Transcript Type 2 Diabetes in 2014 - NHS South Worcestershire CCG

Type 2 Diabetes in 2014
Dr. James Mather
Clinical Lead for Diabetes SWCCG
S
Diabetes in the UK
• Approximately 2.61 million adults suffer from type 2 diabetes in the UK (2011)1
• It is estimated that there are around 850,000 people in the UK who have type
2 diabetes but have not been diagnosed1
• By 2025, it is estimated that 5 million people will have diabetes in the UK1
*
2
1. Diabetes in the UK 2011/2012: key statistics in diabetes
The Challenge
of
Diabetes
4.2% of population in Wales
(1/2 million undiagnosed
nationally)
prevalence increasing
8-10% total healthcare
costs
> £5 billion pa
80% costs related to
diabetes complications
MAJOR PUBLIC HEALTH PROBLEM
Diabetes
£5.2
Alcohol
£3
Smoking
£1.5
Cost pa £billions
Diabetes and obesity are closely interlinked
Relationship between BMI and risk of type 2 diabetes
Normal weight
100
Overweight
Obese
Age-adjusted relative
risk of diabetes
Women1
75
50
Men2
25
0
<22
22–22.9 23–23.9 24–24.9 25–26.9 27–28.9 29–30.9 31–32.9 33–34.9
BMI
BMI, body mass index.
1. Colditz GA, et al. Ann Intern Med 1995;122:481–6; 2. Chan J, et al. Diabetes Care 1994;17:961–9.
5
≥35
Environmental Causes of Obesity
Gluttony or Sloth?
Bariatric Surgery
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New NHS service at WRH
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Martin Wadley and Anthony Perry
S
PCT funding is for 50 patients per year-BMI>55kg/m2
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Only proven intervention to cure T2DM
S
Life-changing cost-effective intervention IF THE RIGHT PATIENTS
ARE CHOSEN
Steno 2-Multiple risk factor
intervention trial: NEJM Jan 2003
S All had microalbuminuria
S Behaviour modification (smoking,
diet,exercise)
S Glycaemic control (HbA1c < 6.5%, Insulin if >
7.0%)
S BP control (< 130/80 vs. 135/85 in
conventional)
S Lipids (fasting Chol < 4.5, TG < 1.7)
Steno 2: Event Reduction
67%
70
60
61%
58%
53 %
50
40
30
20
10
0
cardiovascular nephropathy
disease
retinopathy
autonomic
neuropathy
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Steno-2 : Conclusion
“ A target driven, long-term, intensified
intervention aimed at multiple risk factors in
…type 2 diabetes and microalbuminuria reduces
the risk of cardiovascular and microvascular
events by about 50%.”
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Non-Adherence to Medications
 In the background-we assume pts are doing as
instructed
 Health gains foregone in England in 5 LTC are approx
$930 million per year-$100 million for T2DM and $400
million for hypertension
 Estimated that improving adherence to 80% would save
the NHS in England $500 million per year
 Worth enquiring about
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HBGM-Who needs it?
 National scrutiny of prescribing suggests that we are not
following guidance
 We could save a lot of money and still do the best job
for our patients-the figures are staggering
 HBGM is indicated for patients treated with: Insulin and
SUs
 You may have some unusual characters who want to plot
graphs when they are on metformin alone-discussion
about the pros and cons need to be blunt
 INSULIN or SULPHONYLUREAS. (This is a fullstop).
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The role of the kidney in type 2 diabetes
and SGLT2 inhibition
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Normal renal glucose handling1–3
Majority of glucose is
reabsorbed by SGLT2
(90%)
Proximal tubule
SGLT2
Remaining glucose is
reabsorbed by SGLT1
(10%)
Glucose
Glucose
filtration
SGLT, sodium-glucose co-transporter.
