My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and remember that guidelines are there to be interpreted and applied using your clinical judgement. What I am doing here is sharing with you what my interpretation would be in this case. It does not mean that it is the only way, or indeed the best way to treat any individual patient. There is a YouTube version of this and other videos that you can access here:· The NICE GP YouTube Channel: NICE GP - YouTubeThis podcast also appears in: 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/id1608821148Prescribing information links: · Website: DPP-4 inhibitors | Prescribing information | Diabetes - type 2 | CKS | NICE or· Download PDF: DPP-4 inhibitors- Prescribing information- Diabetes- type 2- NICE.pdf· Website: GLP-1 receptor agonists | Prescribing information | Diabetes - type 2 | CKS | NICE or· Download PDF: GLP-1 receptor agonists- Prescribing information- Diabetes- type 2- NICE.pdf 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 TranscriptHello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a new random diabetic case to see how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; see the description for full information about this:· NOT medical advice· Intended for health care professionals· Only my interpretation of the guideline· Use your clinical judgement And as you know, we are focusing only on the pharmacological treatment. Remember that there is also a podcast version of these videos so have a look in the description below. Remember that there is also a Youtube version of these episodes so have a look in the episode description.Right, so let’s generate our random patient. So, we have 45-year-old woman with poorly controlled T2DM with an HbA1c of 60 mmols/mol/7.6%, who has CKD stage 3a with an eGFR of 45 and who is also at high risk of CVD. She is also on triple therapy with Metformin 500 mg BD, Dapagliflozin 10 mg OD and Saxagliptin 2.5mg OD. And finally, she is severely obese with a BMI of 43So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines but at the end I will tell you what my interpretation would have been following the EASD / ADA consensus guideline.Firstly NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea.And for the clinical presentation we will say that she has no symptoms of diabetes, her obesity is long-standing and being managed with diet, lifestyle advice and bariatric referral. We have excluded other causes of Obesity e.g. hypothyroidism or Cushing’s disease and, because of her age, other causes of CKD such as glomerulonephritis or obstructive nephropathy have also been excluded and she has the diagnosis of diabetic nephropathy.Right, so what are my thoughts? Firstly, that she is relatively young and she already has a degree of diabetic nephropathy. So we should manage her fairly aggressively to try and improve her diabetic control and improve long term outcomes.Secondly, it seems quite clear that her main problem is her weight. She is severely obese and already being managed for that. I am very pleased to see that she is not on any medication that promotes weight gain. Both metformin and SGLT2 inhibitors promote weight loss and DPP4 inhibitors are weight neutral. So Dr Spinning Wheel has done very well indeed.The first step is always metformin which would be helpful for her weight too. So I would be interested to see why she is only on 500mg BD instead of the full dose, double that, 1000mg BD.I would first look if it has been kept at that dose because of safety reasons, for example because of her renal function. You can prescribe metformin 1000 mg BD to anyone with an eGFR of 45 or above. Her eGFR is exactly that, 45. Because of being right on the limit, I would want to be sure and I would look back and see what her previous renal function tests have been. If previously the eGFR has been bumping along the high 40s or 50s that I would definitely increase the dose because the drop to 45 could be just a temporary “blip”, although, of course, we would watch her renal function closely. If on the other hand...
