Oral Anti-Hyperglycaemic Medication in Patients with Type 2 Diabetes
Quality improvement toolkit
Author: Primary Care Quality and Information Service
Date: February 2013 / Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) / PHW (Intranet)
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication
Purpose and summary of document:
This document is for use by general practitioners treating and advising patients with Type 2 Diabetes. The purpose of this toolkit is to support practices to review and reflect on the service they provide and the information they record following patient consultations.
This audit may be of particular interest to clinicians who have seen the recent WeMeReC Bulletin; Newer medicines for type 2 diabetes (May 2012) and the accompanying education module, and reinforces its main points and supplements learning opportunities provided by the case studies.
This toolkit provides patient review criteria and guidance on how to complete a straightforward audit. Also included is a review section designed to prompt reflection and comment on the results of the audit process. Completion of this audit would constitute a suitable piece of Continuing Professional Development that could be included within the appraisal process.
Publication / distribution:
· Publication in PHW document database (Primary Care Quality and Information Service)
· Link from PHW e-bulletin
Contents Page Number
Background 3
Newer drugs in the management of type 2 diabetes 3
Key Points from the WeMeRec Bulletin 3
Monitoring 4
Aim of the Review 4
Review Objectives 4
Patients to be Included 4
Methodology 4
Audit Criteria 5
References 5
Practice Review Sheet 6
Appendices 7/8
Background – Type 2 diabetes develops when the body produces insufficient insulin, or when the insulin that is produced does not work properly (insulin resistance). If there is not enough insulin, or it is not working properly glucose builds up in the blood.
Type 2 Diabetes usually appears in people over the age of 40, though in South Asian and black people, who are at greater risk, it often appears from the age of 25. It is becoming increasingly common in children, adolescents and young people of all ethnicities. Type 2 accounts for between 85 and 95 per cent of all people with diabetes, and is treated with a healthy diet and increased physical activity. In addition to this, medication and/or insulin is often required.1
Type 2 Diabetes is defined by high blood glucose and is characterised by an increased risk of problems including, among others, coronary, cerebrovascular, ophthalmological and renal disease. In addition to encouraging a healthy lifestyle and modifying levels of blood pressure and lipids, good care for people with diabetes includes lowering blood glucose in order to reduce the risk of complications. Blood glucose control is assessed by estimating plasma glucose and measuring haemoglobin A1c (HbA1c), which reflects control over the previous 2 to 3 months. High levels of HbA1c indicate the need for glucose-lowering drugs. With progression of type 2 diabetes over time multiple drugs, including insulin, are usually needed for good glycaemic control. 2
Newer drugs in the management of type 2 diabetes
In recent years new agents have been developed for blood glucose control. These include:
• DPP-4 inhibitors (sitagliptin and vildagliptin – also known as gliptins, or incretin enhancers)
• GLP-1 mimetics (exenatide – also known as incretin mimetics)
• Long-acting insulin analogues (insulin detemir and insulin glargine)
In addition, there have been recent safety concerns on the use of thiazolidinediones (pioglitazone and rosiglitazone) for blood glucose control in type 2 diabetes 2
Key Points from Welsh Medicines Resource Centre (WeMeRec) Bulletin
The newer anti-hyperglycaemic medicines – pioglitazone, the gliptins and the GLP-1 analogues are recommended by NICE as second or third line options in Type 2 Diabetes, only in combination with metformin and / or a sulfonylurea.
The newer anti-hyperglycaemic medicines all lower HbA1c levels, and improved glycaemic control is linked with reductions in micro-vascular complications. Their effectiveness in reducing macro-vascular outcomes is not proven.
Pioglitazone is associated with weight gain and with serious adverse events that can limit its use.
The use of the gliptins and GLP-1 analogues is increasing but long-term safety data from clinical trials is not available.
The GLP-1 analogues promote weight loss and may have a greater effect on HbA1c levels but they require subcutaneous injection and are expensive. They are reserved for second line use when other medicines cannot be tolerated, or third line in selected patients.
The newer long-acting human insulin analogues are not considered cost-effective in type 2 diabetes and are recommended only in specific circumstances.
Monitoring
The WeMeRec Bulletin highlights the need to “tailor” therapy in line with patient needs. The importance of involving patients in their treatment is referenced when stating that patient education and engagement is key to establishing personalised goals for therapy.
