Dr Kevin Fernando describes eight common co-morbidities in patients with type 2 diabetes and how the co-existing conditions should be managed
Read this article to learn more about:
- detecting and managing cardiovascular risk factors and kidney disease in diabetes
- adapting HbA1c, blood pressure, and lipid targets in older people with diabetes
- assessing for ‘diabetes distress’.
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. Earn 0.5 CPD credits.
Multimorbidity is now the norm for people with chronic disease: recent high-quality Scottish epidemiological data1 informs us that nearly one in every four patients seen in primary care has multimorbidities, and one of their co-morbidities is often diabetes.
Co-morbidities have a significant impact on both the quality and length of life in people with diabetes. Individuals with co-morbid diabetes require individually tailored care with the patient at the centre of the decision-making process to optimise outcomes.1
This article will focus on the management of commonly encountered co-morbidities that occur alongside diabetes.
1. Cardiovascular disease
The Scottish Diabetes Survey 20162 revealed that 4.8% of the Scottish population (257,728 people) are registered with type 2 diabetes (T2D). Importantly, and relevant to new key clinical recommendations in SIGN 1543 (see below), 9.7% of those with T2D had previously had a myocardial infarction (MI).2State of the nation 2015: the age of diabetes4 published by Diabetes Scotland informs us that around 2000 people with diabetes die early every year, predominantly from vascular complications.
SIGN 154: Pharmacological management of glycaemic control in people with type 2 diabetes3 was published in November 2017 and made some clinical recommendations differentiating therapies by their efficacy, any cardiovascular benefit, risk of hypoglycaemia, impact on weight, main adverse effects, and prescribing restrictions in renal impairment. Below are two of the four key recommendations from SIGN 154 regarding individuals with type 2 diabetes and established cardiovascular disease (CVD):3
- Sodium glucose co-transporter 2 inhibitors—
- In individuals with T2D and established CVD, sodium glucose co-transporter 2 (SGLT2) inhibitors with proven cardiovascular benefit (currently empagliflozin and canagliflozin) should be considered
- Glucagon-like peptide-1 receptor agonists—
- For individuals with T2D and established CVD, glucagon-like peptide-1 receptor agonists (GLP1RAs) with proven CV benefit (currently liraglutide) should be considered.
2. Pancreatic cancer
Surgery to remove pancreatic tissue, or any pathological process that damages the pancreas can cause diabetes. Pancreatic disease, particularly pancreatic cancer, is also more common in those with diabetes compared with those without.5
NICE Guideline (NG) 12 Suspected cancer: recognition and referral provides a recommendation to consider in primary care to improve the early diagnosis of pancreatic cancer:6
- Consider an urgent direct access computed tomography (CT) scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
- back pain
- abdominal pain
- new-onset diabetes.
3. Diabetic kidney disease
Diabetes and kidney disease commonly occur together; around 25% of people with diabetes will have either some degree of proteinuria or abnormal renal function.7 The management of kidney disease in the presence of T2D is essentially straightforward, with the active detection and management of CV risk factors.
Delaying the progression of diabetic kidney disease8
- Smoking cessation
- Statins as per NICE CG181: Cardiovascular disease: risk assessment and reduction, including lipid modification:9
- chronic kidney disease (CKD) is an independent risk factor for developing CVD and those with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2 and/or albuminuria should be offered atorvastatin 20 mg for primary or secondary prevention of CVD
- Offer antiplatelet therapy to people with CKD for the secondary prevention of CVD but be aware of the increased risk of bleeding:
- a recent meta-analysis10 found no clear benefit of aspirin for primary prevention in non-end-stage CKD, and unsurprisingly aspirin increased the risk of major bleeding
- Aim for a blood pressure (BP) of 120–129/<80 mmHg but as with HbA1c targets, BP targets should be individualised according to functional status, life expectancy, other co-morbidities, and patient preference.
With respect to the management of hyperglycaemia, tight control of blood glucose levels have been demonstrated to reduce the risk of microvascular complications including diabetic kidney disease;11 however, there is no consensus on glycaemic control in diabetic kidney disease. A recent Cochrane systematic review12 explored glucose targets for preventing diabetic kidney disease and its progression and found that the clinical benefits of an HbA1c <53 mmol/mol were uncertain, and the harms of this approach are largely unmeasured.
