Long Term Conditions Pyramid The prevalence of diabetes in the West - - PDF document

15/03/2017 1

• The prevalence of diabetes in the West

Midlands is one of highest in the UK.

• Current data indicates there are

approximately 16,000 people with diabetes in the city of Wolverhampton.

• TREND data suggests that the diabetes

prevalence is INCREASING in Wolverhampton & is consistently ABOVE national comparisons.

Long Term Conditions Pyramid ABOUT US

• Our specialist team is based at the Diabetes &

Endocrinology Centre (WDC) at New Cross Hospital.

• Our team consists of Doctors, Specialist

Nurses, Specialist Podiatrists, Dietetic Services, Retinal Screeners and Researchers.

Wolverhampton Integrated Diabetes Service

Dr A Viswanath – C.D Dean Gritton – Directorate/Service Manager Consultant Medical Team – 7 x Permanent Dr H N Buch, Professor B M Singh, Dr C Hariman, Dr J Young, Dr R Raghavan, Dr V N Cherukuri, Dr K Jadoon 1x Locum Dr R Bellan Kannan Debbie Edwards - Matron Jenny Dudley In-Patient Stream Lead Research Fellow x 1 Dr S Gillani Registrars/Clinical Fellows x 8 Dr A Vijay, Dr F Babwah, Dr R Chaudhary, Dr R Chopra, Dr C Gherman-Ciolac, Dr T Kalaria, Dr F Hatta, Dr I Clark GP Clinical assistant x 2 Dr D Macdonald Dr M Sidhu Diabetes Specialist Nurse’ Band 6 x 6 Pauline Beach, Emily Cothey, Gaynor Curtis, Jodie O’Hagan, Lorna Smart, Elisabeth Wilson Clinical Nursing team x 5 Toni Shaw, Allison Spencer, Claire Bevan, Susan Fullwood, Vacancy Education Support x 1 Satbinder Suman Brett Healey Intensive Insulin Pump Stream lead Sonya Smith Community Stream Lead

Integrated Working with Allied Health Professionals

• Sue Huddart & Team – High Risk Chiropody

Services.

• Lynsey Richards & Team – Dietetic Services
• Retinal Screening Service Team
• Research Nurses

Bariatric Surgery

• Tertiary Services

Islet cell transplantation

WDC Services Provided

• Specialist Clinics
• Insulin Pump
• Transitional & Adolescent clinic
• Joint Diabetes Antenatal Clinic
• Joint Renal Clinic
• High Risk Foot Services
• Nurse Led ‘Hypo’ Clinic
• Case Management
• Community Focus

To work closely with Practice Nurses’ to up skill

• Medication management
• Insulin titration/commencement
• GLP1 initiation

15/03/2017 2

In-Patient Services

• Identification of diabetic patients via clinical web portal

system.

• Diabetes risk flag on PAS system
• COBAS referral system
• Pro- Active Ward Triage
• Safety 1) Think GLUCOSE insulin safety.

2) Insulin passports, redesigned prescription charts. 3) Audit. 4) Feedback.

Community Services (care closer to home initiative)

• Community Specialist Nurse led clinics
• Bilston Health Centre (Mon AM)
• Pendeford Health Centre (Wed AM)
• Warstones Health Centre (Wed PM)
• Whitmore Reans Health Centre (Thurs AM)
• Phoenix centre (Wed PM)
• Mayfields (Tues pm)
• Home Visits

For those patients that are housebound & would otherwise not be able to access diabetes specialist services. ASSESS, PLAN, IMPLEMENT.

Multidisciplinary Team Meetings

• Diabetes Specialist (linked consultant and

diabetes specialist nurse) work closely with local services including the community team.

• Each GP will be contacted & consultant will meet

with them to discuss complex patients. Management Plans will be formulated & follow up agreed (consideration for case management).

• Communication has been encouraged by

whatever means (Tel; email;letter etc).

Community MDT Meetings

• Monthly: alternating between NW; SE and

SW

– Community Matrons – District Nurses – Specialist Nurses – Social services – Dietetics – CCG representative

Education & Training

• Type 1 Education Programme
• Insulin titration programme
• Professional education

WE DO NOT OFFER BASIC DIABETES EDUCATION This should be done either: - within GP practice Or via the X-pert Diabetes programme.

Screening Services

• Diabetes Eye Screening – offered annually to

all diabetic patients.

