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Practical Diabetes Care Practical Diabetes Care FOURTH EDITION David Levy MD FRCP Formerly Consultant Physician, Barts Health NHS Trust, Whipps Cross University Hospital, London The London Diabetes Centre, Marylebone, London This fourth edition first published 2018 © 2018 by John Wiley & Sons Ltd Edition History John Wiley & Sons Ltd (3e, 2011) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of David Levy to be identified as the author in this work has been asserted in accordance with law. Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging‐in‐Publication Data Names: Levy, David, 1954– author. Title: Practical diabetes care / by David Levy. Description: Fourth edition. | Hoboken, NJ : Wiley, 2017. | Includes bibliographical references and index. | Identifiers: LCCN 2017040598 (print) | LCCN 2017041148 (ebook) | ISBN 9781119052234 (pdf) | ISBN 9781119052227 (epub) | ISBN 9781119052241 (pbk.) Subjects: | MESH: Diabetes Mellitus–therapy | Diabetes Mellitus–diagnosis Classification: LCC RC660 (ebook) | LCC RC660 (print) | NLM WK 815 | DDC 616.4/62–dc23 LC record available at https://lccn.loc.gov/2017040598 Cover design: Wiley Cover image: Courtesy of David Levy Set in 8.5/10.5pt Frutiger by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1 Contents Acknowledgments, vii Introduction, ix Clinical trials and organizations: abbreviations and acronyms, xv 1 Classification, diagnosis and presentation, 1 2 Diabetes emergencies, 25 3 Infections and the diabetic foot, 49 4 Eyes and kidneys, 77 5 Neuropathy, musculoskeletal and skin, 115 6 Diabetes and the cardiovascular system, 141 7 Type 1 diabetes: glycaemic control, 171 8 Type 1 diabetes: technology and transplants, 197 9 Type 2 diabetes: weight loss, exercise and other ‘lifestyle’ interventions, 217 10 Type 2 diabetes: glycaemic control, 241 11 Hypertension, 315 12 Lipids, 359 13 Clinical aspects of the metabolic syndrome, 387 14 Youth and emerging adulthood; old age, 401 15 Psychological aspects of diabetes, 425 Index, 439 v Acknowledgments This book’s peer reviewers have added clarity, focus and critical detail and have been astonishingly sweet and supportive. Without their clear advice I would have blundered up several, possibly many, more medical garden paths leading to cul‐de‐sacs all named Embarrassment Drive. I applaud their directionality and comradely scholarship. My dear long‐time friend and colleague Dr Tore Julsrud Berg (Oslo University Hospitals) reviewed Chapter 1 (Classification) and the two chapters on Type 1 diabetes (Chapters 7 and 8). Everything I have written over the years on Type 1 diabetes has been improved by his patience and encouragement. I can only aspire to his intense pragmatism com- bined with academic rigour (and to the wonderful modernist Oslo house meticulously treasured and preserved by Tore and his wife, Anne Valle). Dr Edouard Mills, a specialist registrar in endocrinology who previously worked with me during his foundation training, meticulously and thoughtfully reviewed Chapter 2 (Diabetes emergencies) and Chapter 11 (Hypertension). Dr Albert Mifsud gently chided and guided me about antibiotics in diabetic infections (Chapter 3) with the same patience my late colleague Dr Louise Neville had shown in earlier editions. I hope there are no remnants in the text of our intellectual fist‐fights on the Whipps Cross wards (and many years ago at the Central Middlesex Hospital) – both part of the great outer circle of University Hospitals in London whose heyday of teaching, research and clinical care from the end of World War II up to the 1980s has been eclipsed by progressive resource starvation and massively increased clinical stresses over the past two decades. Professor Miles Fisher, coiner of one of the great aphorisms of diabetes, reviewed Chapter 6 (Diabetes and the cardiovascular system) with the same speed and efficiency with which he no doubt traverses the glens of his native country by bike. Helen Alston, specialist registrar in nephrology, brought me up to date on many renal secrets. Carin Hume, a wonderfully practical dietician at London Medical who inhabits the real world of dietetics, even allowed me to pursue higher protein, lower carbohydrate diets in Chapter 8. Professor Alan Sinclair, doyen of diabetes care in older people, forgave me the mere hemi‐chapter I devoted to his critical subject (Chapter 14) and reminded me about the pervasive impact of frailty in older people with diabetes. Dr Nicoletta Dozio and Dr Marina Scavini of the Diabetes Research Institute of San Raffaele Hospital in Milan helped with all the sections of the book relating to diabetes and pregnancy. Wonderful stays at Nicoletta’s and Stefano’s beautiful palazzo in Merate undoubtedly increased my retention rate of key facts in an area of diabetes practice that continues to be neglected by clinicians in primary and secondary care. Professor Karim Meeran (Imperial Centre for Endocrinology) kindly provided me with access to the invaluable online manual of endocrine test protocols. He is happy to share the intranet link with all readers: http://imperialendo.co.uk vii viii Acknowledgments Pretty well every paragraph of this book owes any breadth and new insight to Timo Pilgram, Senior Library Assistant at Whipps Cross University Hospital. Every reference I requested (and a lot of illustrations) pinged into my inbox in full text form within a few hours, sometimes minutes; but more important, dozens of references that I would never have found using my kindergarten skills in Boolean logic are here because of Timo’s pure talents of modern librarianship, combined with curiosity and tenacity and seemingly unlimited manoeuvrability around the internet, shared