Find Courses Find Online Courses Find Booklets Find Appraisal Essentials Basket 0

Hot Topics Blog

SGLT2 inhibitors - benefits for the pump, pipes and filter

Dr Rob Walker - 30 Jul, 2020

As we start progressing to the ‘new normal’ in General Practice (hands up like me who is less than enthusiastic about that term - what, on earth, is normal about what are doing currently?!) one of the areas I know all our practices will be busy looking at is our patients with diabetes. After a 4-5 month hiatus in reviewing our chronic disease registers, we are all too aware of the potential harm our diabetic population may be exposed to if we don’t start reviewing their glycaemic control and CVD risk factors. The risks patients with diabetes (especially if poorly controlled) are exposed to has been sharply brought into focus with their excess complication rate from COVID-19. So I’m sure your brilliant nurses and admin staff will be ferreting through high HbA1c results, overdue checks, and getting patients like Jim in for their reviews. 

Obviously, really focusing on lifestyle changes, weight loss, etc. is of paramount importance for Jim, but what pharmacological agents should we be using for hyperglycaemia in type 2 diabetes? It used to be so much more straight forward…metformin +/- a sulphonylurea, and if you’re not winning insulin. The thiazolidinediones made a bid for their place on the rostrum in the early 2000s but then CVD safety concerns over rosiglitazone put a large dampener on that. However, since about 2010 we have had 3 new kids on the block that have really come into regular use in primary care - the GLP1 agonists (the ‘tides’), DPP4 inhibitors (the ‘gliptins’) and the SGLT2 inhibitors (the ‘flozins’), which has been fantastic to give our patients more choice and options, but has made our life even more complicated! 

Most interest in the last few years has centred around the SGLT2 inhibitors. I’m sure many of us were a little wary of these drugs when they first started making their way into primary care, especially if like me you are not an ‘early adopter’ of either medicines (or technology..). When concerns were being raised over lower limb amputations, even in tightly controlled RCTs, as well as euglycaemic DKA, I was not rushing to prescribe them - it just felt like we may be heading to another rosiglitazone story. But my fears have been substantially allayed - yes there are (very rare) risks of lower limb amputations and euglycaemic DKA, but we now have convincing evidence that they improve CVD outcomes, especially for people with known IHD, they reduce heart failure risk and have increasingly been shown to improve renal outcomes. The CREDENCE trial published a year ago, recruited patients with type 2 diabetes and albuminuric CKD and was stopped early after just over 2 and a half years, due to significant improvements in the canagliflozin group vs placebo, with a 30% lower risk of the primary outcome (a composite of dialysis, transplant, sustained eGFR <15, doubling of serum creatinine and death from renal or CVD causes). What about the absolute risk improvement I hear you cry? Well, that was pretty impressive too with a NNT of only 28 over 2.5 years to prevent a combined renal outcome (end-stage kidney disease, doubling of serum creatinine or renal death). Importantly many of the patients had low eGFRs down to 30. In June 2020 this led to the European Commission granting a change in the license for canagliflozin (for the lower 100mg dose) to be initiated in CKD with eGFRs ≥30. Currently in the UK licensing restrictions remain that we can only initiate canagliflozin (and all SGLT2 inhibitors) with eGFR ≥60, but it is highly likely the UK will follow suit and relax prescribing guidelines for lower eGFRs, but in the meantime, we should still consider SGLT2 inhibitors for patients with albuminuria and eGFR ≥60. 

So, as a good NEJM editorial concluded 18 months ago, the SGLT2 inhibitors have in-creasing evidence now to support benefits for the ‘pump’ (heart failure), the ‘pipes’ (vascular disease) and the ‘filter’ (kidneys). There is no such thing as a drug for everyone, but the SGLT2 inhibitors are increasingly looking like a second-line option, after metformin, for many people with type 2 diabetes, including someone like Jim. 

We have updated all of our diabetes material ready for our Autumn/Winter LIVE webinar series, so if you need a brush up of your diabetes management why not join us then? Or if you need some more in-depth diabetes training why not join us for our bespoke LIVE diabetes webinar on Thursday 3rd December? We look forward to seeing you then!

Upcoming LIVE webinars from NB Medical

Need an immediate update? – all our courses are available on demand

View and Book our other Online NB Courses


Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.

Login

Will remote consulting contribute to the COVID cancer crisis?

Dr Simon Curtis - 15 Jul, 2020

I had a busy day in the practice yesterday. I arrived at 8am, I left at 8.15pm knackered and limped home too tired to talk to my family. I worked flat out, and yet I only ‘saw’ two patients all day. To be honest, I didn’t find it very satisfying. I was laying hands not on patients but on a computer keyboard, dispatching prescriptions for painful abdomens that in the past I would have felt.

Of course, I was talking to people all day on the phone and computer screen and was busy ordering tests, prescribing, making referrals etc. But I didn’t feel that I was connecting with and assessing people with the same depth as when I see people face to face.

Does that now officially make me a dinosaur? Possibly, but I’d like to argue not. As my friends and family will testify, I love a gadget. I’m an early adopter of new technology (I’d rather not contemplate how much money I’ve ploughed into the Apple empire over the years). But I became a doctor, and especially a GP, because I want that personal contact and communication with patients, to use my hard-learned diagnostic skills, to help patients through the difficulties that life and illness throw at them. Of course, you can do all of that on the phone or via a video call and anyway it’s not about me and my job satisfaction, it’s about what’s best for the patient. I just think you can’t do it as well and that it may be particularly problematic for symptomatic, vulnerable patients.

As we nervously skate along the long green piste of the tail of the pandemic curve we find ourselves on thin ice. The collateral damage is starting to emerge across all three of the bio-psycho-social domains of health and illness. For us in primary care, there are massive challenges in how we help our patients with long term conditions, mental health problems and with diagnosis of new disease especially cancer.

Back in May, my colleague Kate discussed the post-covid cancer time bomb. Since then we have had data published on the ‘brutal impact’ BMJ2020;369:m2386 of the pandemic on urgent cancer referrals and this week it has been widely reported in the media that the pandemic could result in up to 35,000 excess cancer deaths in the UK. There are many reasons for this, including patients’ reluctance to come forward and the suspension of screening and secondary care services.

However, a drop in diagnosis of cancer in primary care may be a vital contributory factor. If a patient calls us with a clear red flag (breast lump, rectal bleeding, haematuria…) then it’s easy. We act. But most patients present with vague symptoms (fatigue, low grade pain, some weight loss, a bit of nausea…) often dismissed by the patient as trivial and easy to ignore on a telephone or video call. Remote consulting has some evidence to support it as safe; but we have seen a whole system change of seismic proportions built on pragmatism, to protect patients and staff from covid-19, rather than a solid evidence base.

So, I am seriously worried that remote consulting may contribute to the cancer crisis through missed diagnoses, as we miss out on the vital cues and clues that we pick up when seeing people face to face. These clues and the unspoken energy in the room are crucial to our diagnostic ‘sixth sense’ or gut feel. Every GP has experience of thinking ‘something is going on here’ that the patient has not expressed, and that line of thought ends up in a diagnosis. We save many lives this way. General practice has always been about managing uncertainty, but remote consulting just adds another level to it.

Another major concern is that remote consulting favours the digitally savvy from higher socioeconomic groups whom, as Tudor Hart famously taught us with the inverse care law, are more likely to call on our resources despite having less need. During all my calls yesterday I was struck by how many were young, educated, and working age. I work in a city centre practice and I feel we are having less contact with the elderly, the housebound, the homeless, and those from minority ethnic groups and I fear that this will compound further pre-existing cancer-related inequalities in referral and outcomes.

Remote consulting became a necessity to protect patients and staff from coronavirus. But I believe we need to be very mindful of how it may contribute to the cancer crisis, and that we need to lower our thresholds for seeing patients face to face especially from vulnerable and disadvantaged groups.


Simon Curtis

Upcoming LIVE webinars from NB Medical

Need an immediate update? – all our courses are available on demand

View and Book our other Online NB Courses


Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.

Login

Burnout - Burning the COVID Candle

Dr Neal Tucker - 22 Jul, 2020

How are you doing?

Earlier in the week, I ran a virtual Hot Topics course and the final topic was burnout. 3 in 10 medics reported currently experiencing every cardinal feature of burnout – exhaustion, negativity, and inefficacy. As I sat in my practice, staring at the growing list of phone calls to patients I realised I should put myself in that 30%, and perhaps the topic could have been higher on the agenda.

Initially in the pandemic things were tough: uncertainty surrounded us, fear for our patients and ourselves, belated direction from authorities always one step behind the disease. But we adapted, we learned and thankfully most of us got through it. And in the face of adversity something else flourished – camaraderie, a sense of belonging and closeness so easily lost in practices which helped protect our minds as masks and gloves protected our bodies.

Then infection rates fell. This was good news. And the normal demands of general practice crept back, the day returned to the usual business in an unusual way.

And now I find I am tired, cynical, and inefficient. My day is full even though I feel I’m achieving less. Clearly, I am not alone.

There are reasons why now is the time in the pandemic when the risk of burnout is greatest. There are 6 key areas of risk for burnout: sustainability of workload, autonomy, recognition and reward, community, fairness, and values or meaningful work. When any of these are disrupted burnout can follow.

Initially, workload was an issue, but this was balanced by a sense of teamwork and the importance of the work we were doing.

Then the covid (now lower case) workload was replaced by the usual day-to-day grind but with the addition of a loss of autonomy due to a restricted health service, a loss of the community due to lack of the face-to-face connection with patients which just doesn’t seem to be replicated on the phone (I am surprised how much I have missed this), a lack of recognition of the hard work we continue to do when the media and public believe general practice is closed (a friend asked me this week what she should do about her child’s overdue vaccination – call your surgery and get it done, I told her looking puzzled), and a refractory sense that much of our work lacks meaning in the face of a global life-threatening infection (even if our patients don’t feel that way and still value what we do).

So, if you are feeling burned out, what can you do?

Talk to your colleagues, share how you feel, consider those six domains, could anything be improved? Research shows that organisational change has the greatest impact on improving burnout in systems.

There is still a benefit in personal measures as well. Cut non-essential work, spend time with friends and family, remember the things in life that give you pleasure and make time for them, watch a movie, eat popcorn. As Phil Hammond says: try to have five portions of fun a day.

Most importantly take a break. You deserve it. We’ve been working hard in the most challenging of circumstances. Many us of have delayed holidays. We need some respite, even if it’s respite at home. We don’t know what the Autumn and Winter will have in store so now is the time to fill up the tanks.

And if you’re don’t have burnout and you’re still reading, take a look around, are any of your colleagues struggling? Ask them how they are doing and see where the conversation goes. It may just be the most meaningful ‘work’ you do today.

For more resources on mental health click here for Dr Rob Walker’s excellent compilation.

 

Neal Tucker

Upcoming LIVE webinars from NB Medical

Need an immediate update? – all our courses are available on demand

View and Book our other Online NB Courses


Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.

Login