Foundation In Diabetes Course Community Diabetes Specialist Nurse Team, BHFT West
Learning Outcomes Understand what Diabetes is Understand how to recognise and diagnose diabetes Understand key medications Understand key diet principals Understand the impact of diabetes complications Understand diabetes care in Berkshire West
Session 1 What is Diabetes?
What is Diabetes? https://www.diabetes.org.uk/newlydiagnosed-with-diabetes/
Who is at risk of developing diabetes? You re overweight or have a high Body Mass Index (BMI). You have a large waist (more than 80cm/31.5 inches in women, 94 cm/37 inches in men or 90cm/35 inches in South Asian men). You re from an African-Caribbean, Black African, Chinese or South Asian background and over 25. You re from another ethnic background and over 40. You have a parent, brother or sister with diabetes. You have ever had high blood pressure, a heart attack or a stroke. You have a history of polycystic ovaries, gestational diabetes or have given birth to a baby over 10 pounds/4.5kg. You suffer from schizophrenia, bipolar illness or depression, or you are taking anti-psychotic medication.
Diagnosis of diabetes
Classification WHO 1999 Encompasses clinical stages and aetiological types of diabetes. Four classifications: Type 1 Type 2 Gestational Other ( drug induced / pancreatic disease/mody )
Monitoring of diabetes HbA1c A measurement of average control over past 3 months. Venous blood test If raised blood becomes thick and sticky
HbA1c > 75 64-75 58-64 48-58 Very poor control Poor control Acceptable control Excellent control
Self Blood Glucose monitoring Before meals: 4.0 7.0 mmol/l After meals: (2 hours) < 8.5 mmol/l 80% of readings at target should equate to target HbA1c of < 54 mmol/mol Targets need to take into account personal/social situation/patient choice
NICE guidelines for blood glucose management Self Monitoring should: not be a stand-alone intervention Have a clear need and purpose Be used in conjunction with appropriate therapy as part of integrated self-care with agreed targets and goal
UKPDS: Benefits of tight control Reducing HbA1c from 63-53 mmols/mol reduces Any diabetes related complication by 12% Any microvascular complication by 25% Progression of retinopathy by 21% Cataract by 24% Myocardial infarction by 16%
Diet
Content of Food Blood glucose levels are affected by the type of food eaten. Key to controlling blood glucose levels is to understand how and why different foods affect it. Dietary changes can help to keep blood glucose levels within the target range. Food consists of 3 main nutrients which are broken down to form their basic units. Carbohydrates Protein Fats Sugars Amino acids Fatty acids & Glycerol
Carbohydrates All carbohydrate eaten and drank are broken down into sugars. Carbohydrates can be classified into two main groups. Starch Sugar
Principle of the Glycaemic Index The type and amount of carbohydrate consumed makes a difference to blood glucose levels. Some carbohydrate foods breakdown more quickly than others. Quick = High Glycaemic Index Slow = Low Glycaemic Index Type of starch, fibre content, cooking process, high fat/protein content, acidic foods affect the glycaemic index of food.
Glycaemic Index of Foods Fruit Vegetables Cereals Breads Legumes Grains Low (<55) apples, grapes, berries, banana, oranges most vegetables, sweet potato, corn on the cob, sweet corn oats, oat bran, muesli, all bran pumpernickel, soya and linseed, sourdough, rye baked beans, kidney beans, butter beans, soya beans, chick peas, lentils pasta, bulgur wheat, barley Dairy Foods milk, yoghurt, custard ice cream Snack foods nuts, oatcakes, chocolate Medium (55-70) melon, pineapple, figs, raisins, banana (ripe) new potatoes, beetroot Weetabix, Shredded Wheat granary, chapatti, pitta basmati rice, gnocchi, couscous rye crackers, digestive biscuits watermelon High (>70) baked potato, mashed potato (and instant), chips cornflakes, rice krispies, white, brown, bagels jasmine rice sugary drinks, jelly beans
From XPERT Carbohydrate Quiz
Oral Agents
What would your ideal diabetes drug do? Effective in lowering HbA1c No hypoglycaemia No effect on weight/ weight loss? Reduce CV risk Also reduce lipids and B.P.? Few/ no side effects Safe
