1. Update on Diabetes Services 41 st Annual General Practitioner Study Day 28 th January 2012 Dr. Eoin O’Sullivan Consultant Endocrinologist Bon Secours Cork

3. Diabetes service development What’s done (or almost done!) –Laboratory developments –Type 1 diabetes –Pre-diabetes policy –Podiatry –Exercise classes for type 2 diabetes –Nurse-led diabetes clinics What’s next –Insulin pump clinic restructuring –More work on in-patient hyperglycaemia

4. Laboratory developments HbA1c –Same day turnover in new in-house assay –Better decision making on in-patients with diabetes/hyperglycaemia –Clearer advice on discharge for patients and GPs Blood ketone testing –Vital for assessment of hyperglycaemic ketosis –Being incorporated into new “Sick day rules” patient information leaflet

5. Type 1 Diabetes Continuous glucose monitor sensors (CGMS) –To assist in maximising glycaemic control including avoidance of hypoglycaemia Restructuring of insulin pump clinics –Unified approach between diabetes nurse specialist, dietician and clinician Blood ketone monitoring –Home care as well as during admissions

6. Pre-diabetes “Impaired Glucose Regulation” (IGR) or “Non-Diabetic Hyperglycaemia” (NDH) Risk factors similar to T2DM 1 in 7 adults, with annual progression to diabetes of 5-12% Approx 50% will develop T2DM in 5 years IGT especially is associated with increased cardiovascular risk Management –Diet and exercise (±Metformin) –Cardiovascular risk factor reduction

7. Diagnostic criteria for diabetes NormalPre- diabetes Diabetes* F glucose (mmol/l)<6.16.1-6.9≥7.0 R glucose (or 2 hr on OGTT) <7.87.8-11.0≥11.1 HbA1c (%)<5.75.7-6.4≥6.5 *Single abnormal value sufficient if hyperglycaemic symptoms; otherwise repeat the same test on subsequent day unless have 2 different but concordant tests

8. Pre-diabetes patient information leaflet What is pre-diabetes? What is the significance of pre- diabetes? How do Imanage my pre-diabetes –Dietary and exercise advice How should my pre-diabetes be followed up? Useful contact information

9. How should my pre-diabetes be followed up? Your GP will need to follow up your blood sugar levels (as well as your blood pressure and cholesterol). This can be done in a number of ways e.g. a fasting blood test, a non-fasting blood test, and/or an oral glucose tolerance test. This involves a fasting blood test, followed by a prescribed sugary drink and another blood test 2 hours later.

10. Podiatry Foot ulcers in diabetes are a significant cost of care Podiatry access will be provided for patients with diabetes who are found to have foot ulcers

11. Exercise classes for type 2 diabetes Minimum of 6-8 patients with diabetes/pre-diabetes Pre assessment/ screening 8 exercise classes once a week (1 hour) Exclusion criteria include insulin use/high risk of hypoglycaemia, poorly controlled diabetes, unstable cardiovascular disease

12. Nurse-led diabetes clinics Restructuring of types of clinics offered to maximise patient needs Increasing communication between diabetes nurse clinic and review in Cork Clinic More referrals from Rooms to nurse-led clinic to try to maximise home control and where possible avoid admission

13. Diabetes clinics

14. What next?

15. Inzucchi SE et al. NEJM 2006

16. In-patient hyperglycaemia (10- 25%) Increased in-hospital mortality Increased risk of infection Increased length of stay

17. In-patient hyperglycaemia New ward-based insulin prescription chart Structured approach to in-patient hyperglycaemia Protocols for management of hyperglycaemia

18. Endocrine developments Synacthen tests in OPD Thyroid nodule MDT

19. Thank you Dr Eoin O’Sullivan Suite 6, Cork Clinic, Western Road Tel: 021-4341955 Fax: 021-4346148 E-mail: ccendocrinology@gmail.com