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Good evening, everyone. And you are so warmly. Welcome to this middle primary care session where we're gonna be talking about modern management of type two diabetes, including SGL T two inhibitors. We're really grateful that we've got Doctor Kevin Fernando joining us this evening who is a GP with a specialist interest in diabetes and medical education. He works as a GP partner in North Berwick in Edinburgh and has main specialist topics of interest include people living with type two diabetes, the interpretation and the management of commonly abnormal blood tests in primary care. Kevin has been elected to the fellowship at the Royal College of GPS, the Royal College of Physicians of Edinburgh, and also the Academy of medical educators for his work in diabetes and medical education. We're really excited that he's joining us this evening and we're in for a real treat. Er, if you've got, er, questions, we're gonna have time for questions. Er, so please pop some questions in at the end. We'll try to do as many of them as we can. Um, if you are joining us on metal for the first time, I'd really recommend that you download the app onto your phone. It's available in the Apple and Android app stores and I'll pop a link into the chat. It means that you'll be the first to hear about any medical primary care sessions that are happening and coming up next, you'll be the first to get an invite and you'll also be the first to get access to any slides or on demand material afterwards. Um, so I'll pop the link into the chat without any further ado, I'm gonna hand over to Doctor Fernando and we're really looking forward to this session on the modern management of type two diabetes. Doctor Fernando. Good stuff. Uh, thanks, Phil, thanks for the kind introduction and good evening, ladies and gentlemen, er, Phil said, Kevin Fernando GP partner in North Berwick Health Center just east of Edinburgh. In fact, some of you may now know where North is cos it, it was just voted last week, the nicest town in the UK to live in actually in a, in a times. Uh, it's the first time I think a Scottish town has topped, topped that times, er, list. So it's just east of Edinburgh, been a partner there 15 years. But as Phil said, a long standing interest in diabetes, but as we'll be chatting about over the next hour, so much overlap now, isn't there in all things, diabetes, cardiovascular, renal and metabolic. I also work one day a week for Medscape Global. I'll show you some of my resources I've put together for primary care relevant to, to type two diabetes. And I also have a role with the University of Dundee where I'm an honorary uh clinical reader. So as Phil said, we're gonna talk about the modern management of type two diabetes. When I first had an interest in diabetes over 15 years ago. Now we managed to the type two diabetes in a very gluco centric manner, completely different to how we manage type two diabetes. Now, a lot of that change has just been over the last couple of years. So a first pop quiz then for everyone. WW why do you think I put a picture of an apple tree up there? Any any any ideas? Phil? Any thoughts? What, why have I got an apple tree out there? Um The sugar in apples, I don't know. Not that we've got some ideas. It's sweet SGL T two inhibitors, which we're gonna be talking about a big part of how the type two diabetes management of has changed is it are derived from a substance called flora which was first discovered in apple tree bark in the 1800. So it's one of many medications we use in primary care that's derived from a plant source. So yeah, that's why I of often start with just a picture of an apple tree bar to illustrate it. It is actually originally a naturally founding uh f found er substance. So these are my disclosures but of course, today is a completely independent session. No, uh, no industry involvement at all. So you'll be proud of me. I just a few weeks back actually from, er, er, Kilimanjaro. And again, uh, just to illustrate how they are such a joined up approach to managing type two diabetes and comorbidities. I've, I've done a number of charity things in the past raising money for diabetes. UK, but very much, er, this time chose to raise money for kidney research. UK. Common comorbidity, isn't it for people living with type two diabetes? Estimated 40% of people living with type two diabetes have some element of renal dysfunction. Be a lower EGFR or higher levels of protein in the urine and how we manage CKD and diabetic kidney disease is also completely changed face. So I'll take you through that just shortly. So these are a couple of my Medscape resources. These are freely available, er, er, online. Uh I'm active on social media, I'll leave my contact details there and happy to send you a PDF. So I've got some QR codes you can scan as well. So the first one I co authored with a GP in northern Ireland called IMA da Real pioneer for a more joined up approach again to managing type two diabetes and comorbidities. So we put together this checklist, the type two diabetes, cardiovascular renal metabolic review checklist by no means. Do we expect any of us in primary cares? GP nurses, pharmacists to cover all of these uh item. But I just wanted to illustrate that breath of knowledge we now all require as GPS nurses, pharmacists when supporting that person living with type two diabetes. At the top left, lifestyle considerations pivotal. Isn't it to the, the, the management, not just the type two diabetes of all long term conditions and we know reversal and remission of type two diabetes is a very real goal for many individuals that was from the seminal study with people newly diagnosed or relatively newly diagnosed with type two diabetes. If they lose about 15 kg, over 12 months, they have a near 90% chance of reversing their type two diabetes and putting it into remission. So lifestyle pivotal, of course, individualized HBA one C goals, particularly important in our more frail patients where we need to take a foot off the pedal and aim for higher HBA A1C goals, the kidneys, I'll be covering BP lipids, lots change in the world of lipids. Er, if tonight's webinar goes well film perhaps we can do a future one about lipids because a a big change is there particularly for higher risk patients such as those individuals living with type two diabetes. And then top right here, Mazz. Some of you may not be familiar with this newer terminology. Mazz is the new terminology for NAFLD non alcoholic fatty liver is now, has been now renamed just last year to metabolic dysfunction associated steatotic liver disease. Um So I know a bit of a mouthful, but it's to reflect the fact that fatty liver disease is in essence, primarily a metabolic condition. It's not primarily a liver condition. It's primarily a metabolic condition. And again, a close relationship with type two diabetes. Estimated 85 to 90% of people living with type two diabetes have some element of fatty liver disease or Mazz. So, uh we can uh touch on that later on other comorbidities, prescribing considerations when to phone a friend MDT, referrals, coding and follow up. So it's a an aid memoir. By no means, can any of us cover this in a 10 minute appointment or less, as I said, but again, just want to illustrate that breath of knowledge. And the one most relevant tonight are, is this the extra glycemic indications of SGLT two inhibitors? Now, we're gonna be focusing a lot on this class of drug shortly and I know it maybe sounds like hyperbole. But since I graduated from Edinburgh Uni in 2000, I reckon SGLT two inhibitors are the biggest therapeutic advance in my career. Today. 