by few clinicians. Imagination and new stories (as they now say everywhere) are possible only when these startling skills combust slightly after catalysis by the tiniest addition of serendipity. He deserves to be a co‐author. More generally, librarianship in hospitals, just like libraries in the community, is inevitably an easy target of cost‐cutting. Ensure, at least, that before they disappear from your own institution you understand their continuing centrality to the pursuit of modern medical thinking. Most of the writing was done during 2016. My wife, Laura Liew, left me during the first nine months to gain a Grande Diplôme in cuisine and patisserie at the London Cordon Bleu School in Bloomsbury Square. Most days I could sit and write for twelve hours, by which time Laura had returned, usually exhausted, with a take-away box con- taining a French dish of staggering complexity and subtlety that had been the product of her industry and rigorous supervision and assessment by the teaching chefs. Practical Diabetes Care by day, lobster Thermidor for dinner: the haute cuisine recipe for extracting the best possible performance from an author. I thoroughly commend it. Introduction Excuses normally round off the preface, but I owe readers some up‐front explanations: for a fourth edition that’s at least three times weightier than the original of eighteen years ago, and one still penned by a single author. As to the first, maturity doesn’t always bring concision and simplification (in music Brahms managed it, Schoenberg and Berg brought it to a state of crystalline perfection, but Wagner certainly didn’t), and the rela- tively terse bulleted form (if not style) I managed in the dash to the millennium has yielded, through normal aging and a desire to try and write real sentences, to a more discursive approach. Recognizing the hazards to readers’ patience, this new edition is riddled with Practice Points, which I hope are useful, in addition to the usual burden of devices (boxes, tables, figures etc.) that I suspect are the 21st century equivalent of the ornate Victorian section marker, and probably command a similar degree of attention. A second problem, more substantive, is whether a single‐author book has any meaning in the new world (let’s set aside the equally important matters of books versus electron- ics, and textbooks versus monographs). In a tepid review of the last edition someone wondered (I paraphrase) how I had the brass neck to invade territory such as diet therapy in diabetes. But the reviewer made a minor category error in his understandable defence of a non‐medical area, which I suspect he felt had been traduced by someone he consid- ered a typical arrogant hospital doctor: his argument should have applied with at least equal force to the sections on cardiology, psychology and bits of pathophysiology for that matter. But of these other territorial meanderings there was no mention. The conventional resolution is superficially simple: do multi‐author, much as now everything is done multidisciplinary. There are wonderful multi‐author books (as I write this, the Textbook of Diabetes, edited by Richard Holt and colleagues has reached its fifth edition, and from the same publisher the fourth edition of the wide‐ranging International Textbook of Diabetes) and I have huge admiration for any editor brave enough to grapple with the stylistic lurchings and lumpy content that can gravitate to pet and hobby‐horse topics of individual chapter authors. But probably through a combination of real and perceived pressures to comply the writing often homogenizes to standard passive academic prose, fuelled by the output of the meta‐analysis industrial complex (of which more shortly) with a persistent risk of imbalance both within and between chapters, in addition to the risk of trying to update the non‐updatable, when the best option, probably involving little more work, is to start from scratch. I’ve gone for the easy options. First, I’ve restructured the contents and completely rewritten the book, strategies I hope have helped expunge old and less‐relevant material. For example, I have now twinned diabetic eye disease with renal disease in the same chapter, and continued to de‐emphasize the details of retinopathy, as the UK screening programme has – fortunately – taken over from individual doctors attempting to wield an ancient and non‐illuminating ophthalmoscope in vaguely the right direction. Type 1 diabetes, now more commonly encountered in primary care, has a fully deserved greater prominence and there is a separate new chapter on technology, which of course is already out of date. More patients and even some practitioners are emphasizing the increasing evidence‐base of non‐pharmacological interventions in Type 2 diabetes, and ix x Introduction I have enjoyed elaborating the fascinating detail emerging in diet, weight loss and exercise. The chapter on the pharmacological treatment of Type 2 diabetes has also, despite my best efforts, expanded. This is not just because new agents have been intro- duced since the last edition in 2011 but we now have more evidence that helps us place classes of drugs more precisely than before. However, more than ever we must maintain a balanced approach to medication in relation to the wishes of patients and the burgeoning cost of new drugs, especially when used in combination. The trial portfolios that now accompany the launch of a new agent or insulin (some so self‐important they have their own registered trademark) comprise bewildering numbers of individual studies, some of which explore minute gaps in therapeutic combinations that may not have occurred even to experienced practitioners. Superior brains might not make it to the end of the