1. Diabetes in special circumstances Sham Acharya Consultant Endocrinologist HNEHEALTH Tamworth workshop 30/11/09

2. Management of DM Adolescence and young adulthood (YPC) Pregnancy (pre-conception, Type1 & 2, GDM) Diabetes and mental health disorder DM in renal failure DM in elderly Tamworth workshop 30/11/09

3. YPC Tamworth workshop 30/11/09 Source: Google

4. Case studies Ms A is 19-yrs old T1D 8 yrs On basal bolus insulin HbA1c >14% Patchy attendance in clinic She is slim, wants to remain slim Insulin omission major concern RBGL >30 on many occasions, recurrent admissions Early retinopathy and nephropathy Tamworth workshop 30/11/09

5. Ms A. Contd.. Difficult social circumstances Alcohol and drugs… MTP once How do we manage such patients? Tamworth workshop 30/11/09

6. Ms W Intelligent 22-yrs- old Uni student T1D, Graves’ disease & Coeliac disease Highly motivated Insulin pump last 6 years Meticulous in her approach BGL 2-20, HbA1c 6.3% loss of hypo awareness - driving implications She is very frustrated…. Tamworth workshop 30/11/09

7. YPC – why special? Biological changes with puberty Insulin resistance Poor glycaemia Transition from parental control to individual Transfer from paediatric to adult set up Lifestyle issues (alcohol, drugs, smoking) Tamworth workshop 30/11/09

8. Problems High DNA rates (migration, lack of motivation) Episodic rather preventative care Recurrent admissions with DKA, hypos Unplanned pregnancy Insulin omission and eating disorders Timing of clinics Tamworth workshop 30/11/09

9. Complications Tamworth workshop 30/11/09

10. Retinopathy Acharya et al. Diabetic Medicine 2008 Group 1 15 to 18 Group 2 18.1 to 22 Group 3 22.1 to 25 Overall Females2%19%30%17% Males7%20%24%16% Mean duration of diabetes 6.7 yrs (SD 3.9) 8.6 yrs (SD 8) 11 yrs (SD 6) Overall5%19%27%16%

11. Complications in T1D Cumulative incidence after 30 years (DCCT) PDR 50%, Nephropathy 25%, CVS 15% VS. PDR 21%, Nephropathy 9%, CVS 9% (DCCT) (intensive) Role of additional specialist services Tamworth workshop 30/11/09

12. What are the treatment goals? Free from symptoms, hospital admissions Free from life threatening hypos and swings Stable and good glycaemia (HbA1c<7%) Free from complications Lead normal life Tamworth workshop 30/11/09

13. Are we doing well? HVIDORE DIABAUD 3 Grampian data Australian data Tamworth workshop 30/11/09

14. HVIDORE study Mortensen et al. Diabetes Care 1997; 20(5): 714-20 Data from 18 countries (Europe, Japan, North America) 2873 subjects Tamworth workshop 30/11/09

15. DIABAUD 3 DIABAUD 3: Green S & Waugh NR (SSGDY) Data from 986 children in Scotland Mean HbA1c 9.2% Tamworth workshop 30/11/09

16. Mean HbA1C levels in YPC - Grampian experience 15 to 1818.1 to 2222.1 to 25 P < 0.001 between group 3 and group 1 Tamworth workshop 30/11/09 Acharya 2008 Diabetic Medicine

17. Australian data Dabadghao P, Vidmar S, Cameron FJ. Diabetic Medicine. 2001;18:889–94. Tamworth workshop 30/11/09

18. Glycaemic control in young people Poor control seems to be universal Long term complications Financial burden Services -Efficient -Evidence based approach -Emphasis on self management Tamworth workshop 30/11/09

19. Requirements for ideal YPC services Transition services rather than transfer clinic MDT (educator, dietician, specialist) Database (local, regional, links with primary care) One stop clinic (annual care cycle including retinal screening) Emphasis on self management (structured educational programmes) Pump services (CSII + CGMS + intense education) Effective protocols and policies for dealing with DNAs Flexible clinic times Tamworth workshop 30/11/09

