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Diabetes in primary care

Diabetes_in_primary_care

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Diabetes in primary care

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  1. Diabetes in Primary Care

  2. Type 1 (5-15%) Type 2 Pre-diabetes (IFG, IGT, GD) Secondary diabetes Types of diabetes and related conditions

  3. Epidemiology • One million diagnosed diabetics in England (~2%) • 1 in 20 people age > 65 • 1 in 5 people age > 85 • Increasing prevalence – Type 2 DM increased from 2.8% in 1996 to 4.3% in 2005 • 40-60 patients per General Practitioner • 41% NHS funding for Type 2 spent on inpatient care for complications • Most diagnosed after 40 with peak onset age 60

  4. What are the problems in diabetes? • Mortality from CHD 5 times higher • Mortality from CVA 3 times higher • Leading cause of renal failure • Leading cause of blindness in working age • Second commonest cause of lower limb amputation

  5. Aims of diabetes care • Identify those with DM and related conditions • Improve quality of service for diabetic patients • Tackle variations in care • Make best practice the norm • Reach communities at greatest risk • Reduce complication rates • Eliminate discrimination

  6. Challenges in dealing with diabetes • Increasing numbers • Morbidity • Medical resource usage • Cost • Changing lifestyle • Improving outcome

  7. Risk factors for Type 2 diabetes • Age • Obesity (80%) esp truncal • Physical inactivity – activity increases insulin sensitivity • Genetic factors • Ethnicity

  8. Finding Type 2 diabetes • 50% diabetes undiagnosed i.e. 1 million • Onset of diabetes may be 7-12 years before clinical recognition • 25% have evidence of microvascular complications at clinical diagnosis • Value of population screening has not been established • Early interventions of diet & lifestyle amongst at-risk groups is preventative and worthwhile • Focus on at-risk populations - who could you screen in practice & how?

  9. At risk populations for Type 2 DM • All with cardiovascular disease • Those with BMI > 30 • Skin sepsis especially if recurrent • Thrush especially if recurrent • Those with +ve FH of Type 2 DM • Ethnic groups especially at certain ages • Annual review of those with pre-diabetes

  10. Identifying diabetes in practice • Protocols/prompts/reminders • New patient screening • All within CV care system • NHS screening checks • Registers & systematic monitoring of at-risk patients

  11. Diagnostic Criteria for Type 2 DM(WHO) • If symptoms of hyperglycaemia: a single fasting plasma >7 or a single random plasma glucose >11.1 or • If asymptomatic: fasting glucose >7 on two separate occasions

  12. Management Type 2 DM • Education/diet/lifestyle • Smoking • Monitor & control blood sugar • Control hypertension < 140/80 (<130/80 if end organ damage) • Manage lipids • Monitor for renal damage • Monitor for retinopathy • Feet • Depression • Monitor for neuropathy • ED • Autonomic

  13. Monitoring • HBA1c = Glycated HbA1c • Measure of integrated blood glucose control over preceding 3/12 but with extra weighting for 1/12 prior to sampling • NICE target 6.5% • QOF target moving to 7.5% • HbA1c will become a diagnostic test • Role of self-monitoring • 20% can do this with combination diet/lifestyle/exercise • The rest will need lifestyle modification & mono or multiple therapies including insulin

  14. Medication • Metformin • Starting point for most patients • Reduces cardiovascular mortality compared with other hypoglycaemic agents • Helpful with weight • Review dose of metformin if creatinine >130 or eGFR <45 • Stop metformin if creatinine >150 or eGFR <30 • Temporarily withdraw with tissue hypoxia • For 3 days after iodine containing contrast medium • 2 days before GA

  15. However….. • Natural trend of disease is of deteriorating beta cell function • 50% of those on monotherapy require additions at 3 years • 50% of patients with chronic illness do not take medications as prescribed • Achieving & sustaining long term lifestyle change is difficult – over time non-medication Rx becomes ineffective

  16. Medications • Sulphonylureas • Thiazolidinediones – pioglitazone • Post-prandial glucose modifiers • DPP-4 inhibitors - gliptins • GLP-1 mimetics – exenatide, liraglutide • Orlistat • Insulin – regime?

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