Diabetes
Nick Pendleton
Diabetes (part one of two)
• Relevance to General Practice and wider
health economy
• Diabetes - Type 2 and in pregnancy
• What guidance is available to help
identify and manage risk of DM?
Diabetes
• Example patients
• Diabetes and Driving
• What’s new or on the way?
Diabetes in the UK
• Currently £9.8 billion of NHS budget is spent
on patients with Diabetes
NHS spending on diabetes 'to reach
£16.9 billion by 2035‘
• 17% of entire NHS budget!
• 79% of diabetes spend is on treating complications from
Diabetes
From Impact Diabetes report published in Journal of Diabetes Medicine April 2012
Why?
• Numbers of people at risk of DM are
increasing
• The numbers of people developing diabetes
are increasing
• More people with DM are being identified
• Expensive new medications
• Complications of diabetes are significant and
costly to treat
RISK FACTORS FOR DEVELOPING TYPE 2
DIABETES
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PMH - Hypertension, IHD, Stroke
Being overweight/High BMI
Waist Circumference eg. > 37 inches in men
PCOS, Gestational DM or baby over 10 lbs
Ethnicity (African-Caribbean, Black African, Chinese or South Asian )
1st degree relative with DM
Severe Mental Illness treated with
Medication (schizophrenia, bipolar disorder or depression)
http://www.diabetes.org.uk/Guide-to-diabetes/What-is-diabetes/Know-your-risk-of-Type-2-diabetes/Diabetes-risk-factors/
What is happening in the
body in Type 2 Diabetes?
NORMAL INSULIN
RESPONSE
INSULIN
• Insulin is required for glucose to enter cells of
muscle, fat and liver so that it can be stored
and used for energy
• It also stops fat being used as an energy
source by inhibiting glucagon
Insulin response +120 mins
GLUCOSE LEVELS
Insulin response Lean v Obese (non-DM)
Development of Diabetes
• People with Type 2 DM produce insulin but
can not use it properly – Insulin resistance
• At first they produce more insulin to make up
for this
• With time, sustained high levels of insulin
trigger pancreatic Beta-cell death
• As time passes the pancreas cannot keep up
and glucose levels begin to rise
• Capacity to produce insulin diminishes
Complications of Diabetes
• A high glucose level in the blood is toxic
and causes damage to tissues and organs:
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Complications of Diabetes
• A high glucose level in the blood is toxic
and causes damage to tissues and organs:
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Kidneys
Nerves
Infections
Vascular
Eyes
Skin
Complications of Diabetes
• Kidney – nephropathy
• Neuromuscular – peripheral neuropathy,
mononeuritis, amyotrophy
• Infective – UTIs, TB
• Vascular –
coronary/cerebrovascular/peripheral artery
disease
• Eye – cataracts, retinopathy
• Skin – lipohypertrophy/lipoatrophy,
necrobiosis lipoidica
Necrobiosis Lipoidica
http://www.patient.co.uk/doctor/necrobiosis-lipoidica-pro
The effect of Diabetes on Kidneys
• Renal atherosclerosis
• UTIs
• Diabetic nephropathy - diffuse or nodular
(Kimmelstiel-Wilson lesion).
• High levels of blood glucose cause the kidneys
to work harder and filter more blood
• Over time this damages the glomeruli and
associated capillaries which then become
leaky
eGFR
Early intervention
Late intervention
No intervention
Dialysis
Time from Diagnosis of Diabetes
Diabetic Nephropathy
• Early stages cause an elevated glomerular
filtration rate with enlarged kidneys but the
principal feature of diabetic nephropathy is
proteinuria.
• Proteinuria develops insidiously, starting as
intermittent microalbuminuria
• Progresses to constant proteinuria and
occasionally nephrotic syndrome.
Monitoring and Detection
• All Diabetics - recall and annual review
• Measure urinary ACR or albumin
concentration annually. Use a first morning
urine sample when possible.
• Repeat if abnormal (and not due to UTI)
within a maximum of 3-4 months.
• Measure serum creatinine and estimated
glomerular filtration rate (eGFR) annually
Preventing Diabetic Nephropathy
• Tight blood glucose control to HbA1c< 48 mmol/l (6.5%)
• Tight blood pressure control to <140/80)
• 5 ways to lower BP - lose weight, eat less salt,
avoid alcohol, avoid tobacco, and get regular
exercise
• BP target is <130/80 if already have
nephropathy, eye or vascular complications
(NICE Clinical Pathway)
• ACE inhibitors (even if not hypertensive)
• A2RBs (but not both together)
HbA1c
To Monitor Control of Diabetes
What is HbA1c?
