BJDVD

ABCD Spring Meeting, Renaissance Manchester Hotel, 21–22 April 2016, in conjunction with the North West Endocrine Society

A lot of delegates took full advantage of the newly configured meeting to maximise their CPD by attending the inaugural ABCD IPN-UK conference on 21 April. Those who could not be spared from the workplace for the whole day took advantage of the Roche-sponsored Insulin Pump Symposium, and were treated to a practical exposition of how to incorporate bolus advisors into pump practice by Karen Spowart. Pratik Choudhary then introduced the concept of intraperitoneal insulin infusion as a potential means of achieving better glucose control and the DiaPort system designed to deliver it.

After the association’s Annual General Meeting, Dr Gerry Rayman accepted the second Rowan Hillson Insulin Safety Award from Dr Hillson herself for the utilisation of a networked ward blood glucose monitoring system to reduce the incidence of severe hypoglycaemia for inpatients at Ipswich Hospital.

We were sorry that Russell Drummond, ABCD's meetings secretary, was not able to attend to see the success of the programme he had put together. Once again each presentation had a song title assigned to it that presenters embraced to a varying extent. Kevin Fernando got the conference off to a lively and thought-provoking start. A GP working in Scotland with a special interest in diabetes and medical education, he challenged us to think what we as diabetologists could do for primary care. His suggested model of joint community clinics with GPs and diabetologists working together generated polarised comments from the floor. He revealed the potential academic utility of the Clinical Practice Research Datalink as a database for primary care across the UK. His presentation was punctuated with eminently useable quotations.

Peter Trainer came from Manchester's Christie Hospital to give a masterful update about acromegaly. The results of trans-sphenoidal surgery are much better when done by surgeons who do a lot of procedures. Even so, large tumours will not be cured by surgery, so is it acceptable to use octreotide only? The message seems to be that primary medical therapy is worthwhile, especially if the growth hormone is less than 25 µg/L, but if it is greater than 50 µg/L only one-third of cases return to normal. Medical treatment prior to surgery seems not to guarantee cure either. Pasireotide is more diabetogenic than octreotide. Oral octreo-tide is being evaluated, as are anti-sense drugs directed at the growth hormone receptor.

So what do cardiologists think about diabetes trials? Not much if Mark Petrie is to be believed. They don't usually measure HbA1c, they regard UKPDS as having raised a cardiac concern about sulphonylurea and metformin in combination, and they have ‘no idea’ what the new diabetes drugs are! They are, however, very interested in cardiovascular outcome trials such as PARADIGM-HF which showed that sacubitril/valsartan, compared with an angiotensin-converting enzyme inhibitor, significantly reduced rates of the composite outcome of cardiovascular death and hospitalisation for heart failure, rates of the component outcomes and of all-cause mortality in patients with symptomatic chronic heart failure with reduced ejection fraction. Although recent and current cardiovascular outcome trials of diabetes drugs are based on major adverse cardiovascular events (MACE), the definitions of the included primary events are not universally agreed and this can change the results. Furthermore, the CALIBER programme looking at a cohort of 1.9 million people with type 2 diabetes showed that heart failure and peripheral arterial disease are the most common initial manifestations of cardiovascular disease, which implies that MACE does not include the most relevant set of outcomes.

The double act of Paddy Mark, nephrologist, and Peter Winocour, diabetologist, did a splendid job of publicising the new ABCD-Renal Association guideline for the Management of Diabetes on the Haemodialysis Unit. This NICE-accredited guideline is a much needed resource, and recommends more relaxed glycaemic targets for this group of patients who are susceptible to hypoglycaemia, discusses preferred antidiabetic medications and changing doses for dialysis versus non-dialysis days. Lipid management was discussed and we were reminded that there is no evidence of benefit from starting lipid lowering medication after haemodialysis. The guideline is on the JBDS-IP section of the ABCD website.

