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Hong Kong Reference Framework for Diabetes care for Adults in the

Primary Care Settings

MANAGEMENT OF DIABETES USING THE REFERENCE

FRAMEWORK

OUTLINE OF PRESENTATION1) Reference Frameworks - Core Document

2) Reference Frameworks – Modules

3) Implementation issues

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CORE DOCUMENT - TABLE OF CONTENTChapter

1 Epidemiology

2 Population-based Intervention and Life Course Approach

3 Role of Primary Care in the Management of Diabetes

4 Patient Education

5 Aim of the Framework

6 Prevention of Type 2 Diabetes

7 Early identification of People with Diabetes

8 Clinical Care of Adults with Diabetes

9 Patient Empowerment

10 Future Direction to Promote the Use of the Framework

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MODULESModule

1 Framework for population approach in the prevention d t l f di b t th lif and control of diabetes across the life course

2 Early identification of people with diabetes

3 Dietary intervention for people with diabetes

4 Recommending exercise to people with diabetes

5 Glucose control and monitoring

6 Drug treatment for hyperglycaemia

7 Drug treatment in type 2 diabetes with hypertension

8 Lipid management in diabetic patients

9 Diabetic nephropathy

10 Diabetic eye disease

11 Diabetic foot problems

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Type 2 diabetes is a progressive disease: early identification and intervention is critical

Macrovascular complicationsMacrovascular complications

Microvascular complicationsMicrovascular complications

Blood

-cell function

Insulin resistance

Adapted from DeFronzo RA. Med Clin N Am 2004;88:787–835.

Prevention Treatment–10 10+ YearsDiagnosis

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IFG/IGT Type 2 diabetes

Blood glucose

IFG: impaired fasting glucoseIGT: impaired glucose tolerance

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The need of early diagnosis and optimise management

At diagnosis of type 2 diabetes:50% f ti t l d h 50% of patients already have complications1

Over 80% of patients are insulin resistant2

Up to 50% of -cell function has already b l t3been lost3

1UKPDS Group. Diabetologia 1991;34:877–890. 2Haffner S, et al. Diabetes Care 1999;22:562–568.3Holman RR, Diabetes Res Clin Pract 1998;40:S21–S25.

Prevention and early detection is important

Recommendations Grades

Population approach vs. risk based approach

Implement interventions to reduce overweight and obesity at all stages of life to

reduce future risk of diabetes A

Advise individuals at increased risk of developing Type 2 diabetes and patients with

i i d l t l (IGT) t A

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impaired glucose tolerance (IGT) to maintain optimal body weight and practice

healthy lifestyles

A

Test individuals known to be at high risk of developing diabetes B

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Framework for Population Approach in The Prevention and Control of Diabetes Across the Life Course (MODULE 1)

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Framework for Population Approach in The Prevention and Control of Diabetes Across the Life Course

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Early Identification of People with Diabetes (MODULE 2)

1 ≥45 ld bd i l

Risk-based screening for type 2 DM:

1. age ≥45 years old2. One or more risk

factors: family history of DM overweight or obese previous impaired

abdominal circumference:≥80cm(women) ≥ 90cm (men)

metabolic syndrome clinical cardiovascular previous impaired

glucose tolerance or impaired fasting glucose

women with GDM hypertension

clinical cardiovascular disease / risk factors

polycystic ovarian syndrome

long term systemic steroid therapy

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2011 ADA Diagnostic Criteria for DM

1. Fasting plasma glucose 7.0 mmol/l. Fasting is defined as no caloric intake for at least 8 hours.*caloric intake for at least 8 hours.

2. 2 hours plasma glucose 11.1 mmol/l during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 gram anhydrous glucose dissolved in water.

3. In a patient with classic symptoms of hyperglycaemia or p y p yp g yhyperglycaemic crisis, a random plasma glucose 11.1 mmol/l (200 mg/dl).

4. HbA1c 6.5 %. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.

Recommendations on initial treatment Grades

Achieve optimal blood glucose control in all diabetic patients and to reduce microvascular and

macrovascular complications A

The target blood pressure in people with diabetes is The target blood pressure in people with diabetes is below 130/80 mm Hg A

Use lipid modifying drug treatment to control dyslipidemia in diabetic patients A

Advise all patients on maintaining optimal body weight (or reducing body weight if overweight/ obese) and

adopting healthy eating habitA

Advise people with diabetes to increase level of physical activity and take up regular exercises B

Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care B

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Dietary Intervention for People with Diabetes (MODULE 3)Key to Healthy Eating: Eat regular meals and consistent portions Follow a balanced diet:

different food groups less fat, sugar and sodium

Eat more fibre-rich foods: soluble fibre: e.g. oatmeal, fruits, dried

beans insoluble fibre: e.g. whole wheat bread, fruits

and vegetables Use healthy cooking method

cut down fat, sugar and sodium in diet Follow own meal plan

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Meal Planning Approach

Carbohydrates can affect blood glucose levels and should be evenly distributed in meals and and should be evenly distributed in meals and snacks for blood glucose control

~ 50% of total daily calorie intake from CHO, spread out 3-5 small meals a day

Mostly complex CHO, high fibre foods Simple sugar and food with high sugar content

should provide no more than 10% of total calorie should provide no more than 10% of total calorie intake

For a 1800 kcal diet, the daily CHO intake should be 200 gram of CHO = 20 portions

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Meal Planning Approach (2)

Carbohydrate Exchange System: Example 1: Each contains 10g of carbohydrates Example 1: Each contains 10g of carbohydrates

and can be exchanged: 1 slice of wheat bread (thin cut, trimmed crust) 4 soda crackers 1 small fruit (e.g. small orange, kiwi, or pear)

Example 2: Each contains 50g of carbohydrates: 1 bowl of cooked rice 1 bowl of cooked spaghetti 1 medium-sized baked potato

(1 bowl= 300 ml)

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Recommending Exercise to People with DM (adopted from Department of Health Exercise Prescription) (MODULE 4)

Physical Activity P fil

Recommendations*

Profile

Frequency • Moderate to vigorous aerobic exercise spread out at least 3 days per week• Resistance exercise at least twice per week

Intensity • Aerobic exercise at least at moderate intensity• Additional benefits from vigorous aerobic exercise• Resistance exercise should be moderate

Time • Perform 20 to 60 minutes of aerobic exercise per day accumulated to total of 150min per week• For resistance exercise, should perform 3 sets of 8-10 repetitions on 8-10 exercise involving the major muscle groups

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Recommending Exercise to People with DM Physical Activity Profile

Recommendations*

Profile

Type Recommends aerobic exercise of any form that: uses large muscle groups causes sustained increase in heart rateBrisk Walking, swimming or cycling are good choices

Recommends resistance exercise that:Recommends resistance exercise that: uses large muscle groups involves a combination of exercisesE.g. dumbbell, leg extension, abdominal curls

21*Exercise prescription should be tailored to patients with co-morbidities

Exercise Prescription to Patients with Diabetes – special considerations (1)

Gradual progression of intensity is advisableadvisable

Exercise stress testing not a routine may be considered in sedentary adults at high

risk for CHD and would like to undertake more intense activities

Vigorous activity should be avoided in presence of ketosis but it is not contraindicated in simply high blood glucose

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Exercise Prescription to Patients with Diabetes – special considerations (2)

In patients taking insulin or sulphonylureas, exercise can cause hypoglycaemiaexercise can cause hypoglycaemia Advised on identification and management of

hypoglycaemia Added carbohydrate if pre-exercise glucose

level <5.6mmol/l Proliferative or severe non-proliferative DM

retinopathy contraindicated for vigorous retinopathy – contraindicated for vigorous exercise or resistance exercise

Peripheral neuropathy - comprehensive foot care recommended

Glucose Control and Monitoring (MODULE 5)

HbA1c measures glycaemic effect on haemoglobin over measures glycaemic effect on haemoglobin over

preceding 2 to 3 months strong predictive value for DM complications goal of <7% in general. In selected patients 6.5% as measured half yearly as an indicator for blood glucose

control, more frequent for unstable cases limitations: limitations:

conditions affecting red blood cell lifespan may alter HbA1c levels

not a measure for glycaemic variability or hypoglycaemia 24

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Glucose Control and Monitoring

Self-monitoring of blood glucose (SMBG): Recommended in patients using insulin and have Recommended in patients using insulin and have

been educated about insulin titration or those at risk of hypoglycaemia

In patients not using insulin: SMBG is likely to be an effective self-management tool and improve glycemic control if results are reviewed and acted upon by health care providers and/or patients upon by health care providers and/or patients themselves

American Diabetes Association suggested: 3.9 to 7.2 mmol/L for Preprandial fasting <10mmol/L for Postprandial 1-2 hours.

