Diabetes in Primary Care

This episode makes reference to guidelines produced by the "National Institute for Health and Clinical Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a fictitious clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it.  I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.   There is a YouTube version of this and other videos that you can access here: There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrkThe patient was created using the following Chat GPT prompt: A)   Provide a fictitious patient. Details that you should include are: 1)   patient's medical information including:·      name·      age·      sex·      ethnicity·      BMI·      blood pressure2)   medical history- you must include:·      either one or two of the following poorly controlled conditions: ·      type 2 diabetes·      hypertension ·      dyslipidaemia, ·      Asthma or COPD·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”Medications given:·      indicate whether the patient is currently taking medication for each medical condition or not.·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.4)   blood test results (give a bulleted list but do not number them):·      HbA1c expressed in % and mmol/mol·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units) ·      lipid profile expressed both in mmol/L first and then in mg/dL.·      If the patient has asthma, give the peak flow reading expressed as a percentage of their best or expected reading.·      If the patient has COPD, give the FEV1 reading expressed as a percentage of the predicted reading ·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years. C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourselfD)  Do not include a disclaimer that the patient is fictitious. The NICE hypertension flowcharts can be found here: Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn  The full NICE Guideline on hypertension (NG136) can be found here:  Website: https://www.nice.org.uk/guidance/NG136 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus  The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  ·      https://www.nice.org.uk/guidance/ng28  The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: ·      https://www.nice.org.uk/guidance/cg181The full NICE guidance on asthma (NG80) can be found here: ·      https://www.nice.org.uk/guidance/ng80 The full NICE guidance on depression in adults (NG222) can be found here: ·      https://www.nice.org.uk/guidance/ng222 The full guidance on obesity (CG189) can be found here:·      https://www.nice.org.uk/guidance/cg189  Thumbnail photos- From: www.freepik.com·      Image by Freepik: Image by a href="https://www.freepik.com/free-photo/excited-young-friends-running-beach_9057871.htm#page=2&query=45%20year%20old%20obese%20woman&position=10&from_view=search&track=ais"Freepik/a  Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   Music provided by Audio Library Plus   Watch: https://youtu.be/aBGk6aJM3IU  Free Download / Stream: https://alplus.io/halfway-through  Transcript   Hello everyone. My name is Fernando and I am a GP in the United Kingdom. Today we are looking at a fictitious patient generated by Chat GPT with a view to looking at the NICE guidelines from a practical perspective.  If you would like to know the Chat GPT prompt that I have used, you can find it in the episode description.  Right, so let’s jump into it. Patient Information:·      Name: Sarah Davis·      Age: 45·      Sex: Female·      Ethnicity: CaucasianExamination:·      BMI: 32 (Obese)·      Blood Pressure: 153/91 mm HgMedical History:·      Type 2 Diabetes·      Hypertension·      Dyslipidemia ·      Asthma ·      Obesity ·      Depression Medications:·      Metformin 1000 mg twice daily·      Gliclazide 80 mg once daily·      Amlodipine 10 mg once daily·      Indapamide MR 1.5 mg once daily·      Atorvastatin 20 mg once daily·      Salbutamol inhaler as needed·      Sertraline 50 mg once dailyMedication Tolerance:·      Sarah tolerates her medications well. She has not reported any significant side effects.Blood Test Results:·      HbA1c: 8.5% (69 mmol/mol)·      Renal Function:o  Creatinine: 90 µmol/L (1.02 mg/dL)o  eGFR: 91 mL/min/1.73m²·      Lipid Profile:o  Total Cholesterol: 5.2 mmol/L (200 mg/dL)o  LDL Cholesterol: 3.0 mmol/L (116 mg/dL)o  HDL Cholesterol: 1.2 mmol/L (46 mg/dL)o  Triglycerides: 2.5 mmol/L (220 mg/dL)Cardiovascular Risk (QRISK3):·      Sarah's 10-year cardiovascular risk is estimated at 18%.So, what treatment recommendations would we make?Although there is a lot that we can do from a lifestyle perspective, we will focus on the drug treatment only.  Right, let’s start with her diabetes, which is poorly controlled with an hba1c of 8.9% or 74 mmol/mol. Sarah is on metformin 1gr BD and gliclazide 80 mg OD and we know she is at high risk of cardiovascular disease with a QRISK3 of 18%. NICE says that for step 2 treatment after metformin, if a patient is at high risk of CVD, we should choose an SGLT2 inhibitor. But this patient has been given gliclazide instead. We would like to see if there is a reason for this and whether an SGLT2 inhibitor was tried before but not tolerated. So, assuming that there have been no issues, I would recommend starting an SGLT2 inhibitor.SGLT2 inhibitors are also associated with a degree of weight loss, and given that Sarah is obese, this will be good for her. Gliclazide on the other hand is associated with weight gain, which is the last thing that Sarah needs. The question now is whether we should stop gliclazide and, if so, when.In my opinion, gliclazide should be definitely stopped and substituted by another diabetic agent which is weight neutral, for example, a DPP4 inhibitor. A more difficult question would be when to make this switch. Doing it straightaway has got the disadvantage that, if a side effect develops, we may not know which drug is the culprit. Also, we do not know how much the HbA1c will drop with the SGLT2 inhibitor so there could be a risk of overtreatment. Right, a balanced decision that you can make depending on your clinical judgement. I think that I would start the SGLT2 inhibitor first, so, I would start her on something like dapagliflozin 5 mg OD initially and, if tolerated, I may increase it to 10 mg daily fairly quickly, possibly within 3 or 4 weeks to get the maximum effect as soon as possible.Research studies have shown that the introduction of an SGLT2 inhibitor can lead to a drop in Hba1c of around 1%. Although this could vary depending on the individual patient, Sarah’s HbA1c is poor at 8.9% so even after the SGLT2 inhibitor, she is likely to require a third diabetic agent.NICE says that if dual therapy with metformin and another oral drug is not enough, we should consider either triple therapy by adding a DPP‑4 inhibitor, pioglitazone or a sulfonylurea or starting insulin. Because of the risk of weight gain, I would try to avoid gliclazide and insulin.Given that she is on gliclazide 80 mg daily, that is, a quarter of the maximum daily dose of gliclazide, I would probably switch Sarah to a DPP4 inhibitor as soon as she is tolerating the full dose of dapagliflozin. So, we could stop gliclazide and start her on, for example, sitagliptin 25mg daily, which is also a quarter of the maximum daily dose of 100mg.But I do not think that there is a right or wrong approach in terms of the gliclazide switch. The decision about the timing is very dependent on the individual patient and your clinical judgement. Switching early has some more uncertainty about treatment response whereas switching later may mean that the patient remains on a potentially unsuitable drug for longer.We have to make sure that we inform the patient that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations and Fournier’s gangrene. So, on starting the SGLT2 inhibitor:1.   We will educate her about DKA symptoms and when to seek advice.2.   We will also advise against ketogenic diets to lose weight while on an SGLT2 inhibitor, as this also increases the risk of DKA.3.   We will improve foot care and4.   We will advise patients to seek urgent medical advice if they experience pain, eryth

