Diabetes Newsletter – April 2021

www.berkshirewestdiabetes.org.uk April 2021
Monthly diabetes news for healthcare professionals and
others in Berkshire West

  100 Diabetes Tips for 100 Years  
Did you know that 2021 marks 100 years since Insulin was discovered? 

In 1921 Frederick Banting and his assistant Charles Best discovered insulin. A female dog, Marjorie, was the first to be kept alive with insulin treatment. The first humans to be injected with insulin were Banting and Best themselves, and this was not without problems. Frederick Banting won the Nobel Prize in Medicine in 1923 for his work. He decided that insulin should be available to all, and gave away the patent for insulin for $1.

To mark this life saving discovery the Berkshire West Community Diabetes Team has put together 100 Diabetes Tips for 100 years. These Tips will be published each month in this newsletter during the coming year - we hope that you find this useful and enjoyable. 

This month the focus is on Oral Therapies. 
Oral Therapies 10 Tips
  1. Consider using a GLP1 or SGLT2 as a second agent with metformin (or as monotherapy if metformin is not tolerated). These agents have proven cardiovascular and renal benefits, independent of their glucose lowering effect. EASD-ADA Consensus Guidelines can be found here.
  2. Metformin - If someone on metformin has GI side effects, even longstanding, consider that it may be caused by intolerance of metformin. Change to SR and find the max tolerated dose – even 500mg once daily has benefit.
  3. Metformin can cause B12 deficiency and periodic monitoring is recommended. If someone on metformin has symptoms of B12 deficiency, check levels. Metformin can be continued if effective and B12 supplemented.
  4. When starting SGLT2 consider risk of DKA and discuss rules for “pausing” during illness. TREND “Appropriate use of SGLT2 inhibitors in type 2 diabetes”. 
  5. Use Linagliptin as DPP4 of choice in patients with declining eGFR – the dose does not need adjusting. “TREND renal prescribing guidance”.
  6. Stop DPP4 when starting GLP1 – there is no benefit in taking both and GLP1 is more effective. “Berkshire West CCG Core Stepped Approach in Diabetes”. 
  7. GLP1s – the newer GLP1 receptor agonists (Trulicity, Victoza and Ozempic) are much more effective and there is evidence of CV and renal benefit. Consider switching people who are still on Byetta and Lyxumia at review, even if the Hba1c is at target.
  8. Trulicity - a 3mg weekly dose is now available at the same cost as 1.5mg weekly – this can be considered for people who have a response to Trulicity but would benefit from a greater effect. 
  9. Gliclazide is normally a poor choice of oral medication in type 2 diabetes – it causes weight gain and we now have other medications available with proven cardiovascular and renal benefit. There is a place for gliclazide as a rescue therapy or in early diabetes, in non-obese people where other options are not suitable.
  10. Pioglitazone has a long duration of action and it may be a while before you see a reduction in blood glucose. We normally recommend starting Pioglitazone at 30mg once daily and it may take up to 6 months to see the full effect in the HbA1c.
  Diabetes UK “Get Moving” Programme  
Diabetes UK is running a free 10-week physical activity programme for patients with diabetes, starting in mid-May.  A letter aimed at healthcare professionals is available here, and a letter which can be sent to patients via accuRx here
  Structured Education for Type 2 Diabetes  
The LIVA online structured education offering has now closed to new referrals. XPERT is still being offered as an online only option, but places are limited as it is only possible to accommodate ten people in each group.

Practices are still encouraged to refer newly-diagnosed patients to XPERT in the usual way, but for those patients who need/prefer face-to-face education, it would be worth warning them that there is likely to be a significant wait for this at present. Please consider signposting patients to the Diabetes UK website for educational resources in the meantime.
  Virtual Diabetes Clinics  
It's hoped that practices will by now have fully resumed their programme of annual reviews for all patients with diabetes. One of the eight care processes often seems to be forgotten, however – Urine ACR! Although this is no longer a QOF requirement, it is nevertheless an important marker of incipient diabetic nephropathy, and it is therefore important that patients are reminded to bring a urine sample to be tested. Please also bear in mind that advice and support remains available from community diabetologist Dr Ian Gallen, and practices are strongly encouraged to make full use of Ian’s expertise.
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
Twitter: available here
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