10 years ago, I've been, we've been initiating SGLT two S for 10 years in primary care initially just for type two diabetes. But over the years, particularly just the last few years, we're prescribing it for people with and without diabetes and also in a wide range of conditions, cardio vascular disease, atherosclerotic, cardiovascular disease, heart failure, both types of heart failure, hep, ref heart failure with reduced ejection fraction and HEP pef heart failure with preserved ejection fraction. And we're now also prescribing it for CKD in people with and without diabetes. So exciting times but potentially confusing times, isn't it for us in primary care? So I put this little tool together to try and make sense of how we prescribe SGL T two. So again, you can access that via the same QR code. Er but I'll share my contact details. Happy to email you out links er directly. Um and very quickly another SGL T two inhibitor you resource, you might find helpful. I know you'll all laugh. I've actually dipped my toes into youtube. Um and I have a youtube channel er with four brief videos so far on what SGL T twos are their benefits. Importantly, their side effects, sick, day guidance, et cetera. Because most days I'm in, I work two days as a GP partner, Mondays and Thursdays. I was in er er today, I'm starting at least a couple of people on SGL T two. So we text out links to these short youtube videos, uh just 2 to 3 minutes just to compound that valuable interaction. Of course, between yourself and your patient. So feel free to use them. They're just freely available online. Happy for if you find them helpful, happy for you to uh uh to distribute them to your uh your patients. Ok. So let's crack on then with a case study. First of all, always, always helps to have a case study that we can all identify with in primary care. To hang, hang our learning on. So this is one of my patients grant in North Berg. He's 52 years old, just a young chap BM I 31. He's of a Scottish Caucasian background. No family history of note. And he's been relatively recently diagnosed with type two diabetes just about six months ago. Also has a longer standing background of hypertension current medications which he assures me he is taken quite regularly. Metformin 1 g twice a day. Lisinopril 20 mg daily for his hypertension and atorvastatin 20 for the primary prevention of cardiovascular disease. So he works as an architect. He's got a young family, busy life. Um and so he, he, you know, he, he admits he leads quite a sedentary lifestyle. I did refer him to Desmond when he was newly diagnosed for, for self education about diabetes. But unfortunately, like many of my patients he didn't, didn't attend. And again, like many of my patients, he tells me he drinks alcohol within recommended limits. So his numbers, his HBA1C was 58 minimal, be more or 7.5% in all money. His total cholesterol to HDL ratio is 3.9 home BP average 100 and 2979 and his renal function is normal. So, well, certainly his G fr is over 60 his urine A cr was actually below three as well. So I'm sure we can all identify patients over, er, or, or, er, have patients like grant in primary care. So, first question for us all and this is perhaps where we can fire up the pole, uh filled. What might you do consider doing next with respect to grant ongoing management? Ok. So there's no right or wrong answer often. Is there in, in, in diabetes, in primary care? Modern diabetes care is an art, isn't it not an exact science? So do let me know what you think. Would you not make any change to his drug regimen and reinforce that all important lifestyle advice? Would you dangle that carrot of diabetes remission in front of him? You know, if he loses 15 kg, he has a near 90% chance of uh of reversing his type two diabetes or would you add in a sulfur aurea add in a Gliptin add in an SGL T two? Would you consider a G LP one if you can get hold of it? We can talk about that in Q and A A major G LP one shortage isn't there at the moment or would you do something else entirely different? So why don't you vote now or type in uh your thoughts in the, in the messages box as well if you would do something different. So w what are we looking at there, Phil. So we have got 63% of people saying they're gonna add in an SGL T two inhibitor. OK. So that's a far, I suppose the clue is in the title of my talk, isn't it? But there's no right or wrong answer, but we'll talk through how current guidance perhaps would direct us to considering earlier on an SGL T two inhibitor for someone like Grant. But let me quickly change the goalpost. So actually for grant, I opted not to add in any medication, even an SGL T two inhibitor and reinforce that lifestyle advice. I actually referred him to our local weight management part pathway in Edinburgh for consideration of uh you know, an an approach to try and put his diabetes into remission. We're quite lucky to have a pathway for that locally. But unfortunately, while he was waiting for that pathway, he suffered a non ST elevation M I was admitted brief admission as it often is these days for a percutaneous intervention and he's got a couple of stents inside you. So he's only 52. Um So unsurprisingly because of that cardiac event, he's on more medication. He's on a secondary prevention dose of atorvastatin 80. He's on a beta blocker and he's on dual antiplatelet therapy clopidogrel for 12 months because of those stents. His BM I has come down a wee bit, which is great, but his HBA1C has gone up a wee bit 64 millimoles per mo or 8%. His lipids, his LDL is 1.8 total cholesterol 3.9 BP, average home BP average 100 and 2674 and his renal function remains normal. So now that I've changed the goalpost, would this alter what you might do for uh grant? So I've got the same options and a couple more actually. So maybe we can fire up this poll quickly. Phil. And let's see what everyone's thoughts are, what we, what we seeing there now for. So we have got a lot of people still saying and SGL T um, no, no, no. That's quite appropriate because that is the big change. He is now high risk, isn't he? Someone's written in the chat box, high CV risk. He's at high risk of a recurrent cardiovascular event. What's the leading cause of people living with type two diabetes? Well, actually a slightly trick question is no longer actually, cardiovascular disease. The leading cause of people live uh, of death in people, sorry. The leading cause of death in people living with type two diabetes is now cancer actually. And partly our fault in primary care because we've been so good with primary and secondary prevention. Our patients are living for longer. So bowel cancer, pancreatic cancer, breast cancer in women are now the leading causes of death. But we mustn't be complacent about cardiovascular disease. It's still a very close second and that's certainly what we're all worried about with grames, isn't he? If he has a recurrent cardiovascular event, potentially a fetal cardiovascular event? So I'm gonna tell you what nice guidelines and other guidelines tell us on how we should manage. Grant centered around as many of you rightly said, the SGL T two inhibitors. But before we do that, I wanted to show you a lovely infographic about reinforcing the importance of lifestyle intervention for people like Grant. So this was lifted from joint American and European diabetes guide published about 18 months ago or now. So I'm not going to take you through the whole guideline. But what I love about this guideline is this infra graphic. This is talking about the five S the importance of 24 hour physical behaviors for people living with type two diabetes. So the first s is sitting or specifically breaking up prolonged sitting. So many of us use smart watches of course, which remind us to get up uh at least once an hour. So we have high quality evidence that breaking up prolonged sitting um has a positive impact on lowering glucose levels. A positive impact on your overall cardiovascular risk. Many, many people are saying sitting is the new smoking now. Whilst the science doesn't quite back that up. It is quite a snappy way. Isn't it illustrate the the harmful effects on your cardiovascular system for prolonged sitting? Certainly, man, I don't, I've gotta be admit, I've got to admit, but many of my colleagues use standing desks at work now. So certainly, er, er, something we should all consider the second desk is sweating secondary to moderate to vigorous activity. So this is, um, exercise that leaves you sweaty or short of breath. For those of you who've been up to where I work and, uh, near where I live, I'm forever telling my patients, golf is not exercise, you know. So we do need to remind patients but don't get me wrong. Golf gets your step count up, keeps you active. But we do need to tell patients to introduce more vigorous exercise that leaves you sweaty and short of breath. And again, high quality evidence, this lowers glucose levels lowers BP improves cardiovascular function. The third is