• Diabetes Foot Health – offered annually to all

diabetic patients.

• Diabeta_3

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Duty Nurse Service

• Telephone queries/Advice
• Urgent assessment (Hot Clinics)
• ‘Walk –ins’
• Telephone clinics (01902 695310)

Referrals and Criteria's.

Requiring referral to Emergency Services

Accident & Emergency/Medical Assessment Unit

• Suspected Diabetes Ketoacidosis/Non-ketosis

Hyperosmolar state

• Severe hypoglycaemia (unconscious)
• Sudden loss of vision (Eye casualty)
• Critical limb ischemia

Same Day Referrals

• Newly diagnosed Type 1 Diabetes/suspected

Type-1 diabetes

• Patients with infected foot/ulceration or

suspected Charcot Foot.

• Women with pre-existing diabetes (type-1 or

2) who become pregnant

• Newly diagnosed Gestational Diabetes

Urgent Referrals

• Recurrent/Severe hypoglycaemia
• Symptomatic hyperglycaemia
• Significant ‘at risk’ feet
• Significant decline in renal functions/

worsening proteinuria

• Pre-surgical optimisation of glycaemic control

Routine Referrals

• Poor glycaemic control despite intensive management
• Consideration for intensive insulin/pump therapy
• Obesity management
• Optimisation of cardiovascular risk factors (BP, Lipids)
• Type-1 structured education programme
• Painful peripheral neuropathy not responding to standard treatment
• Patients with CKD stage 3b & 4 for optimisation of metabolic parameters
• Self management/insulin adjustment training and support
• Women with diabetes contemplating pregnancy

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Same Day Referrals

• Same Day Referrals:

Diabetes Specialist Team at New Cross Hospital: can be contacted Monday to Friday directly on 01902 695310 (9:00 to 5:00 PM) (Out of Hours diabetes advice: contact on-call medical team at New Cross Hospital via switchboard) Urgent / Routine Referrals: Via Choose & Book or direct referral to the Diabetes Centre

• Useful Contact Numbers:
• Diabetes Administration Team:

01902 307999; Ext: 5310/12/13/14/15; Fax: 01902 695325

• Diabetes Reception & Appointments:

01902 695310; Fax: 01902 695628

3/15/2017 1

Diabetes in Pregnancy

• Dr. Ananth Viswanath

Consultant WDC

Outline

• Background
• Challenges
• Pre-conception care
• Antenatal care
• Post natal follow-up

Diabetes Mellitus and Pregnancy

Before Insulin

• 40% women died during

pregnancy (usually DKA)

• Remainder died within 2

years of delivery

• Foetal loss rate >50%

After Insulin

• Insulin improved
• utcome
• Maternal mortality fell to

2-3%

• Foetal loss rates

remained high

• Impact of abnormal glucose levels on foetus identified in

1970’s

• Optimisation of maternal control and foetal surveillance

lead to improvement in perinatal mortality

• Recent studies show PNMR still double compared to

women without diabetes

Diabetes NSF

Gestational DM

• Type-1
• Type-2

Pre-existing DM

• Glucose intolerance first

diagnosed in pregnancy

• Includes pre-existing DM

first detected in pregnancy

• 650,000 births in England & Wales per year
• 35,000 women have either pre-existing or GDM
• Around 4000 births in Wolverhampton

Diabetes in Pregnancy: Epidemiology

25-30/year 300-350/year

3/15/2017 2 Normal glucose metabolism

• Glucose enters

bloodstream from food source

• Insulin aids in storage
• f glucose as fuel for

cells

• Insulin resistance is

defined as insensitivity

• f cells to insulin,

therefore resulting in increased levels of insulin and glucose in the bloodstream

Pregnancy- ‘stress test’!

