Pam Brown (GP, Swansea and Welsh representative of the Primary Care Diabetes Society [PCDS]) and David Millar-Jones (GP, Cwmbran and Welsh representative of the PCDS) welcomed delegates to the 3rd Welsh Conference of the PCDS.
Diabetes therapies: “Out with the old and in with the new” – a motto to be adopted wholeheartedly or to be taken with caution?
David Millar-Jones, Cwmbran
“It is becoming ever more challenging to achieve good glycaemic control in people with type 2 diabetes, with increasing financial pressure,” said Dr Millar-Jones. He discussed the pressure to reduce prescribing costs, with many localities recommending the use of older glucose-lowering therapies (such as metformin or sulphonylureas) in preference to newer, more expensive therapies (such as glucagon-like peptide-1 [GLP-1] receptor agonists and dipeptidyl peptidase-4 [DPP-4] inhibitors.
However, there is an argument that newer therapies may be more effective at reducing blood-glucose levels in people with diabetes if used earlier in the treatment pathway. Dr Millar-Jones admitted that it is challenging to research the economics of different oral antidiabetes drugs, and emphasised that therapies must be individualised.
Dr Millar-Jones looked at newer therapies, and their place in the treatment pathway. He discussed a once-weekly preparation of the GLP-1 receptor agonist exenatide, which may provide a more convenient dosing option for some people with diabetes, compared with a once- or twice-daily GLP-1 receptor agonist.
Regarding the economics of using older versus newer insulins: “be cautious about switching everyone on analogue insulins to human insulins,” he said, urging delegates to individualise treatments and take heed of advice from Diabetes UK (2012).
He also mentioned development of new insulins (such as ultra long-acting and buccal insulins) and new drugs, such as sodium-glucose co-transporter 2 inhibitors, which affect the reabsorption of glucose in the kidneys to control blood glucose levels.
Is addressing one risk factor more effective than addressing any other in managing type 2 diabetes?
Steve Bain, Professor of Medicine (Diabetes), Swansea
Professor Bain had the challenging task of ranking diabetes risk factors in the order of importance for the prevention of complications of diabetes. He evaluated the evidence for targeting each risk factor, such as obesity, dyslipidaemia, hypertension and glycaemic control. “The evidence base supporting the degree of control of the various risk factors depends on whether the major aim is to reduce microvascular or macrovascular complications,” he said, informing delegates that there does not appear to be a lower limit for optimum blood pressure in people with type 1 diabetes: “the lower the better.” He commented on using aspirin for the primary prevention of cardiovascular disease, saying that “it looks like it doesn’t do any harm, but, looking at the evidence, I’m not sure if it does any good either, in people with diabetes and at low cardiovascular risk.”
Professor Bain looked at using fibrates in type 2 diabetes for the treatment of dyslipidaemia. Evidence from the Fenofibrate Intervention and Event Lowering in Diabetes study (Keech et al, 2005) suggests that there is no additional benefit from adding a fibrate to statin therapy in people with type 2 diabetes, a view supported by more recent data from the Action to Control Cardiovascular Risk in Diabetes study in the US (ACCORD Study Group et al, 2011).
Regarding high blood pressure, after reviewing evidence from major trials, he summarised by saying: “there is a lower limit of optimum blood pressure for those with type 2 diabetes; treatment options for this population need careful consideration.”
For type 1 diabetes, Professor Bain recommended ensuring good blood pressure control, then working on the glycaemic control. For people with type 2 diabetes, he recommended first treating blood pressure (with the caveats that there is a lower limit and the evidence for angiotensin-converting enzyme inhibitors is less strong than is generally thought), followed by cholesterol, and finally glycaemia.
Diabetes care – the Welsh agenda
Chris Jones, Medical Director, NHS Wales, Cardiff
“Diabetes in Wales has not been as high on the agenda as it should have been,” said Dr Jones and assured delegates that it would now be high priority, particularly with the publication of the Diabetes Action Plan later this year. He reminded delegates that Wales has a world-class retinopathy screening programme to be proud of. Dr Jones discussed how diabetes services can be organised so that they offer the best care for people with diabetes and are as cost-efficient as possible. “The amount of money going into the NHS is not increasing so we will have to save 5% of costs each year,” he said. “A ministerial Task and Finish Group on community diabetes services last year provided work that will inform the development of the Action Plan and a 3-month public consultation period is due to start in September,” Dr Jones explained. He expressed his enthusiasm for healthcare professionals from all areas of diabetes care, including primary, secondary and community services, to have an input into reorganising diabetes services.