20. Principles Encouragement rather punishment! Communicate in the preferred way (text, email etc) Post clinic discussions Open access clinics Continuity of care Long term specialist follow-up in view of complications Tamworth workshop 30/11/09

21. What do we have in Newcastle Transition service? YPC service with Dedicated team ✔ ✔ Regular meetings ✔ Empowerment program ✔ ✔ Electronic database × Technology ✔ ? Specialist services (ophthalmology)? Support services (out of hours etc)? Tamworth workshop 30/11/09

22. Pump services in Newcastle Insurance funded Who would benefit -Basal-bolus, Carb counting -Commitment to monitor and improve -Intense in terms of resources Pump not for everyone! Tamworth workshop 30/11/09

23. Pumps Unpredictable or inconsistent control Severe recurrent hypoglycaemia including hypoglycaemia unawareness Dawn phenomenon Early signs of nephropathy, neuropathy, retinopathy Gastroparesis Pre conception or during pregnancy Extreme insulin sensitivity Allergy to intermediate/long acting insulin Antibody-mediated insulin resistance Tamworth workshop 30/11/09

24. Technology Tamworth workshop 30/11/09

25. DM and Pregnancy Tamworth workshop 30/11/09

26. Diabetes and Pregnancy Maternal complications Unstable glycaemia DKA, Hypos Miscarriage Retinopathy, nephropathy Pre-eclampsia Increased C-section Fetal complications Birth defects cvs, neural tube, genitourinary Macrosomia Still birth Birth injury Hypoglycaemia Tamworth workshop 30/11/09

27. Pre existing Diabetes & Pregnancy: Australian data 55% Type 2, 45% Type 1 3.4% neonatal death (4 times higher) Neonatal hypos 25%, shoulder dystocia 8% Major anomaly 8.1%, minor 12% (4 times) Type 1 - 20% had pre-conception advice Type 2 – 12% <50% Folic acid Adrian McElduff 2005 Diabetes Care Tamworth workshop 30/11/09

28. England pregnancy data Perinatal mortlaity 32/1000LB (4 times) Major congenital anomaly 46/1000B (twice) Neural tube defects and CHD (4 times) PNM & congenital anomaly rates similar type 1 and type 2 DM Only 37% HbA1c of <7% Median HbA1cs Congenital anomaly 7.9% Still birth/neonatal death 8% CEMACH BMJ 2006

29. Role of pre-pregnancy planning HbA1c (aim <6%) Review of complications Discontinue teratogenic medications Folic acid 5mg Contraception till time is right Tamworth workshop 30/11/09

30. Management during pregnancy OGTT not required for type 2! Intense glycaemic control Pre meals <5.5, 2hr <7, HbA1c 6% Regular obstetric + diabetes review (Joint clinics) Diabetic emergencies - admit as needed Management during labour Post-natal visit (contraception) Tamworth workshop 30/11/09

31. GDM Diagnostic criteria changing Lower the better Use MF + Insulin High risk of DM in future (50%) Life style changes Contraception, monitoring for future Tamworth workshop 30/11/09

32. Diabetes and mental health disorder Prevalence of DM 15% (risk factors) Newer anti psychotics diabetogenic Clozapine, Olanzapine, Risperidone, Quetiapine Hyperglycaemia - independent of weight gain Olanzapine, Clozapine → DKA, T1D Regular monitoring essential Treat as in type 2 DM, individualised targets Combined clinics useful Tamworth workshop 30/11/09

33. Diabetes and renal failure Microalbuminuria earliest marker Progression to ESRD once macroalbuminuric Metformin should be discontinued GFR<30 - SU, Exenatide, glitazone, gliptins and insulin can be still used ESRD – insulin appropriate Risk of hypos increase Combined clinics beneficial Tamworth workshop 30/11/09

34. Diabetes in elderly Targets need not be strict! Avoid hypos Poly pharmacy dangerous Remember type 1 DM! Use of insulin as appropriate Once a day (protaphane) Twice daily pre-mixed Basal-bolus Tamworth workshop 30/11/09

36. Thank you Shamasunder.Acharya@hnehealth.nsw.gov.au Tamworth workshop 30/11/09