• HbA most common Hb molecule
• HBA1c is glycosylated HbA
• Amount of glycosylation depends of
prevailing Glucose levels
• Blood cells last 120 days
• Measuring HbA1c gives measure of
glucose levels in last 4 months
HbA1c
Low HbA1c
Controlled diabetes, not
much glucose, not much
glycosylated haemoglobin
High HbA1c
Uncontrolled diabetes, more
glucose, much more glycosylated
haemoglobin
QOF Target
HbA1c < 59 mmol/l (7.5%)
Diet and lifestyle advice for Diabetics:
http://www.patient.co.uk/doctor/Diabetes-Diet-andExercise.htm
There appears to be a good correlation between glucose levels,
Hba1c levels and clinical outcomes
Development of retinopathy
DIAGNOSING TYPE 2 DIABETES
What are the possible ways Diabetes can
be diagnosed?
Diagnosing Type 2
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Screening
New patient check (urine)
>40s campaign
Private health check
Used someone else’s BM machine
Pre-op clinic
HbA1c or serum glucose fasting or random
Incidental abnormal blood glucose result
Incidental glycosuria
Symptoms present
Investigating symptoms
Identified during pregnancy
Oral glucose tolerance test
Hba1c for Diagnosis
WHO Report 2011
http://www.who.int/diabetes/publications/report-hba1c_2011.pdf
• HbA1c can be used if the test is stringently
quality controlled and its results can be
internationally referenced
• And there are no conditions present which
preclude its accurate measurement.
What are the advantages of using
HbA1c?
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Patient doesn’t need to fast
Can be performed any time of day
Plasma glucose is variable
Don’t need to do an OGTT (inconvenient)
Can be used for screening
HbA1C testing
HbA1c > 48 indicate diabetes is present
• If symptomatic diagnosis can be made at
this point
• If asymptomatic test needs to be repeated
between 2 – 4 weeks
When should HbA1c not be used?
• ALL children and young people
• Patients of any age suspected of having Type 1
diabetes
• Patients with symptoms of diabetes for less
than 2 months
• Patients at high diabetes risk who are acutely
ill (e.g. those requiring hospital admission)
When should HbA1c not be used?
• Patients taking medication that may cause
rapid glucose rise e.g. steroids, antipsychotics
• Patients with acute pancreatic damage,
including pancreatic surgery
• In pregnancy
• Presence of genetic, haematologic and illnessrelated factors that influence HbA1c and its
measurement
HbA1c is affected by:
• Erythropoiesis (RBC production)
• Increased HbA1c: iron, vitamin B12 deficiency,
decreased erythropoiesis.
• Decreased HbA1c: administration of
erythropoietin, iron, vitamin B12,
• reticulocytosis, chronic liver disease.
HbA1c is affected by:
• Altered Haemoglobin
• Genetic or chemical alterations in
haemoglobin: haemoglobinopathies,
• HbF, methaemoglobin, may increase or
decrease HbA1c.
HbA1c is affected by:
• Glycation
• Increased HbA1c: alcoholism, chronic renal
failure, decreased intraerythrocyte pH.
• Decreased HbA1c: aspirin, vitamin C and E,
certain haemoglobinopathies, increased intraerythrocyte pH.
• Variable HbA1c: genetic determinants.
HbA1c is affected by:
• Erythrocyte destruction
• Increased HbA1c: increased erythrocyte life
span: Splenectomy.
• Decreased A1c: decreased erythrocyte life
span: haemoglobinopathies,
• splenomegaly, rheumatoid arthritis or drugs
such as antiretrovirals, ribavirin and dapsone.
HbA1c is affected by:
• Assays
(the tests)
• Increased HbA1c: hyperbilirubinaemia,
carbamylated haemoglobin,
• alcoholism, large doses of aspirin, chronic
opiate use.
• Variable HbA1c: haemoglobinopathies.
• Decreased HbA1c: hypertriglyceridaemia.