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a real-life case to demonstrate how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and you must use your clinical judgement. The PDF version of this episode can be found here:·      Colour version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz·      Printer friendly version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxbThere is a YouTube version of this and other videos that you can access here:·      The NICE GP YouTube Channel: NICE GP - YouTubePrescribing information links:·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-throughTranscriptHello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom. We have looked at fictitious patients in previous episodes but, in today’s episode, I am going to look at a real diabetic case to see how the guidelines could apply to it. And as you know, we are focusing only on the pharmacological treatment. If you want to download a PDF version of this episode, the link is in the episode description. Please note that I am not giving medical advice; this is only my interpretation of the guidelines and you must use your clinical judgement Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s get straight into it. The details, which have been anonymised, belong to a real patient, so we have 46-year-old man of Asian descent with T2DM who presents with the following: HbA1c is 68 mmols/mol/8.4% (therefore poorly controlled) Cholesterol 5.9 Triglycerides 5.72 HDL 0.97 ·      The path lab has not calculated LDL because triglycerides >4.5 ·      Liver and Renal function tests are normal with an eGFR of 97  Thyroid function tests show a borderline low T4 of 9 (NR 9-19.1) and a raised TSH of 9.88 (NR 0.35-4.94 ACR normal FBC and other routine blood tests were normal.  His BMI is 32, so he is obese His BP is 147/89 His PMH includes: Hypothyroidism T2DM His regular treatment is with: Levothyroxine 200mcg daily Metformin 500 mg TDS He comes to discuss his test results, feeling well in himself. His obesity is long-standing and being managed with diet and lifestyle advice. He has had hypothyroidism for 15 years and, on prompting, he says that he is feeling a little tired So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines and we will have to looks at the guidelines on type 2 diabetes, hypertension, prevention of cardiovascular disease, and hypothyroidism  Let’s look at his diabetes first. Firstly, NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea. However, he is well and asymptomatic so we do not have to do this. We see that his current dose of metformin 500 mg 3 times a day is not enough to control his diabetes. So, given that his renal function is completely normal.  we should increase the dose to the maximum of 2000mg daily, that is, 1000mg twice a day. However, this is unlikely to be enough to bring his HbA1c of 68 or 8.4% to target. And let’s remember that according to NICE we should strive for the following targets: ·      Lifestyle management only— 48 mmol/mol (6.5%). ·      A single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%). ·      Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%). ·      Always adjust for people who are frail, elderly or with other co-morbidities This patient is young and otherwise well so we should aim to treat him aggressively. NICE says that for people not controlled on metformin alone, we should consider dual therapy but which?  We need to assess the person's cardiovascular status and risk to determine whether they have chronic heart failure, established atherosclerotic cardiovascular disease, or are at high risk of developing cardiovascular disease. This patient does not have heart failure or cardiovascular disease but using an online calculator, his 10-year QRISK3 score is 12%. So, being over 10%, we will consider him at high risk of developing CVD.  And NICE says that if the patient is at high risk of developing cardiovascular disease, we will consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin. This is good because it seems quite clear that his obesity is a problem and both metformin and SGLT2 inhibitors promote weight loss. Because we would want to manage him aggressively, I would advise him to increase metformin straightaway and as soon as we know that it is tolerated, which could be a matter of days, we could start the SGLT2 inhibitor. SGLT2 inhibitors with proven cardiovascular benefit includes dapagliflozin, empagliflozin and canagliflozin Remember that SGLT2 inhibitors are associated with an increased risk of DKA and lower limb amputation. Therefore, before starting an SGLT2 inhibitor, we need to check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if: they have had a previous episode of DKA they are unwell with intercurrent illness Or they are following a very low carbohydrate or ketogenic diet, and if so, not to start the SGLT2 inhibitor until they have changed their diet. We will also advise them not to start this type of diet while they are on this medication.   The increased risk of lower-limb amputation has been shown with Canagliflozin but there is some concern that the risk may be a class effect. We will need to ensure that foot care is optimised before starting the SGLT2 inhibitor.   So, this would be my pharmacological action from a diabetic perspective. Increase metformin to 1000mg BD and start an SLGT2 inhibitor, for example, dapagliflozin 10 mg OD.  Now let’s have a look at his BP, which is elevated at 147/89.  NICE says that people under the age of 80 should have a BP below 140/90.  To confirm the diagnosis, we should arrange ambulatory or home blood pressure monitoring and if the average is greater than 135/85 we will start him on antihypertensive treatment. We have more or less established that he does not have end-organ damage because of his normal renal function, normal urinary albumin / creatinine ratio and, looking at his records, normal fundoscopy, as he attends for his annual diabetic retinal screening programme. To be strict, we should also arrange an ECG to ensure that there are no signs of left ventricular hypertrophy.   Let’s assume that his BP is indeed above the target. What treatment should we start?  NICE says that for someone with diabetes of any ethnicity and any age, we should start and ACEI or ARB. We know that ACEI confer significant renal protection in diabetes, so we will start him on an ACEI, something like lisinopril 2.5 mg daily, monitoring his renal function and increasing the dose gradually according to our clinical judgement. This patient is of Asian family background but remember that if the patient is of Afro-Caribbean family origin, we should opt for an ARB in preference to an ACEI. This is because Afro-Caribbean patients are considered “low renin responders” and therefore ACEI are less effective in this group.  Now let’s look at his lipids and what we would do based on the NICE guideline on prevention of cardiovascular disease. Firstly, we will calculate his CV risk.Using the online QRISK3 calculator we find that his 10-year risk is 12% Further details are: Your 10-year QRISK®3 score  12% The score of a healthy person with the same age, sex, and ethnicity 2.6% Relative risk**  4.6 Your QRISK®3 Healthy Heart Age 66 But remember that NICE also says that the CVD risk may be underestimated by risk assessment tools if the triglyceride levels are raised, which is this patient’s case. Could this be treated with lifestyle alone? Because we need to treat him aggressively, I would say no. Furthermore, his cholesterol has been elevated well over 5 mmol/l (200 mg/dL) for the last 3 years so it is clear that diet and exercise alone are not doing the job.  NICE says that for Primary prevention: If lifestyle modification is ineffective or inappropriate, we will offer a statin, generally atorvastatin 20 mg, for the primary prevention of CVD to people who have a 10% or greater 10‑year CVD risk using the QRISK assessment tool.  For people 85 years or older we will still consider atorvastatin 20 mg as statins may be of benefit in reducing the risk of non‑fatal MI. Should we do anything different from the point of view of his triglycerides?  Well, first of all, we will look to see if they have been this high for long. Previous entries show levels moderately elevated but not to this degree. Triglycerides are also affected by diabetes control and it may very well be that once his hyperglycaemia improves, and his HbA1c goes down, his triglycerides will too. Triglycerides may be also elevated in situations where excess alcohol is consumed. So, we should enquire about this. And hypothyroidism can also influence lipids in general and triglycerides in particular. Improving his hypothyroidism treatment is also likely to improve the lipid situation.  Also, atorvastatin will have some effect on the triglycerides, although this effect may not be very pronounced.     Other drugs like fibrates, such as fenofibrate, are potent agents in reducing triglyceride

"Chat GPT Patient Meets NICE - Here's What Happened!" My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a complex random clinical case of a patient created by Chat GPT to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this podcast is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  There is a YouTube version of this and other videos that you can access here: The NICE GP YouTube Channel: NICE GP - YouTube ChatGPT prompt to create a patient:  A)   Provide a fictitious patient. Details that you should include are: 1)   patient's medical information including:·      name·      age·      sex·      ethnicity·      BMI·      blood pressure2)   medical history- you must include:·      either one, two or three of the following poorly controlled conditions: ·      type 2 diabetes·      hypertension ·      dyslipidaemia, ·      Any number of other medical conditions of your choice, along with whether they are well controlled or not – the medication for these conditions should appear in the next section “medications”Medications given:·      indicate whether the patient is currently taking medication for each medical condition or not.·      If medication is prescribed for a condition, indicate the specific drug(s) and their dosages. You may choose to prescribe one, two, or three drugs for each condition as appropriate.3)   State whether the patient tolerates the medication well or not, and if not, describe the side effect(s) and their severity.4)   blood test results (give a bulleted list but do not number them):·      HbA1c expressed in % and mmol/mol·      renal function tests to include creatinine (expressed first in µmol/L and then in mg/dL), eGFR, urea, sodium, and potassium (expressed in UK units first and then USA units) ·      lipid profile expressed both in mmol/L first and then in mg/dL.