THE HOT TOPICS AND DIFFICULT AREAS IN DIABETES

The number of people with diabetes is growing and there is now estimated to be five million people with diabetes in the UK. That creates a considerable burden on the NHS budget, both in prescribing and in managing complications. This fourth article in his series on the subject by Dr Bobby Huda outlines new developments in diabetes and current areas where problems in management can arise.

Type 1 diabetes

People with type 1 diabetes are generally diagnosed as children or as younger adults. Type 1 diabetes can present later and may be initially mis-diagnosed as type 2 diabetes.

People with type 1 diabetes are now living longer due to significant improvements in their care. Those people usually produce very little or no insulin of their own – insulin is a hormone from the pancreas gland that is needed to keep blood sugar down. Without insulin they will eventually go into a coma and die from it. Thankfully, since the discovery of insulin that is now very rare.

People with type 1 diabetes usually give themselves insulin through injections into the skin. In the past 20 years many people have been giving insulin through an insulin pump – which is an automated device that is attached to their body by tubing and gives insulin under the skin. They usually need to test their blood glucose several times a day with a finger prick glucose meter, but more recently they can use a glucose sensor. That also sits under the skin and each sensor lasts up to two weeks.

The sensor tells them their glucose 24 hours a day, avoids the need for frequent glucose testing and alerts them when their blood sugar level is too low or too high. These sensors were traditionally quite expensive but the NHS is now funding more of them and availability has increased.

In the last five years, we now have devices where the pump and the sensor can talk to each other – and the pump will automate the amount of insulin given, depending on the glucose. It is almost an ‘artificial pancreas’ – but not fully as the user will still need to estimate how much food they are eating and enter the values into the pump. Nevertheless, it is a significant breakthrough and for the first time represents a partial ‘cure’ for type 1 diabetes. More people will be using the devices as the NHS widens access to funding.

Type 2 diabetes

People with type 2 diabetes are usually older, overweight and have a family history of diabetes. They may be from an ethnic minority background. People with type 2 diabetes still produce insulin, but are insulin resistant due to their body weight and genetic profiles.

Insulin pumps can be used in people with type 2 diabetes but it is more common to focus on oral medications. There are some groundbreaking medications – SGLT-2 inhibitors (eg Forxiga) and GLP-1 agonist medications (eg Ozempic: the weight loss drug) – which reduce glucose and body weight and can reduce complications such as kidney and heart failure as well as overall mortality. Some of the medications can now be used outside of diabetes.

Inpatient diabetes

Up to 20% of hospital inpatients can have diabetes in the UK. That means that people with diabetes are often looked after by non- specialists in diabetes. Most hospitals have diabetes inpatient teams and guidelines, protocols or education programs to upskill non-specialist staff; but unfortunately problems with care do still arise. That can be due to lack of glucose monitoring – often a result of understaffing on wards – or errors in insulin or drug administration.

Most hospitals take part in the National Diabetes Inpatient Audit (NaDIA), which has shown that on the whole errors in hospital are improving with better standards of care. Sub-optimal diabetes control can also lead to increased wound infections after surgery.

Rarely, people with diabetes can have a diabetes emergency while in hospital, including a severe hypoglycaemia episode (very low blood sugar) or develop diabetic ketoacidosis – usually where a person with type 1 diabetes has not received the correct amount of insulin. q

• To contact Dr Huda call 020 3594 6058 / 07919 924925, email bobby.huda1@nhs.net alternatively visit londondiabetes.com or clevelandcliniclondon.uk