FRUCTOSAMINE TEST
• Alternative test if HbA1C cannot be used
• Gives a measure of diabetic control in last 1421 days
NICE PUBLIC HEALTH GUIDANCE (PH38)
July 2012
WHO did not give any guidance about how to manage those at risk…
• Preventing type 2 diabetes: risk
identification and interventions for
individuals at high risk
• HbA1c 42-47 = high risk of developing DM
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http://publications.nice.org.uk/preventing-type-2-diabetes-risk-identificationand-interventions-for-individuals-at-high-risk-ph38/recommendations
Recommendations
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Identify people at risk
Offer testing
Stratify people into high, moderate & low risk
High = 42-47, mod = 39-41, low/normal <38
Match intervention to the risk
High risk – intensive structured lifestyle
management programme and reassess annually
(Health Trainer)
• Lower risk – brief intervention: tell the patient,
advocate healthy lifestyle, test 3 yearly
NICE Guidelines & Pathways
Link to clinical pathways:
http://pathways.nice.org.uk/pathways/diabetes
• CG 87 is an update of CG 66 (2008) and is about managing
Type 2 DM and includes newer agents (published 2009)
• On the way by 2015...
• Diabetes in Children (Type 1 and 2)
• Diabetes in Pregnancy
• Diabetes in Adults – Type 1
• Diabetes in Adults – Type 2
Mrs Rachelle Patel, 26
28 weeks pregnant
Attends practice based-midwife led clinic
Found to have glucose in urine
• Next initial steps...
• Complications if diabetes not detected and
treated
• Follow up after delivery?
Mrs Rachelle Patel, 26
• Oral Glucose Tolerance Test
• This should be offered as a screening tool to
women at risk:
• FH DM in 1st degree relative
• Previous Gestational Diabetes Mellitus
• BMI > 30
• Previous macrosomic baby > 4.5 kg
• Family origin with a high prevalence of
diabetes (South Asian, black Caribbean and
Middle Eastern)
Mrs Rachelle Patel, 26
If undetected/untreated risks are:
• Macrosomia, difficult delivery, neonatal
hypoglycaemia, respiratory distress syndrome,
increased perinatal mortality
Follow up:
• OGTT at 6-8 weeks after delivery
• Increased chance of developing Diabetes
• If OGTT normal Annual HbA1C
Daryl Duncan, 37, Mechanic
• I think I’ve got Diabetes Dr!
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Lost 1 stone in weight in 3-4 weeks
Feels exhausted
Really thirsty
Passing a lot of urine
• Initial management in the surgery?
Daryl Duncan, 37
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Urine Dipstick 3+ Glucose, 2+ Ketones
Finger prick BM 26
Pulse rate 101 bpm, BP 118/70
Looks pale but alert
Admission?
Newly diagnosed type 1 DM
HbA1c and serum glucose in under 40s as still
could have Type 1
• Established on insulin and followed up by Diabetes
Centre and in GP Practice
MODY
Maturity Onset Diabetes of the Young
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Rare 1-2% of UK popn
Different to Type 1 and 2
Familial, Single Gene Mutation
Typically diagnosed in late childhood,
adolescence, or early adulthood
• 90% of people with MODY may have
been misdiagnosed as Type 1 or 2
MODY
Maturity Onset Diabetes
of the Young
MODY
Maturity Onset Diabetes of the Young
Key features
• Being diagnosed with diabetes under the
age of 25
• Having a parent with diabetes, with
diabetes in two or more generations
• Not necessarily needing insulin
MODY: Why is it Important?
• There are different types of MODY each
needing a different treatment approach
• The different types of MODY progress in
different ways
• As it is genetic there are implications for
other family members
MODY
Maturity Onset Diabetes of the Young
• HNF1 –alpha: 70% of cases, decreased insulin
prodn, treated with sulphonylureas
• HNF4 –alpha: large birthweight, neonatal
hypoglycaemia, sulphonylureas and then insulin
• HNF1 –beta: Diabetes assoc with gout, renal
cysts and uterine abnormalities
• Glucokinase: Cannot recognise blood sugar
levels, levels increase
DIABETES AND DRIVING
QUIZ
1. A newly diagnosed diet-controlled Type 2
diabetic who drives a car (Group 1) must
inform the DVLA of the diagnosis
No – unless having hypos with impaired
awareness, or disabling hypos, or have other
complications of diabetes eg impaired vision
Diabetes and Driving
2. A car driving gestational diabetic on insulin
for less than 3 months does not need to
notify the DVLA
Correct- unless they have problems with
hypos/severe hypos/hypo unawareness
Diabetes and Driving
3. A Bus-driver (Group 2) started on Gliclazide
for control of type 2 Diabetes must notify the
DVLA
• Yes – and must be aware of hypos, must
regularly monitor blood sugar twice daily and
related to driving, must show they
understand the risks of hypos. 1,2 or 3 year
licence issued
Diabetes and Driving
4. A Taxi Driver who has been started on Insulin
must monitor her blood sugar at the start of
the journey and every 2 hours
• Yes and Must inform DVLA
• And must have hypo awareness
Diabetes and Driving
5. An HGV driver on insulin must present 3
months of blood glucose readings to a
Consultant Diabetologist annually
Correct - and the Consultant completes a report
for the DVLA
Diabetes and Driving
6. A car driver who has impaired awareness of
hypoglycaemia must stop driving
Yes – until it can be demonstrated that hypo
awareness has been regained as evidenced
by GP or Consultant report (how?)
DVLA GUIDANCE
https://www.gov.uk/current-medicalguidelines-dvla-guidance-for-professionals
What’s New?
DIABETES RESEARCH
A Vaccine for Type 1 DM
• Researchers funded by Diabetes UK are
currently conducting a multi-centre trial
of a vaccine which they hope will trigger
an immune response to protect against
Type 1 diabetes.
https://www.diabetes.org.uk/Research/Research-round-up/Researchspotlight/Research-spotlight-a-vaccine-for-Type-1-diabetes/
Low-Calorie Liquid Diets
Can an intensive course of low calorie liquids put
Type 2 Diabetes into remission?
• What will the diet used in this study consist of?
• The diet used in this study will last for between 8
and 20 weeks and consist of approximately 800
calories a day. This will be comprised of four diet
soups or shakes per day providing all essential
vitamins and minerals, plus ample fluids.
https://www.diabetes.org.uk/Research/Research-round-up/Research-spotlight/Research-spotlight-low-calorie-liquid-diet/
An Artificial Pancreas
• Measures blood glucose levels on a minute-tominute basis using a continuous glucose
monitor (CGM)
• Transmits data to an insulin pump
• The pump calculates and releases the required
amount of insulin
https://www.diabetes.org.uk/Research/Research-round-up/Research-spotlight/Researchspotlight-the-artificial-pancreas/
Length of Sleep and DM Risk
• American Teenagers
• Length of Sleep and Insulin Resistance
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(Cells unable to respond to insulin leading to higher glucose levels in the blood)
• Insulin resistance is a risk for developing
DM
• Teenagers who slept less had more
Insulin Resistance
• Small study with limitations and
confounding factors
Matthews KA, Dahl RE, Owens JP et al. Sleep duration and insulin resistance in healthy black and white adolescents. Sleep.
Short Bursts of Activity and DM Risk
Imperial College and University College
London examined data from 20,000
commuters
• People who walk to work are 40% less
likely to have diabetes than those who
drive and 17% less likely to be
hypertensive
• Cyclists have 50% lower risk than drivers
Am J Prev Med. 2013 Sep;45(3):282-8. doi: 10.1016/j.amepre.2013.04.012
LSE, Harvard & Stanford
Meta-analysis
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305 trials, 339,274 people
Exercise v Drugs
Mortality Outcomes
Physical activity is potentially as effective
as many drug interventions in secondary
prevention of coronary heart disease,
stroke, heart failure, and pre-diabetes
http://www.bmj.com/content/347/bmj.f5577
LSE, Harvard & Stanford
Meta-analysis
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305 trials, 339,274 people
Exercise v Drugs
Mortality Outcomes
Physical activity is potentially as effective
as many drug interventions in secondary
prevention of coronary heart disease,
stroke, heart failure, and pre-diabetes
http://www.bmj.com/content/347/bmj.f5577
Britons getting fatter despite
consuming fewer calories
• Britons are consuming 600 fewer calories a day
by healthy eating choices but are actually
getting fatter because of sedentary jobs and a
lack of exercise
Institute of Fiscal Studies 2013 (Daily Telegraph - June 17 2013)
Diabetes Part 2
Medications for Diabetes
• There will be a second session on Diabetes
later in the programme exploring
prescribing for Diabetes including Insulin.
Upcoming Sessions
• 9th December 2014: COPD
(Michaela Bowden)
• 6th January 2015:
Lower Limb Orthopaedic Conditions
(Dr Khawer Ayoub)
• 20th January 2015: Asthma
(Michaela Bowden)