Erectile dysfunction (ED) is common in men with diabetes and is associated with microvascular disease, maladaptation to chronic illness, poor quality of life, and increased levels of diabetes-specific health distress. Traditionally, most diabetologists were poor at asking about ED and patients themselves are not always forthcoming with information, given the embarrassing nature of the disease. However, times are changing and the inclusion of screening for ED in Quality and Outcomes Framework and current general practice templates emphasises its current importance. Licensed treatments have been limited in their application towards the provision of symptomatic relief and are offset by adverse effects, intolerance, limited effectiveness and contraindications in the presence of co-existent cardiovascular disease. This review critically considers the utility of novel treatments for ED in diabetes that have been developed to overcome these barriers.
Introduction: In obesity, bariatric surgery is effective but carries morbidity and mortality risks. In type 2 diabetes, glucagon-like peptide-1 (GLP-1) agonist therapy results in weight reduction. Randomised controlled trials show efficacy in the non-diabetes obese population. Thus we have audited GLP-1 agonist use for weight reduction in morbidly obese people without diabetes. Methods: A protocol for GLP-1 use in non-diabetes obesity (body mass index >35 kg/m2) was agreed with local clinical governance committees. After liraglutide initiation, follow up was monthly, and the dose was up-titrated to a maximal 3 mg daily if indicated. Results: Of 34 people offered treatment, 22 proceeded (age 42 ± 14 years, 17 females, 16 White Caucasians) and 14 completed 12 months of treatment. Absolute weight fell significantly from a baseline of 127 ± 19 kg (n=22) to 121 ± 19 kg (n=22), 119 ± 21 kg (n=21) and 110 ± 15 kg (n=14) kg at 3, 6 and 12 months respectively (all p<0.001 from baseline) amounting to -5.3 ± 4.4 kg, -7.4 ± 7.7 kg and -12.1± 9.6 kg at 3, 6 and 12 months respectively (all p<0.001 from baseline). Conclusions: GLP-1 agonist therapy may play a significant role in people who have failed other weight loss options and are potential candidates for bariatric surgery.
Introduction There has been ambiguity in managing the complications related to insulin overdose, despite the passage of about 70 years since the first case was reported.1 Mild-to-moderate, transient and self-limiting liver dysfunction associated with high strength and prolonged dextrose load to treat hypoglycaemia due to insulin overdose has been reported sparsely in the literature and is relatively poorly understood.2 We attempt to highlight this uncommon, transient complication of managing hypoglycaemia in a patient with insulin overdose.
Introduction I was taken aback by unattributed criticism of 'consultant clinicians' (sic) in the minutes of a recent meeting of the UK APPG for Diabetes investigating the provision of education for people with diabetes.1 Apparently they 'lamentably have failed to champion education across the country. They have failed their patients and failed their profession...'. When questions about access to diabetes education were included in the National Diabetes Audit for the first time, it appeared that provision was low across England and Wales with 6% of all people with type 2 diabetes being offered structured education.2 However only 1.6% of people with type 2 diabetes who were offered structured education participated. At the subsequent APPG meeting, I listened to articulate and passionate consumers of diabetes education and some articulate and passionate providers of the same – some of whom were consultant clinicians! Some people were very pleased with the education they had received (notably via DAFNE, DESMOND and X-PERT courses), but not all were so impressed. Low attendance at courses was seen by some as inevitable, but others had made efforts to address this and driven attendance up.3 Perhaps it is in the nature of users of an NHS that is free at the point of need to take what they want and leave what they do not fancy – usually preventative measures such as screening, immunisation and education. There might appear to be an absence of carrot and stick.
In February 2015 the National Institute for Health and Care Excellence (NICE) published new guidance (NG3) on the management of diabetes in pregnancy. Care teams need to be aware of this guidance and implement its recommendations. These include preconception care with target HbA(1c) 48 mmol/mol. Women at risk of gestational diabetes mellitus (GDM) should have a 75 g oral glucose tolerance test (OGTT). Diagnostic criteria for GDM have changed to fasting glucose of 5.6 mmol/L or above or 2 hour glucose of 7.8 mmol/L or above.Glycaemic targets in all diabetic pregnancies have changed to fasting glucose below 5.3 mmol/L (4-5.2 mmol/L if on insulin) and 1 hour postprandial glucose below 7.8 mmol/L if these can be achieved safely. Continuous glucose monitoring and insulin pump therapy should not be used routinely but can be used if glycaemic control is problematic. Capillary ketone testing should be routine for women with type 1 diabetes when hyperglycaemic and for all women with diabetes including, GDM when acutely unwell.More flexibility is offered around recommended delivery timing: 37+0 weeks to 38+6 weeks for women with types 1 and 2 diabetes; prior to 40+6 in GDM (and earlier if complications arise). Postnatal testing following GSM should be by fasting glucose (not OGTT) at 6-13 weeks post partum. Testing later than this can use HbA(1c).Introducing these changes will have resource implications, including a likely increase in the number of women diagnosed with GDM.
