INSULIN DEPENDENT DIABETES TRUST

July 2008 NEWSLETTER

Self-monitoring in Type 2 Diabetes

Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education. Discuss its purpose and agree how it should be interpreted and acted upon.

NICE Guidelines for Type 2 diabetes, May 2008

The NICE Guidelines recommend human insulin, not analogues as first line treatment for people with Type 2 diabetes

Preferably begin with human NPH [intermediate-acting] insulin taken at bedtime or twice daily according to need.

Alternatively, consider a once daily insulin long-acting analogue [glargine/Lantus] if:

· the person requires assistance to administer insulin injections

· his or her lifestyle is significantly restricted by recurrent symptomatic

hypoglycaemic episodes

· twice daily basal insulin injections plus oral glucose lowering medications would otherwise be needed.

Offer a trial of long-acting insulin analogue [glargine /Lantus] if NPH insulin causes significant nocturnal hypoglycaemia.

Consider twice-daily bi-phasic human insulin [pre-mixed] regimens, particularly where HbA1c is greater than 9%. Once daily may be an option when starting this therapy.

Consider pre-mixed insulin analogue preparations rather than human insulin

preparations when:

· immediate injection before a meal is preferred

· or hypoglycaemia is a problem

· or there are marked postprandial blood glucose excursions.

Review use of sulphonylurea if hypoglycaemia occurs with insulin plus sulfonylurea.

NICE Guidelines for Type 2 diabetes, May 2008

What is Patient centred care?

Treatment should take into account patients’ individual needs and preferences. Good communication is essential, supported by evidence-based information, to allow patients to reach informed decisions about their care. Follow Department of Health advice on seeking consent if needed. If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care.

NICE Guidelines for Type 2 diabetes, May 2008

LATEST NICE GUIDELINES

The front page of this Newsletter covers three key statements from the recently published NICE Guidance for Type 2 diabetes [National Institute for Health and Clinical Excellence]. We highlight these 3 statements because they recommend what IDDT and many people with diabetes have been saying for a long time, even though what is happening at the ‘sharp end’ – where people are treated, can be quite different.

Firstly NICE is not saying that people with Type 2 should be refused blood glucose test strips but that they should be offered blood glucose testing alongside education in how and when to carrying it out and how to interpret and act on the results. So in future people who are denied test strips can quote NICE guidelines!

Secondly, first line insulin treatment is not with insulin analogues but with human insulin supporting the view that analogues have not been shown to be superior and of course, they are significantly more expensive, so we assume that NICE is not advocating wasting valuable resources on them, except under certain circumstances. It is worth noting that Levemir is not mentioned in these guidelines – it is still being assessed as a ‘new agent’ by NICE.

Thirdly, it is good to see that NICE favours addressing individual needs and preferences and that patients should make informed decisions about their care on evidence-based information.

NICE Guidance for Type 2 diabetes [May 2008]

Here is the summary of the key NICE recommendations for the treatment of people with Type 2 diabetes for implementation by health professionals:

Patient education

· Offer structured education to every person and/or their carer at and around the time of diagnosis – this can be in group sessions run by people who have been specially trained to do this.

· Provide individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition.

Setting a target HbA1c

· Involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with Type 2 diabetes in general.

· Encourage the person to maintain their individual target unless the resulting side effects [including hypoglycaemia] or their efforts to achieve this impair their quality of life.

· Offer therapy [lifestyle and medication] to help achieve and maintain the HbA1c target level.

· Inform a person with higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health.

· Avoid pursuing highly intensive management to levels of less than 6.5%.

Self-monitoring

· Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education. Discuss its purpose and agree how it should be interpreted and acted upon.

Starting insulin therapy

When starting insulin therapy, use a structured education programme that includes:

· continuing telephone support and support from an appropriately trained and experienced healthcare professional

· frequent self-monitoring

· dose titration to target [how to adjust insulin doses]

· dietary understanding

· management of hypoglycaemia – how to avoid it and treat it

· management of acute changes in glucose control.

The type of insulins that NICE recommends is covered on the front page.

Other recent NICE guidelines

Pregnancy and diabetes [April 2008]

New NICE guidelines on pregnancy and diabetes have been issued and they recommend that:

· women with diabetes should be able to access specialist services before they become pregnant.

· They should aim for a fasting blood glucose of 3.9 to 5.9mmol/l and one hour post-prandial [after meals] blood glucose below 7.8mmol/l if planning to become pregnant and during pregnancy.

· Women should be directed to take folic acid supplements and given lifestyle advice.

· They should be told of the importance of maintaining vitamin D levels during pregnancy and while breast feeding and if required, they should be offered Vitamin D supplements.

· Health professionals should advise on good glycaemic control to reduce the risk of miscarriage, malformation at birth, still birth and neonatal death.

· GPs must tell women who are pregnant and those planning to conceive to avoid alcohol because it can increase the risk of miscarriage in the first trimester.

