Type 2 diabetes

Why is it important Diagnosis Pre diabetes Managing diabetes Insulin

WHY IS IT IMPORTANT? People with type 1 diabetes, on average, have shorter life expectancy by about 20 years. People with type 2 diabetes, on average, have shorter life expectancy byabout 10 years. Cardiovascular disease is a major killer in diabetes. However, a US study shows that CV-related deaths are falling in diabetics in the US – and the same is therefore probably true in the UK (Lancet 2018;391:2430). The data was extracted from national datasets, and compared 1988–94 with 2000–15. It showed that, for people with diabetes: The overall death rate fell, from 23/1000 in 1988–94 to 15/1000 in 2000–15. The overall death rate among non-diabetics also fell, but the fall was more dramatic amongst diabetics

glycaemic control vs. cardiovascular risk factor control (BP, cholesterol).

For MACROvascular disease BENEFITS LONGER LASTING Tight BP control for 5y resulted in reduced CV and all-cause mortality after 10y of follow-up (ADVANCE trial, NEJM 2014;371:1392). Tight glycaemic control for 5y reduced vascular events at 10y by 8.6/1000 – above (Veterans Affairs Diabetes trial, NEJM 2015; 372:2197). For MICROvascular disease Tight glycaemic control for 5y reduced nephropathy but not other microvascular outcomes during the trial. The renal benefits did not persist on returning to normal care (ADVANCE trial, NEJM 2014;371:1392).

Intensive control resulted in: A reduction in renal disease (mainly a reduction in progression to macroalbuminuria rather than a reduction in the need for dialysis/transplant). You would need to treat 73 people intensively over 5y to prevent 1 person developing renal problems/1 person progressing to macroalbuminuria (DTB 2017;55(6):62). A small and barely significant reduction in eye disease. No reduction in neuropathic complications.

Is tight glycaemic control good or bad? Long-term glycaemic control An increasing number of studies have suggested that really tight blood sugar control may offer no additional benefits, and may, in fact, actually be harmful in terms of cardiovascular or all-cause mortality (NEJM 2008;358:2630 & 2633; Lancet Commission 2009;373:1737) The evidence suggests there may be a J-shaped curve associated with blood sugar control: poor control (raised blood sugars) increases mortality, but so does very tight control. The optimum point seems to be around 53mmol/mol (7%). An important meta-analysis showed that severe hypoglycaemia increases cardiovascular risks. It was a UK primary care cohort study of 900 000 people who had an episode of severe hypoglycaemia impairing consciousness or requiring medical help. All the episodes of hypoglycaemia occurred outside the acute hospital setting, where comorbidity may fudge the results (BMJ 2013;347:f4533)

Episodes of severe hypoglycaemia increased CVD risk 2-fold Episodes of severe hypoglycaemia increased CVD risk 2-fold. This increased risk could not be entirely explained even when comorbidity and other confounders were adjusted for. Why might this be the case? Severe hypoglycaemia causes a sympathetic nervous system response: the catecholamines released have an adverse effect on the myocardium and vasculature, and also increase platelet aggregation and other inflammatory responses that may encourage atherosclerosis development. Added to that, severe hypoglycaemia can also trigger arrhythmias. May be why Metformin is beneficial - doesn’t cause Hypoglycaemia

Tight BP control may be harmful low blood sugars may be associated with a J-shaped curve. Evidence is emerging that this may also be true for blood pressure control in type 2 diabetes. A meta-analysis pooled data from over 70 000 people with type 2 diabetes, and showed that reducing baseline systolic blood pressure was not always beneficial (BMJ 2016;352:i717) At a baseline systolic BP of above 140mmHg, lowering the blood pr mortality and some other benefits. At a baseline systolic BP of below 140mmHg, lowering the blood pr no benefits in any other areas.

Are ACE inhibitors/ARBs the best drugs for BP control in diabetes? A meta-analysis of 25 000 people (19 trials) showed no significant benefits in important outcomes (death, cardiovascular death, IHD, CVA, heart failure) compared with other antihypertensives in diabetic patients. It also showed no benefit in terms of the risk of developing end-stage renal disease (BMJ 2016;352:i438). The accompanying editorial pointed out that this was a relatively healthy cohort of diabetics: none of the patients had CHD, heart failure, renal failure or proteinuria. In diabetics with these other comorbidities, there are good reasons why ACE inhibitors/ARBs would be a preferred first-line drug (BMJ 2015;352:i560). In healthy diabetics - WITH high bp – BP control is more important than agent used. In non healthy (Ie with CV markers – ihd, hf, nephropathy) ACE-I give added benefit.

Optimal treatment goals NICE suggested targets for glycaemic control but made it clear that targets should be tailored to individual needs. JAMA Intern Med 2014;174:1227 -QALY it found most benefit in lowering blood sugar in those who were younger. The benefit was minimal in those over 75 (unless HbA1c was above 9%) A BMJ review of diabetes in older people with comorbidities reminds us of (BMJ 2016;535:i2200): The seriousness of hypoglycaemia in all groups, but especially the elderly. The burden of daily tablet taking (and blood sugar measuring). The impact of diabetes and complications on quality of life. The lack of evidence base for many of the new drugs in older people or those with comorbidities.

Diagnosis of diabetes - PRE DIABETES Education /lifestyle measures Optimum weight/weight management BP and cholesterol and CV risk assessment (Qrisk) Refer to diabetes prevention program Pre diabetes register Yearly blood

DIABETES – HBa1C => 48 Diabetes Education /lifestyle measures Optimum weight BP and cholesterol and CV risk assessment (Qrisk) Refer to Structure education program (DESMOND) RETINALSCREENING Diabetes register DIABETES TEMPLATE – FOOT CHECKS FLU JAB

Management – oral diabetic agents

METFORMIN

Sulphonylureas

Glitazone

GLIPTINS

GLIFOZINS

GLP-1 ANALOGUES

INSULIN