Berkshire West Diabetes Newsletter - November 2015 Special Edition


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 23 November 2015
Diabetes news for healthcare professionals and
others in Berkshire West
  Why is it important to reduce the HbA1c in patients with very poor control?  
  By Dr Ian Gallen, Community Diabetes Consultant  
  Q. Is very poor diabetic control an issue locally?
A. Yes (in many practices but not all)
Poor glycaemic control remains a challenge in Berkshire West. Although we have together made huge strides over the last two years, there remain 1500 people with Type 2 diabetes (of whom 200 are >75 years old) and 300 with Type 1 diabetes who have extremely poor control (HbA1c >85 mmol/mol). This group requires specific urgent attention, because they have the highest risk of cardiovascular events and premature deaths from diabetes, but also have low risk of harm from intervention.

Review of outcomes show that there is marked variation between practices in the numbers of patients with poor control, with some practices having none or few patients with very poor control but others having >20% of patients with HbA1c >85mmol. Mapping of practices demonstrates that these variations in performance are not explained by either socio-economic or demographic factors, and are more likely to reflect differences in clinical practice.

Q. What are the risks for patients with HbA1c>85 mmol/mol?
A. Risk of all cardiovascular events and premature death is between 2-5 times more likely.
We understand that on average, diabetes doubles the risk for a wide range of vascular diseases , and when we look at glycaemia specifically, the predictive evidence of poor glycaemic control is strong. The landmark Hope study found an independent relationship between HbA1c level and the risk of cardiovascular mortality, death from any cause, or worsening heart failure in patients with chronic heart failure. The relative risk of premature death or cardiovascular event more than doubles for people with HbA1c >85 compared with those with <58 mmol/mol. The risk of stroke increases still further for those patients with the poorest control (HbA1c >85mmol/mol) for diabetes. They have five times the risk of stroke than people without diabetes

Finally, a recent meta-analysis of 26 prospective studies provides evidence that chronic exposure to increased glycaemic level was associated with increased risks of all-cause mortality and cardiovascular outcomes in Type 2 diabetes. Every 1% (11mmol/mol) increase in HbA1c is associated with a 15% increase in hazard of all-cause mortality, 25% in CVD mortality, 17% in CVD.

Patients with very poor control are also at the highest risk of emergency admission. For every 11 mmol/mol increase in HBA 1c above the threshold of 60 mmol/mol, the risk of hospital admission increases by 6.3% for all admissions, 6.4% for diabetes admissions and 15.9% for cardiovascular admission .

Q. Does improving glycaemic control reduce excess risk?
A. Yes, but care required if aiming for HbA1c < 58 mmol/mol
The predictive value of high HbA1c does not necessarily mean that reducing HbA1c will improve outcomes and Indeed, there is some evidence that excessively tight glycaemic control to <48mmol/mol may cause harm .

It is clear that multifactorial intervention to improve lifestyle, blood pressure, lipids and dysglycaemia is associated with marked reductions in adverse outcomes of diabetes . There is now also good evidence that improved glycaemic control does reduce cardiovascular outcomes and premature death in patients with diabetes mellitus. Data from the UK PDS and other prospective studies show significant reductions in microvascular disease event and death rates with improved glycaemic control in Type 2 diabetes. The size of this effect is that with a 10mmol/mol reduction in HbA1c, there is a 17% reduction in events of non-fatal myocardial infarction and a 15% reduction in events of coronary heart disease.

Q. How can we best tackle this issue locally?
A. There is a wide range of effective clinical services to support practices to tackle the problem of very poor control. Some patients may not wish to engage with available services, but most will!
Clearly identifying the "at risk" group of patients in practice is the first step. This can easily be done at least quarterly by the use of our innovative database "Eclipse", to which all practices have access. Once identified, individualized action plans can made, and once again this is easily achieved through the virtual diabetic clinic.

The virtual clinic review is a structured review of patient demographic information, BMI, renal function, glycaemic control, past medical history, complications and past and current treatment. A word picture of the patient is presented by the host team to better understand each patient's motivation and social circumstances, to help plan the best way forward for that individual.

The outcome of the virtual clinic review is also structured and recorded. Much of the work centres on glycaemic control and reviews of therapy with the addition or substitution oral agents, the introduction or change in GLP1 agonist agents or initiation of insulin therapy being the outcome. These outcomes are recorded in the practice records, for implementation in the care planning process.

There is a wide range of services available for patients with very poor control. Patients can be referred for adult education; X-PERT for T2DM and DAFNE or CarbAware (an intensive three-hour course) for T1DM. These educational programs are highly effective, each reducing HbA1c in attendees. Patients on insulin treatment can be reviewed in practice by the diabetes specialist nurse team, and a new insulin intensification course in available for patients with T2DM with HbA1c >85mmol/mol. Patients with T1DM should be referred to the specialist team at the diabetes centre or community clinic for investigation and management of the complications of diabetes, managing hypoglycaemia or to consider insulin infusion pump therapy. Patients with BMI >35 kg/m2 can be referral to our bariatric service. Where ongoing referral from the virtual clinic is requested, this is completed by the visiting team so as not to add to any delay for the patient, or to increase workload on the practice.

For practices which are engaged in the virtual diabetic clinic process and who have had more than three visits, a clear majority have the proportion of patients HbA1c > 85mmol/mol below 10%, whereas practices which are not engaged in the virtual diabetic clinic process have higher values. It is also noted that some of the practices with the lowest rates of poor control are amongst those which serve the most deprived communities in the area.

An audit of the efficacy of the virtual diabetic clinic showed that for the first 411 individuals discussed, the HbA1C fell from 88.9±21 (SD)mmol to 81±19 p<0.001 (2 tail t-test). This equates to clinically significant reduction in risk of microvascular complications by 40%, and premature death by 21%.

You can find this paper in word format with references on the Berkshire west diabetes website here.

Diabetes Specialist Nurse Hotline: 07879 814922 (Monday to Friday 10am – 4pm) Consultant Hotline: 07717 867448. Email:
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