Inaugural National Conference of the Primary Care Diabetes Society

Are there lower limits for cardiovascular targets?
‘Current management strategies are reducing cardiovascular risk in diabetes,’ said Dr Miles Fisher, Consultant Physician at Glasgow Royal Infirmary.

Dr Fisher explained that trials such as the Hypertension in Diabetes Study (HDS) have shown the significant benefits of tight blood pressure control in reducing diabetes-related end points and death. ‘But how low should we go?’ he asked, explaining that the Hypertension Optimal Treatment study and epidemiological analysis of HDS have suggested that there is no low blood pressure for which a person with diabetes does not gain benefit. Reanalysis of the data is informing lower and lower targets.

Studies such as the Scandinavian Simvastatin Survival Study and the Collaborative Atorvastatin Diabetes Study have collectively demonstrated the important benefits of lipid lowering in preventing primary and secondary cardiovascular events. As with hypertension management, said Dr Fisher, ‘the data from trials such as Treating to New Targets suggest that the more you can reduce a patient’s total or low-density lipoprotein-cholesterol level, the less likely they are to experience a cardiovascular event.’

Involvement in the National Diabetes Audit encouraged
There is some uncertainty within primary care about knowing whether improvements in services are taking place. With this in mind, Dr Sue Roberts, National Clinical Director for Diabetes, drew the audience’s attention to the ongoing National Diabetes Audit: ‘Encourage your primary care trust  to join and see what effect your efforts are having.’

‘Now is a unique time for unique leadership from primary care,’ said Dr Roberts, explaining how crucial the role of primary care is in the current management of diabetes in the UK. Dr Roberts looked back at how the role of primary diabetes care has evolved – from the primary care ‘diabetes days’ and ‘mini-clinics’ of the 1980s, up to the publication of the National Service Framework for diabetes.

Now, she explained, diabetes care is again entering a new world. The Quality and Outcomes Framework has been a great success, with 92% of the available diabetes points achieved by primary care practices over the last year. But, she said, many new challenges lie ahead.

The debate on diabetes screening could be ‘put to bed’
If the ADDITION study gives positive results, ‘the [diabetes] screening debate will be put to bed,’ stated Professor Melanie Davies of the University of Leicester.

‘The UK Prospective Diabetes Study has told us that we can reduce deaths from diabetes [and its complications] with good glycaemic control,’ said Prof Davies, which is why early detection can be so useful.

There is reasonably good evidence for simple tests to use, and the American Diabetes Association has recently shown that screening can be cost-effective, explained Prof Davies. Thus, while there is ‘still a way to go with staffing and facilities for a screening programme,’ she said, it is worth considering the research being carried out in the area. The ADDITION study is currently half-way through recruiting.

Another trial, the Screening Those At Risk study, has taken a very practical look at screening, stated Prof Davies. The study examined the utility of different screening methods based on age and ethnicity. To get 90% sensitivity for diabetes in white Europeans, for instance, 40–75 year olds should be targeted using a fasting plasma glucose cut-off level of 6.0mmol/l, she noted.

>Practice-based commissioning is the ‘only way forward’
With only a limited amount of primary care funding available, ‘the only way forward is practice-based commissioning,’ stated Dr Peter Holden, GP in Matlock, Derbyshire.

‘The health of the new General Medical Services contract has significant bearings on the health of primary care teams,’ Dr Holden explained. The establishment of the contract and the associated Quality and Outcomes Framework (QOF) results achieved in 2004/2005 represent ‘a world-first, truly groundbreaking change in healthcare delivery’, he said. ‘For the first time, general practice is being reimbursed by clinical results based upon scientific evidence.’
    Dr Holden added that important challenges remain in 2006: ‘We’ve got to become future proof,’ he said, outlining some practical tips for individual practices on time management, planning efficiency and software. ‘The future of the QOF is something of a conundrum,’ he said.  ‘Neighbouring practices need to start talking to each other, and their Local Medical Committee.’

Approaches to obesity must note that the causes will not go away
‘Whatever we do with obesity, we have to remember that its causes are not going to go away,’ said Omar Ali, Prescribing Consultant Primary Care and Formulary Development Pharmacist with the Surrey & Sussex NHS Trust. ‘The world around us has changed – cars, computers and lifts are here to stay. The current epidemic of obesity is a profound, abnormal metabolic reaction to our current environment, which results in disease pathology.’