strengthening. So resistance exercises. Um so you can do squats lunges or just use seated exercises, lifting a weight or even just a tin of baked beans. Uh Strengthening exercises have also been proven to lower lower uh glucose levels. Fourth S is stepping. So step count that that exercise law is 10,000 steps, isn't it? But it's not realistic, is it for many of us, for many of our patients? So what I like about this guideline, it tells us that even just increasing your step count by 500 steps a day. So, I mean, it's gonna vary on your stride length, of course, but that's about 400 m of average, increasing your step count by 500 steps a day, reduces your future cardiovas a risk by 10% and your risk of dying from a cardiovascular even. So, I love these little nuggets in this, in this er er er infographic that can hopefully help motivate our patients. And interestingly, the finalist is sleep. So not only good quality sleep but good quantity sleep have a positive impact on reducing glucose levels, insulin resistance and other cardiovascular parameters. But it's au shaped curve that so the sweet spot is about 7 to 8 hours. Too little sleep is not good for you from a cardio metabolic point of view, but too much sleep isn't good for you either. Really interesting. That is a, you know, I've been doing a few talks and that recently just the impact of cardio, sorry, poor sleep on cardiometabolic health. Quite terrifying and quite difficult to juggle, isn't it? How do we juggle the crippling pressures of modern life, young families, busy jobs, et cetera against getting enough sleep? So, uh it, it, it it really is quite a conundrum for many of us. So I really like this. The five ss the importance of 24 hour physical behaviors. So again, yes, we're gonna be talking about SGL T twos, but we wanna lay those foundations of good lifestyle intervention for people living with type two diabetes. And indeed, any long term condition, these are all relevant, aren't they? For, for most long term conditions we look after in primary care. But this is the crux really of the talk today. This joined up approach. As I briefly mentioned already over the years, we've taken a very glucose centric approach to the manage of management of type two diabetes. What the updated nice guideline and many other guidelines ask us to do is to use the presence of comorbidities to go guide choice of therapy rather than just glucose. Now, don't get me wrong. I'm not saying good glucose control is an important, good glucose control. Of course, is pivotal to protect against the microvascular complications of diabetes. The blindness, the neuropathy, but good glucose control or tight glucose control only has a modest impact on the macrovascular outcomes. The heart attacks, the strokes, the amputations. So what nice asked us to do is to look for the presence of atherosclerotic cardiovascular disease, heart failure, chronic kidney disease and use these to guide choice of therapy. So very much encourages us to take a more holistic approach to the management of type two diabetes. And this very much brings to mind one of my all time favorite medical quotes by Sir William Osler, the late great Canadian physician, the good physician or nurse or pharmacist treats the disease, the great physician uh treats the person who has the disease. So we need to take that more. We need to take that more holistic approach to the management of type two diabetes in, in in primary care. And I'll take you through, uh, how we can make those uh, um medication choices just shortly. And I'm delighted, nice. Does go into a bit more detail about that, about the importance of individualized care. One size does not fit all. I'm not when I talk about it today. That's another whole talk in itself. The management of the older person with diabetes, particularly with frailty for years, people with frailty have been over treated from a glycemic point of view, putting them at harm of things like hypoglycemia. So, um I was delighted to see that. Nice, very much encouraged us to take an individualized approach and take our foot off the pedal in terms of glycemic control, particularly as one gets more functionally dependent and and frail. So this is a cartoon colleagues and I put together to illustrate the key, take home messages from the updated nice type two diabetes guideline. So if we look at the top bubble, anyone living with type two diabetes, of course, look at their HBA1C, look at their cardiovascular risk, 10 year cardiovascular risk using the Q risk three score. And also look at their kidney function. And that's both eg fr and urinary acr and I'll come onto that uh later on. So let's start in the middle column. If your patient living with type two diabetes has established, also has established heart failure, both types of heart failure or established atherosclerotic cardiovascular disease. Be a heart attack like my patient gran or a stroke or peripheral vascular disease. Discuss lifestyle, as we've said already offer Metformin. But the big change as soon as that Metformin is well tolerated, add in an SGL T two inhibitor with proven cardiovascular benefit. And importantly, we should add in the SGLT two inhibitor independent of the HBA1C because the cardioprotect of SGLT two inhibitors are independent of their glucose lowering effects. Ok. So early combination therapy with both Metformin and an SGLT two inhibitor for our highest risk patients. So to give you an example, then if you've got someone with type two diabetes who has a AAA who goes on to have a, a heart attack like gran, he's already on Metformin. But say he wasn't, I would discuss with me uh lifestyle, I would add in Metformin 500 mg once a day, week, one week two, if he's tolerating it, OK, 500 mg twice a day. And at that point, I would add in an SGL T two inhibitor with proven cardiovascular Bennett. So early combination therapy. So a big change in practice for many of us. And importantly, even if that patient had a HBA1C of just 48 millimoles per mole or less, we would still add in the SGL T two inhibitor because again, the cardioprotective benefits are independent of the glucose lowering benefits. But then in true, nice style, they take things one step further. If we look at the right hand side column for those individuals with who are at higher risk of cardiovascular disease. So if they have a cure risk score of 10% or higher, we should do the same lifestyle Metformin. And as soon as that Metformin is well tolerated add in an SGLT two inhibitor with proven cardiovascular benefit. Ok. So workload implications. We're already stout out, aren't we in primary care? We're on our knees. So II did a back of the envelope calculation. I reckon if I follow these guidelines to the T 85% or 80 to 85% of my patients living with type two diabetes should be on Metformin and an SGL T two. So I've been an earlier doctor of the class, I've been an earlier doctor of this guideline, but I'm nowhere near 8080 85%. So we can talk about workload implications, how we can realistically implement this in primary care. Er Given our current resource constraints uh maybe in the Q and A at their uh at the end film. So early combination therapy with both Metformin and an SGL T two. So why have nice made this change, sweeping changes. It's because of multiple positive cardiovascular outcome studies for the SGL T two inhibitors. The first one was called ereg outcome. It looked at empagliflozin in a a group of high risk people living with type two diabetes. And that was actually way back in 2015, 9 years ago. Now, nearly um and then that was replicated in the Canagliflozin trial and also the Dapagliflozin trial more recently as well. So that's why SGLT two inhibitors are really the preferred add on therapy to Metformin for, for the majority. To be honest of people living with type two diabetes and guidelines are changing all over the world and not just diabetes guidelines. Our cardiology colleagues are jumping on the bandwagon as well. I was lucky last year and my wife gave me a pass to go to the E SE European Society of Cardiology Congress. Um, and er, they had specifically published a guideline last year on the management of cardiovascular in people living with diabetes. So this is the central algorithm from that guideline and you can see it's very much looking for those same comorbidities, cardiovascular