• Physiological change - INSULIN RESISTANCE
• Facilitates transfer of glucose to the fetus
• Decrease in insulin sensitivity by late pregnancy
• Increased lipolysis (preferential use of fat for fuel, in order to

preserve glucose and protein)

• Mechanisms
• Insulin desensitizing placental hormones
• Increasing maternal adiposity

To maintain euglycaemia insulin production should increase by 2-3 fold

Pedersen hypothesis

‘Maternal hyperglycaemia

leads to foetal hyperglycaemia which evokes an exaggerated response to insulin which causes increased neonatal fat deposition and abdominal girth with increased birth weight’

Macrosomia Shoulder dystocia

Potential problems for the baby

• Congenital malformation
• Large for gestational dates (macrosomia)
• Shoulder dystocia (difficult birth)
• Birth trauma
• Unexplained IUD
• Prematurity and Respiratory distress syndrome
• Neonatal metabolic abnormalities:
• Hypoglycemia
• Hyperbilirubinemia/jaundice
• Polycythemia
• Long term predisposition to childhood obesity and

metabolic syndrome

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Potential problems for the mother

• Miscarriage
• Hypoglycaemia
• Pregnancy induced hypertension
• Deterioration of diabetes retinopathy
• Deterioration of renal function
• Birth injuries
• Polyhydramnios
• Higher risk of C section and/or instrumental

delivery THE OBJECTIVE OF CARE IN A DIABETIC PREGNANCY IS TO ACHIEVE PREGNANCY OUTCOMES THAT APPROXIMATE TO THOSE IN WOMEN WITHOUT DIABETES

Objective

When do we start planning?

Preconception Counseling for Women With T1D or T2D

All Women of Child-Bearing Age

• At diagnosis and annual visit
• Discuss pregnancy plans
• Stress the importance of good metabolic control

in preparation for pregnancy

• Provide contraception advice for those who

have no pregnancy plans National audit: Only 30% of all diabetes pregnancies are planned

Mrs MS

• 33 year old lady
• T-1 diabetes 10 years duration
• Keen to remove implantable

contraceptive device as she desires pregnancy

Initial consideration

• Glucose control
• Insulin regime
• Last HbA1c
• Micro-vascular burden
• Evidence of macro-vascular disease
• Medication review
• Other: Rubella/ TFT

3/15/2017 4 Initial assessment

• HbA1c- 9.8%
• Humulin M3 22/18
• Eyes: R2 M1 both eyes
• ACR: 6.5
• TSH: 5.1
• Ramipril for microalbuminria

Glucose control

• Aim for HbA1c closer to 6.5% (preferably

around 7%)

• Safe control with hypoglycaemia

avoidance

• Multi-dose injection regime
• May need pump therapy
• Consider referral to specialist service

Subcutaneous Insulin Insulin Use During Pregnancy

Insulin option Pregnancy Category Notes Basal (control of fasting/preprandial glucose) NPH B Detemir B Glargine C Not formally studied in pregnancy, though frequently prescribed Pump therapy with rapid- acting analogs B Bolus (control of postprandial hyperglycemia) Aspart, lispro B Regular B Glulisine C Not studied in pregnancy Inhaled C Not studied in pregnancy Components of patient education

• Insulin administration
• Dietary modifications in response to SMBG
• Hypoglycemia awareness and management

Insulin Conversion

Humulin M3 22 AM & 18 PM HbA1c- 9.8%; Weight 64 kg TDD is 40 units Basal: 28 Bolus:12

Basal: -2O% basal 22 units Bolus: 18 units *4-6 B *4-6 L *6-8 E

* Carb counting- refer to dietician

Next step: medication review

• Stop ACE1, ARB
• Alternatives: Methyldopa, Labetalol
• Stop statins/fibrates (dietary advice
• nly)
• Start Folic acid 5 mg

3/15/2017 5 Diabetes retinopathy & Pregnancy

• Sharp improvement in control can

worsen retinopathy (Glucose Paradox)

• Increased plasma volume and output

can worsen maculopathy

• Growth factors increase risk of PDR

Ensure retinopathy is treated and stable before planning pregnancy

Thyroid dysfunction and pregnancy

• TSH 5.2 mIU/L, fT4 14 pmol/L (N)
• Sub-clinical hypothyroidism
• Check TPO antibodies
• Aim for TSH < 2.5
• Levothyroxine 50 microgram/day

Inadequate thyroxine can Impact on neuro- developmental delay in early years of life

Potential Contraindications to Pregnancy in Women with Established Diabetes

• Ischemic heart disease
• Untreated active proliferative

retinopathy

• Renal failure
• Severe gastroparesis

Next step

• Remove implanted contraceptive

device

• Consider alternative contraception till

glucose control is acceptable

• Monitor regularly (2-3 monthly HbA1c)
• Same day referral to combined ANC
• nce pregnancy is confirmed.