Introduction OSA is a common and frequently unrecognised disorder with a prevalence of approximately 4% in middle-aged men and 2% in middle-aged women.1 It is often found in patients with obesity and type 2 diabetes mellitus. This case report shows the infrequently documented link between OSA and type 1 diabetes and highlights the need to confirm the type of diabetes especially in complex and atypical cases.
Aims: To establish whether a recently reported performance index scoring system developed in two diverse populations (Medway and Guildford, UK) could be used to successfully negotiate with a Clinical Commissioning Group (CCG) to shape diabetes services and set priorities.Methods: We collated demographic details for the area's population with diabetes with diabetes scores from local primary care Quality and Outcomes Framework (QOF) records, together with exception reporting. Data from Hospital Episode Statistics and Dr Foster were used to record the Standardised Admission Rate (SAR) for a first/new referral to a secondary-care diabetes outpatient appointment or for emergency admission to hospital for diabetes. Hospital notes for patients from one GP practice were reviewed to clarify why patients were seen in secondary rather than primary care.Results: The prevalence of diabetes was low (4%) compared with figures from the Strategic Health Authority (SHA) (4.5%) and nationally (5.6%). Total diabetes QOF points achieved (99.3) were higher than for the SHA (97.8) and nationally (95.3); 61.1% achieved HbA(1c) <7%, which was much higher than the SHA (57.2%) or national average (54.3%). The exception-reporting rate (9.8%) was lower than the SHA (10.5%) or national average (14%). The SAR was lower than the Surrey average for a first outpatient visit (87.8 vs. 128.9) or emergency admissions (85 vs. 106.7).Conclusions: The performance index scoring system enabled an assessment of diabetes care that transcended primary and secondary care. A successful negotiation took place between the local diabetes stakeholders and the CCG with a plan for improving and developing the current model of care. The scoring system is applicable to any district in the UK and may be of interest to clinicians and commissioners.
Patients with severe diabetic gastroparesis with intractable bouts of nausea and vomiting are often refractory to drug therapy and have poor quality of life with malnutrition, weight loss, poor glycaemic control and frequent hospital admissions. Such patients may benefit from gastroelectrical stimulation (GES). The NICE guidance on GES for gastroparesis in 2004 did not support its use but since then a considerable amount of new evidence has become available and NICE updated the guidance in May 2014.
Background: The Joint British Diabetes Society (JBDS) consensus guideline published in 2010 has provided the framework for the effective management of diabetic ketoacidosis (DKA) in adults in the UK.Methodology: A retrospective study of 50 patient episodes admitted to our teaching hospital between February and December 2012, with a discharge diagnosis of DKA.Results: Twenty-seven (54%) patients were male, mean (SD) age was 43 (21) years and duration of diabetes was 11 (9) years. In the first 60 minutes from diagnosis, median (interquartile range [IQR]) time to fixed rate intravenous insulin infusion (FRIII) was 49 (29-110) minutes and to intravenous fluids was 19 (0-42) minutes. During ongoing management, 46% of patients developed hypokalaemia and, of those, in 70% potassium supplementation was not prescribed as per protocol. Forty percent of patients experienced hypoglycaemia in the first 24 hours, of whom 80% had 10% dextrose prescribed appropriately according to protocol. Median time to hypoglycaemia from diagnosis was 12 hours 54 minutes. Median (SD) time to resolution of DKA was 12 hours 6 minutes. Eighty six percent of patients were reviewed by the diabetes specialist team during admission. No deaths due to DKA or complications of its management were reported. Median length of hospital stay was two days.Conclusions: Adherence to the JBDS DKA guideline was good in the immediate stage of treatment. Inadequate metabolic monitoring, fluid management and iatrogenic hypoglycaemia remain areas of concern. A high proportion of patients received diabetes specialist nurse input with reduced length of stay and no recorded mortality. Our recommendations as a result of this audit include a strengthened programme of teaching and education for nursing and medical staff, focus on metabolic monitoring and improved patient contact after hospital discharge.
