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
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
The Top 10
International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011.
http://www.idf.org/diabetesatlas
Diabetes Prevalence
International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011.
http://www.idf.org/diabetesatlas
The Top 10 by Prevalence
International Diabetes Federation. IDF Atlas, 5th edn. Brussels, Belgium: IDF, 2011.
http://www.idf.org/diabetesatlas
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
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
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
Diagnosis of Diabetes
Category
Plasma Glucose (mmol/l)
Fasting
2h Post-Glucose Load
Diabetes mellitus
≥ 7.0
≥ 11.1
Impaired glucose tolerance (IGT)
< 7.0
7.8 – 11.0
Impaired fasting glycaemia (IFG)
6.1 – 6.9 (WHO)
5.6 – 6.9 (ADA)
< 7.8
< 7.8
Not diabetic or glucose intolerant
≤ 6.0 (WHO)
≤ 5.6 (ADA)
< 7.8
Category
Plasma Glucose (mg/dl)
Fasting
2h Post-Glucose Load
Diabetes mellitus
≥ 126
≥ 200
Impaired glucose tolerance (IGT)
< 126
140 – 199
Impaired fasting glycaemia (IFG)
110 – 125 (WHO)
100 – 125 (ADA)
< 140
< 140
Not diabetic or glucose intolerant
< 110 (WHO)
< 100 (ADA)
< 140
Aim of Treatment
● Prevention, detection and management of complications
● Microvascular & Macrovascular
Background retinopathy
Kidney glomerulus
Neuropathic foot ulcer
Proliferative retinopathy
Glomerular sclerosis
Ischaemia
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
Antidiabetic Drugs
Carbohydrate
DIGESTIVE
Acarbose
Sulphonylureas
Meglitinides
GLP-1 analogues
DPP-IV inhibitors
ENZYMES
Glucose
I
GLP-1
Glitazone
I
Adipose
tissue
Insulin
(I)
Pancreas
I
Metformin
Metformin
Liver
Glitazone
Muscle
Glitazone
Stepwise Management of Diabetes
Insulin ± oral agents
Oral combination
Sulphonylureas
Oral monotherapy
Metformin
Diet & exercise
Gliptins
GLP-1 analogues
Insulin Therapy
● Physiological insulin regimen
24 hour insulin and glucose profile in non-diabetic persons
Basal-Bolus Insulin Regimen
e.g. Insulin aspart (Novorapid) + insulin glargine (Lantus)
Breakfast
Lunch
Dinner
Bedtime
Insulin
(Rapid)
Insulin
(Rapid)
Insulin
(Rapid)
Insulin
(Basal)
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)
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
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)
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
Whittington Joint Diabetes
Thalassaemia Clinic
Measure
Fructosamine (umol/l)
HbA1c (%)
Capillary blood glucose (mmol/l)
Pre-prandial
Post-prandial (2 h)
Target
< 322 (< 299)
< 7.0 (< 6.5)
4–7
5–8
Blood pressure (mmHg)
- with nephropathy
< 130 / 80
< 125 / 75
Total cholesterol (mmol/l)
< 4.0
LDL cholesterol (mmol/l)
< 2.0
Triglycerides (mmol/l)
< 1.7
Smoking status
Body mass index (kg/m2)
Non-smoker
20 – 25
Exercise
Daily
Aspirin (75 mg) if > 50 y of age or CV risk
Daily
Whittington Joint Diabetes
Thalassaemia Clinic
Clinic Population Description
Gender - Female
Male
Age*
Ethnic origin
Greek Cypriot / Greek
South Asian (Indian, Pakistani, Bangladeshi)
Ferritin at first appointment*
59%
41%
39 years (28 – 59y)
36%
64%
1827 ug/l (600-6143ug/l)
Diabetes duration*
13 years (<1 – 29y)
Age at diagnosis*
21 years (10 – 40y)
BMI*
24.8 kg/m2
Treatment – insulin
73%
Treatment – oral antidiabetic drugs only
14%
Treatment – diet control only
14%
*median values
Performance: Joint Clinic vs.
National Audit for England
Care Process
Performance of Key Care Processes
Joint Clinic
(2005-2009)
National Diabetes Audit
(2007-2008)
Fructosamine (HbA1c)
97.5%
91.1%
Serum cholesterol
91.1%
89.9%
Serum creatinine
100%
91.2%
Urinary albuminuria
91.1%
62.7%
Weight / Body mass index
97.5%
88.8%
Blood pressure (BP)
80.4%
93.7%
Foot assessment
89.2%
77.1%
Smoking status
89.2%
86.5%
Target achievement: Joint Clinic
vs. National Audit for England
Target
Percentage of patients achieving treatment target
Joint Clinic
(2005-2009)
National Diabetes Audit
(2007-2008)
Fructosamine < 345 umol/l
(HbA1c < 7.5%)
72.7%
62.9%
BP < 135/75 mmHg
57.9%
30.1%
Total cholesterol < 5.0 mmol/l
82.1%
78.0%
Metabolic improvement in
Joint Clinic
Parameter
Fructosamine
BP
Total cholesterol
First appointment
1 year follow-up
Change
344 umol/l
319 umol/l
-25 umol/l
122/70 mmHg
124/77 mmHg
+2/7 mmHg
3.8 mmol/l
3.5 mmol/l
-0.3 mmol/l
● 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
Diabetic Complications in Patients
Attending Joint Clinic
Diabetic complication
Prevalence in patients attending
Joint Clinic
Microalbuminuria
13.6%
Diabetic retinopathy
13.6%
≥1 microvascular complication
22.7%
Charcot neuroarthropathy
4.5%
Cataracts
9.1%
Macrovascular complications
0
Diabetic emergencies
0
Endocrinopathies in Patients
Attending Joint Clinic
Endocrinopathy
Prevalence in patients attending
Joint Clinic
Hypogonadism
- Hypogonadotrophic hypogonadism
- Primary hypogonadism
86%
59%
27%
Hypothyroidism
18%
Hypoparathyroidism
23%
Osteopenia
14%
Osteoporosis
55%
Glucocorticoid deficiency
0
Growth hormone deficiency
0
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
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
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