Combined Antenatal Service

• NICE recommendation
• Agreed pathway
• Evidence based
• MDT:

Obstetric team Diabetes specialist Dietician Ultrasonographer Phlebotomy Administration team

http://www.wdconline.org.uk/default.htm

Case 2: Mrs CD

• 23 year old type 1 DM
• 12 year duration
• Last HbA1c last checked 6 months

ago- 11%

• Novomix 30 24 AM, 16 PM
• Last eye screening 3 years ago
• Booking scan- 8 weeks gestation

3/15/2017 6 Where do we start?

• Glucose control
• Change insulin regime to MDI
• HBGM: 6-8 times/day
• Targets: near normal glycaemia
• FBS/Pre-meal BG 4-6 mmol/L
• Post-prandial <7.8 mmol/L
• Microvascular disease screening
• Retinal screening in each trimester
• Low threshold to refer to HES
• Start folic acid 5 mg
• Inx: TFT, urine ACR, HbA1c

Ketones>Hyperglycaemia> Hypo

• Sick-day rules
• Increase risk of ketosis
• Beware of normoglycaemia DKA
• Ketostik
• Low threshold for admission
• Hypoglycaemia
• Reduced awareness
• Tight control
• Glucagon kit

Diabetes & Driving

• Check BG in relation to driving
• If BG<5, do not drive
• Carry refined carbs in the car
• Stop and re-check if driving for >2hrs
• Stop driving if hypo symptoms- treat

and resume driving after 45 minutes

• Do not drive if hypo-unaware
• Mrs. CD: next review?
• Returns to ANC in 2 weeks
• Booking HbA1c 10.9%
• Frequency of testing?
• Main issue if hypoglycaemia
• Over-correction due to fear of

‘hyperglycaemia’

• Reduced hypo awareness

Insulin Dose Changes during Pregnancy

• Patients with T1D

– 10-14 weeks gestation: period of increased insulin sensitivity; insulin dosage may need to be reduced accordingly – 14-35 weeks gestation: insulin requirements typically increase steadily – >35 weeks gestation: insulin requirements may level off or even decline

Mrs CD- 14 weeks gestation

Upset that her midwife was not happy with her DM control (HbA1c- 9.1%)

• HBGM is the cornerstone for

managing diabetes in pregnancy

• HbA1c is not helpful in day to day

management

• How else do we monitor progress

during pregnancy?

3/15/2017 7 Monitoring

• Booking

scan

• Anomaly

scan

• Growth

scans

• Bio-physical

profile

* + +

* * *

+

Delivery plan:

• FTND
• Planned elective LSCS
• Induction of Labour
• Emergency LSCS
• Influencing factors:
• Poor control
• Macrosomia
• Foetal distress
• Preeclampsia

labour and post delivery

• IV insulin sliding scale if insulin

dependent

• Breast feeding encouraged

immediately post delivery

• Roughly 50% insulin reduction post-

delivery of placenta

• Further reduction if breast feeding

Gestational Diabetes

• Who is at risk of GDM?
• When should we screen?
• How do we diagnose GDM?
• How do is GDM managed?

Gestational diabetes is defined by the World Health Organization as ‘carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy (WHO 1999)

Risk Factors for GDM

• BMI> 30kg/m²
• Previous macrosomic baby 4.5 kg or above
• Foetal abdominal circumference >97th centile on USS
• Previous Gestational Diabetes
• Polyhydramnios
• History of PCOS
• Family history of Diabetes (first degree)
• Family origin with a high prevalence of Diabetes

(South Asian, Afro-Caribbean, Middle Eastern, Chinese)

Screening for GDM

• Risk factors checked at

booking: if high risk then test for gestational diabetes mellitus

• 75 g OGTT at 28 weeks

for women at high risk of GDM

• OGTT at 12-14 weeks

for women with previous history of GDM.

