Endocrinology and Diabetes

1200-P: Diabetes. Predictors of glycaemic and weight gain response to empagliflozin treatment: The ABCD Nationwide Empagliflozin Audit. (2019)

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Type of publication:
Poster presentation

Author(s):
Thong K, Chung-wah-Cheong J, Yadagiri M, Cull ML, Bickerton A, Phillips SM, Evans A, Sennik DK, Rohilla A, Reid H, *Morris DS, Atkin M, Robinson AM, Williams DM, Stephens JW, Adamson K, Gallen IW, Ryder RE.

Citation:
Diabetes 2019 Jun; 68 (Supplement 1)

Abstract:
Introduction: We investigated clinical parameters that are potentially associated with improved empagliflozin treatment response.

Methods: We obtained data from a large-scale audit of empagliflozin use in the UK. We analyzed the association between patients’ baseline age, HbA1c, weight, diabetes duration, alanine aminotransferase (ALT), sex, chronic kidney disease (CKD) stage, empagliflozin dose (25 vs. 10mg), use of GLP-1RAs and use of insulin with HbA1c and weight changes at 26 weeks of treatment.

Results: Among 1436 patients, HbA1c reduced by, mean[95% CI], 1.35%[1.27,1.42] (p<0.0001) from a baseline of, mean±SD, 9.41±1.41%. Among 1381 patients, weight reduced by 3.6 kg[3.3,3.9] (p<0.0001) from a baseline of 100.2±20.7 kg. Results of univariate analyses are shown in Table 1. In multivariate analysis, higher baseline HbA1c (p<0.0001), lower CKD stage (p=0.002) and higher ALT (log transformed)(p=0.02) were associated with greater HbA1c reduction. Higher baseline weight (p<0.001) and non-insulin use (p<0.0001) were associated with greater weight reduction.

Conclusion: As expected, HbA1c reduction was associated with baseline HbA1c and background renal function, while weight reduction was associated with baseline weight. The interactions between HbA1c reduction and ALT levels, and weight reduction with insulin treatment status warrant further investigations.

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1201-P: Characteristics and Treatment Outcomes of Patients Treated with Empagliflozin in the ABCD Nationwide Empagliflozin Audit (2019)

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Type of publication:
Poster presentation

Author(s):
Thong K, Chung-wah-Cheong J, Yadagiri M, Cull ML, Bickerton A, Phillips SM, Evans A, Sennik DK, Rohilla A, Reid H, *Morris DS, Atkin M, Robinson AM, Williams DM, Stephens JW, Adamson K, Gallen IW, Ryder RE.

Citation:
Diabetes 2019 Jun; 68 (Supplement 1)

Abstract:

Introduction: We investigated characteristics and treatment outcomes of patients treated with empagliflozin in a large-scale audit of routine clinical practice in the UK.

Methods: Data was obtained from the Association of British Clinical Diabetologists Nationwide Empagliflozin Audit. Between December 2014 to September 2018, multiple sites submitted data through 10 major centers on 1947 patients with at least one follow-up visit after empagliflozin initiation.

Results: Baseline characteristics of patients were, mean±SD, age 59.9±9.9 years, diabetes duration 6.4±5.4 years, HbA1c 9.41±1.43%, weight 99.6±20.8 years, BMI 33.6±9.1 kg/m2and 62.1% were male. Proportion of use of empagliflozin 25mg (vs. 10mg), GLP-1 receptor agonist, and insulin were 63.7%, 13.7% and 20.1%, respectively. There were 44.9%, 49.9%, 5.1% and 0.1% of patients with eGFR>90, 60-89, 45-59 and <45 ml/min/1.73m2, respectively. By 26 weeks, treatment with empagliflozin was associated with, mean±SD, HbA1c reduction of 1.35±1.49% (p<0.0001), weight reduction of 3.6±5.1 kg (p<0.0001) and systolic blood pressure reduction of 5±14 mmHg (p<0.0001).

