Diabetes

• Macrovascular Complications of Diabetes

  • Ischemic Stroke
  • Myocardial Infarction
  • Other Cardiovascular Diseases (Heart Failure, Peripheral Vascular Disease, etc.)
• Microvascular Complications of Diabetes

  • Nephropathy (End-Stage Kidney Failure)
  • Retinopathy (Leading Cause of Preventable Sight Loss)
  • Neuropathy (Including Autonomic Neuropathy)
  • Diabetic Foot Complications (Leading to Amputations)
• Prevention of Type 2 Diabetes (T2DM)

  1. NHS Health Check for 40-74-year-olds

  2. Use validated risk assessment tools

  3. Offer self-assessment questionnaires

  4. Structured education programs

  5. Dietary advice: high-fiber, low-glycemic-index foods

  6. Choice of antihypertensive drugs

  7. Monitor blood pressure targets
• Individualized Care


  Approach to management of T2DM
• Management of T2DM


  1. Patient Education & Dietary Advice

  2. Blood Glucose Management

  3. Metformin as first-line treatment

  4. Consideration of other oral antidiabetic drugs

  5. Insulin therapy if necessary
• Drug Treatment for T2DM


  • Metformin as First-Line Treatment
  • DPP-4 Inhibitors
  • Pioglitazone
  • Sulfonylureas
  • GLP-1 Mimetics if triple therapy needed
  • Insulin therapy if HbA1c not controlled
  • Consideration of SGLT2 inhibitors for cardiovascular benefits
• Other Complications of Diabetes

  • Periodontitis (Gum Disease)
  • Gastroparesis
  • Diabetic Neuropathy
  • Autonomic Neuropathy
  • Diabetic Foot Complications
  • Chronic Kidney Disease (CKD)
  • Erectile Dysfunction
  • Eye Problems (Retinopathy, Glaucoma, Cataracts)
• Failure to inform DVLA about a medical condition affecting driving can result in fines up to £1,000
• Prosecution possible if involved in an accident due to undisclosed medical condition
• When to Inform DVLA

  • Medicines associated with hypoglycemia (e.g., severe hypo in the last 12 months on sulfonylureas)
  • No requirement for informing DVLA for diabetes treated by non-insulin medication, diet, or both if free of complications
• Severe Hypoglycemia


  • Assistance of another person required
  • Main danger to safe driving
  • Symptoms and dangers discussed extensively
  • Reporting requirements for Group 2 drivers (bus/lorry) outlined
• Reporting Requirements


  • Multiple severe hypoglycemic episodes within the last 12 months
  • Impaired awareness of hypoglycemia
  • Severe hypoglycemia while driving
  • Need for insulin or specific eye treatments
  • Circulation or sensation problems in legs/feet affecting driving
• How to Inform DVLA

  1. Online reporting or submission of medical questionnaire

  2. Contact information provided for various methods
• Diabetes & Driving Recommendations for Insulin-dependent diabetics

  • Must carry glucose meter and testing strips
  • Keep emergency supply of fast-acting carbohydrate in the vehicle
  • Regular blood glucose monitoring before and during driving
  • Guidelines for blood glucose levels and actions to take before and during driving provided
• ACCORD Trial


  Randomised controlled trial
• ACCORD Trial


  • 10,251 adults aged 40-79 years with established type 2 diabetes
  • Mean HbA1c: 67mmol/mol (8-3%)
  • Patient assigned to intensive therapy: target HbA1c less than 42mmol/mol (<6%) OR standard therapy: 53-63mmol/mol (7-7.9%)
  • Mean follow up period 3.7 years
• Outcome measures


  Fatal/non-fatal MI, coronary revascularisation, UA, and new angina
• Number of events


  • Intensive therapy
  • Standard therapy
• Intensive therapy


  Hazard ratio (95% CI) and p-value for various outcomes compared to standard therapy
• Intensive therapy was discontinued after the data safety and monitoring board detected increases in all-cause and cardiovascular mortality
• Your target HbA1c: weighing it up


  Tool to help decide the best target HbA1c for you
• UKPDS 34 Trial


  • 753 participants
  • Mean 10.7 years follow up
  • Metformin vs. conventional treatment (diet control)
• Endpoint


  • ARR
  • NNT
• DECLARE TIMI 58


  • 17,160 participants - 6,974 patients (40.6%) with established atherosclerotic cardiovascular disease and 10,186 (59.4%) with multiple risk factors for atherosclerotic cardiovascular disease
  • Adults with T2DM ages >40 years old
  • HbA1c 48-108mmol/mol (6.5-12%)
  • Median follow up 4.2 years
  • Dapagliflozin 10mg vs. placebo
• Outcome


  • Dapagliflozin
  • Placebo
• Dapagliflozin vs Placebo


  Hazard Ratio (95% CI) and P-Value for various outcomes
• Using SGLT2 Inhibitors earlier in the T2DM treatment pathway should help reduce the number of CV deaths & hospital admissions. In particular for patients with atherosclerotic CV disease.