Editorial: Keeping abreast of the ever-changing landscape of diabetes care

This is my first editorial as sole Editor-in-Chief, after Pam Brown offered her farewells as Joint Editor-in-Chief in the last issue. It has been an absolute pleasure and a privilege to work alongside Pam on the journal since 2015. I will miss her enthusiasm, expertise and guidance very much. It has been quite an emotional time – Pam was awarded the 2022 PCDS Lifetime Achievement Award, and I was delighted to say a few words at the PCDS National Conference in November, highlighting some of her incredible career achievements and sharing a few interesting photos from years gone by! I cannot think of a more worthy winner – congratulations Pam! Happily, we have persuaded her to remain on the Editorial Board as a GP Advisor.

I am also delighted to announce some new additions to our Editorial Board: Samina Ali, Natalie Constable and Lisa Devine. We are keen to expand the editorial board for the journal. If you are interested, you can click here to learn more about the role, and email us to apply. Please do get in touch!

What’s happening in practice?

I was a little surprised to see a few gaps in my clinics just after Christmas, having previously struggled to fit everyone in. Then again, who wants to have their HbA_1c measured after a period of celebration and perhaps a little over-indulgence? I am sure I am not alone in having encounters where patients go to great lengths to explain that the reason for their worsening glycaemic control is Christmas excesses, a birthday, a cruise and so on. Diabetes is not an easy condition to live with, and of course we should be supportive and empathetic to the relentless challenges people face on a daily basis – but should we collude in this?

We tread a fine line between under- and over-treatment. Clinical inertia, defined as failing to start or intensify therapy appropriately, is a well recognised and researched phenomenon. In 2017, it was reported that more than a fifth of patients cared for by GPs with a special interest in diabetes showed evidence of clinical inertia (Seidu et al, 2018). Bear in mind, this was before the COVID-19 pandemic and all the additional challenges it has brought; furthermore, the participants in this study were healthcare practitioners with specialist diabetes skills and knowledge!

Clinical inertia is a complex and complicated problem, and is influenced by many different factors relating to healthcare practitioners, patients and the wider healthcare system. However, the start of a new year may be a good time to focus our attention on this subject. For many, this is a time for reflection and to resolve to make changes, do things differently, set new goals and objectives, and start the year with a clean slate. So it may be a good time to reach out to those who might benefit most from our help. Re-running searches to identify and prioritise is a good way to start, and the searches created to tackle the backlog following the pandemic remain easily accessible.

Lifestyle medicine

As my clinics fill up once more, I am noticing more people are keen to negotiate lifestyle changes – sometimes to avoid starting or intensifying a treatment. I am a huge advocate of lifestyle medicine and have seen on numerous occasions the positive impact it can have. An increasing number of people are seeking to achieve type 2 diabetes remission, and we must make every effort to support them. The recently updated American Diabetes Association Standards of Care in Diabetes have a new emphasis on promoting “positive health behaviours”. Our new At a glance factsheet summarises what’s new in the Standards, while our analysis of the latest ADA/EASD advice on lifestyle discussions, including the 24-hour physical behaviours recommended for type 2 diabetes, can be found here.

Also in this issue, we continue our sub-series of factsheets centred around lifestyle discussions with Rose Stewart’s guide to stress and type 2 diabetes. Rose takes us through the sources of stress and outlines tools and resources that we can make use of to support our patients.

Of course, there are situations and circumstances where it may not be in the person’s best interest to defer the initiation or intensification of diabetes medication. The skill comes in conveying this to them and, while NICE has developed patient decision aids which serve as a tool to support this, ultimately, I think it becomes easier with experience. However, we absolutely must stay up to date with the therapeutic options – no easy task given that the diabetes drugs landscape is forever changing.

In recent years, one of our key priorities for the journal has been to update on any changes that impact your everyday practice through our concise, practical resources, including the How to series, At a glance factsheets, the Need to knowseries, Diabetes Distilled and, most recently, Prescribing pearls. All of these are easy to access by the sidebar on the journal homepage.

