Individualisation and remission

The recent European Association for the Study of Diabetes conference (see our extended news section on page 190) focused on individualisation of therapy, and we had informal discussions on how to code diabetes remission. With this in mind, two recent publications have caught my attention.

Individualisation and the ominous octet
It is easy to forget that there is more driving type 2 diabetes than just increased insulin resistance and reduced insulin secretion. Understanding other six aspects of the so-called “ominous octet” contributing to hyperglycaemia – increases in liver glucose production, glucagon secretion, renal glucose reabsorption and lipolysis, as well as decreased incretin effect and neurotransmitter defects – helps us understand how we may achieve synergy with drug treatments.

A recent point/counterpoint debate in Diabetes Care challenges us to think logically about individualising therapies and targeting more of the ominous octet (Abdul-Ghani and DeFronzo, 2017; Inzucchi, 2017). Metformin is the first line in most guidelines, yet it is often poorly tolerated, requires titration and is slow to impact hyperglycaemia. Thus, it does not help us capture the newly diagnosed person’s initial motivation to make lifestyle changes and adhere with medication, as it is difficult to demonstrate early treatment success. In contrast, glucagon-like peptide-1 (GLP-1) receptor agonists target more of the ominous octet with early weight loss, so Abdul-Ghani and DeFronzo recommend using this class earlier in people with higher HbA_1c at diagnosis.

NICE guidelines continue to recommend metformin monotherapy as the first line, with newer drugs that target multiple defects reserved for later in the treatment algorithm. Since early tight control and patient motivation are our goals, is it time for a paradigm shift and to use drugs that tackle as many of the underlying pathological processes as possible, immediately at diagnosis?

Type 2 diabetes remission
It is now recognised that weight loss of around 15 kg, achieved with either surgery or intensive medical treatment, reduces ectopic fat in the liver and pancreas, resulting in improved beta-cell function and, possibly, remission of type 2 diabetes. However, there is currently no consensus on the definition of remission. Researchers from the University of Glasgow and Newcastle University recommend using two measurements of HbA_1c <48 mmol/mol (6.5%), at least 2 months apart, off all treatment, to confirm remission (McCombie et al, 2017).

It is likely that each of us will identify several such people in our practice. Coding as C10P – “diabetes in remission” – ensures these individuals will continue to have annual review and retinal screening recalls, and will remain on our Quality and Outcomes Framework (QOF) diabetes registers. We should reserve the “diabetes resolved” coding (21263 or 212H) for those who are misdiagnosed or in whom previous diabetes was secondary to steroids or other medications that have now been stopped, with return to normoglycaemia.

In this issue
We continue our “Studies that changed clinical practice” series with a discussion of the key diabetes prevention studies. On a recent home visit, I found nearly 100 unused insulin pens in the fridge. Therefore, in our “How to” series, Jane Diggle helps us tailor our insulin prescribing to avoid stockpiling and potential waste. Alia Gilani explores hard-to-reach groups in our CPD module, and Colin Kenny provides a comprehensive update on the sodium–glucose cotransporter 2 inhibitors.  Sometimes an article in the Journal of Diabetes Nursing proves so useful to readers that we decide to share it too, so some of you may experience a bit of “deja vu” when reading Johanna Taylor and David Shiers’ article. We also have a short report from the PocketMedic team, an update from Richard Quigley on diabetes care without QOF in Scotland and insight from the Fixing Dad family.

I look forward to meeting as many of you as possible at the national PCDS conference this month. We will be meeting with our editorial board at the conference to discuss content for the journal next year, so do please email your ideas to [email protected].