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T2DM: NICE Guidelines

T2DM: NICE Guidelines. Dr Nemanja Stojanovi ć Consultant Endocrinologist Queen’s Hospital, Romford. The Talk. Diabetes: Definition/ Classification A few cases NICE Guidelines New Developments. Definition. Fasting plasma glucose 7mmol/l- 2 occasions

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T2DM: NICE Guidelines

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  1. T2DM: NICE Guidelines Dr Nemanja Stojanović Consultant Endocrinologist Queen’s Hospital, Romford

  2. The Talk • Diabetes: Definition/ Classification • A few cases • NICE Guidelines • New Developments

  3. Definition • Fasting plasma glucose 7mmol/l- 2 occasions • 2 h plasma glucose or random glucose of 11.1 mmol/l

  4. Case1: What is Your Next Question ? • Is there family history of Diabetes? • She should be referred and genetic counselling offered

  5. DM Classification • Type 1 DM • Type 2 DM • GDM • ? Double Diabetes • Type 1.5 • LADA • Other subtypes

  6. MODY HNF-4α (1) Glucokinase (2) HNF-1α (3) IPF1  (4) HNF-1β (5) Neuro D1 (6) Neonatal Diabetes Mitochondrial DNA defects Genetic defects of insulin action Genetic Diabetes

  7. Drug Induced • Steroids • Pentamidine • T4 • β blockers • Dizoxide • Nicotinic Acid • Thiazides • α Interferon

  8. ENDOCRINOPATHIES Acromegaly Cushing’s Disease Glucagonoma Hyperthyroidism Somatostatinoma Aldosteronoma Pheochromocytoma Others Exocrine Pancreas Cystic Fibrosis Hemochromatosis Haemosiderosis Cancer Trauma/ surgery Pancreatitis Other Forms of DM

  9. NICE May 08 • Patient centred care • Good communication is essential • Support the care with evidence based medical information • Allow patient is to reach informed decisions about their care

  10. Self Monitoring • Offer it only as a part of integral care • Discuss the purpose • Insulin treatment • OHA’s: to provide information on hypoglycaemia • To assess changes in glucose control resulting from medications and lifestyle change • To monitor glucose during intercurrent illness • To ensure safety during activities, including driving.

  11. Education • Meet the national criteria laid down by DoH • Meet the local cultural, linguistic, cognitive and literacy needs • Provide appropriate resources to support the educators, who should be properly trained and allowed time to develop and maintain their skills.

  12. Diet • General advice for healthy eating: • Include high-fibre, low-glycaemic index sources of carbohydrate • Include low-fat dairy products and oily fish • Control the intake of foods containing saturated fats and trans fatty acids

  13. HbA1c • Target: 6.5% • Discuss with the patient appropriate levels, set individual A1c targets • Escalate treatment when HbA1c is> 7.5%

  14. Metformin • Start over several weeks • Consider SR if GI side effects • Stop if Cr> 150umol/l or GFR< 30ml/min • In patient with moderate liver impairment /cardiac dysfunction discuss with the patient risk vs benefit

  15. Sulphonylureas • Start low cost (not glibenclamide) when indicated • Educate about the risk of hypoglycaemia • PPGs

  16. Glitazones • Warn about significant oedema and tell the person what to do if it happens • Do not start if evidence of LVF or high risk of fracture • When selecting a glitazone take into account most up-to-date advice, safety and cost issues

  17. Exenatide • HbA1c> 7.5% • BMI (Caucasian)> 35 • Has specific psychological, biochemical or physical problems arising from high body weight • Would otherwise be starting TZD or insulin. • Continue if of 1% in A1c over 6 months and BW of 5% over 12 months

  18. Acarbose • If unable to tolerate other medications

  19. Insulin • If HbA1c> 7.5% • Structured programme • Start once or twice daily NPH with SU + metformin • Injection devices/ sharps

  20. Glargine • Patients who need help injecting • BD insulin otherwise needed • Significant hypoglycaemia including nocturnal hypos