Omar outlined the well-established relationship between overweight/obesity and the increasing risk of insulin resistance and type 2 diabetes. Measuring waist circumference is a useful, practical way of identifying people at risk of developing insulin resistance, he said.

Omar also outlined the results of the Diabetes Prevention Program in the USA, which compared the effects of placebo, metformin treatment, and diet and exercise regimens. While treatment with metformin was beneficial in preventing the onset of type 2 diabetes, the greatest effect was seen with lifestyle interventions. ‘Exercise does work if you do it,’ said Omar.

Pharmacotherapy (e.g. using orlistat [Xenical; Roche] or sibutramine [Reductil; Abbott]) and bariatric surgery also have a role in obesity treatment. The current NICE guidelines on obesity management state that if treatment with a drug does not cause weight loss, pharmacotherapy should not be continued, explained Omar. ‘I believe this is wrong – even weight maintenance is a success, since most people’s weight increases over time. Instead of stopping treatment, we should be more aggressive and use more agents.’

Spending on new therapies may cut spending on hospitalisations
Hospitalisations account for the majority of the costs of managing diabetes, stated Dr Cliff Bailey of Aston University, Birmingham, but ‘it is hoped that spending on new therapies can cut spending on hospitalisations,’ he noted.

Pramlintide (Amylin Pharmaceuticals) is a soluble analogue of amylin, a hormone which helps to suppress glucagon secretion and which is reduced or absent in people with diabetes, noted Dr Bailey. There are ongoing discussions with the European Medicines Agency for its use along with insulin.

Glucagon-like peptide (GLP)-1 stimulates the secretion of insulin in response to elevated blood glucose levels. Approval is being sought for the GLP-1 analogue exenatide (Amylin/Eli Lilly), which was derived from the saliva of the Gila monster lizard. According to Dr Bailey, ‘weight reduction is a very important part of the equation for exenatide.’

Dipeptidyl peptidase (DPP)-4 is an enzyme that inactivates GLP-1. Inhibiting DPP-4 could thus augment insulin secretion. There are DPP-4 inhibitors in the pipeline, such as vildagliptin (Novartis), but Dr Bailey recommended that, before drawing firm conclusions, ‘we should wait to see what the side effects are like.’
    PPARa/g agonists, which have the potential to improve glycaemic control and dyslipidaemia, are another emerging class of ingested therapies that Dr Bailey discussed. Another potential use for an ingested therapy is the treatment of obesity (which is directly related to glycaemic control). The cannabinoid receptor blocker rimonabant (Sanofi-Aventis), which is in phase III, may be used in such a role, based on evidence that the cannabinoid system is overactive in obesity, explained Dr Bailey.

OTHER MEETINGS
Austria will use EU presidency to highlight type 2 diabetes
The Austrian Presidency of the EU in 2006 will highlight prevention of type 2 diabetes ‘to intensify the exchange of expertise’ and discuss potential steps at a community level, said Maria Rauch-Kallat, Federal Minister for Health and Women, in her welcome message for the EU Conference on Prevention of Type 2 Diabetes.

The conference, held on 15–16 February 2006, in Vienna, was organised with input from the European Association for the Study of Diabetes and the International Diabetes Federation.

Discussion at the conference will be used to compile an ‘expert paper’ that will include recommendations to be put forward to health ministers in an informal conference in April 2006 as well as formal council in June 2006. It is hoped that this will help Europe to face the challenges presented by diabetes, by allowing people to work more closely together.

Diabetes nurses discuss issues of choice
Over 200 diabetes nurses met at the Second European Diabetes Nursing Conference held at BayKomm, in Leverkusen, Germany. Held over 13–15 October 2005, the theme of the event was ‘Choice: Benefit or Burden in Diabetes Care’.

Chaired by Anne-Marie Felton (Co-founder and Chair of FEND [Federation of European Nurses in Diabetes]), the conference comprised a series of plenary lectures and breakout workshops in which the delegates debated questions posed by the lecturers. Although presented in English, the plenary sessions were simultaneously translated into French, German, Spanish and Italian languages, enabling nurses from around Europe to participate. Workshops were also conducted in each of the five languages. After each workshop session, the delegates reconvened to hear and further discuss the findings of each of the workshop groups.