The video version of this podcast can be found here: ·      https://youtu.be/t8U8-isTieMThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by them.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through recommendations on the diagnosis and monitoring of type 2 diabetes, which includes guidance by NICE. The links to the NICE guideline is in the episode description. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here:·      https://www.nice.org.uk/guidance/ng28TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll go through recommendations on the diagnosis and monitoring of type 2 diabetes using HbA1c, focusing on what is relevant in primary care only. This information includes guidance by NICE contained in the NICE guideline on Type 2 diabetes. The link to it is in the episode description. Right, let’s jump into it.Let’s start with the diabetic diagnostic thresholds. They could be:An HbA1c of 48 mmol/mol or 6.5% or more orA Fasting plasma glucose level of 7.0 mmol/L or more orA Random plasma glucose of 11.1 mmol/L or more in the presence of symptoms or signs of diabetes.Why have these thresholds been chosen?These thresholds are based on the evidence of glucose levels at which the risk of diabetes-related complications—particularly retinopathy—increases significantly.They have been agreed in order to strike a balance between diagnostic accuracy and early intervention, helping to catch diabetes at a point where treatment can prevent progression and complications.And let’s also remember that if the person has symptoms of diabetes, a single abnormal HbA1c or fasting plasma glucose level can be used, although repeat testing is always advisable to confirm the diagnosis.However, If the person is asymptomatic, we should not diagnose diabetes on the basis of a single abnormal HbA1c or plasma glucose result. Instead, we should arrange repeat testing, preferably with the same test, to confirm the diagnosis. If the repeat test result is normal, we will monitor the person for the development of diabetes, and the frequency of such monitoring will depend on our clinical judgement.This guidance to not diagnose diabetes in an asymptomatic person based on a single abnormal result is based on principles of biological variability, and the importance of avoiding misdiagnosis.This is because Glucose levels and HbA1c can fluctuate due to a variety of reasons and a single abnormal result may not reflect the person's usual glycaemic status. Repeating the test helps rule out false positives due to possible transient factors or a lab artefact or error.Can we use HbA1c and plasma glucose interchangeably to diagnose type 2 diabetes?Well, in general, yes, but there are times when HbA1c should not be used to diagnose diabetes. This is the case for:Children and young people under the age of 18. Pregnant women or women within 2 months postpartum. People with symptoms of diabetes for less than 2 months. People at high diabetes risk who are acutely ill.People taking medication that may cause hyperglycaemia (for example, long-term corticosteroids). People with acute pancreatic damage, including pancreatic surgery.And People with end-stage renal disease (ESRD).Additionally, HbA1c should be interpreted with caution in people with abnormal red blood cell turnover or abnormal haemoglobin type, like: Abnormal haemoglobin, such as haemoglobinopathy, including sickle cell trait. Severe anaemia (of any cause). Altered red cell lifespan (for example, in post-splenectomy). And a recent blood transfusion.Why do we need caution in these situations? Well, HbA1c reflects the percentage of haemoglobin that has glucose attached to it—essentially giving us an average of blood glucose over the past 2 to 3 months, which is the typical lifespan of a red blood cell. However, anything that alters red blood cell turnover or haemoglobin structure can affect the accuracy of this measurement. For example:In conditions like haemoglobinopathies (e.g. sickle cell trait or thalassaemia), the structure of haemoglobin is different, which can interfere with how HbA1c is measured or how glycation occurs.In severe anaemia or increased red cell turnover, red blood cells are cleared from the circulation more quickly, so there’s less time for glucose to attach—leading to falsely low HbA1c.Conversely, if red cells live longer than normal (such as after splenectomy), HbA1c may be falsely high because glucose has more time to accumulate.And finally, after a recent blood transfusion, the donor’s red blood cells—often with a different glycaemic history—can distort the result.So, in these cases, HbA1c may not accurately reflect the patient’s glycaemic control, and alternative measures like fasting glucose or an oral glucose tolerance test may be more reliable.What about diabetic monitoring?NICE recommends that we should measure HbA1c levels in adults with type 2 diabetes:Every 3 to 6 months until HbA1c is stable on unchanging therapy orEvery 6 months once the HbA1c and diabetic therapy are stable. If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will need to estimate trends in blood glucose control using one of the following:quality-controlled plasma glucose profilestotal glycated haemoglobin estimation (if there are abnormal haemoglobins) orfructosamine. What do these alternative forms of monitoring involve?Well:Quality-controlled plasma glucose profiles involve measuring fasting and postprandial glucose at regular intervals, giving a day-to-day picture of control, although they don’t reflect long-term trends as well as HbA1c.Total glycated haemoglobin measures all forms of glycated haemoglobin (not just HbA1c), and may be more accurate when variant haemoglobins interfere with standard HbA1c assays.And finally, fructosamine reflects glycation of serum proteins (mainly albumin) rather than haemoglobin, giving an average of blood glucose over the past 2–3 weeks. As we have said, it's useful in cases where red blood cell lifespan is abnormal, but also in pregnancy, or when rapid changes in glucose control are occurring.Each of these methods has limitations, but they can give a more reliable picture than HbA1c when red cell-related interference is present.What about HbA1c targets?NICE advises that we should discuss and agree an individual HbA1c target with patients, encouraging them to reach and maintain it, unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target impair their quality of life. However, from a general perspective, for those managed either by lifestyle and diet alone, or combined with a single drug not associated with hypoglycaemia, we should aim for an HbA1c target of 48 mmol/mol (6.5%). For those on a drug associated with hypoglycaemia, we will aim for an HbA1c target of 53 mmol/mol (7.0%). In adults, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:we will review and reinforce their current treatment andthen proceed to intensify drug treatment, generally by adding a second drug.These thresholds are heavily influenced by the results of clinical trials such as the UKPDS (or United Kingdom Prospective Diabetes Study), which is still one of the most influential long-term RCTs on glycaemic control in type 2 diabetes.It showed that intensive blood glucose control (targeting HbA1c around 53 or ~7.0%) significantly reduced:Microvascular complications (like retinopathy, nephropathy, and neuropathy).And additionally, long-term benefits for macrovascular outcomes emerged in extended follow-up giving rise to the so-called “legacy effect”What is exactly the legacy effect?Well, it describes the fact that participants in the UKPDS randomised controlled trial were followed for 10 years after the trial ended. Although the differences in HbA1c between intensive and conventional groups disappeared within a year, the intensive group still had significantly lower rates of both micro and macrovascular complications as well as all-cause mortality. In a way, this showed that early good control leaves a "metabolic imprint" that protects patients long term, even if later control becomes less strict.However, although tight control can be beneficial, we will consider relaxing the target HbA1c on a case-by-case, with particular consideration for people who are older or frailer, if:they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancyif tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired hypoglycaemia awareness, or they drive or operate machinery as part of their jobor if intensive management would not be appropriate, for example if they have significant comorbidities. This is because there is strong evidence that in older or frail adults, sometimes the risks of hypoglycaemia may outweigh the benefits of strict control. In particular, the ACCORD Trial found that intensive glucose lowering (with a target HbA1c of less than <6.0%) increased all-cause mortality in people with type 2 diabetes at high cardiovascular risk. In fact, the trial had to be stopped early due to this excess mortality. Our take home message is that tight control is not always safe, especially in older, comorbid populations.On the other hand, if the HbA1c level is lower than their target and they are not experiencing hypoglycaemia, we will encourage them to maintain it, being aware that there are other possible reasons for a low HbA1c level, for example deteriorating renal function or sudden weight loss. So that is it, a review of the diagnosis and monitoring of type 2 diabetes. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye.

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