Main classes of oral drugs available Biguanides (Metformin) Sulphonylureas (Gliclazide, Glimiperide, Glibencalmide etc) Thiozolendinediones (Pioglitazone) Glinides (Replaglinide, nataglinide) Alpha-glucosidase inhibitors (Acarbose) DDP-4 inhibitors or Gliptins (Sitagliptin, Saxagliptin,Linagliptin, Vildagliptin, Allogliptin) SGLT2 inhibitor agents (empagliflozin, cangligliflozin, dapagliflozin) Coming soon dual SGLT1/2 inhibitor agents
Metformin Is the basis for the oral treatment of most people type II diabetes Introduced in 1957, has a proven track record of efficacy and safety Lowers blood glucose with a low risk of hypoglycaemia with modest weight loss UK PDS suggest that it reduces cardiovascular events although subsequent studies less certain. Generally well-tolerated
Metformin mechanisms of action Metformin decreases hyperglycemia primarily by suppressing glucose production by the liver Mechanism of metformin is not completely understood Increases insulin sensitivity, enhances peripheral glucose uptake to muscle
Adverse effects of metformin Gastrointestinal intolerance Risk of acute kidney injury with other medications add x-ray contrast material Lactic acidosis with renal impairment Heart failure Liver disease Reduced TSH B12 deficiency
Sulphonylureas First generation drugs carbutamide, acetohexamide, chlorpropamide, and tolbutamide. Second generation drugs glipizide, gliclazide, glibenclamide, glyburide, glibornuride,gliquidone, glisoxepide, and glyclopyramide. Third generation drugs glimepiride
Sulphonylureas Increase insulin secretion through opening up a potassium channel in islets cells Cause insulin release unrelated to blood glucose Are powerful glucose lowering agents in early type II diabetes but are less effective with longer duration diabetes Adverse effects are hypoglycaemia weight gain and there are concerns about increased risk of cardiovascular events Can accumulate in the elderly and should be used with caution
Glinides Repaglinide and Nataglinide Act in a similar manner to sulphonylureas but has shorter duration Excreted via GI Tract, so safe in renal impairment and elderly Hypoglycaemia do not combine with SU s Useful to control post meal glucose
Pioglitazone Effective No hypoglycaemia as monotherapy or with metformin Long duration of effectiveness Reduction in CVS events May help with NAFLD Weight gain Can cause osteoporosis Can precipitate heart failure due to fluid overload Ian Gallen 28
Physiology of postprandial glucose regulation Meal ❶ ❷ Insulin Rising plasma glucose stimulates pancreatic β-cells to secrete insulin 1 Glucagon Insulin Glucagon Gastric emptying Plasma glucose inhibits glucagon secretion by pancreatic α-cells 1 PPG ❸ Gastric emptying Delaying and/or slowing gastric emptying is a major determinant postprandial glycaemic excursion 2 of Hepatic glucose output + Glucose uptake PPG = postprandial glucose 1 DeFronzo RA. Med Clin North Am 2004;88:787-835 2 Horowitz M et al. Diabet Med 2002;19:177-94
DPP4 inhibitors Increases GLP-1, hence increase insulin secretion with hyperglycaemia Glucose lowering effect limited Some weight gain but reduced risk of hypoglycaemia Very well tolerated Concerns about heart failure with Saxogliptin and Alogliptin
GLP-1 agonists
Actions of GLP-1 agonists Promote 1 st phase insulin secretion Reduce glucagon release Delay gastric emptying Weak satiety effect Thus lowering blood glucose with modest weight loss without hypoglycaemia
Choice of GLP-1 receptor agonist: short acting versus long acting The pharmacological profile and half-life of a GLP-1 receptor agonist influences its effects on postprandial and basal (fasting) glycaemia SHORT ACTING GLP-1 receptor agonists Lixisenatide OD, Exenatide BD or LONG ACTING GLP-1 receptor agonists Liraglutide OD, Exenatide/Dulaglutide QW Effect on FPG Effect on PPG Effect on FPG Effect on PPG FPG = fasting plasma glucose PPG = postprandial glucose Fineman MS et al. Diabetes Obes Metab 2012;14:675-88
GLP1 agonist and cost per month Lixisenatide 20mg od; 54.14 Exenatide (10µg bd); 68.24 Byduron; 73.76 Liraglutide (1.2mg od); 78.48. Liraglutide (1.8mg od); 117.72 Dulaglutide (1.5mg) ; 73 pm IDegLira (50 dose daily); 159.22
When to use GLP1-agonists HbA1c>58 mmol/l +oral agents; Overweight. With metformin/pioglitizone/sglt2 inhibitors. Stop DPP4 and Sulphonylureas. Or with basal insulin; To avoid further weight gain. To reduce hypoglycaemia.