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1. Wright EM. Am J Physiol Renal Physiol 2001;280:F10–18; 2. Lee YJ, et al. Kidney Int Suppl 2007;106:S27–35;
3. Hummel CS, et al. Am J Physiol Cell Physiol 2011;300:C14–21.
Minimal to no
glucose excretion
Existing and novel mechanisms to reduce hyperglycaemia
in type 2 diabetes1−4
Insulin-dependent mechanisms
Insulin-independent mechanism
SGLT2 inhibition
1
Insulin sensitisers
• Thiazolidinediones
• Metformin
Adipose tissue, muscle and liver
2
Insulin releasers
•
•
•
•
3
Sulphonylureas
GLP-1R agonists*
DPP-4 inhibitors*
Meglitinides
Pancreas
Insulin replacement
• Insulin
Glucose utilisation
Glucose excretion/caloric loss
*In addition to increasing insulin secretion, which is the major mechanism of action, GLP-1 agonists and DPP4 inhibitors also act to decrease glucagon secretion.
DDP-4, dipeptidyl peptidase-4; GLP-1R, glucagon-like peptide-1 receptor.
1. Washburn
WN. J Med Chem 2009;52:1785–94; 2. Bailey CJ. Curr Diab Rep 2009;9:360–7; 3. Srinivasan BT, et al. Postgrad Med J 2008;84:524–31;
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4. Rajesh R, et al. Int J Pharma Sci Res 2010;1:139–47.
Dapagliflozin: A novel insulin-independent approach to
remove excess glucose
SGLT2
Dapagliflozin
Proximal tubule
Dapagliflozin
SGLT2
Glucose
filtration
Glucose
Increased urinary
glucose
excretion
Dapagliflozin selectively inhibits SGLT2 in the renal proximal tubule1
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1. FORXIGA Summary of Product Characteristics
The benefits of dapagliflozin’s novel mechanism of action
• Dapagliflozin offers an insulin-independent mechanism that can be used as
add-on therapy1,4
• Dapagliflozin inhibition of SGLT2 results in daily urinary glucose excretion of
approximately 70g,2 providing:
• Significant and sustained HbA1c reductions versus placebo when added to
metformin1,3
• Secondary benefit of weight loss1
1. Bailey CJ, et al. Lancet 2010;375:2223–33; 2. List JF, et al. Diabetes Care 2009;32:650–7;
3. Bailey CJ, et al. Poster 988-P. Poster presented at 71st Scientific Sessions of the American Diabetes Association, San Diego, California, 24–28 June, 2011
4. FORXIGA Summary of Product Characteristics
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Dapagliflozin is indicated in adults aged 18 and over with type 2
diabetes to improve glycaemic control as:
• Add-on combination therapy1
• In combination with other glucose-lowering medicinal products including
insulin, when these, together with diet and exercise, do not provide
adequate glycaemic control.
• Monotherapy1
• When diet and exercise alone do not provide adequate glycaemic control in
patients for whom use of metformin is considered inappropriate due to
intolerance
The use of dapagliflozin with pioglitazone is not recommended.
Dapagliflozin has not been studied in combination with DPP-4 inhibitors or GLP-1 analogues.
1. FORXIGA Summary of Product Characteristics
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Dapagliflozin dosing
• Dapagliflozin 10mg daily can be used in patients with mild or moderate hepatic
impairment
• In patients with severe hepatic impairment, a starting dose of 5 mg is recommended. If
well tolerated, the dose may be increased to 10 mg
• No known pharmacokinetic drug–drug interactions with other commonly prescribed type 2
diabetes treatments
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FORXIGA Summary of product characteristics
Summary
In patients with type 2 diabetes uncontrolled on metformin FORXIGA®
(dapagliflozin) offers;
• Significant and sustained HbA1c reductions
1-3
• Secondary benefit of weight loss
1-3
• Low incidence of hypoglycaemia when added to metformin
1
• Oral, once daily dosing
3
1-4
.
1.
2.
3.