Obesity: A Welsh perspective
Jeff Stephens, Reader in Diabetic Medicine and Consultant Physician, Swansea
Professor Stephens began by looking at obesity rates in the US. “The UK always follows US weight trends and the US has seen a 10-fold increase in obesity in the past 20 years,” he said. “Obesity is increasing in Wales and 56% of Welsh adults are overweight,” he continued and went on to look at treatments for obesity.
He briefly discussed obesity drugs, of which only one, orlistat, is still in production. Others were discontinued for various reasons. He said that there are nine obesity drugs in phase II clinical trials, so there will be a few more options emerging in the coming years.
Considering the high rates of obesity and overweight in Wales compared with other UK nations, bariatric surgery operations are rarely performed, with only 11 procedures taking place between January 2010 and January 2011. “The number of bariatric surgery procedures has recently increased to around 80 in the past year,” said Professor Stephens, “but although this is a huge improvement, it is very much a work in progress.” He discussed the relative merits of each bariatric procedure and pointed out that gastric banding requires more follow-up than the other options, with band slippage and adjustments requiring a further operation to correct. He expressed his preference for sleeve gastrectomy, because, in his experience, it has fewer adverse effects.
Complications of diabetes: How are we doing in Wales?
Karen Gully, Senior Medical Officer, Welsh Assembly Government
Dr Gully started by commending delegates on their detailed knowledge of diabetes impressing on them the importance of sharing their knowledge (including learnings from this conference) with their colleagues. Improving the rate of complications in people with diabetes requires early identification and consistent, evidence-based advice. Dr Gully highlighted the importance of working to improve population outcomes, as measured through QOF, whilst ensuring that clinical management focuses on individual needs and patient-centred care. She encouraged delegates to participate in the National Diabetes Audit and to access the summary reports which provide detailed comparative analyses of care provision and are beginning to link process measures with outcomes such as complication rates.” Dr Gully acknowledged the difficulty of translating statistics into meaningful, clear information for people with diabetes and encouraged delegates to look at how data relate to their local population. “Professional networks, such as the PCDS, play a key role in sharing best practice and improving the care of people with diabetes,” concluded Dr Gully.
Overall, the conference provided an overview of the most current topics in diabetes care and delegates left armed with key information to inform their practice.
A series of five interactive masterclasses were available. Delegates chose to attend the two sessions that were of most interest to them.
How to diagnose diabetes and how to screen for it
Julia Platts, Consultant Diabetologist and Endocrinologist, Cardiff
In light of the move towards using HbA1c to diagnose diabetes, Dr Platts discussed the consensus for this method of diagnosis in the UK. She clarified the situations in which a glucose tolerance test is still recommended and gave some practical advice on screening for type 2 diabetes.
Driving under the influence of diabetes
David Millar-Jones, GP and Welsh Representative of the PCDS, Cwmbran
Dr Millar-Jones set out the changes to and implications of driving regulations for people with diabetes and the role of healthcare professionals. He emphasised the importance of giving clear and current advice to people with diabetes and being vigilant and up to date on the latest criteria.
Insulin initiation and intensification
Richard Chudleigh, Consultant Physician, Diabetes, Swansea
Dr Chudleigh looked at the indications for insulin therapy, and summarised the different types of insulin. He discussed how to choose the right insulin regimen for each individual.
How to confront psychological issues such as depression
Sam Rice, Consultant in Diabetes, Carmarthenshire
Dr Rice discussed Welsh guidance for the management of depression in people with diabetes and presented some case studies illustrating the importance of good communication between different teams.
Sarah Flowers, Consultant Clinical Psychologist, Aneurin Bevan Health Board (ABHB) Cancer Services, Newport and Dr Elanor Maybury, British Heart Foundation clinical psychologist, Torfaen Weight Management Service and ABHB
Drs Flowers and Maybury looked at why behaviour change can be difficult and introduced some of the ideas underlying motivational interviewing and solution-focused approaches. They emphasised the importance of listening for individuals’ own goals and working with them to find solutions.