How to use GLP1-agonists With Oral Treatment; Use least expensive agent (lixisentatide). Continue with Metformin and/or Pioglitazone. Add SGLT2 inhibitor if post-prandial hyperglycaemia. Move from lixisenatide/exenatide to a Glutide; if nauseous or sub-optimal response. Transfer to biphasic insulin (Humulin M3); if no weight loss or improved glycaemic control. With OD human basal (Humulin I); with dose increasing by 10% alternate days to reduce FBG < 6mmol.
Filtered glucose load > 180 g/day Renal glucose re-absorption in patients with diabetes 1,2 SGLT2 ~ 90% SGLT1 ~ 10% When blood glucose increases above the renal threshold (~ 11 mmol/l), the capacity of the transporters is exceeded, resulting in urinary glucose excretion SGLT, sodium glucose cotransporter. 1. Adapted from: Gerich JE. Diabet Med. 2010;27:136 142; 2. Bakris GL, et al. Kidney Int. 2009;75;1272 1277.
Filtered glucose load > 180 g/day Urinary glucose excretion via SGLT2 inhibition 1 SGLT2 inhibitor SGLT1 SGLT2 inhibitors reduce glucose re-absorption in the proximal tubule, leading to urinary glucose excretion* and osmotic diuresis SGLT, sodium glucose cotransporter. *Loss of ~ 80 g of glucose per day = 240 cal/day. 1. Bakris GL, et al. Kidney Int. 2009;75;1272 1277.
Across all studies and empagliflozin Improves Glycaemic control Reduction of HbA1c as monotherapy or with Metformin, Pioglitazone and as part of triple therapy or with insulin Sustained weight loss Reduction in SBP and DBP Well tolerated Reduce death rates (RRR 32% in Empa-Reg)
NICE 2015 For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).
NICE 2015 In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: reinforce advice about diet, lifestyle and adherence to drug treatment and support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment.
What information would you consider when choosing oral therapies? HbA1c BMI egfr Age Current therapy Ethnicity Occupation
Medication selection for type 2 patients under 75 years of age BMI < 25 BMI 25 30 BMI > 30 Metformin for all if tolerated bigger effect in higher BMI DPP4 (gliptin) OR Gliclazide (not with DPP4) DPP4 weaker agent SGLT2 (Empagliflozin) + / - Pioglitazone + / - DPP4 (gliptin) SGLT2 (Empagliflozin) + / - GLP1 (Lixisenatide/Trulicity) + / - Pioglitazone Consider insulin start
Insulin Workshop Profiles and Devices
Injection Sites Sites should always be inspected prior to injecting Avoid injecting into areas of lipohypertrophy Hands should be washed prior to injecting Use of alcohol swabs are not required
Storage and Suspension Store unopened insulin supplies in the fridge Opened insulin can be kept at room temperature for 28 days Cloudy insulins need suspending and this is done by rocking and rolling until the crystals go back into the solution and the solution looks milky white
Insulin re-suspension For all insulin preparations that contain human insulin or are an analogue mixture insulin to ensure uniform distribution Recommend to re-suspend use rock and roll technique Inappropriate re-suspension will negatively impact glycaemic control.
Needle length Gibney and colleagues recently published data about calculated injection tissue depth with 90 degree insertion and no skin fold from 1208 paired tests. Needle length % of subcutaneous injections 4mm 99.5% 5mm >98% 6mm >94% 8mm >84% 12.7mm 45%
Injection technique Air shot Dart like action Leave the needle in the skin for at least 10 seconds after plunger fully depressed Dispose of needle safely immediately after use instead of leaving attached to pen. Prevents entry of air Prevents leakage of medication Needles should only be used once
Lipohypertrophy Thickened rubbery lesions Long term insulin use Re using needles Poor rotation of injection sites
Lipohypertrophy Indicators: Fluctuating blood glucose levels Recurrent hyperglycaemia Unpredictable hypoglycaemia High HbA1c National recommendations: Do not inject into areas with lipohypertrophy Sites checked yearly, ideally every 2-3 months, especially if lipo present Patients should be taught to inspect their own sites and how to detect for lipohypertrophy
Painful injections Keep insulin at room temperature. Use shorter needles. Always use new needle. Insert the needle in a quick dart like action Massaging the injection site is not recommended and may speed up absorption. Needles will on occasions hit a blood vessel and cause bleeding or bruising this does not appear to have any adverse affect on absorption, but if occurs frequency patients injection technique may need to be reassessed