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ENC J2

BARNSLEY

DIABETES CARE PATHWAY

VERSION 3 April 2014


BARNSLEY DIABETES CARE PATHWAY

This Care Pathway is modified from the Enfield Diabetes Care Pathway, version 5, May 2010. The Barnsley Local Diabetes Service Advisory
Group is most grateful to the clinicians responsible for the Enfield Care Pathway and, in particular, Debbie Hicks, Nurse Consultant, for
permission to utilise their work. In turn, the pathway is based on: NICE CG 66 Type 2 diabetes guidelines for Diabetes 2008 and NICE CG 87
Type 2 diabetes: partial update 2009. Version 2 was launched in Barnsley in March 2013 and the Local Diabetes Service Advisory Group agreed
an update (Version 3) in January 2013. Revisions will be issued every 2-3 years or as required.

CONTRIBUTORS

Enfield
Dr Chris Baynes Consultant Physician Barnet & Chase Farm Hospital
Paul Gouldstone Head of Medicines Management NHS Enfield
Debbie Hicks Nurse Consultant – Diabetes NHS Enfield Community Services
Kit McAuley Diabetes Specialist Nurse NHS Enfield Community Services
Dr Hilary Tindall Consultant Physician North Middlesex University Hospital

Barnsley
Dr Keith Sands Consultant Physician South West Yorkshire Partnership FT
DIABETES CARE PATHWAY TYPE 2 DIABETES1

MILESTONE 1 MILESTONE 2 MILESTONE 3 MILESTONE 4 MILESTONE 5

Diagnostic phase Educative phase Treatment management Complication/risk Maintenance phase


phase management

a. Lifestyle changes* a. Check and recheck a. – Offer dietary advice a. Hypertension a. Regular review if
understanding – Trial of lifestyle unstable 2-3 monthly
b. Patient given Interventions including
information booklet b. Lifestyle issues incl increased activity b. Lipid management
smoking and exercise b. 6 monthly review once
c. Patient given hand-held stabilised
c. Medication b. Treat all co-existent c. Anti-platelet therapy
record
pathology eg BP, lipids for secondary
prevention c. Annual review
d. Referral to dietitian d. Complications Arrange screening for (see Appendix 2)
complications
e. Referral to group
e. Importance of regular • See Milestone 4 d. Microalbuminuria
education sessions review d. On-going review of
educational needs
f. Driving c. See medication
f. Regular review (see algorithm e. Management of CKD
Maintenance phase)
g. Importance of good BP e. Review of dietary
control needs
g. Assessment of d. Continued education & f. Management of painful
emotional wellbeing h. Importance of good support neuropathy
BG control (HbA1c) f. People with existing
h. People with severe diabetes should be
i. Retinal photography e. 3-4 monthly HbA1c
mental health g. Retinopathy/foot care monitored for
diagnosis should be depression
checked annually for j. Foot health
f. Continue to follow
diabetes medication algorithm h. Erectile dysfunction
k. Sexual health g. Information about
monitoring and
l. Travel g. Once stabilised, glucose meters where
i. Obesity appropriate
regular review. See
m. DUK/support groups
Maintenance phase
n. Offer structured j. Peripheral arterial
education programme disease

*
See laminated version appendix 1 & 2
MILESTONE 1: DIAGNOSIS OF DIABETES MELLITUS

PRESENTING SYMPTOMS

1. Patient presents with signs and symptoms suggestive of type 2 diabetes


 Excessive thirst
 Increased urination, especially at night
 Lethargy
 Weight loss
 Blurred vision
 Infections (eg pruritis, balanitis)
 None of the above
2. At routine /ad hoc health review patient has glycosuria
3. Increased suspicion due to risk factors eg
 Ethnicity
 Family history >40 years of age
 Previous gestational diabetes
 Existing severe mental illness such as schizophrenia

WHO DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS


Most cases can now be diagnosed through a combination of clinical features, BG and HbA1c levels. OGTT is rarely required except during pregnancy. If
RBG 6.0–11.0 mmols/L check FBG. If RBG  11.1 mmols/L diabetes diagnosed (OGTT NOT required). If FBG < 6 mmols/L, diabetes is unlikely.
Confirmation of diagnosis requires laboratory and not finger prick testing. Diagnosis should never be based on a single test result. Laboratory testing
of HbA1c a useful diagnostic test in adults without conditions known to affect HbA1c measurement (ie anything that interferes with red cell or Hb
turnover). Do not use in pregnancy or if type 1 diabetes is suspected. HbA1c<48mmol/mol (6.5%) is recommended as the cut-off point for diagnosing
diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests, but one of greater than 48 mmol/mol
(6.5%) should be regarded as indicating a high risk of diabetes. HbA1c 42-47 mmol/mol (6.0-6.4%): lifestyle advice, warn to report symptoms of
diabetes, recheck in a year, HbA1c <42 mmol/mol (6.0%): may still be at high risk of diabetes. Review individual risk and manage accordingly.

NB: In the absence of osmotic symptoms 2 consecutive venous samples are required to diagnose diabetes mellitus

PLASMA DIABETES CONFIRMED IMPAIRED GLUCOSE TOLERANCE IMPAIRED FASTING GLYCAEMIA

≥6.1
FBG ≥7.0 <7.0
<7.0

OGTT ≥7.0
≥11.1 Check HbA1c (as above)
2 hour value <11.1

NB: In the elderly and some ethnic minority groups fasting glucose levels may not be a reliable indicator of diabetes
MILESTONE 2: EDUCATION IN TYPE 2 DIABETES

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 STEP 5


Assess Review Discuss Discuss Facilitate Understanding Review
Learning Understanding Lifestyle Complications Diabetic the Annual Understanding
Needs Issues Referral Review

Is English the first Diet Eyes Give ‘stop gap’ Height, weight, Importance of
What is diabetes? dietary advice regular diabetes
language? BMI, waist
circumference checks
Exercise CVD
Has patient been
Is the patient Importance of Smoking referred to BP Review
literate in regular diabetes Kidney dietitian? concordance with
English? checks medication
Alcohol Urine/blood tests
Erectile YES
 HbA1c
dysfunction  Recheck Review
Is the patient
What to expect at Importance of understanding  U&E concordance with
literate in own medication  TFT healthy eating
an annual review
language? Neuropathy  LFT regimen

Social NO  Lipid profile


Arrange adjustments PVD  Refer to  eGFR
appointments as Barnsley support
dietitian  ACR Assess gaps in
necessary with group knowledge and
Psychological Foot provide education
interpreter
wellbeing Foot Assessment as appropriate
 Pedal pulses
Driving  Neuropathy
Offer patient status
EPCT structured regulations
diabetes
education
programme Retinopathy
Status
Enrolment in
Retinopathy
Screening
Programme
MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES

= = Usual approach = Alternative approach


Us Us
INDIVIDUALISE THE HBA1c TARGET BUT, IN GENERAL, UNLESS THERE IS A CONTRAINDICATION, AIM FOR 48 mmols/mol (6.5%) INITIALLY
Review at least annually and, as diabetes progresses, the HbA1c target for intervention can be increased to 59 mmols/ml (7.5%)
INITIATE HEALTHY EATING PLAN AND INCREASED ACTIVITY FOR AT LEAST 12-16 WEEKS UNLESS SYMPTOMATIC

AGREE LEVEL OF HBA1c FOR INTERVENTION

Consider first:
METFORMIN SULFONYLUREAS
 METFORMIN SHOULD NOT BE STARTED IF SERUM If not overweight, metformin not tolerated or a rapid response is
CREATININE (sCr) >150 mcmol/L &/OR eGFR <30 ml/min required because of severe hyperglycaemia
 Review response to medication using the step guidelines, within 28 Consider a rapid-acting secretagogue (ie repaglinide, nateglinide)
days in the first instance, then 3-4 monthly using HbA1c for people with erratic lifestyles
 Commence 500mg bd/tds, with further increases over a few weeks GLICLAZIDE GLIPIZIDE GLIMEPIRIDE
as tolerated up to a maximum dose of 1g bd/tds
 If unable to tolerate metformin, or concordance issues, consider 80mg od/40mg bd 5mg od 1mg od
reducing dose or change to mr metformin up to 2g od 80mg bd 5mg bd 2mg od
 Review metformin dose if sCr >130 mcmol/L &/or eGFR < 45ml/min
160mg am/80mg pm 10mg bd max 4mg od
SEE CKD PATHWAY FOR LONG TERM MONITORING 160mg bd max 6mg od max

Consider second when HbA1c >48 mmols/mol (6.5%), if sulfonylurea/metformin intolerance or hypoglycaemia with sulfonylurea :

(METFORMIN +) DPP-4 INHIBITORS (DPP4I) (METFORMIN +) THIAZOLIDINEDIONES (TZD)


 In combination with metformin or a sulfonylurea or a glitazones  Only use pioglitazone
 Sitagliptin and linagliptin can be used as monotherapy  Avoid in those with active (or a history of) bladder cancer, heart
 Sitagliptin and saxagliptin can be added to insulin ( metformin) failure or a higher risk of fractures
 Continue only if HbA1c reduction of at least 0.5 percentage point (5  Licensed as monotherapy if control sub-optimal and intolerant of
mmol/mol) at 6 months, which is maintained metformin
 Discontinue if symptoms of acute pancreatitis  Can be added to metformin, sulfonylurea or both. Combination with
 Dose of concomitant sulfonylurea or insulin may need reduction metformin preferable, particularly in the overweight
 Continue only if HbA1c reduction of at least 0.5 percentage point (5
Sitagliptin Saxagliptin Linagliptin mmols/mol) at 6 months, which is maintained
 Caution when used with sulfonylurea as maximum response
100mg od 5mg od 5mg od may not be evident for 6-12 weeks
MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES

(METFORMIN +) SGLT2 INHIBITOR


 Use as for DPP-4 inhibitors above
 Dual combination with metformin
 Can also be used with insulin ( metformin)
 Not recommended as triple therapy
 Use with caution in patients on diuretics or who are volume depleted
 Avoid if <18 yrs or >75 yrs or eGFR <60 ml/min (does not apply to
canagliflozin – avoid if eGFR<45 ml/min)
 May cause genital thrush or UTI – treat conventionally; does not
usually require discontinuation of SGLT-2 inhibitor

Dapagliflozin Canagliflozin*
10mg od 100-300mg od
(100 mg od if eGFR 45-60 ml/min)

*Not approved by NHS Barnsley APC at time of writing


MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES
Consider third when HbA1c >58 mmols/mol (7.5%):
DPP4I or SGLT2I TZD GLUCAGON-LIKE PEPTIDE-1 NPH INSULIN OTHER INSULIN ALPHA
AGONISTS (GLP-1) GLUCOSIDASE
See overleaf and See overleaf and 
2
If BMI ≥35kg/m and other  Ensure  Ensure injectables INHIBITOR
 If insulin is not  If insulin is not psychological/medical problem injectables care pathway is
acceptable or acceptable or associated with raised BMI or if BMI care completed ACARBOSE
inappropriate inappropriate 2
<35kg/m and insulin unacceptable for pathway is  Consider if
occupational reasons or where weight completed assistance required 50mg od
loss would benefit other co-morbidities from a carer/HCP
Increase to
 Continue only if HbA1c reduction of at to administer
50mg tds after 6
least 1 percentage point (11 mmols/mol)  If lifestyle is weeks
and weight loss of at least 3% at 6 restricted by
months recurrent 100mg tds
 Use exenatide before liraglutide hypoglycaemia
200mg tds
 Avoid or stop if symptoms/history of  If would otherwise
acute pancreatitis require bd insulin
 Avoid exenatide if eGFR <30ml/min and and OHAs
liraglutide if eGFR <60 ml/min  If cannot manage
 Dose of concomitant sulfonylurea or injection device for
insulin likely to need reduction NPH insulin
 The 1.8mg dose of liraglutide is not
recommended
 Exenatide licensed for addition to basal
insulin; insulin detemir licensed for
addition to liraglutide

APPROVED AS ‘AMBER-G’ BY APC

Insulin or GLP-1 agonists should only be initiated by:


A. Practices that are currently receiving enhanced diabetes payments or
B. Those who have attended an appropriate training course/update within the last 2 years.