disease, heart failure and chronic kidney disease. So, somewhat controversially, though what this guideline tells us typical cardiologists. I apologize if anyone on tonight's or has a partner as a cardiologist. They are telling me it's time to dispense with Metformin and go straight to SGLT two S and GLP ones for their cardioprotective effects. I strongly disagree with that because what, what's one of the key pathophysiological abnormalities of people living with type two diabetes? It's insulin resistance, isn't it? And one of the key benefits one of the key benefits of Metformin, it directly tackles insulin resistance. So I still think there will always be a place for Metformin, but certainly I'm, I'm, I'm open to early combination therapy as per the nice guideline. Ok. How so if you have, your patient has type two diabetes and atherosclerotic cardiovascular disease, we should preferentially use uh Metformin SGL T twos and G LP ones again if we can get hold of them. However, if you have heart failure and type two diabetes, your preferred choice should be an SGL T two inhibitor. And if you have a chronic kidney disease and type two diabetes, your preferred option should be an SGLT two inhibitor. And some of you may be familiar with another new option called Ferre. It's specifically a drug. It's, it's got a nice ta. It's been around for a wee while now and it's specifically used to reduce the progression of diabetic kidney disease. Again, if we have some time, I can pick up on that later on. Uh So you can see a number of new therapeutic options available for us in primary care. So let's quickly talk about heart failure though because there have been some sweeping changes there as well. I think it's well worth bringing you all up to date. You're probably aware SGLT two inhibitors have taken the heart failure world by storm. This was a an editorial from the Lancer, you know, arguably the world's highest impact medical journal entitled SGLT two inhibitors as the bedrock of therapy for heart failure. And that's both types of heart failure. As I've told you already, heart failure with reduced ejection fraction HEP ref and heart failure with preserved ejection fraction HEP pef. OK. So HEF ref, let's start with, well, we, we've had some big changes in the pillars of heart failure for HEF ref, I'm sure you're all familiar with the pillars. We've traditionally use an ace or an A RB beta blocker spironolactone. But you can see now that SGL T two inhibitors are a new pillar of treatment for HEP ref. So two of the key heart failure studies for SGLT two inhibitors, one was called the DAPA HF study. Looking at dapagliflozin in he ref the other one was emperor reduce, looking at emfs in uh reduced heart failure. And they both demonstrated significant reductions in hospitalization for heart failure and importantly, death from heart failure. Um after only about two years trial. So the number needed to treat after two years was just 19 in those trials to prevent one hospitalization from heart failure or one death from heart failure. So compellingly low numbers needed to treat, which is why SGLT two inhibitors have entered heart failure guidelines a around the world. So this guideline from about 18 months ago was suggesting we start off with an re so that's uh entresto which some of you will be familiar with CCU Valsartan, a combination of an A RB Valsartan and something we call secure, which is a nerosin inhibitor. Then the beta blocker, then the spironolactone or Clarin and then the SGLT two inhibitor. But big changes have happened. Even in the last few months. There was this really interesting paper published just in November of last year, telling me that because of the compelling numbers needed to treat with SGL T two inhibitors, it's time to challenge the hierarchy of heart failure medications. So they have published this algorithm telling us a different sequencing of heart failure medications. So what they're suggesting is a one at the top if your patient has a normal or near normal BP, actually at diagnosis, start a beta blocker, low dose beta blocker and an SGLT two inhibitor. First for heff week two, go straight for entresto. So, Citryl Valsartan um at a low dose and then week six add in a low dose spironolactone or a plein. So get all the all the pillars in early within six weeks at a low dose and then in week 6 to 12, titrate up the doses of all the the pillars. So of course, that's a lot of workload for us in. But many of us have excellent heart failure teams who, who really cover that 1st 6 to 12 weeks for us in terms of titration, monitoring bloods, et cetera. But I just wanted to give you an idea of what's happening in the world of heart failure and inevitably what's going to happen to her for us in primary care. I'm sure many of you have been asked already by your cardiology colleagues to start an SGLT two inhibitor for failure or indeed, you may have started uh an SGLT two for heart failure yourself. And remember the heart failure benefits were seen in people both with and without diabetes. So, uh some of the biggest evidence, some of the the you know, the most compellingly low numbers needed to treat for a heart failure therapy in many, many years. So a lot of things, a lot of changes going on in the world of type two diabetes and uh comorbidities. So, what did I do for grant? I absolutely agreed with all of you. You know, he's had this semi non ST elevation M I, so he's at high risk of a recurrent cardiovascular event. So I started him on an SGL T two inhibitor with proven cardiovascular benefit. Ok. So that says coming aortic cardiovascular disease and heart failure. Let me quickly tell you about diabetic kidney disease and don't worry, I'll then balance out the conversation with the side effects and potential harms of SGL T twos. I've been waxing lyrical, haven't I about SGL T twos? No drug is without harm. So I'll balance out the conversation. I've told you already, er C KD, very common comorbidity alongside type two diabetes. It's not good news. Is it once your eeg fr drops below 60 once your eeg G fr drops below 60 you're more likely to suffer from a cardiovascular event and tragically more likely to die from a cardiovascular event. Cos ultimately, what do most people die of with KD is not actually their kidney disease. Sadly, most don't live long enough to get to dialysis. Most die of a cardiovascular event. Ok. It's more difficult to achieve BP targets. In KD, you are more prone to fluid retention because of changes in calcium metabolism. You are more uh more susceptible to osteopenia, osteoporosis and fractures and you're at an increased risk of hypoglycemia. But really the key message with CKD is protect your kidneys, save your heart. C KD is an independent risk factor for cardiovascular disease. Most people uh uh with, sadly, with CKD, die of a cardiovascular event rather than the kidney disease itself. This was a slogan actually from world kidney thir 13 years ago. But I think it's even more relevant now. Uh in in view of all the new therapies we have available for C KD. So another case study. This is a patient of mine Russell in North Beg 67 years old. A male. Of course, BM I 28 Scottish Caucasian as well. He's had type two diabetes for around six years now, hypertension, but he's also got some complications. He's got background diabetic retinopathy and he's known to have CDC KD stage G three BA three. Now, don't worry if you're not familiar with that terminology, I'll take you through it just shortly and he's known to have uh sorry, he's known to my local virtual renal clinic already. He's on Metformin 500 twice a day, erbes and A R b3 100 once a day. Atorvastatin 10 bisoprolol 7.5 and Doxycin 8 mg the latitude for BP. So he came to see me because last year his eg fr was 46. But when he came for his annual diabetes review with my nurse, it had dropped to 34 and he had 100 and 6 mg per millim of protein in the urine. His urine in a CR was 100 and six. Now, he's very diligent with his medications. His HBA1C is not too bad. Is it 58 millimoles per M? But his lipid ratio is quite high 7.4 and his home BP average 100 and 26/70. So again, not too bad at all. Calcium, uh potassium is ok. Hemoglobin, a wee bit low 121. We often see a slight anemia, don't we? And then d and no evidence of fluid overload and clinical examination. Now, importantly, despite these comorbidities, he is functionally independent. He enjoys a good quality of life. He looks after his grandkids every Friday. He which he really enjoys. He's absolutely exhausted by the end of the day, but he really enjoys it. It helps out his daughter as well with her, her busy work. He's married, uh and he's an ex smoker. So my concern, my practice nurse concern is if he keeps dropping his EG fr at that rate. He may well require dialysis. And his concern is exactly the same. He's worried he may have to start dialysis, which would have a catastrophic impact on his quality of life. His ability to look after his grandkids. He'd have to attend the Edinburgh Renal unit three times a week, wouldn't he? For, for dialysis? So, ladies and gentlemen, what might you do next for Russell? Would you pray that his next Renal review is in? Would you look up GP notebook before realizing you've used up your, the for access pages or on a serious note? Would you add an Aspirin? 