Somerset Diabetes Service Integrated Care Pathway

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THE SOMERSET DIABETES SERVICE INTEGRATED CARE PATHWAY CLINICAL GUIDELINES AND DIRECTORY OF SERVICES FOR PRIMARY CARE

Endorsed by: The Somerset Diabetes Pathway Management Group and the NHS Somerset Professional Executive Committee

April 14th 2011

INTRODUCTION

This document provides information, advice and guidance on the day to day management of diabetes within primary care, focusing on the primary care contribution to the Somerset Diabetes Service, Integrated Care Pathway.

The 'Somerset Diabetes Service' is the umbrella term for all services contributing to the care of adults with diabetes. The Somerset Diabetes Service is supported by an 'Integrated Care Pathway' which forms part of a Somerset-wide 'Model of Care' for adults with diabetes. The Somerset Model of Care for adults with diabetes is the outcome of a consultation with a wide range of stakeholders, including people with diabetes, carers and clinicians, and has the sign up of all the main providers that contribute to the care of people with diabetes in Somerset.

The document is not intended to be fully comprehensive or prescriptive. Decisions on what treatment to give and when to refer should always be based on clinical judgement, taking into account the individual circumstances of the patient and any more specific national guidance. Targets for optimum control will vary between individuals, as will triggers for referral.

In case of doubt, advice may be sought from the clinical leads for the pathway:

  • Dr Paul Lambert, Consultant Physician and Endocrinologist, level 3 Clinical Lead for Taunton and Somerset NHS Foundation Trust and overall Pathway Lead tel 01823 342037 e/m paul.lambert@tst.nhs.uk
  • Dr Alex Bickerton, Consultant Diabetologist, level 3 Clinical Lead for Yeovil District Hospital NHS Foundation Trust tel 01935 384468 e/m alex.bickerton@ydh.nhs.uk
  • Dr Tony Robinson, Consultant Diabetologist, Clinical Lead for Royal United Hospital Bath, NHS Trust tel 01225 824530 e/m tony.robinson@ruh-bath.swest.nhs.uk
  • Dr Sarah Pearce, Interim GP Clinical Lead for level 1 tel 01460 63380 e/m sarah.pearce@springmead.nhs.uk
  • Su Down, Nurse Consultant, level 2 Clinical Lead, Somerset Community Health tel 01460 238754 e/m su.down@somcomhealth.nhs.uk

The document draws from clinical guideline documents already being used in other health-care communities, in particular the Bristol, North Somerset and South Gloucestershire Integrated Care Pathway and is congruent with the Somerset Prescribing Formulary. National standards have been included where these are available. This document supersedes the Somerset Diabetes Service Pathway and Referral Guidance published in March 2010. The document will be subject to regular review and updating in the light of experience and any new national and local guidelines that may be published. In particular, it is intended that the document will be expanded in 2011/12 to incorporate more information on the care of children with diabetes.

OVERVIEW OF SOMERSET MODEL OF CARE

Aims and objectives

The Model of Care for Adults with Diabetes aims to increase the capacity and capability of the healthcare system as a whole to meet the needs of growing numbers of people with diabetes, ensuring equity of access and the highest possible standards of care.

The vision is for care to be more integrated and accessible, with an increased focus on:

  • preventing illness and helping people stay well
  • earlier diagnosis and better care to reduce the risk of complications
  • support for people to manage their own care

The objectives are to:

  • improve the care and health outcomes of adult people with diabetes in Somerset
  • promote partnership working and a shared care approach between providers so people experience appropriate care, seamlessly, and in a timely manner
  • provide accessible services as close to where people live or work as possible
  • optimise the use of resources

A major goal of the Service is to address the differences in the standards of diabetes care that exist across Somerset.

OVERVIEW OF SOMERSET MODEL OF CARE

Structure and high level pathway

The Diabetes Model of Care is set out diagrammatically in Figure 1 below.

For the purposes of the model, diabetes care has been divided into levels . The levels indicate relative complexity of care and degree of clinical specialism but do not necessarily relate to location. An underlying principle of the model is as much care as possible, at all levels, to be delivered locally by multidisciplinary teams. All levels include an emphasis on prevention, early intervention and support for self care.

A summary of elements of care in each level is provided in Table 1 below. GP practices are primarily responsible for Level 1 - Core Primary Care, with some practices opting to provide specific aspects of Level 2 of Intermediate Care, for example insulin initiation.

The Model of Care is supported by a high level pathway for the care of adult people with diabetes. The pathway demonstrates how people registered with a GP in Somerset are supported throughout their journey under the new Model of Care.

The Specification for the Provision of Services for Adults with Diabetes in Somerset including a full description of the Model of Care, may be accessed from the WyvernHealth.Com Somerset PBC Consortium website at http://www.wyvernhealth.com/pathways.htm (under the Commissioning documents section)

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Table 1 - Levels of Care

Level Key elements
Level 1: core primary care
  • Awareness raising and health promotion
  • Case finding
  • Care management of non-complex Type2 people with diabetes, including medication management and annual checks
  • Referral to support services (eg structured education) as required
  • Referral of people with Type1 diabetes and complex Type 2 patients to appropriate colleagues
  • Offering women of childbearing age contraceptive advice, referring on to Level 2 when considering pregnancy
Level 1: community services
  • Dietetics support for people with diabetes unsuitable for structured education or who continue to have diet problems after attending structured education
  • Podiatry support for people with diabetes at risk of or with foot ulcers
  • Weight reduction courses, exercise groups, smoking cessation programmes
Level 2: intermediate care
  • Confirmation of initial diagnosis for those outside normal parameters
  • Treatment and management planning for people with sub-optimal glycaemic control at Level 1
  • Structured education
  • Other support for self care
  • Psychological support (moderate level)
  • Liaison with community matrons over people with complex needs
  • Telephone helpline
  • Insulin initiation
  • Optimising diabetes therapies
  • Specialist dietetics
  • Podiatry
  • Retinopathy screening (annual)
  • Agreement of management plans for complications in complex patients (retinal, renal, vascular, feet)
  • Pre and post pregnancy advice in conjunction with Level 3
Level 3: specialist care
  • Complex obesity management
  • Classification of genetic or auto-immune disorders
  • Education for complex cases and agreement of management plan with people with Type 1 Diabetes and complex needs
  • Review of appropriate Type 1 and complex Type 2 Diabetes patients
  • Acute in-patient management including for people with diabetes who are admitted with diabetes but not for diabetes
  • Complex complications management (retinal, renal, vascular, foot)
  • 24 hour helpline (complex cases)
  • Pregnancy care (Pre and post pregnancy advice in conjunction with Level 2)
  • Transition management from children to adult services
  • Insulin pump clinics
  • Psychological support (specialist)

Pathway for the care of adults with diabetes

The high level pathway for the care of adults with diabetes is set out below. The pathway aims to demonstrate how patients registered with a GP in Somerset are supported throughout their journey under the new Model of Care. The Pathway includes the following sections:

  • Case finding
  • Diagnosis and initial management (Type 2)
  • Continuing care (Type 2)
  • Diagnosis and initial management (Type 1)
  • Continuing care (Type 1)

Supporting guidance for each of these sections of the Pathway is provided in subsequent sections of the document.

The Pathway has been colour coded to indicate the levels of care which apply at each stage of the Pathway.

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DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Diagnosis of diabetes

Diabetes can only be diagnosed with the use of venous plasma blood glucose concentrations.

HbA1c (glycosylated haemoglobin), glycosuria and capillary blood glucose are not recommended for the diagnosis of diabetes.

The number of tests required for diagnosis is dependent on the presence or absence of symptoms or unequivocal hyperglycemia.

Symptoms (or Unequivocal Hyperglycemia) present:

Symptoms include polyuria, polydipsia, weight loss, vaginal candidiasis or balanitis.

Symptoms such as tiredness and poor energy should not be considered with respect to diagnosis of diabetes.

In the presence of symptoms only one diagnostic test is required.

Diagnostic tests include

Random glucose ≥11.1 mmol/litre
Fasting glucose ≥ 7.0 mmol/litre
75g oral glucose tolerance test (OGTT) - fasting glucose ≥ 7.0 mmol/litreor 120min glucose ≥11.1 mmol/litre

Fasting is defined as no caloric intake for at least 8 hours.

Symptoms Absent:

The same diagnostic criteria are used as when symptoms are present, but two tests are required on different days and both tests must be positive.

Other Diagnostic Categories

Normal Glucose Tolerance

Fasting glucose ≤ 6.0 mmol/litre

75g oral glucose tolerance test (OGTT) - fasting glucose ≥ 6.0 mmol/litre and 120min glucose < 7.8 mmol/litre

Impaired Fasting Glucose (IFG)

Fasting glucose 6.1-7.0 mmol/litre

Impaired Glucose Tolerance (IGT)

75g OGTT - 120min glucose 7.8-11.0

IFG and IGT are not clinical entities in their own right, but are risk factors for future diabetes and cardiovascular disease. People in these categories should have an appropriate test repeated annually.

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Case finding

Identifying and screening people at increased risk of diabetes

Identification of those at increased risk of diabetes will aid diagnosis, may prevent diabetes from occurring, and may allow targeted management to reduce cardiovascular morbidity.

