Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

1. Diabetes and Thalassaemia 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Dr Maria Barnard & Dr Ploutarchos Tzoulis Romilla Jones, Emma Prescott, Dr Farrukh Shah The Whittington Hospital NHS Trust, London

2. The Diabetes Epidemic • Diabetes affects 366 million people worldwide • Predicted to affect 552 million people by 2030 • Diabetes caused 4.6 million deaths in 2011 • Every 10 seconds a person dies from diabetes-related causes • Every 10 seconds two people develop diabetes • Greatest number of people with diabetes are between 40 to 59 years of age • 78,000 children develop type 1 diabetes each year International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

3. The Top 10 International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

4. Diabetes Prevalence International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

5. The Top 10 by Prevalence International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

6. Healthcare Expenditure (2011) • USD ($) 465 billion spent on healthcare for diabetes • 11% of all healthcare spending is for diabetes • USD ($) 1,274 is spent on diabetes care per person with diabetes International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas

7. Diabetes in β-Thalassaemia Major • Diabetes prevalence ~20% (age, chelation therapy) • Aetiology and risk factors: • Transfusional iron overload • Poor chelation therapy, poor compliance, advanced age of onset • Altered β-cell insulin secretion • Autoimmunity • Insulin resistance secondary to liver disease • HCV infection • Global epidemic – type 1/type 2 diabetes

8. Early Diagnosis of Diabetes • Annual oral glucose tolerance tests (OGTT) from puberty or from age 10 years if there is a positive family history • Prompt treatment of hyperglycaemia • Intensification of iron chelation therapy Thalassaemia International Federation. Guidelines for the Clinical Management of Thalassaemia. 2nd Revised Edition 2008. Available at: http://www.thalassaemia.org.cy/publications.html United Kingdom Thalassaemia Society. Standards for the Clinical Care of Children and Adults with Thalassaemia in the UK. 2nd Edition 2008. Available at: http://www.ukts.org/pdf.html

9. Diagnosis of Diabetes

10. Background retinopathy Kidney glomerulus Neuropathic foot ulcer Ischaemia Glomerular sclerosis Proliferative retinopathy Aim of Treatment • Prevention, detection and management of complications • Microvascular & Macrovascular

11. Mortality in Diabetes • Risk for death among people with diabetes twice that of people of similar age but without diabetes • In 2004, heart disease noted on 68% of diabetes-related death certificates among people aged 65 years or older (USA) • In 2004, stroke noted on 16% of diabetes related death certificates among people aged 65 years or older (USA) Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2011

12. Carbohydrate DIGESTIVE ENZYMES Glucose Acarbose I G Glucose (G) Glitazone GLP-1 Sulphonylureas Meglitinides GLP-1 analogues DPP-IV inhibitors I Adipose tissue G Insulin I (I) G I I I Pancreas G G I I G G Metformin Metformin I Liver Glitazone Glitazone Antidiabetic Drugs Muscle

13. Insulin ± oral agents Oral combination Oral monotherapy Diet & exercise Stepwise Management of Diabetes Sulphonylureas Gliptins GLP-1 analogues Metformin

14. Insulin Therapy 24 hour insulin and glucose profile in non-diabetic persons • Physiological insulin regimen

15. Basal-Bolus Insulin Regimen e.g. Insulin aspart (Novorapid) + insulin glargine (Lantus) Breakfast Lunch Dinner Bedtime Insulin (Rapid) Insulin (Rapid) Insulin (Rapid) Insulin (Basal)

16. Insulin Dose Adjusting • To calculate rapid insulin dose given with a meal: • Take capillary blood glucose before eating • If >7 mmol/l, calculate insulin correction dose • Estimate carbohydrate content of food • 10g carbohydrate = 1 Carbohydrate Portion (CP) • Calculate food insulin using 1 – 3 units for each CP • Remember to adjust for all other factors that may affect glycaemic control (exercise, illness, alcohol etc) • Give insulin (correction dose + food insulin)

17. Whittington Joint Diabetes Thalassaemia Clinic • Aims: • Provide high quality diabetes, endocrine and haematology care • Optimise metabolic control • Support patient self-management • Support partnership working between specialist teams and between patients and clinicians • Provide education, training and research opportunities

18. Whittington Joint Diabetes Thalassaemia Clinic • Patients seen jointly: • Consultant Diabetologist (Dr Maria Barnard) • Consultant Haematologist (Dr Farrukh Shah) • Diabetes Specialist Nurse (Romilla Jones) • Haematology Specialist Nurse (Emma Prescott) • Senior Diabetes Dietitian • Clinical Psychologist • Access to Whittington type 1 diabetes structured education courses (WINDFAL)

19. Whittington Joint Diabetes Thalassaemia Clinic • Complete full diabetes annual review once a year • Address the 9 Key Care Processes for diabetes: • [1] Glycaemic control • [2] Blood pressure • [3] Serum cholesterol • [4] Serum creatinine • [5] Urinary albumin • [6] Weight • [7] Diabetic foot examination • [8] Smoking status assessment • [9] Retinal screening

20. Whittington Joint Diabetes Thalassaemia Clinic

21. Whittington Joint Diabetes Thalassaemia Clinic *median values

22. Performance: Joint Clinic vs. National Audit for England

23. Target achievement: Joint Clinic vs. National Audit for England

24. Metabolic improvement in Joint Clinic • 33% of patients achieved reduction in ferritin of >10% • 23% were on antihypertensive agents • 23% were on lipid lowering agents • 32% on antiplatelet/anticoagulant agents

25. Diabetic Complications in Patients Attending Joint Clinic

26. Endocrinopathies in Patients Attending Joint Clinic

27. Whittington Joint Diabetes Thalassaemia Clinic - Discussion • Joint Diabetes Thalassaemia Clinic effective at providing high quality care in the most complex patients • 41% patients diagnosed with diabetes <19 years of age • Early effective iron chelation is critical • Be aware of diabetic complications (microvascular) • Optimise glycaemic control • Modify cardiovascular risk

28. Diabetes and Thalassaemia -Conclusions • Patients with diabetes and thalassaemia have complex medical care needs • Psychological impact – treatment burden, impact on daily life, feeling of difference, dependence and anxiety • Partnership working of the Joint Diabetes Thalassaemia Clinic: • Patients have easy access to senior specialist clinicians • Continuity of care • Supported by multidisciplinary team • Working together with the patient and each other • Supporting self-management

29. Diabetes and Thalassaemia -Conclusions • Patients receive training in carbohydrate counting and insulin dose adjustment • Patients access type 1 diabetes structured education • Significant educational opportunities for healthcare professionals and staff in training • Managing diabetes is one of the greatest challenges a person with thalassaemia can face. • Joint Diabetes Thalassaemia Clinic enables our patients to effectively manage their physical and psychological long-term health