75? I've told you KD is an independent cardiovascular risk factor. Would it make sense to add an aspirin? Would you optimize his lipid profile? Remember his lipid ratio was quite high over seven or would you optimize his antihypertensive therapy? His home BP average was 100 and 26/70. But would you want something a wee bit more tighter? Would you optimize his glycemic control? His HBA1C is 58. Would you go for 53 or even 48 or would you do something else differently? So, so we follow up this whole film and let's see what people say. So we've got a few people saying that they want to pray that his next renal review is imminent. Um The votes are still coming in here but a bit more split this time compared to this is definitely a trickier case study, isn't? We? Would all do things just a wee bit differently, would we in primary care? Uh, if you do wanna vote, um, p your vote in, we're gonna close it soon. Ok. So we've got 38% of people saying we're gonna optimize his lipid profile. 27% saying we're gonna optimize his glycemic control and 19% saying they're gonna do something else. Yeah. Ok. So a real mix. So I'll talk you through about what we, we should maybe prioritize there's a number of er er factors we can address in, in, in his lifestyle, of course, but also his cardiovascular risk factors and directly to try and reduce his proteinuria as well. So let's start off with the classification of his C KD. OK. So remember I told you he, he has CKD stage G three, BA three. So I've put an asterisk on the heat map here. So he is in a dark red box. So he's at very high risk of future adverse cardiovascular and renal outcomes. So recent guidance encourages us to classify d by both stage of veg fr but also stage of albuminuria two because each of these factors independently predicts the risk of adverse renal and cardiovascular outcome. So the lower your EGFR, the higher the cardiovascular risk, but the, the higher the urinary ac are, the higher the cardiovascular risk. And you've got both together like Russell had, has your risks multiply. So he indeed is someone we should be very worried about and he's right to have concerns about uh requiring dialysis or perhaps suffering er, a potentially fatal cardiovascular event. So, bit of practical guidance, how often should we check someone like Russell's U and E. So there was another really helpful heat map telling us approximately how many times per year we should be monitoring his EG fr um and urinary acr but mainly G fr. So for someone like him with stage G three ba three, I've circled that the guidance suggests at least twice a year. The rule of thumb I use is if your EGFR is in the sixties, check it six monthly, fifties, five monthly, forties, four monthly, so on and so forth. So his is in the thirties. So three monthly and I see um and pretty bo three monthly. Absolutely. That would that would be adequate. Ok. So how have nice KD guidelines changed the management of my patient Russell? Well, we had a as well as an updated nice type two diabetes guideline. We had a nice updated C KD guideline towards the end of 2021 again, driven by some of the compelling evidence for SGL T two inhibitors and renal outcomes. So the first SGL T two inhibitor trial to show benefit in diabetic kidney disease specifically with the Creedence trial looking at Canagliflozin. Then came the AC KD trial looking at Dapagliflozin in KD with or without diabetes and then came the emer kidney trial looking at sin in people with or without diabetes. And KD and these all showed significant red er reduction in the progression of KD but also a reduction in death from renal or cardiovascular causes. So, the biggest thing that happened in the world of, of kidney medicine since the advent of ace inhibitors and Arbs, that was around the time when I graduated, it was about 2000, 2001. The ace inhibitor and ARB studies were published. So our renal colleagues have had no new therapies for 20 years plus until the advent of the SGLT two inhibitors. So this is a cartoon summarizing what nice tell us to do um in terms of KD. So next time you see a person, of course, with diabetes, we need to check their renal function, both their EGFR and urinary ACR. If the ACR is above three, that is clinically meaningful proteinuria and that individual is at increased risk of adverse cardiovascular or renal outcomes. So, what should we do? Well, we all know the basics offer an ace or an A RB and titrate that up to the maximum tolerated dose. But what we do next is the big change in practice. So even if your patient is on a maximum tolerated dose of an A B, like my patient, Russell is, he's on 300 of Irbesartan. If his urinary ACR is still above 30 on an optimized dose of an ace or a RBI should add in an SGL T two inhibitor with proven renal benefit. Again, independent of the HBA1C. But nice take things one step further. Even if Rossell is on an optimized dose of Irbesartan or an ace inhibitor and his ACI is still between three and 30. I should still do the same offer an SGLT two inhibitor with proven renal benefit independent of the HBA1C. So again, big changes in practice for many of us, primary care and workload, implication, workload implications again, isn't there for us in primary care and we can perhaps pick that up in Q and A. And that's again because of the compelling evidence by SGL T twos um in, in the world of of chronic kidney disease. So there's a number of questions about which SGL T two cut off. So I'll quickly go back to this slide actually. Um So Canagliflozin is specifically licensed for the use of diabetic kidney disease. OK. And it can be initiated all the way down to an EGFR of 20. OK. Dapagliflozin can be used for CKD with or without diabetes and can be initiated all the way down to an EGFR of 15. And empagliflozin can be used for CKD with or without diabetes and can be initiated all the way down to an EGFR of 20. So you can see we have a good bit of flexibility in using starting SGLT two inhibitors for uh for the management of CKD and I can share this PDF with you. Um or what, what I'll share my contact details and then, but a very important point that I'll pick, maybe pick up just now is that the glucose lowering effect? So I've also put together a prescribing tool for using diabetes drugs uh in the context of renal impairment and diabetes. But we have to remember when talking about the SGLT two inhibitors, all SGL T two inhibitors have negligible glucose lowering effect once EGFR drops below 45 OK. And that's because the mode of action of the drug, you need an adequate filtration rate in the kidneys. So to give you an example, if you have type two diabetes and CKD and see an EGFR of 35 but an HBA1C of 64 I would still want to start an SGLT two inhibitor for renal benefit. But I cannot rely on that SGL T two inhibitor to bring down that HBA one C of 64. So I would have to add in an additional glucose lowering agent. OK. So I used to add in a GLP one, but of course a huge shortage of those. So that's a real challenge. So I am using some of the other older therapies. So very important, we all remember the glucose lowering effect of all SGL T twos is negligible. Um once EGFR drops below 45 OK. So guidelines are changing all over the world. So this is an updated UK Kidney Association guideline, just updated last year, telling us also that we should