SGLT2 inhibitors

In my July 2022 editorial, I focused on the implications of prescribing SGLT2 inhibitors to a wider population in light of the new NICE guidance, as well as the challenge of remembering which agent is licensed, at which eGFR thresholds, for which specific indication (be that insufficiently controlled type 2 diabetes, diabetic/chronic kidney disease and/or heart failure – with or without reduced ejection fraction). In this issue, we publish yet another update of the cribsheet on SGLT2 inhibitors created by Pam Brown for our Need to know series, which reflects changes to the licence for empagliflozin (which allows us to prescribe for symptomatic chronic heart failure regardless of the ejection fraction – provided the eGFR is ≥20 mL/min/1.73 m² – in those with or without type 2 diabetes). Currently, empagliflozin is not licensed specifically for chronic kidney disease in the UK; however, watch this space as this looks set to change imminently following the results from the EMPA-KIDNEY study (EMPA-KIDNEY Collaborative Group, 2023).

I am reminded again of the quote, “Change is the only constant in life” (Heraclitus, the Greek philosopher). Pam’s cribsheet has proved invaluable; indeed, I have a laminated copy that I regularly refer to before prescribing. Going forward, however, I think it will be simpler to bookmark it and refer to the latest digital format instead!

GLP-1 receptor agonists

We have experienced challenges regarding the limited supply of once-weekly GLP-1 receptor agonists (GLP-1 RAs), which has been intermittent and variable across the country. I was disappointed to receive a notification from Novo Nordisk that there is little change to the current supply situation of Ozempic, and that intermittent disruption to supply of all doses can be expected throughout 2023.

In October 2022, the PCDS published a consensus statement on managing the GLP-1 RA supply shortage, and this seems as relevant now as it was then. I am not sure of the extent to which the use of GLP-1 RAs privately as anti-obesity agents has impacted on their availability for diabetes management, although I suspect it is significant.

Nicki Milne has updated her How to use GLP-1 receptor agonist therapy safely and effectively resource, and this is well worth looking at to remind ourselves of the full range of agents available within the class, with which we may need to re-familiarise ourselves.

Insulins

We recently announced that the PCDS Six Steps to Insulin Safety e-Learning module has been updated and relaunched. Just to let you know, we have made a few more further updates to this free-to-access CPD module, following the announcement from Sanofi of its discontinuation of the remaining Insuman products in the UK. These are detailed in Box 1. This discontinuation is not due to any safety concern but rather because demand for these insulins in the UK has declined significantly in recent years.

A Department of Health and Social Care medicine supply notification provides further information, including actions required in terms of providing suitable alternatives to patients currently prescribed any of the listed Insuman formulations.

Heart failure

In this issue, David Morris provides his latest interactive case study covering heart failure and diabetes. During the Autumn, I spent a day “shadowing” my local Heart Failure Specialist Nurse. After communicating about shared patients via electronic tasks – mostly regarding the use of SGLT2 inhibitors – I decided it would be NICE (sorry!) to put a face to the name. We spent much of the day visiting those with quite advanced heart failure, and it reminded me just how devasting and debilitating this condition can be.

People with diabetes have more than twice the risk of developing heart failure and have worse cardiovascular outcomes, more hospitalisations and a worse prognosis than those without diabetes. In my How to on heart failure, published in 2020, I documented that around 80% of heart failure diagnoses in England are made in hospital, despite 40% of patients having symptoms that should have triggered an earlier assessment (Bottle et al, 2018), and I was reminded of how important our role is in lowering our threshold of suspicion and ensuring we obtain a good history. You may find it useful to read the useful questions to ask patients during a diabetes included in How to identify, diagnose and manage heart failure, and to share these with nursing and healthcare assistant colleagues.

PCDS National Conference

And finally, a few weekends ago, the PCDS committee gathered for our annual conference planning meeting. I am pleased to announce that this will be a face-to-face event taking place a little earlier than usual: on Thursday 14^th September and Friday 15^th September 2023 at the National Conference Centre, Birmingham. We have a fantastic programme lined up, so be sure to book early!