ABCD has been informed that the Guideline Development Group has considered the feedback received from stakeholders and has made ‘substantial changes’ to the draft recommendations. Publication is now scheduled for August 2015. ABCD has signed a letter on behalf of stakeholders asking NICE to consider making the revised draft available for consultation before publication.
Dr O’ Hare and others recently published an editorial in BJDVD with comments on the strengths and problems of the guideline for type 2 diabetes (strengths: guidance on life style, education, monitoring and targets; problems: guidance on use of glitazones and glinides as second-line therapy, use of GLP-1 agonists for people with BMI >35 kg/m2, advice to continue GLP-1 based therapy only with weight and HbA1c reduction criteria and restriction of use with insulin for specialist only, preference for NPH over long-acting insulin analogues).
http://bjdvd.co.uk/index.php/bjdvd/article/view/47
Dr R Andrews and P Narendran, with the help of Prof Davies’s Team in Leicester, I Gallen and D Nagi plan to develop/pilot an education programme for patients and healthcare professionals to guide insulin and carbohydrate adjustment for safe and effective exercise. A survey is being set up to collect data on the current status of education of people with type 1 diabetes on exercise and on resources provided or signposted to patients. The aim is to generate guidelines which will be accessible to all centres that contribute. We are particularly keen to survey nurses, dietitians and registrars, so please tell your local teams. The survey is here:
https://www.surveymonkey.com/s/EXTOD1
Rob Gregory (ABCD Chair) and Russell Drummond attended the awards ceremony on 6 May to present certificates to the finalists, and the trophy to the winners, the South Asian Health Foundation, Birmingham for their South Asian Diabetes Education Programme. The shortlisted teams in diabetes and other fields of medicine are shown here:
http://thebmjawards.bmj.com/38529
The above award is now open for entries to recognise and award best initiatives to improve diabetes care, education and management.
http://www.qualityincare.org/awards/diabetes
NHS England has launched its first national drive to help prevent diabetes in the UK. The aim is to reduce the number of people who are expected to develop diabetes by 2025 (from 4 million).
http://www.england.nhs.uk/2015/03/12/diabetes-prevention/
A new report from 9th March has shown that more children and young people with type 1 diabetes in England and Wales are exhibiting early signs of long term complications. The Annual National Paediatric Diabetes Audit has shown that only 16.1% of young people with type 1 diabetes aged 12 and older are getting the seven annual checks they need. The report also shows that 27.5% of patients have high BP, >7% have microalbuminuria, >14% have retinopathy and 20–25% are obese. HbA1c was classed as “excellent” in 18.4% of patients. Children from disadvantaged backgrounds and ethnic minorities have worse outcomes.
http://www.rcpch.ac.uk/system/files/protected/page/2014%20NPDA%20Report%201%202014%20FINAL.pdf
The judges have chosen the best four apps to improve diabetes as finalists in a competition organised by Plymouth University with Diabetes UK. People are now being urged to vote for the winners. The four finalists are:
• BetterBGs, a real-time food and medication dose advisory system
• EasyDiabetes, a complete organiser for teens with diabetes
• BWell Sugars System, a data logging and tracking tool
• Dap’n’, a game designed to support medical adherence
http://diabetestimes.co.uk/app-challenge-hots-up/#sthash.AG3UBVp7.dpbs
A parliamentary group has identified poor diabetes education delivery as an important source of complications and a drain on resources. A new report ‘Taking control: Supporting people with diabetes to look after their condition’, published by the MPs in March 2015, raises concerns that only 16% of people newly diagnosed with diabetes are offered a structured course on how to manage their diabetes more effectively and only 3% actually attend such a course. The report also highlights the key obstacles. Some CCGs are not commissioning formal education courses in their areas and when these courses are offered, they are not conveniently timed for patients or promoted well by the health care professionals. The report presents evidence of the lack of support to patients after diagnosis, e.g. refresher courses, online support and more informal learning, such as peer-to-peer groups.
