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BARNSLEY
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
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
NB: In the absence of osmotic symptoms 2 consecutive venous samples are required to diagnose diabetes mellitus
≥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
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
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 :
Dapagliflozin Canagliflozin*
10mg od 100-300mg od
(100 mg od if eGFR 45-60 ml/min)
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
Step 4
Add alpha blocker Doxazosin 2-16mg od
Add beta-blocker Metoprolol 50-200mg od or bisoprolol 2.5-20mg od
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
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
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
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:
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
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
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:
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:
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
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).
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
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
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:
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
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
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
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
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
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