Type 2 Diabetes Care Plans

Patient is admitted to nephrology assessment due to declining renal function, patient presenting with tiredness and SOB. He smokes 10/day, drinks occasional alcohol.

NKDA

Amlodipine 10mg OD

Ramipril 7.5mg OD

Metformin 500mg ON

Gliclazide 80mg BD

Patient is 85Kg, BP 145/98mmHg, passing 900ml urine a day, mild oedema

K - 6.7 mmol/L

HbA1c - 58mmol/mol

Plan - Start furosemide 80mg daily

What would be key to calculate before commencing anything?

Calculate patients creatnine clearance / GFR

Patient’s GFR = 27ml/min

This is important as it helps us to determine drug doses/ which should be withdrawn and helps us to assess whether or not a person has AKI/CKD

Based on analysis what is the likely diagnosis of this patient?

AKI on top of CKD - Renal function was likely declining before this (diabetic and hypertensive so would not be unusual) but patient has been tired and unwell so it is likley his illness has caused AKI on top of this hence symptom progression. Diabetic nephropathy - remember this is damage to the small blood vessels in the kidney making glomerulus filtration more leaky and this paired with hypertension will increase risk of CKD.

Patient has urine output of 900ml per day, is this considered normal?

Normal urine output per day = 800-2000ml per day is typical

Anything below 400-500ml = low urine output and indicative of AKI

What would you address here first?

Patient has hyperkalaemia - likely due to the combined effect of AKI with medications that induce AKI (Ramipril) - Think THANKSB - Trimethoprim, heparin, ACE, NSAIDs, Potassium-sparing diuretic, Beta blocker

What has been missed from patients treatment?

Patient has not been assessed for the risk of VTE prophylaxis. Inform ward staff that no VTE prophylaxis has been prescribed. If the patient is deemed to be immobile commence LMWH. BUT wait till potassium levels have been returned to normal before initiating - risk of hyperkalaemia with LMWH

Reviews the patients diabetic medication - what would you advise?

• Patient is currently taking Metformin 500mg ON - This should be stopped during AKI, as reduced clearance of metformin will result in lactic acidosis. Metformin should only be reinitiated once AKI has resolved - guidance says stop in GFR less than 30ml/min - review dose upon initition in line with updated GFR.

• Patient is also taking Gliclazide, which is a sulphonylurea - this should be stopped in AKI due to risk of hypoglycaemia. If the patient is not drinking/ eating properly, then this will result in reduced clearance of the sulphonylurea and increase the risk of hypoglycaemia.

• For ongoing diabetic medications, could offer SGLT2i once GFR has increased, cardio and renally protective

Review the patients hypertensive medications - what would you advise?

The patient is on Ramipril and amlodipine, but is still hypertensive

• Ramipril should be stopped in AKI due to additional reduced renal perfusion - therefore stop ramipril due to risk of worsening AKI and hyperkalaemia

• Amlodipine can be continued - fine in renal impairment

• If still hypertensive consider alpha blocker - doxazosin or beta blocker but only initiate beta blocker if hyperkalaemia returns to normal as it can cause hyperkalaemia.

What would you do with the furosemide?

Furosemide is a loop diuretic. Initially, you think, the patient has AKI - Diuretic = CANDA so avoid BUT the patient has oedema due to fluid accumulation and SOB could indicate fluid on lungs, so a loop diuretic is important to clear fluid accumulation. THEREFORE,

AKI due to Dehydration + hypovolaemia → AVOID diuretic (additionally reduces perfusion)

AKI due to Unwell + SWELLING/ OEDEMA present → Diuretics are advised

As per BNF:

Dose adjustments

High doses of loop diuretics may occasionally be needed in renal impairment.

Monitor renal function, oedema and electrolytes

Mr Browns haemoglobin was checked on admission to be 91LL (120-160). Provide the main reason for anaemia.

• Chronic kidney disease

What other risk factor does he have for anaemia?

• Diabetes

Explain how CKD leads to anaemia?

The kidneys produce erythropoietin, a protein required to stimulate the bone marrow to make RBCs. In CKD, the production of erythropoietin causes reduced red blood cell production. AKI is more temporary so more uncommon for anaemia to occur but is no unheard of.

How does diabetes cause anaemia?

Diabetic nephropathy can lead to CKD so reduced erythropoietin protein due to kidney damage

What other causes of anaemia need to be addressed?

MHRA warning where metformin increases the risk of Vitamin B12 deficiency. A deficiency in vitamin B12 and folate will increase the risk of macrocrytic anaemia where a deficiency in vitamin B12 and folate (which are required for regulation of cell growth) leads to a prolonged cell cycle in RBC which means they grow larger before they divide - megablastic anaemia. This causes reduced RBC, and more fragile RBC. To confirm diagnosis further testing is required, Hb, RBC, folate, B12 and MCV - Mean corpuscular volume looks at the size of the red blood cells. Microcrytic = red blood cells are too small - iron deficiency anaemia, macrocrytic = vitamin B12 and folate deficiency which have a role in cell growth regulation.