Consider fourth if HbA1c remains >58 mmols/mol (7.5%)

NPH INSULIN OTHER INSULIN Consider pioglitazone or sitagliptin/saxagliptin with insulin


 Ensure injectables Ensure injectables care pathway is completed if:
care pathway is 1. Long-acting insulin analogue – see above and switch if
completed  Target HbA1c not reached due to significant hypoglycaemia  Pioglitazone or a DPP-4 inhibitor has previously had a
 Cannot manage insulin injection device marked glucose-lowering effect or
 Requires assistance from carer/HCP to administer  Blood glucose cannot be adequately controlled without
NOT to be initiated in pregnancy high-dose insulin
2. Pre-mix insulin MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT
HYPERTENSION

Step 1
1. BP targets: Offer an angiotensin-converting enzyme (ACE) inhibitor or, if ACE not tolerated or not appropriate,
a low-cost angiotensin-II receptor blocker (ARB)
 If NO microvascular  Do not combine an ACE with an ARB to treat hypertension
complications ACE: Lisinopril 5mg od initially, titrating up to usual dose of 10-20mg od or ramipril 2.5-5mg od
≤140/80 mm Hg ARB: Losartan 50-100mg od (>75yrs start with 25mg) or irbesartan 150-300mg od (>75yrs start with
 If microvascular complications 75mg)
(proteinuria, retinopathy,
microalbuminuria) present aim Calcium-channel blocker (CCB) as alternative to above or as preferred treatment for black people
for ≤130/80 of Afro-Caribbean origin (± diuretic)
 If nephropathy(eg proteinuria Amlodipine (caution with statin dose) 5-10mg od or felodipine 5-10mg od
>1g/day) is present aim for  Preferred choice if possibility of pregnancy
≤125/75  If CCB not suitable or evidence/high risk of heart failure offer a thiazide-like diuretic
Chlortalidone 12.5-25mg od or indapamide 1.5mg mr od or 2.5mg od
2. Non-pharmacological measures: Continue treatment in those receiving conventional thiazide (bendroflumethiazide or hydrochlorothiazide)
where BP stable and well controlled
 Encourage healthy eating,
including salt reduction IF BP REMAINS ABOVE TARGET
 Increase physical activity
 Stop smoking
 Encourage weight reduction, Step 2
including reducing excess Add CCB or diuretic (see above)
alcohol intake
 Stress management IF BP REMAINS ABOVE TARGET

3. Monitor patient monthly, titrating


medication upwards to maximum Step 3
dose before adding the next anti- Add diuretic or CCB (see above)
hypertensive agent
IF BP REMAINS ABOVE TARGET

Step 4
Add alpha blocker Doxazosin 2-16mg od
Add beta-blocker Metoprolol 50-200mg od or bisoprolol 2.5-20mg od

CONSIDER SPECIALIST REFERRAL IN CASES OF RESISTANT HYPERTENSION


MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
LIPIDS
Aims:
To improve the lipid profile in order to :
 Reduce the risk of cardiovascular disease (CVD)
 Reduce the risk of pancreatitis in those with severe hypertriglyceridaemia

1. Offer a statin to all those with type 1 or type 2 diabetes aged 40 years or above (and to those under 40 years with a risk factor for CVD*)
2. Aim for total cholesterol (TC) ≤4.0 mmol/L and LDL-cholesterol ≤2.0 mmol/L, but consider each case individually.
3. If TC ≥4.0 mmol/L and/or LDL-C ≥2.0 mmol/L
 Exclude hypothyroidism, excess alcohol intake, liver disease and pancreatitis
4. Encourage weight loss, healthy eating and increased activity
5. Optimise blood glucose control
6. Stop smoking

*Risk factors
 Multiple features of the metabolic syndrome
 Presence of conventional risk factors
 Microalbuminuria/nephropathy; Retinopathy
 At-risk ethnic group
 Strong family history of premature CVD

Step 1. Simvastatin 40mg nocte (a lower dose of simvastatin, or pravastatin 40mg , may be considered if there are potential drug interactions or
simvastatin 40mg is contraindicated)
Step 2. Simvastatin 80mg od (more cost-effective to prescribe 2 x 40mg tabs) or atorvastatin 40mg od
Step 3. Atorvastatin 80mg od
Step 4. If target not achieved and in presence of existing CVD consider the addition of ezetimibe or switching to rosuvastatin 10mg od
Step 5. In patients failing to achieve target, unable to tolerate statins or who have a high CVD risk and triglycerides 2.3-4.5 mmol/L despite a statin,
consider the addition of a fibrate (first choice fenofibrate) on a case by case basis and consider specialist referral
Elevated triglycerides (fasting lipid profile)
 Assess and manage other possible causes (poor diabetes control, hypothyroidism, renal impairment, liver damage, particularly from alcohol)
 If triglycerides >4.5 mmol/L initiate fibrate (first choice fenofibrate) either before or in addition to a statin
 Only consider nicotinic acid or derivatives if intolerant to statins and fenofibrate
 Omega-3-fish oils – only use as part of specialist management of hypertriglyceridaemia
Monitoring
 Check liver enzymes before starting a statin, then measure LFTs at 3 months and 12 months, and then annually if clinically indicated
 Only exclude from statin treatment those with liver enzymes ≥3x upper limit(s) of normal
 Do not measure creatine kinase routinely but only in those who develop muscle symptoms (pain, tenderness or weakness)
 In case of unexplained peripheral neuropathy, statin should be discontinued and specialist advice sought
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …

ANTI-PLATELET THERAPY
 Aspirin is not licensed for the primary prevention of vascular events in people with diabetes. If aspirin is used in primary prevention, the
balance of benefits and risks should be considered for each individual, particularly the presence of risk factors for vascular disease and
the risk of gastrointestinal bleeding
 Patients on existing low-dose aspirin for primary prevention of vascular events should be reviewed and the benefits and risks of the
treatment discussed with them
 Aspirin, 75mg od, should be given routinely and continued long term in patients with diabetes and established coronary heart disease,
transient cerebral ischaemia or stroke or peripheral vascular disease
 It may also be considered in people with diabetes at very high vascular risk (eg 2 or more risk factors - hypertension, smoking,
dyslipidaemia)
 In addition to long-term aspirin, clopidogrel 75mg od should be continued for 3 months in people with diabetes who sustain a non-ST
elevation acute coronary syndrome and for up to 4 weeks in those who sustain an ST elevation acute coronary syndrome

First line

Soluble aspirin 75mg daily

Second line

For patients who are unable to tolerate soluble aspirin or have a history of ulceration add in either lansoprazole 15mg od or omeprazole
20mg od and continue either soluble or enteric coated aspirin

Third line

If aspirin is still poorly tolerated or contraindicated or there are compliance issues favouring monotherapy, consider clopidogrel 75mg od
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT

OBESITY

ASSESSMENT

Body mass index (BMI) should be recorded at least annually in everyone with diabetes

Classification of overweight and obesity (WHO, 2000)

Classification BMI (kg/m2) Risk of comorbidities


Underweight <18.5 Lowa
Healthy weight 18.5-24.9 Average
Overweight (or pre-obese) 25-29.9 Increased
Obesity, class I 30-34.9 Moderate
Obesity, class II 35-39.9 Severe
Obesity, class III ≥40 Very severe
a
Other health risks may be associated with a low BMI

Waist circumference (WHO, 2000)