Therefore, HbA1c targets should be individualised depending on e.g. patient expectations, life expectancy, likelihood of renal replacement therapy, other co-morbidities, and risk of hypoglycaemia.
Pragmatically, an HbA1c target of 53–64 mmol/mol is reasonable in those with CKD stage G3, and an even higher target in those with end-stage renal disease (CKD stage G5) is often appropriate.13
4. Thyroid disease
Individuals with type 1 diabetes (T1D) need an annual check with thyroid function tests because of the close autoimmune relationship between T1D and thyroid disease.14 The situation is different for T2D.15,16
All those with T2D require screening for thyroid disease at diagnosis (TSH/fT4), but then annually only if TSH >2 mU/L and thyroid peroxidase (TPO) antibody is positive.17
See Figure 1 for a useful flowchart from NHS Lothian Edinburgh Centre for Endocrinology and Diabetes.18
It is well established that lowering glucose is associated with significant improvements in microvascular disease and to a lesser extent macrovascular disease.3 However, priorities for glycaemic control may shift in older, frail populations to favour safety and avoidance of hypoglycaemia, rather than to achieve stringent HbA1c targets.
The International Diabetes Federation published a global guideline in 201319 on managing older people with T2D, which delineated functional categories of older people with diabetes and suggested HbA1c, blood pressure, and lipid targets according to each functional category (see Table 1). The authors refer to this guideline as a ‘guiding philosophy’, respecting the fact that older people are very individual and that their needs can differ considerably.
|Functional category||Category definition||Usual HbA1C target (mmol/mol)||Usual BP target(mmHg)||Management of lipids|
Category 1: Functionally independent
Living independently and have no impairments of ADL
Actively manage to reduce CV risk
Category 2: Functionally dependent
Have impairments of ADL and at risk of admission to a care home
Actively manage to reduce CV risk
Subcategory A: Frail
Severe restriction in mobility and strength and high falls risk
Up to 70
Statin use as clinically indicated
Subcategory B: Dementia
Cognitive impairment, disorientation, personality change, and unable to self-care
Up to 70
≤140/90 should be attempted
Consider appropriateness of statin in non-atherosclerotic dementia
Category 3: End of life care
Significant medical illness or malignancy and have a life expectancy of less than 1 year
Avoid symptomatic hyperglycaemia
BP control not necessary unless readings are immediately life-threatening; consider stopping therapy
Lipid control not necessary; consider stopping therapy
ADL=activities of daily living; HbA1c =glycated haemoglobin; BP=blood pressure; CV=cardiovascular
6. Mental health
Chronic conditions such as diabetes place considerable lifestyle and treatment burden on individuals, as well as resulting in potentially debilitating complications and a reduced life expectancy. Mental health problems such as depression are therefore an understandable consequence of a diagnosis of diabetes.
In particular, the concept of diabetes distress has gained a lot of traction recently. It is described as ‘the unique, often hidden emotional burdens and worries that are part of the spectrum of patient experience when managing a severe, demanding chronic disease like diabetes’.20 Depression is defined in the Diagnostic and statistical manual of mental disorders (DSM-V)-as a disorder with specific symptoms; however, diabetes distress reflects an emotional response to a chronic condition (see Box 1).
Box 1: Recognising diabetes distress21
Diabetes burnout can include the following symptoms:
- feeling overwhelmed and defeated by diabetes
- feeling angry about diabetes and frustrated about the demands of managing it
- feeling as though diabetes is controlling your life
- worrying about not taking enough care of your diabetes but unmotivated or unwilling to change
- avoiding parts of your diabetes routine e.g. attending appointments, testing
- not caring about blood sugar levels
- reverting to unhealthy behaviours e.g. poor diet
- feeling alone and isolated with diabetes.
Diabetes UK website. Diabetes burnout: a natural response. www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/diabetes-burnout (accessed 6 June 2018).