Conclusions: An audit of empagliflozin use in the UK revealed poorly controlled diabetes being frequently encountered in practice in contrast to randomized clinical trials. There was a preponderance of empagliflozin 25mg dose use, disproportionate prescribing to men rather than women, and frequent co-prescription with GLP-1 receptor agonists and insulin. The audit showed excellent adherence to prescribing guidelines in relation to avoiding empagliflozin use in patients with eGFR<45 ml/min/1.73m2. There was similar treatment efficacy with empaglilfozin as was seen in clinical trials.

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Ketoacidosis in patients on SGLT2 inhibitor: Experience from a district general hospital (2019)

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Type of publication:
Conference abstract

Author(s):
*Kandaswamy L.; *Al-Salihi A.; *Singh P.K.; *Rangan S.; *Moulik P.K.

Citation:
Diabetic Medicine; Mar 2019; vol. 36 ; p. 174

Abstract:
Introduction: European Medicines Agency recognised diabetic ketoacidosis (DKA) as a rare and serious side effect of SGLT2 inhibitors (SGLT-2i). In six months, five cases of DKA in Type 2 diabetes on SGLT-2i were diagnosed at Royal Shrewsbury hospital. Case reports: Case 1: A 63 year old lady on metformin, dapagloflozin, gliclazide with HbA1c-102mmol/mol presented with nausea, vomiting and breathlessness was treated for DKA and pneumonia with pH 7.24, blood sugar-16mmol/l, bicarbonate-17 and ketones-3.6. Case 2: A 61 year old lady on liraglutide, gliclazide, canagliflozin with HbA1c 98mmol/mol presented with nausea, vomiting and polyuria had pH 6.9, blood sugar-16.4mmol/l, bicarbonate-<3 and ketones-5.4. Cases 3, 4 and 5: Patients established on insulin treatment with compliance issues (significantly reducing and missing insulin) had DKA. One of them had associated infection.
Discussion(s): Infection predisposed to DKA in two patients. Two patients had long duration of diabetes and poorly controlled glucose on maximum oral therapy indicating reduced beta cell reserve and three were already on insulin but reduced or missed the doses. All patients were treated according to DKA protocol and made full recovery, SGLT2i was stopped and insulin commenced in two of them and continued with others. Sick day rules emphasised.
Conclusion(s): SGLT2i lowers plasma glucose through glycosuria and promotes ketogenesis. Declining beta cell reserve with increasing duration of diabetes and relative insulin deficiency at the time of stress increases the risk of DKA. Patients on SGLT-2I should be educated of these risks particularly when they have a long duration of diabetes and are established in insulin therapy.

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Variable clinical presentations of renal cyst and diabetes (RCAD) syndrome in two patients (2019)

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Type of publication:
Conference abstract

Author(s):
*Al-Salihi A.; *Kandaswamy L.; *Qamar S.; *Rangan S.; *Moulik P.; *Singh P.K.

Citation:
Diabetic Medicine; Mar 2019; vol. 36 ; p. 86

Abstract:
Maturity onset diabetes of the young Type 5 (MODY 5), known as RCAD syndrome, results from mutations in the hepatocyte nuclear factor 1-beta (HNF1B), most commonly 17q12 deletion. We present two patients with this syndrome: Patient 1: A 31 year old male presented with symptomatic hyperglycaemia. He was diagnosed with diabetes three months previously and had been treated with a sulphonylurea. His past medical history included deranged liver function tests (LFT), azoospermia and a single functioning dysplastic kidney. He had a family history of diabetes in first-degree relatives. Genetic tests confirmed HNF1B heterozygous whole gene deletion. Patient 2: A 34 year old male with diabetes diagnosed two years previously was referred for his
complex medical background. He had a history of renal problems (renal agenesis on right and cysts on left), gout and deranged LFT. His glycaemic control was adequate on Linagliptin monotherapy. Despite the absence of relevant family history, he has been referred for genetic testing.
Discussion(s): RCAD syndrome comprises 2% of all cases of MODY and features renal cysts and diabetes alongside a spectrum of other conditions such as renal dysplasia/hypoplasia/agenesis, reproductive tract anomalies, psychiatric problems, deranged LFTs and other metabolic abnormalities in various combinations. Genetic mutations can be inherited or sporadic. Absence of family history and variability in clinical manifestations can lead to delayed recognition.
Conclusion(s): Patients with RCAD syndrome can present with a varied combination of clinical features. Clinical suspicion, irrespective of family history, is key to diagnosis and management.

