Transcript Abbey Medical Practice Diabetes Protocols

Abbey Medical Practice
Personalised Diabetic Care
Wednesday 10th September 2014
Abbey Medical Practice:
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Semi-rural, dispensing practice
Cover 200 miles2
4 Partners, 1 GP Assistant, 3 Practice Nurses
7702 Patients
Diabetics make up 5.5% of Patient Population:
- 394 Type 2 Diabetics (5.11%)
- 30 Type 1 Diabetics (0.39%)
Annual UK Cost of Diabetes:
£9.8 billion
Drugs: 2% (£196 million)
Complications: 98% (£9704 million)
• Early tight control reduces long-term
complications.
• Poor compliance with medication is responsible for
poor control and thus increased complications.
Using better tolerated but more expensive drugs is
cost effective in the long-term.
Improved Metformin Compliance
• Metformin is the primary drug for T2D
• One chance to get patients on Metformin
• Standard preparation has higher incidence of GI SEs
and require multiple dosing
• Modified Release preparations better tolerated &
only once daily
• Start 500mg Metformin SR once daily, increasing to
2g once daily over 3-4 weeks
Sulphonylureas
Pros
Cons
Cheap (but not very cheerful!)
WEIGHT GAIN
Hypoglycaemia
Need to test BM with driving
? CVS Sequelae
Pioglitazone
Pros
Cons
Effective
Weight Gain (fluid retention)
V.Low risk of Hypoglycaemia
Not in heart failure
Good lipid profile
Not in undiagnosed
Haematuria/Bladder cancer
Reduced dose in elderly
DPP-4 Inhibitors (Gliptins)
Pros
Cons
WEIGHT LOSS
Increased risk of Pancreatitis
V.Low risk of Hypoglycaemia
Reduced dose in CKD
Well tolerated
Relatively expensive
Novel (long-term data unknown)
GLP-1
Pros
Cons
WEIGHT LOSS
Nausea
V.Low risk of Hypoglycaemia
SC daily/weekly injection
Expensive
Novel (long-term data unknown)
Alpha-Glucosidase Inhibitors
Pros
Cons
WEIGHT LOSS
Nausea
V.Low risk of Hypoglycaemia
Diarrhoea
Germans like it!
Poorly tolerated
SGLT-2 Inhibitors
Pros
Cons
WEIGHT LOSS
Glycosuria
V.Low risk of Hypoglycaemia
UG thrush
Expensive
Novel (long-term data unkown)
UKPDS
Single most important factor to reduce longterm complications of T2D is BP control.
(And the key to BP control is Patient compliance)
Antihypertensives
Class
Pros
Cons
ACEi
Cheap
Renal Protection
Dry Cough in 10-15%
ARB
Well tolerated
Renal Protection
Best agent is expensive
(Olmesartan)
Alpha Blocker
Cheap
Oedema, Postural
Hypotension
Beta Blocker
Cheap
Metabolic profile , ED,
Contraindicated Asthma
Calcium Antagonist
Cheap
Oedema
Diuretic
Cheap
Metabolic profile,
ED
Conclusion
• Improve patient compliance to reduce complication
rate, and therefore costs. Use the best tolerated and
most effective medication where possible.
• Tailor care to the individual patient – review depends
on BP, eGFR , Microalbuminuria and HbA1c
• Nurses are infinitely better than doctors for following
protocols and are the key to getting good results and
reducing long-term complications & NHS costs