Targeted screening with annual fasting glucose measurement may be appropriate in high risk groups such as:

  • Age > 40 years if white, or age >25 if Asian, African and Afro-Caribbean origin, with one of the following
    • First degree relative with diabetes
    • BMI ≥30 or ≥27.5 in individuals of Asian, African and Afro-Caribbean origin
    • waist measurement ≥94cm (37 inches) for white and black men, and ≥90cm (35 inches) for Asian men, and ≥80cm (31.5 inches) for white, black and Asian women
  • Age >65 years
  • Anyone with known impaired fasting glucose or glucose intolerance
  • Hypertension
  • Established macrovascular disease (ischemic heart disease, cerebrovascular disease or peripheral vascular disease)
  • Pregnant women (see Diabetes in women section for specific guidance)
  • Women with a history of gestational diabetes or who have given birth to a large baby (birthweight>4kg)
  • Women with Polycystic Ovarian Syndrome
  • People with peripheral neuropathy or proteinuria
  • People on medication known to be associated with diabetes
    • Corticosteroids
    • Long-term antipsychotic medication

Based on Diabetes UK guidance http://www.diabetes.org.uk/Documents/Professionals/Earlyid_TYPE2_PS.doc

Note: The national NHS Health Check programme aims to provide health checks for people aged 40-74 on a five yearly basis which include the identification of people at high risk of diabetes based on the BMI and blood pressure filters referred to above. People identified to be at high risk of developing diabetes will be referred to the GP practice for further diagnostic testing.

In Somerset the initial focus for the NHS Health Check Programme has been on people in the lowest 2 deprivation quintiles. The programme is currently being delivered in Somerset by pharmacies, outreach teams and some GP Federations.

It is recommended that practices complement the Health Check programme by running searches on their clinical data base in all of the above at risk groups who are not known to have diabetes, and for those with any raised blood glucose reading (FBG > 6.0 mmol/l, RBG > 7.0 mmol/l), arrange further testing as appropriate.

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

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Initial management of Type 2 Diabetes

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DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Diabetes Information Pack

GP practices are encouraged to give all newly diagnosed people with diabetes a Diabetes Information Pack.

This pack contains information about diabetes and about maintaining a healthy diet, keeping active, foot care and monitoring health.

An order form for supplies of the Diabetes Information Pack can be obtained from the WyvernHealth.Com website at http://www.wyvernhealth.com/pathways.htm (under Documentation and Guidance section).

Further first line information and advice is also available from the Diabetes UK website at http://www.diabetes.org.uk/

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Structured education

People with Type 1 Diabetes

People who have been diagnosed with Type 1 Diabetes for at least 6 months will normally be offered a DAFNE (Dose Adjustment For Normal Eating) course. This course is not suitable for people newly diagnosed with Type 1 Diabetes.

DAFNE involves attending a 5-day training course (9am - 4.30pm Monday - Friday) made up of up to 8 people, plus a follow-up session six weeks after the course, and a yearly half-day update session. Courses are run Somerset-wide in varying locations.

The structured teaching programme covers topics including carbohydrate estimation, blood glucose and ketone monitoring, eating out, reading food labels, hypos, foot education, illness and exercise.

The DAFNE course is about learning from experience. During the week people with Type 1 Diabetes practise the skills of carbohydrate estimation and insulin adjustment.

DAFNE was introduced in the UK in 2000 and is now a nationally accredited programme.

DAFNE has been shown to reduce HbA1c without increasing the risk of severe hypoglycaemia, increase quality of life and improve satisfaction with treatment.

For further information: go to www.dafne.uk.com or contact paul.lambert@tst.nhs.uk paul.lambert@tst,nhs.uk

People with Type 2 Diabetes

All people with newly diagnosed diabetes should be referred to DESMOND (Diabetes Education for Ongoing and Newly Diagnosed). People benefit most from starting the programme within four to six weeks from diagnosis, but referrals are accepted for those who have been diagnosed for up to six months.

The programme consists of one full day 09.30 am - 16.30 pm for 10 people who are all invited to attend with a partner/friend.

Referral to DESMOND is via Choose and Book using a referral form available from the WyvernHealth.Com website at http://www.wyvernhealth.com/Documents/pathways/diabetes/DESMONDReferralFormRevised260810.pdf

The structured education programme covers topics including:

  • Understanding Diabetes
  • Monitoring diabetes
  • Dietary awareness of carbohydrates and other dietary recommendations
  • Long term consequences of diabetes
  • Annual review
  • Exercise
  • Planning for change

Desmond is a nationally accredited programme delivered by trained, assessed educators, at venues throughout Somerset.

For further information go to www.desmond-project.org.uk or see the Directory of Services .

Ongoing education packages and an education programme for people diagnosed before DESMOND was available are currently in the process of being developed.

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Diet

Initial Dietary advice

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Resources

Diabetes Information Pack - includes first-line information on diet and exercise and the care people with diabetes should expect to receive.

Structured education - available for people who have been diagnosed with Type 1 Diabetes for at least 6 months and newly diagnosed people with Type 2 Diabetes.

Community Dietitian -people with newly-diagnosed Type 2 Diabetes who are unable to attend DESMOND or who have attended a DESMOND course but are still having problems with their weight or diet may be referred to a Community Dietetian.

Eating Well with Diabetes leaflet - to be given to patient prior to attending DESMOND, also available at www.somcomhealth.nhs.uk or from Somerset Diabetes Services at Bracken House, Crewkerne Road, Chard, Somerset TA20 1YA; T: 01460 238754 and be advised to achieve and maintain a healthy weight.

Other dietary guidance

  • www.diabetes.org.uk - guide to food and diabetes
  • www.bda.uk.com/foodfacts - guide to food and diabetes

See the Directory of Services for Community Dietetics Service contact details .

Lifestyle and exercise

Initial lifestyle and exercise advice

Smoking

People can be referred directly to the Somerset NHS Stop Smoking Service on 0303 033 9840. Details of all providers of the Stop Smoking Service and other means of contact in GP surgeries and pharmacies are available www.somersetstopsmoking.nhs.uk at .

Other available sources of help can be found at:www.ASH.org.uk/documents/ASH_128.pdf

.

Exercise

Anyone can do low impact exercise, and health care professionals should encourage this.

Exercise does not worsen diabetic retinopathy, nephropathy or neuropathy and is safe in pregnancy.

Individuals who have:

  • blood pressure drop on standing
  • loss of heart rate variation
  • severe neuropathy
  • very low fitness levels

are at most risk of cardiac events and should initially be supervised when exercising.

People with diabetes should be advised not to take up strenuous activity suddenly.

Key messages

  • Being more regularly active is the aim.
  • Any increase in activity is beneficial
  • Ask people to pick an activity that suits them and that they enjoy doing
  • Start slowly and build up gradually
  • The target for exercise is 30 minutes of moderate exercise on 5 days a week, starting with small bouts of 10 minutes

Advice about glucose control and exercise

Type 1 Diabetes

People with Type 1 Diabetes may find it helpful to discuss management of diabetes and exercise with a Diabetes Nurse Specialist.

General Principles:

  • Physical activity reduces blood glucose levels. There may be an immediate effect and with bouts of heavy or prolonged activity, there may also be a delayed effect - up to 12 hours
  • Learning about these will help people with diabetes to anticipate the fall in glucose and act before they become hypoglycaemic rather than afterwards
  • Exercise should be avoided if unwell or blood glucose high with ketones in blood or urine
  • Extra carbohydrate may be needed before, during and after prolonged exercise
  • If exercise is done in the evening, long acting/evening insulin may have to be reduced to prevent hypoglycaemia

Type 2 Diabetes

  • People with Type 2 Diabetes rarely have problems with blood sugar when exercising
  • Extra carbohydrate is rarely needed
  • If exercise-induced hypoglycaemia is a persistent problem consider reducing Oral Hypoglycaemic Agents (OHAs) rather than compensating with extra food
  • Exercise should be avoided if unwell

Follow Up

  • Aim to see patients regularly to review how they are doing as this provides encouragement.
  • Best results are seen with supervised classes

Resources

Diabetes Information Pack - includes first-line information on diet and exercise and the care people with diabetes should expect to receive . There is a specific leaflet available for people with Type 1 Diabetes entitled Diabetes and Sport. This can be ordered from the WyvernHealth.Com website at http://www.wyvernhealth.com/pathways.htm (under Documentation and Guidance section).

Structured education - available for people who have been diagnosed with Type 1 Diabetes for at least 6 months and newly diagnosed people with Type 2 Diabetes.

Local exercise facilities - details of facilities for exercise available locally are available on the Somerset Community Health website www.somcomhealth.nhs.uk and advice to target weight management.

Somerset Integrated Lifestyle Service - provides information, advice and support, including treatment where appropriate, to people wishing to change to a healthier way of life. The objectives of the service are to:

  • act as a 'one stop shop' for Somerset residents to access information and advice relating to health and well-being including support to stop smoking, physical activity, healthy eating and weight management
  • provide enhanced support to the Fresh Steps NHS Trainer Service for those living in areas of high health and social need and those with higher health needs who are receptive to making lifestyle changes
  • promote the use of community based facilities and services

See the Directory of Services

ProActive Physical Activity Referral Scheme (forms part of Somerset Integrated Lifestyle Service) - for people who are currently inactive and are in need of additional support and advice to help them to lead a more physically active life. Referral is by selected healthcare professionals eg GP, dietitian or physiotherapist. Onward referral is to accredited leisure service providers, offering a range of physical activities. Participating leisure providers will have been assessed and recognised by the Somerset Physical Activity Group. Please note there is a cost to the patient for this scheme.

See the Directory of Services

Other useful web-sites

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Foot education

Initial foot care advice

General foot care advice for people with diabetes should be provided following diagnosis. Advice may be accessed from the Somerset Community Health website at http://www.somerset.nhs.uk/community/our-services2/podiatry/looking-after-your-feet/diabetes-and-your-feet/ .

Resources

Diabetes Information Pack - includes first-line information on foot care for people with diabetes.