Introduction Ovarian stromal hyperthecosis in post-menopausal women is a rare disorder characterised by gradual virilisation and features of the metabolic syndrome similar to PCOS.1 Improvement of diabetic control in hyperthecosis has been reported following oophorectomy, perhaps secondary to normalisation of the hyperandrogenaemia.2 This is a report of worsening diabetes following oophorectomy. The case and possible explanations for the response are described.
Diabetic renal disease is associated with increased cardiovascular risk and is one of the leading causes of end-stage renal disease worldwide. A combination of hyperglycaemia and hypertension drives the development and progression of diabetic renal disease, with glomerular hyperfiltration being an early manifestation of the disease process. Sodium- glucose linked transporter 2 (SGLT2) inhibitors represent a novel class of drugs that lower plasma glucose levels through the inhibition of renal proximal tubular glucose uptake and secondary glycosuria. Clinical evidence that SGLT2 inhibitors attenuate glomerular hyperfiltration is complemented by animal data suggesting that these agents can prevent progression of diabetic renal disease. In clinical studies involving patients with type 1 and type 2 diabetes, SGLT2 inhibition reduces glomerular hyperfiltration and appears (albeit in post-hoc and pooled analyses) to reduce urinary albumin excretion. The longer term potential reno-protective effects of this class of drugs are currently under evaluation in large randomised clinical trials.
Achieving tight glycaemic control early on in the disease trajectory has been shown to have beneficial effects on macrovascular and microvascular complications and mortality in people with type 2 diabetes. International guidelines recommend individualised targets for glycaemic control, but many people with type 2 diabetes are not adequately reaching these targets. One major reason for not achieving these targets is ‘clinical inertia’, defined as ‘failure of healthcare providers to initiate or intensify therapy when indicated’. This article gives an overview of clinical inertia in the management of type 2 diabetes, relating to the initiation of oral antidiabetic and insulin therapies, reasons for clinical inertia and strategies for overcoming clinical inertia.
Aim: To assess the association of inflammatory markers and the risk of developing contrast-induced nephropathy (CIN) in patients with diabetes undergoing lower limb angiography.Methods: This was a retrospective study of 77 patients undergoing lower limb angiography. We measured renal function and markers of inflammation, in particular neutrophil and lymphocyte count and C-reactive protein (CRP) levels, before and at 24, 48 and 72 hours after administration of contrast medium.Results: Those with pre-existing renal disease were at increased risk of CIN. We found no relationship between baseline renal function and CRP. There was a reduction in haemoglobin and lymphocyte count that is currently unexplained.Conclusions: While several traditional risk factors for CIN have been identified, further work is needed to determine the significance of changes in other haematological parameters.
CHFcongestive heart failure FDA US Food and Drug Administration GLP-1 glucagon
The National Diabetes Inpatient Audit for 2013 described insulin-related prescription errors in over 21% of patients each year from the beginning of data collection in 2010. Error rates have fallen year on year but remain unacceptably high, with significant variation between hospitals. Many of these issues were related to insulin prescribing.In 2014, the Joint British Diabetes Societies for Inpatient Care (JBDS) organised a competition for the 'best in class' current insulin prescription chart from hospitals in the UK. The aim was to identify safe and effective insulin charts, and make them available to the other clinical teams. A total of 41 Trusts submitted their insulin prescription charts, which were considered by an expert panel of independent judges against predefined criteria based on guidelines on the safe prescription of insulin from the UK National Patient Safety Agency.The charts from Nottingham University Hospitals won this competition, with East Sussex Healthcare, Worcestershire Royal Hospital and Western Sussex Hospitals as runners up. The competition identified areas of particular strength in the winning charts, which are available online (see Box 1).This article describes the background to the competition, with an account of the winning entry. The judging process highlighted a number of valuable mechanisms for improving insulin prescribing in UK hospitals.
