Guidelines and Management Type 2

Diabetes Day Centre, Beaumont Hospital Disclaimer This publication is intended as a guide for General Practitioners managing . As with all guidelines use clinical judgement. Any other use will require the permission of the copyright owner of the material, Beaumont Hospital. Any commercial use of this material is strictly prohibited. All comments and requests should be directed to The Diabetes Day Centre, Beaumont Hospital. All rights reserved © 2013 Beaumont Hospital

Diabetes Day Centre, Beaumont Hospital Foreword

These guidelines were devised by the Diabetes Day Centre in Beaumont Hospital in consultation with a number of primary care practices in the North Dublin Area.

The guidelines have a number of objectives:

Improve delivery and quality care of patients with type 2 diabetes attending both their GP and the specialist diabetes team in Beaumont Hospital

Develop integration of care between primary care and the diabetes service in Beaumont Hospital for patients with type 2 diabetes

As an educational resource for both primary care and Beaumont Hospital

It is hoped that these guidelines are the start of a process to improve communication and consultation between the hospital and primary care and that further initiatives will follow which will continue to develop integrated care for patients with type 2 diabetes

Yours Sincerely

Dr Diarmuid Smith Professor Chris Thompson Dr Amar Agha Helen Twamley Consultant Endocrinologist Consultant Endocrinologist Consultant Endocrinologist CNS Diabetes Integrated Care

Clinical Nurse Specialist - Diabetes Integrated Care

Amanda Ledwith | email [email protected] | Tel 086 8139734 Helen Twamley | email [email protected] | Tel 0860478100

These nurses can assist your practise in setting up diabetes clinics, support existing clinics or provide training and educational updates on

HbA 1c

During 2010 a new type of measurement was introduced for measuring the average blood glucose level. This means HbA 1c is now recorded in mmol/mol (millimols per mol) instead of percentage. Both readings are shown below.

HbA 1c (%) 46789 10

HbA 1c (mmol/mol) 20 42 53 64 75 86

No In target range Above target range diabetes

1 Diagnosis guidelines Guidelines for Practice Nurses

Diagnosis of Diabetes Referral to Beaumont Diabetes Service

Patients are triaged according to their HBA 1c result • 2 FPG ≥ 7.0 mmol/L or and are invited to attend a structured education • OGTT 2hr glucose value ≥ 11.1 mmol/L or programme for Type 2 Diabetes called DESMOND •*Random glucose ≥ 11.1 mmol/L with osmotic symptoms or Here they receive education about T2DM and diet, exercise, blood glucose testing, targets and diabetes • HbA ≥ 6.5% / 48 mmols on two occassions 1c medications.

Data to be collected at diagnosis 1. If your patient has a fasting plasma/blood glucose > 18.0 mmol/L or positive ketones or a Body weight/ BMI LFTs foot ulcer then they will be seen as an Blood pressure TFTs emergency. Please fax referral to the Waist circumference Diabetes Day Centre HbA 1c Urine for microalbumin (ACR) Fasting lipid profile eGFR 2. Annual Review in OPD (once engaged) FBC Ferritin & transferrin saturation Patients will be placed on a waiting list for a U&E ECG consultant review in OPD

Diabetes management should take place *Osmotic symptoms include polyuria,nocturia and polydypsia in general practice 4/6 monthly

Diagnosis of Type 2 Diabetes Triage for Desmond

• HbA ≤ 8.0% / 64 mmol/mol; Consider lifestyle 1c • If HbA 1c < 8.0% / 64 mmol/mol - modification for 3 months, especially if intake of Routine DESMOND appointment refined carbohydrates are high. • If HbA 8.0 - 9.9% / 64 - 85 mmol/mol - • HbA ≥ 8.1% / 65 mmol/mol; Commence oral 1c 1c DESMOND in 3/12 hypoglycaemic agents.

