And finally…

Here is the final bulletin from Linda Goldie at the ADA.

On the last full day I went to a series of lectures called ‘Is there a Gold Standard for the Diagnosis of Diabetes’. As you are aware the ADA adopted the use of HbA1c for the diagnosis of diabetes over 12 months ago and earlier this year the WHO gave its own stamp of approval on its use. I was hoping to come away from this session feeling confident on the role of HbA1c but unfortunately I am not so sure. Some things are fairly clear as far as the level at which complications start, With a HbA1c greater than 5% (31 mmol/mol) there starts to be a rise in macro-vascular risk, whereas for micro-vascular this risk is generally not seen until HbA1c is around 8% (64 mmol/mol), but there are still factors for the use of HbA1c in diagnosis that are harder to clarify. The problem seems to be on the under-diagnosis, with Dr Mayer Davidson quoting that 42% of people diagnosed using glucose criteria will have a normal HbA1c. I think that the debate will never be completely settled and that in the meantime all we can do is follow the guidelines we have. In the UK we can use HbA1c for screening as per the vascular checks programme and I think the most important thing is that we ensure that whatever method we use we perform it as accurately as possible to ensure we get the diagnosis right.

Other things of interest during the day were discussions on new longer acting basal insulins ( up to 40 hours) and the use of insulin and GLP-1’s in combination therapy. The next generation of oral hyperglycaemic agents will be the SGLT2’s. These drugs work to stimulate glycosuria therefore giving a reduction in blood glucose. Now at the end of phase 3 and commencing early 4 stage trials we wait to see what this will bring to our armoury in conquering hyperglycaemia.
The final day at the conference, and the day we came home, started bright and early and I found myself at 7.30am  in a debate on the use of basal analogue versus NPH insulins. The main points here were that both insulins give similar glycaemic control but the basal analogues cause less hypo and weight gain. One point I learnt here was with regard to NPH, and that in type 2 diabetes using a low dose of NPH twice a day can improve glycaemic control with fewer hypos, in particular when a patient has had good structured education. In these days of looking at costs it might be worth reviewing this option for some of our patients.

Later in the morning the group that I travelled with met to share our conference experiences and then set off on the long journey home. Overall the conference was a success and I would like to thank the pharma company who supported and looked after us all so well (you know who you are so no advertising here!) and also my fellow delegates, predominantly secondary care diabetologist and endocrine consultants who made this primary care nurse feel very welcome!

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