· Women with gestational diabetes should be offered advice on diet and exercise and offered a fasting plasma glucose test at the 6-week postnatal check and yearly after that.

Transplanting donated pancreatic islet cells for patients with Type 1 diabetes [April 2008]

NICE has issued an ‘interventional procedures guidance’ on islet cell transplantation and this advises the NHS on when and how new procedures can be used in clinical practice. It is also to help people who have been offered islet transplantation to decide whether to agree to it [consent], or not. In brief NICE says:

· Pancreatic islet cell transplantation is safe enough and works well enough for use in NHS hospitals with experience of the procedure. So it can be offered routinely as a treatment option for Type 1 diabetes provided that doctors are sure that [i] the patient understands what is involved and consents and [ii] the results are monitored.

· Before the patient agrees [or doesn’t agree] to the procedure, doctors should make sure that extra steps are taken to explain the potential risks of the procedure and the uncertainty about how well it works in the long-term.

· A team of specialist doctors should decide which patients should have islet transplantation. They should take into account that it is particularly suitable for people who have sudden hypos without warnings or people who are already using immunosuppressant drugs because of a kidney transplant.

· NICE has decided that more information is needed about how islet transplantations affect quality of life and how well it works long-term.

NICE looked at 8 studies on the benefits and risks of the procedure. The possible benefits appear to be reduction in severe hypos, improved hypo awareness, better control, less fear of hypos. The possible risks are bleeding into the abdomen, a blood clot in the portal vein, high blood pressure in the liver, problems caused by the patients lowered immune system [through using immunosuppressants for life] and the possibility of donor cells carrying infections or cancerous cells.

NICE approves Rimonabant for obesity [March 2008]

NICE has approved the use of rimonabant [sold as Accomplia] for the treatment of overweight and obesity as an addition to a controlled diet and regular exercise for people who are either intolerant or contraindicated for orlistat and sibutramine [two other weight reducing drugs.] This approval means that GPs can prescribe rimonabant to overweight and obese people with associated risks factors such as Type 2 diabetes.

Licensed in 2006, the European drug regulator issued a warning against using rimonabant in people with major depression. However, the US has not approved its use because of concerns over psychiatric risks. A recent study presented at the American College of Cardiology meeting in April, added to these concerns - it showed that Accomplia [rimonabant] did not slow heart disease in obese people with fat round the waist and 40% of people who took it developed psychiatric problems.

NICE guidance on lifestyle changes for repeat heart attacks

For the first time NICE has issued guidance that has recommended lifestyle change, alongside drugs, for preventing repeat heart attacks. This is in line with the growing evidence that specific lifestyle changes reduce the risk of second heart attacks.

The new lifestyle section says patients should:

· give up smoking

· be physically active for 20-30 minutes a day

· eat a Mediterranean-style diet

· eat more oily fish or be prescribed certain preparations of omega 3 fatty acids.

Research has found that one specific omega 3 supplement called Omacor, cut the risk of a patient dying suddenly by up to 45%. Omacor is currently the only omega 3 supplement with a licence for post heart attack treatment. NICE estimate that the cost to the NHS of using it might be quite high as around 260,000 people have a first heart attack every year and 20% of them might need supplements because they are intolerant to oily fish. NICE estimates that the cost could be £7million.

All NICE Guidelines can be found by visiting: http://www.nice.org.uk

INJECTION ISSUES

Mixing up your insulins

In IDDT’s April Newsletter we supported Diabetes Health’s call on the insulin manufacturers to make changes so that people would not mix up their insulins – especially important with the use of insulin analogues where both the short- and the long-acting insulins are clear. Diabetes Nurse Specialist, Carole Malloch has kindly sent us the solution she has devised for her patients.

Simple yet innovative solution for illiterate or non-English speaking people using insulin

Carole Malloch, Diabetes Nurse Specialist

A number of our patients are illiterate or cannot read English. This presents a real problem for these patients. Their treatment is multi-daily injections of insulin which they administer themselves. Two different types of insulin are used and it is very important that the correct insulin is administered. There have been numerous incidents when patients have got their insulins mixed up causing their diabetes to be very unstable eg taking the fast-acting insulin, which should be given with food, instead of the night-time

slow-acting insulin can cause a severe hypoglycaemic attack during the night which can lead to fitting and unconsciousness or, worse case scenario, brain damage.

I have therefore, devised stickers to apply to the insulin pen devices. As you will see from the examples of the stickers, the pictures indicate when to take the insulin. [ie one for the insulin to be taken with food and another for the insulin to be taken at bedtime.]

Also insulin cartridges have coloured tops and the border colour of the stickers indicates the coloured top therefore the patient only has to put the correct colour top to match the sticker on the pen. At the moment I am using paper stickers covered with cellotape but ideally the labels should be more durable.

Day-time – at meal times