·      include any other relevant test results for the patient, expressing them in both UK and USA units. If the patient has hypothyroidism or takes levothyroxine medication, provide the results of their thyroid function tests, including both T4 and TSH levels, in both UK and USA units. Also, include the normal range for these investigations.B)  Provide the patient's cardiovascular risk using the QRISK2 tool, calculated as a percentage of the likelihood of experiencing a cardiovascular event over the next 10 years. C)   At the end of the patient information, ask: 'What treatment recommendations would you make?' – do not make recommendations yourselfD)  Do not include a disclaimer that the patient is fictitious. The NICE hypertension flowcharts can be found here: Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn  The full NICE Guideline on hypertension (NG136) can be found here:  Website: https://www.nice.org.uk/guidance/NG136 Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus  The full NICE Guideline on Type 2 diabetes (NG28) can be found here:  ·      Overview | Type 2 diabetes in adults: management | Guidance | NICE The full NICE guidance on osteoarthritis (NG226) can be found here: ·      Overview | Osteoarthritis in over 16s: diagnosis and management | Guidance | NICE The full NICE guidance on cardiovascular disease risk reduction (CG181) can be found here: ·      Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICEThe full NICE guidance on asthma (NG80) can be found here: ·      Overview | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE The full NICE guidance on depression in adults (NG222) can be found here: ·      Overview | Depression in adults: treatment and management | Guidance | NICE Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   Music provided by Audio Library Plus  Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through Transcript  Today we'll be exploring the world of NICE guidelines and how they apply to a complex patient. But this isn't just any patient - this one was randomly created by the latest buzz in town, ChatGPT. Our focus will be on the pharmacological treatment.Hello and welcome, I'm Fernando Florido, a GP in the United Kingdom.Before we dive in, I'd like to make it clear that I'm not here to provide medical advice. Rather, I'll be sharing my interpretation of the guidelines with fellow healthcare professionals. Please always use your clinical judgement when treating your patients.If you prefer a video format, we've also got a YouTube version of these episodes. The link is in the episode description.Alright, let's generate our patient using ChatGPT. It was created using a specific prompt, which is available in the episode description. Let's get started!Right, so our fictitious patient is Sarah Johnson, a 52-year-old African American woman. Sarah is currently obese with a BMI of 31, and her Blood Pressure is above the target at 142/88 mmHg. She has a Medical History of Type 2 diabetes and Hypertension, which are both poorly controlled as well as Osteoarthritis (which is well-controlled with ibuprofen) Asthma (which is well-controlled with salbutamol inhaler) and Depression (which is well-controlled with fluoxetine)Her regular Medications are:Metformin 1000 mg twice a day for diabetesLisinopril 20 mg once a day for hypertensionAtorvastatin 40 mg once a day for dyslipidaemiaIbuprofen 400 mg twice a day for osteoarthritisSalbutamol inhaler 2 puffs as needed for asthmaFluoxetine 20 mg once a day for depression Fortunately, she tolerates all medications well without any side effects.We also have her blood test results, which show the following:An HbA1c: 8.5% (69 mmol/mol) A Creatinine: 94 µmol/L (1.06 mg/dL)·      An eGFR: 72 mL/min/1.73m2 (Urea: 5.2 mmol/L (14.67 mg/dL) Sodium: 139 mmol/L (139 mEq/L) Potassium: 4.2 mmol/L (4.2 mEq/L))·      A Total Cholesterol: 6.1 mmol/L (236.39 mg/dL) (HDL Cholesterol: 1.3 mmol/L (50.1 mg/dL))·      And an LDL Cholesterol: 4.1 mmol/L (158.57 mg/dL) (Triglycerides: 1.8 mmol/L (159.27 mg/dL) TSH: 2.5 mIU/L , 2.5 µIU/mL Free T4: 15 pmol/L, 1.2 ng/dL Normal TSH range: 0.4-4.0 mIU/L , 0.4-4.0 µIU/mL Normal Free T4 range: 9-25 pmol/L , 0.8-2.0 ng/dL ) Finally, Sarah's QRISK2 score is 20%, indicating a high risk of developing cardiovascular disease over the next 10 years.Based on Sarah's medical history, blood test results, and QRISK2 score, I would recommend the following treatment options.Upon initial examination, this 52-year-old woman presents with a significant amount of multimorbidity, including diabetes, hypertension, dyslipidaemia, osteoarthritis, asthma, and depression. Her obesity is likely exacerbating her conditions, particularly her diabetes, hypertension, and osteoarthritis, and may also be contributing to her depression. Given this, tackling her obesity could potentially have a positive impact on her overall health. However, for the purpose of this case, we will focus on the pharmacological treatment rather than lifestyle interventions.It is worth noting that the patient's eGFR of 72 indicates stage 2 CKD, which will factor into our treatment decisions. We will assume that there is no significant microalbuminuria since ACR results are not available. Additionally, the patient has a high risk of CVD, so managing her conditions aggressively will also help mitigate this risk.Moving on to her poorly controlled diabetes, which is currently being treated with metformin 1gr BD and has an HbA1c of 8.5% or 69 mmol/mol, NICE guidelines recommend an SGLT2 inhibitor as step 2 treatment after metformin for patients at high risk of CVD. SGLT2 inhibitors are also beneficial for those with CKD and can promote weight loss, so a good option for this patient. In this case, starting the patient on dapagliflozin 5mg OD initially, and potentially increasing to 10mg daily within four weeks if well-tolerated, would be a suitable option.It is important to note that SGLT2 inhibitors have been associated with an increased risk of DKA, toe and lower limb amputations, and Fournier's gangrene. Fournier’s gangrene is a rare but life-threatening type of necrotizing fasciitis, which specifically affects the genital and perineal area. The condition develops rapidly, and symptoms may include fever, severe pain, redness, swelling, and foul-smelling discharge in the affected area. The infection can spread quickly and cause significant tissue damage, leading to sepsis, shock, and organ failure if not treated promptly.Therefore, it is crucial to educate the patient on DKA symptoms, advise against starting a ketogenic diet while taking an SGLT2 inhibitor, as this increases the risk of DKA, and promote excellent foot care. Additionally, we should advise the patient to seek urgent medical advice if they experience severe pain, erythema, or swelling in the genital or perineal area, especially if there is fever or malaise, as urogenital infection or perineal abscess may precede necrotising fasciitis.While GLP-1 receptor agonists would be recommended for patients with high CVD risk following the European and American guidelines, the NICE guidelines are more restrictive in this respect. However, an SGLT2 inhibitor is still an effective and straightforward option for this patient.Now that we have addressed her diabetes, let's move on to her hypertension.We'll be treating our patient's clinic BP as accurate, in accordance with NICE guidelines. If a patient has hypertension, we don't need to use ABPM or HBPM unless there are concerns, but for patients with diabetes, both sitting and standing BP should be checked due to the risk of postural hypotension, especially if affected by autonomic neuropathy.Our patient is being treated with an ACEI, lisinopril

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. There is a YouTube version of this and other videos that you can access here:·      The NICE GP YouTube Channel: NICE GP - YouTubeThis podcast also appears in: Primary Care guidelines podcast: ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148Prescribing information links: ·      Website: DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICE or·      Download PDF: DPP-4 inhibitors- Prescribing information- Diabetes- type 2- NICE.pdf·      Website: GLP-1 receptor agonists | Prescribing information | Diabetes - type 2 | CKS | NICE or·      Download PDF: GLP-1 receptor agonists- Prescribing information- Diabetes- type 2- NICE.pdf Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through TranscriptHello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random diabetic case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; see the description for full information about this:·     NOT medical advice·     Intended for health care professionals·     Only my interpretation of the guideline·     Use your clinical judgement And as you know, we are focusing only on the pharmacological treatment. Remember that there is also a podcast version of these videos so have a look in the description below. Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s generate our random patient. So, we have 45-year-old woman with poorly controlled T2DM with an HbA1c of 60 mmols/mol/7.6%, who has CKD stage 3a with an eGFR of 45 and who is also at high risk of CVD. She is also on triple therapy with Metformin 500 mg BD, Dapagliflozin 10 mg OD and Saxagliptin 2.5mg OD. And finally, she is severely obese with a BMI of 43So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines but at the end I will tell you what my interpretation would have been following the EASD / ADA consensus guideline.Firstly NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea.And for the clinical presentation we will say that she has no symptoms of diabetes, her obesity is long-standing and being managed with diet, lifestyle advice and bariatric referral. We have excluded other causes of Obesity e.g. hypothyroidism or Cushing’s disease and, because of her age, other causes of CKD such as glomerulonephritis or obstructive nephropathy have also been excluded and she has the diagnosis of diabetic nephropathy.Right, so what are my thoughts? Firstly, that she is relatively young and she already has a degree of diabetic nephropathy. So we should manage her fairly aggressively to try and improve her diabetic control and improve long term outcomes.Secondly, it seems quite clear that her main problem is her weight. She is severely obese and already being managed for that. I am very pleased to see that she is not on any medication that promotes weight gain. Both metformin and SGLT2 inhibitors promote weight loss and DPP4 inhibitors are weight neutral. So Dr Spinning Wheel has done very well indeed.The first step is always metformin which would be helpful for her weight too. So I would be interested to see why she is only on 500mg BD instead of the full dose, double that, 1000mg BD.I would first look if it has been kept at that dose because of safety reasons, for example because of her renal function. You can prescribe metformin 1000 mg BD to anyone with an eGFR of 45 or above. Her eGFR is exactly that, 45. Because of being right on the limit, I would want to be sure and I would look back and see what her previous renal function tests have been. If previously the eGFR has been bumping along the high 40s or 50s that I would definitely increase the dose because the drop to 45 could be just a temporary “blip”, although, of course, we would watch her renal function closely. If on the other hand her previous eGFR readings have been in the high 30s or low 40s, then I would not increase the dose because I would want to see a stable eGFR above 45 before increasing it. If she is suitable for a dose increase, I would also like to look at previous records and see if she has not tolerated higher doses. And if that is the case, I would also want to make sure that she has been managed appropriately. NICE says that metformin should be increased gradually over several weeks to minimise the risk of gastrointestinal side effects. So, if the previous increase in dose was abrupt, I would want to revisit it. Also I would make sure that the patient is counselled and advised that for many patients the side effects are temporary and get better over a number of weeks. So, I would advise her that, if the side effects are not severe, to try and work through them to see if the short term inconvenience of the side effects can translate into a long term therapeutic benefit. And finally, if she has not been able to tolerate it despite these efforts. NICE says that we should consider a trial of modified‑release metformin, so I would offer this to her too. So I am really emphasizing that we should leave no stone unturned before giving up of the benefits of a full dose of metformin, especially in a person with such an obesity problem. So, let’s assume that she is keen and able to increase the dose, so we do that. Would I try to add or increase other medication in this consultation too?Because I want to manage her aggressively and all her medication has a very low risk of hypoglycaemia, I would say yes. True, we may advise her to delay the addition or the increase of other drugs for a few days or weeks to make sure that if side effects develop, we know which medication is the culprit. But as soon as that patient is sure that the increased dose of metformin is not causing any issues, I would add or increase the other medication. I would not want to leave her for, say, 3 months before further action is taken. So as a next step, NICE says that, for patients at high risk of CVD, we need to consider an SGLT2 inhibitor with proven cardiovascular benefit. And she is on the full dose of dapagliflozin, which is one of them. The cardiovascular benefit of SGLT2 inhibitors is a drug class effect so there isn’t necessarily any need to consider other types if there is no concern with the use of dapagliflozin. Dapagliflozin can be initiated as long as the eGFR is above 15 so her eGFR of 45 is not a problem.So, we now look at the third drug, which is a DPP4 inhibitor, saxagliptin 25mg OD. NICE says that for patients who are not controlled with dual therapy with metformin and an SGLT2 inhibitor, we should consider either:u triple therapy, including combinations with either a sulphonylurea or a DPP‑4 inhibitor or, u going directly from dual therapy to starting insulinI am definitely going to exclude insulin and a sulphonylurea at this stage because they can be associated with weight gain, which is the last thing that we want for this patient. As we have seen, DPP4 inhibitors are acceptable and saxagliptin is already prescribed. NICE says that the recommended dose of saxagliptin is 5 mg OD and the patient is only on 2.5mg OD. However, the dose of saxaglitpin has to be reduced to 2.5 mg OD if the eGFR is below 45. So, we are in the same situation as the metformin earlier. If her eGFR has consistently been above 45 you can increase the dose but not otherwise.There are many other considerations when choosing which DPPG4 inhibitor you are going to use and they all have different thresholds for renal impairment, and also other conditions like hepatic impairment, heart failure and for the elderly. So I would encourage you to look at your formulary carefully before making the decision. I will put in the episode description the link for the NICE guidance on DPP4 inhibitor prescribing in case that you are interested. DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICEIt is worth saying that linagliptin is the only DPP4 inhibitor that does not require dose adjustment for renal or hepatic impairment so if there is any doubt, you can always give linagliptin at the full recommended dose of 5 mg OD. So this is my interpretation for this patient following the NICE guidelines:1- increase metformin if at all possible, 2- continue dapagliflozin at the full dose and 3- increase the dose of saxagliptin to 5 mg OD if renal function allows or switch it to linagliptin 5mg OD if there are concernsWhat would I do if I were following the EASD / ADA consensus guideline?Well, I would still try to increase metformin if at all possible and then, because this patient has a high CVD risk, she would be started on a GLP1 receptor agonist for their cardiovascular benefit, independently of the HbA1c level. This would also have the benefit of their added weight loss so that would be great for this patient too. The difference is that NICE is more restrictive when it comes to GLP1 receptor agonists and they would only be considered if the initial suggestion that I

My name is Fernando Florido and I am a GP in the United Kingdom. With this episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. This episode also appears in the Primary Care guidelines podcast: ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: ·      The NICE GP YouTube Channel: NICE GP - YouTube Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]Music provided by Audio Library PlusWatch: https://youtu.be/aBGk6aJM3IUFree Download / Stream: https://alplus.io/halfway-through TranscriptHello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.With today’s episode I am starting a new series on Diabetes Guidelines in Practice, looking at how the guidelines could apply to randomly selected clinical cases. By way of disclaimer, remember that guidelines are there to be interpreted and applied using your clinical judgement. I am not giving medical advice here and what I am only doing is sharing with you what my interpretation of the guideline would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. So, you must always apply your clinical judgement at all times. I will also say that I will only focus on the pharmacological treatment of type 2 diabetes. By all means, we will need to advise about diet, exercise, lifestyle etc, but this will not be addressed in these episodes.Remember that there is also a podcast version of these videos so have a look in the description below.Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s get started and let’s generate our random patient. For that we are going to spin a random wheel: Right, so we have an 85-year-old man, newly diagnosed with type 2 diabetes who is poorly controlled with an HbA1c of 65 mmols or 8.1%, who also has heart failure and CKD stage 3b with an eGFR of 32. In addition, he is underweight, even possibly malnourished to some degree. Right, we are going to look at the guidelines and how to apply them. Although I will focus on the NICE guideline, in this case my interpretation and the outcome would be exactly the same if you follow the EASD recommendations or the ADA guideline.So, what does NICE say that we should do? Firstly, we need to consider if rescue therapy is necessary because, for symptomatic hyperglycaemia, we will need to consider insulin or a sulfonylurea and review when blood glucose control has been achieved. So, we are going to assume that he is well and that he has no symptoms of diabetes. He is underweight, but this has been like this for a few years. There hasn’t been rapid weight loss indicating an urgent need for insulin and his urinary ketones are negative. Other causes of unintentional weight loss such as cancer have also been excluded.So, we are just focusing on the diabetes. His HbA1c is high and has not improved with diet and lifestyle advice, so we should do something. However, given his age, we are not going to manage him too aggressively because, at 85, we are probably more concerned about harmful hypoglycaemia. But he does need treatment and certain diabetic agents could also help his co-morbidities. So, next, we must look at his medical history. He has both CKD and heart failure and we know that SGLT2 inhibitors can be beneficial for both these conditions.However, because of the benefits of metformin, NICE says that first, we should consider starting metformin alone to assess tolerability and once this has been confirmed, we could add an SGLT2 inhibitor.Arguments against using metformin at all in this patient are that his eGFR is fairly low and at 32 he is quite close to CKD stage 4.Also, because he is underweight with possible low muscle mass, we need to remember how the estimated GFR is calculated and consider that, as a result of the low muscle mass, his eGFR may be overestimated and that his actual GFR could be below 30. We know that we can use metformin quite normally if the eGFR is above 45, we need to review the dose and prescribe it cautiously if the eGFR is between 30 and 45 and then stop it completely when the eGFR falls below 30.The manufacturer of metformin also advises caution in chronic stable heart failure with the advice to monitor cardiac function closely.We also know that metformin can have potential gastrointestinal side effects and promote weight loss, which we would not want in this patient.And finally, the mode of action of metformin is primarily by reducing insulin resistance. But in an 85-year-old underweight patient, it is more likely that his diabetes is due to insufficient insulin secretion by the ageing pancreas.On the other hand, we also know that metformin has proved to have cardiovascular benefits.So, a controversial decision. You could justify both giving and not giving metformin based on this patient’s individual circumstances.Right, time to decide. What would I do?I would probably err on the side of caution and not give metformin. It can always be introduced later if his weight goes up and his renal and heart failure are stable or improve with other medication.If you really wanted to prescribe metformin, it would be best to start a very cautious introduction, maybe at 500 mg OD and then monitoring this patient very closely. Generally, the maximum accepted dose of metformin for patients with an eGFR between 30 and 45 is 500 mg twice daily but I would be quite nervous about it and I would not increase the dose above 500mg OD for this patient unless the circumstances really changed.So, we are not giving metformin but we still need to prescribe something for this patient. And NICE says that if there is a history of heart failure, we should give an SGLT2 inhibitor with proven cardiovascular benefit. NICE says that the benefits in reduction of hospitalisations for heart failure and cardiovascular mortality can be attributed to SGLT2 inhibitors as a drug class, although at present ertuglifozin has not consistently shown these cardiovascular benefits in clinical trials. So, we are likely to choose either dapaglifozin, canaglifozin or empaglifozin for this patient.Remember that SGLT2 inhibitors are also associated with possible weight loss, so along with this prescription there should be appropriate nutritional advice.We also know that there may be an increased risk of DKA associated with SGLT2 inhibitors so NICE advises us that before prescribing, we should check the patient’s individual risk of DKA, for example if, they have had a previous episode of DKA, they are unwell with intercurrent illness or they are following a very low carbohydrate or ketogenic diet. In particular, I would be very keen to make sure that this patient does not continue to lose weight as this is also likely to put him at greater risk of DKA once the SGLT2 inhibitor is started.Also remember that we will need to check our formulary or BNF if you are in the UK because each drug has its own recommendations and eGFR thresholds for dose reduction, caution or avoid. Acceptable options would be:·     dapaglifozin maybe starting cautiously at 5 mg OD possibly increasing to 10 mg OD if no issues develop.·     canaglifozin starting at 100mg OD, which is the starting dose and also the maximum daily dose for anyone with eGFR <60 or·     empaglifozin starting at 10 mg OD, which is also the starting dose and the maximum daily dose for anyone with eGFR <60So that would probably be my first pharmacological action for this patient, but by no means is necessarily the only or best one.Remember that we need to keep monitoring the patient and consider other treatments as and when the situation changes. We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye  

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I I give my summary of the online course by the EASD learning website “Cardiovascular health and diabetes”.This podcast will be saved on a website. There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw The online course can be found on the EASD learning website:https://easd-elearning.org/courses/cardiovascular-health-and-diabetes/ Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]Music provided by Audio Library PlusWatch: https://youtu.be/aBGk6aJM3IUFree Download / Stream: https://alplus.io/halfway-throughTranscriptHello everyone and welcome to the channel. My name is Fernando Florido and I am a GP in the United Kingdom. Today we are going to talk about the link between cardiovascular health and diabetes. The information that I am going to give is based on an online course that is available on the EASD learning website. I highly recommend it and I will put the link to access this course in the episode description. It has seven modules and it is likely to take you between 5 and 7 hours to complete it, depending on how quickly you can process the information. Today’s episode is a summary of the course, which I hope that you will find useful. As ever, remember that there is a YouTube version of this episode and the link to the YouTube channel is also in the episode description.People with type 2 diabetes have twice as many coronary heart disease and strokes as those without it. At first glance, you could think it was too much, but in reality, this is a significant improvement. Previous data indicated that the risk of cardiovascular disease increased by around four to six times. Thus, doubling the risk indicates a significant improvement. Blood pressure control and strict cholesterol treatment are now standard management. And as a result, there are far fewer atherosclerotic events that affect persons with type 2 diabetes. However, as a result, heart failure is now becoming more common.According to research, people with type 1 diabetes have steadily experienced a decline in CVD, CV mortality, and CV hospitalisation. However, there is still a significant gap between those who have type 1 diabetes and those who do not.The same research, however, revealed that those with type 2 diabetes had experienced a far bigger improvement, resulting in, at worst, a doubling of the risk of cardiovascular disease (CVD), hospitalisation for CVD, and cardiovascular mortality. And once more, this has been associated with intensive blood pressure and cholesterol management; perhaps this is something that might be applied to patients with type 1 diabetes, where the focus is still often on glycaemia-related issues.According to other studies, people with type 2 diabetes have an increased chance of developing heart failure. This increased risk is most noticeable in the middle-aged group, perhaps those up to the age of 55, and it appears to be less of an issue as people get older. Therefore, heart failure is now one of the most significant CVD symptoms in persons with type 2 diabetes.Atherosclerotic disease, coronary heart disease, or strokes are still the earliest signs of vascular illness in the non-diabetic population. However, peripheral vascular disease or heart failure are the most typical early presentations of vascular disease in persons with type 2 diabetes.Heart failure in diabetics is caused by a number of different ways. First, excess atherosclerotic disease. Also, the heart's ability to operate can then be impacted by hypertension itself. Additionally, a lot of our patients are now recovering from myocardial infarctions, and as time passes, the ventricle develops scarring that exacerbates heart failure. Furthermore, apart from atherosclerosis and hypertension, there is a heart condition known as "diabetic cardiomyopathy" that damages the myocardium. The ventricle becomes extremely stiff due to a combination of metabolic and pathological causes, making it difficult for the ventricle to relax and fill. And finally, diabetic autonomic neuropathy also plays a role in the development of heart disease in patients with diabetes.Variations in glycaemic control and chronic hyperglycaemia are recognised epidemiologically as risk factors for cardiovascular disease in people with