Abbey Medical Practice Personalised Diabetic Care Wednesday 10 th September 2014

Abbey Medical Practice: Semi-rural, dispensing practice Cover 200 miles 2 4 Partners, 1 GP Assistant, 3 Practice Nurses 7702 Patients Diabetics make up 5.5% of Patient Population: Type 2 Diabetics (5.11%) - 30 Type 1 Diabetics (0.39%)

Annual UK Cost of Diabetes: £ 9.8 billion Drugs: 2% (£196 million) Complications: 98% (£9704 million) Early tight control reduces long-term complications. Poor compliance with medication is responsible for poor control and thus increased complications. Using better tolerated but more expensive drugs is cost effective in the long-term.

Improved Metformin Compliance Metformin is the primary drug for T2D One chance to get patients on Metformin Standard preparation has higher incidence of GI SEs and require multiple dosing Modified Release preparations better tolerated & only once daily Start 500mg Metformin SR once daily, increasing to 2g once daily over 3-4 weeks

Sulphonylureas ProsCons Cheap (but not very cheerful!)WEIGHT GAIN Hypoglycaemia Need to test BM with driving ? CVS Sequelae

Pioglitazone ProsCons EffectiveWeight Gain (fluid retention) V.Low risk of HypoglycaemiaNot in heart failure Good lipid profileNot in undiagnosed Haematuria/Bladder cancer Reduced dose in elderly

DPP-4 Inhibitors (Gliptins) ProsCons WEIGHT LOSSIncreased risk of Pancreatitis V.Low risk of HypoglycaemiaReduced dose in CKD Well toleratedRelatively expensive Novel (long-term data unknown)

GLP-1 ProsCons WEIGHT LOSSNausea V.Low risk of HypoglycaemiaSC daily/weekly injection Expensive Novel (long-term data unknown)

Alpha-Glucosidase Inhibitors ProsCons WEIGHT LOSSNausea V.Low risk of HypoglycaemiaDiarrhoea Germans like it!Poorly tolerated

SGLT-2 Inhibitors ProsCons WEIGHT LOSSGlycosuria V.Low risk of HypoglycaemiaUG thrush Expensive Novel (long-term data unkown)

UKPDS Single most important factor to reduce long- term complications of T2D is BP control. (And the key to BP control is Patient compliance)

Antihypertensives ClassProsCons ACEiCheap Renal Protection Dry Cough in 10-15% ARBWell tolerated Renal Protection Best agent is expensive (Olmesartan) Alpha BlockerCheapOedema, Postural Hypotension Beta BlockerCheapMetabolic profile, ED, Contraindicated Asthma Calcium AntagonistCheapOedema DiureticCheapMetabolic profile, ED

Conclusion Improve patient compliance to reduce complication rate, and therefore costs. Use the best tolerated and most effective medication where possible. Tailor care to the individual patient – review depends on BP, eGFR, Microalbuminuria and HbA 1 c Nurses are infinitely better than doctors for following protocols and are the key to getting good results and reducing long-term complications & NHS costs