Individualising targets in diabetes: NICE or not NICE?

Laura referred to the 6.5% (or lower) HbA1c target recommended by NICE and ... small proportions of patients on insulin achieve HbA1c targets of <6.5%. Skiptocontent [email protected]+44(0)1352706190/+6495705775  0 ViewCartCheckout Noproductsinthecart. Subtotal:$0.00 ViewCartCheckout Search HomeAboutRxAboutRxOurVisionOurValuesOurExperienceEthics&ComplianceWhyChooseRxJoinUsOurTeamServicesPublicationsPlanning&MedicalWritingStrategicCommunicationsHealthEconomicsCommunicationsPatientInformationEvidence-BasedTools&ServicesProcessAuditsMedicalEducation&TrainingCreativeSolutionsEducation&TrainingBookletsDigitalhealthRxCommsPlusBookletsHOCContact LandlineNZ:+6495705775 Individualisingtargetsindiabetes:NICEornotNICE? SearchHOC Search: Author: CarolinePerry RxCommunications AttheDiabetesUKConferenceheldinGlasgow,March2016,leadingcliniciansandapatientwithdiabetesdebatedtopicsrelatedtotheupdated(2015)NICEguidanceforadultswithdiabetes. Chairs:NicolaMilne,ManchesterandPaulNewman,Glasgow Settingthescene:apatient’sperspective PresentedbyLauraCleverly@ninjabetic1 LauraCleverlyisadiabetesbloggerknownas“Ninjabetic”andaregularcontributortotheDiabetesTimes Laurahastype1diabetesandsetthesceneforthisprimaryandsecondarycaresessionbyprovidingpersonalinsightontheissueofindividualisingglycaemictargetsforadultswithtype1diabetes.Lauratalkedabouttheimportanceofempoweringpatientsandindividualisingtreatment,aswellaseducationforhealthcareprofessionalsworkinginthefieldofdiabetes.SharingherpersonalexperiencesoftreatmentandherinsightsintotheNICE2015glycaemictargetsforadultswithtype1diabetes,1Laurasaidthatasapatientshefeltthatshehadbeenplacedinaboxinwhichshedidn’tnecessarilyfit,andshehighlightedtheissueofindividualisationoftreatment/individualtreatmenttargetsandthelatestNICEguidance.Laurareferredtothe6.5%(orlower)HbA1ctargetrecommendedbyNICEandexplainedthefeelingsoffailurethatshemighthaveifshewasnotabletoachievethistarget. Referringtoherstaysinhospitalasapatient,Lauraalsoquestionedthecommonpracticebyhospitalstaffoftakingherinsulinawayfromherforstorageinthelockedfridge.Asapersontakingfullresponsibilityforhertreatmentaroundtheclock,Laurasaidthatshefeltthispracticetookawayherpowerandidentity,andsheemphasisedtheimportanceofgoodcommunicationandengagementbetweenhealthcareprofessionalsandpatientssothattheindividualneedsofthepatientarefullyunderstoode.g.uponadmissiontohospital. Whichtargetforwhichpatient? PresentedbyProfessorBrianFrier. ProfessorBrianFrierBSc(Hons),MD,FRCP(Edin),FRCP(Glas),isHonoraryProfessorofDiabetesattheUniversityofEdinburgh,affiliatedtotheBritishHeartFoundationCentreforCardiovascularScience. ProfessorFrier,aleadingexpertondiabetesandhypoglycaemia,introducedhistalkbybrieflydiscussingglycaemictargetsinthecontextoftheQualityandOutcomesFramework(QOF)guidelinesthatrewardhealthcarepracticesforqualityinclinicalcareindiabetes.  2,3 However,ProfessorFrierpointedoutthattheseguidelinesdonotuseanindividualisedapproach.Referringtomajortreatmentguidelinesforadultswithdiabetes,ProfessorFriernotedthat,since2006,thesehavebeenbasedonglycaemictargetsforthelong-termmanagementofpatients;inmostmajorguidelines,basedonbestevidence,theHbA1ctargetshavebeen6.5–7%.ProfessorFriersaidthatthelatestNICEguidelineshaveplacedmoreemphasisontheneedsoftheindividualpatient. Reviewingkeyfindingsofthemajorlandmarkstudies:UnitedKingdomProspectiveDiabetesStudy(UKPDS)4andtheDiabetesControlandComplicationsTrial(DCCT),5ProfessorFrierremindedtheaudiencethatthesestudiesshowedthatthelowertheHbA1clevel,thelowertheriskofmicrovascular,cardiovascularandothercomplications.Referringtothe`legacyeffect’,ProfFrieremphasisedthatifgoodglycaemiccontrolisachievedearlyoninthetreatmentofapersonwithdiabetesthenaclinicalbenefitwillusuallycontinueovertime. IntheDanishSTENO2studyinpatientswithmoreadvancedtype2diabetes,6patientswhoreceivedintensivemultifactorialtherapyhadalowerincidenceofcardiovasculareventsthanpatientswhoreceivedconventionaltreatment.ProfessorFriernotedthatthelowertheHbA1clevelthebettertheoutcome,particularlyinyoungpeoplewithtype1diabetes.However,heexplainedthatitcanbedifficulttoachievestrictglycaemiccontrolwithinsulintreatmentandmostmajorstudieshaveshownthatrelativelysmallproportionsofpatientsoninsulinachieveHbA1ctargetsof <6.5%. Morbidityofhypoglycaemia Morbiditiesassociatedwithhypoglycaemiaincludecardiovasculareffects,neurologicalissues,fallsandaccidents,dependingonage.Hypoglycaemiainpeoplewithtype2diabetesiscommonacrossalllevelsofglycaemiccontrol.Also,thelongerpatientsareoninsulin,thegreatertheriskofhypoglycaemia,eveninpatientswithgoodglycaemiccontrol.Achievingandmaintainingstrictglycaemiccontrolcanthereforebedifficult.Thisposesthequestionastowhetherstrictglycaemiccontrolisappropriateforsomepatients,ProfessorFriernoted. Fearofhypoglycaemiaanditsclinicalimplications ProfessorFriersaidthatmanypatientsareveryconcernedaboutseverehypoglycaemia,sometimesratingitasseriousasgoingblindordevelopingkidneyfailure;heexplainedthatsomepotentialrisks,suchashypoglycaemia,areassociatedwiththeachievementofverytightglycaemiccontrol.Importantly,fearofhypoglycaemiainfluencesself-management,duetoconcernsabouttheimplicationsofhypoglycaemiaintermsofsocialrelationshipsandotherfactors,includingdrivinglicencerestrictions.Thisinturnfuelsanxiety.Therefore,patientsoninsulinmayrelaxtheirglycaemiccontrol. Concludinghisinterestingandinsightfulpresentation,ProfFriernotedthatforsomepatientswithtype2diabetes,glycaemictargetsareunattainable,andhestressedtheimportanceofa“commonsenseapproach”,ashasbeentakenbytheAmericanDiabetesAssociation(ADA)intheADA2016guidelines7andothertreatmentguidelines.ProfessorFrierreinforcedthemessagethatglycaemictargetsshouldbeindividualisedforindividualpatients. OnthesubjectofincentivesandQOFs,amemberoftheaudiencecommentedthatifGPsarerewardedfor“achievingtargets”,thiswillnotencourageindividualisedcare.Thistopicislikelytocontinuetobethesubjectofdebateamonghealthcareproviders,includingprimarycarephysicians,andpeopleaffectedbydiabetes. NICEguidelines:Type2diabetes PresentedbyDavidMillar-Jones. DavidMillar-JonesistheChairofthe PrimaryCareDiabetesSocietyUKandIreland,andtheAssociateSpecialistandGPleadfordiabetesinAneurinBevanLHB.DavidisinvolvedinestablishinganintegratedservicefordiabetesandisactivelyinvolvedineducationanddiabetessupportwithinPrimaryCare. Duringtheintroductiontohistalk,DrMillar-Jonesstressedthehighincidenceofdiabetes,stating: thetsunamiofdiabetes…issettounfold