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4th Welsh Conference of the Primary Care Diabetes Society: Management of type 2 diabetes the Welsh way

This conference aimed to provide healthcare professionals with guidance and advice on how to optimise the provision of diabetes care in Wales. Talks covered a broad range of topics that included challenges in diagnosis, risk identification and initial management. This report provides a summary of the conference.

Pam Brown (Welsh representative of the Primary Care Diabetes Society [PCDS]) and David Millar-Jones (a second Welsh representative of the PCDS and chair of the PCDS Committee) welcomed delegates to the 4th Welsh Conference of the PCDS.

Are we all singing from the same song sheet?
David Millar-Jones, GP, Cwmbran
In the opening talk of the morning session, Dr Millar-Jones began by outlining the current challenges faced by healthcare professionals (HCPs) in achieving uniformity of diabetes care. Increasing workload, the arrival of new therapies, and the pressures of working cost-effectively were all highlighted as issues affecting clinical practice in diabetes on a daily basis. Dr Millar-Jones said: “The direction of diabetes care is continually changing with the introduction of new therapies and, thus, new targets.”

Clarifying diagnosis: Not as straightforward as we sometimes think
Steve Bain, Professor of Medicine (Diabetes) and Consultant Diabetologist
Opening this interactive session, Professor Bain began by presenting a number of case studies which illustrated the difficulties in distinguishing type 1 diabetes from type 2 diabetes. He discussed the importance of HbA1c as a marker of diabetes in clinical practice and outlined the clinical situations in which HbA1c can be used as a suitable diagnostic test for diabetes. Professor Bain continued by summarising the diabetes diagnostic criteria according to Diabetes UK, the American Diabetes Association and, most recently, the World Health Organization, which accepted HbA1c into their diagnostic criteria in 2011 (World Health Organization, 2011). He also highlighted the recent inclusion of HbA1c in the Welsh diagnostic criteria. The talk concluded with the presentation of several interactive case studies, which enabled questioning on the method of diagnosis that was most appropriate according to the diagnostic guidelines and the clinical scenario.

Risk identification and prevention in high-risk groups
Kamlesh Khunti, Professor of Primary Care Diabetes and Vascular Medicine, Leicester
This presentation examined the different methods of risk identification and prevention available for people at high risk of developing diabetes. Professor Khunti opened his talk by discussing the approaching “tsunami of diabetes” – a “paradigm shift” in lifestyle causing an increase in obesity. The cost of diagnosis can vary between £148 and £913 per case for impaired glucose regulation or type 2 diabetes in the UK (Khunti et al, 2012). Various computer risk-scores were considered in conjunction with HbA1c measurements for the identification of high-risk individuals. Professor Khunti emphasised that type 2 diabetes is preventable and outlined the role of primary healthcare teams, public health and pharmacists in prevention. He argued that screening high-risk populations is cost-effective when coupled with an intensive lifestyle intervention. Even without weight loss, he observed, physical activity has been found to reduce the onset of diabetes in high-risk populations. According to NICE (2012), intensive lifestyle changes that can reduce the risk of diabetes include:

  • A total of 150 minutes of “moderate-intensity” physical activity per week.
  • Gradual and sustained weight loss to achieve a healthy BMI.
  • Increased whole-grain, vegetable and high-fibre food consumption.
  • Reduced fat intake (including saturated fat).

Professor Khunti’s presentation stressed the importance of intensive lifestyle interventions for diabetes prevention in high-risk populations. He concluded: “Everyone should be able to do exercise.”

Initial management of diabetes: Challenges and priorities
Gaynor Harrison, Senior Specialist Nurse, Cardiff
Gaynor began by describing the heterogeneous group of people that present with diabetes, emphasising the importance of an individualised approach in diabetes management. She outlined the necessity of empowerment and described how to promote self-management during consultations with patients. She continued by explaining the topics that should be covered during an initial consultation and why people with diabetes should be encouraged to voice their concerns.

Gaynor also gave recommendations on when to approach the subject of diabetes-related complications, taking into account the psychological well-being of patients in addition to their biomedical indicators. She stressed the importance of developing a collaborative, ongoing relationship with people with diabetes, by offering continual support, reassurance and achievable targets.

Gaynor concluded: “The challenge for us as HCPs is to be more flexible and creative in our consultations, and to remember that it is not ‘a race’, despite the pressures we may feel from the Quality and Outcomes Framework (QOF). If we always take it back to the individual, then I don’t think we can go far wrong.”

Masterclasses
Five interactive masterclasses were available during the conference. Delegates chose to attend the two sessions that were of most relevance to them.

The primary care role in insulin-managed patients
Sian Bodman, Diabetes Lead Nurse, Torfaen
“How can we help people use insulin in the right way to help them achieve symptom control and agreed HbA1c targets without suffering the consequences of hypoglycaemia, blood glucose swings or weight gain?” was the question that Sian opened her talk with, in describing the challenges faced by HCPs when initiating insulin therapy in people with diabetes. She reviewed currently available insulins and regimens, with a focus on integration into an individual’s everyday life. Several different insulins and dosing regimens were considered, taking into account patient physiology, psychology and sociology.

Sian also raised the issue of recreational drug use among insulin-treated people with diabetes and gave some recommendations on how to prevent injury.

The session was closed with several case histories exhibiting the difficulties of insulin dose adjusting. “The decision as to how to change a regimen should be made jointly by the patient and the healthcare team,” concluded Sian.