consider using SGLT two inhibitors even in people without diabetes. So that is then dapagliflozin and empagliflozin. So they clearly tell us anyone without diabetes with CKD with a urinary ACR above 22.6 we should consider adding in an SGLT two inhibitor with proven renal benefit such as Dapagliflozin or empagliflozin. So you can see sweeping changes happening um because of these quality trials, but somewhat concerning for us, as I've said already because of the workload implications. So uh global guidelines are also changing. We have a Kygo, this is a global kidney disease organization. They publish guidelines on diabetes and D with this lovely infographic, the pyramid of care of people with diabetes and CKD and a key part of the pyramid is indeed the SGLT two inhibitors. And in fact, hot the press just last week, the same organization ko published a 2024 guideline on the management of D for people without diabetes. And again, a big part of that guideline was starting an SGL T two inhibitor. So you can see guidelines are changing all over the world. And that's exactly what I did for Russell. I actually increased his atorvastatin as well to 20 because of that quite high lipid ratio. But I started him on an SGLT two inhibitor. To be honest, this was from a couple of years ago and uh I II did let my renal team know and I got a lovely letter back from the renal team. So his urinary acr back then was 100 and six. Can you believe his most recent urinary acr from his diabetes check last year is only 12. Now, his EGFR is plateaued. It's much the same. It's hovering around about below thirties. But his urinary A CR is right down. So I got a lovely letter from my kidney consultant telling me that by starting that SGLT two inhibitor early a couple of years ago, I've staved off the need of dialysis for, for Russell by 15 to 20 years. So it was great to get that sort of feedback. So I'll put that in my uh GP appraisal folder. Um So it just gives you the er the impact of this class of drugs both on quality of life, but indeed quantity of life too. So I'm conscious of time, I'll just finish up with some of the side effects cos as I said, I'm very keen to keep the conversation balanced, but hot off the press. These are going live tomorrow. Me and colleagues have also produced a couple of handouts on identification and management of KD in primary care. Again, these a freely distributable. Um We just want to make lives a wee bit easier for all of our colleagues in primary care, but ultimately help improve the lives of our patients. So this is the identification of CKD in primary care and this is CKD interventions in primary care. So again, I hope you'll find those helpful. So let's finish off then with some of the common side effects of SGLT two inhibitors because no drug is without harm. Another one of my favorite quotes by Paracelsus, he was a Swiss German Renaissance physician and the founder of the discipline of toxicology and he famously said poison is in and no thing is without poison. The dosage makes it either a poison or a remedy. So as always, we must balance the compelling benefits of wax lyrical about SGL T two inhibitors against the potential side effects and harms. And that's what I'll finish off in the last four or five minutes. So the best way to look at the side effects of SGLT two inhibitors, they're very similar to the side effects. Uh sorry to the symptoms and signs of type two diabetes itself. So by far, the commonest adverse effect I've seen in 10 years of prescribing SGL two S are mycotic genital infections. So thrush like infections in women, balanitis like infections in men. So good personal hygiene is a very important message when starting an SGLT two inhibitors, UTI S were originally thought to be a potential issue, but that hasn't really been borne out both in my own clinical practice, but also in clinical studies. But if they do get a UTI, you can just treat it as usual. Three days of microphone tone for a lady seven days for a man and same with thrush, some topical clotrimazole or good old trimate for for balanitis patients might also describe some osmotic symptoms. So a slight first polyuria on average if you're on an XG LT two, you pee one extra time a day. And occasionally individuals might feel a wee bit lightheaded or fatigued as well. It's very rare for SGL T two inhibitors to cause volume depletion or clinical dehydration. But they are possibilities. So if you are worried about the fluid status or hydration status of a patient, then perhaps this is not the best class of drug for them. We reassured there's no signal for AK I acute kidney injury. Quite opposite. As I've told you already, it protects against chronic kidney disease and indeed actually emerging data protects against acute kidney injury as well. So two key messages when I start an SGL T two for patients good hydration. So advise patients to drink at least a liter and a half to 2 L of fluids a day, clear fluids a day, not including tea, coffee or alcohol and good personal hygiene um as well. OK. But the two key safety updates I wanted to highlight, first of all were the DK A issue and I'm sure many of you will be familiar with this. We've had a number of M HRA alerts over the last seven or eight years about the risk of DKA diabetic ketoacidosis with SGL T two inhibitors. It is rare. You're talking one in 1000 to 1 in 10,000 and the benefits do outweigh the risks. Ok. The challenge for us though in primary care is the DK, we sometimes see with SGL T twos is a new glycemic DK glucose levels are normal or near normal because you're peeing out that extra glucose. So how do we make sense of this in primary care? Well, if I'm starting an SGL T two inhibitor, I warn patients about the signs and symptoms of DK, which is pretty challenging. Anyway, isn't it cos it's very nonspecific abdominal pain, nausea, vomiting, malaise. Basically, I tell my patients if you are significantly unwell on an SGL T two, particularly if you have a fever, at least pick up a phone and ask me or a colleague for some advice if we deem them significantly unwell, bring them in, check their blood sugar levels, but importantly, go on and check ketone levels even if their glucose levels are normal or near normal. Ok. Now, ideally, we should be checking blood ketone levels rather than uh uh urinary ketone levels. As blood ketones are more specific and sensitive, but we can use urinary test strips if you are using blood ketones. The number you're looking for is 1.6 and above that increa er that suggests an increased risk of ketosis, ketoacidosis. Importantly, there's no need to issue ketone testing strips to those on SGL T two inhibitors, but we do need to have access to them ourselves as GPS nurses and pharmacists in primary care. So, very much ladies and gentlemen, uh we need to add SGLT two inhibitors to our ever expanding list of sick day guidance drugs, drugs to temporarily pause during any acute intercurrent illness. So the pneumonic I often teach my colleagues is temporarily pause the sad man drugs during any acute dehydrating illness such as diarrhea and vomiting, temporarily pause. The S for SGLT two inhibitor A for ace inhibitor D for diuretic, M for Metformin, A for A RB and N for non steroidal. And importantly, we need to restart these drugs or tell patients to restart these drugs once they're eating and drinking, normally, usually three or 2 to 3 days later, something like that. So sick a guidance. Very important. So what my practice pharmacist has done, we use vision in North Bering automatically appended to all prescriptions of S PLT two S in my practice are these day guidance as a reminder to the patient to me as an ACP and to the community pharmacist as well. So there's a number of great leaflets out there, decision tools, et cetera to remind us to temporarily pause the sad man drugs during any acute dehydrating illness. OK. And the last thing to finish off with is the issue about fournier's gangrene. Now again, I'm sure many of you are familiar with this in 2019 that M HRA warned us about a possible association with Fournier's gangrene, necrotizing fasciitis of the genitalia of perinea potentially fatal. And I was a bit annoyed about this M HRA report because it's incredibly rare. You're talking just six yellow card reports at that point in over 5500 and 50,000 patient years of