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Elton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of new diabetes therapies ABCD Autumn Meeting, Royal College of Physicians, London November 6, 2015
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Page 1: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Elton John “Your Song” ABCD Audit Update

Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

new diabetes therapies ABCD Autumn Meeting, Royal College of Physicians,

London November 6, 2015

Page 2: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

ABCD nationwide and worldwide audits of new diabetes therapies

Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

new diabetes therapies ABCD Autumn Meeting, Royal College of Physicians,

London November 6, 2015

Page 3: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Disclosures

• Dr Bob Ryder has received speaker fees, consultancy fees and/or educational sponsorships from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Novo Nordisk, Sanofi-Aventis and Takeda

Page 4: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

• I hope you don't mind

• I hope you don't mind

• That I put down in words

• How wonderful life is while you're in the world

Page 5: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

ABCD nationwide exenatide and liraglutide audits

• Real-life data

– >13000 patients from

– >150 centres

– >500 contributors

• There have been (by 2015)

– 11 published papers

– 23 abstracts

– 13 oral presentations

http://www.diabetologists-abcd.org.uk/GLP1_Audits/PresentationsPostersAbstractsExenatide.htm

http://www.diabetologists-abcd.org.uk/GLP1_Audits/PresentationsPostersAbstractsLiraglutide.htm

Page 6: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

What did we learn from these audits?

• Combined trials v real world

Page 7: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

What did we learn from these audits?

• Combined trials v real world

Page 8: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

What did we learn from these audits?

• Combined trials v real world

• Difference in HbA1c and weight responses – exenatide v liraglutide audits

• Reality versus NICE guidelines

• Off licence use with insulin

• An important safety issue uncovered

• Pancreatitis

• GLP1-RAs in professional drivers

• Liraglutide in renal impairment

Page 9: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

What else did we learn from these audits?

• Diabetes and NAFLD – impact on ALT

• Liraglutide with different insulin regimes

• Effectiveness in South Asians

• Liraglutide – predicting treatment response

• Switching to liraglutide from BD exenatide or from DPP4 inhibitor

• Influence of age and non-use of metformin on GI side effects with liraglutide

• Safety

Page 10: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

SLGT2 inhibitors – a chance to learn in the same way about a new class

• Dapagliflozin

http://www.diabetologists-abcd.org.uk/n3/Dapagliflozin_Audit.htm

Page 11: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

The ABCD nationwide audits

• Immediate local and personal interest to you

• Remove the rust with regard to data analysis and medical statistics

• Contribute to national effort and understanding – listed in all output – CV, appraisal, CEA etc

• Gain ideas and confidence with regard to other possible projects

• An idiots guide now follows!

Page 12: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 13: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 14: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

How am I going to get the data?

Page 15: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 16: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Resources – paper forms that match the online tool

Page 17: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

How am I going to get the data?

• Going forward – fill in forms or enter data in clinic

• How can I get at patients already on dapa?

• Depends on local set up

• Ask to be alerted of all dapa patients – retain notes

• SpRs, CTs, FYs, medical students, secretaries, DSNs

• Local GPs

• Feet up, gin and tonic, think!

Page 18: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

How am I going to get the data?

• The data I am about to show

• SWBH (City hospital) • Combination – forms in

clinics – me and junior staff and DSNs

• Colleague had list of his dapa patients from before audit

• CT1 enhanced colleagues data by looking at clinic systems and getting notes out – entered it into the audit tool

Page 19: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Analysing your own data

• Tool allows easy analysis including

– HbA1c

– Weight/BMI

– Lipids

– BP

– ALT

– Creatinine/eGFR

– Other diabetes medications

– Side effects

Page 20: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 21: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

n=64!

Page 22: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

HbA1c at patients first return visit – data on 33 patients

Page 23: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Paste into minitab

Page 24: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Paired t test. 33 patients. Statistically significant reduction in HbA1c – 8.89mmol/mol

Page 25: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Paired t test. 33 patients. Statistically significant reduction in Weight – 2.69kg

Page 26: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 27: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

n=33 n=33

P=0.008 P=0.001

HbA1c and weight baseline vs first return to clinic following dapagliflozin

Page 28: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

n=33 n=33

P=0.008 P=0.001

HbA1c and weight baseline vs first return to clinic following dapagliflozin

Page 29: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Learning from your own data

• Can investigate individual local cases to get an idea of reasons for differing responses

– Those who deteriorate

• Why?

Page 30: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 31: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

NICE on dapagliflozin

Page 32: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Was it because the pioglitazone was stopped - you have data on other medications in the tool

Page 33: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Learning from your own data

• Can investigate individual local cases to get an idea of reasons for differing responses

– Those who deteriorate

– Those who don’t respond

• Why?

Page 34: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 35: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Learning from your own data

• Can investigate individual local cases to get an idea of reasons for differing responses

– Those who deteriorate

– Those who don’t respond

– Those who respond especially well

• Why?

Page 36: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 37: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Learning from your own data

• Can investigate individual local cases to get an idea of reasons for differing responses

– Those who deteriorate

– Those who don’t respond

– Those who respond especially well

• Why?

Page 38: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 39: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 40: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Through national analysis there is power to really sort out answers

• Can investigate reasons for differing responses – Those who deteriorate – Those who don’t respond – Those who respond especially well

• What about patients – With an older age – With long duration – With differing numbers and types of other diabetes

therapies – any especially effective combinations – From different ethnic groups – With a lower eGFR? – With side effects

Page 41: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of
Page 42: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

ABCD nationwide SGLT2i audits

• Dapagliflozin - becoming well established

• Canagliflozin - launch imminent

• Empagliflozin?

Page 43: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

ABCD nationwide SGLT2i audits

• Dapagliflozin - becoming well established

• Canagliflozin - launch imminent

• Empagliflozin - audit almost certain

• Collect data on all your SGLT2i patients

• Forms for each audit can be ordered through the website or email me

Page 44: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Please join the current ABCD audits

• Dapagliflozin, Canagliflozin, Empagliflozin

• Exenatide QW

• Degludec

0

20

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Page 45: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Please join the current ABCD audits

• Dapagliflozin, Canagliflozin, Empagliflozin

• Exenatide QW

• Degludec

0

20

40

60

80

100

120

140

160

180

200

220

Glargine

Degludec

Intra-subject day to day variability much less with degludec – does it translate into real benefit in patients – or not?