• Optimise Blood Pressure to < 140/80 mm/Hg • If HbA 1c > 10% / 86 mmol/mol - DESMOND in 2-3 /52. • Teach blood glucose monitoring as per national guidelines and inform about maintaining targets of 4.0 - 7.0 mmol/L pre meals. • Give information on healthy eating and exercise. Leaflets available from Diabetes Centre. • Provide patient with Diabetes Passport. • Carry out foot assessment and classify foot risk according to National model of footcare • Refer for retinal screening

Diabetes Day Centre, Beaumont Hospital 2 Management in GP Service 4-6 monthly

• Assess knowledge of self management skills / self monitoring skills • Optimise cardiovascular risk factors • Carry out foot assessment as per national model of foot care • Provide patient with a Diabetes Passport if they do not already have same, and record information in Passport • If a change is made to medication, patients should be reviewed in GP practice with repeat bloods after 4 to 6 months • Refer to National Retinopathy Screening Programme

Data to be collected at 4-6 monthly intervals in GP service

Every visit Weight BMI Waist Circumference Blood Pressure

Bloods at Annual Review HbA 1c Lipids (Fast if not on ) U/E LFTs Urine ACR TFTs and B12 if on metformin

Bloods at review visit HbA 1c Lipids LFTs U/E. Repeat any previous abnormal test

Blood Glucose Testing

Patients on diabetes medications are encouraged to test their blood glucose. Frequency depends on the treatment they are on - liase with DDC or Clinical Nurse Specialist (Diabetes Integrated Care) for advice. Patients should wash their hands before testing Glucometers should be replaced every 2 - 3 years. Patients should register the meter with manufacturing company. If blood glucose levels are > 9.0 mmol/L consistently for 2/52, patients are advised to contact DDC or GP for a review of medication. If health professionals use Glucometers in surgery on multiple patients, quality control testing should be carried out on a regular basis. Contact relevant company for information on this.

Notes

Patients can be referred to CODE or XPERT education programmes instead of DESMOND - see HSE website for referral details. If patient is not suitable for group education please state this in hospital referral letter then patients can be reviewed individually in Diabetes Centre. Diabetes Passports are available from Beaumont Diabetes Centre and Clinical Nurse Specialist (Diabetes Integrated Care). Please advise patients to bring their passport to each diabetes hospital appointment and GP/ Practice nurse appointments. Patients with Pre diabetes – screen annually for diabetes and advise re diet and lifestyle modification. Patient Information Leaflets are available from Diabetes Centre.

3 Adult presenting with Type 2 Diabetes Mellitus

ADULT PRESENTING WITH TYPE 2 DIABETES MELLITUS

Target HbA 1c ≤ 7% (53 mmol/mol) Dietary advice; weight loss; increased physical activity Targets and treatment should Refer to Diabetes Day Centre, Beaumont Hospital (DDC) be individualised GP Review in 3 to 4 months

Target HbA 1c achieved?

No

BMI 18-25 kg/m 2 BMI 25-30 kg/m 2

Asymptomatic

Symptomatic METFORMIN 500 mg twice daily (titrate to max. dose 1000 mg BD Eg. Weight-loss, until HbA 1c target achieved) polydypsia, polyuria

HBA 1C TARGET NOT ACHIEVED

Add SU Eg Gliclazide MR 30 mg OD; Option 1 Option 4 Option 2 Option 3 titrate to max. 120 mg OD SU and titrate SGLT2 DPP-4 + Metformin GLP 1 + Metformin Educate re. hypoglycaemia + Metformin + Metformin

HBA 1C TARGET NOT ACHIEVED

Add SU and titrate Add SU and titrate Add SU and Remains symptomatic Add DPP-4 or SGLT2 or DPP-4 (Stop GLP1) titrate or DPP-4 Eg.further weight loss, ketones or SGLT2 or SGLT2 continue or GLP1 (stop DPP-4) or GLP 1 GLP 1

HBA 1C TARGET NOT ACHIEVED

Contact Diabetes Day Centre

Diabetes Day Centre, Beaumont Hospital 4 Hypoglycaemic Agents )

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. r L p o G s E Pharmacological Therapy for Type 2 Diabetes Mellitus

Metformin First line for T2DM especially if overweight (BMI ≥ 25kg/m 2)

Side effects include GI upset, Vitamin B 12 deficiency Contraindicated in renal impairment creatinine > 150 umol/L or eGFR < 30 ml/min Use with caution in those with creatinine > 130 - 150 umol/L or eGFR < 45 ml/min - seek specialist advise.

