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At this year’s Diabetes UK Professional Conference, results from the second year of the Diabetes Remission Clinical Trial (DiRECT) were presented. The data for diabetes control, HbA1c, and weight management suggest that intensive weight management has the potential to reduce or delay complications of diabetes and improve clinical outcomes; type 2 diabetes is potentially reversible through weight loss and it is therefore not necessarily a lifelong condition. This has the potential to revolutionise treatment, and means that in the future, early remission may become the primary management target for type 2 diabetes. Research in this area is ongoing and it could be a while before such evidence is adopted in guideline recommendations, but it is interesting to see how the landscape is evolving and speculate about what the future may hold for the management of type 2 diabetes.

In October 2018, the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) published an updated consensus report on the management of hyperglycaemia in type 2 diabetes to reflect new evidence published since the 2015 consensus statement. The updated report puts additional emphasis on holistic, person-centred care and includes a new approach to the selection of glucose-lowering medication based on the patient’s individual co‑morbidities and characteristics. Dr Clare Hambling and Dr Patrick Holmes highlight the key recommendations from the joint ADA/EASD consensus report and describe the factors that influence treatment choice.

Advice about diet, weight management, physical activity, and smoking cessation are fundamental elements of diabetes care, as are psychological support and structured diabetes self-management education. In line with NICE guidance, the ADA/EASD report recommends lifestyle management as the first-line therapy for type 2 diabetes. In cases where diet alone does not provide sufficient glycaemic control, metformin is recommended as the first-line pharmacological treatment option. The ADA/EASD report includes a useful algorithm, reproduced in this article, to guide selection of the most appropriate subsequent treatment for each individual patient.

Also covered in this issue:

The Scottish Intercollegiate Guidelines Network (SIGN) has published the first UK guideline on fetal alcohol spectrum disorder (FASD). Traditionally, FASD has been used as a collective term to describe a range of conditions caused by prenatal exposure to alcohol (PAE). It is likely that FASD is under-diagnosed because of a lack of awareness among professionals and failure to consider PAE as a possible cause of neurodevelopmental delay and/or behavioural difficulties. SIGN aims to reduce confusion and improve diagnosis by defining FASD as a diagnostic term.

Dr Jenny Bennison summarises the recommendations from SIGN and highlights the role of primary care healthcare professionals in identifying children who are at risk. Although diagnosis of FASD cannot be made in primary care, GPs should be familiar with its signs and symptoms so that appropriate referrals for further investigations are made. Primary care professionals are also in an ideal position to gather accurate information about maternal alcohol history before, during, and after pregnancy.

In part one of a two-part series, Dr Toni Hazell provides 10 top tips on sexually transmitted infections (STIs). In this first article, Dr Hazell starts by explaining how to take a full sexual history and screen asymptomatic patients. The remaining tips focus on chlamydia, with discussion of new treatment recommendations, when a test of cure is necessary, and how to handle partner notification. The June 2019 issue of Guidelines in Practice will feature part two, which includes top tips on other STIs.

Dr Honor Merriman shares top tips for GPs on how to ensure that they are ready for their appraisal, and how to get the most out of it. Capturing reflections and learning is harder to do when the relevant event took place months ago, and it may also mean that opportunities for a change in practice are missed. Collecting information throughout the year can help to avoid unnecessary stress. It is also important to be selective about the items included in the appraisal portfolio; not all meetings or events need to be added, and not all items need to have reflective notes. The appraisal should also be recognised as an opportunity to improve GP morale, and create a healthier workforce—Dr Merriman recommends: ‘Instead of thinking, “I need to postpone my appraisal because I am stressed’’, practitioners should think, “I need to arrange my appraisal because I am stressed”’.

In the View from the ground, Tamsyn Crane ponders the complexities of co-sleeping based on her own experience, and what information and advice is available to ensure that it is done safely.