Driving assessment
David Millar-Jones, GP, Cwmbran
Dr Millar-Jones discussed the medical and legal implications of current Driver and Vehicle Licensing Agency (DVLA) regulations for drivers with diabetes. He highlighted the low percentage of drivers who are aware of DVLA regulations regarding blood glucose monitoring before driving and stressed the importance of good glycaemic management in this population. He outlined the risks of hypoglycaemia while driving, particularly as many people with diabetes are unable to recognise the signs of a developing hypoglycaemic event. Dr Millar-Jones also described the implications of other diabetes-related comorbidities including neuropathy, obesity, retinopathy and cardiac disease in relation to driving. He concluded by emphasising the role of HCPs in ensuring patient safety and enforcing compliance with DVLA regulations.

Non-insulin therapies: Tablets and injectables
Sam Rice, Consultant in Diabetes, Carmarthenshire
In this session, Dr Rice explored the increasing range of therapeutic options available to people with diabetes, including newer agents such as dapagliflozin and lixisenatide in addition to older treatments. Using a number of case histories, he discussed the difficulties of deciding what medication to use and in which clinical situation, taking into account patient benefit, cost-effectiveness and prescribing guidelines. Dr Rice outlined the multiple treatment options associated with newer therapies, and discussed the primary care initiation of injectable therapy. He ended his talk by reminding the audience to also encourage lifestyle interventions when evaluating the treatment regimen of their patients.

Erectile dysfunction: Meeting QOF requirements
Paul Downie, GP, Ross-on-Wye
The objective of this masterclass was to discuss the prevalence, aetiology and management of erectile dysfunction (ED) in people with diabetes. Dr Downie outlined the recent introduction to QOF that states that clinicians should regularly enquire about the incidence of ED, emphasising that the condition is often under-reported by patients. He suggested that psychosocial history, education on how to use medications appropriately and long-term follow-up are essential for successful pharmacological treatment. The role of phosphodiesterase-5 inhibitors and testosterone deficiency were also investigated in the session, which concluded with an interesting case presentation. Dr Downie said: “ED represents a great opportunity to reinforce lifestyle changes and the importance of good glycaemic control.”

Contraception and preconception counselling
Julia Platts, Consultant Diabetologist and Endocrinologist, Cardiff
“Hyperglycaemia is harmful to pregnancy,” opened Dr Platts. “Poor glycaemic control during pregnancy is associated with an increase in pre-term delivery, miscarriage, still birth and major congenital abnormalities,” she continued. Dr Platts suggested that preconception counselling and good glycaemic control can significantly reduce the rates of congenital abnormalities and other unfavourable outcomes. The value of blood pressure control, retinal care and lifestyle interventions were also explored.

Dr Platts provided an overview of potentially teratogenic medications relevant to people with diabetes that should not be used by pregnant women, including angiotensin-converting-enzyme inhibitors and statins. She outlined the different contraceptive methods available to people with diabetes, concluding that: “Generally, the benefits of contraception outweigh the risk, although there are a few caveats.”

“Who wants to be a millionaire”: An interactive keypad quiz for the whole audience
Pam Brown, GP, Swansea, and David Millar-Jones, GP, Cwmbran
The afternoon’s scientific programme continued with a lively “Who wants to be a millionaire” quiz hosted by Drs Brown and Millar-Jones, in which the audience was asked 16 questions about the day’s many topics. Delegates could take part by using interactive voting buttons and answered questions on HbA1c targets, renal safety, driving, hypoglycaemia, cardiovascular risk reduction and preconception care, as a part of this fun and informative refresher session.

Latebreaking news and its impact on your day-to-day practice
Jeff Stephens, Professor of Medicine (Diabetes and Metabolism) and Consultant Physician, Swansea
“This is a great session to send us back to clinical practice with, as it will provide a comprehensive overview of what’s new and what is changing in the area of diabetes,” commented Dr Brown as she opened the final session of the conference.

Professor Stephens began his presentation by discussing the challenges in diabetes management, which can be complicated by the various clinical phenotypes observed in the condition.

“We can appreciate that one drug cannot target all the different pathological mechanisms involved in diabetes; it is not a case of one treatment fits all,” argued Professor Stephens. He continued by explaining the difficulties in diagnosing diabetes and evaluated the diagnostic value of HbA1c compared with the traditional oral glucose tolerance test.

The dilemma of balancing stringent glucose control, cardiovascular risk, obesity and hypoglycaemia was also discussed with regard to glucose-lowering agents. Professor Stephens called for more tailored clinical guidelines that take into account factors such as hypoglycaemia, cardiovascular risk and age. He concluded: “Choose the agent that suits the patients and their complications as opposed to always following an algorithm.”

Acknowledgement
This report was written by Hemali Parekh (SB Communications Group) and approved by the speakers.

REFERENCES:

Khunti K, Gillies CL, Taub NA et al (2012) A comparison of cost per case detected of screening strategies for Type 2 diabetes and impaired glucose regulation: modelling study. Diabetes Res Clin Pract 97: 505–13
NICE (2012) Public Health Guidance 38: Prevention of type 2 diabetes – risk identification and interventions for individuals at high risk. NICE, London. Available at: www.nice.org.uk/PH38 (accessed 23.05.13)
World Health Organization (2011) Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus. WHO, Geneva. Available at: www.who.int/diabetes/publications/report-hba1c_2011.pdf (accessed 23.05.13)

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