Structured education - available for people who have been diagnosed with Type 1 Diabetes for at least 6 months and newly diagnosed people with Type 2 Diabetes.

DIAGNOSIS, CASE FINDING AND INITIAL MANAGEMENT

Psychological support

It is well known that people with long term conditions can suffer from depression, control issues and eating disorders. It is recommended that people with diabetes are annually assessed using the Hospital Anxiety Depression Scale (HADS) which has been validated for use in community and primary care settings. It is self-administered and takes up to five minutes to complete. The HADS can be ordered from http://shop.glassessment.co.uk/home.php?cat=417&gclid=CPPr3fjJhpkCFQ6wQwodI2Krlw

Resources

Somerset Right Steps Emotional Health and Wellbeing Service - for people suffering from anxiety, stress, depression, obsessive compulsive disorder, sleeping problems.

Somerset and Wessex Eating Disorders Association, Psychological Therapies - for people with eating disorders - anorexia nervosa, bulimia nervosa, compulsive eating, binge eating disorder and all related eating disorders.

Somerset Partnership NHS Foundation Trust - for people with:

  • severe and complex mental health problems;
  • a less severe degree of problem where there are risk behaviours or complex dynamics;
  • requiring specialist intervention;
  • marked behavioural difficulties as a consequence of mental health problems

See the Directory of Services.

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CONTINUING CARE

Annual review

A check-list of tests and other areas to be considered at the annual review is provided in Table 3 below.

The annual review is an opportunity for the patient to understand their diabetes and what they can do to help get their condition under control and keep it that way, thereby reducing the risk of complications.

It is suggested practices may wish to use the results sharing sheet developed by NHS Somerset as a means of raising the patient's awareness of optimum targets for the clinical indicators and recording tailored targets which have been discussed and agreed with the individual (see Table 4 below).

The results sharing sheet can be sent to patients before their appointment or completed with the patient in the consultation. It is believed this process will increase patients' motivation to achieve improved health outcomes and result in better concordance with prescribed medication.

Practices will also need to complete a computer template for QOF which will record results for the key areas covered by the annual review.

Review of coding, classification and diagnosis of diabetes

A report published by the Royal College of General Practitioners in March 2011 identified that significant numbers of diabetes patients have classification anomalies in their data.

The report highlights 3 possible errors:

  1. Miscoding - diabetes is diagnosed, but they are given a strange code. This is a technical problem and affects about 1%.
  2. Misclassification - the person is correctly identified as having diabetes but is misclassified, ie given a diagnosis of type 2 when they may have type 1 or MODY. This is important as it affects patient education in particular. This is about 2%
  3. Misdiagnosis - probably the most important group. They are diagnosed as having diabetes, but either never had it or may no longer have it eg gestational diabetes, steroid diabetes. Clearly this is important as it may affect treatment. This is about 2%.

An audit tool designed to help practices identify people to target to check their diagnosis has been developed by the researchers for the audit project. It is available from www.clininf.eu/cod. The tool can extract data from all the main practice IT system suppliers.

It is recommended that practices use this tool on an annual basis to help identify potential coding anomalies.

Table 3: Annual review checklist

Assessment parameter Target
Height
Body weight & waist circumference BMI 19-25 (weight(kg)/height(m)2 ) or waist circumference to be in low risk category ≤94cm for men (≤90cm if Asian) ≤80cm for women
Blood pressure BP < 130/80
125/75 target for younger renal disease
Injection sites/technique Injection technique good, free from lipodystrophy
Feet Patient's foot in an intact state
Pedal pulses Palpate dorsum of foot (doralis pedis) and behind medial malleolus (posterior tibial artery)
Foot sensation Sensation to be intact in 5 sites on plantar aspect of foot with 10G monofilament
Eyes To undergo retinal screening annually
HBA1c 48-59 mmol/mol
Targets will vary, depending on individual circumstances. See also explanation below of new HbA1c measures.
Cholesterol Cholesterol <4.0mmol/l
LDL ≤ 2.0
Triglyceride ≤1.7mmol/l
HDL-C ≥1mmol/l m. 1.3 F
Refer to CV risk pathway . The above is for Type 2 Diabetes, T1 DM for more than 10 years or T1 DM and complications
eGFR Kidney Dysfunction .
See NICE guidance on CKD http://guidance.nice.org.uk/CG73/QuickRefGuide/pdf/English
Urine ACR Measure annually. microalbuminuria screening.
Urine dipstick for protein Negative , if +ve and no infection refer (see Kidney Dysfunction .)
Sexual Health Discuss erectile dysfunction and give advice or prescribe - go to erectile dysfunction
Lifestyle and other issues
Cigarette smoking STOP! lifestyle and exercise
Diet Eat three meals a day
Include starchy carbohydrate foods at each meal
Reduce added fat and salt
Aim for five portions of fruit and vegetables a day
Limit sugar and sugary foods
Advise weight loss if overweight
Keep alcohol within safe limits
diet
Alcohol Less than 21 units for men
Less than 14 units for women per week
Exercise 30 minutes moderate intensity, exercise 5 x weekly
lifestyle and exercise
Use of devices Appropriate use of blood glucose meters, finger pricking devices and insulin injection devices
Pregnancy and contraception diabetes in women diabetes in women
Hospital Anxiety and Depression score Measure annually, refer if necessary for psychological support - go to psychological support for details of psychological support available

Table 4: Results Sharing Sheet

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The New HbA1c measurement

A number of assays are available for measuring the HbA1c. From June Pathology labs in Somerset will be using a definitive international reference range in mmol/mol. The old way of recording ie percentages will stop .There is a formula for converting one to the other:

(HbA1c %-2.15) x 10.929= New HbA1c mmol/mol)

For whole numbers you can use the 'minus 2,minus 2' rule for example if the old HbA1c was 6%,the new figure will be 6-2=4/4-2=2 so the new HbA1c is 42.

Here some are some conversions:

HbA1c (%) HbA1c (mmol/mol)
4.0 20
5.0 31
6.0 42
6.5 48
7.0 53
7.5 59
8.0 64
9.0 75
10.0 86

This only works on whole percentages and the full formula must be used for other numbers with decimal places.

For further information on the new measurement go to http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/HbA1cHCPs_web_LM5_0110.pdf/

CONTINUING CARE

Glycaemia

Targets

Plasma glucose

Fasting ≤ 7.0 mmol/l

Postprandial ≤ 8.5 mmol/l

Glycated haemoglobin (HbA1c)

HbA1c should be monitored 3-6 monthly. As the results reflect glycaemic control over a period of 6-8 weeks, tests performed at intervals of less than three months are uninformative and should be avoided. The frequency of testing depends on the target for glycaemic control, stability of blood glucose and changes in therapy.

Fructosamine - Use for monitoring glycaemic control in haemoglobinopathies

HbA1c 48-59 mmol/mol

Before any pharmacological interventions are considered for glycaemia there should be a 3 month period of diet & lifestyle interventions.

Education - provide structured education to every patient and/or their carer at or around the time of diagnosis and review annually.

Diet - provide individualised and ongoing specialist nutritional advice.

Lifestyle - encourage weight loss and exercise.

The VADT, ACCORD and ADVANCE trials show that tight control of blood glucose in long standing Type 2 diabetics (reducing HbA1c to below 53 mmol/mol may be harmful. CG 87 agrees with this view and recommends:

  • Involve the person in decisions about their individual HbA1c target which may be above the general target of 48 mmol/mol
  • Offer lifestyle advice and medication to help achieve and maintain the HbA1c target
  • Inform patients with a higher HbA1c that any reduction towards the agreed target is advantageous to their health and reduces the risk of microvascular disease
  • Avoid pursuing highly intensive management to levels of <48 mmol/mol

A higher target may be appropriate in people with a limited prognosis or higher risk of iatrogenic hypoglycaemia (e.g. the elderly) and lower targets may be appropriate in certain circumstances, e.g. pregnancy or early Type 1 Diabetes.

Impaired Fasting Glucose

Fasting glucose 6.1-6.9 mmol/l is impaired fasting glucose, which is associated with increased cardiovascular disease (CVD) risk.

  • CVD risk factors should therefore be aggressively addressed in people in this group
  • Lifestyle changes (moderate weight loss and increased, regular exercise) markedly reduce the rate of progression to overt diabetes in people in this category. Patients should be advised accordingly
  • An Oral Glucose Tolerance Test (OGTT) is advised for this group to clarify status, but this is unlikely to change patient management
  • Annual testing of fasting glucose, re-assessment of CVD risk factors and lifestyle review is recommended

References:

NICE clinical guideline 66: Management of Type 2 Diabetes (update) (2008)http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf
NICE clinical guideline 87: Type 2 Diabetes (2009)http://www.nice.org.uk/nicemedia/live/12165/44318/44318.pdf

Oral hypoglycaemic agents and insulin

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Notes:

With all these drugs attempt is made to keep them up to date with latest NICE guidance, Somerset Prescribing Formulary and the drug SPC. Links to these sites are:

NICE Guidance
http://guidance.nice.org.uk
http://guidance.nice.org.uk/CG87/NICEGuidance/pdf/English
http://guidance.nice.org.uk/CG66/NICEGuidance/pdf/English

Somerset Prescribing Formulary
http://nww.somerset.nhs.uk/welcome/directorates/primary-care-development/prescribing-and-medicines-management/formulary-traffic-light-system/