titles of some of the more rococo comparisons. Second, I have asked trusted colleagues to review some chapters and to deploy the electronic equivalent of the blue pencil. They deserve their more prominent place, and my thanks, in Acknowledgments rather than as another afterthought to the Introduction. A fourth edition of any book should, above all, prompt general reflection, now a ubiquitous box‐ticking requirement in appraisal and revalidation and therefore another thoroughly diminished component of our professional life. But let me explain one characteristic – increased true scepticism – that I hope the careful reader will detect throughout the book. During the first half of the first decade of the 2000s I was a strong advocate of the now largely discredited glitazone drugs. We’d already had a warning in the later 1990s: the first agent, troglitazone was a cause of fatal liver disease and in the United Kingdom was withdrawn within weeks of launch but it remained available else- where far too long. This terrible outcome, attributed to a pharmacologically gratuitous addition of a supposedly anti‐oxidant vitamin moiety to the molecule, served to de‐focus concerns about other, more widespread adverse effects, and when the two follow‐on drugs, rosiglitazone and pioglitazone, were introduced in 1999, battle was joined: not in scrutinizing with greater ferocity their pros and cons but regrettably in a largely commercial feud around antiatherosclerotic actions and minutiae of differences in achieved lipid profiles, the aspirations of all of which disappeared in a puff of non‐ significances in clinical trial outcomes. At the same time we didn’t yet have the results of the mega‐trials of the middle and latter part of the decade and therefore hadn’t properly understood the limited importance to patients of what were – and still are – relatively small changes in glucose levels in comparison with the clinical evidence of substantial weight gain, oedema and possible heart failure, and trial data of increased risk of fractures and anaemia. Statistical nit‐picking still rumbles on over the possible increased risk of bladder malignancy with pioglitazone, at the same time as the drug itself is no longer prescribed. In 2007, Nissen and Wolski published highly suggestive but contested meta‐analyses raising further concerns, this time about increased cardiovascular risk associated with rosiglitazone; but groaning under an increasing burden of adverse effects the prescribing status of rosiglitazone was not changed until 2009. The combined belief system, that glycaemia is still of primary importance in the Type 2 syndrome, and that improvements in intermediate measures of atherosclerosis somehow meant something for patients, still hasn’t been confined to its proper speculative place, and after a few years of relative calm, the potential antiatherosclerotic effects of the newest antihyperglycaemic agents are still eliciting hyper‐excitable responses. As a result of all this activity, I hope you will detect a much more cautious and a properly critical approach to all drugs, including the seemingly interminable battle for supremacy over long‐acting analogue insulins, which is Introduction xi tiresome after witnessing nearly two decades of angels and camels alike struggling for pole position at the extremities of small sharp structures, but clearly distracts from much more important and eminently fixable matters, especially in Type 1 diabetes, and has made the management of insulin‐treated diabetes in the USA a nightmare for many patients because of cost. I am grateful for the thoughtful approach of Edwin Gale and John Yudkin, long‐time techno‐ and pharma‐cynics, for activating my own concerns. We’re only a few years away from the centenary of the first use of insulin, and I don’t think the heroic early clinicians would be much impressed with our persistent bickering over minute differences in nocturnal hypoglycaemia rates with long‐acting analogues to try and convince ourselves and our patients that they are in any meaningful way better than NPH insulin. The more the arguments, the more it becomes clear that the superior- ity of a furiously defended insulin preparation is irrelevant compared with the way we work with patients to use insulin. Two further concerns can probably be detected. First, the invasion of our medical lives by the increasingly raucous onslaught of systematic review and meta‐analysis, which some commentators now believe is distorting research priorities. Evidence‐based medi- cine, the broad principles of which we all subscribe to, is now within striking distance of being considered coterminous with systematic review and meta‐analysis; that is, meta‐ analysis is moving to a privileged position as the highest form of evidence‐based medi- cine. It is of course an important component of the evidence base, but in clinical diabetes our most reliable source should be the well‐conducted clinical trial, published in a high quality peer‐reviewed journal, preferably with all the supplementary data readily acces- sible, because for a variety of reasons much important information is relegated to sup- plementary data files. Forest plots, even more than woods, obscure the beautiful structure of individual trees. Second, more important, is the balance between opinion and evidence. We are rapidly shifting, again in part under the baleful influence of meta‐analysis, to declaring opinion unnecessary, and in its strong form, hazardous. In turn, this perverse view was based on the now largely derided ‘experience’ without which, so the medical educationalists tell us, we can practice the highest quality medicine, so long as we have access to a smartphone, guidelines and do competent handovers. But