http://www.diabetes.org.uk/About_us/News/MPs-Postcode-lottery-on-diabetes-education-leading-to-devastating-health-complications-and-huge-costs-to-NHS/
A new concentrated insulin U300 glargine will soon be marketed as Toujeo® by Sanofi following a positive recommendation from the EMA Committee for Medicinal Products for Human Use (CHMP). The positive recommendation is based on the EDITION trials, which showed that U300 glargine was as effective as the U100 formulation but was associated with a lower incidence of hypoglycaemia, particularly at night.
http://en.sanofi.com/NasdaQ_OMX/local/press_releases/toujeo_receives_positive_opini_1897975_27-02-2015!13_15_43.aspx
NICE (Feb 2015) has revised its guidance about the threshold for diagnosis of gestational diabetes. The new diagnostic cut-offs are fasting plasma glucose ≥ 5.6 mmol/L or a 2-hour plasma glucose ≥ 7.8 mmol/L. The new target for pre-meal glucose is now set at 5.3 mmol/L and for 1-hour post-meal glucose at 7.8 mmol/L. The incidence of all types of diabetes in pregnancy (type 1 type 2 or gestational diabetes) has increased recently due to a number of factors including lifestyle changes and increasing obesity. This will have major resource implications for many trusts.
https://www.nice.org.uk/news/article/new-thresholds-for-diagnosis-of-diabetes-in-pregnancy
https://www.nice.org.uk/guidance/ng3
“Current evidence on the safety and efficacy of implantation of a duodenal–jejunal bypass liner for managing type 2 diabetes is limited in quality and quantity. Therefore the procedure should only be used in the context of research”.
https://www.nice.org.uk/guidance/ipg518
Many thanks to the ABCD members who have contributed their data for the U500 pilot audit. This will help us quantify U500 use and its reasons in the UK. It will also help us understand when and how we can use the higher strength insulins which are going to be available very soon in the UK. Umesh Dashora and Andrew Macklin will soon be contacting teams who are using U500 in a number of patients to gather more information.
Prof Mike Sampson, Chair JBDS-IP, is due to announce the annual Rowan Hillson Insulin Safety Award for 2015. It will aim at identifying best practices in the country to reduce hypoglycaemia episodes in hospitals. Please be on the lookout for the announcement and submit your entry to Christine Jones, JBDS-IP coordinator. Umesh Dashora, Erwin Castro and Debbie Stanisstreet of the Insulin Safety group will co-ordinate the competition on behalf of JBDS-IP.
A new report has emphasised the importance of diet and exercise for general health, irrespective of body weight.
http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/845/845.pdf
The ABCD National Diabetes Consultant Mentorship Programme (NDCMP) continues to grow stronger. Potential mentees who would like to use this programme for personal professional development are welcome to join. The next mentee workshop will be Tuesday 23 June 2015 and there will be a further one later in the year. If you have been a consultant for 5 years or more and would like to be a mentor, the next mentor meeting is on 23rd April in Cardiff. You do not have to be an ABCD member to be an NDCMP Mentor. For further information please contact: baldev.singh@nhs.net.
http://www.diabetologists-abcd.org.uk/NDCMP.htm
Patients with diabetes and hypothyroidism are entitled for free prescription, but this however requires an exemption certificate that needs to be renewed every 5 years. Many doctors and patients are not fully aware of this. As a result some patients are facing a fine of £100. This action is clearly draconian and could affect many millions of patients. Following interventions from Rob Gregory (ABCD Chair) and others, the NHS Business Authority has agreed to waive these fines if an exemption certificate can be presented in 60 days; those who have already paid fines will be able to claim the money back if they provide evidence they have since obtained a certificate. ABCD members are requested to share this information with their patients.
