update on diabetes services 41 st annual general practitioner study day 28 th january 2012 dr. eoin...
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Update on Diabetes Services
41st Annual General Practitioner Study Day
28th January 2012Dr. Eoin O’Sullivan
Consultant EndocrinologistBon Secours Cork
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Diabetes service development
• What’s done (or almost done!)– Laboratory developments– Type 1 diabetes– Pre-diabetes policy– Podiatry– Exercise classes for type 2 diabetes– Nurse-led diabetes clinics
• What’s next– Insulin pump clinic restructuring– More work on in-patient hyperglycaemia
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Laboratory developments• HbA1c
– Same day turnover in new in-house assay– Better decision making on in-patients with
diabetes/hyperglycaemia– Clearer advice on discharge for patients and
GPs
• Blood ketone testing– Vital for assessment of hyperglycaemic ketosis– Being incorporated into new “Sick day rules”
patient information leaflet
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Type 1 Diabetes• Continuous glucose monitor sensors (CGMS)
– To assist in maximising glycaemic control including avoidance of hypoglycaemia
• Restructuring of insulin pump clinics– Unified approach between diabetes nurse
specialist, dietician and clinician• Blood ketone monitoring
– Home care as well as during admissions
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Pre-diabetes• “Impaired Glucose Regulation” (IGR) or “Non-
Diabetic Hyperglycaemia” (NDH)• Risk factors similar to T2DM• 1 in 7 adults, with annual progression to
diabetes of 5-12%• Approx 50% will develop T2DM in 5 years• IGT especially is associated with increased
cardiovascular risk• Management
– Diet and exercise (±Metformin)– Cardiovascular risk factor reduction
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Diagnostic criteria for diabetes
Normal Pre-diabetes
Diabetes*
F glucose (mmol/l) <6.1 6.1-6.9 ≥7.0
R glucose (or 2 hr on OGTT)
<7.8 7.8-11.0 ≥11.1
HbA1c (%) <5.7 5.7-6.4 ≥6.5
*Single abnormal value sufficient if hyperglycaemic symptoms; otherwise repeat the same test on subsequent day unless have 2 different but concordant tests
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Pre-diabetes patient information leaflet
• What is pre-diabetes?• What is the significance of pre-diabetes?• How do Imanage my pre-diabetes
– Dietary and exercise advice• How should my pre-diabetes be followed
up?• Useful contact information
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How should my pre-diabetes be followed up?
Your GP will need to follow up your blood sugar levels (as well as your blood pressure and cholesterol). This can be done in a number of ways e.g. a fasting blood test, a non-fasting blood test, and/or an oral glucose tolerance test. This involves a fasting blood test, followed by a prescribed sugary drink and another blood test 2 hours later.
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Podiatry
• Foot ulcers in diabetes are a significant cost of care
• Podiatry access will be provided for patients with diabetes who are found to have foot ulcers
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Exercise classes for type 2 diabetes
• Minimum of 6-8 patients with diabetes/pre-diabetes
• Pre assessment/ screening• 8 exercise classes once a week (1 hour)• Exclusion criteria include insulin use/high
risk of hypoglycaemia, poorly controlled diabetes, unstable cardiovascular disease
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Nurse-led diabetes clinics• Restructuring of types of clinics offered
to maximise patient needs• Increasing communication between
diabetes nurse clinic and review in Cork Clinic
• More referrals from Rooms to nurse-led clinic to try to maximise home control and where possible avoid admission
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Diabetes clinics
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What next?
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Inzucchi SE et al. NEJM 2006
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In-patient hyperglycaemia (10-25%)
• Increased in-hospital mortality
• Increased risk of infection
• Increased length of stay
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In-patient hyperglycaemia
• New ward-based insulin prescription chart
• Structured approach to in-patient hyperglycaemia
• Protocols for management of hyperglycaemia
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Endocrine developments
• Synacthen tests in OPD
• Thyroid nodule MDT
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Thank you
Dr Eoin O’SullivanSuite 6, Cork Clinic, Western Road
Tel: 021-4341955Fax: 021-4346148
E-mail: [email protected]