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Editorial: Little chance of a summer lull this year!

Jane Diggle
Jane Diggle asks how best to manage a growing number of queries from patients unable to source their GLP-1 receptor agonist therapy.

I am not sure about you, but I haven’t experienced any lull in workload and demand in general practice over the summer months. In fact, it seems busier than ever. Of course, this has not been helped by the added challenges of dealing with the supply problems of various diabetes drugs, most particularly the entire GLP-1 RA class. I wrote a lot about this problem in my last editorial, but it is probably now that the shortage is exerting the greatest impact. Every day in practice, over and above the usual responsibilities, I am tasked with an increasing number of queries from patients unable to source their GLP-1 receptor agonist therapy, and I know I’m not alone in this.

No two cases will be the same. Important factors need to be considered, with a comprehensive review that cannot be done in a few minutes. This will have a significant impact on our workload and will also test our communication skills. Quite understandably, many of the individuals affected will feel angry, frustrated, upset, anxious and uncertain about their future diabetes management and potentially worsening control. Decisions will need to be made about the most appropriate way to manage each case.

Where GLP-1 RA therapy has been initiated later in the treatment pathway, as currently recommended by NICE NG28, other oral therapy options are likely to have already been tried. Typically, SGLT2 inhibitors would be used before considering a GLP-1 RA, but if not, this class may be the most appropriate replacement, particularly for those with established atherosclerotic cardiovascular disease, chronic kidney disease or heart failure, or indeed high cardiovascular risk. For those clinicians still feeling unsure about prescribing SGLT2 inhibitors, Pam Brown has updated her very popular How to use SGLT2 inhibitors safely and effectively.

I do think it is worth mentioning that, for those individuals who have tried an SGLT2 inhibitor in the past, it is worth looking back to see why they stopped, as there may be a change in circumstances and potential to consider re-prescribing. I have noticed a number of individuals who stopped their SGLT2 inhibitor because of a single genital mycotic infection. At initiation, as part of the counselling, I encourage them to seek treatment for such an infection and to continue the SGLT2 inhibitor, only recommending them to stop if there are recurrent infections or intolerable symptoms. However, in practice this may not happen. I have also found that the propensity to genital candidiasis is greater when glucose levels are particularly high, so if glycaemic control has improved then this side effect may be less likely to happen and it may be worth another go with the SGLT2 inhibitor.

Many more therapies for treating type 2 diabetes and obesity are likely to launch in the not-too-distant future, and these featured strongly at the American Diabetes Association (ADA) 83rd Scientific Sessions this year. Pam provides a comprehensive summary report highlighting the progress so far, with a number of familiar and not so familiar agents.

Kevin Fernando also provides a little more detail from the ADA Sessions on the dual GLP-1/GIP receptor agonist tirzepatide. Results from the SURMOUNT-2 trial demonstrated that use of tirzepatide resulted in a mean body weight reduction of up to 14.7% after 72 weeks in people living with type 2 diabetes and comorbid obesity or excess weight. At the time of writing, it is not clear when this agent will be available to prescribe in the UK. In the meantime, I still believe that the current GLP-1 RA shortage presents an opportunity for us to emphasise the huge impact of diet and lifestyle in type 2 diabetes management. At a time when pharmacological options that support weight loss are limited, this has prompted several of my patients who previously relied on GLP-1 RA therapy to re-engage with healthy lifestyle choices.

While type 2 diabetes remission will not be a realistic goal for all, it also makes sense to include discussion about this, where appropriate. In a couple of my patients, being unable to get hold of a reliable supply of their GLP-1 RA was the trigger for them to embark on our local Type 2 Diabetes Path to Remission programme, which is being rolled out across England. For more information on this programme, and on how to increase uptake, I would strongly recommend reading Chirag Bakhai and Rose Stewart’s overview.

Still on the subject of diet, it is probably not a surprise to read about the potentially detrimental effects of ultra-processed foods on weight and obesity, mortality, cardiovascular disease, type 2 diabetes and other chronic conditions. I am always intrigued by health outcome studies that explore lifestyle choices in healthcare professionals, and especially nurses, who one might expect to understand the impact of unhealthy choices and make healthier lifestyle decisions! In Diabetes Distilled, Pam Brown outlines the key findings from a review of more than 5 million person-years in the Nurses Health Studies 1 and 2 and the Health Professional Follow-up Study, in which ultra-processed foods were linked to poor health outcomes.

In practice, I do advocate “real foods” rather than processed. What was interesting in this study were the definitions and classifications of processed food. With fairly broad categories that group together foods with different nutritional attributes, questions have been raised as to whether the detrimental health effects relate to the higher energy density and high fat, salt and sugar content of these foods, rather than their degree of processing specifically. Clinical trials investigating the impact of different dietary approaches are inherently difficult – most are observational studies and often there are numerous confounding factors that can impact results but which may not have been adequately considered. We shouldn’t, therefore, jump to conclusions, and it seems prudent to interpret these studies cautiously.

If the phrase “It’s not only what you eat but when you eat” resonates, you will be interested in Pam’s other Diabetes Distilled exploring how irregular meal patterns, skipping breakfast, night-time eating and snacking are associated with metabolic disease. As this review shows, these behaviours may be important factors in the risk of non-alcoholic fatty liver disease.

The development of type 2 diabetes at a younger age is a cause for concern. These individuals appear to have a higher risk of complications and a more rapid deterioration in beta-cell function than is seen in people with later-onset type 2 diabetes. As the number of younger adults with type 2 diabetes increases, early-onset type 2 diabetes is predicted to become a more frequent feature within our practice. In our latest interactive case study, David Morris offers two scenarios outlining the clinical implications and management of early-onset type 2 diabetes, as well as the challenges inherent in correctly diagnosing younger adults who present with symptoms of diabetes.

The menopause can bring with it a debilitating set of symptoms, the severity and duration of which are highly variable. Hot flushes and night sweats can impact sleep, leading to fatigue, loss of energy, irritability, forgetfulness and loss of concentration. These are important issues for any woman, but managing diabetes during and after the menopause can be particularly challenging. Claire Partridge provides an interesting factsheet covering the relationship between menopause and type 2 diabetes, with useful recommendations on how to optimise HRT in women with diabetes.

As part of our medication reviews, discussions around gastrointestinal side effects of diabetes medications such as metformin are common, but do we ever consider the possibility of gastroparesis? In our second factsheet this issue, Simon Saunders tackles this common but frequently ignored complication of diabetes.

Finally, in response to the announcement that the FreeStyle Libre 2 device can now function as a real-time continuous glucose monitor when paired with the LibreLink app on a smartphone, Nicola Milne has very swiftly updated her How to guide on CGM. Our thanks to her for keeping it so up to date!

By the time you read this editorial, the annual PCDS National Conference will be upon us: a little earlier than usual, on 13–14th September. For those of you attending in person, please do come and introduce yourselves – I would love to hear your thoughts on future topics of interest for the journal. I look forward to seeing you then!

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