Current Evidence and Best Practice in the Management of Diabetes
Ganesh ArunagirinathanConsultant Physician
Western General HospitalEdinburgh
Diabetes mellitus
• Coined by the Greek Physician Aretaeus-Diabetes meaning siphon
• Mellitus meaning Honey in Latin
• Group of metabolic diseases characterised by high glucose levels in blood (hyperglycemia)
• Defects in insulin secretion or insulin action or both
• Long term damage, dysfunction and failure of various organs
Classification of Diabetes
• T2 Diabetes Mellitus
• T1 Diabetes Mellitus
• Gestational Diabetes Mellitus
• Monogenic Diabetes
• Secondary diabetes- pancreas, hormonal/endocrine including steroids
• Rare & related to syndromes
UK-Diabetes data (Facts & Figures, Diabetes UK 2015)
• More than 1 in 16• 4 Million in UK (90% T2DM, 10% T1DM)• 56% Men, 44% Women• I person is newly diagnosed every 2 minutes
• Undiagnosed 549000• Impaired Glucose Tolerance prevalence 5.9%
• Scotland 271,312
Ethnicity
• South Asians upto 6 times higher risk of diabetes than Caucassians
• Black African/Carribean have upto 5 times higher risk
• Children of Asian origin are 8.9 times & black African origin 5.8 times more likely to have T2DM than Caucassian children
Children & Diabetes(DUK)
• Prevalence of T1DM - 22.8/100,000
• Peak age of onset is 9 to 14
• 95% T1DM
• 1.9% T2DM
• 2.73% Monogenic & others
Gestational DM
• 5% of all pregnancies in UK
• 7.5% T1DM, 5% T2DM
• Manifest in the 2nd or 3rd trimester
• 7 fold higher risk of diabetes in later life
• Children born to women with GDM are usually overweight & have 6 times higher risk of T2DM later in life
HbA1C
Glycosylated Haemoglobin Marker of glucose control
DCCT to IFCC conversion
Burden of the disease
• T1DM• By age 20, life expectancy reduced by 11 years in
men and 14 years in women
• T2DM• Life expectancy reduced by 6 years around age 50
• 10% of NHS budget spent on diabetes(1 million an hour)
Diabetes Control &Complications Trial(DCCT) T1DM
• 1983-1993
• US & Canada
• Age 13-39
• T1DM between 1 to 15 years from diagnosis, no or minimal retinopathy
• 1441
DM diagnostic criteria
DCCT- EDIC 30 year MACE follow upLegacy effect-Metabolic memory
Diabetes Care 2016
United Kingdom prospective Diabetes Study (UKPDS) T2DM
• 1977 to 1997
• 23 UK centres
• 5102 patients with median follow up of 10 years
• Intensive vs conventional glucose control
UKPDS Summary
• There is a direct relationship between the risk of complications of diabetes and glycaemia over time
• No threshold of glycaemia was observed for a substantive change in risk for any of the clinical outcomes examined
• The lower the glycaemia the lower the risk for complications
• The rate of increase of risk for microvasculardisease with hyperglycaemia is greater than that for macrovascular disease
UKPDS
0
2 0
4 0
6 0
8 0
0 5 6 7 8 9 1 0 1 1
Myocardial
infarction
Microvascular
disease
Updated mean HbA1c (%)
Incid
ence p
er
1000 p
atient-
years
UKPDSIntensive (SU/Ins) vs. Conventional glucose control
HR (95%CI)
UKPDS
BP 154/87 vs 144/82
Risk for macrovascular disease
• Hypertension
• Dyslipidaemia
• Insulin resistance
• Obesity
• Smoking
• Higher HbA1C
• Synergistic interaction of above factors
Pathophysiology
• Similar to non-diabetic population
• More extensive, diffuse, aggressive, distal & multivessel involvement
• Higher rate of hypertension(50%) and dyslipidaemia(30%) at diagnosis
• HbA1C is an independent risk factor for vascular disease
MRFITStamler J et al, Diabetes Care 1993
“Diabetes is Coronary Artery disease equivalent”
MRFIT study- Haffner SM et al, NEJM 1998
Statins- Metaanalysis CTT collaborators, Mar 2012, Lancet
STATINS sign 116
• 1mmol/L reduction in LDL = 21% reduction in risk of CVD
• CARDS study- Benefit noted irrespective of baseline cholesterol concentration
• Simvastatin 40mg or atorvastatin 10mg daily for T2DM over 40 years (consider in T1DM)
• Statin should be recommended in <40 age group with higher risk eg microalbuminuria
• In established CVD/ACS, atorvastatin 80mg/day
Smoking- Nurses Health Study
Management of T1DM
• Structured education- Carbohydrate counting and insulin dose adjusting
• DAFNE (Diet Adjustment For Normal Eating)
• Insulin pumps- special features like low glucose suspend etc.
• Monitoring devices- Continuous glucose monitor, Flash sensors
Insulin pens and regimens
Pumps, sensors and data
SIGN 116- Psychosocial• Regular assessment of a broad range of psychological and
behavioural problems in children and adults with type 1 diabetes is recommended
• In children this should include eating disorders, behavioural, emotional and family functioning problems
• In adults this should include anxiety, depression and eating disorders
• Children and adults with type 1 and type 2 diabetes should be offered psychological interventions (including motivational interviewing, goal setting skills and CBT) to improve glycaemic control in the short and medium term.