Page 46: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

All contributors listed in all output ABCD nationwide dapagliflozin audit contributors The following are those whom we know about. ABCD nationwide dapagliflozin audit – initial setup, maintenance and nationwide analysis: Ryder REJ, Adamson K, Bailey CJ, Walton C, Thong KY, Sen Gupta P, Cull ML, Yadagiri M. Statistician: Blann A England Aintree University Hospital NHS Foundation Trust (University Hospital Aintree): Wilding J, Yunus A. Bromley CCG (Selsdon Park Medical Practice): Cheah Y, Lovie K. County Durham And Darlington NHS Foundation Trust (Darlington Memorial Hospital): Kamaruddin S, Khan U, Partha P, Peter P, Tarigopula G, Tee SA. Doncaster And Bassetlaw Hospitals NHS Foundation Trust (Bassetlaw Hospital): Chaturvedi P, Payne G. Dorset County Hospital NHS Foundation Trust (Dorset County Hospital): Graja A, Macklin A, Wotherspoon F. Dorset County Hospital NHS Foundation Trust (Cerne Abbas Surgery): Murphy H, Wakeman C. Dudley Group Hospitals NHS Foundation Trust (Russells Hall Hospital): Pang T. East and North Hertfordshire NHS Trust (Queen Elizabeth II Hospital): Phylactou M, Darzy K, Winocour P. East Sussex Healthcare NHS Trust (Conquest Hospital): Batson D, Castro E, Combes A, Dashora U, Govindan R, Kumar S, Moor C, Ravelo M. Great Western Hospitals NHS Foundation Trust (The Great Western Hospital): Bhattacharya B, Broughton C, Ghaffar I. Hull and East Yorkshire Hospitals NHS Trust (Hull Royal Infirmary): Varghese J, Walton C. King's College Hospital NHS Foundation Trust (Orpington Hospital): Allinson R, Allitt C, Amo-Konado S, Barratt M, Cheah YS, Cunningham S, Fisher N, Hopkins D, Hussey S , Lewis D, Lovegrove-Saville L, Mukuva P, Mustafa O. Lancashire Teaching Hospitals NHS Foundation Trust (Chorley And South Ribble Hospital): Balmuri LMR, Imtiaz K. London Medical, London (Private): Abraham R, Palik E. London North West Healthcare NHS Trust (Brent Community Services): Anthony J, Carroll M, Godambe S, McCabe-Hughes F, Murali KS, Ogida L, Patel N, St-John J. Maidstone And Tunbridge Wells NHS Trust (The Tunbridge Wells Hospital): Agarwal G, Barnes D, Billings D, Butler C, Cairns S, Crosby Z, Danby T, Haq M, Ryan A. Pennine Acute Hospitals NHS Trust (North Manchester General Hospital): Tarpey S. Pennine Acute Hospitals NHS Trust (Royal Oldham Hospital): Tarpey S. Royal United Hospital Bath NHS Trust: Robinson T. Sandwell And West Birmingham Hospitals NHS Trust (Cape Hill Medical Centre, GP): Gardner G. Sandwell And West Birmingham Hospitals NHS Trust (City Hospital Birmingham): Bajwa R, Basu A, Cull M L, De P, Lee B, Kaur A, Pickles O, Ryder R E J, Sen Gupta P, Taylor N, Wyres, M, Yadagiri M. Sandwell And West Birmingham Hospitals NHS Trust (Tower Hill Medical Centre, Dr DK Nandis Practice, GP): Bath S, Chiam W. Sandwell And West Birmingham Hospitals NHS Trust (Norvic Family Practice, GP): Pathan A, Charm E. Sandwell And West Birmingham Hospitals NHS Trust (Sherwood House Medical Practice, GP): Hoffman H. Sandwell And West Birmingham Hospitals NHS Trust (Sundial Lane Surgery, Dr K Akhtar, GP): Akhtar R, Baker O, Durk D, Woakes E. Sandwell And West Birmingham Hospitals NHS Trust (Park House Surgery, GP): Baker O, Hallan P. Surrey and Sussex Healthcare NHS Trust (East Surrey Hospital): Brockett K, Clark J. The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust (Royal Bournemouth General Hospital): Hampton K, Partridge H, Walker J, Williams E. The Royal Wolverhampton NHS Trust (New Cross Hospital): Aziz U, Lekkakou L, Oguntolu V. Whitstable Medical Practice (Dr Jm Ribchester & Partners, GP): Brice R, Rollings R, Sansom H. Scotland Greater Glasgow & Clyde: Huang F, Jones G. NHS Fife (Victoria Hospital, Kirkcaldly): Baird J, Burns D, Chalmers J, Creagh M. Royal Infirmary of Edinburgh NHS Trust: Reid H. West Lothian NHS Trust: Adamson K, Reid H, Vanlook L. Western General Hospitals NHS Trust: Reid H. Wales Abertawe Bro Morgannwg University NHS Trust (Morriston Hospital): Bain S C, Eyles J, Kumar P, Min T, Price D, Stephens JW. Abertawe Bro Morgannwg University NHS Trust (Neath Port Talbot Hospital): Chokor M, Peter R. Abertawe Bro Morgannwg University NHS Trust (Singleton Hospital): Bain S C, Eyles J. Abertawe Bro Morgannwg University NHS Trust (Swansea University): Bain S C, Eyles J. Betsi Cadwalader University Healthboard (Wrexham Maelor Hospital): Ahmad S, Khalily N, Stanaway S. Cardiff And Vale NHS Trust: Roberts A. Northern Ireland Belfast Trust (Belfast): Johnston PC, Nugent A. Northern Trust (Antrim Area Hospital): Kennedy A, Strzelecka A. Acknowledgment The ABCD nationwide dapagliflozin audit is an independent audit supported by an unrestricted grant from Astra Zeneca

Page 47: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Top contributors are made co-authors – eg the latest liraglutide audit paper

November 6, 2015: The above paper is BJDVD in press

Page 48: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Top contributors are made co-authors – current

dapagliflozin audit abstracts

Abstracts – ABCD meeting Autumn 2015

Abstracts – DUK APC Spring 2016

Page 49: Elton John “Your Song” - diabetologists-abcd.org.uk · PDF fileElton John “Your Song” ABCD Audit Update Dr Bob Ryder, Clinical lead, ABCD nationwide and worldwide audits of

Please join the current ABCD audits

• Dapagliflozin, Canagliflozin, Empagliflozin • Exenatide QW • Degludec

Do it now - volunteer - email Bob Ryder

[email protected] or

[email protected] or text

07527 389 878