1. Dr Mohammed Babsail, Dr Bhavin Bakrania
The Use of Dipeptidyl Peptidase-4 inhibitor (DPP-4i) therapy for Non Insulin Dependent Diabetics in General Practice
Dr Mohammed Babsail, Dr Bhavin Bakrania
Acknowledgements to Dr Sunitha Padmanabhan, Dr Raj Rai
INTRODUCTION
The prevalence rates of diabetes are 6% and 6.7% in England and Wales, respectively.
Approximately 90% of all diabetics have type 2 diabetes.
The financial cost of diabetes care approximately equates to 10% of NHS expenditure and 5% of UK healthcare expenditure.
Diabetic patients require regular monitoring to minimise the occurrence of vascular complications and reduce the risk of hypoglycaemia.
NICE guidelines stipulate that DPP-4i should only be continued if patients demonstrate a reduction of at least 5.5 mmol/mol in HbA1c over a period of 6 months.
66% (37) of patients showed a reduction of at least 5mmol/mol and correctly remained on treatment as indicated
2% (1) of patients did not demonstrate the recommended reduction and their treatment was correctly discontinued as indicated
29% (16) of patients did not demonstrate the recommended reduction but their treatment continued against guidance
4% (2) of Patients demonstrated the recommended reduction but their treatment was discontinued one due to recommendation from a cardiologist and one due to patient complaining of shoulder pain.
17 of the 56 (30%) patients should have had their DPP-4i stopped due to their HbA1c readings. 16 of these patients continue to take the DPP-4i inappropriately (94%)
T2DM medications work by increasing insulin availability, improving sensitivity to insulin, delaying the delivery and absorption of carbohydrates from the gastrointestinal tract, or increasing urinary glucose excretion.
DPP-4i enhance glucose-dependent insulin secretion, slow gastric emptying, and reduce postprandial glucagon and food intake. They are not known to cause hypoglycaemia.
CONCLUSIONS
DPP-4i are efficacious at adequately reducing HBA1c
DPP-4i are continued in keeping with NICE guidance
DPP-4i are NOT discontinued in accordance with NICE guidance
Looking further into those inappropriately continued on a DPP-4i.
Out of the 16 in this criteria, 9 patients (56%) had their bloods taken prematurely. They could have shown a significant enough drop in HbA1c had there bloods been taken closer to the 6-month mark
The average length of time for HbA1c checks in these 9 patients was 2.6 months
Of the other 7 patients, two were under the care of Diabetes Speciality Services upon time of review. Regarding the remaining 5, there was no clear reason as to why DPP-4i were inappropriately continued.
Therefore out of the 16, five (32%) should definitely have had their DPP-4i stopped by the GP in practice.
Initial therapy in type 2 diabetics should begin with diet, weight reduction, exercise, and metformin. DPP-4i can be considered as monotherapy in patients who are intolerant of or have contraindications to metformin, sulfonylureas, or thiazolidinediones.
DPP-4i can be considered for dual therapy in combination with either metformin, pioglitazone, a sulfonylurea, or insulin (when treatment with these drugs alone fails to achieve adequate glycaemic control), or as triple therapy in combination with metformin and either pioglitazone or insulin.
LIMITATIONS
Exclusion was unexpectedly high
Timely HbA1c checks were often difficult to achieve due to patient compliance
Difficult to assess how much lifestyle played a role in reducing HbA1C
SUGGESTIONS
Tighter adherence to NICE guidelines is recommended.
When starting a DPP-4i ensure a repeat HBA1c in 5-6 months’ time
Inform patients that their DPP-4i will be stopped if a less than 5mmol decrease in HbA1c over 6 months is seen so that they can also flag up the need to stop the medication
We have constructed a digital proforma on SystmOne which enables early and timely recognition of diabetics requiring future HbA1c checks or medication reviews. It also aims to ensure that only patients who have achieved the recommended reduction in HbA1c are continued on a DPP-4i.
OBJECTIVES
Quantify our adherence to NICE guidelines concerning DPP-4i therapy for Non Insulin Dependent Diabetics in General Practice
Evaluate active protocols for monitoring diabetics in the community
METHOD
This was a retrospective study analysing all diabetic patients in a GP practice of approximately 4500 patients who are currently on or previously have been on a DPP-4i. Using SystmOne, the total number of patients generated was 75, 19 of whom were excluded due to the following reasons:
The date of initiating DPP-4i therapy could not be identified
The HBA1c level was not checked prior to initiation of therapy
A period of 6 months had not lapsed since starting DPP-4i therapy
Patients who were new to the practice had very limited data on therapy and previous monitoring
This left a total number of 56 patients to be included in the audit.
RESULTS
Within six months of initiating therapy:
84% (47) of patients had their HbA1c checked and 9 patients did not
The average change in HbA1c for all 56 patients was a reduction of 9.9 mmol over an average testing period of 4.4 months.
REFERENCES
Monthly Index of Medical Specialities, Management of Type 2 Diabetes (NICE Guideline). [online] Available at: < [Accessed 28 August 2016]
National Institute of Clinical Excellence , Type 2 diabetes: alogliptin. [online] Available at: < [Accessed 27 August 2016]
National Institute of Clinical Excellence, Type 2 diabetes in adults: management. [online] Available at: < [Accessed 28 August 2016]
Up to Date, Dipeptidyl peptidase 4 (DPP-4) inhibitors for the treatment of type 2 diabetes mellitus. [online] Available at: < > [Accessed 30 August 2016]
Up to Date, Plasma glucose multihormonal regulation of glucose. [online] Available at: < [Accessed 27 August 2016]