diabetes.There are now numerous things we can do for our patients with diabetes to lower cardiovascular risk, just as there are numerous risk factors for heart disease in those with diabetes. One factor we take into account is lifestyle, but studies have shown that this is a pretty unsatisfactory intervention when we focus on heart disease, frequently failing to show any benefit on lowering cardiovascular disease rates. However, we continue to believe that lifestyle intervention is crucial for some people.After bariatric surgery, cardiovascular morbidity and death have been demonstrated to decrease in people with type 2 diabetes.Controlling glycaemia, blood pressure, and cholesterol are crucial for patients with diabetes.Numerous trials have examined glycaemic control in persons with type 1 and type 2 diabetes. The effects of intensive glycaemic control on microvascular and macrovascular complications were investigated in these trials.In the DCCT study which looked at type 1 diabetes patients, strict glycaemic management resulted in a highly significant decrease in retinopathy and nephropathy. Although the initial decline in cardiovascular events was modest, subsequent studies revealed that, up to 30 years after the initial intense management, the persons who received intensive management saw a decline in cardiovascular disease, as well as total mortality. As a result, a relatively short time of intense control has long-lasting repercussions on the cardiovascular system. This phenomenon is known as the "legacy effect" or "metabolic memory."The UKPDS trial showed that strict glycaemic control in the first 10 years from diagnosis resulted in significant decreases in retinopathy, nephropathy, and neuropathy in individuals with newly diagnosed type 2 diabetes. There was, however, a rise in serious hypoglycaemia as well. Following UKPDS for a further 10 years, that is, for a total of 20 years of follow-up, there was a highly significant reduction in myocardial infarctions and mortality even if the initial reduction in myocardial infarction was not statistically significant. Again, the initial 10-year period of strict management following diagnosis has been shown to have long-lasting effects in lowering cardiovascular disease.In contrast, other studies that examined the intensive management of glycaemia in individuals with type 2 diabetes who had this condition for a while revealed either no benefit in terms of cardiovascular disease or an increase in mortality in the intensive treatment group as a result of individuals receiving large amounts of insulin, massive weight gain, and very frequent hypoglycaemia.A meta-analysis of all type 2 diabetes research findings revealed a decline in coronary heart disease but no impact on overall mortality. In light of this, we can say that glycaemic control does not have a very potent effect when compared, for instance, to blood pressure or cholesterol.In conclusion, it is best if rigorous glycaemic intervention occurs as soon as possible following diagnosis if we are to receive cardiovascular benefits from it. And once someone has had diabetes for ten years or longer, it is doubtful that treating their glycemia will result in any significant cardiovascular benefits. At least this is supported by the evidence from older anti-diabetic medications. Research results may vary with newer medications because more advanced diabetic treatments now show improved cardiovascular risk in addition to lowering blood pressure and producing weight loss.We will now look at individual treatments and their effect on cardiovascular disease.The data for metformin comes from the UKPDS, where a very small subset experienced further benefits in terms of lower rates of myocardial infarction, cardiovascular disease, and overall mortality.Secondary outcome data for pioglitazone showed significant decreases in cardiovascular death, myocardial infarction, and stroke. However, there were also adverse effects such weight gain, fluid retention, and a rise in fractures. As a result, pioglitazone is not that frequently used.DPP4Inhibitors have been the subject of numerous studies. Major adverse cardiovascular events, or MACE, which were the focus of all these investigations, were unaffected. These medications have a modest glycaemic impact and are not extremely powerful. Therefore, it is not that surprising that MACE have not been affected.A surprise side effect of saxagliptin and a subgroup of individuals using alogliptin was a large rise in heart failure hospitalizations. In conclusion, we can state that DPP-4 inhibitors do not affect MACE and that some of them have increased hospitalisation for heart failure, even if this has not always been confirmed in the other trials.SGLT-2 inhibitors have been investigated in numerous cardiovascular outcome trials.Empagliflozin, canagliflozin, and dapagliflozin have all demonstrated a highly significant decrease in heart failure hospitalisation and a significant decrease in severe adverse cardiovascular events (MACE).A meta-analysis of SGLT2 inhibitor studies was able to show that the SGLT-2 inhibitors significantly decreased subsequent MACE events for patients with atherosclerotic disease. A very substantial decrease in heart failure hospitalisation followed for patients with heart failure or had a high cardiovascular risk.Although it has been noted that SGLT-2 inhibitors have a fairly early onset of benefit, the mechanism of benefit is yet unknown.A number of cardiovascular outcome trials using GLP 1 agon

Episode: EASD ADA consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes This podcast is intended for healthcare professionals. My name is Fernando Florido and I am a GP in the United Kingdom. In this episode I go through the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes. I will firstly give you a list of the changes to the previous consensus recommendations followed by a description of the consensus recommendations flowchart on the subject. The original article was published on 19 December 2019 with a subsequent correction published on 15 May 2020.There is a YouTube version of this episode in the NICE GP YouTube Channel that you can access here: ·      https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw This episode also appears in the  Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 Diabetes in Primary Care podcast: ·      Redcircle: https://redcircle.com/shows/diabetes-in-primary-care·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/us/podcast/diabetes-in-primary-care/id1562910252 The ADA-EASD consensus guidelines can be found here:  ·      Website: o  https://link.springer.com/article/10.1007/s00125-019-05039-w ·      Or download here: o  https://1drv.ms/b/s!AiVFJ_Uoigq0lW-4rilnP_mruV41?e=FjPLGo The Summary of the changes to the previous consensus recommendations can be·      Viewed on website above:o  https://link.springer.com/article/10.1007/s00125-019-05039-w·      Or downloaded here:o  https://1drv.ms/b/s!AiVFJ_Uoigq0lW72FZuzZZiv8bPr?e=7Fib8M The Visual summary “glucose lowering medication in type 2 diabetes- overall approach” can be found here:·      Website: o  Figure 1 | 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) | SpringerLink ·      Or download here: o  https://1drv.ms/u/s!AiVFJ_Uoigq0lXCNFscGYei60BiV?e=3n0ErnIntro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through Transcript:This podcast is intended for healthcare professionals. Thank you for listening and welcome to a new episode, bringing you medical information and clinical guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.In today’s episode I am going to go through the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus guidelines on the overall approach in glucose lowering medication in type 2 diabetes.I will firstly give you a list of the changes to the previous recommendations followed by a description of the consensus recommendations flow chart.If you have been following previous episodes, you may be familiar with the updated NICE guidelines on the management of type 2 diabetes. However, the NICE recommendations, primarily followed in the UK, have some substantial differences when compared to other international recommendations and this is why I have decided to do this episode today. You will notice that the main difference with NICE refers to the use of GLP1 mimetics which NICE considers to be less cost effective. However, from a clinical perspective, there is now ample evidence in their favour, which justifies a wider use as described in the consensus guidelines.I will put in the description below a link to download the full article as well as the summary of the changes and the flow chart. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative. Right, let’s go right in. So, we are going to start looking at the European Association for the Study of Diabetes and the American Diabetes Association consensus guidelines on managing hyperglycemia in type 2 diabetes, published in December 2019, corrected in May 2020 and I have put links in to it in the episode description.Now, before starting the treatment flow chart, we are going to go through the changes to the consensus recommendations and this is just a brief summary of what the changes are.As a general consideration we will say that, in high-risk patients, the decision to treat with a GLP 1 receptor agonist or an SGLT 2 inhibitor should be considered independently of the HbA1c. This is because these agents have been proven to reduce major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular deaths and CKD progression.We will say that in patients with established atherosclerotic cardiovascular disease, the level of evidence for cardiovascular benefit is greatest for GLP 1 receptor agonist and this is in terms of reducing major adverse cardiovascular events.And because of this, to reduce the risk of cardiovascular disease, the GLP 1 receptor agonists can also be considered in patients who have no cardiovascular disease but who are at high risk of cardiovascular disease. For patients with heart failure, especially if their heart failure has a reduced ejection fraction, that is, an ejection fraction less than 45%, or if they have CKD with an eGFR between 30 and 60 and microalbuminuria, with urine albumin creatinine ratio greater than 30 particularly if it is greater than 300, the level of evidence is greatest for SGLT 2 inhibitors. So, SGLT 2 inhibitors are recommended with patients with heart failure and equally the SGLT 2 inhibitors are recommended for patients we CKD to prevent progression of CKD as well as the cardiovascular outcomes.Obviously, because there is a link between SGLT 2 inhibitors and an increased risk of amputation, patients with foot ulcers or at high risk of amputation, should only be treated with SGLT 2 inhibitors after careful shared decision making around the risks and benefits and with comprehensive education and foot care and amputation prevention.Well, that was the summary of the changes. Now we are going to dive in straight into the flow chart, which is titled: “glucose lowering medication in type 2 diabetes: overall approach”. And in the right top corner there is a note that tells us that, to avoid clinical inertia, we need to review the patients regularly, ideally every three or six months.Now, the first thing that the flow chart tells us is that the first line therapy is always metformin and comprehensive lifestyle including weight management and physical activity. So, metformin first of all, and then, we are going to see if there are indicators of high risk or established atherosclerotic cardiovascular disease, CKD or heart failure. If the patient has any of these, then we will consider independently of the HbA1c the treatment.This side of the flow chart then divides in two, one if cardiovascular disease predominates or, two, if heart failure or CKD predominate.So, if atherosclerotic cardiovascular disease predominates, either because there is established cardiovascular disease or there are indicators of high risk for getting cardiovascular disease, then we will preferably give a GLP 1 receptor agonist with proven cardiovascular disease benefit and the chart tells us at the bottom in the notes that proven cardiovascular benefit means that it has a label indication for reducing cardiovascular events.If you cannot give or do not want to give a GLP 1 receptor agonist then we will give an SGLT 2 inhibitor with proving cardiovascular benefit, as long as the eGFR is adequate. And again, it reminds us at the bottom of the chart that we have to be aware that SGLT 2 inhibitor labelling varies by region and individual agents with regard to the indicated level of eGFR for initiation and continued use.Right, so we repeat again, independently of the HbA1c and if cardiovascular disease predominates, we will give either GLP 1 receptor agonist or an SGLT 2 inhibitor.And then, we will look at the HbA1c and if the HbA1c remains above the target then we will consider further intensification of the treatment. For patients who are on GLP 1 receptor agonists we will give an SGLT 2 inhibitor and, likewise, if they had initiated an SGLT 2 inhibitor then we will give them a GLP 1 receptor agonist. As an alternative, we can give a DPP 4 inhibitor if the patient is not on a GLP 1 receptor agonist, and this is because of their mode of action or we can also give basal insulin, pioglitazone or a sulphonylurea. So, we are just going to mix and match those agents, always preferably starting with GLP 1 receptor agonist, then SGLT 2 inhibitors and then we can give a DPP 4 inhibitor if the patient is not on a GLP 1 receptor agonist, or basal insulin, pioglitazone or a sulphonylurea. And, also in the notes at the bottom, it tells us that degludec and U 100 glargine have demonstrated cardiovascular disease safety. It also tells us that a low dose of pioglitazone may be better tolerated though less well studied for cardiovascular effects and, in terms of sulphonylureas, it reminds us that we should choose later generations of sulphonylureas to lower the risk of hypoglycaemia and glimepiride has shown similar cardiovascular safety to the DPP 4 inhibitors.So, that concludes the section where cardiovascular disease predominates. Now if heart failure or

My name is Fernando Florido and I am a GP in the United Kingdom. In this video I go through the Visual summary “choosing medicines for first-line and further treatment” corresponding to the 2022 updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 29th June 2022. The video focuses on the drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.This podcast will be saved on a website.There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovwThis podcast also appears in the Primary Care Guidelines podcast which can be found here:·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148NICE Guideline NG28 can be found here:https://www.nice.org.uk/guidance/ng28  The full NG28 full guideline PDF document can be found here:·      Website:https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493·      If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWqK_tYk1rnOolRO The visual summary “choosing medicines for first-line and further treatment” can be found here:·      Website:https://www.nice.org.uk/guidance/ng28/resources/visual-summary-full-version-choosing-medicines-for-firstline-and-further-treatment-pdf-10956472093·      If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWugUmhgaYv1PHyf Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]Music provided by Audio Library PlusWatch: https://youtu.be/aBGk6aJM3IUFree Download / Stream: https://alplus.io/halfway-throughTranscriptThank you for listening and welcome to a new episode of this podcast bringing medical information and NICE guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.Now, imagine that we have Mr. Johnson, who is 78 and has type 2 diabetes. His diabetes control is reasonable or metformin, 500mg BD. With an HbA1c of 7.1% or 54 mmol/mol, but he has just developed stable angina. How should his diabetic treatment change? We have covered the 2022 NICE diabetes management update in previous episodes, but perhaps we need a quick reminder?And this is what we’re going to do today because in this video I am going to go through the flow charts produced by NICE in respect of the blood glucose management in type 2 diabetes. The full guideline has 59 pages in a PDF format and NICE has produced a 5-page summary on the blood glucose management. This video is going to focus on the two flow charts that will advise how to choose first line medicines and how to choose medicines for further treatment.I will put in the description below a link to download the full NICE guideline as well as the five-page summary. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative.Now the first flow chart that we are going to look at is the one about how to choose first line medicines. It is only one page and there is a combination of arrows that will guide us through the treatment pathways and a number of boxes with further information and clarification on the treatments described.Right at the top of the chart, we find a box that tells us about rescue therapy and it reminds us that for patients with symptomatic hyperglycaemia, we will consider insulin or a sulphonylurea and then review the treatment when their blood glucose control has been achieved.Then the next step is to assess the HbA1c, the cardiovascular risk and kidney function. Obviously, as you know, to calculate the cardio vascular risk with, for example, the QRISK2 tool, we will need to know the patient’s age, sex, smoking status, blood pressure and the total cholesterol/HDL ratio.Now, having checked the renal function, before starting to follow the pathway, there is a little box on the left telling us that for information on using SGLT 2 inhibitors for people with type 2 diabetes and CKD, there is specific guidance that is not on this flow chart and we will have to refer to CKD section of the diabetic guideline.So, after we have done our initial assessment with the HbA1c, cardiovascular risk and kidney function, the flow chart divides into three categories. One, it could be that the patient is not at high cardiovascular risk. Two, that the patient has chronic heart failure or established atherosclerotic cardio vascular disease. Or three, that the patient has a high risk of cardiovascular disease, which is defined as a QRISK 2 of 10% or higher over ten years, or an elevated lifetime risk.Now, the first pathway would be when the patient is not at high risk of cardio vascular disease and for these patients, we will offer metformin, or, if there are gastrointestinal side effects, we will give Metformin slow release. Now if metformin is contraindicated, we will consider one of the other antidiabetic agents, either a DPP-4 inhibitor, pioglitazone or a sulphonylurea, although