DrMillar-JonespresentedanoverviewofthecurrentNICEguidelinesforadultswithtype2diabetes,8reviewingthecurrentguidanceontreatmentoptionsfortype2diabetesandemphasisingtheimportanceofanindividualisedapproach,tailoredtotheneedsandcircumstancesofthepatient.Heemphasisedthatpatientstatusshouldbeassessedregularlyandthatpatientsshouldhavetheirsayintreatmentselection,takingintoconsiderationthepotentialrisks,benefitsandeffectivenessoftreatment.DrMillar-Jonesexplainedthatpatientsaremorelikelytobecompliantwithtreatmentiftheyareinvolvedintreatmentselection.Heremindedtheaudiencethat,asstatedintheNICEguidelines,drugtreatmentsthatarenoteffectiveforanindividualpatientshouldbediscontinued. DrMillar-JonesalsotalkedaboutcurrentNICErecommendationsfortheuseofmetformin,includingtheuseofstandard-releasemetforminasinitialdrugtreatmentforpatientswithtype2diabetes.Ifmetforminisanunsuitabletreatmentoption(e.g.duetotolerabilityissues,orcontraindications),initialtreatmentwithadipeptidylpeptidase-4(DPP-4)inhibitor,orpioglitazone,orasulphonylureashouldbeconsideredaspotentialtreatmentoptions.[NICEguidanceshouldbereferredtoforothertreatmentoptions].Highlightingtheimportanceofanindividualisedapproachtotreatment,DrMillar-Jonesconcluded: GuidanceisNICEtohavebutthebesttreatmentwillalwaysbebespoke NICEguidelines:Type1diabetes:autopianfantasy? PresentedbyDrParthaKar@parthaskar DrParthaKarisClinicalDirectorofDiabetes,PortsmouthHospitalsNHSTrust,andalsotheAssociateEditoroftheDiabetesTimes IntroducinghistalkontheupdatedNICEguidelinesforadultswithtype1diabetes,DrKarreflectedonthe2004NICEguidelines,comparingthesewiththecurrentguidelines.DrKarraisedquestionsabouttheNICE2015HbA1ctargetsforpatientswithtype1diabetes,whichmaybedifficultforsomepatientstoattain.Inresponse,ProfessorStephanieAmiel,whowasinvolvedinwritingtheguidelines,explainedthattheglycaemictargetsintherevisedNICEguidelinesshouldbeconsidered“aspirationalgoals”. Duringhisexcellentandthought-provokingpresentation,DrKarurgedtheaudiencetousetheirstrongvoicetohelpimprovecareforpeoplewithdiabetes. YoucannotescapetheresponsibilityoftomorrowbyevadingittodayAbrahamLincoln TheimportanceofstructurededucationwasalsohighlightedbyDrKarandheasked NICEtocommissionDoseAdjustmentforNormalEating(DAFNE)acrosstheUK.9 DAFNEprovidespeoplewithdiabetes,aswellashealthcareprovidersandcommissioners,withtheskillsthatarerequiredtoestimatethecarbohydratecontentofeachmealandtoinjectthecorrectamountofinsulin. References Type1diabetesinadults:diagnosisandmanagement.NICEguidelines[NG17]PublishedAugust2015:https://www.nice.org.uk/guidance/ng17 BMAQOFGuidance:http://www.bma.org.uk/qofguidance TheNICEIndicatoryMenufortheQOF:https://www.nice.org.uk/Standards-and-Indicators/QOFIndicators HolmanRR,PaulSK,BethelMA,etal.10-yearfollow-upofintensiveglucosecontrolintype2diabetes.[UKPDSstudy].NEnglJMed2008;359:1577-1589October9,2008DOI:10.1056/NEJMoa0806470.http://www.nejm.org/doi/full/10.1056/NEJMoa0806470 TheDiabetesControlandComplicationsTrialResearchGroup.TheEffectofIntensiveTreatmentofDiabetesontheDevelopmentandProgressionofLong-TermComplicationsinInsulin-DependentDiabetesMellitus.[DCCTstudy].NEnglJMed1993;329:977-986September30,1993DOI:10.1056/NEJM199309303291401 http://www.nejm.org/doi/full/10.1056/NEJM199309303291401 GædeP,VedelP,LarsenN,etal.MultifactorialInterventionandCardiovascularDiseaseinPatientswithType2Diabetes.[STENO2study].NEnglJMed2003;348:383-393.January30,2003.DOI:10.1056/NEJMoa021778http://www.nejm.org/doi/full/10.1056/NEJMoa021778#t=articleDiscussion AmericanDiabetesAssociation.StandardsofMedicalCareADAinDiabetes–2016http://care.diabetesjournals.org/site/misc/2016-Standards-of-Care.pdf NICEType2diabetesinadults:management.NICEguidelines[NG28]Publisheddate:December2015.https://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#individualised-care DoseAdjustmentForNormalEating(DAFNE). RelatedPosts: PostViews: 1,063 LikePost: Sharethispost ShareonFacebookShareonFacebook TweetShareonTwitter PinitShareonPinterest