in this sense medicine remains, frustratingly, way behind the times. In other fields we have passed peak ‘objectivity’; to take another musical analogy, the radical ‘early music’ movement of the 1970s and 1980s, which cel- ebrated baroque music as inflexible machine‐music translated directly from the dots on the unencumbered urtext page, has moved to a proper accommodation between textual accuracy and recognition that Kapellmeister Bach and his musicians were likely to be no less affected by the emotional impact of his miraculous music than twenty‐first century listeners. I have, therefore, attempted here to present balanced information with an occa- sional personal view. Don’t ignore the former (or preferably look for more and contradic- tory material) but at least consider the latter – and then discard it. There shouldn’t be much difficulty in spotting the difference between the two. Another tangential advantage of a single‐author work is that I have been able to zig‐zag my way through the manuscript right up to the time of submission, adding new information and references supplied by colleagues and friends. Chapter 1 is, therefore, as dated as, but no more than, Chapter 15. PMID numbers will help you track down papers that do not have consistent citations by entering the eight‐digit number into the PubMed search box. I have deliberately included as many papers as possible that are available as free full text, with their associated seven‐digit PMC (PubMed Central) identifiers. In trawling through hundreds of references I have been struck by the widely xii Introduction differing practices of quality journals; without naming individual publications I don’t think are behaving very well – which I would have dearly loved to do – let me applaud at least the New England Journal of Medicine, which seems to maximize the availability of free full text articles, and without the mendacity of imposing a year’s delay or, even more pernicious, making available a ‘printer‐friendly’ version that isn’t so friendly when your printer churns out 50% more paper because the article isn’t properly formatted. These matters are far from trivial. They include the converse situation, pharma companies pre- sumably paying for immediate full‐text availability of research papers that support the use of their new agents, and also the startlingly perverse practice of issuing grand con- sensus statements, of which there are unstoppable torrents, with no free full text avail- ability. Such practices distort the availability of research and scholarship and risk adding substantial bias to our views. Though I know I tormented Pri Gibbons, my patient editor at Wiley Blackwell, by exceeding our original agreed word count at least twofold and delivering it at least two years late, writing it has been therapeutic for me, and I hope will be entertaining in places for readers. In this edition, originally commissioned by Oliver Walter, I have been guided by the principles and practices of Stephen Pinker, one of the finest modern scien- tific writers. He suggests at least three full re‐writes of manuscripts and encouraged me in my first attempt to rigorously avoid the ‘curse of knowledge’ – the infuriating and anti‐educational practice of ‘experts’ writing as if every reader has immediate command of as much information as the author, thereby obviating its primary educational purpose. Everyone considering writing non‐fiction should first read his magical blend of serious linguistics and hilarious examples of grotesque misuse of English in The Sense of Style (Pinker, 2015). I didn’t regret doing so. If there is any graceful writing in the book it’s mostly due to Pinker’s benign influence. The previous edition drew warm comments from friends and colleagues, and some- one even claimed that five years on they were still referring to it, which is heartening but also a bit scary. It was wonderful to see copies of translations of the third edition into, among other languages, Polish and Chinese. The latter reminded me that the widely‐ repeated and mostly self‐serving fib of the ‘diabetes epidemic’ in the West is almost certainly true when applied to South East Asia, and though the literature is shockingly slender, I have tried to include discussion and references relevant to that critically impor- tant part of the world. In general I hope that this edition has slightly more international relevance than the technocratic focus of the previous three. There are lots and lots of books on diabetes, and many have ‘Care’ somewhere in the title. The word was included in the title of the third edition at the ‘request’ of Wiley Blackwell, because a senior editorial team felt that ‘Practical Diabetes’ (as the first two editions were titled) couldn’t exist (I disagree: nobody would object to a book called plain ‘Practical Plumbing’ or even – I think there are many already – ‘Practical Philosophy’. There is a good popular journal in the United Kingom called ‘Practical Diabetes’ that hasn’t felt the need for the obligatory ‘care’ designation). It doesn’t matter: it’s on the ‘Practical’ that I would like this book to be judged. But a book designed to help practis- ing healthcare professionals can’t just be a recipe book (nor, of course, can a good recipe book). Some of the chapter reviewers felt that the introductory stuff was a little heavy on background material and numbers, and they may be right. But if this book, like its predecessors, helps practitioners think about sleek minimalism in management, while suggesting an occasional evidence‐based trick that might shorten the journey time for some patients, then I don’t mind too much if readers omit some of the introductory bits.

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