This reflects the corresponding Quality Standard recommended by NICE which states that people with diabetes agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia3.
This theme of partnership is continued in terms of deciding a regime for medication; NICE recommending that people with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.
The WeMeRec Bulletin also acknowledges that reducing blood glucose is only one aspect of effective patient management. The significance of reducing cardiovascular risk factors and the role of lifestyle issues such as smoking cessation and weight control are discussed. The NICE Quality Standards recommend also that people with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately3.
Aim of review
To improve the care of patients with Type 2 Diabetes, and to ensure that where appropriate they are in receipt of the correct oral anti-hyperglycaemic medication.
Review Objectives
· To ensure that patients with Type 2 Diabetes, who require medication are in receipt of the correct drugs
· To ensure that those patients are being monitored to assess the effectiveness of those medications
Methodology
· Use retrospective data gathered prior to the audit start date
· Compile, from the practice records a list of those with a diagnosis of Type 2 Diabetes
· Of those select a sample (suggest 10) who take oral anti-hyperglycaemic agents for inclusion in the audit
· On a case by case basis review the records (computer or manual as required) of those selected
· Collate, using the data summary sheet and analyse results of the data collection
· Reflect on the results of the audit and agree those recommendations that you consider appropriate, which may include recalling patients who do not meet the criteria
· Decide on a date to re-audit. PCQIS suggests that the audit is repeated 6-12 months from the date that the current audit is completed
IMPORTANT
The results and subsequent recommendations should be viewed as a development opportunity, and it is for the practice to decide how best to utilise the findings.
Criteria
Patients to be included;
Patients taking Oral Anti-hyperglycaemia medication for Type 2 Diabetes
A. Patients with Type 2 Diabetes and taking Oral Anti-hyperglycaemic medication
B. Of A those who have had their anti-hyperglycaemic medication reviewed in the last 12 months (4)
C. Of A those who have had their target HbA1c recorded in the last 12 months (4)
D. Of C those whose latest HbA1c is between 6.5% and 7.5% (4)
E. Of A those who have had their BMI recorded in the last 12 months (4)
F. Of E those whose latest BMI was greater than 35
G. Of A those patients who, on reflection you consider are on the best medication regime
References
1) Type 2 Diabetes; Diabetes UK (2012) http://www.diabetes.org.uk/Guide-to-diabetes/Type-2-diabetes/
2) National Institute of Health and Clinical Excellence (NICE); Clinical Guideline (CG) 87
3) National Institute of Health and Clinical Excellence (NICE) Quality Standards (March 2012)
4) WeMeRec Bulletin; New Medicines for Type 2 Diabetes (May2012)
Practice review
A. What lessons did the practice discover from carrying out this Review?
B. What changes, if any have the practice agreed to implement as a result of this
Review?
C. What support would enable the practice to enhance the service it provides to
patients?
This Review was compiled by;
Name(s) ______
Signature(s) ______
Practice (name and address) ______
Date ______
Primary care quality and information service / Date
Jan 2013 / Status; Final
Version; 1 / 1 / Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales / Oral Anti-Hyperglycaemic Medication in Patients with type 2 diabetes
Appendix A
Case Review – Data Collection Summary
Start date of the audit ______End date of the audit ______
Question / Criteria / READ Codes / Number / %A / Patients with Type 2 Diabetes and taking Oral Anti-hyperglycaemic Medication / 8B3l.Diabetes medication review
B / Of A those who have had their anti-hyperglycaemic medication reviewed in the last 12 months
C / Of A those who have had their target HbA1c recorded in the last 12 months / 66Ae.
D / Of C those whose latest HbA1c is between 6.5% and 7.5% / 42W..
E / Of A those who have had their BMI recorded in the last 12 months / 22K..
F / Of E those whose latest BMI was greater than 35
G / Of A those patients who, on reflection you consider are on the best medication regime
Author
Primary care quality and information service / Date
Jan 2013 / Status; Final
Version; 1 / 1 / Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS
Public Health Wales / Oral Anti-Hyperglycaemic Medication in Patients with type 2 diabetes
Appendix B Use of anti-hyperglycaemic medicines (when HbA1c target is not met)
Mono-therapy Dual Therapy Triple Therapy
AuthorPrimary care quality and information service / Date
Jan 2013 / Status; Final
Version; 1 / 1 / Intended audience: Public (Internet) /
PHW (Intranet / Internet) / PCQIS