Background: Liraglutide may be less effective in patients with more advanced type 2 diabetes. This study from the Association of British Clinical Diabetologists Nationwide Liraglutide Audit analysed changes in HbA1c of patients after 26 weeks of treatment with liraglutide 1.2 mg, stratified according to the intensity of their background diabetes therapy, or according to their duration of diabetes.Methods: Patients using liraglutide as add-on therapy were stratified for receipt to one, two or three oral antidiabetic agents (OADs) or insulin (+/- OAD), or for diabetes duration of 0-5 years, 6-10 years, or >10 years. Changes in HbA(1c) were compared across groups after adjusting for baseline HbA(1c).Results: After exclusions to standardise comparisons, 937 patients with background diabetes treatment and 802 patients with recorded diabetes duration were analysed. Least-squares adjusted mean changes in HbA(1c) (+/- SEM) were -1.8% +/- 0.1 for 135 patients on one OAD, -1.7% +/- 0.1 for 284 patients on two OADs,-1.9% +/- 0.1 for 94 patients on three OADs (n=94) and -1.0% +/- 0.1 for 424 patients receiving insulin. HbA(1c) changes did not differ significantly between OAD groups, but all OAD groups had greater HbA(1c) reductions compared with the insulin group (all p<0.00001). Adjusted mean HbA(1c) changes were -2.0% +/- 0.1 for patients with diabetes duration 0-5 years (n=147, p<0.05 vs. longer diabetes durations), -1.6% +/- 0.1 for 6-10 years (n=256), and -1.2% +/- 0.1 for >10 years (n=399).Conclusion: The need for insulin and long diabetes duration, but not the number of OADs taken, predicted a smaller treatment response to liraglutide.
A variable rate intravenous insulin infusion (VRIII) is used commonly to achieve normoglycaemia in hospital inpatients. Most acute trusts in the UK have VRIII guidelines, but there is wide variation in the indications for its use, in rates of infusion, and in duration of use. This heterogeneity increases the risk of errors which can potentially lead to significant morbidity and mortality and also hinders study of the efficacy, optimisation and safety of VRIII. Thus, VRIII is often used when not indicated, for too long, and with inappropriate transfer to other glucose lowering medication. This article summarises the key recommendations in a recent guideline produced by the Joint British Diabetes Societies for Inpatient Care on the use of VRIII in ‘medical’ inpatients. The guideline is designed to be a practical guide to support the safe and effective use of VRIII by any healthcare professional who manages ‘medical’ inpatients with hyperglycaemia. Use of the guideline will help to harmonise the use of VRIII, with added benefits of facilitating collection of outcomes data from at multiple sites and allowing continual refinement in the therapeutic use of VRIII.
The diabetes service at Newham, East London, exemplifies challenges faced in the National Health Service with increasing demand, pressure to improve efficiency, high non-attendance rates and poor health outcomes, reflecting the complex lives of many patients with long-term illness. Perceived lack of control, poor engagement with inflexible services and poor self-management are common with these patients. Early evidence from our work so far suggests that web-based appointments can be used as part of outpatient services to improve patient experience and provide better access to effective care, with the potential to improve longer-term efficiency. By using readily available video conferencing software (Skype), our service model can be easily replicable across the majority of outpatient care. Further work is now being done to explore the impact of online consultations on improving patient self-management, particularly for those patients labelled "hard to reach".
The latest NICE guidelines for the management of type 2 diabetes are now available for consultation. They contain sensible recommendations regarding lifestyle, patient education, monitoring and targets.Unfortunately, the pharmacotherapy section shows a distinct failure of common sense. The recommendations include using the insulin secretagogue repaglinide as a first-line agent, where metformin is not tolerated or contraindicated, or second-line in combination with metformin. Pioglitazone is recommended as the principal second-line therapy with metformin. The advice on glucagon-like peptide-1 receptor agonist (GLP-1ra) usage and assessment of efficacy and failure to recommend long acting analogue insulins over isophane are also major concerns.The recommendations appear to be based on meta-analyses and pharmacoeconomics, driven by an imperative on costs and failing to appreciate the "value" of the options under consideration. The cost to patients and the health service of the serious side-effects of these treatments is underestimated.Given the emphasis in these guidelines on the importance of lifestyle changes, including weight loss, plus an over-riding need to avoid hypoglycaemia, these pharmacotherapeutic recommendations appear paradoxical in the extreme.We believe that these recommendations, if enacted, will undermine seriously the reputation of NICE both nationally and internationally.