Smoking can lead to chronic inflammation which overtime can lead to anaemia

Anaemia as a result of metformin usually is as a result of longer exposure and occurs over time.

Anaemia can also occur as the patient is a diabetic and therefore may be diet related - reduced oral intake of iron

Ramipril can increase risk of reduced erythropoietin production

What medications cause anaemia?

A Big Fat RBC

A- Ace inhibitors -reduced erythropoietin

B- bone marrow suppressants e.g. methotrexate, carbamazapine, ciclosporin, chemo

I- Interfering with folate - methotrexate and trimethoprim

G-GI bleeding e.g. NSAIDs, anticoagulants

F-folate indirect antagonists -phenytoin

A- alcohol - reduced folate

T- thiazide diuretics - rare

R- Rifampacin

B-B12 deficiency - metformin, PPI

C-Clopidogrel

Who is eligible for NMS?

Those starting a new medicine for a long-term condition such as:

• Type 2 diabetics, e.g. metformin, gliclazide

• Asthma/COPD - inhalers

• Cardiovascular - hypertension, heart failure and anticoagulants

• Antiplatelets - e.g. clopidogrel

What must you do before conducting NMS?

• Before conducting the service we must gain informed consent as you are sharing data with GP and NHS

• Ask the patient what they already know about this medication. Ask if there are any specific queries that he had. Explain that you are going to address his queries and explain more about metformin and T2 diabetes

When should a patient be initiated on a statin for primary prevention of CVD?

• QRISK score over 10%

• Start regardless of QRISK if:

  • Type 1 diabetic

  • Type 2 diabetic

  • CKD

  • Familial hypercholesterolaemia

Those with hypertension are not eligible for statin based on this alone, but likley hypertensive patient will have other risk factors which put thier QRISK score over 10 e.g. even if its just age alone.

What is a normal HbA1c?

Anything less than 42mmol/l

What is pre-diabetic HbA1C?

42-47mmol/l

What is diabetic HbA1C?

48mmol/l and over

What is the target HbA1C for diabetic?

48mmol/l (if patient is young and newly diagnosed and chance the condition could be reversed then could even aim for 42 - but gold standard for achievable taget =48mmol/l)

What is the target HbA1C for diabetic patient on a hypoglycamic inducing drug?

E.g. patient on gliclazide/ sulphonylurea or insulin then target is 53mmol/l (prevent hypos - prioritise safety over control)

How often should type 2 diabetics have HbA1C monitored?

HbA1C should be monitored every 3-6 months if initiated on treatment / treatment just changed or targets not being met

every 6 months if HbA1C is stable and within target

What is HbA1?

A measure of glycated haemoglobin → tells us long term diabetic control (3 months = lifespan of RBC)

How often should T2 diabetic patients check their blood sugar levels?

• Not routinely needed for T2 diabetics managed with diet, metformin etc

• BUT if patient is on a hypoglycaemic inducing drug such as gliclazide (sulphonylurea) or insulin then the patient should check before meals and at bedtime- also check if unwell - SICK day rules

What lifestyle advice would we give to T2 diabeitc?

• Your answers should be patient focused e.g.

• How does the patient feel about their current lifestyle? have they tried anything?

• Ask patient around his motivation to loose weight, eat healthier etc

• Eating healthier can help to reduce blood sugars and control diabetes. Reducing intake of fast foods, processed foods which are high in saturated fats and sugar, increase fruit and veg (5 a day). This will also reduce cardiovascular risk. Reducing patients weight will also help - this can be done through diet and exercise. Patient should aim for 150 mins of moderate actiivty - running, fast walk, swimming per week.

What is DESMOND?

DESMOND - This is a course that is structured education for diabetic patients. Can reduce HbA1c by 12 points

Patient is on metformin and sulphonylurea. Has CKD and HbA1c = 58mmol/mol. What would you recommend?

Patient is on metformin which has been stopped whilst CKD is being managed, if renal function improves, can re-initiate metformin when GFR is over 30ml/min. Sulphonylurea has been stopped due to risk of hypoglycaemia as patient has CKD and is unwell - sick day rules.

Patient could stop sulphonylurea due to hypoglycaemia risk but also patient is already overweight and sulphonylureas will only worsen this as they cause weight gain. Advise stopping gliclazide and replacing for SGLT2i such as dapigloflozin due to added cardiovascular and renal protection. wait to initiate SGLT2i when GFR is above 30 (threshold) and eating and drinking have returned to normal - prevention of dehydration.

Patient reports that upon review, they have changed their diet but have not been able to implement exercise yet. How would you respond?

The patient has increased exercise but not changed exercise. Ensure you praise them for changing their diet. To encourage exercise ensure the patient is aware of the cardiovascular risks associated with obesity and poor diabetic control. Exercise will help to improve heart health and diabetic control, poor diabetic control can lead to:

• macrovascular complications such as increased risk of heart attacks and strokes

• microvascular complications such as increased risk of nephropathy, neuropathy and retinopathy

Equation to calculate BMI

BMI = Weight (kG)/ Height (m²)

What does DESMOND stand for?

Diabetes Education and Self Management for Ongoing and Newly diagnosed Diabetes