Acute complications
• Hypoglycemia
• DKA
• HHS
Hypoglycemia treatments
T2DM
• Diet
• Lifestyle
• Oral meds- metformin, sulphonylureas, pioglitazone, acarbose, Gliptins, SGLT2 inhibitors
• Injectable- GLP1 analogues(daily, weekly)
• Insulins
• Weight management and bariatric surgery
DESMOND
• Diabetes Education and Self Management for Ongoing and Newly Diagnosed patients with Type 2 Diabetes
• Within the 1st year of diagnosis
Bariatric surgery
• Interventions –individualised lifestyle, pharmacological and surgical- should be offered SIGN 116
• Body Mass Index above 35 with diabetes or other comorbidities
• Benefit in reversing T2DM or reducing medication requirements
Bariatric surgery
Retinal photography
Slit lamp biomicroscopy
Optimal Coherence Tomography (OCT)
Normal Macular oedema
EDIC Retinopathy progression
Risk factors for Diabetic Retinopathy
Duration of disease- severity
Poor glycaemic control
Renal disease – risk factor for onset and progression
Hypertension-linked to PDR & established risk factor for macular oedema
Dyslipidaemia associated with hard exudates
Pregnancy, puberty, smoking, obesity
Retinopathy prevention & treatment
• Tight glycaemiccontrol
• BP, weight, lifestyle
• Lipids- fenofibratesuseful
• Smoking cessation
• Pre-pregnancy counselling- screen during each trimester
Scatter photocoagulation to peripheral retina
Focal laser photocoagulation for Clinically Significant Macular Oedema
Macular Grid laser for diffuse macular neovascularisation/ leak
Pars plana Vitrectomy for fibrovascularproliferation, severe retinal disease not amenable to laser
Structure of a kidney and nephron
Management of nephropathy
• ACEI/ARB- withhold if dehydration, contrast
• BP- as low as tolerable; 130/80 & below
• Glucose
Statins-
• May preserve renal function over time and reduce microalbuminuria
• Reduce albuminuria even if EGFR <30ml/mt
• avoid fibrates in CKD- 4 & 5
• Smoking cessation
• Avoid nephrotoxics eg NSAIDs
• Hb – check from CKD-3
• Refer to Nephrology if rapid decline in EGFR, Blood in dipstik, CKD 4 ,5 OR atypical presentation
Peripheral nerve anatomy
Clinical presentation of Diabetic NeuropathiesPickup J, Williams G, Textbook of Diabetes Vol 1, 1997
Diabetic Neuropathy
• Varied
• Silent, non-specific or mimic other diseases
• Diagnosed by exclusion
• Grossly under diagnosed
• Complications are equal in type 1 and type 2 DM
• Symptomatic Autonomic neuropathy has 25-50% mortality in 5 to 10 years
Evidence for achieving good glycemiccontrol
• DCCT- 50% reduction in neuropathy over 5 years with intensive insulin therapy
• UKPDS -“Legacy Effect”- despite worsening control later neuropathic symptoms improved
• EDIC study confims Legacy Effect
• STENO trial showed 0.32 reduction in ODDs ratio for development of autonomic neuropathy with treatment of all metabolic comorbidities
Diabetic foot ulcers
• 1.7 to 3.3% in <50 yrs; 5 to 10% in >50 yrs
• 50% annual risk in those with previous ulcers
• Lifetime risk of getting diabetic foot ulcer is 25%
• Amputation performed in 3 per 1000 diabetics
Risk factors for Diabetic foot ulcers
• Neuropathy as such does not cause ulcers
• Callus, deformity & high foot pressures
• Ill fitting shoes
• Foot trauma
• Combination with ischaemia
• Retinopathy, CKD & dialysis
• Previous ulcers
Foot ulcers
Peripheral Vascular Disease
Osteomyelitis
Charcot foot
Aircast, scotch cast, Total Contact Cast, Removable Cast walker
SIGN 116
• Running-style, cushion soled trainers should be used by those with foot disease
• Custom-built footwear or orthotic insoles should be used to reduce callus severity and ulcer recurrence
• Active foot disease to be referred to MD footcare Team
• Cardiovascular risk management should be addressed for anyone with foot disease
Pregnancy planning
• GDM Prevalence 19.8%
• GDM 171300
• Preconception contraception
• Need HbA1C to be very well controlled ideally below 53mmol/mol
• Folic acid 5mg daily upto 12 weeks
• STOP ACE inhibitors/ARBs/Statins
Older people with diabetes
• Diet- minimal restriction in care homes
• Nutritional assessment and individual advice
• Risk of dehydraion/HHS
• Ensure physically active
• Hypo risk is high
• Mental health issues /depression/dementia
• Continence issues
Standards of medical care for older adults, Diabetes Care Jan 2016
Diabetes UK statement• The 15 Healthcare Essentials is the minimum level of healthcare everyone
with diabetes deserves and should expect.
• 1. Get your blood glucose levels measured (HbA1c blood test)2. Have your blood pressure measured3. Have your blood fats measured4. Have your eyes screened for signs of retinopathy5. Have your feet and legs checked6. Have your kidney function monitored7. Get ongoing, individual dietary advice8. Get emotional and psychological support9. Be offered a local education course10. See specialist healthcare professionals11. Get a free flu vaccination12. Receive high-quality care if admitted to hospital13. Have the chance to talk about any sexual problems14. If you smoke, get support to quit15. Get information and specialist care if you are planning to have a baby