The alphabet mnemonic is useful for remembering all the things that need to be discussed with patients:
- Advice – smoking, diet, exercise, weight loss. See about referring to structured educational programmes.
- Blood pressure
- Diabetes control
- Eye checks
- Foot checks
- Guardian drugs (ACEi or ARB, statins, and to my surprise they also advised aspirin)
Remember that the exercise recommendation for adults 150 min/wk of moderate activity (i.e., harder for you to have a conversation but still possible) plus muscle exercises twice a week plus reducing amount of sedentary activity. If physical activity is vigorous rather than moderate, you can halve the amount of time needed per week (i.e. 75 min/wk for anyone whose arithmetic is as bad as mine); this doesn’t seem to be recommended for >65s, and advice on exercise for this age group should be individualised according to their capabilities; which seems like a good idea for anyone from any age group, but what do I know). Activity can be split into bouts of 10 mins or more.
Target is <140/80 if no complications or <130/80 if end-organ damage is present. (As far as I can see from the algorithm, if the systolic is <140 and diastolic is 80 – 89, you can manage with lifestyle advice.)
Don’t start antihypertensives straight away for raised BP unless it’s over 180 systolic or 110 diastolic. Instead, give lifestyle advice and advise review in two months, unless the BP is >150/90 in which case make it one month.
- 1st drug: ACEi
- 2nd drg: CCB or diuretic
- 3rd drug: whichever wasn’t picked for 2nd drug
- 4th drug: alpha-blocker, beta-blocker or potassium-sparing diuretic
- 5th drug: same as 4th but also consider specialist review.
When checking renal function after starting ACEi or ARB, the things to look for are a 30% rise in creatinine or a 25% drop in renal function. However, if this happens, look for other possible causes before stopping tablets. (Which is all very well, but in practice having a trial off the tablets is probably going to be easier than any other investigation.)
The goal is >40% reduction in non-HDL cholesterol. Things I would love to know at this point: How much extra benefit does that goal hold over a flat target or even just a fire-and-forget strategy? What evidence is there for this? And how does that work out in terms of effective use of time and resources?
The normal starting dose for primary prevention is 20 mg od. For secondary prevention, it’s 80 mg od, although still 20 mg in cases of CKD (it doesn’t say what level of CKD).
Targets are 48 in people who are on either no medication or metformin only, and 53 in people who are on multiple diabetic meds or any hypoglycaemia-inducing medication.
Options after metformin are as I wrote in this post here, but now SGLT-2 inhibitors are also an option for a second or a third drug. In the third-line, the combos with SGLT-2 can be metformin + sulfonylurea or metformin + DPP-4-inhib. Remember insulin can also be used at this stage; in some circumstances so can GLP-1 agonists, but they’re only supposed to be used when under the advice of a specialist team, so I won’t really have a role there beyond referring people. Through all of this, keep reinforcing advice on lifestyle.
Note that SGLT-2 inhibitors can promote weight loss and help blood pressure and lipid profile. Interestingly, it seems the creatinine increase that can be seen is actually transient (which interested me as I had a patient whom I took off one of the flozins for this reason). However, they do cause polyuria and an increased risk of UTIs/genital infections, and they can cause volume depletion and dizziness (I assume due to the polyuria) so ideally I wouldn’t use them in the elderly. They can also increase LDL cholesterol, although that might well not be an issue as the EMPA-REG outcome study showed them to be associated with a significant drop in the risk of CV events (14% drop in events, 38% drop in mortality from CV events). They have been associated with an increase in lower limb amputations, especially toe amputations, and in rare cases with necrotising fasciitis of the perineum, so be very alert for any tenderness, redness, or swelling of the perineal area in patients taking these drugs.
DPP-4 inhibitors are weight-neutral, generally well tolerated, and useful in situations where hypoglycaemia needs to be avoided (e.g. in elderly patients). In renal failure the best one to use is linagliptin, which is mainly excreted via the liver, but any can be used with appropriate dose adjustment. They have been linked with an increased risk of acute pancreatitis, but the suspected increased risk of pancreatic cancer has probably been disproved, as a large study showed no risk increase compared to SUs; however, this possibility will need to be followed up for longer.
Interestingly, it now looks as though pioglitazone probably isn’t associated with bladder cancer. However, remember the side-effects of fluid retention, weight gain, and increased risk of distal long bone fracture.
(BMJ Learning module on management of diabetes)