Bailey CJ, et al. Lancet 2010;375:2223–33;
Bailey CJ, et al. Poster 988-P. Poster presented at 71st Scientific Sessions of the American Diabetes Association, San Diego, California, 24–28 June, 2011;
FORXIGA. Summary of product characteristics;
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Insulin Use in Type 2 Diabetes
This document is designed to aid product
choice when using insulin in type 2 diabetes.
The most cost effective product in each section
is highlighted in green although the decision to
prescribe a particular insulin may be influenced
by the choice of delivery device. For example,
elderly people with dexterity or visual problems
may find an injection device with a large visible
dial easier to use.
Start with human isophane insulin (NPH) taken at bedtime or twice daily according to need.
Human Isophane Insulins (Intermediate acting)
Pre-filled Pens
Insuman Basal SoloSTAR
Humulin I KwikPen
5 x 3ml
5 x 3ml
£19.80
£21.70
5 x 3ml
5 x 3ml
5 x 3ml
£17.50
£19.08
£22.90
10ml
5ml
10ml
£7.48
£5.61
£15.68
Cartridges
Insuman Basal Cartridge (Autopen 24 & ClickSTAR)
Humulin I Cartridge ( Autopen Classic or HumaPen range)
Insultard Penfill Cartridge (NovoPen 3 demi, NovoPen Junior or NovoPen 4)
Vials
Insulatard Vial
Insuman Basal vial
Humulin I Vial
Consider a once-daily long-acting insulin analogue
(insulin detemir, insulin glargine) if:
 the
person needs help with injecting insulin and a
long-acting insulin analogue would reduce injections
from twice to once daily, or
 the person's lifestyle is restricted by recurrent
symptomatic hypoglycaemic episodes, or
 the person would otherwise need twice-daily basal
insulin injections plus oral glucose-lowering drugs,
or
 the person cannot use the device to inject NPH
insulin.
Long-acting insulin analogues are considerably more
expensive than isophane insulin.
Long Acting Analogues
Pre-filled Pens
Insulin glargine (Lantus SoloSTAR)
5 x 3ml
£41.50
Insulin detemir (Levemir FlexPen)
5 x 3ml
£42.00
Insulin detemir (Levemir InnoLet)
5 x 3ml
£44.85
Insulin glargine cartridge (Autopen 24 and ClickSTAR)
5 x 3ml
£41.50
Insulin detemir cartridge (NovoPen 3 demi, NovoPen Junior or NovoPen 4)
5 x 3ml
£42.00
10ml
£30.68
Cartridges
Vials
Insulin glargine vial
Consider switching to a long acting analogue from
human isophane insulin if the patient:
 does
not reach target HbA1c because of
hypoglycaemia or
 has significant hypoglycaemia with human isophane
insulin irrespective of HbA1c or
 cannot use the delivery device for human isophane
insulin but could administer a long acting analogue or
 needs help to inject insulin and could reduce the
number of injections with long acting analogues.
A biphasic preparation containing a soluble insulin and an isophane
insulin might be considered first-line if the person's diabetic control
is particularly poor — for example, when glycated haemoglobin
(HbA1c) is more than 9.0% (75 mmol/mol).
For people taking isophane insulin or a long-acting analogue, a
switch to a biphasic insulin preparation should be considered if:


Their HbA1c remains above target — particularly if the value is 9%
(75 mmol/mol) or more, or
They have persistent post-prandial hyperglycaemia (greater than
8.5 mmol/L).

Biphasic preparations of soluble insulin and isophane
insulin
Pre-filled Pens
Insuman Comb 25 SoloStar
5 x 3ml
£19.80
Humulin M3 KwikPen
5 x 3ml
£21.70
Insuman Comb 15 Cartridges (Autopen 24 & ClickSTAR)
5 x 3ml
£17.50
Insuman Comb 25 Cartridges (Autopen 24 & ClickSTAR)
5 X 3ml
£17.50
Insuman Comb 50 Cartridges (Autopen 24 & ClickSTAR)
5 x3ml
£17.50
Humulin M3 Cartridge ( Autopen Classic or HumaPen range)
5 x 3ml
£19.08
Insuman Comb 25 Vial
5ml
£5.61
Humulin M3 Vial
10ml
£15.68
Cartridges
Vials
Only consider prescribing a biphasic insulin preparation containing a
rapid-acting analogue (insulin aspart or insulin lispro) if any of the
following apply:
• The person prefers to inject the insulin immediately before a meal.