Reproduced with permission (PENDING)
Consider formally assessing for diabetes distress using the two-item Diabetes distress scale (DDS-2) and the 17-item Diabetes distress scale (DDS-17). People whose responses to DDS-2 show positive findings (mean scores of 3 or higher) can complete DDS-17 so that appropriate interventions can be offered. Printable text for both scales can be found at: www.diabetesed.net/page/_files/diabetes-distress.pdf.22,23
Given the time pressures in primary care, it can be challenging for practitioners to tackle these deep emotional issues of diabetes distress. However, they can offer support by:21
- acknowledging that it is normal to experience these feelings. Emphasise that diabetes distress is not a mental health condition, but rather a natural and common aspect of living with diabetes
- show empathy and reassure that there is support available (see Box 2)
- offer referral for structured diabetes education to improve self-management and confidence, and for peer support
- offer referral to psychological services.
Box 2: Diabetes UK resources for people with diabetes
- Diabetes UK voluntary groups provide a useful social forum for discussion and can be helpful in dealing with feelings of isolation or marginalisation.
- This service offers an opportunity for people with diabetes, their parents, partners or carers to talk to someone in a similar situation.
7. Steroid-induced hyperglycaemia
The use of steroids in those with pre-existing diabetes will likely result in worsening glucose control; this is referred to as steroid-induced hyperglycaemia. The condition will often require temporary additional glycaemic control. A rise in glucose levels related to steroid therapy in those without established diabetes is termed steroid-induced diabetes. This may or may not resolve when steroid therapy is stopped.24
The Joint British Diabetes Societies for in-patient care (JBDS-IP) published a useful guideline on behalf of Diabetes UK outlining best management of steroid-induced hyperglycaemia (see Box 3).24
Box 3: Type 2 diabetes and steroid treatment—general guidance24
- Agree individualised target for CBG e.g. 6–10 mmol/l according to patient preference, other co-morbidities (particularly frailty), and risk of hypoglycaemia
- Take the opportunity to refresh diabetes education with patient (diabetes management, healthy lifestyle choices, and the risk of hypoglycaemia with insulin and non-insulin therapies)
- Consider increasing monitoring to four times daily:
- before or after meals, and before bed, irrespective of background diabetes control
- if CBG is consistently >12 mmol/l on two occasions during 24 hours, individuals should be treated as below
- If patient has hyperglycaemia on non-insulin therapies:
- a short-acting SU taken once daily such as gliclazide is the best option—titrate to maximum of 240 mg in the morning. An evening dose may also be considered, to achieve a maximum daily dose of 320 mg
- metformin—titrate to maximum of 1 g twice daily
- there is no evidence to support the use of newer therapies such as DPP-4 inhibitors, GLP-1 analogues, or SGLT-2 inhibitors to manage steroid-induced hyperglycaemia
- If patient has hyperglycaemia on insulin therapies:
- if taking evening once-daily human insulin, consider switching to morning dosing
- if there is uncontrolled hyperglycaemia or multiple daily dosing, consider a switch to basal analogue insulin (or alternative regimen) and involve local diabetes team
- beware of nocturnal and early morning hypoglycaemia.
CBG=capillary blood glucose; SU=sulfonylurea; DPP-4=dipeptidyl peptidase 4; GLP-1=glucagon-like peptide-1; SGLT-2=sodium-glucose co-transporter-2
Adapted from Joint British Diabetes Societies for inpatient care. Management of hyperglycaemia and steroid (glucocorticoid) therapy October 2014. Available at: www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_Steroids.pdf
It is now well established that T2D is not a coronary heart disease (CHD) risk equivalent state at diagnosis, or in those with a shorter duration of disease of less than about 10 years. Risk levels approach that of CHD after 8–10 years, or in those with CKD.25
NICE CG181: Cardiovascular disease: risk assessment and reduction, including lipid modification9 recommends the reintroduction of CV risk scoring for those with T2D, but not T1D, to individualise lipid-lowering therapy. This is a significant change from the ‘fire and forget’ approach where statins are recommended for all individuals with newly diagnosed T2D aged over 40 years. There are still merits to a ‘fire and forget’ approach as it reflects the greater lifetime CV risk in those with diabetes; as always, we must take an individualised approach to CV risk reduction in those with T2D.
Cardiovascular disease prevention for people with type 2 diabetes9
NICE CG181 recommends:
- Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool
- Offer atorvastatin 80 mg for secondary prevention of CVD. [Note: atorvastatin does not currently (June 2018) have UK marketing authorisation for secondary prevention of CVD. The prescriber should follow relevant professional guidance, taking full responsibility for all clinical decisions. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices26 for further information.]
