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This week is the annual Diabetes Awareness Week organised by Diabetes UK. Working in primary care we cannot help but be “diabetes aware” with a significant number of the patients we see in every surgery either diagnosed with type 2 diabetes or at risk of the condition. I am currently sat in San Francisco Airport about to fly home to Wales after being fortunate enough to attend the American Diabetes Association conference 2019. It has been exciting to be here “live” to listen to the new advances and great to see several UK primary care practitioners represented on the international stage.
So, what is new and how will it affect us in primary care?
The strongest message from the conference for me was all about the kidney. There has been a real shift in the approach to managing type 2 diabetes over recent years following on from the exciting studies showing cardiovascular protection from the newer classes of diabetes medications, i.e. the SGLT2 inhibitors (“gliflozins”) and a number of the GLP1 receptor agonists (injectable “glutides”). These led to the development of new consensus guidelines from the US and European diabetes associations advising us to prioritise these medications in our patients with type 2 diabetes and cardiovascular disease. The cardiovascular outcome trials also showed evidence of renal protection, so renal outcome trials are ongoing. The first of these published a few months ago and its results and implications for clinical practice were discussed in depth during the conference.
The CREDENCE trial was a large multi-centre RCT of the SGLT2 inhibitor Canagliflozin in patients with type 2 diabetes and established chronic kidney disease. The primary endpoint was renal outcomes but secondary endpoints included cardiovascular outcomes. We are all aware of the increased cardiovascular risk associated with CKD. The trial was halted early due to the positive outcomes. They found a 30% relative risk reduction in the primary endpoint of end stage kidney disease, doubling of creatinine and renal or cardiovascular death. There was a number needed to treat of just 28 to prevent renal progression and 40 to prevent CV death, MI or stroke. Don’t forget that until now the only option for slowing renal disease has been ACE/ARBs. I spoke to one renal physician who very much felt these will be renal drugs and that their effect on lowing HBA1c is just a side effect! There are trials ongoing with the other SGLT2 inhibitors and indeed also in patients without diabetes.
Is this really a relevant finding for us? Well the answer is a definite yes. Diabetic kidney disease is an often complex situation to manage, so what should be our approach? Screening is vital and there were several reminders at conference of the importance of checking both eGFR and urinary ACR. The National Diabetes Audit data in the UK shows that our rates of urinary ACR measurements are falling so trying to improve this is a great practice project. It is important because a raised ACR is an independent cardiovascular risk factor and predicts a poor outcome.
Our priority in diabetic kidney disease is to optimise CV risk factors – good BP control, lipid management, ensuring patients are taking the maximum tolerated dose of ACE/ARB and of course lifestyle factors. I also feel that communication with patients is vital, informing them about their kidney disease encourages empowerment and engagement. Diabetes UK information prescriptions include one about kidney disease – a nice single piece of A4 we can give to patients with a good explanation, and can be integrated into computer systems to be pre-populated with their most recent results. An excellent resource.
In terms of management of HBA1c in renal disease we need to ensure that we prescribe appropriately according to eGFR and beware the associated increased risk of hypoglycaemia. The findings from CREDENCE and the renal outcomes seen in the CV trials support prioritising SGLT2 inhibitors in diabetic kidney disease. The American Diabetes Association has just updated its guidelines a s a result to recommend using SGLT2 inhibitors in patients with type 2 diabetes and kidney disease with eGFR > 30. At present our licence for these medications is an eGFR of 60 to commence and we can continue to prescribe down to 45 but then stop. We are likely to see this change over the next few years and NICE are in the process of reviewing and updating their guidelines for the management of type 2 diabetes in the light of all this new evidence.
As you can tell and as anyone who has been to the NB diabetes course will know, I am passionate and genuinely excited by these advances which will make real difference to outcomes for our patients with type 2 diabetes.
Now time for home and back to the normality of school runs and surgeries, with memories of San Francisco to keep me smiling!
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