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Diabetes: new treatments and guidance

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As the number of people with diabetes increases, the consequences of untreated or inadequately treated diabetes are being realised. People with diabetes are more likely to have coronary heart disease, to have a stroke, to develop renal failure and require dialysis or a renal transplant, to have visual impairment and to develop foot ulcers. They may also require amputation as a result of peripheral vascular disease or neuropathy. The cost of these complications has been estimated to be at least 8 per cent of the total cost of the NHS budget, with 80 per cent of this money being spent on treating and caring for people with these complications (King’s Fund Policy Institute, 1996). It has been shown that many of these complications are preventable (UKPDS, 1998). People who are disadvantaged socially and economically develop diabetes in greater numbers than those who are less disadvantaged, and they have worse outcomes.

Abstract

VOL: 99, ISSUE: 03, PAGE NO: 30

Mary Burden, RGN, MPH, is consultant nurse, diabetes, Heart of Birmingham Teaching Primary Care Trust

As the number of people with diabetes increases, the consequences of untreated or inadequately treated diabetes are being realised. People with diabetes are more likely to have coronary heart disease, to have a stroke, to develop renal failure and require dialysis or a renal transplant, to have visual impairment and to develop foot ulcers. They may also require amputation as a result of peripheral vascular disease or neuropathy. The cost of these complications has been estimated to be at least 8 per cent of the total cost of the NHS budget, with 80 per cent of this money being spent on treating and caring for people with these complications (King’s Fund Policy Institute, 1996). It has been shown that many of these complications are preventable (UKPDS, 1998). People who are disadvantaged socially and economically develop diabetes in greater numbers than those who are less disadvantaged, and they have worse outcomes.

 

Care in the community
There are several models of diabetes care in the community. One example is the Ladywood Project, first set up in the Ladywood area in Birmingham. This is an area of great social deprivation, with a black and ethnic population of over 50 per cent where, at one time, many single-handed GPs, with three acute trusts, struggled to provide adequate diabetes care. The initial aims of the project were to move routine diabetes care into the primary care sector, and this was done by practice nurses and GPs undertaking a nine-month course accredited by Warwick University and obtaining a certificate in diabetes care (see Useful Websites, p31).

 

A particular aspect of the Ladywood Project was that patients’ details could be accessed by means of a computer information system by both primary and secondary care staff. This meant that patients who had been seen at the hospital could be discharged to designated GP-led diabetes clinics in the surgery where there was at least one member of staff trained as above in diabetes care. If further support was needed, a community clinic was set up in a local health centre, where a multidisciplinary team consisting of a diabetologist, a diabetes specialist nurse, a dietitian and a podiatrist could be consulted. Originally, the clinic was run by secondary care staff but gradually, with the creation of primary care trusts, community-based staff have been appointed, and they have been involved in developing other services such as insulin start clinics, group education and diagnostic prevention clinics.

 

In 2000, the Audit Commission (2000) reported some of the experiences of people with diabetes in England and Wales. Many of these were negative, and demonstrated inequalities in care and treatment, and inadequate services, although some examples were given of good practice. It is hoped that those responsible for diabetes care will look at these examples and address inadequacies in their own areas.

 

New treatments for diabetes
In the past few years, several new treatments for diabetes have been developed.

 

Glitazones (thiazolidinediones): These reduce insulin resistance, leading to a reduction of blood glucose concentration. They can be used instead of a sulphonyl-urea or metformin if these cannot be tolerated by a patient or if the blood glucose remains high despite an adequate trial of sulphonylurea and metformin. They are not, however, licensed for use in combination with insulin therapy. The advantages of glitazones are that they cause few hypoglycaemic episodes and that patients may not have excessive weight gain when taking them. But they are more expensive than traditional sulphonylurea and metformin therapy and their effect is slow - it takes about a month before they have their full effect.