A swimming event for all family in the river Thames, massive research support for Dr Melton’s success in turning stem cells into insulin-producing β-cells…see these stories and many more at the JDRF site.
http://www.jdrf.org.uk/news/latest-news?gclid=CMKuxe_v0MQCFSXnwgod55kA0A
Among the top 10 priorities are ensuring high quality and affordable specialist care for conditions including obesity and diabetes.
http://www.england.nhs.uk/about/business-plan/
This report from a coalition of 10 charities has highlighted poor access to best quality NHS care for patients with long term conditions. The report emphasises the importance of integrated care and prevention of complications in long term complications. It notes that half a million people with diabetes remain undiagnosed.
http://www.richmondgroupofcharities.org.uk/PDFs/richmond-group-vital-signs-report.pdf
A new report from the ABPI finds that diabetes is a low national priority and there is widespread variation in care and outcomes. CCGs are promoting short-term cost savings at the expense of patient outcomes. It recommends local champions to support CCGs to design diabetes care with an emphasis on outcomes and national leadership to drive improvements.
http://www.abpi.org.uk/our-work/library/industry/Documents/diabetessnapshot.pdf
Partha Kar reports on a number of service models in the country with their advantages and limitations.
http://www.practicaldiabetes.com/SpringboardWebApp/userfiles/espdi/file/Jan 2015/SR Kar.pdf
ABCD Information and Communications Lead, Andy Macklin, has announced, “I will be doing the Wiggle Jurassic Beast cycle ride in May: 101 miles of cycling around the Purbeck hills, with a total of 1.4 miles of vertical ascent. All in one day! I'm raising money for JDRF. I'm also doing it with a person with diabetes for company - he's likely to show me up though! If you’d like to sponsor us, or just see the subtitled Downfall video, then visit:
http://www.justgiving.com/JurassicBeast.”
In this worrying report there is very little improvement in diabetes care in the past year with 40% of patients not receiving the ten essential checks. Young people are in worst health. Treatment targets for glucose, BP and cholesterol are being met only for a third of people. There are recommendations for CCGs to urgently design action plans and performance targets for their population.
http://www.diabetes.org.uk/Documents/About Us/What we say/State of the nation 2014.pdf
This new scheme will alert the GPs if their patient is not meeting all three treatment targets, namely glucose, BP and cholesterol. A one-page printout with targets and means to achieve them can be tailored to individual patient and be taken away for action.
http://www.diabetes.org.uk/About_us/News/Launch-of-information-prescriptions-for-people-with-diabetes/
The report finds rising incidence of type 1 diabetes, higher mortality for young women and high rates of minor amputations but improvements in the rates of complications of both types of diabetes. There are recommendations for hospital trusts and CCGs in the report.
http://www.hscic.gov.uk/catalogue/PUB16496/nati-diab-audi-12-13-rep2.pdf
ABCD Twitter is a good forum for interesting real time discussion. Here is a flavour of what is being discussed at https://twitter.com/ABCDiab.
Mar 19: Could we follow up thyroid nodules with benign USS appearances less closely? HT @EvidBaseMed_BMJ http://blogs.bmj.com/ebm/2015/03/18/primary-care-corner-with-geoffrey-modest-md-natural-history-of-thyroid-nodules-and-why-do-we-care/…
Mar 12: Only 4 new consultant posts in diabetes/endo UK in 2014 according to the latest manpower survey. #dpc15 This is the lowest on record.
Mar 11: All-cause & cause-specific mortality rates (for diabetes) declined over 2007-2012: unrelated to #QOF http://www.bmj.com/content/350/bmj.h904 … HT @bmj_latest
Mar 11: Research into diabetes vaccines (& the UK’s first ever trial of a prototype vaccine in children & teenagers) launches today @DiabetesUK APC
Interesting recent papers
Here is a rapid-fire collection of interesting recent papers in diabetes, with links to full content.
1. Engineered commensal bacteria reprogram intestinal cells into glucose-responsive insulin-secreting cells for the treatment of diabetes
The paper reports on increased insulin secretion by diabetic rats when they were fed human lactobacilli engineered to secrete GLP-1. These rats developed insulin-producing cells in their intestines. This could potentially be an oral treatment for people with diabetes.
http://diabetes.diabetesjournals.org/content/early/2015/01/27/db14-0635
2. Association between familial hypercholesterolaemia and prevalence of type 2 diabetes mellitus
The prevalence of type 2 diabetes is lower among patients with familial hypercholesterolaemia in the Netherlands. This may possibly be linked to the cholesterol transport receptor being involved in the aetiopathogenesis of diabetes.
