Diabetes Newsletter – May 2019

www.berkshirewestdiabetes.org.uk May 2019
Monthly diabetes news for healthcare professionals and
others in Berkshire West

  Diabetes in remission  
It used to be considered that Type 2 Diabetes was an irreversible condition that always progressed over time. We now know that is it potentially “reversible” with change in lifestyle or bariatric surgery. The DiRECT Trial published last year was in many ways a landmark.

A commonly raised  question is how to code and treat patients with T2DM who, with successful management, now have normal or pre-diabetic blood glucose levels. I think there has been a tendency to code them as “Diabetes Resolved” which is incorrect. These patients should be coded as “Diabetes in Remission” (C10P). Unfortunately, despite the best efforts of Diabetes UK last year, there isn’t currently an agreed definition or consensus and this is because different criteria have been used in research and clinical practice, including the ADA.
In 2016/17 the General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) Guidance for GMS contract 2016/17 (published April 2016) was changed to include a code for “diabetes in remission” with the following guidance:

“Successful management of diabetes with lifestyle, medication, pancreatic or islet cell transplant and/or bariatric surgery may result in glucose levels falling below those diagnostic of diabetes. However these people may still experience the macrovascular and microvascular complications of diabetes and therefore need continued monitoring.

Experts from the diabetes classification working group have endorsed the use of this code for people where treatment has normalised hyperglycaemia but still require continued monitoring”.

Please note - patients coded 'diabetes in remission'(DiR): 
  • are included in the NDA audit
  • will receive automatic invitation for annual diabetes retinal screening
  • need continued review for micro and macro-vascular complications, i.e. annual diabetes review checks, and for development of hyperglycaemia
This is because there is currently insufficient evidence on the impact of DiR on diabetes complications. Also, DiR is not a permanent state and therefore is not a “cure”.

As stated, we don’t have national agreement on the precise definition of “diabetes in remission”. In the meantime, there is consensus that patients should have an HbA1c < 42mmol/mol and be off all diabetic medication, but for how long is not agreed. In Thames Valley the Clinical Leads have suggested six months. 

Suggested management:
  • ​a) HbA1c < 42 for first time off medication, then repeat after six months. If still < 42 then patient receives additional DiR code and moves to annual monitoring, which will reduce  workload in primary care.
  • b) HbA1c < 42 on metformin – stop metformin and repeat after six months. If remains < 42 patient receives additional DiR code and moves to annual monitoring.

DiR is important for patients as it can provide motivation and hope, something to aim for. It can improve how patients engage with their condition and can reduce the impact it has on their daily lives.

Please note that pre-diabetes patients should remain coded even if their metrics become normal as they still retain an increased CV risk. 
Diabetes Specialist Nurse Hotline: 07879 814922 (Monday to Friday 10am – 4pm) Consultant Hotline: 07717 867448. Email: virtualdiabetes@royalberkshire.nhs.uk
Visit our website: www.berkshirewestdiabetes.org.uk
Click here to read online