Check B 12 levels annually

Insulin Secretagogues (Sulphonylureas (SU), Prandial glucose regulators) Sulphonylurea is the insulin secretagogue of choice: to optimise compliance use Gliclazide MR 30 mg up to 120 mg or Glimepiride 1 mg up to 6 mg once daily Side effects include hypoglycaemia and weight gain. Education on hypoglycaemia treatment and prevention is essential Use with caution in renal impairment

GLP 1 Agonist (GLP-1) Use in overweight or obese individuals. May promote weight loss Given as a S/C injection - Medications in this class include: Liraglutide OD S/C injection, start at 0.6 mg and titrate every 2 weeks to 1.8 mg per day as tolerated. Exenatide 5 mcg BD S/C injection increasing to 10 mcg BD S/C. Exenatide LAR 2 mg once weekly. Dulaglutide Monotherapy 0.75mg weekly add on therapy 1.5mg weekly Side effects include: nausea, bloating, diarrhoea, pancreatitis (rare). Avoid in patients with history of pancreatitis and medullary thyroid cancer. In combination with sulphonylurea, may need to reduce the dose of sulphonylurea to prevent hypoglycaemia. No long-term safety data

Dipeptidyl Peptidase-4 Inhibitors (DPP-4) Medications in this class include: Sitagliptin 100 mg OD or 50 mg BD Reduce by half Vildagliptin 50 mg BD in renal Saxagliptin 5 mg OD } impairment Linagliptin 5 mg OD (can be used in renal failure) Side effects include: nausea, dizziness, headache, sinusitis. Higher risk of heart failure observed in high C.V. risk patients on Saxagliptin Fixed dose combinations with Metformin available No long term safety data

Thiazolidinediones (TZD/Pioglitazone) TZDs can be given if Metformin poorly tolerated or in combination with Metformin, Sulphonylurea or DPP-4 inhibitor. Start Pioglitazone 15 mg up to 45 mg once daily Side effects include weight gain, fluid retention and anaemia. AVOID IN HEART FAILURE, history of heart failure or active liver disease. Measure LFT at baseline then at review May increase risk of bladder cancer Avoid in elderly females with high fracture risk. TZD reduce bone mineral density in post menopausal women

Sodium Glucose like Transporters-2 (SGLT2) Dapagliflozin 10 mgs OD. Do not use if eGFR <60 ml/min Empaglifloxin 10 mgs OD can be increased to 25 mgs OD. Do not use if eGFR <45 ml/min Canagliflozin 100 mgs can be increased to 300 mgs OD. Reduce dose if eGFR <60 ml/min and stop if eGFRis <45ml/min. Caution in patients with amputation risk. Side effects include urinary tract infections, genital infections, postural hypotension. Increased urinary output which can cause volume depletion. Increased risk of ketosis. Use with caution in elderly (> 75 yrs) and patients on loop diuretics. No long term safety data.

Diabetes Day Centre, Beaumont Hospital 6 Treatment of Hypertension in Type 2 Diabetes Mellitus

Target BP 140/80 mm Hg BP >140/90 mm Hg Lifestyle on 2 seperate visits, If not meeting target, or on 24hr ABPM modifications add in next agent in alogrithm

ACE Inhibitor or H Angiotensin y

Reception Blocker p e r t e n s i

Beta Blocker o Calcium Channel

Thiazide Diuretic (for ischaemic heart n Blocker disease)

Calcium Channel Calcium Channel Thiazide Diuretic Blocker Blocker

Beta Beta Thiazide Blocker Blocker Diuretic Consider specialist referral (three or more agents) Alpha Alpha Alpha Blocker Blocker Blocker