ShareonLinkedInShareonLinkedIn PostnavigationPreviousPreviouspost:mHealth:CurrentOpportunitiesandChallengesNextNextpost:ANewcomer’sViewpointoftheDiabetesUKConferenceRelatedPostsRareDiseases–AGrowingFocusforHealthcareProductDevelopers9thJuly2018ISPORBaltimore–GreatInformationbutMedicalWritingTrainingNeeded…6thJune2018DoOutcomeMeasuresinPainTrialsHamperDrugDevelopment?5thJune2017 LatestUpdates GetourHealthOutcomesCommunicatordirecttoyourinbox–sign-upnow! HOCSign-Up SearchHOC Search: Connect    RecentPosts DistillingtheComplexityoftheBody Top10Sarcomajournalsin2022 Newtechnology-enabledcommunicationssolutionsinthepharmaceuticalindustry Theethicalchallengeofhumanchallengetrials VirtualMedicalConferencesVsIn-Person:WhereToIn2022? Categories Archives Blog Communications Editorial Featured HealthEconomics heor.tv HTA&MarketAccess Newsletter Tips&Tools Uncategorised CustomisedBooklets WecancustomizeallourEducation&TrainingBookletsinyourcompanylogoandincludespecificexamplesofstudiesandresearchresultsdependingonyourclinicalarea. Requestacallbacktofindoutmore. RequestaCallback SecurePaymentsby GotoTop CallbackForm ---(GMT-12:00)InternationalDateLineWest(GMT-11:00)MidwayIsland,Samoa(GMT-10:00)Hawaii(GMT-09:00)Alaska(GMT-08:00)PacificTime(US&Canada)(GMT-08:00)Tijuana,BajaCalifornia(GMT-07:00)Arizona(GMT-07:00)Chihuahua,LaPaz,Mazatlan(GMT-07:00)MountainTime(US&Canada)(GMT-06:00)CentralAmerica(GMT-06:00)CentralTime(US&Canada)(GMT-06:00)Guadalajara,MexicoCity,Monterrey(GMT-06:00)Saskatchewan(GMT-05:00)Bogota,Lima,Quito,RioBranco(GMT-05:00)EasternTime(US&Canada)(GMT-05:00)Indiana(East)(GMT-04:00)AtlanticTime(Canada)(GMT-04:00)Caracas,LaPaz(GMT-04:00)Manaus(GMT-04:00)Santiago(GMT-03:30)Newfoundland(GMT-03:00)Brasilia(GMT-03:00)BuenosAires,Georgetown(GMT-03:00)Greenland(GMT-03:00)Montevideo(GMT-02:00)Mid-Atlantic(GMT-01:00)CapeVerdeIs.(GMT-01:00)Azores(GMT+00:00)Casablanca,Monrovia,Reykjavik(GMT+00:00)GreenwichMeanTime:Dublin,Edinburgh,Lisbon,London(GMT+01:00)Amsterdam,Berlin,Bern,Rome,Stockholm,Vienna(GMT+01:00)Belgrade,Bratislava,Budapest,Ljubljana,Prague(GMT+01:00)Brussels,Copenhagen,Madrid,Paris(GMT+01:00)Sarajevo,Skopje,Warsaw,Zagreb(GMT+01:00)WestCentralAfrica(GMT+02:00)Amman(GMT+02:00)Athens,Bucharest,Istanbul(GMT+02:00)Beirut(GMT+02:00)Cairo(GMT+02:00)Harare,Pretoria(GMT+02:00)Helsinki,Kyiv,Riga,Sofia,Tallinn,Vilnius(GMT+02:00)Jerusalem(GMT+02:00)Minsk(GMT+02:00)Windhoek(GMT+03:00)Kuwait,Riyadh,Baghdad(GMT+03:00)Moscow,St.Petersburg,Volgograd(GMT+03:00)Nairobi(GMT+03:00)Tbilisi(GMT+03:30)Tehran(GMT+04:00)AbuDhabi,Muscat(GMT+04:00)Baku(GMT+04:00)Yerevan(GMT+04:30)Kabul(GMT+05:00)Yekaterinburg(GMT+05:00)Islamabad,Karachi,Tashkent(GMT+05:30)SriJayawardenapura(GMT+05:30)Chennai,Kolkata,Mumbai,NewDelhi(GMT+05:45)Kathmandu(GMT+06:00)Almaty,Novosibirsk(GMT+06:00)Astana,Dhaka(GMT+06:30)Yangon(Rangoon)(GMT+07:00)Bangkok,Hanoi,Jakarta(GMT+07:00)Krasnoyarsk(GMT+08:00)Beijing,Chongqing,HongKong,Urumqi(GMT+08:00)KualaLumpur,Singapore(GMT+08:00)Irkutsk,UlaanBataar(GMT+08:00)Perth(GMT+08:00)Taipei(GMT+09:00)Osaka,Sapporo,Tokyo(GMT+09:00)Seoul(GMT+09:00)Yakutsk(GMT+09:30)Adelaide(GMT+09:30)Darwin(GMT+10:00)Brisbane(GMT+10:00)Canberra,Melbourne,Sydney(GMT+10:00)Hobart(GMT+10:00)Guam,PortMoresby(GMT+10:00)Vladivostok(GMT+11:00)Magadan,SolomonIs.,NewCaledonia(GMT+12:00)Auckland,Wellington(GMT+12:00)Fiji,Kamchatka,MarshallIs.(GMT+13:00)Nuku'alofa PleaseproveyouarehumanbyselectingtheCar. HOCSignupForm PleaseproveyouarehumanbyselectingtheTruck.