• Hypoglycaemia is a problem.
• Blood glucose levels increase markedly after meals.
Pre-filled Pens
NovoMix 30 (Aspart/protamine insulin)
5 x 3ml
£29.99
Humalog Mix 25 KwikPen (lispro/protamine insulin)
5 x 3ml
£30.98
Humalog Mix 50 KwikPen (lispro/protamine insulin)
5 x 3ml
£30.98
NovoMix 30 Penfill Cartridge (NovoPen 3 demi, NovoPen Junior or NovoPen 4)
5 x 3ml
£28.84
Humalog Mix 25 Cartridge ( Autopen Classic or HumaPen range)
5 x 3ml
£29.46
Humalog Mix 50 Cartridge ( Autopen Classic or HumaPen range)
5 x 3ml
£29.46
10ml
£16.61
Cartridges
Vials
Humalog Mix 25
Consider intensifying insulin treatment with a
short-acting insulin if there is post-prandial
hyperglycaemia or if glycated haemoglobin (HbA1c)
levels remain elevated despite optimum titration of
a basal insulin or a biphasic insulin.
Add a short-acting insulin to the basal regimen,
usually given with the largest meal. If this is
insufficient, the short-acting insulin can be added
sequentially to the second and third largest meals
(leading to a basal bolus regimen).
Short-acting soluble insulins (also known as regular, rapid-acting, or neutral
insulins)
Pre-filled Pens
Insuman Rapid cartridge (Autopen 24 and ClickSTAR)
Humulin S cartridge (Autopen Classic or HumaPen range)
5 x 3ml
5 x 3ml
£17.50
£19.08
10ml
10ml
£7.48
£15.68
5
5
5
5
3ml
3ml
3ml
3ml
£28.30
£29.46
£30.60
£32.13
5 x 3ml
5 x 3ml
5 x 3ml
£28.30
£28.31
£28.31
10ml
10ml
10ml
£16.00
£16.28
£16.61
Vials
Actrapid vial
Humulin S vial
Rapid-acting analogues
Pre-filled Pens
Insulin glulisine (Apidra SoloSTAR)
Insulin Lispro (Humalog KwikPen)
Insulin Aspart (NovoRapid FlexPen)
Insulin Aspart (NovoRapid FlexTouch)
x
x
x
x
Cartridges
Insulin glulisine (Autopen 24 and ClickSTAR)
Insulin Lispro ( Autopen Classic or HumaPen range)
Insulin Aspart (NovoPen 3 demi, NovoPen Junior or NovoPen 4)
Vials
Insulin glulisine vial
Insulin Aspart vial
Insulin Lispro vial
 References
 NICE
Clinical Guideline 87. Type 2 diabetes. May
2009
 Clinical
Knowledge summaries accessed at:
http://cks.nice.org.uk/insulin-therapy-in-type-2diabetes
 Ultra
long acting basal analogue insulin
 Twice the price of insulin glargine
 This insulin is designed to be given daily or in
some cases alternate days
 It’s place is in patients T1 or T2 who cannot
achieve optimal control with other insulins
without significant nocturnal hypos
 Studies show a significant drop in severe
nocturnal hypos in both T1 and T2
 Expensive but in the correct patients will
save money and improve life quality
My Two Cents
S Basic principles still apply- Steno 2 shows we can make a
real difference
S Never under-estimate the power of weight loss at diagnosis
S Therapeutic options after weight loss are varied
S Bariatric surgery cures type 2 diabetes
S Newer treatments have a place if used in the right patients.