Optimising control of T2DM

Factors to consider for every patient with T2DM

• Age and frailty status

• Time since diagnosis

• Renal function and degree of microalbuminuria – calculate kidney risk

• Weight

• Occupation and social history

• Age of diagnosis

• Family history

• Co-morbidities and risk factors for CV disease

• Polypharmacy - many medications cause a rise in blood glucose e.g. steroids, anti-psychotics

• Menopause

• Driving status

• Is patient able / willing to BG monitor?

Non-pharmacological treatments of Diabetes

• Reduce smoking

• Reduce alcohol

• Physical activity

• Weight management

• Healthy diet

  • high veg, high protein, low carb

HbA1c tagrets in T2DM

• Diet/Lifestyle ± metformin = 48mmol

• SU or insulin = 54mmol

• Mild/moderate frailty = 53-64

• Severe frailty = 64-75

Clinical Inertia

Where healthcare providers fail to intensify treatment when a patient isn't meeting evidence-based goals

Why is achieving target HbA1c so important in diabetes?

• Reduction in micro- and macrovascular complications

• Reduce symptoms of diabetes

• Reduce risk and episodes of hypoglycaemia

• Avoid hospital admissions

• Reduce risk of infection

• Improve quality of life

Time in Range

percentage of time that a person spends with their blood glucose levels in a target range

(# in range finger pricks/ total finger pricks) x 100

taken over at least 14 days

Non insulin treatments for T2DM

• GLP1

• SGLT2i

• Sulfonylureas

• Pioglitazone

SGLT2i

inhibits SGLT2 (Sodium–Glucose Co-Transporter 2) which is a glucose transporter leading to decreased glucose reabsorption and increased glucose loss via urine.

Common SE:

• UTIs

• Genital fungal infections

Serious SE

• euglycaemic DKA

• Forneirs Gangrene

Weight Loss: Yes

Hypo risk: Low

Sulfonylureas

Close pancreatic β-cell KATP channels which leads to an increase in insulin secretion

Common SE:

• Hypo

• Weight Gain

Serious SE:

• severe prolonged hypoglycaemia

Weight Loss: No

Hypo risk: High

Biguanides

Decrease the hepatic gluconeogenesis and increase insulin sensitivity. This leads to a decrease in intestinal glucose absorption

Common SE:

• GI upset

• B12 deficiency

Severe SE:

• lactic acidosis

Hypo risk: No

Weight loss: No - neutral effect

DPP4i

inhibit the DPP-4 enzyme which increases the breakdown of GLP-1 leading to an increase insulin release/decreases glucagon

Common SE:

• URTI symptoms

• headache

Serious SE:

• pancreatitis

• severe joint pain

Hypo risk = low

Weight effect = neutral

Pioglitazone

PPAR-γ agonist. It increases insulin sensitivity in muscle/adipose

Common SE:

• weight gain

• oedema

Serious SE:

• HF exacerbation

• fractures

Hypo risk = low

Weight effect: weight gain

GLP1s

• reduce desire for sweet things

• cannot be used with DPP4i

• once weekly injections

SE:

• GI side effects

• pancreatitis (rare)

Which antidiabetics have a cardio/renal protective?

• Metformin

• SGLT2i

• GLP-1

Drug safety considerations of Inslulin

• Healthcare professionals who handle, prescribe or administer insulin need to receive regular training and demonstrate competence

• Over 30 different insulin preparations available!

• NEVER STOP insulin in people with type 1 diabetes

Insulin types

• rapid acting analogue

  • onset is in 5-15mins

  • peak in 30mins-1.5h

  • lasts 3-5h

• short acting human

  • onset is in 30mins

  • peaks in 2-4h

  • lasts 6-8h

• intermediate acting

  • onset is in 2h

  • peaks in 4-8h

  • lasts 14-16h

• pre-mixed

  • onset is in 30-60mins

  • peaks in 2-4h

  • duration is 12-14h

• long acting

  • onset within 2h

  • no peak period

  • duration is 24-42h

Insulin injection sites

• Back of upper arms

• abdomen

• upper buttocks

• upper outer thighs

inject into one area no more frequently than every 4 weeks. each injection should be at least 1cm away from the last

Lipohypertrophy

a thickened rubbery lesion of fat tissue that develops in the subcutaneous layer where insulin is repeatedly injected.

Primary causes include incorrect rotation of injection sites or not  rotating, duration of insulin use, frequency of injections and needle reuse

Insulin use in T2DM

Insulin therapy should be offered to people with diabetes with inadequate blood glucose control on optimised oral glucose-lowering drugs

• Regime should be chosen based on patient lifestyle, preference and risk of hypoglycaemia

• First line recommendation is neutral protamine Hagedorn (NPH) insulin injected once or twice daily

How do you change medications when starting injectibles?

Metformin - continue

SU - reduce dose or stop depending on type of insulin

TZD - STOP or reduce dose

DPP-4i - stop if GLP-1 initiated

SGLT2i - continue

What do we need to consider when starting insulin in T2DM?

• Any recent changes to dietary intake – does the individual injecting insulin have carb awareness?

• Any change in level of physical activity - has the individual injecting insulin taken up any new or extra activities such as going to the gym or have they recently changed work patterns?

• Any recent weight change – either planned or unplanned?

• SICK DAY RULES

• Has any oral diabetes medication been missed recently?

• Check injection sites – any lipohypertrophy

How to adjust basal insulin?

reduce insulin by 10-20% if patient is experiencing hypos

How do you adjust BD insulin regimens?

elevated glucose before bed/breakfast = increase evening dose by 10%

elevated glucose before lunch/evening = increase morning insulin by 10%

Smartpens

• reusable pens which record time and dose of insulin given to patient

• links to smartphone and to CGM apps

• allow patients to take control over their diabetes as they can see daily patterns and make associations between good glycaemic control and injection patterns

CGM

Continuous glucose monitors

• More often seen in T1D but becoming more common in T2D

• Many patients self-funding (if T2DM)

• e.g. Dexcom one+ and Freestyle Libre 2 Plus are approved for All Type 1 patients and Type 2 patients on multiple daily insulin injections fitting certain criteria

• Sensor changed every 7-14 days depending on type

CSII

Continuous SC insulin infusion or Insulin pumps

Used for T1DM

Two types of pump: tethered and patch

CSII therapy be initiated only by a trained specialist team

Only uses fast acting insulin, delivered as basal (background) and bolus (to cover meals)

Hybrid Closed Loop Systems

Only uses fast acting insulin, delivered as basal (background) and bolus (to cover meals)

Monitoring in T2DM

• Annual review including:

  • a blood test (FBC, U&Es, LFT, eGFR, HbA1c and cholesterol panel)

  • Foot check

  • BP

  • Weight check (BMI)

  • Urine ACR

• More frequent HbA1c, eGFR and urine ACR monitoring if control not optimal or signs of kidney disease / stress

• Retinal screening annually

AGP

Ambulatory Glucose Profile

a summary of blood glucose values from the report period with the median (50%) and other percentiles shown as a single day

How to approach reviewing and interpreting AGP?

• Get consent for sharing data

• Find something positive in data to discuss with patient

• Look for a ‘good day’ and try and replicate it

• Data should only be interpreted after 14 days of collection

• Glucose variability – ideal <36%

Priorities when reviewing AGP

Priority 1: Hypoglycaemia

• how often

• when

• any trend

Priority 2: Hyperglycaemia

• Reducing hyperglycaemia (measured by HbA1c) is associated with clinically significant reductions in microvascular complications and long-term macrovascular disease

Priority 3: Glucose variability

• important risk factor for CV compliations