Emma Harris Medicines Management Pharmacist West Suffolk Clinical Commissioning Group Educational Event 28 th January 2014 West Suffolk Hospital Education Centre Blood glucose self-monitoring in type 2 diabetes mellitus

Total spend on all BGTS by 10% No.4 on the WSCCG Rx Recommendation Top 10 savings areas (excluding PIP metrics) Potential 12-month saving of £92,442 WSCCG Prescribing Data T2DM not treated with insulin

Self-monitoring of plasma glucose should be available to: those on oral glucose-lowering medications to provide information on hypoglycaemia assess changes in glucose control resulting from medications and lifestyle changes monitor changes during intercurrent illness ensure safety during activities, including driving NICE CG87: The management of type 2 diabetes

self-monitoring skills the quality and appropriate frequency of testing the use made of the results obtained the impact on quality of life the continued benefit the equipment used Assess at least annually & in a structured way: NICE CG87

Medical Standards of Fitness to Drive Drivers Medical Group, DVLA, Swansea (2013)

(2012) “Drivers with a Group 1 licence on insulin have been advised to test their blood glucose before driving. If this practice were to be encouraged in people on sulphonylureas, it would increase enormously the cost of blood glucose monitoring.”

Greatest risk of hypoglycaemia in first 3 months of sulphonylurea treatment Maintain current practice Extra testing only in those people who are  starting treatment  experiencing hypoglycaemia or reduced awareness

For Group 1 drivers (car/motorcycle) the frequency of blood glucose monitoring should depend on the clinical context A Group 2 driver (bus/lorry) on a sulphonylurea or glinide is required by law to monitor blood glucose at least twice daily and at times relevant to driving

Position Statement on Self monitoring of blood glucose (SMBG) for adults with Type 2 diabetes (April 2013) Exact role of SMBG in Type 2 diabetics not on insulin less clear and widely debated Volume & cost of Rx for monitoring rising SMBG should be available to people receiving sulphonylurea and prandial glucose regulators Access to SMBG based on individual assessment Arbitrary withdrawal of SMBG in those who clearly benefit should not occur

Reflect on practice Responsibility to use resources wisely Education, appropriate and timely reviews, responding to results Support those who find SMBG useful Identify those who gain no benefit SMBG performed indefinitely? Testing for a defined period may be appropriate

Type 2 diabetes mellitus treated with: THESE MEDICINES CAN CAUSE HYPOGLYCAEMIA Blood glucose monitoring may therefore be required in patients: who are not stabilised on treatment who are drivers in other certain circumstances Drug classExamples Meglitinides (Prandial glucose regulators/Glinides) Nateglinide, Repaglinide SulfonylureasGlibenclamide, Gliclazide, Glimepiride, Glipizide, Tolbutamide

Type 2 diabetes mellitus treated with: Diet and exercise alone REGULAR BLOOD GLUCOSE MONITORING NOT NECESSARY A supply of blood glucose test strips may be required (as an acute prescription) in certain circumstances Drug ClassExamples Alpha glucosidase inhibitorsAcarbose BiguanidesMetformin DPP-4 Inhibitors (Gliptins) Linagliptin, Sitagliptin, Saxagliptin, Vildagliptin GLP-1 Analogues (Incretin mimetics) Exenatide, Liraglutide, Lixisenatide Thiazolidinediones (Glitazones) Pioglitazone SGLT2 InhibitorsDapagliflozin

Blood glucose monitoring may be required in patients:  with acute illness  up to 7 days post-surgery  co-prescribed steroids  undergoing significant changes in pharmacotherapy or fasting  at increased risk of hypoglycaemia/hypo unawareness  with unstable or poor glycaemic control (HbA1c >8.0%)  with postprandial hyperglycaemia  who are pregnant or planning pregnancy

DVLA guidance for diabetic patients managed by sulphonylurea or glinide tablets Driver GroupDVLA Advice Group 1 (cars, motorcycles) It may be appropriate to monitor blood glucose regularly and at times relevant to driving Group 2 (buses, lorries) There is a requirement that the patient regularly monitors blood glucose at least twice daily and at times relevant to driving

 Clinical judgement  Choice of treatment  DVLA  Seek advice  Repeat vs. acute prescription  Regular review  Suitable quantities to meet patient needs, prevent stockpiling and waste  Patient education How frequently should my patient test their blood glucose? How many test strips should I prescribe?

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