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Peterborough Diabetes Study Day - 30 January 2019

The supporting guidance and presentations from this event are on the 'Related Documents' tab to the right.

The Q&A is below (and also available as a download in the Related Documents tab).

STRUCTURED EDUCATION QUESTIONS:

Is MyDES available in different languages?
Not currently but DESMOND are working on it.

Should I get patients to self-refer or refer as a GP?
If the patient is with you as a GP or PN it would be quicker to refer the patient yourself as they will need their blood results. However, if the patient is not convinced at the moment you are with them you can send them away with the self-referral form.

Is MyDES available for those with hearing problems and those who are not able to do the day course?
Yes it is, if you refer into DESMOND noting the patients requirements CPFT admin will contact them about MyDESMOND. 

Is there availability to provide a follow up for DESMOND?
Unfortunately CPFT do not have capacity to provide follow up sessions for DESMOND at the moment. However, MyDESMOND does act as a follow up and CPFT are offering it to every patient who attends a DESMOND session.

Can someone come to DESMOND with an interpreter?
DESMOND is a group session and is not an appropriate setting for patients to attend with their interpreter as it would be very disruptive. These patients are eligible for 1:1 sessions with a Dietitian. 

Can Type 2 patients attend PDAC?
Type 2 patients can attend PDAC providing they are in insulin.

I am not able to find MyDES app in the Appstore on my Iphone. Is there a certain way to search for it?
MyDESMOND is not an app but a website www.mydesmond.com, you can then save the link to your home screen. Patients will be sent a login code by our team once we have been provided with their email address.

DIET AND LOW CARB QUESTIONS:

Is instant porridge in sachets ok to recommend to patients?
The porridge sachets are a good way to control portion sizes and are absolutely fine to recommend as long as it is not one of the ones with added sugar like the golden syrup version etc.

I advise patients to have a piece of fruit rather than a biscuit but is this not advised?
It is all about portion control – fruit is good, provided it is not eaten in large quantities. A healthy lifestyle is what we should all advise patients on so absolutely it is good to advise patients to have a piece of fruit rather than a biscuit 

DPP QUESTIONS:

What are the new criteria for DPP? Are they on S1 because on the lab results we are advised to refer when HbA1c comes back between 42-47.
The CCG are looking into changing the advice from the lab results to the new criteria HbA1C.

The new referral criteria is: 

  • Aged 18 years and over
  • HbA1c between 44-47mmol/mol (6.2%-6.4%) or Fasting Plasma Glucose between 6.5-6.9 mmols/l within the last 12 months
  • Not pregnant
  • Able to take part in light/moderate physical activity

Referrer information sheet - Healthier You: NHS Diabetes Prevention Programme

CHOOSING DIABETES TREATMENT WITH THE PATIENT:

Metformin induced B12 deficiency, to screen or not to. If screened and deficient what treatment is advised?
As far as metformin-induced B12 deficiency is concerned, my policy (Dr Roland) is not to screen directly but I do check a full blood count routinely and look at the mean cell volume (MCV). If that is raised or looks as if it is going up, I then do check the B12 level.  If a deficiency is revealed, I have found 1 injection of Hydroxocobalamin 1mg annually more than sufficient to correct the deficiency.  The BNF recommendations are for  a greater frequency than that but  I do routinely check B12 levels thereafter in such patients.  From my experience, it is a pretty rare phenomenon.  

Are we saying we can’t reverse Diabetes, the media is saying it?
Telling patients that they can reverse their Diabetes gives them unrealistic hope. If they bring their HbA1c down they have put their Diabetes into remission but all the risks will remain if they gain the weight again. Patients should be congratulated and encouraged to put their Diabetes into remission but telling them they can reverse it will only disappoint them later.

If a patient loses weight and brings down their HbA1c should they stay on Metformin?
Dr Rowland recommended keeping the patient on Metformin regardless as it has helped them bring down their weight and HbA1c and has no evidenced medical downsides

Patient presented with cardiac symptoms and their GTT was positive but subsequently their HbA1c has been normal what is the course of action?
Repeat the GTT and if it is normal then the initial reading could have been an anomaly. 

What is the ideal meds approach for diabetic patients?
Offer DESMOND and Metformin as the first step for all patients however, following that the GP or Practice Nurse should go through each drug and their positive and negative effects with the patient to see what would work best for them.

What is the best advice for prescribing Sulphonylureas for HGV drivers?
This is not recommended practice and would need to be thought about carefully. If you have to start patients on this then you must ask them to test their blood glucose before driving and it needs to be at least 7. Prior to doing a long drive you should ask them to test their sugars to see how quickly they fall.

Can you do a C-Peptide test whilst patients are still on medications?
Yes, you can test a C-Peptide at any time.

I have patients adamant that statins have caused Diabetes – what are your thoughts?
As far as statin-induced diabetes is concerned, this seems to occur mostly in people who have pre-diabetes or features of the metabolic syndrome.  Large scale studies do indicate a small increase in the incidence of diabetes compared to placebo in those patients put on statins.  The precise mechanism hasn’t been fully elucidated. There are suggestions statins decrease insulin sensitivity.  However, there is also a simpler nutritional explanation, that in a cross sectional follow up of more than 20,000 adults over 10 years (the NHANES study) it was shown that those on statins liberalise their fat and total calorie intake and therefore gained weight over time, compared with those not on statins.  So the progression to diabetes could be explained by lifestyle liberalisation.

HYPERTENSION MANAGEMENT:

For ambulatory monitoring, what BP do you use?
You need to use the daytime mean – the machine should tell you what stage of hypertension the patient is in. 

Are the Specialist Diabetic Team encouraging patients to buy their own BP machines?
No, we don’t currently but this might be something we can look into as it will support GPs. 

PODIATRY

What sorts of things should go to Advanced Specialist Podiatry?
Only Diabetic wounds/risks – this team do not see non-diabetic hard feet or cut toenails etc. 

What do you think of over the counter creams etc. like Flexitol?
These are all ok to use for patients. It is important to keep patients feet moisturised but ensure that you don’t put moisturiser between patients toes.

Can we use Curinail for Diabetic feet?
Yes, just check the patient’s sensation first. The biggest danger is corn plasters – try to advise patients not to use these.

PREGNANCY QUESTIONS:

What meds do you keep pregnant women with Type 2 on?

We only keep patients on Metformin

IAPT

When a patient self refers are they still picked up by the integrated team?
Yes, they are filtered into the integrated team, however it is a slower process so if you are able to refer patients in then do, just for speed.

Do you offer the option for home visits?
Unfortunately, no we are a clinic-based service, however we are able to provide telephone support for those patients that are unable to leave the house.

HEALTHY PETERBOROUGH

To be eligible for these programmes do you have to pay council tax in Peterborough?
Patients need to have a Peterborough post code to be eligible. Otherwise they will fall under Everyone Health.

26/04/2019