Drug SPCs
http://www.medicines.org.uk/emc/

  1. Metformin
    • First line OHA if BMI ≥25 Side Effects
      • Gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhoea, abdominal pain, flatulence)
      • Lactic acidosis
    • Contra-indications
      • Renal impairment - Creatinine ≥150 mmol/l or eGFR <30 ml/min
      • Use Metformin only with caution if eGFR 30-59 ml/min. ensure renal function is stable before starting treatment, monitor eGFR regularly and discontinue Metformin if the eGFR is falling or in the event or any inter-current illness likely to be associated with dehydration
      • Cardiac failure not controlled by minimal doses of loop diuretic (Furosemide 40mg once/day or equivalent without Digoxin) and/or ACE inhibitor (Ramipril 10mg once/day or equivalent without Digoxin)
      • Significant chronic pulmonary disease with potential for hypoxia (exercise tolerance less than one flight of stairs)
      • Liver disease with Liver Function Test (LFT) ?3 x upper limit of normal range (if pre-treatment results raised but <3 x upper limit, recheck LFT after one-two months of treatment and investigate according to local guidelines if still abnormal
    • Treatment Schedule
      • Start at low dose (500mg once/day with or after food) increase by 500mg per day each week to highest tolerated dose up to usual maximum 1g twice a day
      • Always advise patient to take tablets with or after food
      • If Gastro Intestinal (GI) side effects, reduce back to previously tolerated dose
      • Modified release Metformin should not be used routinely but may be better tolerated compared to immediate-release Metformin formulations by some patients. If patients have persistent GI side effects in spite of slow introduction of the standard formulation, a short trial of modified release Metformin should be considered before using alternative treatments
  2. Gliclazide and other sulfonylurea drugs
    Consider as first line agent if BMI <25 kg/m2, but otherwise typically used as second line therapy with Metformin
    • Cautions:
      • Warn patient of potential risk of hypoglycaemia if meals omitted or activity increased - Glibenclamide should be avoided
      • Drivers need to notify the DVLA on starting treatment See DVLA Guidance at http://www.dft.gov.uk/dvla/medical/ataglance.aspx
  3. Treatment Schedule:
    • Start Gliclazide 40-80mg once daily and adjust according to response
    • Increase at fortnightly intervals if necessary
    • Maximum dose 160mg twice daily
  4. Metformin/Gliclazide combinations
    Second line if single agent treatment fails to achieve target.
  5. Prandial glucose regulators e.g.
    • Repaglinide and Nateglinide
    • Short acting agents potentially used in place of sulfonylureas
    • Their role currently lacks a clear evidence base and their use is not therefore recommended except in people with erratic lifestyles
  6. Thiazolidinediones/Glitazones
    • Pioglitazone can be used as alternative second or third line agent if blood glucose targets are not achieved.
    • Associated with weight gain
    • Pioglitazone are associated with fluid retention.
    • Avoid if current or previous heart failure, ischaemic heart disease or high CVD risk.
    • If initiation of Pioglitazone treatment is indicated discontinue if the patient develops heart failure or ischaemic heart disease, no treatment effect is seen or weight gain and other adverse effects are unacceptable.
  7. GLP-1 (Exenatide or Liraglutide)
    • GLP-1 therapy (given by subcutaneous injection) may be considered for use in patients whose diabetes is not controlled on maximum tolerated OHA (Metformin and Sulfonylurea) in whom insulin conversion is being considered but
    • Specific guidance on GLP-1 analogue therapy is shown on Page 35.
  8. DPP-4 inhibitors (gliptins)
    • DPP-4 inhibitors (Sitagliptin, Vildgliptin, Saxagliptin) may be suitable second-line therapy instead of Sulfonylurea if a patient is considered to be at significant risk of iatrogenic hypoglycaemia, i.e. frail older people living alone.
    • Renal impairment
    • If HbA1c has not fallen 6mmol/mol after 6 months Gliptins should be stopped.
  9. Anti-obesity drugs and obesity surgery
    • Orlistat may be considered as part of a weight-loss strategy for people with Type 2 Diabetes and BMI ≥28 kg/m2 accordance with NICE guidance. Treatment should be discontinued after 12 weeks if patients have been unable to lose at least 5% of the body weight as measured at the start of drug therapy
    • People with Type 2 Diabetes with BMI ?35 kg/m2 may be suitable for gastric banding or other bariatric surgery in accordance with NICE guidance. Referrals to the service are accepted only from secondary care and people who are potentially suitable should therefore be referred to the diabetes specialist team in the first instance (see Page 63)
  10. Insulin
    • Insulin can be initiated in Level 2 (intermediate care) or in primary care practices accredited under the Somerset PCT LES. (see Page 37)
    • Use if treatment with combined oral hypoglycaemic agents fails to achieve targets. If Metformin has previously been tolerated, it should generally be continued in people with Type 2 Diabetes when starting insulin.

References:
NICE clinical guideline 66: Management of Type 2 Diabetes (update) (2008)http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf
NICE clinical guideline 43: Obesity (2006) http://www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdf

Use of GLP-1 analogues in the treatment of adult patients with Type 2 Diabetes

When should GLP-1 agonist be considered?

  • HbA1c ≥59mmol/mol on maximum tolerated doses of Metformin and Sulphonylurea/other oral agents. (Not licensed for used with insulin.)
    AND
  • BMI ≥35 Kg/m2 and patient has specific psychological or medical problems associated with high body weight
    OR
  • BMI ≤35 Kg/m2 and insulin treatment would have significant occupational implications, or weight loss would benefit other significant obesity related co-morbidities

Who cannot receive a GLP-1 agonist?

EXENATIDE LIRAGLUTIDE
Ketoacidosis Ketoacidosis
Pregnant mothers Pregnant mothers
Breast feeding mothers Breast feeding mothers
Severe GI disease IBD, Diabetic Gastroparesis
Avoid if eGFR <30 mL/min/1.73 m2 Caution if eGFR 30 50 mL/min/1.73 m2 Avoid if eGFR <60 mL/min/1.73 m2
Avoid in hepatic impairment
History of medullary thyroid cancer/MEN 2

Who should continue taking GLP-1 agonists beyond 6 months?

  • Only continue treatment if: 11 mol/mol fall in HbA1c and ?3% reduction in body weight at six months
  • If parameters not achieved, consider alternative treatment, usually insulin

Initiation of Exenatide therapy

Baseline Tests and Check for Contra-Indications

  • Perform and document baseline BMI
  • Blood tests - HbA1c, LFT, U & E

Counsel Patient

  • Correct injection technique
  • Warn re: side effects especially:-
    1. Nausea which is usually self limiting - stop eating before full to minimise this
    2. Pancreatitis - if patient develops abdominal pain/nausea and vomiting they must stop the treatment and seek prompt medical attention. If pancreatitis confirmed, treatment must be discontinued
  • Give contact number for DSN
  • DVLA - if patient holds Group 2 (LGV or PCV) licence and is on a Sulphonylurea inform DVLA on commencement of Exenatide. See DVLA Guidance at http://www.dft.gov.uk/dvla/medical/ataglance.aspx

Review Current Treatment

  • Stop Glitazone treatment, Gliptin inhibitor therapy
  • Halve dose of Gliclazide unless HbA1c >86 mmol/mol, dose may need to be increased depending on response to Exenatide treatment
  • Drugs eg., Warfarin, OCP, antibiotics should be taken 1 hour before or 4 hours after Exenatide
  • INR will need to be monitored more frequently in patients on Warfarin

Prescription

  • Both drugs are GREEN drugs in Somerset and prescriptions should be provided by the patient's GP
INITIATION OF THERAPY
Week 1 Start Exenatide 5 g sc twice daily (within 1 hour before two main meals at least 6 hours apart), or Liraglutide 0.6 mg sc once daily (can be taken at any time of day)
Week 2 Enquire about side effects and repeat U & E's and LFT's, if stable, continue treatment
Week 4 Increase Exenatide dose to 10 g sc bd OR Liraglutide 1.2mg once daily
Week 12 Perform and document BMI, HbA1c, LFT's and U & E's
After 6 months of treatment Perform and document BMI, HbA1c, LFT's and U & E's If HbA1c has fallen by ≥11mmol/mol and weight has fallen by ≥3%, continue treatment Otherwise stop and consider alternative treatment

Starting Insulin in Type 2 Diabetes

Insulin therapy may be considered as a treatment option when other measures do not keep HcA1c under control. The decision to start insulin must be individualised and weigh the benefits of improving glucose control, against some of the risks of insulin therapy:

  • Need to inject
  • Hypoglycemia
  • Occupational considerations eg driving
  • Potential weight gain

NHS Somerset offers a Local Enhanced Service payment for insulin initiation in people with Type 2 Diabetes.

Practices who wish to take up this offer are required to undergo a three-day MERIT course or be able to demonstrate equivalent skills. Both a Practice Nurse and a GP from the surgery are required to attend the course. The full specification is available at http://www.wyvernhealth.com/pathways.htm (under the Commissioning Documents section).

Support will be provided to these Practices by the intermediate Diabetes Nurse Specialist and Specialist Dietetic team.

All other patients who require insulin initiation may be referred via Choose & Book to the Intermediate Diabetes Nurse Specialist team.

Choice of Insulin in Type 2 Diabetes

Insulin initiation in Type 2 Diabetes is a complex area and should only be taking place in primary care by teams with special expertise as outlined above (NICE CG 66 & 87). Therefore detailed guidance on choice of insulin regimen is beyond the scope of this guidance.

Choice of insulin regimen should be individualised, and should adhere to NICE guidance. In particular, the use of insulin analogues as the initial insulin regimen in Type 2 Diabetes is not recommended. NICE recommendations are (NICE CG 66 & 87):

  1. Begin with human NPH insulin injected at bed-time or twice daily according to need
  2. Consider, as an alternative, using a long-acting insulin analogue (insulin detemir, insulin glargine) if:
    1. the person needs assistance from a carer or healthcare professional to inject insulin, and use of a long-acting insulin analogue (insulin detemir, insulin glargine) would reduce the frequency of injections from twice to once daily, or
    2. the person's lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes, or
    3. the person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs, or
    4. the person cannot use the device to inject NPH insulin.
  3. Consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c ? 75 mmol/mol). A once-daily regimen may be an option.
  4. Consider pre-mixed preparations that include short-acting insulin analogues, rather than pre-mixed preparations that include short-acting human insulin preparations, if: ? a person prefers injecting insulin immediately before a meal, or
    1. hypoglycaemia is a problem, or
    2. blood glucose levels rise markedly after meals.
  5. Consider switching to a long-acting insulin analogue (insulin detemir, insulin glargine) from NPH insulin in people:
    1. who do not reach their target HbA1c because of significant hypoglycaemia, or
    2. who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached, or
    3. who cannot use the device needed to inject NPH insulin but who could administer their own insulin safely and accurately if a switch to a long-acting insulin analogue were made, or
    4. who need help from a carer or healthcare professional to administer insulin injections and for whom switching to a long-acting insulin analogue would reduce the number of daily injections.

Home blood glucose monitoring

Blood glucose testing strips are primarily intended for people with diabetes treated with insulin. The frequency and of testing and timescale should be as agreed between the health professional and the individual with diabetes. Its purpose should be discussed and there should be agreement how the results should be interpreted and acted upon.

Table 5: Home blood glucose monitoring regimens by treatment group

Diabetes type Treatment Group Monitoring Regimen
Type 1 All people with type 1 Diabetes Blood glucose monitoring should be an integral part of treatment. People with Type 1 Diabetes should receive education to enable them to monitor blood glucose and adjust treatment appropriately.
The majority of people with Type 1 Diabetes should consider testing ≥ four times per day to optimise control and prevent acute complications.
The frequency and timing of tests should be tailored according to the targets and stability of glycaemic control.
Diabetes in pregnancy All women with diabetes in pregnancy Blood glucose monitoring essential during pregnancy and when planning pregnancy. The frequency and timing of tests as recommended by the joint diabetes/antenatal team.
Type 2 Intensive insulin therapy/titration of insulin As with Type 1 diabetes, monitoring should be according to the individual's need to optimise control and prevent acute complications. Fasting blood glucose should be tested daily during basal insulin dose titration.
Type 2 Insulin (with or without oral agents) Wherever possible all patients on insulin or their relatives should be taught to perform blood glucose monitoring, to interpret results and adjust treatment. The frequency and timing of tests should be tailored according to the targets and stability of glycaemic control. People using conventional insulin regimens and have less stable control should test at least once daily, varying the time between fasting, pre-meal and bedtime tests. Those with stable control should test two-three times per week, varying the times as above.
Type 2 Diet and exercise People with good control do not need to monitor unless they are destabilised by other factors. HbA1c should be monitored three - six monthly. If individuals choose to perform blood glucose monitoring as a method of monitoring lifestyle changes, then they should be advised on the most appropriate meter and monitoring advice as below. Offer blood glucose monitoring to a person newly diagnosed only as an integral part of a self-management plan and advise as below.
Type 2 Metformin +/- Glitazones or Gliptins As for diet and exercise.
Type 2 Sulfonylurea alone or in combination with other agents Blood glucose monitoring (BGM) should be available to provide information on hypoglycaemia e.g. due to variable food intake or activity levels. BGM should be available to ensure safety during activities including driving. BGM should be considered for those with poor or deteriorating control particularly those on maximum oral agents who are likely to require insulin in the near future.
Type 2 Incretins There is no evidence to support BGM unless on Sulfonylurea.
Special circumstances Driving
Illness
Changes of treatment
Steroid therapy
DESMOND People who have attended DESMOND should be supported to BGM in order to assist them in the self management of their diabetes. People on insulin and sulfonylureas must be made aware of the DVLA regulations. 'Sick Day' guidance should be available for patients regarding the frequency of testing. See Page 41 Management of Problematic Hypoglycaemia (Notes accompanying chart) and refer to national guidance 'A guide to insulin treated diabetes and driving' http://www.dft.gov.uk/dvla/medical/ataglance.aspx
BGM may be indicated during changes in treatment. People should be advised to test or increase testing to adjust diabetic treatment if taking steroids (see Page 50). Discuss urine glucose monitoring if blood monitoring is found to be unacceptable.
Monitoring advice Assess BGM at least annually and include in the discussion:
  • The purpose of monitoring, how to interpret and act on the results;
  • Self-monitoring skills, the equipment used, quality and frequency of testing;
  • How the results are used, the impact on quality of life and the continued benefit.

References

Consensus Guidelines: Recommendations regarding self-monitoring of blood glucose (Appendix 2) Diabetes and Primary Care. 2005; 7:9-21.

NICE Clinical Guidelines 66 & 87: Type 2 Diabetes (2008 & 2009)http://www.nice.org.uk/nicemedia/live/12165/44318/44318.pdf

Somerset Prescribing Formulary http://nww.somerset.nhs.uk/welcome/directorates/primary-care-development/prescribing-and-medicines-management/formulary-traffic-light-system/

Figure13 (49K)

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Notes:

Blood glucose levels of <4 mmol/l should be treated as hypoglycemia whether or not accompanied by symptoms.

  1. Possible reasons to be considered
    • Changes in food intake - reduced carbohydrate, delayed or missed meals or snacks. Varying carbohydrate intake at meals may also cause hypoglycemia.
    • Physical activity - this can include activity such as housework, ironing, shopping and gardening as well as exercise. hypoglycemia may be delayed following intensive exercise.
    • Medication/insulin - incorrect or too much. Oral hypoglycaemic agents (e.g. Gliclazide, Glibenclamide) can cause hypoglycemia.
    • Alcohol - the effects can often be delayed until the following day, particularly if large amounts of alcohol are consumed. Advise bedtime snack and blood glucose monitoring on the following day.
  2. Potential underlying causes
    • Renal impairment slows down metabolism of some drugs including insulin and most sulfonylureas, prolonging their glucose lowering effects
    • Weight loss effectively increasing the dose/kg body weight
    • Endocrine disorders (e.g. hypothyroidism, Addison's disease)
    • Coeliac disease
    • Pregnancy - particularly during the first trimester
    • Injection sites (especially if the patient has moved sites)
    • Cessation/reduction of steroids without reduction of diabetes medication.
  3. Symptoms
    • Usual symptoms include sweating, trembling, hunger, palpitations, anxiety, speech/visual problems
    • Recurrent hypoglycaemia will cause a change/reduction in hypoglycemia symptoms (less sweating, tremor and hunger usually).
  4. Immediate advice
    • Advise patients to test blood glucose levels if possible in event of further hypoglycaemia symptoms, and to ingest 20g of quick acting carbohydrate - e.g. small glass orange juice, non-diet fizzy drink or Lucozade, 5-6 glucose tablets, 4-5 Jelly Babies.
    • Once blood glucose levels are above 4 mmol/l, they should have a snack of approx 20g of longer acting, starchy carbohydrate.
    • Further information/patient information sheet is available atwww.somcomhealth.nhs.uk
  5. Assessment and management
    • Identify the blood glucose level at which the patient's warning symptoms occur - if significant reduction in warning or symptoms occur only when blood glucose less than 3.5 mmol/l, refer to the Diabetes Specialist Team in Level 3.
    • Encourage patient to test blood glucose levels pre-meals, bed and around the time that hypoglycaemia symptoms most commonly occur.
    • Explore timing of medication and food. Ensure insulin or sulfonylurea is being taken at recommended times in relation to meals.
    • Identify patterns in hypoglycaemia, advise adjust in insulin/medication accordingly.
    • Review injection sites - lipohypertrophy can cause erratic absorption of insulin. If patient advised to move sites reduce insulin by 10-20% initially.
    • Recheck HbA1c. HbA1c <48mmol/mol insulin treated patients or HbA1c 42 mmol/mol on sulfonylureas is suggestive of significant hypoglycaemia
    • If problems continue refer to Intermediate Specialist Team or Diabetes Specialist Team in Level 3.
  6. Reduced Hypoglycemia Awareness
    • If the patient experiences no symptoms until blood glucose is <2.8 mmol/l, he/she is considered to have hypoglycaemia unawareness.
    • Unawareness is potentially dangerous, especially if driving or operating machinery.
    • Often the patient has no adrenergic symptoms, and therefore presents with confusion or other neurological problems.
    • Patients with hypoglycaemia unawareness should be referred to Level 3.
    • Complete avoidance of low blood glucose levels for around three months can help restore warning symptoms. This requires intensive multi-professional input.
  7. Indications for referral to intermediate or secondary care
    • Reduced hypoglycemia awareness
    • Any unconscious episodes of hypoglycaemia
    • More than three hypoglycaemia episodes per week
    • Consider referral of any patient having hypoglycaemia requiring assistance from a third party.
  8. Driving and Hypoglycaemia
    • Patients with hypoglycaemia unawareness should be advised not to drive until warnings return.
    • Always check blood glucose levels before driving, and every two hours during the journey.
    • Do not drive if feeling hypoglycaemic or if blood glucose less than 4 mmol/l.
    • Do not resume driving until 45 minutes after blood glucose has returned to normal. It takes up to 45 minutes for the brain to fully recover.
    • If blood glucose ?5 mmol/l snack before driving.
    • Ensure the patient knows to have a blood glucose meter and fast acting carbohydrate in the car.
      See DVLA Guidance at http://www.dft.gov.uk/dvla/medical/ataglance.aspx

Hypertension

Figure14 (73K)

