Diabetes for the AKT

September 2013

We reproduce below our feedback from AKT 16 which sadly continues to apply in AKT 17. Please re-read!

“In the last feedback, we noted that diagnosis of diabetes appeared to have improved. However, in AKT 16 there were again difficulties in interpreting test results. It is very likely that similar items will appear in subsequent tests. We would suggest that candidates carefully review this aspect of diabetes care which will become even more significant in daily work as the prevalence of diabetes increases. “

AKT feedback Jan 2013

Diagnosis according to…

NICE CKS guidelines for diagnosis…• Fasting Plamsa Glucose = or > 7.0 mmol/l– On 1 occasion if symptommatic (polyuria, polydipsia

and weight loss)– On 2 occasions if asymptommatic

• 2 hr plasma glucose = or > 11.1 mmol/l after 75 g oral glucose load (i.e. OGTT)

• OGTT considered “gold standard”– OGTT > fasting plasma glucose > random plasma

glucose

WHO (via Map of Medicine)…• HbA1C = or > 48 mmol/mol (6.5%) or…

• As above: OGTT, fasting plasma glucose and random plasma glucose (= or > 11.1 mmol/l)

• Perform an OGTT if– Fasting plasma glucose 6.1 – 6.9 mmol/l– Random plasma glucose 6.1 – 11 mmol/l

• So, how to intepret OGTT results…

A

• Fasting plasma glucose < 7 mmol/l and 2 hr OGTT plasma venous glucose = or > 7.8 mmol/l up to (but not incl.) 11.1 mmol/l– IMPAIRED GLUCOSE TOLERANCE

• Fasting plasma glucose 6.1 – 6.9 mmol/l AND 2 hr OGTT plasma venous glucose < 7.8 mmol/l– IMPAIRED FASTING GLYCAEMIA

Gestational Diabetes• SIGN guideline

• At booking– Assess for risk factors– If risk factors present for HbA1C or a fasting glucose

• Risk factors for gestational diabetes are defined as:[16]BMI more than 30 kg/m?.Previous macrosomic baby weighing 4.5 kg or more.Previous gestational diabetes.Family history of diabetes (first-degree relative with diabetes).Family origin with a high prevalence of diabetes, including South Asian, Black Caribbean and Middle Eastern.

• All women with risk factors should have an OGTT at 24-28 weeks

Type 2 Diabetes Management

• NICE CG87, piorities:– Offer structured education to every person at

time of diagnosis– Individualised dietary advice– Target HbA1C = 6.5 (48), avoid pursuing less than

this and tailor to individual patient– Offer self-monitoring…only as an integral part of

their self-management education (??)– When starting insulin use a structured programme

Simple?

Medication Step 1 Step 2 Step 3Metformin Yes Yes YesSulfonylurea (Gliclazide) Yes Yes YesDPP-4 I (Gliptins) No Yes YesThiazolidinedione (Pioglitazone) No Yes YesGLP-1 agonists (Exenatide) No No YesInsulin No No Yes

Blood glucose lowering therapy

• If HbA1C >/= 6.5 (48) after trial of lifestyle METFORMIN, unless;– NOT over-weight– Metformin not tolerated/Cied– Hyperglycaemic symps requiring rapid control

• Essentially step 1:– Mostly METFORMIN or occasionally

SULFONYLUREA

Blood glucose lowering therapy con• Step 2 kicks in if HbA1C >/= 6.5 (48) :– If on METFORMIN add in SULFONYLUREA– If on SULFONYLUREA add in METFORMIN– However, just to make things more complicated…

• If on METFORMIN and worried about hypos (i.e. you do not want to, or unable to, use SULFONYLUREA)– Add in DPP-4 INHIBITOR (gliptins) or THIAZOLIDINEDIONE

(Pioglitazone)

• If on SULFONYLUREA and cannot have METFORMIN– Add in DPP-4 INHIBITOR or THIAZOLIDINEDIONE

So far then…• STEP 1– METFORMIN or SULFONYLUREA

• STEP 2

– METFORMIN + either SULFONLYUREA or DPP-4 INHIBITOR or THIAZOLIDINEDIONE

– SULFONYLUREA + either DPP-4 INHIBITOR OR THIAZOLIDINEDIONE

Step 3• By now using 2 drugs and aiming for HbA1C < 7.5 (59) (note

up until now 6.5)