it does also tell us that SGLT 2 inhibitors can also be given as monotherapy for some patients. Basically, NICE recommends an SGLT 2 inhibitor as monotherapy in people who can’t take metformin and for whom the diabetic control is poor, and only if a DPP-4 inhibitor would otherwise be prescribed and a sulphonylurea or pioglitazone is not appropriate. So, it is fairly restrictive.We also see a small note saying that using your ertugliflozin to reduce cardiovascular risk when the blood glucose is well controlled was an off-label use.So, if no cardiovascular risk, we give metformin first and if contraindicated one of the other agents, sulphonylurea, pioglitazone, DPPG4 inhibitors of an SGLT2 inhibitor, although the latter with a few restrictions.Now the second pathway would be when the patient has got chronic heart failure or established atherosclerotic cardiovascular disease. And the flow chart tells us in a box what they actually mean by established atherosclerotic cardiovascular disease, and this is fairly intuitive. It includes CHD, acute coronary syndrome, previous MI, stable angina, prior coronary or other revascularisation, cerebrovascular disease, which includes both ischemic stroke and TIAs and finally, peripheral arterial disease. So, for those patients, we will do very similar. We will start with metformin or if there are gastrointestinal side effects, we will give Metformin slow release and then, as soon as metformin tolerability is confirmed, we will offer an SGLT 2 inhibitor with proven cardiovascular benefit. And this is because SGLT 2 inhibitors have now been found to reduce cardio vascular events. However, if metformin is contraindicated, then we will give an SGLT 2 inhibitor alone. So, this is fairly straight forward.Finally, the third option after the initial assessment is that the patient has not got cardiovascular disease but is at high risk of it. In this case, the flow chart is basically fairly similar. We will give metformin or, if there are side effects, metformin slow release and then as soon as metformin tolerability is confirmed we will consider an SGLT 2 inhibitor with proven cardiovascular benefit. And also, if metformin is contraindicated, we will consider an SGLT 2 inhibitor alone.So, you may ask what is the difference between those two, having cardiovascular disease and being at high risk of CVD? And the difference is basically that, if the patient has got cardiovascular disease or heart failure, we will definitely offer an SGLT 2 inhibitor, whereas if a patient is only at high risk of cardiovascular disease, we will consider it. But in practice you will probably find that pathways are exactly the same, because you’re going to consider it seriously and you're going to give it unless a contraindication or other major consideration. In the middle of the flow chart there’s a little box that reminds us that we always have to start metformin alone to assess tolerability before adding an SGLT 2 inhibitor. So, metformin is always the start.So, this is really the flowchart on how to choose first line medicines. After this, if the person’s HbA1c is not controlled below the target or a person develops cardio vascular disease or a high risk of cardiovascular disease, then we will move to the second flow chart, which is the one about treatment options if further interventions are needed.So, there we go. The second flow chart which is on how to choose medicines for further treatment.Here, at the beginning, there’s another box telling us again about rescue therapy and using insulin, or a sulphonylurea for symptomatic hyperglycaemia until the levels are controlled.Now, if further treatment options are needed, it will be because either at any point the HbA1c is not well controlled, or at any point, the cardio vascular risk or cardiovascular status change.Right, we’re going to start with the cardiovascular risk of cardiovascular status change and we’ve got two options. The first one is that the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, and the second one is that the person develops a high risk of cardiovascular disease.If the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, we will basically switch or add treatments to make sure that we offer an SGLT 2 inhibitor if this is not already prescribed. So, if the person develops the condition, we will either add an SGLT 2 inhi

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 31st March 2022. The podcast focuses in the new drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.This podcast will be saved on a website.There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw This podcast also appears in the Primary Care Guidelines podcast which can be found here:·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://feeds.redcircle.com/2587ad78-7730-48f6-894e-f1f4178e37c3·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148NICE Guideline NG28 can be found here: https://www.nice.org.uk/guidance/ng28Other links referred to in this episode:  ·      visual summary to provide an overview of the recommendations and additional information to support medicines choice·      visual summary on first-line drug treatment·      recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification·      NICE's technology appraisal guidance on dapagliflozin for treating chronic kidney disease·      visual summary on treatment options if further interventions are needed·      section on insulin delivery in the NICE guideline on type 1 diabetes Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through 

Type 2 diabetes: prevention in people at high riskPublic health guideline [PH38]Published: 12 July 2012 Last updated: 15 September 2017Found at https://www.nice.org.uk/guidance/ph38This podcast is intended for Health Care Professionals.My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline PH38: Type 2 diabetes: Prevention in people at high risk. The podcast focuses on the clinical aspects and the administrative or commissioning guidance has been removed from the podcast.This episode is the first of a trial using a computer voice rather than my own. If the trial is successful, it will enable me to produce content more efficiently and I hope that you will find it useful.This podcast will be saved on a website.Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: https://open.spotify.com/track/7GGulw​...Stream on Apple Music: https://music.apple.com/ru/album/when​...

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:https://www.nice.org.uk/guidance/ng28MHRA safety advice on the risk of cardiac side effects with domperidoneMHRA safety advice on the risk of neurological adverse effects with metoclopramideevidence summary on oral erythromycin for gastroparesis in adultsNICE guideline on neuropathic pain in adultsNICE guideline on diabetic foot problemsNICE guideline on chronic kidney disease in adultsCKD classification according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR) (table 1)1 Recommendations | Chronic kidney disease in adults: assessment and management | Guidance | NICE Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: https://open.spotify.com/track/7GGulw​...Stream on Apple Music: https://music.apple.com/ru/album/when​...

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:https://www.nice.org.uk/guidance/ng28Driver and Vehicle Licensing Agency (DVLA)'s Assessing fitness to drive: a guide for medical professionalsMHRA guidance on the risk of bladder cancer with pioglitazoneNICE's guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetesNICE guidance on canagliflozin in combination therapy for treating type 2 diabetesdapagliflozin in combination therapy for treating type 2 diabetesdapagliflozin in triple therapy for treating type 2 diabetes empagliflozin in combination therapy for treating type 2 diabetesthe relevant section in the NICE guideline on type 1 diabetesIntro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: https://open.spotify.com/track/7GGulw​...Stream on Apple Music: https://music.apple.com/ru/album/when​...

Type 2 diabetes in adults NICE guideline -full guideline- Episode 1 of 3My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast covers the full NICE guideline, adding additional information from other clinical guidelines when a reference has been made to them. Links:NICE Guideline NG28 (Type 2 diabetes in adults) can be found here:https://www.nice.org.uk/guidance/ng28Hypertension in adults NICE guideline can be found here: Overview | Hypertension in adults: diagnosis and management | Guidance | NICECardiovascular disease- risk assessment and reduction NICE guideline can be found here: Overview | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICEIntro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: https://open.spotify.com/track/7GGulw​...Stream on Apple Music: https://music.apple.com/ru/album/when​...

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline). The podcast focuses in the non-insulin drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.NICE Guideline NG28 can be found here:https://www.nice.org.uk/guidance/ng28The algorithm for blood glucose lowering therapy in adults with type 2 diabetes can be found here: https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-pdf-2185604173Intro / outro music by Karveas, provided by YouTube Audio Library.Stream on Spotify: https://open.spotify.com/track/7GGulw​...Stream on Apple Music: https://music.apple.com/ru/album/when​...