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Notes:

  1. Salt intake should be reduced in all patients (patient advice is available on the websites of NHS Direct and the Food Standards Agency: http://www.nhs.uk/Livewell/Goodfood/Pages/salt.aspx http://www.eatwell.gov.uk/healthydiet/fss/salt/
  2. Check eGFR and potassium before and one to two weeks after commencing ACEi or ARB and after any dose increment (AB).
    If potassium 6.0 mmol/l
    • stop ACEi or ARB
    • check HCO3-
    • refer to dietician for low K+ diet
    • monitor K+
    • Consider re-starting ACEi if K+ falls and patient changes to low K+ diet (especially if patient commenced on HCO3-)
    • Stop ACEi/ARB if eGFR falls >25%/Creat rises >30% unless modifiable cause.
    • If eGFR falls but less than 25%, recheck eGFR in one to two weeks.
    • Refer to nephrologists if eGFR falls >15% in patients with CKD1-3
  3. First-line blood-pressure-lowering therapy for a person of African-Caribbean descent should be an ACE inhibitor plus either a diuretic or a generic calcium-channel antagonist (calcium-channel blocker).
  4. Consider stopping ACEi or ARB 1 week prior to elective surgery or during intercurrent illness (especially if fluid depleted) to reduce risk of acute kidney injury
  5. Antihypertensive medication should be reviewed in all women planning pregnancy. If clinically acceptable ACEI and ARB should be stopped in all women planning pregnancy and replaced with alternative antihypertensive medication eg methyl dopa, nifedipine or laβlol. A calcium-channel blocker should be the first-line blood-pressure-lowering therapy for a woman for whom, after an informed discussion, it is agreed there is a possibility of her becoming pregnant.
  6. Diuretics: Bendroflumethiazide 2.5 mg od (maximum effect after 4-6 wk). Use Furosemide 40 mg od if the patient has oedema or GFR is <60
  7. β blocker: Bisoprolol or Atenolol (avoid in critical limb ischaemia) if HR >90 (aim for HR ~ 60)
  8. Calcium channel blocker (CCB): Either a long acting dihydropyridine CCB (e.g. Amlodipine) or a non-dihydropyridine CCB (e.g. Diltiazem modified release preparation or Verapamil). especially if albumin:creatinine ratio >100 (NB caution β blocker - see below) or if dihydropyridine CCB results in unacceptable oedema Long acting dihydropyridine CCB and β blocker may be combined but caution should be used if prescribing Diltiazem and a β blocker. Verapamil should never be prescribed with a β blocker
  9. Alpha blocker: e.g. Doxazosin 1 mg od for one wk → 2 mg od for one wk → 4 mg od for one wk. Increase dose further if target not achieved (max 16 mg od)

Alternative care pathway if ACE inhibitor and Angiotensin II receptor blocker contra-indicated

Figure15 (33K)

CONTINUING CARE

Figure16 (59K)

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Notes:

  1. Additional risk factors

    One or more of the following:
    • Evidence of significant microvascular complications
    • (retinopathy and/or microalbuminuria)
    • Hypertension on treatment
    • Family history of premature cardiovascular disease (age<55)
    • Total cholesterol ≥6.0 mmol/l
  2. Women who are considering pregnancy should stop statins prior to conception as there is a suggestion that statins may affect CNS and limb formation if taken during first trimester.
  3. Guidance on Hypertriglyceridemia
    1. If non-fasting triglycerides elevated, repeat a fasting sample
    2. If fasting triglycerides ≤ 4.5 then continue statin treatment as above
    3. If fasting triglycerides > 4.5 then review possible exacerbating factors
      • Poor glycaemic control
      • Alcohol
      • Diet -consider referral to community dietitian

Treat hypercholesterolemia with statin as above

If hypertriglyceridemia persists commence Fenofibrate in addition to statin

If fibrate not tolerated replace with a nicotinic acid derivative (Niaspan or Tredaptive)

References:

NICE clinical guideline 66: The management of Type 2 Diabetes (update) (May 2008).

NICE clinical guideline 67: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (May 2008).

Anti-platelet agents

National guidance on the use of anti-platelet agents for primary prevention of cardiovascular disease in people with diabetes is currently under review.

While awaiting review of the national guidance, The Medicines and Healthcare products Regulatory Authority (MHRA) Drug safety update (Volume 3, Issue 3, October 2009) gives the following advice on using aspirin for the primary prevention of vascular events - "Aspirin is not licensed for the primary prevention of vascular events. 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 (including conditions such as diabetes) and the risk of gastrointestinal bleeding."

The most recent NICE recommendations are to treat any person with Type 1 or Type 2 Diabetes who meets any of the following criteria:

  • Age ≥50
  • Age <50 and significant other cardiovascular risk factors
    • Hypertension on treatment
    • Family history of premature cardiovascular disease
    • Metabolic syndrome
    • Smoking
    • Microalbuminuria
    • Existing cardiovascular disease (MI or Angina, stroke or TIA or PVD)

Start treatment after systolic blood pressure has been reduced to 145 mmHg. Blood pressure should be kept at 145 mmHg or lower while aspirin is being taken as anti-platelet therapy.

Prescribe dispersible aspirin 75mg once daily unless contra-indicated (see below).

Consider use of combined dipyridamole/aspirin for 24 months in patients who have experienced a vascular event whilst on aspirin.

Contra-indications to anti-platelet agents

  • Aspirin allergy defined by anaphylaxis - rash or wheeze directly attributable to aspirin ingestion. Consider use of clopidogrel for secondary prevention
  • Previous cerebral haemorrhage (ever)
  • Active peptic ulceration. In previous peptic ulcer disease, aspirin can be started in conjunction with a proton pump inhibitor
  • Bleed tendency
  • Active hepatic disease
  • Concomitant Warfarin therapy, unless indicated and carefully monitored uncontrolled hypertension (systolic blood pressure ≥145 mmHg)

References:

NICE clinical guideline 66: Management of Type 2 Diabetes (update) (2008)
NICE clinical guideline 37: Type 1 Diabetes (July 2004)

CONTINUING CARE

Diabetes and steroid care

Known diabetes tablet/insulin treated

Figure17 (43K)

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Figure18 (47K)

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Notes:

Effect of steroids on blood glucose levels

  • Steroids induce a state of relative insulin resistance; most patients will not have significantly different FBG but postprandial hyperglycaemia is exaggerated.
  • Blood glucose levels can start to rise within a few days of commencing oral steroids and subside within 48 hours of stopping the medication. Injected steroids may cause blood glucose levels to rise soon after administration and last three to ten days.
  • Controlling blood glucose levels will improve hyperglycaemic symptoms, reduce the risk of infections and hyperglycaemic emergencies.

Managing diabetes and steroid therapy

  • Start blood glucose monitoring (BGM) or increase the frequency - check fasting and postprandial levels for two days.
  • Diet/tablet controlled - if blood glucose ≥15 mmol/l add Gliclazide for people normally controlled on diet alone or with Metformin.
  • If blood glucose remains ≥15 mmol/l after increasing OHAs, consider adding Isophane insulin, initially at breakfast time, depending ton the likely duration of the treatment.
  • Frail or elderly patients may benefit from other regimens suited to their glucose profile and circumstances. Contact the intermediate DSN team for advice if in doubt in any of these situations.
  • Insulin treated - increase insulin if blood glucose ≥11 mmol/l consider a basal bolus regimen or adding short acting insulin to a twice daily regimen or adjust as per sick day guidance.
  • Not known to have diabetes but displaying symptoms that may be related to hyperglycaemia: initiate blood glucose monitoring for two days and treat as for diabetes if blood glucose ≥15 mmol/l.

General Advice

People on steroids often have additional causes for the increase in blood glucose levels, such as decrease in activity, increased appetite and weight gain.

  • Follow a healthy eating plan and see a dietitian if indicated.
  • Refer to DSN for ongoing education and support if indicated.
  • These guidelines are intended for use in people on short term steroid treatment or at the end of life. Lower blood glucose targets may be appropriate in people needing longer term steroid therapy.

COMPLICATIONS

Coronary Heart Disease (CHD)

Risk factor control and targets

Targets
Total cholesterol Cholesterol ≤4.0 mmol/l or LDL ≤2.0 mmol/l
Blood pressure ≤ 130/80 mmHg ( ≤ 125/75 mmHg if microalbuminuria or proteinuria)
Smoking Non-smoker

It should be emphasised that any improvement in the level of control of BP and cholesterol is associated with reduction in risk of macrovascular disease, even if the targets are not achieved.

References

NICE guideline 66: Management of Type 2 Diabetes (update 2008). http://www.dtu.ox.ac.uk/index.php?maindoc=/riskengine/

COMPLICATIONS

Foot complications

Foot screening and examination

It is advised that all people with diabetes have an annual foot examination to assess risk of ulceration and to ensure appropriate and timely referral.

  • The legs and feet should be examined at the annual review to detect any problems with the skin, circulation and nerve supply.
  • Diabetes can cause problems with these areas and a thorough examination is necessary for early detection and treatment options.
  • The healthcare professional carrying out the review should have training in assessing the foot correctly

Examination of the foot should include:

  • General Observation for foot deformity
  • Vascular Examination
    • Inspection for gangrene
    • Palpation of foot pulses
    • Measurement of ABPI
  • Neurological
    • Foot sensation using 10g monofilament/vibration 128Hz tuning fork or Vibratip
  • Inspection of shoes
  • Education on foot care

Following foot assessment ensure you classify foot risk and record in patient notes.

  1. Low current risk (normal sensation and palpable pulses)
  2. Increased risk (impaired sensory nerve function or absent pulses, or other risk factor)
  3. High risk (any previous toe or partial foot amputation, previous ulcer, impaired sensory nerve function or absent pulses plus deformity/skin changes)
  4. Foot care emergency or ulcer present

Assessment should be performed by staff who have received appropriate training in foot examination - see http://www.wyvernhealth.com/pathways.htm for details of diabetes courses and events for Primary Care.

Foot education is also advised at annual review (see Page 21)

Referral pathway for diabetes foot complications

Figure19 (91K)

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COMPLICATIONS

Neuropathy

Management of painful diabetic neuropathy

See care pathway in NICE Guidance at http://www.nice.org.uk/nicemedia/live/12948/47936/47936.pdf

See also the Somerset Prescribing Formulary Guidance at http://nww.somerset.nhs.uk/welcome/directorates/primary-care-development/prescribing-and-medicines-management/formulary-traffic-light-system/.

This guidance includes advice the on the treatment of patients whose neuropathic pain is already well controlled and on the changing of existing treatments.

COMPLICATIONS

Kidney dysfunction

Microalbuminuria Screening

Nephropathy Screening

Management of Persistent Proteinuria or Microalbuminuria

Figure20 (53K)

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Notes:

  1. Chronic kidney disease (CKD) cannot be diagnosed from a single eGFR. If eGFR is reduced acute renal failure must be excluded. An eGFR result ≤60 ml/min1.73m2 in a person not previously tested, must he confirmed by repeating the test within two weeks.
  2. A progressive fall in eGFR is defined >5 ml/min/1.732 in less than one year or >10 ml/min/1.732 over five years.
  3. ACEI/ARB Therapy Check eGFR and potassium before and one to two weeks after commencing ACEI or ARB and after any dose increment.
    • If potassium ≥ 6.0 mmol/l
      • stop ACEI (and ARB)
      • check HCO3-
      • refer to dietician for low K+ diet
      • monitor K+
      • Consider re-starting ACEI if K+ falls and patient changes to low K+ diet (especially if patient commenced on HCO3-)
    • If eGFR falls / Creatinine rises
      • Stop ACEI/ARB if eGFR falls ≥ 25%/Creat rises ≥ 30% unless modifiable cause.
      • If eGFR falls but less than 25%, recheck eGFR in one to two weeks.
      • Refer to nephrologists if eGFR falls ≥ 25% in patients with CKD1-3
  4. Consider stopping ACEI or ARB one week prior to elective surgery or during intercurrent illness (especially if fluid depleted) to reduce risk of acute kidney injury.
  5. Check kidney function during acute illness and pre-operatively.

References

  • NICE clinical guideline 73: Chronic Kidney Disease: early identification and management of chronic kidney disease in adults in primary and secondary care, (September 2008).
  • Joint British Association of Urological Surgeons/Renal Association consensus document on management of haematuria.

COMPLICATIONS

Eyes (retinopathy)

Diabetes can cause problems with the eyes and so a regular retinal examination is required for all people with diabetes mellitus.

Eye screening should be carried out at least yearly and commonly more frequent checks are necessary to monitor changes in the condition of the eyes.

Digital retinal photography is unnecessary if patient is already attending the Eye Department for their diabetes but is still required if attending for Glaucoma.

NHS Somerset commissions Somerset Community Health to provide the Diabetic Retinopathy Screening Service to residents within Somerset. The East Mendip area is currently served by the Bath Retinal Screening Programme.

All patient appointments organised by Somerset Community Health are managed by the Call/Recall team in Patient and Practitioners Services at East Reach Taunton. Appointments are created in the ORION software system, which is reliant on the MiQuest upload of newly diagnosed patients. All patients are invited to attend for screening within 3 months of the service being notified of a diagnosis. Appointments are sent out 3 weeks prior to the patient's appointment. Data is updated on a daily basis with information taken from the Exeter system for patients who have moved out of area or died. When grading is completed, the patient and the patient's GP are sent the results within 2 weeks.

Patients in the East Mendip area (East of and including Shepton Mallet) should be referred to the Bath retinal screening service for retinal photographs (rbulford@nhs.net).

Those unable to attend for screening should have dilated fundoscopy by a trained operator but all people with diabetes should be very strongly encouraged to take part in the regional quality assured service wherever possible ( http://www.nscretinopathy.org.uk/ )

At annual reviews ask if the patient is up to date with their eye screening.

Taunton & Somerset NHS Foundation Trust, Yeovil District Hospital NHS Foundation Trust and Royal United Hospital, Bath assess and treat patients referred from the screening programme.

COMPLICATIONS

Sexual dysfunction

Management of Erectile Dysfunction

Figure22_large (56K)

Notes:

  1. Erectile Dysfunction (ED) is usually multi-factorial
  2. Organic cause likely if: gradual onset, present in all situations (incl. Waking and self stimulation), lack of tumescence, normal ejaculation, risk factors.
  3. Psychogenic cause likely if: sudden onset, early collapse of erection, normal spontaneous/ waking/ self stimulation erections, premature or absent ejaculation.

Identify treatable causes if possible

  1. Urological causes: e.g. curved penis (Peyronie's disease), pelvic injury, pelvic/prostatic surgery or radiation treatment.
  2. Many drugs can theoretically cause ED but medication changes rarely result in improvement apart from stopping β blockers.
  3. To exclude an endocrine cause check 9am testosterone, SHBG, LH, FSH, prolactin and thyroid function. Refer for endocrine opinion if appropriate.
  4. Effective erections occur after a mean of 8-12 doses of oral phosphodiesterase inhibitors. If any appears ineffective, patient should try the drug on at least eight occasions at the maximum or maximum tolerated dose before abandoning.
  5. PDE5 inhibitors: Sildenafil (Viagra) 25-100mg or Vardenafil (Levitra) 5-20mg. Start at Sildenafil 50mg, Vardenafil 10mg or Tadalafil 10mg and titrate to response and adverse effects as above. If either appears ineffective, try on at least eight occasions before abandoning.

COMPLICATIONS

Obesity management

Guidance to follow.

SPECIAL GROUPS

Diabetes in Women

From adolescence and throughout potential child-bearing years

Figure23 (52K)

The following methods of contraception are generally most suitable for women with diabetes:

  • Mirena coil
  • Cerazette
  • Nexplanon
  • Combined hormonal contraceptives

Pre-pregnancy in women

From adolescence and throughout potential child-bearing years

Figure24 (49K)
  1. There is an increased risk of neural tube effects in babies of women with diabetes. All women planning pregnancy should be given folic acid 5mg once daily (not 400 micrograms) prior to conception and up to 13 weeks gestation.
  2. Advise women to aim for an HbA1c below 43mmol/mol, if safe.
    Inform women that any reduction in HbA1c may reduce risks.
    Advise women with HbA1c above 86mmol/mol to avoid pregnancy
  3. Diabetic retinopathy can worsen in pregnancy, therefore all women must have retinal assessment by digital imaging with Mydriasis using Tropicamide within the six months prior to conceiving.
  4. Medication review
    • Oral hypoglycaemic agents may need to be stopped and insulin started if required. However, NICE guidance allows the use of Metformin (and exceptionally, with informed consent, Glibenclamide) in pregnancy under specialist antenatal care.
    • Angiotensin-converting enzyme inhibitors and Angiotensin-II receptor antagonists should be stopped and alternative antihypertensives started (Labetalol or Nifedipine).
    • Statins should be stopped.

Reference:

NICE clinical guideline 63: Diabetes in Pregnancy (July 2008) http://www.nice.org.uk/nicemedia/pdf/CG063NICEGuideline.pdf

Confirmed pregnancy

Figure25_large (50K)
  1. Advise women to aim for an HbA1c below 43mmol/mol, if safe.
  2. Inform women that any reduction in HbA1c may reduce risks.
  3. Prescribe folic acid 5mg daily and review medications as indicated in pre-pregnancy section.

Reference: NICE clinical guideline 63: Diabetes in Pregnancy (July 2008)

Pregnancy in women at risk of gestational diabetes

Figure26 (37K)

Post natal care

General:

  • Breastfeeding - continue to avoid drugs discontinued for safety reasons.
  • Advise on the importance of contraception and pre-conception care when planning future pregnancies.

Gestational diabetes:
Advise on

  • Weight control, diet / exercise
  • Symptoms of hyperglycaemia
  • Risks of gestational diabetes and need for screening when planning pregnancy.
  • FBG at the six week postnatal appointment, then annually.

Insulin-treated pre-existing diabetes:

  • Encourage frequent monitoring as insulin requirements may change
  • Risk of hypoglycaemia, especially while breastfeeding- often need significant dose reduction
  • Food available before/during breastfeeding
  • Refer back to routine diabetes care.

Type 2 Diabetes:

  • Resume or continue Metformin, Glibenclamide or insulin while breastfeeding. Other oral hypoglycaemic agents to be avoided
  • Refer back to routine diabetes care.

Ophthalmological follow-up

  • Women with preproliferative diabetic retinopathy diagnosed in pregnancy should be offered ophthalmological follow-up for at least six months post partum.

SPECIAL GROUPS

Older People with Diabetes

Diabetes in the elderly and housebound

Figure27 (70K)

Notes:

Diabetes is very common in the elderly; often undiagnosed; up to 25% care home residents have diabetes.

Diagnosing and classifying diabetes

Type 1 Diabetes can have an insidious onset in the elderly. Secondary diabetes can be caused by:

  • Other medication such as steroids
  • Chronic pancreatitis and malignancy

Due to physiological changes in the elderly may not present with classical symptoms. When screening remember the fasting glucose may be normal in undiagnosed diabetes in the elderly.