• FBS ≥ 5.6
• 2hr ≥ 7.8

3/15/2017 8 Management of GDM

• Dietary and life-style advise
• HBGM
• BG targets
• FBS <5.5
• 1hr post prandial<7.5
• Growth scans
• Choose healthy low-carbohydrate, high-fiber

sources of nutrition, with fresh vegetables as the preferred carbohydrate sources

• Count carbohydrates and adjust intake based
• n fasting, premeal, and postprandial SMBG

measurements

• Avoid sugars, simple carbohydrates, highly

processed foods, dairy, juices, and most fruits

• Eat frequent small meals to reduce risk of

postprandial hyperglycemia and preprandial starvation ketosis

Dietary advice during Pregnancy Physical Activity During Pregnancy

• Unless contraindicated, physical activity

should be included in a pregnant woman’s daily regimen

• Regular moderate-intensity physical activity

can help to reduce glucose levels in patients with GDM, T1D, T2D

• Walking
• Cardiovascular training with weight-bearing,

limited to the upper body to avoid mechanical stress on the abdominal region

• Monitor for hypoglycemia

Pharmacological intervention

• Threshold not achieved with lifestyle

modification

• Metformin
• Safe and effective
• Monotherapy or with insulin
• Up to 2.0gm/day
• Insulin
• Added to metformin or monotherapy
• Most patients need QDS insulin, pre-mixed

BD insulin with or without additional meal time bolus

Post delivery

• Women with GDM stop all medications

after delivery

• CBG (24-48 hrs) after delivery
• Fasting blood glucose at 6 week post

natal check

• GP and patient informed about the test

result

Long term FU

• Risk of development of type 2

diabetes mellitus

• Lifestyle intervention
• Encourage weight loss
• Annual screening for diabetes
• Pre-pregnancy planning

3/15/2017 9 Questions/Discussion:

1 Wolverhampton Insulin Pump Program

Brett Healey Insulin Pump Lead

Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (review of technology appraisal guidance 57)

2008

Implementing NICE guidance

NICE technology appraisal guidance TA151

Definitions

CSII – Continuous subcutaneous insulin infusion Disabling hypoglycaemia – repeated and unpredictable

• ccurrence of hypoglycaemia which results in persistent

anxiety about recurrence associated with a significant adverse effect on quality of life Hyperglycaemia – high blood glucose levels Hypoglycaemia – low blood glucose levels MDI – multiple daily injection

Recommendation: Adults and children 12 years and older

• attempts to achieve target haemoglobin A1c

(HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia

• r
• HbA1c levels have remained high (8.5% or above)
• n MDI therapy despite a high level of care.

Insulin pump therapy is recommended as a treatment

• ption for adults and children 12 years and older with

type 1 diabetes provided:

Recommendation: Adults and children 12 years and older

Only continue CSII therapy if it results in a sustained improvement in glycaemic control evidenced by:

• a fall in HbA1c levels
• r
• a sustained decrease

in the rate of hypoglycaemic episodes

Recommendation: Children younger than 12 years

• MDI therapy is considered to be impractical
• r inappropriate, and
• children on insulin pumps would be expected

to undergo a trial of MDI therapy between the ages of 12 and 18 years. CSII therapy is recommended as a treatment option for children younger than 12 years with type 1 diabetes provided:

2

Recommendation: Type 2 diabetes

CSII therapy is not recommended for the treatment of people with type 2 diabetes mellitus

Recommendation: Specialist teams

CSII therapy should be initiated only by a trained specialist team comprising:

• physicians with a specialist interest in insulin pump

therapy

• diabetes specialist nurses
• dietician.

Insulin pump technology

Insulin pump models currently available:

• Animas Vibe
• Medtronic 640G
• Accu-Chek Combo/Insight
• Cell Novo
• Omnipod

Image reproduced courtesy of Diabetes UK

Current provision

Adult patients started <24 months >6 months ago 2016 n = 46, 2013 n = 27, 2010 n = 16 Adult patients started <24 months >6 months ago 2016 n = 46, 2013 n = 27, 2010 n = 16

3

Significant Hypo (BG < 3 mmol/l) Adult patients started <24 months >6 months ago 2016 n = 46, 2013 n = 27, 2010 n = 16

2016: BG< 3 in 30 days 2016: BG< 3 in 30 days

2016 2016 2016

4 CSII continuation

• Evidence of benefit – Hba1c or reduction in

significant hypoglycaemia

• Continued engagement/motivation
• Regular review/ self review
• Telemedicine
• Structured testing – Basal testing/paired meal testing
• Self funded Libre
• Pump renewed every 4 years

Further therapies

Engaged/motivated yet still not gaining adequate benefit

• r target control;

Consider continuous glucose monitoring system (CGMS) Predicted low glucose suspend Islet cell transplantation Full pancreas transplant

Future therapies

Closed loop CGMS insulin automated delivery