Another Mancunian presenter, Steve Ball, had the challenge of explaining hyponatraemia to Homer Simpson. To this reporter it was a matter of ‘Too many cans of beer drunk too quickly dilutes the plasma’, but fortunately it was not as simple as this, and we were treated to a guided tour of the European Society of Endocrinology ‘Clinical practice guideline on diagnosis and management of hyponatraemia’ by one of its authors. A key question is whether the patient is acutely unwell as a result of hyponatraemia. If so, then urgent treatment with hypertonic saline is indicated in a closely monitored environment. The rate of rise of serum sodium is critical to avoid the dreaded complication of osmotic demyelination syndrome. In the absence of symptoms, the approach is directed to finding and treating the cause of the hyponatraemia. Tolvaptan does not seem to be the perfect solution for syndrome of inappropriate antidiuretic hormone secretion (SIADH).

We were then treated to an update on the management of common endocrine disorders in pregnancy by David Carty. This was full of pragmatic recommendations – propylthiouracil pre-pregnancy and first trimester and carbimazole thereafter seems the best way to manage the embryopathic potential of carbimazole versus the hepatotoxic potential of propylthiouracil. There was a scholarly analysis of the importance of subclinical hypothyroidism on fertility, childhood cognitive function etc, concluding with a recommendation to treat women with a thyroid-stimulating hormone level >2.5 without a need to measure thyroid antibodies. The TABLET trial is designed to tell us whether treating women with positive thyroid antibodies is of value.

ABCD's first research project, REVISE Diabesity, an open-label multicentre parallel group randomised controlled trial of Endobarrier implantable duodenal-jejunal liner alone or with liraglutide 1.2 mg daily versus liraglutide only 1.8 mg daily in obese patients with type 2 diabetes who had not achieved target weight loss or HbA1c despite at least 6 months treatment with liraglutide is building to a climax. We were treated to interim 1-year results from Piya Sen Gupta, Barbara McGowan and Bob Ryder on behalf of the research team. This showed that Endobarrier treatment was associated with weight loss and improved HbA1c, especially when liraglutide treatment was continued. There were two cases of liver abscess in the 48 recipients of Endobarrier. Ultimately, the safety comparator will be Roux-en-Y gastric bypass surgery.

Ketan Dhatariya, our diabetic ketoacidosis (DKA) guru, exposed a lack of in-depth knowledge of the subject in the audience that has no doubt prompted us all to read the recommended papers. Having produced a JBDS-IP evidence-based guideline for the management of DKA that has been adopted throughout the UK, he shared the results of a national audit. This showed a high rate of compliance with the guideline but a surprisingly high incidence of (usually mild) hypoglycaemia and hypokalaemia during the course of treatment. Although it seems likely that delays in setting up a glucose infusion and adding potassium to the intravenous fluid contribute to some cases, it is possible that the algorithm may need tweaking. If a higher concentration of potassium is required than previously thought, it will mean all patients with DKA being managed acutely in a level 2 high dependency facility, but the capacity for this is lacking. The selection of 3 mmol/L as the level of ketonaemia defining DKA was challenged as unjustifiably low. If raised to 4.4 mmol/L it would reduce the number of patients requiring the treatment protocol without obvious detriment.

The final session saw Bob Ryder mount a robust defence of pioglitazone as a treatment for type 2 diabetes. He showed data that called into question the assertion that pioglitazone causes bladder cancer, which has subsequently formed the basis for an ABCD position statement and a BMJ rapid response on the topic. He also revisited the ProACTIVE trial data in the light of cardiovascular outcome studies of newer agents. Will we soon be prescribing a combination of metformin, pioglitazone and empagliflozin? Watch this space.

See you in Brighton in November.

 Rob Gregory
Chair, Association of British
Clinical Diabetologists
 Correspondence:
E-mail: Rob.Gregory@uhl-tr.nhs.uk

 http://dx.doi.org/10.15277/bjd.2016.094
Br J Diabetes 2016;16:140-141

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