treatment. And actually, if you look at all the big SGL T two inhibitor trials, I've quickly taken you through the kidney ones, the heart failure ones, there was actually no imbalance in cases of fus gangrene in those studies. OK. There was similar number of cases or no cases in both the SGL T two arm of the study and the placebo arm. So I don't explicitly, I'm gonna be honest, I don't explicitly tell patients about fo gang. You can imagine what Grant and Russell would say if I told them, oh, I can stop you having a heart attack or stop your progression of KD, but your willy might fall off. So II don't explicitly mention for G but I do reinforce good person personal hygiene. And of course, I will tell Grant and Russell all my female patients, you know, if they do experience any pain tenderness, erythema, swelling in the genital or perineal area, they need to get some advice. So again, reinforce the importance of good personal hygiene. OK. So I think that's really all I was gonna cover. I appreciate that was quite a whistle stop tour. There. What I was gonna quickly show you is very quickly. I think we've got two minutes, one of my SGL T two videos to give you an idea, uh, of, of the sort of information we should be giving patients. And again, if you find these helpful, they're freely available on, on youtube, my kids are mortified. I have a youtube and tiktok channel but, uh, hopefully, er, your patients might find them helpful. So if it's OK with you, Phil, I'll just play that. It's two minutes and then we'll go uh to some Q and A. OK. Hello, I'm Kevin Fernando and GP Base near Edinburgh in Scotland. You're watching this video because you've been started on OK? Or thinking about starting on an SGL T two inhibitor medication, SGL T two stands for sodium glucose cotransporter two. And there are four of this type of drug currently available in the UK, Canagliflozin brand name Invokana Dapagliflozin brand name, Farxiga Empagliflozin brand name, Jardiance and Agli Flosin brand name Steglatro. They are sometimes referred to as Flosin or Gliflozin SGL T two inhibitors are based on a substance called flora which is actually found in apple tree bark SGL T two inhibitors can be prescribed on their own or in combination with other diabetes medications you might be on such as Metformin and even insulin SGL T two inhibitors were initially developed to treat people living with type two diabetes as they can help reduce blood sugar levels. SGL T twos work in the kidneys to prevent the reabsorption of sugar from the urine back into the circulation. And instead this excess sugar is passed out in the urine. Other benefits of SGL T two inhibitors include weight loss, average weight loss of around 2 to 4 kg over 6 to 12 months because you're passing this excess sugar into the urine. SGL T two inhibitors can also help reduce your BP. And more recently SGLT two inhibitors have been found to protect the heart and kidneys and reduce the risk of heart attacks and strokes as well as reduce the risk of kidney and heart failure. Now importantly, the kidney and heart benefits also work in people without diabetes, which is why you may have been prescribed an SGLT two inhibitor even if you don't have type two diabetes. This all sounds too good to be true, doesn't it? Trust me? I'm a doctor, but of course, all medications have side effects. And in the next video, I will outline some of the more common side effects people experience with SGL T two inhibitors and some practical advice on how to manage them. However, the advantages of SGL T two inhibitors do outweigh the side effects of the majority of people who would benefit from them. I hope you found this video helpful and thank you for listening. Good stuff. Thanks. So I've got some nice comments, you know, feel free to use them. Uh and please follow me on youtube. I only have about uh 50 followers or something. I don't think I'm gonna be the next Mr Beast in the near future. So uh finish off then a last quote. As you can tell, I like my quotes. Um the past is a foreign country. They do things differently there where in a new era of managing type two diabetes and comorbidities, we need to think beyond glycemia and look at the presence of comorbidities such as atherotic cardiovascular disease, heart failure and chronic kidney disease and use the presence of these comorbidities to choice of therapy. But there's no doubt the evolution of research guidance is pretty overwhelming for us in primary care. So it's there's workload implications for us as well and that's what I'm hoping we can maybe pick up in the Q and A just now. So here my contact details, everyone. Thanks so much for listening. I see some lovely comments in the chat box. That's very kind of you all feel free to drop me an email after today or any time. Uh If you want me to clarify anything or if you want me to share resources. I'm also active as I said on social media, Twitter, um linkedin and of course youtube. So thanks again everyone. Thanks for listening. Thanks for inviting me Phil. Uh Kevin. Thank you so much for an amazing session. And by the way, I think you're born for youtube and don't listen, don't listen to your kids. Um, thank you so much, er, really great session. We've got some time for questions, Tim, I'm gonna let you pick out some of the best questions. We've only got a few minutes, but uh I'm gonna let, um, doctor Tim Neal who's joining us this evening, uh, pick out some, some questions whilst you're doing that. Tim Kevin, what we can actually do is we can actually share a QR code for your youtube video. So what that means is if you're joining this evening and you think actually that's a really useful resource for my patient. We'll add it on the middle primary care, patient information, er resource section. So you can actually just share the QR code with your patients. So just pull up the QR code, they can scan it on their phone and then bind straight to us. So we'll, we'll put that, we'll put that on the patient resources section on medical primary care. Um er Tim I'm gonna hand straight over to you to, to feel some uh some of the great questions that we've got. Sure thing, Phil and uh some fantastic questions coming through there just as I was as I was listening in Kevin, um Kevin, I'm going to take it right back to the start to one of the first questions that came in from the, we've talked a lot about um SGL T two inhibitors towards the end there. But right back at the start talking more about the modern management. Yeah. Why does no one discuss mental health with regards to diabetes? There's a lot of, obviously a lot of our time in general practice is spent dealing with those kind of complaints. Um So have you anything to say just about that? Oh, it's a very important physical as we are. I'm telling you all to suck a physical and mental health inextricably linked. And we have high quality evidence that worsening mood anxiety in the context of type two diabetes worsens outcomes as well. So we absolutely, it's just there's so much to talk about isn't there. And uh II think sometimes that's why, sadly, it gets forgotten. We tend to focus on the glucose or the comorbidities that I've told you to do so. And sometimes, unfortunately, we only give lip service to mental health. Um So there's this great, um there's this great tool called lesser positive cardiometabolic resource which encourages us to look at cardiometabolic health of our patients living with severe mental illness such as schizophrenia, severe depression, with psychosis, et cetera. And people with schizophrenia um are as we know at higher risk of cardiometabolic disease such as diabetes. So we should be screening all our patients for, for uh with severe mental illness, for the development of cardiovascular disease and diabetes. So that's one thing we've been doing in our practice. But you're right. People with existing type two diabetes, we should be screening them for diabetes distress, for low mood anxiety, any long term condition. Remember? Well, we haven't had cough in Scotland for many years, but when we did have cough, um, there were those two questions, weren't they? Where we would ask any one with long term conditions, including diabetes? Uh, have you been feeling down depressed or hopeless recently? Have you lost enjoyment and things? So, absolutely, mental health is pivotal