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UKPDS: over 10 years every 1% fall in HbA1c is associated with a

reduced relative risk of complications

A1

c 0

Any diabetes-related

endpoint

Diabetes-related death

All-cause

mortalityMyocardialinfarction Stroke

Peripheral vascular disease‡

Micro-vascular disease

Cataract extraction

on

in r

elat

ive

risk

(%

)d

ing

to

a 1

% f

all

in H

bA

–30

–25

–20

–15

–10

–5

21%

*

21%

*

14%

*

14%

*

12%

†19%

*

*p<0.0001 vs baseline; †p=0.035‡Lower extremity amputation or fatal peripheral vascular disease Adapted from Stratton IM, et al. BMJ 2000;321:405–412.

Red

uct

ioco

rres

po

nd

–50

–45

–40

–35

43%

*

37%

*

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10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes: N Engl J Med 2008; 359:1577-1589Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R. Matthews, F.R.C.P., and H. Andrew W. Neil, F.R.C.P.

Conclusions

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ConclusionsDespite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up. A continued benefit after metformin therapy was evident among overweight patients.

Drug Treatment for Hyperglycaemia(MODULE 6)

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Stepwise strategy can delay patients achieving goals and increase complications

10Diet andexercise

OADmonotherapy

OAD combination

OAD + basal insulin

OAD monotherapy

uptitration

OAD + multiple daily

insulin injections

Duration of diabetes

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6

9

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Hb

A1

c(%

)1

Mean

OAD = oral anti-diabetic

Duration of diabetes

1Adapted from Campbell IW. Br J Cardiol 2000;7:625–631. 2Stratton IM, et al. BMJ 2000;321:405–412.

Complications2

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The case for early combination therapy: reaching and maintaining glycaemic goals

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Diet andexercise

OAD

OAD + basal insulin

OAD + multiple daily insulin injections

Duration of diabetes

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6

9

8

OAD monotherapy

OAD combination

OAD Up titration

Mean

Hb

A1

c(%

)1

Duration of diabetes

1Adapted from Del Prato S, et al. Int J Clin Pract 2005;59:1345–1355. 2Stratton IM, et al. BMJ 2000;321:405–412.

Complications2

OAD = oral anti-diabetic

Drug Treatment in Type 2 DM with Hypertension (MODULE 7)

Target BP < 130/80mmHgA i t i ti i hibit Angiotensin-converting enzyme inhibitor (ACEI) and Angiotensin Receptor Blockers (ARB) confirmed to confer additional vascular and

renoprotective effects should be included in the anti-hypertensive should be included in the anti hypertensive

regime, especially for those with diabetic nephropathy

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Drug Treatment in Type 2 DM with Hypertension

Combination Specific benefits DisadvantagesDiuretic + -blocker Possibly aggravate

h l i i T

Combination Specific benefits Disadvantages

ACE inhibitor + calcium- Calcium-channel blocker-- hyperglycaemia in Type

2 diabetes

Diuretic + calcium-channel blocker

Diuretic reduces mild ankle swelling due to calcium-channel blocker

--

channel blocker has a neutral effect on lipid and glucose metabolism. Combination of calcium-channel blocker with ACEI or ARB is effective in the treatment of diabetic hypertension.

--

-blocker + calcium-channel blocker

-blocker counteracts tachycardia due to calcium-channel blocker’s vasodilator action,Effective anti-anginal therapy

May aggravate or provoke cardiac failure (both are negative inotropes)

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ypDiuretic + ACE inhibitor ACE inhibitor prevents

activation of angiotensin-aldosterone system due to diuretic-induced extracellular fluid volume contraction, and helps to retain potassium

High risk of ‘first dose’ hypotension with ACE inhibitor in patients over-treated with diuretics

Lipid Management in Diabetic Patients (MODULE 8)

At least annual screening, more frequent if neededOptimal treatment target of various lipid Optimal treatment target of various lipid

components: LDL-Cholesterol:

< 2.6 mmol/L<1.8 mmol/L (for patients with pre-existing cardiovascular diseases)

HDL-Cholesterol:>1.0 mmol/L for male >1.3 mmol/L for female

Triglyceride (TG): <1.7 mmol/L

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Management of Diabetic Dyslipidaemia (adopted from ADA) – in order of prioritiesI. LDL-Cholesterol lowering HMG-CoA reductase inhibitor (statin)II. HDL-Cholesterol raisingg behavioural interventions fibrates (gemfibrozil, fenofibrate)** or nicotinic acidIII. Triglyceride lowering glycaemic control fibrates Statins moderately effective at high dose in hypertriglyceridemic

subjects who also have high LDL cholesterolIV. Combined hyperlipidemia First choice - Improved glycaemic control plus high dose statinSecond choice - Improved glycaemic control plus statin* plus fibrates* (gemfibrozil, fenofibrate)Third choice - Improved glycaemic control plus statin * plus nicotinic acid* (glycaemic control must be monitored carefully)

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Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes: N Engl J Med 2008; 358:580-591Peter Gæde, M.D., D.M.Sc., Henrik Lund-Andersen, M.D., D.M.Sc., Hans-Henrik Parving, M.D., D.M.Sc., and OlufPedersen, M.D., D.M.Sc.