Waist circumference and waist-to-hip ratio, in addition to BMI, may be used to refine risk of obesity-related comorbidities

At increased risk Asian Caucasian


Men Women Men Women
Waist-to-hip ratio >1.0 >0.85 >1.0 >0.85
Waist circumference ≥90cm (35in) ≥80cm (31.5in) ≥102cm (40in) ≥88cm (35in)

 Weight loss targets should be based on an individual’s comorbidities and risks rather than weight alone
 5-10% weight loss may be adequate to achieve cardiovascular and metabolic risk reduction at lower starting BMIs, but >15-20% may be more
appropriate for those with a BMI >35 kg/m2
 Willingness to change and to alter different behavioural aspects (eg dietary and/or activity) should be discussed with the patient
 Dietary interventions for weight loss should be tailored to the dietary preferences of the individual and calculated to produce a 600kcal/day energy
deficit
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT

OBESITY CONTINUED …

TREATMENT OF OBESITY

Aim of treatment is to:


 Reduce calorie intake
 Increase physical activity
 Increase self-awareness about day-to-day behaviours that affect calorie intake and activity levels
 Discuss 5-10% reduction in weight in the first instance. Provide stop gap information* or relevant education / support materials for healthy eating
(See Appendix 1)

Considerations:
 Referral to health trainer
 Referral to dietetic department
 Encourage exercise to reduce sedentary behaviour: The goal being 30 minutes of moderately intensive activity (eg brisk walking at least 5 times a
week)
 Discuss behavioural strategies to enable patient to sustain weight loss

Review:
 Review should be 1-3 monthly and assessment of weight loss carried out. If patient has not reached target weight loss after 6 months, refer to
Health Trainer Department using appropriate referral form.
 On discharge from Health Trainer department repeat HbA1c and BMI If Hba1c is not at target and BMI still >30kg/m2 see drug therapy
recommendations below

DRUG THERAPY

 Drug treatment should be considered for patients who are unable to reach their weight loss target or have reached a plateau on dietary, activity and
behavioural changes alone after 3 months (NICE)
 Discuss potential benefits, limitations, mode of action, adverse effects with patient:

Orlistat (lipase inhibitor)


120mg tds with meals

GLP-1 agonist (incretin mimetic- exenatide or liraglutide) can be considered if HbA1c > 59 mmol/L (7.5%) and BMI >35 kg/m2. Refer to Community
Diabetes Specialist Nursing Team using referral form

IF BMI IS > 40 kg/m2 CONSIDER BARIATRIC SURGERY


MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
MANAGEMENT OF PERIPHERAL ARTERIAL DISEASE (PAD)

 Patient presents with


 Intermittent Claudication (IC): A cramp-like pain in the legs when walking or exercising (can be experienced in calf or thigh muscles and
buttocks)
 Known arterial disease (coronary, carotid or renal artery disease)
 Absent or diminished dorsalis pedis or posterior tibial pulses
 Rest pain or gangrene of leg / foot
 Poorly healing / non healing wounds on leg or foot
 Increased risk of arterial disease (eg smokers, dyslipidaemia, hypertension)
 Ankle:Brachial Pressure Index (ABPI) to be calculated. If this facility is not available ‘in-house’ please refer to specialist podiatrist for neurovascular
assessment using referral form stating level of urgency

ABPI < 0.9 ABPI > 0.9


**Actively treat risk factors**
 BP Aim for  130/ 80  The ABPI may be falsely elevated due to medial artery calcification. This
 Aim for good glycaemic control (see Milestone 3:Treatment management) may elevate the ABPI to > 1.3
 Commence antiplatelet therapy  If IC symptoms present, patient will need to be referred to the specialist
 If Cholesterol > 4mmol/L commence statin (See Milestone 4: Complications podiatry clinic at Barnsley Diabetes Centre for more detailed assessment
/ Risk management) via referral form
 Smoking cessation  If drop in ABPI post exercise occurs, PAD is diagnosed and patient to be
 Weight loss treated as if ABPI is < 0.9 See text box opposite
 Exercise therapy “ Keep walking”  If ABPI shows no reduction other causes for painful symptoms may need to
If lifestyle impairment be considered
SEVERE IMPAIRMENT MILD IMPAIRMENT
Refer to Vascular Clinic via Choose  Exercise therapy
and Book  Review 3 months
 Consider cilostazol 100mg bd
(stop if no improvement after 3
months)
 Monitoring in community
neurovascular clinic

Referral criteria to Specialist services


 (6Ps) Rapid onset of symptoms: Pain, pulselessness, pallor, paraesthesia, paralysis, perishingly cold = Emergency referral
 Deterioration in chronic symptoms: Ischaemic rest pain, gangrene, non-healing wound or ulceration, infection = Urgent referral
 There is rapid access to advice about foot problems at Barnsley Hospital Monday to Friday 0900-1700 hrs (01226 433173). If a patient has acute foot ulceration,
infection, signs of acute ischaemia or penetrative foot injury: urgent queries working hrs (01226 43433173/432379; Out of hours Fax 01226 434406, refer to A&E
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
TREATMENT OF ERECTILE DYSFUNCTION (ED)
Identify and treat curable causes of ED where possible:
 Endocrine: Poor control of DM, hypogonadism, hyperprolactinaemia, hypo / hyperthyroidism, Cushing’s syndrome (will need Endocrine referral)
 Vascular: Peripheral vascular disease, chronic kidney disease
 Urological: Previous injury, pelvic / prostatic surgery or radiation therapy (may need Urology referral)
 Neurological: Multiple sclerosis, Alzheimer’s, Parkinson’s disease, spinal cord injury (may need Neurology referral)
 Medications: Beta-blockers, alpha adrenergic antagonists, diuretics, sedatives, tranquillisers, anxiolytics, antidepressants, antipsychotics, corticosteroids, digoxin,
NSAIDs, H2 antagonists etc
 Lifestyle / habit / addiction: Substance abuse, smoking, alcoholism, anabolic steroids, heroin, marijuana
 Psychological

 Lifestyle changes and risk factor  Education for patients and partners  Counselling for patients and
modification  Describe treatments available partners
 Send blood for hormone levels  Assess current CV risk & medication history (eg nitrates)  Refer for psychosexual therapy

PRESCRIBE PDE5 INHIBITORS TRIAL: ALTERNATIVE THERAPIES:


The prescribing physician should be aware of mode of action, cautions, contraindications, NB: PATIENT NEEDS TO BE REFERRED TO UROLOGY
side-effects as per BNF CLINIC TO BE TRAINED IN USE OF THESE PRODUCTS
Frequency of treatment needs to be considered on a case by case basis. One
treatment per week is usually appropriate (DoH)  Intracavernosal injections: Caverject, Viridal Duo
DRUG DOSE MINIMUM INFORMATION FOR  Intraurethral alprostadil: Muse
PATIENTS  Vacuum devices
SILDENAFIL 50-100 mg.  Effective 30-60 mins in  Penile implants
Viagra Start at 50 mg and titrate presence of sexual stimulation
according to response and  Effect reduced by fatty meal
side-effects  Half-life 4 hours
ASSESS THERAPEUTIC OUTCOMES
VARDENAFIL 5-20 mg  Effective 25-60 mins in
Levitra Start at 10mg and titrate presence of sexual stimulation  IT IS ESSENTIAL TO ADVISE PATIENTS TO TAKE ORAL
according to response and (can be as early as 10 mins) MEDICATION APPROXIMATELY 4 HOURS PRIOR TO
side-effects  Effect reduced by fatty meal SEXUAL ACTIVITY AS IT HAS BEEN OBSERVED THAT
 Half-life 4.5 hours ONSET OF ACTION MAY BE DELAYED IN MEN WITH
DIABETES
TADALAFIL 5-20 mg  Effective after 30 mins in  IF SILDENAFIL IS INEFFECTIVE CHANGE TO ANOTHER
Cialis Start at 10mg and titrate presence of sexual stimulation PDE5
according to response and  Effect not reduced by food and  IF INEFFECTIVE, REFER TO ED/UROLOGY CLINIC
side-effects alcohol
 Half-life 17.5 hours
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …

RENAL COMPLICATIONS / MICROALBUMINURIA SCREENING

PLEASE NOTE THAT THESE TESTS ARE IN ADDITION TO THE eGFR

DIPSTICK URINE FOR PROTEIN USING MULTISTIX / ALBUSTIX

IF NEGATIVE IF POSITIVE

 10ml early morning 'first pass' urine sample in a ‘Universal’  If 1st specimen is abnormal exclude UTI (collect MSU)
specimen container
 Clinical chemistry form for albumin/creatinine ratio (‘ACR’ in  If 2nd specimen is abnormal quantify proteinuria by ACR
mg/mmol)
 Treat to target
Male Female Interpretation Action  BP (Aim < 125/75)
<2.5 <3.5 Normal Repeat in 1 year  Glycaemic control HbA1c 53 mmol/mol (7.0%)
 Commence ACE inhibitor or ARB if intolerant to ACEI
2.5 3.5 Possible Repeat test at the next two
(irbesartan has licence in microalbuminuria)
microalbuminuria clinic appointments and
(MA) within 3-4 months and MA is  Manage CV risk factors aggressively
confirmed if at least one out
of two or more results is also  Repeat ACR after 6 months
abnormal
 If specimen is abnormal, refer to specialist care according to local CKD
 If positive for MA treat to target as for frank proteinuria, but guidelines
aim for BP target of 130/80
SEE eGFR GUIDELINES
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
REFERRAL FOR CKD USING eGFR IN DIABETES MELLITUS

Chronic Kidney Disease (CKD) and the estimated Glomerular Filtration Rate (eGFR)
 Chronic Kidney Disease (CKD) describes abnormal kidney function and/or structure. It is common (10% of the population), frequently
unrecognised, usually asymptomatic, commonly exists with other conditions such as diabetes and cardiovascular disease (CVD), carries a higher
risk of mortality and is often asymptomatic until renal function is severely impaired.
 There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce
the risk of cardiovascular disease and tests for detecting CKD are both simple and freely available.
 Serum creatinine has traditionally been the mainstay for the initial identification of renal disease but, on its own, does not detect minor degrees of
kidney impairment and is not directly related to the glomerular filtration rate (GFR), which is a much more accurate measure of renal function.
 eGFR can be calculated using a mathematical formula forms using serum creatinine, age, gender and race. It can then be used to classify the
severity of CKD and, hence, aid in the selection of the most appropriate management. Normal eGFR is about 100 mls/min/1.73m2 (body surface
area)
 CKD staging and management below only apply to stable renal function. Declining eGFR may need urgent assessment.
 eGFR is only an estimate and can be significantly inaccurate, particularly in people at extremes of body mass (eg malnourished, amputees)
and in pregnancy (do not use the eGFR)
 Afro-Caribbean black patients have a higher eGFR for any given creatinine and a clinician should therefore apply a correction factor of 1.21
 The formula (MDRD) used to predict eGFR in adults is not valid for under 18s, for which there is a separate calculator.
Stage eGFR Severity of CKD Frequency of testing Referral to renal team Type of referral
Only if specifically
1 >90 Normal Annually indicated See below
See table 1
Mild impairment As for stage 1
2 60-89 Annually See below
60-90% renal function See table 1
NO – ONLY if
Moderate impairment Routine referral
3A 45-59 3-6 monthly deteriorating function
45-59% renal function See below
See table 2
Moderate impairment YES
3B 30-44 3-6 monthly Referral or discussion
30-44% renal function See table 3
Severe impairment YES Urgent referral or
4 15-29 3 monthly
15-30% renal function See table 4 discussion
YES Immediate referral or
5 <15 Established CKD 3 monthly
See table 4 discussion
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …

MANAGEMENT OF CKD

YOU HAVE FOUND THAT YOUR PATIENT HAS A HIGH CREATININE (LOW eGFR)

In all cases initial assessment of high creatinine / low eGFR should include:

 Is the patient well? Is there a history of significant disease?


 History of significant associated disease: Referral may need to be considered if indicators present eg urinary abnormalities
 Review previous results: Assess whether stable or deteriorating. If patient appears well, repeat within 2 weeks, sooner if there is any doubt.
NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings
 Clinical assessment: Look for signs of sepsis, heart failure, hypovolaemia, bladder enlargement
 Medication review: Look for recent additions (eg ACEIs, ARBs, NSAIDS, antibiotics, diuretics, mesalazine, PPIs)
 Blood tests: HbA1c, Ca2+, PO4, FBC, CRP. Hypercalcaemia may cause acute renal impairment or deterioration
 Urine tests: Dipstick for blood and protein
 BP/ cardiovascular assessment (including peripheral circulation) : accelerated hypertension and Grade 4 retinopathy need immediate
referral to the on call medical team
 Imaging: Required if function is deteriorating and of unknown origin. Urgency will be ascertained by speed of deterioration

REFER TO RELEVANT TABLE:

 Stage 1 &2 Table 1


 Stage 3A Table 2
 Stage 3B Table 3
 Stage 4 & 5 Table 4
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
Table 1: Management of Stage 1 and 2 CKD in diabetes mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT

 Almost all patients can be managed in primary  Aim is to identify individuals at risk of
care progressive renal disease and reduce
 Patients have normal or near normal eGFR, associated risks
but have other evidence of renal disease ie:  In most patients risk of cardiovascular death
o Proteinuria or haematuria much more likely than progression to dialysis
o A genetic diagnosis of kidney disease (eg  Referral to diabetes or renal clinic is not
known to be have a disease such as polycystic required unless
kidney disease)
o Heavy proteinuria (ACR >70mg/mmol or
o Evidence of structurally abnormal kidneys (eg
protein creatinine ratio [PCR] > 100mg/mmol)
reflux nephropathy, renal dysgenesis).
o Haematuria of renal origin
o Microalbuminuria in diabetes o Declining GFR
o Young age
Initial assessment to include:

Blood tests: HbA1c, TFTs, Ca2+, PO4, FBC, CRP


Urinalysis: Dipstick for blood and protein (if positive quantify proteinuria)
BP/cardiovascular assessment (including peripheral circulation) : Ensure BP within target range (<130/80 mm/ Hg)

On-going management: Haematuria

 Blood tests annually for: a) Visible (macroscopic)


o HbA1c  Usually fast track Urology referral for imaging and cystoscopy,
o Creatinine unless strong pointers to acute renal disease
o Potassium  Refer to Renal Clinic if urological investigations negative
o Cholesterol.
 Urinalysis: Annually for blood and protein b) Invisible (microscopic) without proteinuria and eGFR >60 ml/min
 Meticulous control of BP (<130/ 80 mm Hg)  Age >40, usually refer to Urology
 Smoking, exercise and lifestyle advice (see Diabetes Care Pathway  Age <40, or >40 with negative urological investigations, manage as
Appendix 1) Stage 1/2 CKD
 Consider aspirin (see anti platelet therapy Milestone 4: Diabetes Care
Pathway) c) Microscopic haematuria with PCR >50mg/mmol
 Cholesterol lowering therapy (Milestone 4: Diabetes Care Pathway)  Refer to Renal Clinic, otherwise manage as Stage 1/2 CKD
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
Table 2: Management of Stage 3A CKD in diabetes mellitus
GENERAL POINTS EXCEPTIONS MANAGEMENT

 Almost all patients can be managed in primary  As for Stage 1 and 2 (see above), including
care referral criteria plus referral if eGFR<40ml/min
 Patients have stable renal function (eGFR
and/or creatinine)
Initial assessment to include:
 Review of previous results: Assess whether stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2
days. NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings
 An assessment of the following:
o Is the patient well? Is there a history of significant associated disease which involves kidneys (eg urinary abnormalities)?
o Clinical assessment for heart failure, sepsis, hypovolaemia, examination for bladder enlargement (may need imaging if obstruction suspected) and rectal
examination for prostate enlargement
o Medication review. Look for recent additions (eg ACE inhibitors, ARBs, NSAIDS, mesalazine, antibiotics, diuretics)
o Blood tests: HbA1c, haemoglobin, bone profile, lipids, PTH
o Urinalysis: Dipstick urine for blood and protein (and quantification, if required, by ACR/PCR)
o Cardiovascular assessment: BP and peripheral vascular system
o Imaging: If obstruction a possibility
On-going management:
If creatinine is >150 mcmol/L or eGFR <30 ml/min (if discrepancy between two, use eGFR) stop metformin. Refer to community DSNs via diabetes
referral form if necessary
 Blood tests initially to be done 3 monthly then 6-12 monthly when stable for:
o HbA1c, creatinine and potassium (consider unexplained fall in eGFR of >25% to be acute renal failure. Seek specialist advice for a loss of GFR over 1y of
5ml/min or a loss of GFR in 5y of 10ml/min)
o Haemoglobin (if low consider non-renal cause. ‘Renal’ anaemia rarely significant before stage 3B or 4)
o Bone profile, PTH, lipids
 Urine tests:
o Protein estimation if proteinuria
o If MICROSCOPIC haematuria – Urology referral if > 40 years old, if < 40 years old Renal Clinic referral. All MACROSCOPIC haematuria needs urology
referral
 Blood pressure. Meticulous control <125/ 75 mm Hg (see Milestone 4: Diabetes Care Pathway)
 Smoking, exercise and lifestyle advice (see Diabetes Care Pathway Appendix 1)
 Consider aspirin (see anti-platelet therapy Milestone 4: Diabetes Care Pathway)
 Cholesterol lowering therapy (Milestone 4: Diabetes Care Pathway)
 Immunisation for influenza and pneumococcus
 Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Exercise caution with bisphosphonates.
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
Table 2: Management of Stage 3B, 4 & 5 CKD in diabetes mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT

 Patent will be cared for on a shared  If severe renal impairment is part of another terminal illness  Management is similar to Stage 3A,
care basis  Those patients for whom further investigation and management is but referral to Renal Clinic will
 Refer to Renal Clinic clearly inappropriate usually be required
 There is a clear and understood pathway of care already in place
Pre-referral considerations:
 Clinical Assessment and Medication Review as per stage 3A CKD
 Assess whether values are stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2 days.
 Is the patient well? Is there significant associated disease? If yes, consider urgent referral
 Blood tests: HbA1c, bone profile, PTH, lipids, haemoglobin
 Urinalysis: Dipstick urine for blood and protein (and quantify)
 BP/cardiovascular assessment
 Consider imaging to exclude obstruction
 Dietary assessment
On-going management:
Metformin should be stopped in all patients with an eGFR 30 ml/min
 Blood tests 3 monthly for:
o HbA1c, creatinine, potassium and bicarbonate
o Haemoglobin (if low consider non-renal cause), ferritin, B12 and folate
o Bone profile (oral phosphate binders will often be required), PTH, lipids
 Urine tests:
o Protein estimation if proteinuria
o Haematuria – as Stage 3A
 Correction of acidosis. Oral bicarbonate after discussion with diabetes/renal team
 Blood pressure. Meticulous control <125/75 mm Hg (see Milestone 4: Diabetes Care Pathway)
 Smoking, exercise and lifestyle advice (see Diabetes Care Pathway Appendix 1)
 Consider aspirin (see anti-platelet therapy Milestone 4: Diabetes Care Pathway)
 Cholesterol lowering therapy (Milestone 4 Diabetes Care Pathway)
 Immunisation for influenza and pneumococcus. In Stage 4 & 5 CKD Hepatitis B is added if renal replacement therapy is being considered
 Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Exercise caution with bisphosphonates (specialist
advice should generally be sought before use of agents reducing bone turnover in patients with potential renal osteodystrophy).
Section derived from NICE (CG73, 2008), SIGN (103, 2008) and Renal Association guidelines (revised 2009).

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …


Painful Neuropathy
DIAGNOSIS
 HISTORY
o Consider differential diagnosis (eg alcohol excess, B12 deficiency, malignancy, nerve compression)
o Sometimes acute, sometimes insidious onset and progression
o Paraesthesia in toes, feet and shins
o Anaesthesia/hyperaesthesia
o Symptoms often worse at night or at rest
 PAIN
o A wide variety of descriptions of peripheral symptoms can be present.
o Careful patient questioning is necessary as symptoms can be confusing
o Consider use of Pain Pictures or S-LANNS assessment questionnaire

Neurological symptoms may include:


o Numbness
o Tingling
o Prickling
o ‘Pins and needles’
o Aching
o Dull pain
o Burning
o Buzzing
o Cold
o Sharp
o Knife-like
o ‘Electric shocks’ – or may be very unpleasant but difficult to describe

The severity of individual patient symptoms will influence which step of the care pathway is appropriate for commencement of treatment
SIGNS
 WEAKNESS (motor loss)
o Distal and/or proximal
o Loss of reflexes

 NEUROLOGICAL EXAMINATION (sensory loss)


o 10g monofilament
o Vibration perception (tuning fork 128 Hz), calibrated tuning fork, Bio/neurothesiometer)
o Proprioception
o Light touch (‘glove and stocking’ sensory loss very common)
MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …
Management of Painful Neuropathy

STEP 1
 Improve glycaemic control. Liaise with diabetes nursing team/dietician if appropriate. Aim for normoglycaemia.
 Trial of tricyclic antidepressants (eg amitriptyline), with dose titration from 10mg nocte to a maximal tolerable dose (contraindicated in patients with prostatism,
glaucoma, dysrhythmias or serious heart disease). NOTE: Tricyclics and anticonvulsants usually need to be initiated at a low dose and gradually increased to the
maximally effective/tolerated dose in order to minimise side-effects. Patients should be warned that relief of pain may not begin to occur until a therapeutic threshold is
reached
 Duloxetine 60mg daily (not recommended in under 18’s) is a second line alternative to amitriptyline
 If patient is experiencing night time cramps only consider prescribing:
o Quinine sulphate 200-300 mg nocte (inform patient that improvement may take up to a month to occur)
o May benefit from low calorie Indian tonic water (not available on FP10)
 Reassure (use of pain diary may be useful)
 Review in 1 month If patient is reluctant to take oral medication consider capsaicin cream 45g, noting that initially there may be an intense burning sensation

STEP 2
 Review symptoms, pain and glycaemic control
 If pain still present, reassure. Check concordance with drug(s) previously prescribed in Step 1
 If pain is still present, add in:
o Gabapentin 300mg bd initially (600mg tds often required before any benefit achieved)
 Review in 1 month

STEP 3
 Review symptoms, pain and glycaemic control
 If pain still present or there is no symptomatic relief, refer for specialist advice
 Monitor therapy and increase up to maximum tolerated and/or licensed dose
 Consider prescribing, in place of previous therapy:
o Duloxetine 60mg daily in place of amitriptyline or pregabalin 75-300mg bd in place of gabapentin
o Consider the addition of tramadol 50-150mg tds

STEP 4
 Review symptoms, pain and glycaemic control
 If pain still present or there is no symptomatic relief, refer to diabetic or specialist pain clinic

NICE Guidance (CG 96, 2010)


MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …

RETINOPATHY
1. Ensure that patient understands the importance of annual retinopathy screening
2. Ensure that patient is enrolled on the Barnsley Retinopathy Screening Programme for digital photography. The Barnsley Retinopathy Screening
Department is based in the Diabetes Centre at Barnsley Hospital. It is open between 08:00 and 17.00, Monday to Friday, and weekend and evening
clinics are also available. In addition, sessions take place at locations throughout the community and, wherever possible, screening will be arranged as
close as possible to a patient’s home. Please contact the Diabetic Eye Screening Service on 01226 434577/434576
3. At annual review, check that a result is present in the patient records dated within the last 12 months
4. Results of retinal screening should be discussed with patient
5. If retinopathy is present ensure appropriate referral is made according to NICE guidelines

FOOT CARE
1. Ensure that feet are assessed including foot pulses, vibration, sensation by a competent practitioner annually (See also Milestone 4: Peripheral Arterial
Disease – [PAD])
2. Record results
3. Ensure that principles of good foot care are reiterated at each review
4. Refer for podiatry treatment as appropriate
5. Refer URGENTLY TO ACUTE ASSESSMENT CLINIC if any of the following problems occur:

 Acute foot injury (including any penetrating foot injury)


 Foot ulceration
 Signs of infection
 Evidence of ischaemia or gangrene
 Acute Charcot foot

Complete an Acute Assessment Referral and fax to the Diabetes Centre on 01226 434406 (queries 433173 or 432379). Out of hours: Refer urgently to the
Accident & Emergency Department, Barnsley Hospital.

6. Refer to Painful Neuropathy Care Pathway if symptoms of painful neuropathy are present
MILESTONE 5: MAINTENANCE

1. Regular review if unstable 2- 3 monthly


 BP
 Lipids
 Glycaemic control (there is no benefit to repeating HbA1c reading more frequently than 3 monthly)
 Diet
 Lifestyle

2. 6 monthly review
 As above

3. Annual review
 Weight/BMI
 BP
 Review of medication
 Review of diet
 Review of glycaemic control
 Review of investigations
o HbA1c
o Lipids
o U&E including eGFR
o TFT
o LFT if taking glitazone or statin
o Albumin/creatinine ratio (ACR)

 Foot examination
o Shoes, socks, stockings MUST be removed
o Observation of colour, warmth, sensation, symptoms, general appearance of nails, skin, callus etc
o Pedal pulses: dorsalis pedis and posterior tibial
o 10gm monofilament on BOTH feet

 Lifestyle issues
o Driving
o Activity levels
o Smoking
o Alcohol
o Sexual activity
o Stress (assess for depression)
APPENDIX 1: LIFESTYLE CHANGES

HEALTHY EATING (STOP GAP INFORMATION)