  21. Biphasic Insulin • HbA1c > 9.0%. Biphasic Analogues • Immediate injection before the meals is preferred • Problems with hypos • Postprandial hyperglycaemia is a problem

  22. Blood Pressure • Target 140/80 mmHg • If macro/ microvascular damage: retinopathy, nephropathy, cerebrovascular disease: 130/80 mmHg • Monitor for SE of therapy

  23. Blood Pressure • Monitor annually in normotensive patients without renal disease • BP above the target: • Repeat within a month if > 150/90mmHg • Repeat within 2 months if > 140/80mmHg - Repeat within 2 months if > 130/80mmHg & eye, kidney or cerebrovascular disease

  24. Patients Not at High CVS Risk • Normal weight • BP< 140/80mmHg off treatment • Normal ACR/ AER • Non smokers • Do not have high risk lipid profile • No PMH of CVH • No FH of CVD DO NOT HAVE ANY OF THESE

  25. Effect of reduction of LDL by 1mmol/l by any means on coronary death and non-fatal MI: meta-analysis of 58 trials Law MR BMJ 2003, 326: 1423-9

  26. Equivalent Doses + max dose decreases the LDL by additional 20%

  27. Nephropathy • Assess annually: ACR, Cr • High ACR: repeat 2x within 3-4 months • Treat with ACE/ ARB • Aim for BP< 130/80mmHg

  28. Suspect Intrinsic Renal Disease • No retinopathy • BP resistant to treatment • Proteinuria in the face of previously normal ACR • Rapid decline in ACR • Haematuria • Systemically ill patient

  29. Eye Screening • Annually • Discuss the benefits • Tropicamide and Driving

  30. Referral to Ophthalmologist • Maculopathy • Unexplained loss of VA • Pre-proliferative retinopathy

  31. Studies/ Recommendations that followed the Guideline

  32. ADVANCE • 11140 patients: 5 years • Intensive glycaemic control (A1c 6.5%) vs Conventional (A1c 7.3%) • Intensive group: gliclazide MR 30 to 120 mg daily and other hypoglycamic agents including insulin N Engl J Med 2008;10.1056/NEJMoa0802987

  33. ADVANCE Primary Endpoints • Composite of macro and microvascular events considered jointly and separately • Macro: CVD death, non fatal CVA & MI • Micro:new or worsening nephropathy ; doubling of the serum creatinine; the need for dialysis; death due to renal causes; worsening of retinopathy N Engl J Med 2008;10.1056/NEJMoa0802987

  34. ADVANCE Conclusion • The main contributor to the 10% relative reduction in the primary outcome found with intensive control as compared with standard control was a 21% relative reduction in the risk of new or worsening nephropathy • More modest but significant reduction in microalbuminura

  35. ACCORD Trial • 10,251 patients • Intensive glycaemic control and CVS outcomes • Primary outcomes : CVD death, Non fatal CVA & MI • Intensive Treatment: HbA1c< 6% • Conventional Treatment HbA1c 7-7.9 • Death rates begin to separate after 1 year….. N Engl J Med 2008;10.1056/NEJMoa0802743

  36. ACCORD N Engl J Med 2008;10.1056/NEJMoa0802743

  37. HbA1c and Screening for T2DM • <6% • 6.1-6.5% • 6.5-6.9% • >7% JCEM,2008; 93: 2447-53

  38. Fasting Plasma Glucose and CVA/ Vascular Events: NOMAS • 3298 participants • 572 patients with DM • DM patients: 338 elevated FPG > 7mmol/l • In elevated FPG: CVA HR 2.7(95 CI: 2.0-3.8) • Those with DM and normal FPG were not at increased risk Dia Care 2008; 31:1132- 37

  39. Conclusion • A1c 6.5% ( ? 7.5%) • BP 130/80mmHg (140/8o mmHg) • Cholesterol 4mmol/l • LDL 2mmol/l • Triglycerides 4.5mmol/l • Eyes, Kidneys, Nerves: Screen annually

  40. EndoDiabetes.com

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