• Possibilities:– METFORMIN + SULFONLYUREA + DPP-4 INHIBITOR or

THIAZOLIDINEDIONE– METFORMIN + DPP-4 INHIBITOR + THIAZOLIDINEDIONE– METFORMIN + THIAZOLIDINEDIONE + DPP-4 INHBITOR– SULFONYLUREA + DPP-4 INHIBITOR + THIAZOLIDINEDIONE– SULFONYLUREA + THIAZOLIDINEDIONE + DPP-4 INHBITOR

• The final meds you can add at this point are GLP-1 agonists (i.e. Exenatide, Liraglutide)– NICE guidance only states to use EXENATIDE in combination

with METFORMIN + SULFONYLUREA

Insulin• Insulin is mentioned in Step 3 – presumption

seems to be that most patients would prefer to stick to oral meds though:

“Consider adding sitagliptin or a thiazolidinedione instead of insulin if insulin is unacceptable (because of employment, social, recreational or other personal issues, or obesity)”

• INSULIN + METFORMIN + SULFONYLUREA

Metformin

• Titrate up over several weeks to avoid GI side effects

• Consider MR version if side effects occur

• REVIEW metformin if: – creat > 130 or if eGFR < 45– STOP metformin if creat > 150 or if eGFR < 30

Sulfonylureas

• Prescribe low cost sulfonylurea i.e. gliclazide

• Educate patient about risk of hypos especially if concurrent renal impairment

• The main CI is patients at risk of hypos or if hypos would make occupation difficult

Thiozolidedinione• Pioglitazone• Continue gliptin ONLY if HbA1C reduction of >/=

0.5 points (5.5) by 6 months• Contra-indications:– Heart failure (or a history of it, all stages)– Hepatic impairment (ALT > 2,5 times upper limit

normal or “liver disease”)– A risk, or history, of bladder cancer or uninvestigated

visible blood in urine• Avoid in women at high risk of fractures• Monitoring:– Baseline LFTS and then every 2 Vs 6 months for first

year and then annually

Gliptins

• Sitagliptin, Vildagliptin, Saxagliptin• Contra-indications;– Renal impairment eGFR < 50– Hepatic impairment (does not appear to apply to

Sitagliptin – check BNF, but would req monitoring)– Pregnancy and breastfeeding– Use cautiously in patients aged 75 and over

• Risk of Pancreatitis – warn patient• Continue gliptin ONLY if HbA1C reduction of

>/= 0.5 (5.5) points by 6 months

Exenatide (GLP-1 agonists)• Contra-indications:– GI disease (IBD, gastroparesis)– Renal impairment eGFR < 30– Pregnancy and breast feeding– Acute/chronic pancreatitis or a history of those, warn

patients re risk and symps of pancreatitis

• Continue Exenatide only if the person has a reduction in HbA1c of ≥ 1.0 (11) percentage point and ≥ 3% of initial body weight in 6 months

Blood Pressure

• Target < 140/80 unless– Renal, eye or cerebrovascular damage when

target should be < 130/80

Lipid control• Consider patients with diabetes to be at high CV

risk unless ALL the following apply:– Normal BMI– Normal BP– Non-smoker– No microalbuminuria– No personal or FHx of cardiovascular disease– Normal lipid profile

• In reality nearly all patients with have at least one of these!

Lipid control• < 40 + “CV risk profile seems to be particularly

poor” = statin (simva 40mg)

• >/= 40 and no CV risk factors = assess CVD risk– If < 20% no statin– If >/= 20% = statin (Simva 40mg)

• >/= 40 + CV risk factor = statin (Simva 40mg)

• If trigs > 4.5 – consider fibrate

• Target: TC < 4 or LDL < 2

Aspirin?

• MRHA:

“Aspirin is not licensed for the primary prevention of vascular events. If aspirin is used in primary prevention, the balance of benefits and risks should be considered for each individual, particularly the presence of risk factors for vascular disease (including conditions such as diabetes) and the risk of gastrointestinal bleeding”

Renal problems• Assess at diagnosis and then annually

(creatinine,eGFR and ACR)• Diabetic nephropathy = persistent

albuminuria• Albuminuria – albumin/creatinine ratio first

pass urine morning sample• Abnormal ACR (microalbuminuria)– >/= 2.5 men– >/= 3.5 women– If abnormal repeat x 2 within 3-4 months

Renal Problems

• Raised ACR = ACEi or A2RB (with usual precautions)

• Aim for BP < 130/80

Diabetes and Driving

• Specifications in detail can be found here

Inform DVLA? Sulfonylurea/Glinides Insulin Other DietCar/Motorcycle NO YES NO NOBus/Coach/Lorry YES YES YES NO