 

Quick-acting insulin analogues: These have been available in the UK since the mid-1990s and for some people they have taken the place of soluble insulin. Their advantage is that their action is similar to endogenous insulin in starting within 15 minutes of their being taken and wearing off after two hours. This means that they can be injected immediately before, during or immediately after a meal. This can be convenient when an individual is unsure how much he/she will eat at a particular meal. There is still a need for a basal (long-acting) insulin but the quick-acting analogue can be given either each time a person eats breakfast, lunch or dinner or as part of a twice-daily regimen. Because the action is rapid there is less need for a snack between meals and less hypoglycaemia, particularly at night. Quick-acting insulin analogues allow a flexible regimen for people who lead an irregular lifestyle.

 

Long-acting insulin analogues eg glargine (Lantus): This is given once a day, usually at bedtime, although it can be given at any time during the day. It is a basal insulin, has no peak effect, and lasts for 24 hours. In people with type 2 diabetes, glargine can be used in combination with oral hypoglycaemic agents. In Type 1 diabetes there is still a requirement for either a quick-acting soluble or analogue insulin. The risk of hypoglycaemia with glargine is said to be less than with conventional long-acting insulins.

 

Because glargine is so long-acting, it needs to be adjusted less frequently against home blood glucose readings, for example, weekly rather than every couple of days as is more common with traditional insulins. A disadvantage of glargine, however, is that it is more expensive than traditional long-acting insulins. Also, glargine is slightly acidic and cannot be mixed with other insulins, otherwise the mixture would precipitate. Some people say it is slightly more painful to inject than a traditional insulin.

 

These new insulins offer more choice to people with diabetes than those previously in use. It is possible, now, for people to make their insulin regimen suit their lifestyle. However, this way of managing diabetes does need more effort, with more intense home glucose monitoring, and will not suit everyone.

 

The DAFNE Study Group: A study entitled Dose Adjustment for Normal Eating (DAFNE) (DAFNE Study Group, 2002) has just reported its findings on a new method of treating type 1 diabetes that has been pioneered in Germany. It involves teaching people on a five-day course about the constituents of food and then encouraging them to experiment with the amounts of insulin they need to control their blood glucose. There is no reason why this technique cannot work for people with type 2 diabetes as well.

 

Polypharmacy: The most common cause of death in both type 1 and type 2 diabetes is coronary heart disease (CHD) - the mortality rate is at least twice that for people without diabetes. With the increasing emphasis today on addressing the other risk factors for CHD, polypharmacy has become the norm for people with diabetes. Many people, therefore, may be taking oral hypoglycaemic agents, three to four antihypertensive agents, low dose aspirin, and a statin to reduce their total cholesterol and triglycerides. They may also be having nicotine therapy to help them stop smoking.

 

There have been suggestions that there should be less emphasis by health professionals on routine measuring of lipid levels and blood pressure and that they should, instead, work to ensure that patients take all their prescribed medications.

 

National initiatives for diabetes care
The Diabetes National Service Framework: The National Service Framework on diabetes was set up by the government to try and address inequalities in health care by setting minimum standards that health care delivery systems need to put into place (DoH, 2001) (Fig 1). On publication of the standards, an implementation group was formed with a remit to ensure that the standards would be met.

 

Some of the present inequalities in care have resulted from lack of recognition in the past that there is an increased incidence of diabetes in certain client groups; for example in black and minority ethnic groups, and that there is an increased incidence with age and social deprivation. Furthermore, more men than women develop diabetes (in all groups). The National Service Framework states that care should be person-centred, developed in partnership with other agencies, equitable, integrated and outcomes-oriented. Aims have also been set for the future. Fig 2 lists what the Framework aims to have achieved by 2010.

 

National Institute for Clinical Excellence (NICE): Several NICE guidelines have now been produced on diabetes. The most recent are on the management of type 2 diabetes. These relate to glycaemic control, and include reporting on the effectiveness of educational methods (www.nice.org.uk)

 

 

Conclusion
There is now extensive knowledge about the causes of the complications of diabetes and the means to prevent them. All health professionals need to have the training and knowledge to support both those at risk from diabetes and those who have the disease. Nurses need to encourage self-management of diabetes, and to share the information, skills and tools with people to enable them to make healthy choices.


- Next week: Promoting sexual health in cancer care

 

 

FURTHER READING
Department of Health (2002) Shifting the Balance of Power

 

USEFUL WEBSITES
Warwick Diabetes Care

 

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