Dr Kevin Fernando
GP partner, North Berwick; committee member of the Primary Care Diabetes Society; GPwSI in Diabetes and Medical Education
- Barnett K, Mercer S, Norbury M et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380 (9836): 37–43.
- Scottish Diabetes Survey 2016. Scottish Diabetes Survey Monitoring Group. NHS Scotland. Available at: www.diabetesinscotland.org.uk/Publications.aspx?catId=1
- Diabetes Scotland. State of the Nation 2015: The Age of Diabetes. Available at: www.diabetes.org.uk/In_Your_Area/Scotland
- Scottish Intercollegiate Guidelines Network. SIGN 154. Pharmacological management of glycaemic control in people with type 2 diabetes. Edinburgh: SIGN, 2017.
- Hillson R. Pancreatitis, pancreatic cancer, and diabetes. Practical Diabetes 2016; 33 (5): 77–78.
- NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: www.nice.org.uk/ng12
- Adler A, Stevens R, Manley S et al, on behalf of the UKPDS GROUP. Development and progression of nephropathy in type 2 diabetes: The United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003; 63 (1): 225–232.
- NICE. Chronic kidney disease in adults: assessment and management. Clinical Guideline 182. NICE, 2014 (updated 2015). Available at: www.nice.org.uk/cg182
- NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical Guideline 181. NICE, 2014. Available at: www.nice.org.uk/cg181
- Major R, Oozeerally I, Dawson S et al. Aspirin and cardiovascular primary prevention in non-endstage chronic kidney disease: A meta-analysis. Atherosclerosis 2016; 251: 177–182.
- Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 837–853.
- Ruospo M, Saglimbene V, Palmer S et al. Glucose targets for preventing diabetic kidney disease and its progression (Review). Cochrane Database Syst Rev 2017; 6: CD010137.
- European Renal Best Practice. Clinical practice guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30: ii1–ii142.
- NICE. Type 1 diabetes in adults: diagnosis and management. NICE Guideline 17. NICE, 2015 (updated 2016). Available at: www.nice.org.uk/ng17
- NICE. Eyes on evidence. Thyroid function testing in primary care. NICE, 2016. Available at: arms.evidence.nhs.uk/resources/hub/1049005/attachment
- Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation. UK guidelines for the use of thyroid function tests. Use of Thyroid Function Tests Guidelines Development Group, 2006. Available at: www.btf-thyroid.org/images/documents/tft_guideline_final_version_july_2006.pdf
- NICE. Hypothyroidism. NICE Clinical Knowledge Summary. NICE, 2016. Available at: cks.nice.org.uk/hypothyroidism#!scenario:1
- NHS Lothian. RefHelp website. Thyroid function testing in primary care. Guidance for Thyroid Function Testing in Primary Care in Lothian. Available at www.refhelp.scot.nhs.uk/index.php?option=com_content&view=article&id=700:thyroid-function-testing-in-primary-care&catid=85:endocrinology&Itemid=104 (accessed 21 May 2018).
- International Diabetes Federation. Managing older people with type 2 diabetes global guideline. IDF, 2013. Available at: www.idf.org/e-library/guidelines/78-global-guideline-for-managing-older-people-with-type-2-diabetes.html
- Fisher L, Hessler D, Polonsky W et al. When is diabetes distress clinically meaningful? Diabetes Care 2012; 35 (2): 259–264.
- Diabetes UK website. Diabetes burnout: a natural response. www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/diabetes-burnout (accessed 6 June 2018).
- Fisher L, Glasgow R, Mullan J et al. Development of a brief diabetes distress screening instrument. Ann Fam Med 2008; 6: 246–252.
- Diabetes distress screening scale. www.diabetesed.net/page/_files/diabetes-distress.pdf (accessed 21 May 2018).
- Joint British Diabetes Societies for inpatient care. Management of hyperglycaemia and steroid (glucocorticoid) therapy October 2014. Available at: www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_Steroids.pdf
- Sattar N. Revisiting the links between glycaemia, diabetes and cardiovascular disease. Diabetologia 2013; 56 (4): 686–669.
- General Medical Council. Good practice in prescribing and managing medicines and devices. GMC, 2013. Available at: www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf