Alirae Bunkle, Diabetes Specialist Nurse, West Norfolk.

Alirae Bunkle, Diabetes Specialist Nurse, West Norfolk.



Alirae was warmly welcomed back on 22nd October as the audience of diabetics and their friends and partners anticipated another of her detailed but brilliantly explained talks that help so much with the self-management of diabetes.

To begin with Alirae described various new treatments for diabetes, starting with the SGLT2 (sodium glucose transporter 2) inhibitors that are literally the latest group of medications used for Type 2s. Those now in use include dapagliflozin (Farxiga), canalgliflozin (Invokana) and empagliflozin (Jardiance). They work by reducing the amount of glucose absorbed into by the body from the kidneys so that it is passed out in urine (some 300 calories a day) thus reducing blood glucose and also helping with the control of weight gain. Usefully too the nature of their action means that they do not cause hypos.

The downside to their use however is that extra sugars in urine encourage infections of the genital and urinary tracts. Fortunately these are relatively easily treated with an antibiotic or antifungal treatments(in the case of thrush), and once under control infections do not normally recur, as the body seems to adapt to the higher excreted sugar level.

Dulaglutide (Trulicity) represents a new approach as it uses insulin mixed with an incretin mimetic (these increase the production of the hormones called incretins which help the body produce more insulin). The combination of these two previously separately administered treatments (sometimes used for diabetics with very poor control of blood sugars) simplifies treatment and has an annual cost of £1182 per patient.

New insulins. Tresiba is a new, long-acting, basal-insulin (up to 42 hours) for use by both Type 1s & 2s with its particular use employed where there are certain life-style issues, and it comes in different concentrations. Normally this basal-insulin is at 100 U/mL (units per mL) of carrier, but, for diabetics with some insulin resistance, it is available at 200 U/mL thus reducing the overall volume and making insulin absorption easier. There are also more concentrated U500 mixes at five times the concentration used for extreme cases of insulin resistance, but currently these U500s have to be imported from the USA. Cost is a factor at £72 per 5 cartridges or pens. However as patents for major branded insulins expire biosimilar insulins are now competing on price.  Lantus (insulin glargine) costs £41.50 for 5 cartridges & Abasaglar (insulin glargine biosimilar LY293016) £35.28 for 5 cartridges. Toujeo is a longer-acting version of insulin glargine in U300 formulation said to reduce night-time hypos in Type1s.

Carb counting for food comparisons. Alirae used a question and answer approach to help increase the audience’s awareness of the need to monitor carbs, (essential for the effective management of diabetes) particularly when eating out, and the members found it surprising to realise that just to function the body only needs 120-150 carbs per day with a normal requirement of around 180 carbs. She had prepared lots of slides comparing different commonly eaten foods and snacks. Testing her audience, by asking them to judge what had the lower carbohydrate or calorie count, revealed the many mistakes we make as diabetics when choosing between food options. For example few realised that a crème brulee had only 19 carbs, (less if you remove the burnt sugar topping!) though of its 210 calories 90 come from its fat content, which is probably of more concern to those with hardened arteries!

As a leaving piece of advice Alirae discussed a recent physio presentation she had attended where the value of  ‘armchair exercises’ to those with reduced mobility was demonstrated and highly recommended.

Whilst Alirae is always pleased to take questions throughout her talks, question time itself inevitably overruns as members really appreciate the opportunity of asking such an able practitioner about the very real worries they experience with their various conditions, and all hope she will return to continue with her explanations and advice.