Type 2 Diabetes: Priorities and targets Small group case based meeting

David Porter

SUMMARY

Asses blood pressure and lipids as a priority in people with type 2 diabetes

Individualise blood glucose targets based on patient factors and duration of disease

When intensifying glycaemic therapy, consider the effectiveness of glucose lowering medicines in reducing diabetes-related complications and mortality

Regularly monitor all aspects of the patients health

WHERE HAVE PRIORITIES FOR PEOPLE WITH TYPE 2 DIABETES CHANGED?

Manage absolute cardiovascular risk - Treat ALL individuals for absolute cardiovascular risk

- Aspirin in secondary prevention ONLY

Individualising glycaemic targets - Duration of diabetes

- Cardiovascular disease

- Medication adverse effects including hypoglycaemia

- Co-morbidities

New medications, their place in the Australian market - Glucagon-like peptide-1 analogues (GLP-1 analogues)

- Dipeptidyl peptidase-4 inhibitors (gliptins)

WHAT DO YOU WANT TO COVER ?

MEET “MR E” New patient to practice, 45 year old male with type 2 diabetes presents. He thinks he is due for his “annual diabetes visit” Past medical history

Type 2 Diabetes diagnosed 4 years ago No previous microvascular/macrovascular signs & symptoms

Social history

Non – Smoker Drinks 1-2 glasses of wine every night

Family history

Father had type 2 diabetes Sister had a non fatal myocardial infarction aged 54 years

- BP 140/90 mmHg - Pulse 80 bpm - BMI 28 kg/m2 - Cardiac, neurological &

abdominal examinations are normal

- Fundoscopy normal - No pedal oedema; pedal

pulses normal Medications - Metformin 1000mg bd

Self reported - Adherent to dietician’s advice - Walks for 30 minutes 2-3 days

per week

ON EXAMINATION

RECENT LABORATORY RESULTS Mr E’s results Target */

reference values†

HbA1c 69 mmol/mol (8.5%) < 53 mmol/mol (7%)*

Serum creatinine 78 micromol/L 60-120 micromol/L†

Total cholesterol 6.4 mmol/L <4.0 mmol/L*

HDL-C 1.2 mmol/L (TC/HDL = 5.3) > 1.0 mmol/L*

LDL-C 3.7 mmol/L < 2.0 mmol/L*

Fasting trigycerides 2.2 mmol/L < 2.0 mmol/L*

eGFR 97 mL/min/1.73 m2 > 60 mL/min†

Abumin: Creatinine ratio 2.0 mg/mmol (initial) <3.5 mg/mmol† microalbuminuria 3.5-35 macroalbuminuria >35

Note: All other investigations were normal e.g. electrolytes, LFTs, TFT

WHERE TO START?

3 monthly

• Review SNAP (smoking, nutrition, alcohol, physical activity • Check weight/waist measurements • Check blood pressure • Examine feet • Review self monitoring & adherence to medications

6 monthly • Monitor HbA1c (more frequently if indicated)

Yearly

• Update immunisations • Measure lipid levels, renal function (microalbuminuria) • Conduct full physical (cardiovascular, peripheral nervous

system, eyes, feet) • Review medicines (consider HMR) • Referral to diabetes educator, dietitian, podiatrist, dentist • Consider specialist referral

Every 2 years • Refer to ophthalmologist / optometrist even with no retinopathy

ANNUAL CYCLE OF CARE

Diabetes management in general: guidelines for type 2 diabetes 17th Ed, 2011/12. Canberra: Diabetes Australia & RACGP

LIFESTYLE AND SELF CARE ADVICE

S N A P Diabetes educator?

Dietician?

Optometrist?

Podiatrist?

(“KNIVES”)

MEDICINES? Which ones?

Blood pressure (140/90 mmHg)

Lipids

- Total cholesterol 6.2 mmol/L

- LDL: 3.7 mmol/L

- HDL 1.3 mmol/L

- Total cholesterol/HDL ratio: 5.3

- Calculated CVD risk 10-15%

Glucose (69 mmol/mol [8.5%])

Aspirin

GLYCAEMIC CONTROL NOT AS EFFECTIVE AT LOWERING CARDIOVASCULAR OUTCOMES AS REDUCING LDL CHOLESTEROL OR BLOOD PRESSURE

0

5

10

15

20

25

30

Stroke Coronary event Cardiovascular event

Blood glucose lowering (HbA1c reduced by 0.9%)

LDL lowering (reduced by 1 mmol)

Blood pressure lowering (reduced by 10/5 mmHg)

Even

ts p

reve

nted

per

100

0 pa

tient

s w

ith d

iabe

tes f

or o

ver 5

yea

rs

Modified from Yudkin JS et al. Diabetologia 2010, 53:2079-85; Kearney PM et al Lancet 2008, 37:117-25 & Law MR et al BMJ 2009, 338:b1665

ADDRESS BLOOD PRESSURE & LIPIDS AS A PRIORITY

Modified from National Vascular disease Prevention Alliance Guidelines for the management of absolute cardiovascular risk, 2012 (see NPS leaflet)

CVD RISK

MEDICINES? Which ones?