http://jama.jamanetwork.com/article.aspx?articleid=2190985
3. Paracetamol: not as safe as we thought? A systematic literature review of observational studies
A report of increased cardiovascular, gastrointestinal and renal mortality, especially at higher doses.
http://ard.bmj.com/content/early/2015/02/09/annrheumdis-2014-206914.full
4. Genetic risk, coronary heart disease events, and the clinical benefit of statin therapy: an analysis of primary and secondary prevention trials
The paper described the risk of coronary heart disease across genetic risk score categories in primary and secondary prevention populations from a number of clinical trials. The benefit of statins is apparently greater in patients who are at high genetic risk of a cardiovascular event.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61730-X/abstract
5. Reduction of hypoglycaemic events with a behavioural intervention: a randomized clinical trial for paediatric patients with Type 1 diabetes mellitus
Behavioural interventions targeting problem-solving skills could be considered as practical, non-pharmacological strategies to reduce hypoglycaemia in adolescents with Type 1 diabetes, according to a paper published in Diabet Med.
http://onlinelibrary.wiley.com/doi/10.1111/dme.12744/abstract
6. Relationship between neutrophil-lymphocyte ratio and insulin resistance in newly diagnosed type 2 diabetes mellitus patients
A high neutrophil-lymphocyte ratio may signify the presence of insulin resistance.
http://www.biomedcentral.com/1472-6823/15/9
7. Heart failure and mortality outcomes in patients with type 2 diabetes taking alogliptin versus placebo in EXAMINE: a multicentre, randomised, double-blind trial
Alogliptin does not increase the risk of heart failure in patients with type 2 diabetes and acute coronary syndrome.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62225-X/abstract
8. The influence of glucagon on postprandial hyperglycaemia in children 5 years after onset of type 1 diabetes
Postprandial glucagon levels are associated with deteriorating β-cell function for the first 5 years after diagnosis of type 1 diabetes.
http://link.springer.com/article/10.1007%2Fs00125-014-3486-3
9. Expedited biliopancreatic juice flow to the distal gut benefits the diabetes control after duodenal-jejunal bypass
Biliopancreatic juice in the distal gut may augment GLP-1 secretion and may underlie the benefits of obesity surgery.
http://link.springer.com/article/10.1007/s11695-015-1633-7
10. Impact of type 2 diabetes and chronic inflammation on pancreatic cancer
Type 2 diabetes may have a mitogenic influence in the pancreas, stimulating cancer cell proliferation, whereas metformin inhibits cancer cell proliferation.
http://www.biomedcentral.com/1471-2407/15/51
11. Social deprivation as a risk factor for late presentation of proliferative diabetic retinopathy
In a cohort study, social deprivation was shown to be associated with late presentation of proliferative diabetic retinopathy. Targeted approaches to prevent blindness may therefore be needed.
http://www.dovepress.com/social-deprivation-as-a-risk-factor-for-late-presentation-of-prolifera-peer-reviewed-article-OPTH
12. Insulin requirement profiles of short-term intensive insulin therapy in patients with newly diagnosed type 2 diabetes and its association with long-term glycemic remission
The total insulin dose was reduced in newly-diagnosed type 2 diabetes patients treated with chronic subcutaneous insulin infusion and this may be associated with better long term glucose control.
http://www.diabetesresearchclinicalpractice.com/article/S0168-8227(15)00111-4/abstract
13. Sensitivity to sweeteners; a modern myth?
Dr Thozhukat Sathyapalan, an executive member of ABCD, has recently completed a clinical trial on the interesting controversy surrounding the use of aspartame. He found no evidence of sensitivity to commonly used artificial sweeteners. Dr Sathyapalan said "We used a variety of state-of-the-art tests to monitor the response of our participants throughout the trial. With customer concern over the safety of this sweetener in food and drink products, the results of this trial should be reassuring to the public”. Dr Sathyapalan has also represented ABCD in NICE committees on scoping and combination therapy for empagliflozin and technology assessment of canagliflozin.
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116212