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A comparison of follow-up rates of women with gestational diabetes before and after the updated National Institute for Health and Care Excellence guidance advocating routine follow-up, and the association with neighbourhood deprivation (2019)

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Type of publication:
Journal article

Author(s):
Sebastian Walsh, Mahmoud Mahmoud, Htwe Htun, *Sheena Hodgett, *David Barton

Citation:
British Journal of Diabetes 2019;19:[epub ahead of publication]

Abstract:
Background: Gestational diabetes mellitus (GDM) occurs in one in every 23 UK pregnancies. GDM identifies the mother as high-risk for development of type 2 diabetes. The National Institute for Health and Care Excellence (NICE) published updated guidance in February 2015 recommending routine follow-up of women with GDM.

Aims: This cohort study compared follow-up rates of women with GDM before and after the updated guidance. We also investigated for an association between follow-up rates and deprivation.

Methods: Participants were identified from the database of the GDM service of two English hospitals and were organised into two cohorts: ‘pre-guidance’ (2012–2015) and ‘post-guidance’ (2015–2016). Using the recommendations of the NICE guidance as the follow-up standard, we used the hospitals’ computer system to compare follow-up rates of the two cohorts. The English Indices of Deprivation split the country into 32,844 small areas and rank them in order of deprivation such that 1 is the most deprived area and 32,844 is the least deprived. We compared the patients’ postcodes against the English Indices of Deprivation to investigate the relative levels of neighbourhood deprivation of those followed up compared with those not followed up. The Z statistic was used to test for statistical significance.

Results: 535 participants were included (pre-guidance n=306, post-guidance n=229). Baseline average age (pre-guidance 32.2 years, post-guidance 32.5 years), body mass index (30.7 kg/m2, 30.9 kg/m2) and fasting glucose (4.9 mmol/L, 4.8 mmol/L) were all comparable between cohorts. The follow-up rate improved from 60.5% in the pre-guidance group to 69.9% in the post-guidance group. The median deprivation rank of those followed up was 14,565 compared with 13,393 in those not followed up. This difference was not found to be significant.

Conclusion: A higher proportion of women with GDM were followed up with screening for type 2 diabetes after the updated NICE guidance in 2015 recommended routine follow-up. Across the study, over a third of women were not followed up. There was no statistically significant difference in the deprivation levels of those women followed up compared with those not followed up.

Insulin pump therapy: A guide for non-specialist staff (2019)

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Type of publication:
Journal article

Author(s):
*Richardson, Erica A.

Citation:
Journal of Diabetes Nursing; Jan 2019; vol. 23 (no. 1); p. 1-7

Abstract:
With the growing use of insulin pump therapy worldwide, healthcare professionals from all sectors will see more and more people with diabetes who are currently using this therapy. Although NICE guidance stipulates that this cohort should be cared for by a "specialist team", healthcare professionals from all sectors are increasingly likely to care for these individuals. Therefore, training in the basic functions and principles of this kind of therapy can help us to support them, signpost them to services and involve relevant healthcare teams, to ensure they receive the best quality care and support to effectively manage their diabetes. This article provides basic information for nonspecialist staff to help them identify patients who may be suitable for this therapy, identify emergency situations and signpost to appropriate services.