to, to the successful management of any long term condition. Not just type two diabetes, but time, you know, we only have 10 or certainly in my practice 10 minutes or less. Um, and we need time, don't we to explore all those facets of, of mental health? Absolutely. Absolutely. Yeah, I mean, like the mental health side of things certainly feeds into any chronic condition, as you say, Kevin. Um, the next one I'm going to pick out, we have seen quite a lot of fantastic resources there, Kevin, your Medscape is, is brilliant, those resources with flow charts and that, but just to maybe focus in on the SGL T two. Is there any, is there any evidence that point towards, um, any of the four being more active or renaud protective? Is there any anything you can point us towards there? Yeah. Yeah. So I'm always asked that there's no doubt in my opinion. And, you know, as I showed you in my disclosures, I have spoken on behalf of various SGL T two companies, but there's no doubt in my mind it's a class effect. Ok. Um, so give it a few years, we'll be using SGL T twos like we now use ace inhibitors and ARB S. But at the moment we need to follow their evidence. So II briefly outlined it, didn't, I canagliflozin is specifically for diabetic kidney disease. Ok. Um, and doesn't actually have a heart failure license whereas, uh, uh, dapagliflozin can be used for CKD or heart failure with or without diabetes so can flows in. But in my, in my view, and many of my er, expert colleagues view it is, it is a class effect. So we, we're actually not too far off from having a generic, er, er SGLT two. So I think that will change the goalpost quite significantly then, but the heart failure benefits the renal benefits. The cardioprotective benefits are no doubt a class effect. But currently we have to follow the licensed indications. Yeah, it makes sense better to have one than worry about picking between which one. Exactly. Yeah, I like that and just coming up a little bit, um we touched briefly on, on um DK A as being one of the potential side effect. So I'll maybe I'll maybe make this the last question perhaps. But the, the sort of physiology behind how the SGL T twos can cause that, that can cause the DK A. Yeah. So a really interesting question. I mean, to be honest, we still don't even fully understand how SGL T twos exert their cardiorenal benefits. But the, the, the, the underlying mechanism for the DK A, as I briefly mentioned, SGLT twos work by making you pee out that extra glucose. So during any acute intercurrent illness, normally, of course, your sugar levels increase during any acute illness and therefore your insulin levels would increase. Um as well. That's part of our response to illness. But because you're peeing out that extra glucose with an SGLT two, you're not getting that physiological increase in insulin in response to illness. So you're relatively insulin, but your sugar levels are going up. So that imbalance leads to ketosis potentially decay. That's a, a fairly simple explanation. But in a nutshell, what they uh there's also a complex interplay with the heart as well. Um But uh ii don't want to bore everyone with a complex physiological explanation, but that in a nutshell is why you get some ketosis. Yeah, I'm going to squeeze one more in if I, if I can. There's one I'm interested in. We talked, we talked there about sad man and places where we would temporarily pause, give certain drugs. But I've seen a really interesting question come in that I actually hadn't added to the Q and A yet from Katie. We talked about that potential reversibility of a diagnosis of diabetes. Is there any point or is there any criteria that we can use at a point? Where we would actually start deprescribing these things. Yeah. So that is a fantastic question. And that is something that I, we debate all the time amongst my expert colleagues because these are, in essence secondary prevention drugs, aren't they? These are disease modifying drugs. SGL T twos. So don't get me wrong if Grant loses 15 kg and reverses his type two diabetes. That's fantastic. But if he also has C KD, I would still want him on an SGL T two. If I was in Grant's position, I would still want to be on an SGL T two. Because remember the SGL T two, the renal cardio benefits are independent of the glucose lowering. So it makes for a difficult conversation. You know, I would, I would be telling Grant, you know, I'm telling him lose weight, you can come off your medications. But the caveat is if the presence of comorbidity. So it's not a, we have no clear guidance on the prescribing in the presence of comorbidities. But certainly from my knowledge of the, uh the data, um if, if my patient had heart failure or D or non stemmy, even if they'd managed to reverse their type two diabetes drop the HBA one C below 48 I would still want them to continue on an SGL T two. But as I said, I get a lot of push back and I've had patients who've done that and they say, well, Kevin, what was the point of me losing all that weight and dropping my HBA1C to below 48. I think you'll still get a huge, huge benefit from that. But the SGL T two here is not really for your diabetes. It's specifically for kidney protection. So it is a tricky conversation. But we, we need to stop looking at SGL T twos as diabetes, drugs and look at them as secondary prevention drugs. The analogy is bariatric surgery. We're quite aware. Now, even after bariatric surgery, under significant weight loss, you get with that people are still at risk of cardiovascular events. So previously, bariatric surgeons physicians used to recommend stopping aspirin statins after bariatric surgery. But there's a big push against that. Now that really even after bariatric surgery, people should continue some of these secondary prevention medications. So we're gonna get a lot more guidance about that over subsequent years because uh, you know, because it's gonna be an increasingly common dilemma we come across in primary care. Thank you. Thank you so much, Kevin. I see there, there's so many questions in the chat there, but I think in the in the interest of time, we'll have to have to wrap up with the questions, but Kevin has so kindly provided his contact details there. If anybody does have a burning question for Doctor Fernando, so just go to the app, go to patient information, leaflets and click er SGL two inhibitors. This QR code will take your patient straight to er to Kevin's video and um and so you can share it with them really easily in uh in, in clinic. Um It's right there on the resources section. Thanks so much, Phil. That's good to do that. Scan the QR code. It'll take you straight to download the app and you'll be able to get those resources right there. I'll b you straight to Kevin's wonderful youtube channel and straight to that video. Um Thank you so much, everyone for joining us this evening. Thank you so much, Kevin for an amazing session, really, really helpful, really practical and um and really clear, we're gonna be pinging a feedback form into the chat. Um right now and once you complete that feedback form, you'll automatically get um a certificate awarded, just click the link that's in the chat at the moment. We'll also send it out via the app after the event and via email. So you've got lots of opportunities to provide feedback and you'll also get a certificate. So just complete the link that's in the chat. I'll bring it in again. So it's right there. Um Just click on that link, provide some feedback, you'll automatically get a certificate. Um And um and er if you download the app, we will also ping out a notification when we send the slides and any other resources that that Kevin makes available as well. Thank you so much, everyone for joining us. Thank you, Kevin. Thank you, Tim for sharing our, our questions. Amazing job. And um if you're interested in joining our next meal, primary care sessions, um just hit metal primary care at the top of your screen. We've got a whole host of sessions available and they're all completely open access, completely free. We're doing this really to try to help you and, and really passionate about making medical education more accessible. So I hope it's really helped you this evening and uh we really look forward to, to seeing you next time. Thank you so much. Everyone. Thanks everyone. Cheers. Take care. I.