Transcript the poster - RCGP Annual Conference

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.
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.
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%)
CONCLUSIONS
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.
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.
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 DPP4i. 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.
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.
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.
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.
RESEARCH POSTER PRESENTATION DESIGN © 2015
www.PosterPresentations.com
REFERENCES
• Monthly Index of Medical Specialities, 2016. Management of Type 2 Diabetes (NICE Guideline). [online] Available at:
<http://www.mims.co.uk/management-type-2-diabetes-nice-guideline/diabetes/article/891805> [Accessed 28 August 2016]
• National Institute of Clinical Excellence , 2013. Type 2 diabetes: alogliptin. [online] Available at:
<https://www.nice.org.uk/advice/esnm20/chapter/introduction> [Accessed 27 August 2016]
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• Up to Date, 2016. Dipeptidyl peptidase 4 (DPP-4) inhibitors for the treatment of type 2 diabetes mellitus. [online] Available at:
<https://www.uptodate.com/contents/dipeptidyl-peptidase-4-dpp-4-inhibitors-for-the-treatment-of-type-2-diabetes-mellitus >
[Accessed 30 August 2016]
• Up to Date, 2011. Plasma glucose multihormonal regulation of glucose. [online] Available at:
<http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/11/9398> [Accessed 27 August 2016]