Review of new eTG diabetes guidelines

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Welcome to this Australian Prescriber Podcast. I'm Dr Justin Coleman, a GP on the Tiwi Islands north of Darwin, and I'm editor of the Diabetes Management Journal. I'm delighted to be speaking today with Ralph Audehm, a Melbourne GP and clinical honorary associate professor at the Department of General Practice, University of Melbourne. Welcome Ralph.

Thank you Justin for allowing me to talk about a subject that's so close to my heart.

It's lovely to have you. We're talking today of course about the latest version of Therapeutic Guidelines for diabetes, which you were heavily involved in as a contributor on the expert group updating the guidelines. And being a cutting-edge type of guy, Ralph, I wanted to specifically focus today on what's new in this edition. So things that GPs and other health professionals might not have seen before in the book and how it keeps up with the rapid advances these days in diabetic management. So let's start with hyperglycaemia, which I guess in one way is where all diabetes starts, the new section on management of first presentation with hyperglycaemia, and I guess the urgency very much depends on the context. Is it an older person whose sugars have been slowly creeping northward for months or years, or is it an unexpected finding in a sick child or adolescent?

Justin, I think the two areas that were really stressed were firstly reiterating just how important it is to capture children and adolescents with hyperglycaemia so at the first presentation, basically diabetes or hyperglycaemia has to be considered a medical emergency. There's a lot of evidence to suggest that children who present with their first episode of diabetes or hyperglycaemia aren't sent to the emergency department immediately. There seems to be a delay while people confirm maybe what a finger prick test is by doing a blood test. What we're really strongly iterating here is that in any child or adolescent with hyperglycaemia should be sent directly to the emergency department. It is a medical emergency. And we know that 50 percent of children with diabetes will actually end up being admitted in diabetic ketoacidosis. Half of them will have been seen by a GP within the preceding five days.

Okay so I guess we need a high index of suspicion for the sick child and also once we do see that high sugar it's all hands on deck immediately.

Yes, we often say you can't use finger prick to diagnose diabetes. But in children, if you do a finger prick and the sugar is elevated, they need to go to the hospital.

There's also probably the rarer, but still equally important complication of diabetic ketoacidosis particularly I think with some of the SGLT2 inhibitors. We are likely to see a bit of an increase in diabetic ketoacidosis when people get sick or perhaps undergo surgery or have some other major stress to their physiology.

Yes, throughout the booklet, there is specific mention around the fact that SGLT2 inhibitors can increase the risk of diabetic ketoacidosis. And it can also be a little bit harder to diagnose them as having diabetic ketoacidosis because their sugar levels or glucose levels may not in fact be that high. In a person with type 2 diabetes who is unwell, who is on an SGLT2 inhibitor, do you think could this be ketoacidosis and yes they need to then do a finger prick looking specifically at ketones. If that's unavailable, then if they are vomiting or unwell, really they should be sent to the emergency department.

And the other thing that was specifically mentioned around SGLT2, we are all very familiar with stopping metformin prior to major surgery or through if someone is going to have IV contrast medium, but we've also iterated for people going through surgery or who are unwell who are on an SGLT2 to consider stopping, and certainly before surgery stopping it at least a day beforehand.

Thank you. Let's slide down the sugar pole now if we could from hyperglycaemia up the top and have a look at where we want glucose to sit. The sweet spot, I guess we could call it. And you have updated information in the new Therapeutic Guidelines about ideal HbA1c targets for the individual. How important is it to try to individualise these targets depending on the population you're dealing with and the individual circumstances?

Everyone's come on board now with the personalisation of medicine. And I think this is really key because the one size does not fit everyone. So yes we have a general target but I think when we look at our patients it's actually really critical to see what is a desirable target for them, whether they can achieve it, and whether it is possible to achieve it with our current medications that we've got available to us. Talking to a patient about where they should be I think is really key because a lot of people don't know what their target should be. And then I think we talk about whether they are at target or not at target rather than you're failing. Because I think language is also really important when we talk about individualising targets.

For people who are elderly, who are unwell, or may have other comorbidities where we're not expecting them to live a long time, they will not get benefits from having really tight control of their glucose and so we tend to be a little bit more relaxed in that situation. I think that's important because we do want to avoid hypoglycaemia and management of A1c is about long-term complications not the short-term complications.

I think tha’is a very important point and it is refreshing to see guidelines also look at what medications we should be using but also the potential harms of those medications and I know that Therapeutic Guidelines always does that very consistently. Ralph, despite HbA1c targets being important, there does seem to be increasing recognition that much of the mortality and morbidity of people with diabetes tends to be cardiovascular related and the primary treatment of this starts with lifestyle modifications, so your diet and your exercise, followed by cardiovascular preventative agents such as antihypertensives, and this actually does more good than fine tuning that last half percent on their HbA1c.

You're correct. I mean most people with diabetes will die of heart disease. Of course we see that far more early and far more common in people with type 2 diabetes and so treating the risk factors for heart disease is really key in terms of keeping our patients well.

Look of course Ralph, where would Therapeutic Guidelines be without a comprehensive discussion of all the new agents out there and it is a rapidly changing field over the last four or five years so I was glad to see there a table comparing all the different classes of medications. I think that is one of the most commonly used aspects of the book from a GP's point of view these days.

Yeah, and we’re going to see more and more come along as well within the same classes, it’s getting a pretty busy field out there. One of the participants in our expert reference group came up with this nice little sort of flow chart of what to use and when, and I think that’s really good because it actually at the very top says if you’ve got someone with type 2 diabetes whose symptomatic or really high blood glucose, start insulin. Get in there early, get control, then you can sort out what you're going do in the long run. But it also says if you're starting with a very high A1c, actually start off with dual therapy rather than just metformin and wait to see what happens. So that's a little bit different. When it comes to adding in a second line of medication, it does talk about what the alternatives are and if there is a history of cardiovascular disease or risk factors, there are specific agents that are recommended above others.

Yeah I think the SGLT2s and GLP-1s in particular are starting to emerge and have particular cardiovascular benefits. So we’re talking with Associate Professor Ralph Oldham, a Melbourne GP, who’s part of the diabetes update for the Therapeutic Guidelines. Sliding down to the bottom of the scale now Ralph, the updates look long and hard at hypoglycaemia and this is usually iatrogenic in one way or another. What's important about the new hypoglycaemia management?

What I like about these guidelines which may interest a lot of GPs and even some of the GPs who manage people within hospitals is the use of glucagon but also what we call mini-dose glucagon so within adolescents or children who may be coming low you can actually give them smaller doses of glucagon to avoid an impeding hypo if they're not actually eating very well.

Okay so the smaller doses of glucagon ... you titrate part of a larger dose or it comes as its own smaller ...

No you have to actually draw it up within a syringe itself. It's a nice little equation to use. So within that 3–15 years they have that one unit per year of age up to 15 units which is a nice easy way to remember what dose you should be using.

Excellent. There's also a new section on glucose management in adults with type 2 diabetes who are hospitalised. As a GP, hospital management is always a bit of a black box to me but I guess someone's gotta do it so it's nice to see those guidelines there.

I think this is a really powerful part of the book. One of the things we do stress is that for managing people with hyperglycaemia, within a hospital, you always follow the local guidelines that you have. But if you’re a GP working remotely and you are the GP for the local hospital, and they may or may not have local guidelines, there are suggested things that you can actually do while you are getting either further advice or transferring the patient to a larger centre.

Excellent. I can imagine that being very useful indeed. Ralph, we're seeing a technological revolution in measuring and dealing with blood sugars for people with type 1 diabetes. There’s flash glucose monitoring, continuous glucose monitoring, even do it yourself looping connected via smart phones and watches to insulin pumps. I see you have a bit of an introduction to these things in the guidelines as well.

This revolution that you're talking about is absolutely fantastic and not only for type 1, I mean the continuous blood glucose or the flash glucose monitoring is new technology where basically you can actually have continuous blood glucose readings without them having to prick their finger and it gives a wonderful representation of what happens through a whole day and many of these will last up to a week or two weeks. What we're finding is when you look at the tracing like that you can often see where the burden of hyperglycaemia or even hypoglycaemia is happening. And then you can specifically target those areas.

Patients actually feel really liberated on it because they get a large amount of information and they're not having to do that pricking of the finger 4–6 times in a day when you are trying to work out what's going on. The only issue is that it is only measuring glucose within the interstitial fluid. If there was a little bit of a lag with what's happening within the serum glucose is dropping very rapidly and they are having a hypo, the actual flash glucose monitoring or the continuous blood glucose may not have caught up with it and still say their sugar’s okay even though they are having a hypo. So they still need to check by fingerprint or treat if they are having experiences of hypo.

Thank you and I think the feedback I've had from people with type 1 diabetes who are certainly the main initial uses is that it not only keeps them in range but it just helps the daily life. Helps them think less about their diabetes throughout the day.

I see there's also new advice about women who already have type 2 diabetes and then fall pregnant?

Yes, I think this is a really important topic. We are seeing a lot more women with type 2 diabetes now conceiving and having children. Type 2 diabetes is predominately managed within general practice. So as GPs, we do need to be aware of women who have type 2 diabetes and in fact all women with diabetes that we look after, we need to find out whether they are planning to have children in the near future because improving their control prior to conception is really really important. Involving that multidisciplinary team. And I'll often refer women who are planning a pregnancy to an endocrinologist with an interest in diabetes in pregnancy prior to them getting pregnant so everything is actually in place when they decide to have a baby.

Thank you very much Associate Professor Ralph Audehm. It's been a pleasure talking to you and people can find all this information of course in the Australian Therapeutic Guidelines known to most of us as eTG because that's how we access it on our computers. Thanks very much for spending the time today explaining it.

You're welcome.

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The guest's views are his own, not NPS's, and I just make up things as I go. Ralph declares as a conflict of interest he's participated in advisory boards for AstraZeneca and Novo Nordisk. I'm Dr Justin Coleman. Thanks for listening to another Australian Prescriber Podcast.