Type 2 diabetes mellitus and chronic kidney disease (CKD) frequently co-exist and the increasing burden of both conditions is a global concern. Metformin is established as the first-line treatment for type 2 diabetes because it is associated with improved cardiovascular outcomes and a reduced risk of hypoglycaemia compared with other treatment options. Patients with CKD may benefit in particular because they are at high risk of both cardiovascular disease and hypoglycaemic episodes. However, the use of metformin is restricted in this population due to the concerns over lactic acidosis. Recent reviews have evaluated this risk and concluded that current guidelines for prescribing metformin in CKD may be too restrictive. This narrative review considers this evidence further, but also examines the strength of evidence that favours the use of metformin in CKD patients.

NHSoperational-planning-guidance-201617-201819.pdf.Having made diabetes a national priority, and defined the categories for improvement -achieving the three treatment targets: access to structured education, foot care and inpatient care -the Diabetes Programme Board has announced targeted investment of £40 million recurrent (for at least two years).Bids will be invited for money to support transformation in the above categories that will bring a return on that investment by the end of the current 5 Year Forward View.Since addressing unacceptable variation is a priority, bids from CCGs that are underperforming in particular categories are likely to be prioritised.We are still waiting for instructions about how to apply, but I suggest that members make sure their CCGs are aware of the opportunity and start preparing business cases for additional investment in one or more of the four categories.The first round of CCGIAF (CCG improvement and assessment framework) results has been released and submission of data to the National Diabetes Audit (NDA) is disappointingly low in many CCGs.Although making NDA participation mandatory has been ruled out, I have suggested that the award of new money for diabetes transformation should be conditional on participation in the NDA.

Pruritus is often reported to be associated with diabetes mellitus although this remains controversial. Careful history-taking and examination are key to establishing the cause of itching in a patient with diabetes after excluding local cutaneous disease or an underlying lymphoma. Options for management of this distressing condition include emollients, topical antipruritic agents (e.g. calamine, menthol, capsaicin, corticosteroids, calcineurin inhibitors or local anaesthetics), systemic antipruritic agents (e.g. H1 antihistamines, doxepin and gabapentin), broad-band or narrowband ultraviolet B phototherapy and psychological therapies.

Ischaemic stroke is a major cause of disability and death and the incidence rate of ischaemic stroke is doubled in patients who have diabetes. Admission hyperglycaemia in acute stroke patients is associated with higher mortality, longer hospital stay and worse functional outcome. However, it remains unclear whether hyperglycaemia is in fact a marker of stroke severity or whether hyperglycaemia directly contributes to brain damage. Potential mechanisms of hyperglycaemia related brain damage in stroke include acidosis, oxidative stress and reperfusion injury. Evidence suggests a potential benefit of treatment of hyperglycaemia with insulin in acute stroke patients but the potential for morbidity caused hypoglycaemia should be considered. The American Heart Association/American Stroke Association guidelines recommend maintaining the blood glucose level in the range 7.8–10 mmol/L during acute stroke hospitalisation whilst the European Stroke Organization guideline recommends lowering the blood glucose with insulin to below 10 mmol/L. More research is needed to explore the impact of admission hyperglycaemia and hypoglycaemia on stroke outcomes and the role of other glucose lowering therapies.

Introduction We know what should be done, so why don't we do it?1 There is no shortage of documents produced in the last 20 years addressing the essentials of good diabetes care. Despite this, the evidence demonstrates that the care experienced by too many people with diabetes falls short of the minimum standard expected. The latest National Diabetes Audit data for England and Wales shows that the rate of improvement in delivery of care processes and of achieving targets has slowed.2 The guidance aimed at commissioners and providers is not mandatory and has had limited impact. There are many reasons for this – a lack of political will, a fractured diabetes leadership, vested interests and financial constraints have all been suggested, as well as resistance to innovation and a variable appetite for sharing and implementing best practice. There is general agreement that the Quality and Outcomes Framework has delivered what it can for diabetes, and other quality levers are needed to take performance to the next level. Planning is difficult when the organisations commissioning services are themselves subject to re-organisation. One could argue that the latest top-down reorganisation of the NHS in England set back the cause of diabetes care. NHS Diabetes was dismantled; it became unacceptable to talk about diabetes – a single chronic disease – except as a generic long-term condition. It has taken several years of sustained argument by organisations representing patients, carers and healthcare professionals to get diabetes seen correctly as a priority. Offering NHS contracts to any willing provider while excluding local specialists from commissioning discussions because they have conflicts of interest is another perverse consequence of how the legislation is being interpreted. Although Scotland, Wales and Northern Ireland have been spared this particular upheaval, the NHS in these countries is facing the same financial crisis and a supply versus demand mismatch as the prevalence of type 2 diabetes in particular continues to rise. Each administration has produced a diabetes strategy and a modest amount of dedicated funding.3–5 The only game in town for the NHS in England was articulated before the last general election in Simon Stevens’s Five Year Forward View, which secured additional funding in return for a transformative change to the way we do things.6 At its core is a fundamental push towards service re-design, acknowledging that the traditional model of primary care generalists referring to secondary care specialists for each disease is neither sustainable nor good care. Delivering the vision requires action on several fronts – reducing demand by prevention, harnessing the purchasing power of the NHS through better procurement and working differently in partnership with stakeholders.7 The national Type 2 Diabetes Prevention Programme underway in England is the beacon project seeking to address spiralling demand. A national approach to procurement of diabetes technology including glucose monitoring and insulin pumps is attractive, providing patient choice is not overly-constrained. Re-designing services to be more effective and cost-effective is, however, not something that is best managed at a national level.

Background: Liraglutide may be less effective in patients with more advanced type 2 diabetes. This study from the Association of British Clinical Diabetologists Nationwide Liraglutide Audit analysed changes in HbA1c of patients after 26 weeks of treatment with liraglutide 1.2 mg, stratified according to the intensity of their background diabetes therapy, or according to their duration of diabetes. Methods: Patients using liraglutide as add-on therapy were stratified for receipt to one, two or three oral antidiabetic agents (OADs) or insulin (± OAD), or for diabetes duration of 0–5 years, 6–10 years, or >10 years. Changes in HbA1c were compared across groups after adjusting for baseline HbA1c. Results: After exclusions to standardise comparisons, 937 patients with background diabetes treatment and 802 patients with recorded diabetes duration were analysed. Least-squares adjusted mean changes in HbA1c (± SEM) were –1.8% ± 0.1 for 135 patients on one OAD, –1.7% ± 0.1 for 284 patients on two OADs,–1.9% ± 0.1 for 94 patients on three OADs (n=94) and –1.0% ± 0.1 for 424 patients receiving insulin. HbA1c changes did not differ significantly between OAD groups, but all OAD groups had greater HbA1c reductions compared with the insulin group (all p 10 years (n=399). Conclusion: The need for insulin and long diabetes duration, but not the number of OADs taken, predicted a smaller treatment response to liraglutide.