Aldosterone Antagonist Centrally Acting Agents Specialist advice recommended

7 Principles

Targets should be individualised, e.g. - a lower target (BP 125/75 mm Hg) may be appropriate in patients with nephropathy - a higher target may be desirable for elderly, frail patients Frequency of monitoring - blood pressure should be checked at each clinic/surgery visit and recorded in Diabetes Passport - (minimum of six monthly) Lifestyle advice - smoking cessation - low salt diet - reduce alcohol intake - weight loss Practice Points

Most patients will require two or more antihypertensive agents to achieve target blood pressure

Combination tablets are widely available, particularly for ACE or ARB with thiazide, or with calcium channel blocker, and may improve patient compliance

Lower doses of multiple agents may be more effective than maximum doses of single agents, and may reduce the risk of side effects

Renal function should be checked 1-2 weeks after commencement of ACE, ARB or loop diuretic due to risk of hyperkalaemia (ACE/ARB) or rising urea and creatinine (ACE/ARB/loop diuretic)

The use of ACE I and ARB combined may increase the risk of adverse outcomes and is not recommended except under specialist supervision

Low dose thiazide diuretics should only be used Drug Description Table

Drug Generic names Indications Contraindications Side-effects

Benzapril, Captopril, Hypertension, First Dose Hypotension, Cilazapril, Enalapril, Lisinopril, Heart Failure, Pregnancy, Ace Inhibitors Angiodema, Cough, Perindopril, Quinapril, Secondary Prevention, Renal Artery Stenosis Hyperkalaemia Ramipril, Trandolapril

Candesartan, Eprosartan, Hypertension, Angiotensin Pregnancy, First Dose Hypotension, Irbesartan, Losartan Heart Failure, Severe Hepatic Impairment, Angiodema, Cough, Receptor Olmesartan, Telmisartan, Secondary Prevention, Renal Artery Stenosis Hyperkalaemia Blockers Valsartan Diabetic Nephropathy

Dihydropyridine-Amlodipine, Felodipine, Lercanidipine Hypertension, Aortic Stenosis, Calcium Channel Nifedipine Ankle Oedema Stable Angina Acute Heart Failure Blockers Non-Dihydropyridine - Diltiazem, Verapamil

Bendroflumethiazide, Hypokalaemia Thiazide and Hydrochlorothiazide, Severe Renal or Hyponatraemia, Gout. Hypertension related diuretics Indapamide, Hepatic Failure Use with caution in Chlortalidone elderly patients

Alpha Hypertension, Doxazosin, Prazosin Benign Prostatic Orthostatic Hypotension Postural Hypotension Blockers Hperplasia

Bradycardia, Atenolol, Bisoprolol, Hypertension, Angina, Fatigue, Beta Acute Heart Failure, Carvedilol, Metoprolol, Arrhythmias, Erectile Dysfunction, Heart Block, Untreated Blockers Nebivolol, Sotalol Secondary Preventation Heart Block Phaeochromocytoma

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a i y p l f f s P s I I D D Antiplatelet therapy in Type 2 Diabetes

Previous vascular event?

No Yes

Male > 50 yrs; Female > 60 yrs plus one other risk factor

One or more of: - Microalbuminuria - Smoker - Asymptomatic carotid artery disease (stenosis > 30%) - Atrial fibrillation (if not on Warfarin) - Peripheral arterial disease - Angina

Start low dose daily aspirin 75-150 mg OD Contraindications to antiplatelets apply If Aspirin allergy / intolerance, give Clopidogrel 75 mg OD Combination therapy reasonable for up to 12 months after acute coronary syndrome

Diabetes Day Centre, Beaumont Hospital 10 Antiplatelet / Microalbuminutia 2 m 3 7 y . l 1 e

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Diabetes Day Centre, Beaumont Hospital 12 Notes

13 Diabetes Day Centre, Beaumont Hospital

www.beaumont.ie/diabetescentre

Diabetes Centre Telephone: (01) 809 2744 / 5 Fax: (01) 809 3370

Opening Hours Monday to Friday: 8.00am to 4.00pm.

Urgent referrals Please fax referral letter to Diabetes Centre

The cost associated with the printing of this booklet has been sponsored by Novo Nordisk Ltd. Novo Nordisk Ltd. have had no input to the content of this booklet.

Date of Preparation: May 2016