HHS

• Ensure physically active

• Hypo risk is high

• Mental health issues /depression/dementia

• Continence issues

Standards of medical care for older adults, Diabetes Care Jan 2016

Diabetes UK statement• The 15 Healthcare Essentials is the minimum level of healthcare everyone

with diabetes deserves and should expect.

• 1. Get your blood glucose levels measured (HbA1c blood test)2. Have your blood pressure measured3. Have your blood fats measured4. Have your eyes screened for signs of retinopathy5. Have your feet and legs checked6. Have your kidney function monitored7. Get ongoing, individual dietary advice8. Get emotional and psychological support9. Be offered a local education course10. See specialist healthcare professionals11. Get a free flu vaccination12. Receive high-quality care if admitted to hospital13. Have the chance to talk about any sexual problems14. If you smoke, get support to quit15. Get information and specialist care if you are planning to have a baby