Thread by @jfdwolff

Last talk: Dr Tahseen Chowdhury @NHSBartsHealth about new diabetes therapies. #AGMConfUK

Diabetes worldwide 400 million and rising. Linear increase in the UK. 1:4 hospital inpatients have diabetes. Main problem is the numerous forms of end-organ diabetes damage. Independently associated with some cancer. #AGMConfUK

Diabetes causes relentless vascular injury ("small cuts").

Genetic/ethnic factors but also social deprivation are associated with DM2 risk. Societal cost >1 billion for treatment and DM complications.

Every cigarette is worth five in DM2. #AGMConfUK

Control? @NICEComms suggests individualised targets. ACCORD showed risk of harm with overdone control. HbA1c 7.5% seems to be the "sweet spot" (sorry).

Good control in the first few years, then relax targets later. #AGMConfUK

Metformin not working? What next? Many options with their own pros & cons. (Start metformin slowly. Consider MR form. Restart it if temporarily withheld for AKI.)

Sulfonylureas not great. Weight gain and hypos. Elderly get hypos. Glitazones cause oedema/CCF/fractures. #AGMConfUK

Insulin causes weight gain and hypos and need much education and monitoring.

GLP1 agonists ("gila monster venom") stimulate beta cell mass and function and help lose weight by reduced appetite. Exenatide/liraglutide etc. Oral form pending. #AGMConfUK

GLP1s restricted to BMI>35 unless weight loss would help for other reasons. Pancreatic complications less of a concern. 3% wt loss at six months.

GLP1s give cardiovascular MACE/death and renal protection. (LEADER study 2016.) #AGMConfUK

DPP4 inhibitors also effective but outcome data insufficient for CV benefit.

SGLT2is are a different story. Glycosuria and Na+ excretion but Na+ is resorbed. Caution with diuretics. GFR 45 ml/min is lower cutoff. #AGMConfUK

In one study canaglifozin was associated with minor amputations.

EMPA-REG showed empaglifozin improving CV death RR by 38% including early benefit. Independent from glucose levels - could it be BP or weight? #AGMConfUK

Canaglifozin now also shown to confer mortality benefit.

Renal outcomes with SGLT2i: less ESRD and macroalbuminuria. ACEi to be combined with glifozin?

Watch out for ketoacidosis in SGLT2i (CBG can be normal or mildly elevated). Mechanism not yet fully elucidated. #AGMConfUK

EASD/ADA 2018 guidelines encourage SGLT2i. NICE to update.

Putting diabetes in remission. Can it be done? DIRECT study 2017 showed the benefits of low calorie diet. 46% of DM in remission. Many areas are piloting this in practice. #AGMConfUK

Continuous glucose monitoring can replace fingerprick CBG and is currently only available for DM1.

Coupling CGM with an insulin pump could create a closed loop system. "Artificial pancreas" starting to show benefits but cost high. Mainly for DM1. #AGMConfUK

Newer diabetes drugs continuously coming on line. Glucagon receptor antagonists and new GLP1s/SGLT2is... #AGMConfUK