ADVICE TO BE GIVEN EXAMPLES
Regular meals that include carbohydrates  High fibre low salt and low fat breakfast cereals
This will help to control blood glucose levels*  Wholemeal/whole grain breads, including pitta, crackers, crisp breads
 Pasta and noodles
 Potatoes
 Rice
Foods that are high in fibre*  Beans
 Lentils
 Bran
 Wholemeal and wholegrain breads and cereals
 Fruit and vegetables
Cut down/eat less saturated fat*  Less animal fats and fatty foods
 Choose olive oil, rapeseed oil or other vegetable oils
 Grill, steam ,bake food
 Use less butter, margarine, cheese and fatty meats
 Use low fat dairy foods like skimmed or semi skimmed milk, low fat
yoghurt
Reducing salt*  Less processed food
 Leave out salt in cooking
 Buy reduced salt versions of food
 Use herbs and spices instead of salt
Five a day*  Try to eat five portions of fruit or vegetables a day, but limit fruit intake to
no more than 3-4 portions a day
 A portion is a handful of fruit or vegetables
Cut down on sugar and sugary foods*  This does NOT mean a sugar-free diet
 Sugar can be used as an ingredient in foods in small quantities
 Use sugar-free, diet or low-sugar squashes and fizzy drinks
APPENDIX 1: LIFESTYLE CHANGES CONTINUED …

INCREASING ACTIVITY
ADVICE TO BE GIVEN EXAMPLES
Increase exercise levels gradually until exercising for at least 30 minutes a  Walking daily
day 5 x per week*  Increase distance and speed
 Once exercising regularly, try cycling, swimming etc.
 Housework/gardening if mobility is limited
 If immobile teach armchair exercises

STOPPING SMOKING
ADVICE TO BE GIVEN EXAMPLES
 Assess smoking status  ASK and record information about smoking
 Advise to stop*  Give information about smoking cessation service
 ADVISE patient to stop smoking
 ACT on patient’s response, including referral to Barnsley NHS Stop
Smoking Service on 01226 737077 or EMAIL www.quitsmoking.uk.com

ALCOHOL ADVICE
ADVICE TO BE GIVEN EXAMPLES
 There is no harm in drinking in moderation*  1 unit of alcohol = half a pint of beer or lager, 1 small glass of wine or 1
single measure
 Men should drink no more than 3 units a day
 Women should drink no more than 2 units a day

*Diabetes UK Patient information www.diabetes.org.uk

APPENDIX 2: PATIENT EDUCATION


After diagnosis it is essential that education is given at a level appropriate to individual needs
Introduction Date Signature Comment
What is diabetes?
Explanation of disease process
Tablet Treatment
Action of tablets
Dose
When to take
Side effects
Diet
Basic dietary advice
Detailed dietary advice
Advice on weight management
Alcohol
Testing
Name of meter
Blood glucose testing
Timing/frequency
Recording results
Interpreting results
Safe disposal of lancets
Quality control of meter
Hyperglycaemia
Signs/symptoms
Causes
Prevention
Illness
Sick day rules
Referrals
Structured education
APPENDIX 2: PATIENT EDUCATION CONTINUED …
Retinal screening
Information on Change for Life
Exercise
Hypoglycaemia if treated with sulfonylurea
Causes
Recognition
Avoidance
Treatment with Glucogel
Effect of exercise
General
Driving
- DVLA
- Insurance
- Hypos
Employment
Retinopathy screening
Benefits
Free prescriptions
NHS podiatry services
Foot care information
Smoking cessation advice
Erectile dysfunction
Contraception
Pregnancy
Pre-pregnancy counselling
Holidays/travel
Complications
Annual review
Exercise
HBA1c
Diabetes UK
APPENDIX 3: BLOOD GLUCOSE MONITORING IN PRIMARY CARE
In the interests of safety and value for money, it is the intention of Barnsley LDSAG to promote some standardisation of blood glucose meters available for patient use.
The range is likely to include 2-3 blood glucose meters, at least one of which is also capable of measuring blood ketones.

All patients monitoring blood glucose levels should be advised to check the accuracy (quality assurance) of the blood glucose meter on a monthly basis.
Control solutions used to carry out this procedure are, in most cases, available free of charge from the manufacturer.

FREQUENCY OF TESTING

Type 1 diabetes Type 2 diabetes

 Blood glucose testing is essential for ALL people with type 1 diabetes If on diet and exercise
 If taking basal bolus regimen this could be up to 6 times a day
 Frequency may be increased during intercurrent illness  Daily monitoring of blood glucose levels unnecessary. Ensure 3 monthly HbA1c
 Ketone testing equipment should be available for times of acute  If people wish to test, 1-2 times a week before breakfast is sufficient, aiming for a
illness blood glucose level of 7.0 mmol/L (plus 3 monthly HbA1c)
 Drivers should maintain a record (as per DVLA recommendations)
and test prior to all journeys If on diet, exercise and metformin ( glitazones and/or GLP-1 agonist)
 Pre-pregnancy and pregnancy – may be necessary to test up to 6
times daily  As above

If on sulfonylurea/insulin secretagogue
Approximate usage
 Increased risk of hypoglycaemia. Testing may be necessary to confirm or avoid
 Six tests per day = 48 boxes (50 strips each) per year
= 4 boxes per month Type 2 on conventional insulin therapy

 One test per day = 8 boxes per year  If stable, 2-3 times a week at different times
 If unstable, once daily testing at different times of the day until stability achieved
 Three tests per week = 4 boxes per year  See Type 1 diabetes for DVLA recommendations

(This includes extra strips for testing when ill as well as accidental Type 2 on intensive insulin therapy
wastage)
 May be necessary up to 6 times daily
 See Type 1 for DVLA recommendations
50% of self-monitored glucose measurements are inaccurate, usually due Pre-pregnancy and pregnancy
to operator error. Patients, doctors and nurses using blood glucose
monitoring with or without a meter MUST RECEIVE APPROPRIATE  May be necessary up to 6 times daily PTO…
EDUCATION

APPENDIX 3: BLOOD GLUCOSE MONITORING IN PRIMARY CARE CONTINUED …


When considering suitability for blood glucose monitoring the following points should be considered:

 Visual acuity
 Manual dexterity
 Ability to use a blood glucose meter
 Willingness of patient to perform tests

When initiating blood glucose monitoring the following process should take place:

 Offer choice from standardised range of meters ONLY according to patient needs
 Demonstrate chosen meter and finger pricking device, identifying procedure for patient to follow
 Give information on the safe disposal of sharps
 Issue blood glucose monitoring diary indicating agreed individual target range and frequency of testing (See previous page)
 Give information to patient regarding what to do with self-testing results
 Ensure patient has a contact number for access to HCP advice
 Arrange to review self-testing results at a suitable interval

Reviewed and updated April 2014