Blood pressure (140/90 mmHg)

Lipids

- Total cholesterol 6.2 mmol/L

- LDL: 3.7 mmol/L

- HDL 1.3 mmol/L

- Total cholesterol/HDL ratio: 5.3

- Calculated CVD risk 10-15%

Glucose (69 mmol/mol [8.5%]) Aspirin

RECOMMENDED HBA1C TARGETS Clinical Situation HbA1c target

mmol/mol (%)

General target ≤ 53 (7.0)

Specific clinical situations

Diabetes of short duration & no clinical cardiovascular disease

Requiring lifestyle modification ± metformin

≤ 42 (6.0)

Requiring any anti-diabetic agents other than metformin or insulin

≤ 48 (6.5)

Requiring insulin ≤ 53 (7.0)

Pregnancy or planning pregnancy ≤ 42 (6.0)

Diabetes of longer duration or clinical cardiovascular disease ≤ 53 (7.0)

Recurrent severe hypoglycaemia or hypoglycaemia unawareness ≤ 64 (8.0)

Patients with major co-morbidities likely to limit life expectancy Symptomatic

Aust. diabetes society position statement: individualization of HbA1c targets for adults with diabetes mellitus. Sydney: Australian Diabetes Society, 2009

DOES A REDUCTION IN HBA1C REDUCE MORTALITY?

Mortality increases substantially in those with a HbA1c level over 8-9 regardless of therapy

Any reduction in HbA1c towards the agreed target level is advantageous to future health

HbA1c (1%)

Haza

rd ra

tio (9

5% C

l)

metformin + sulphonylurea insulin regimens

Graph modified from Currie et al Lancet 2010, 375:483-89

ADA AND EASD POSITIONS STATEMENT

Management of Hypoglycaemia in type 2 diabetes: A patient-centred approach, 2012 Inzucchi et al

Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials Faramarz Ismail-Beigi, et al. Ann Intern Med. 2011;154:554-559

WHICH DRUG?

Current: Metformin 2g/day

HbA1c = 69 mmol/mol (8.5%)

Timing?

75% of drug effect at 50% of dose

TREATMENT ALGORITHM FOR TYPE 2 DIABETES

Lifestyle modification

Metformin

Sulphonylurea

Insulin Glitazones GLP-1

receptor agonists

Acarbose DPP-4 inhibitor

Modified from Diabetes management in general: guidelines for type 2 diabetes 17th Ed, 2011/12. Canberra: Diabetes Australia & RACGP

GLP-1 & DPP-4 INHIBITORS

ARE THEY SAFE?

Exenatide (Byetta) – FDA approval 2005

Sitagliptin (Januvia) – FDA approved 2006

Vildagliptin (Galvus) – EU approved 2007

Saxagliptin (Onglyza) – FDA approved 2009

Linagliptin (Trajenta) – FDA approved 2011

ARE THE DPP4 INHIBITORS DIFFERENT?

TREATMENT ALGORITHM FOR TYPE 2 DIABETES

Lifestyle modification

Metformin

Sulphonylurea

Insulin Glitazones GLP-1

receptor agonists

Acarbose DPP-4 inhibitor

Modified from Diabetes management in general: guidelines for type 2 diabetes 17th Ed, 2011/12. Canberra: Diabetes Australia & RACGP

RETURNING TO “MR E”

What if…

he was a 130kg bus driver?

NATIONAL DRIVING ASSESSMENTS

WHO CAN HELP?

DIABETES QUEENSLAND RESOURCES

Pg 14, Annual cycle of care!

QUESTIONS?

SUMMARY

Asses blood pressure and lipids as a priority in people with type 2 diabetes

Individualise blood glucose targets based on patient factors and duration of disease

When intensifying glycaemic therapy, consider the effectiveness of glucose lowering medicines in reducing diabetes-related complications and mortality

Monitor regularly – Annual cycle of care