New type 2 diabetes guidance, which is the first in the UK to include specific recommendations for treating frail older people, is being piloted by pharmacists working in GP surgeries in south west England.
Over 18 months starting on 4 June 2018, generalist pharmacists across ten GP surgeries in Devon will test the guidance, which recommends introducing a frailty assessment pathway for older patients with type 2 diabetes as part of routine diabetes management to allow more appropriate and safer treatment strategies to be employed.
The aim of the pilot is to see if if the primary care pharmacy model works well for delivering the new guidance.
The guidance recommends that patients classified as frail should have their own individual hypoglycaemic target and clinicians should adopt an “active deprescribing policy” for this group of patients, which would avoid over-prescribing of glucose-lowering drugs and other medications.
The remit of the pharmacists taking part in the pilot will be to tackle all patients diagnosed with type 2 diabetes who are either not following their treatment plans or are being over-treated, as is often the case in frail and older patients.
The recommendations, which are also being rolled out across Devon in both primary and secondary care alongside the pharmacy pilot, were developed by academics from the University of Exeter in collaboration with NHS England and were published in Diabetic Medicine (online, 7 April 2018)
The academics are pressing for the guidance to be included in the national Quality Outcomes Framework (QOF) for GPs in England – which is currently out for review – so that family doctors will be financially incentivised to adopt the principles when caring for this group of patients.
Source: Courtesy of David Strain
Lead author David Strain, senior clinical lecturer at the University of Exeter, said that older people are routinely left out of clinical trials for the management of type 2 diabetes.
“This guidance puts the older person with diabetes firmly back at the centre of target-setting, ensuring that appropriate goals are agreed to achieve the best quality of life possible, without continuing treatments that would not provide any benefit and potentially cause harm,” he said.
In the report, the researchers argued that although guidelines from organisations such as the National Institute for Health and Care Excellence and others acknowledge the need for individualised care, the glycaemic targets recommended as good control [HbA1c 53–59 mmol/mol (7–7.5%)] are “too tight for frail older individuals”.
They said that there was growing recognition that intensive glucose-lowering treatment in type 2 diabetes has limited benefits and may in fact be dangerous for older people.
“This recognition should prompt clinicians to modify HbA1c targets in those with limited life expectancy or living with severe frailty.”
They accepted that providing better care and support for older people living with frailty is both a challenge and an opportunity for the NHS, but added that diabetes is the most common chronic metabolic disorder in the UK and an important risk factor for the development of frailty.
“The focus for diabetes healthcare professionals, in collaboration with older adults with diabetes, should be on preventing diabetes-disabling states in older people which lead to dependency and institutionalisation and rising health and social care costs.”
Victoria Ruszala, a specialist diabetes pharmacist at North Bristol NHS Trust, said the guidance is the first from UK academics to recommend a frailty measure for managing older people with type 2 diabetes which reflects recommendations by the American Diabetes Association.
“It’s the frailty measure which is important here – the guidance formalises what other people have been doing for years, it’s not new treatment, but it formalises it,” she said.
“This guidance will be useful for those who are not experts in this area, such as primary care practitioners and those pharmacists working in general practice who are getting more and more involved in diabetes care.”
 Strain WD, Hope SV, Green A et al. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Med 2018. doi: 10.1111/dme.13644