diabetes and thalassaemia 3rd pan-european conference on haemoglobinopathies & rare anaemias
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Diabetes and Thalassaemia3rd Pan-European Conference on
Haemoglobinopathies & Rare AnaemiasLimassol, 24 – 26 October 2012
Dr Maria Barnard & Dr Ploutarchos TzoulisRomilla Jones, Emma Prescott, Dr Farrukh Shah
The Whittington Hospital NHS Trust, London
● 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
The Diabetes Epidemic
International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas
The Top 10
International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas
Diabetes Prevalence
International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas
The Top 10 by Prevalence
International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas
● 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
Healthcare Expenditure (2011)
International Diabetes Federation. IDF Atlas, 5 th edn. Brussels, Belgium: IDF, 2011. http://www.idf.org/diabetesatlas
● 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
Diabetes in β-Thalassaemia Major
● 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
Early Diagnosis of Diabetes
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 DiabetesCategory Plasma Glucose (mmol/l)
Fasting 2h Post-Glucose LoadDiabetes 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
● Prevention, detection and management of complications
● Microvascular & Macrovascular
Aim of Treatment
Background retinopathy
Proliferative retinopathy
Kidney glomerulus
Glomerular sclerosis
Neuropathic foot ulcer
Ischaemia
● 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)
Mortality in Diabetes
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
Muscle
Glucose (G)
Carbohydrate
Glucose
DIGESTIVE ENZYMES
Insulin(I)
I
I
I
I
I
I
G
G
G
GI
G
G
I
IG
SulphonylureasMeglitinidesGLP-1 analogues DPP-IV inhibitors
Metformin
Acarbose
Metformin
Glitazone
Glitazone
Glitazone
GLP-1
Liver
Pancreas
Adipose tissue
Antidiabetic Drugs
Insulin ± oral agents
Oral combination
Oral monotherapy
Diet & exerciseMetformin
Sulphonylureas
Gliptins
GLP-1 analogues
Stepwise Management of Diabetes
● Physiological insulin regimen
24 hour insulin and glucose profile in non-diabetic persons
Insulin Therapy
Breakfast Lunch Dinner Bedtime
Insulin (Rapid)
Insulin (Rapid)
Insulin (Rapid)
Insulin (Basal)
Basal-Bolus Insulin Regimene.g. Insulin aspart (Novorapid) + insulin glargine (Lantus)
● 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)
Insulin Dose Adjusting
● 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
Whittington Joint Diabetes Thalassaemia Clinic
Measure TargetFructosamine (umol/l) HbA1c (%)
< 322 (< 299) < 7.0 (< 6.5)
Capillary blood glucose (mmol/l) Pre-prandial Post-prandial (2 h)
4 – 75 – 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 Non-smoker
Body mass index (kg/m2) 20 – 25
Exercise Daily
Aspirin (75 mg) if > 50 y of age or CV risk Daily
Whittington Joint Diabetes Thalassaemia Clinic
Clinic Population DescriptionGender - Female Male
59%41%
Age* 39 years (28 – 59y)
Ethnic origin Greek Cypriot / Greek South Asian (Indian, Pakistani, Bangladeshi)
36%64%
Ferritin at first appointment* 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 ProcessesJoint 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 targetJoint 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 First appointment 1 year follow-up Change
Fructosamine 344 umol/l 319 umol/l -25 umol/l
BP 122/70 mmHg 124/77 mmHg +2/7 mmHg
Total cholesterol 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
● 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
Whittington Joint Diabetes Thalassaemia Clinic - Discussion
● 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
Diabetes and Thalassaemia -Conclusions
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