Diabetes care can be complex; 25% of people with diabetes suffer from three or more other long-term conditions.1 The National Diabetes Support Team has been set up to provide practical support to diabetes services. The majority of PCTs have a whole system diabetes network and a user champion for diabetes.1 Phase one of a national roll out for structured group education has commenced. 'Diabetes Education and Self-Management for Ongoing and Newly Diagnosed' (DESMOND) is for people with type 2 diabetes. DESMOND supports people to identify their own health risks and respond to them by setting specific behavioural goals.2 Another key programme is 'Dose Adjustment for Normal Eating' (DAFNE) for type 1 adult diabetic patients to learn how to adjust their insulin to suit their free choice of food.2
Currently screening for type 2 diabetes on a population basis is not recommended, however, regular testing for those people known to be at increased risk of diabetes is recommended.3 The management of cardiovascular disease (CVD) risk factors is very important in diabetes management: evidence from trials shows lowering blood pressure and blood lipids is more beneficial for reducing the incidence of diabetic complications than glucose lowering alone. The UK Prospective Diabetes Study (UKPDS) Risk Engine (available at www.dtu.ox.ac.uk/riskengine) is a specific risk calculator based on 53,000 patient years of data; it is useful for estimating risk of coronary heart disease (CHD) and stroke in patients with type 2 diabetes not known to have heart disease.
Blood Pressure Management
The UKPDS showed that tight control of blood pressure is more effective in preventing diabetes-related endpoints and death than tight control of blood glucose.4 An important part of blood pressure management is ensuring that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated and healthcare professionals taking blood pressure measurements have a periodic review of their performance.5 NICE recommends a target blood pressure of <140/90mmHg in patients with diabetes or ≤135/75mmHg if microalbuminuria or proteinuria is present.5 Antihypertensive drug treatment should be offered to all patients with either blood pressure ≥160/100mmHg or in those patients with blood pressure ≥140/90 mmHg and a 10-year CVD risk >20% or microalbuminuria or proteinuria.5 British Hypertension Society guidelines suggest antihypertensive treatment for all diabetic patients where their BP is sustained at ≥140/90mmHg, regardless of their absolute risk of CVD.6 The NICE hypertension guideline recommends any of thiazide diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists as first choice for patients without albuminuria. If microalbuminuria or proteinuria are present then ACE inhibitors should be the first choice.7 Trial data comparing ACE inhibitors to other antihypertensives show that strict control of blood pressure is beneficial, but do not provide convincing evidence that ACE inhibitors offer advantages over other antihypertensive therapy with regard to cardiovascular risk in patients with diabetes.8
Lipid Management
There is continued debate around whether all patients with type 2 diabetes should receive a statin regardless of their cholesterol level. Current NHS policy recommends statin treatment when serum cholesterol concentrations are raised with total cholesterol ≥5mmol/l (or triglycerides ≥2.3mmol/l) for patients with established CVD or without established CVD but a 10-year coronary event risk >15%.7 NICE is reviewing national clinical policy for statins in CHD; their appraisal is due in November 2005.
A randomised controlled trial investigated the effectiveness of daily atorvastatin 10mg for primary prevention of cardiovascular disease in 2,838 patients with type 2 diabetes and concentrations of low-density lipoprotein (LDL)-cholesterol <4.14mmol/l. Atorvastatin was shown to be safe and effective in reducing the risk of first cardiovascular disease events (including myocardial infarction, unstable angina, acute CHD death, coronary revascularisation procedures and stroke). Treating 1,000 people for 4 years would prevent 37 first major cardiovascular events (NNT 27).9 These results concord with results from the Heart Protection Study where treatment with simvastatin for 5 years would prevent about 80 patients per 1,000 from having at least one major cardiovascular event (NNT 21).10
Blood Glucose Management
NICE suggests a target level for HbA1c between 6.5-7.5% for type 2 diabetic patients according to the individual risk of macrovascular and microvascular complications.11 HbA1c should be measured every two to six months. In the UKPDS the median HbA1c over 10 years with conventional control was 7.9% compared with 7.0% with intensive control.4 Achieving target HbA1c is therefore a challenge in many patients. Type 2 diabetic patients usually require drug treatment to control their blood glucose levels in addition to dietary changes. Metformin is the drug of choice particularly in overweight patients (BMI >25kg/m2). A sulphonylurea is a suitable alternative where metformin is contraindicated or where people are not overweight. If either of these drugs fails to control blood glucose, they can be tried in combination. There is limited evidence to support the use of oral antidiabetic triple therapy (rosiglitazone is now licensed for triple therapy). Rosiglitazone and pioglitazone should not be prescribed for patients with cardiac failure or with a history of cardiac failure or in combination with insulin.12 Insulin therapy tailored to the individual may be considered where diet and oral hypoglycaemic drugs have failed to control blood glucose adequately. Local experience, patient preference and relative cost should be used to help decisions on the type of insulin and regimen.11 There is rarely any benefit in frequent self-monitoring of blood glucose in type 2 patients, unless it forms part of a wider management programme.3
NICE suggests a target level of HbA1c of <7.5% for type 1 diabetic patients, or ≤6.5% if at increased arterial risk.13 Type 1 patients may use a meal-time insulin regimen or a basal/nocturnal supply. Meal-time insulin regimens use unmodified (soluble) insulin or rapid-acting insulin analogues; the latter should be used rather than unmodified insulin where nocturnal or late inter-prandial hypoglycaemia is a problem, or to avoid the need for snacks whilst maintaining equivalent blood glucose control.13 Isophane insulin or long-acting insulin analogues are used for basal/nocturnal supply; long-acting insulin analogues should be used where: nocturnal hypoglycaemia is a problem; morning hypoglycaemia on isophane insulin results in difficult day-time blood glucose control or where rapid-acting insulin analogues are used for meal-time blood glucose control.13
Prescribing Data
In the quarter to March 2005, 53% (136,000 items) and 23% (59,000 items) of short-acting insulins are for insulin aspart and insulin lispro respectively. The cost per quarter is £6.8 million (55%) for insulin aspart and £3.2 million (26%) for insulin lispro. Intermediate- and long-acting insulins account for 76% of all insulin prescribing and 74% of cost. Prescribing of insulin glargine (introduced in 2002) accounts for 176,000 items (£9.7 million), biphasic insulin aspart for 110,000 items (£5.5 million) and biphasic insulin lispro for 52,000 items (£2.9 million).
Across English PCTs there is nearly a 7-fold variation in spending on oral antidiabetic drugs (NIC per 1,000 oral antidiabetic STAR(01)-PUs). The median value is £531 per 1,000 oral antidiabetic STAR(01)-PUs (interquartile range 459-655). Higher spending is occurring in PCTs with a higher population of non-whites. Chart 3 shows a 3-fold variation across Strategic Health Authorities in spending (NIC per 1,000 oral antidiabetic STAR(01)-PUs) on rosiglitazone, pioglitazone and rosiglitazone with metformin.
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