Targets: HbA1c < 6.5% Fasting total chol < 175 mg/dl (4 5 Fasting total chol < 175 mg/dl (4.5

mmol/l) Fasting TG < 150 mg/dl (1.7 mmol/l) SBP < 130 mm Hg DBP < 80 mm Hg

Patients were treated with blockers of the renin–angiotensin system because of their microalbuminuria, regardless of blood pressure, and received low-dose aspirin as primary prevention.

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ConclusionsIn at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes.

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The major diabetes complications

Acute complicationsAcute complicationsHypoglycaemiaHypoglycaemiaDiabetic ketoacidosisDiabetic ketoacidosisHyperosmolar hyperglycaemic stateHyperosmolar hyperglycaemic state

Chronic complicationsChronic complicationsMicrovascularMicrovascular

NephropathyNephropathyNeuropathyNeuropathyRetinopathyRetinopathy

MacrovascularMacrovascularMacrovascularMacrovascularCardiovascular complication (IHD)Cardiovascular complication (IHD)Cerebrovascular cx (stroke)Cerebrovascular cx (stroke)Peripheral Vascular disease (PVD)Peripheral Vascular disease (PVD)

Detection and treatment of long term complications

Recommendations Grades

Check the presence of microalbuminuria and serum creatinine in all Type 2 diabetic patients, starting from diagnosis and should review

annually D

y

Treat diabetic patients with microalbuminuria with ACE inhibitors or Angiotensin Receptor Blockers (ARB) to reduce the progression

to diabetic nephropathy if there are no contraindications A

Perform eye examination in patients with Type 2 diabetes shortly after the diagnosis of diabetes. Retinal photography is the evidence-

based best practice and should be carried out by experienced B

p y ppersonnel in screening for DM retinopathy.

Foot care education is recommended as part of a multi-disciplinary approach in all patients with diabetes

B

Screen all patients with diabetes for foot disease annually, and refer to specialist promptly if complication is detected

D

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Diabetic Nephropathy (MODULE 9)

Measure random urine albumin:creatinineratio (ACR) yearlyratio (ACR) yearly > 2.5-25 mg/mmol in men/ 3.5-25 mg/mmol

in women, with confirmation by 2 out of 3 Microalbuminuria

>25 mg/mmol overt diabetic nephropathy

Overt DM nephropathy p p y Perform USG to exclude non-DM causes Test urine microscopy Refer to specialists if indicated

Treatment: ACE and ARB

Screening and Management of Diabetic Renal Disease

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Diabetic Eye Disease (MODULE 10)

An initial dilated and proper eye examination shortly after the diagnosis of diabetesshortly after the diagnosis of diabetes visual acuity (with pin-hole if necessary), lens opacity and

retinopathy.

Retinal photography by experienced personnel in a programme of systematic screening is the evidenced-based best practice should be repeated annually. Less frequent examinations (every 2-3 years) may be

considered following one or more normal eye examinations.

For patient with background retinopathy, more frequent examinations should be done if the patient is at high risk of development of diabetic retinopathy

Screening and Management of Diabetic Eye Disease

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Diabetic Foot Problems (MODULE 11)

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Summary

1. Early intervention and glycaemic control is associated with a long-lasting ‘legacy’ effect in associated with a long lasting legacy effect in reducing later complications

2. Treatment should be individualised over time to maintain an optimal control of all clinical parameters.

3. Multidisciplinary team approach is needed to provide ongoing education to reduce risks provide ongoing education to reduce risks, assess patients’ needs, monitor treatment responses and adherence, identify treatment barriers such as patients’ concerns and misperceptions.

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Challenges on implementation

Setting the standards is easyD l i d i l ti i d l Developing and implementing service models to realize the frameworks is difficult

Structural problems in health care system Public sector :heavily skewed towards

secondary/tertiary care Private sector : lack of allied health

support Financing: whether patients are willing to

pay for care of chronic diseases

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Initiatives Service gaps are being identified in the adoption

of the reference frameworks New service delivery models of care, the

“Community Health Centre” will be explored to foster the provision of more comprehensive and multidisciplinary primary care services

Patient education and empowerment are crucial. The patient’s version of the Reference Frameworks and other education materials are available at the website of the PCO.

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