Conference over coffee: Insulin in practice, frailty and abnormal liver function tests

Abnormal liver tests and NAFLD in diabetes: A primary care approach

Sarah Davies

GP, Cardiff

● Abnormal liver function tests are very common in primary care – look for patterns and make an active diagnosis if possible.

• ALT the most abnormal = hepatic cause.
• Alkaline phosphatase the most abnormal = cholestatic cause; can be from bone – if GGT also elevated then liver cause.
• AST – less liver-specific than ALT, sensitive indicator in alcoholic liver disease.
• GGT – in liver but not bone. Commonly elevated due to obesity and alcohol. Non-specific for liver disease but good predictor of liver mortality. 

● NAFLD is common and not benign, especially in people with metabolic syndrome or type 2 diabetes. Can progress to steatohepatitis and fibrosis. Primary care role:

• Identify and make active diagnosis.
• Assess likelihood of significant fibrosis (FIB-4, NAFLD fibrosis score – see RCGP liver disease toolkit) and refer if required.
• Support to achieve weight loss.
• Cardiovascular risk management. Statins are generally safe: no need to “over-monitor LFTs”.
• Potential for benefit from newer diabetes medications (GLP-1 RAs and SGLT2 inhibitors), although not yet licensed for this indication.

● Take-home point: NAFLD is not a benign condition – that raised ALT requires action!

Resources

• RCGP liver disease toolkit – open-access and includes links to tools and calculators as well as additional e-learning resources
• British Society of Gastroenterology Guidelines on the management of abnormal liver blood tests
• NICE NG46: NAFLD assessment and management
• All Wales abnormal LFT pathway

Managing diabetes in the elderly and frail

Chris Cottrell

Diabetes Specialist Nurse, Swansea Bay University Health Board

● Diabetes management in older adults is complicated by frailty, comorbidities and polypharmacy.

● Undertake a frailty assessment using a recommended tool, such as the electronic Frailty Index or Rockwood Scale, and use it to guide agreement of glycaemic targets.

● Frailty may be improved by simplifying, switching or stopping therapies to avoid hypoglycaemia, falls, hyperglycaemia, weight loss and sarcopenia.

● Consider de-escalation when appropriate – discuss with the person with diabetes and carers so everyone understands it is to ensure safety and improve quality of life, rather than “giving up” on providing care.

● Individualise glycaemic targets after discussion, depending on personal preferences, comorbidities, frailty, polypharmacy risks, likelihood of benefit or harm:

Resource

• National Advisory Panel on Care Home Diabetes Strategic document of diabetes care for care homes

Insulin in practice

Julie Lewis

Nurse Consultant, Primary Care Diabetes, Central Area, North Wales

● A perception of mystery and art to insulin management exists in clinical practice that can create delays to initiating and adjusting this very effective treatment for type 2 diabetes.

● Matching the insulin profile to the person’s specific requirements is key to insulin being an effective therapy choice.

• Glucose targets need to reflect the needs of the individual.
• Consider the support that may be needed to administer and monitor this treatment.

● A thorough understanding of the person’s glucose profile will inform an appropriate insulin regimen choice.

• Self-monitoring of blood glucose (SMBG) is the standard approach to obtain glucose profiles. However, NICE NG28 now supports the use of flash glucose monitoring in certain type 2 diabetes situations.

● Continuing other glucose-lowering therapies: use the guidance to inform a safe and individualised approach:

• Sulfonylureas: Reduce by half or consider stopping. Can re-introduce if needed.
• Metformin: Continue if tolerated/eGFR permits.
• Other oral therapies/injectables: What benefit are they adding (e.g. renal/cardiovascular disease/weight management)?
• Review safety to continue and/or impact of discontinuation (concomitant use of therapies for other conditions; e.g. heart failure).
• Reinforce guidance (e.g. sick-day rules, hypoglycaemia recognition and treatment).

● Insulin initiation:

• Refer to British National Formulary for starting dose advice.
• A lower starting dose is acceptable provided there is active dose adjustment thereafter.
• Use a checklist to guide the process of initiation: confirms what has been covered and records important advice.

● Ongoing management/support:

• Utilise insulin education programmes whenever possible to improve self-management competence.
• Insulin dose adjustment is a fundamental factor to assure insulin effectiveness. This cannot be completed safely without glucose data.

Resources

• The Six Steps to Insulin Safety – free PCDS e-Learning module
• Starting injectable treatments in adults with type 2 diabetes
• Insulin prescribing aid for adults with type 2 diabetes
• Injection Technique Matters resources