Diet

Ensure diet is adequate; weight loss may indicate deficient nutrition. Beware of mobile meals only being delivered on week days.

Insulin is used in Type 2 Diabetes to avoid osmotic symptoms, metabolic decompensation, improve cognition and well being.

  • Use an insulin regimen that fits with the individual's lifestyle or is suitable for the carer to manage - discuss with the community DSN.
  • Assess suitability for self care and ensure the individual is safe administering insulin.

Hypoglycaemia may present as

  • "Off legs" or mobility problems, the elderly have poor hypoglycaemia awareness
  • Confusion - acute or chronic
  • Hemiparesis resembling a stroke or TIA, and fitting.

Confusion

Two to three-fold increased risk of dementia in the elderly with diabetes; consider the following possible causes for confusion:

  • Hypoglycaemia, particularly nocturnal
  • B12 deficiency, hypothyroidism, hypercalcaemia, cerebrovascular disease

Management consists of social support for meals and medication, avoid agents with risk of hypoglycaemia if possible and review targets.

Neuropathy

  • Check B12 and TFT as often abnormal in the elderly and can cause neuropathy
  • Treat neuropathic pain (see Page 56 on neuropathy management)

Falls

70% increased risk of fractures in the elderly with diabetes due to falls; assess:

  • Cognition, vision, neuropathy, postural hypotension, hypoglycaemia, Vitamin D deficiency.

Care home diabetes

Diabetes increases the risk of needing residential care. Hypoglycaemia is a risk, particularly on admission, since medication is enforced and dietary intake may be lower. Ensure adequate diet and then treat the plasma glucose. Weight is likely to decline with time as will BP so monitor and adjust medication.

References:

British Geriatrics Society Compendium Diabetes Guidelines; www.bgs.org.uk;
European Guidelines,www.eugms.org/index.php?pid=30;
DUK residential care guidelines,www.diabetes.org.uk/Documents/Reports/guideline_residents.pdf
; Institute for Diabetes in Older People,www.instituteofdiabetes.org www.instituteofdiabetes.org

SPECIAL GROUPS

End of Life Management

Care pathway for Type 1 Diabetes

Figure27_large (47K)

Care pathway for Type 2 Diabetes

Figure28_large (80K)

Notes:

  1. Objectives of care
    1. To prevent symptomatic hyperglycaemia
    2. To prevent diabetic ketoacidosis (DKA) or hyperosmolar non-ketotic state (HONK)
    3. To prevent iatrogenic hypoglycaemia
    4. To prevent unnecessarily invasive interventions in the last weeks to days of life
    5. To recognise that strict glycaemic control and dietary restrictions are not desirable and aim for blood glucose range 5-20 mmol/l.
  2. Clinical teams should recognise and communicate with the patient, carers and staff that the patient with diabetes is entering the final weeks or days of their life, so that care and medical management can be planned.
  3. The appropriate clinical guidance should be selected on the patient's expected prognosis and diabetes type.

SPECIAL GRUOPS

Children and Young People with Diabetes

The arrangements for the care of children with diabetes are currently being reviewed with the aim of developing an integrated care pathway similar to that available for adult care.

The following section will be expanded over the coming year to reflect the outcomes of this review.

Initial assessment and diagnosis

At diagnosis of diabetes, children should always be referred on the same day to Secondary Care (see Referral Pathway Page 79).

Ongoing management

After diagnosis, children and adolescents continue to have their care delivered through secondary care, in line with the Diabetes NSF. The Secondary Care teams provide multidisciplinary input to the care of these patients and their families, with care provided by paediatric diabetes nurse specialists, paediatric dietitians, and medical staff. There is close liaison with CAMHS and Social Services.

The paediatric diabetes nurse specialists undertake home visits, telephone contact and liaison with other professionals involved in a child/adolescent's care, e.g. health visitors, GPs, nurseries, schools.

Children with diabetes are seen in outpatients every 3-4 months at whichever of the three hospitals is the most convenient for the family: Taunton & Somerset NHS Foundation Trust, Yeovil District Hospital Foundation Trust, Royal United Hospital Bath NHS Trust.

The Annual review is undertaken within this clinic setting, with the exception of retinal screening for children aged 12 and above which is undertaken by the digital Retinal Screening programme See Page 60.

Transition to adult services

Transition to adult diabetes services is a planned process, occurring at a time appropriate for the adolescent's individual requirements e.g. educational, developmental and social. This handover process involves close liaison between paediatric and adult services.

Young adults with Type 1 Diabetes who have just transferred to the adult diabetes service should remain under regular review in specialist clinics in secondary care.

Initial assessment and classification of children and adolescents

Figure29 (67K)

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Notes:

  1. The overwhelming majority of children and adolescents present with diabetes have Type 1 Diabetes. Consider Type 2 Diabetes if the child is overweight, has no ketonuria, has little weight loss and/or has acanthosis nigricans. If in any doubt refer urgently to the paediatric diabetes team as for Type 1 Diabetes.
  2. Children and adolescents with Type 2 Diabetes should currently be managed in the specialist diabetes service rather than in primary care clinics. This allows expertise in the management of this small group of patients to be developed and appropriately focused.
  3. Following a child or adolescent's referral to the Taunton & Somerset Trust, Yeovil District Hospital or Royal United Hospital, Bath, they will be seen straight away, assessed and admitted for management and ongoing education. The duration of their admission will be influenced by presence of DKA. Stabilisation on insulin, education from paediatric diabetes nurses and paediatric dietitians and medical staff commences in hospital, but there is an emphasis on early discharge with significant ongoing input once at home.

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Health Promotion Programmes (level 1)

Fresh Steps NHS Health Trainer Service

People who are vulnerable and living in deprived wards who may benefit from 1:1 support and advice to adopt a healthier lifestyle. This service is not available universally.

ProActive Physical Activity Referral Scheme

People who are currently inactive and are in need of additional support and advice to help them to lead a more physically active life can be referred to the ProActive Scheme by selected healthcare professionals such as a GP, dietitian or physiotherapist. Onward referral is to accredited leisure service providers, offering a range of physical activities. Participating leisure providers will have been assessed and recognised by the Somerset Physical Activity Group. Please note there is a cost to the patient for this scheme.

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Community Dietetic Service (level 1)

Type 2

Newly diagnosed not appropriate for DESMOND

  • people with learning difficulties or mental health problems
  • people with complex lifestyle problems
  • people with BMI <18
  • people with complex dietary needs eg diabetes plus another condition requiring dietary intervention
  • people requiring domiciliary/nursing home visits

People who have already received dietary advice for diabetes/ attended DESMOND but continue to require support on making dietary changes

  • people with poor glycaemic control
  • people needing 1:1 weight management advice

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Structured Education Programme- DESMOND (level 2)

Type 2

  • all newly diagnosed people with Type 2 Diabetes (for DESMOND course)
  • people requiring ongoing structured education (programme tbc)
  • people who did not receive structured education at the time of diagnosis (programme tbc)

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Diabetes Specialist Nursing and Dietetics Service (level 2)

Type 2

  • people with sub optimal glycaemic control, not responding to treatment at level 1
  • people who require insulin initiation (see service specification for eligibility)
  • people whose clinical indicators appear to be outside normal parameters

Type 1

  • people who are not currently receiving care at level 3 whose care can no longer be achieved optimally at level 1

Information to be provided at referral

  • Reason for Referral
  • Past Medical History
  • Known Diabetic Complications
  • Medications and Drug Intolerances
  • Last Three BP Readings (systolic and diastolic) and date of reading

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Podiatry Service (level 2)

Type 1 and 2

Patient unable to reach feet to cut toenails (accompanied by carer) - Podiatry Service may refer patient on to Age Concern Somerset toenail cutting service if nails are non pathological
At risk of foot ulcers
  • neuropathy or peripheral vascular disease or foot deformity likely to cause ulceration
At high risk of foot ulcers
  • two or more of following: peripheral vascular disease, neuropathy, foot deformity likely to cause ulcer
  • ulcerated, non-healing (refer to Specialist Lead Diabetes Podiatrist/wound care leads)

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Retinopathy Screening programme (level 2)

Type 1 and 2

annual referral per retinal screening guidance, encouragement from practice to attend

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Psychology Service - Somerset Right Steps Emotional Health and Wellbeing Service (level 2)

Type 1 and 2

  • People suffering from anxiety, stress, depression, obsessive compulsive disorder, sleeping problems

Psychological Therapies - Somerset and Wessex Eating Disorders Association (level 2)

Type 2 and Type 1

  • Eating disorders - anorexia nervosa, bulimia nervosa, compulsive eating, binge eating disorder and all related eating disorders

Psychology Service - Somerset Partnership NHS Foundation Trust (level 3)

Type 1 and 2

  • severe and complex mental health problems;
  • a less severe degree of problem where there are risk behaviours or complex dynamics;
  • requiring specialist intervention;
  • marked behavioural difficulties as a consequence of mental health problem

SUGGESTED REFERRALS

Local referral options and suggested referral criteria are summarised in the following sections.

Specialist Diabetes Services (level 3)

Type 1 - all initially

People needing diagnostic clarification (eg for genetic/auto-immune disorders)

Type 1 and 2

Sub-optimal glycaemic/lipid/blood pressure control where level 2 intervention not appropriate
People with complications:
  • very high risk feet: suspected osteomyelitis (exposed bone/sequestra/deep infection/ulcer probed to bone); suspected Charcot's foot; heat/inflammation/midfoot pain/'crunching' sensation/history of recent trauma
  • people with severe foot deformities, or healed ulcers that need to be maintained, through surgical footwear, supplied by the orthotist at the level 3 appliance department *
  • rapidly declining renal function cf current guidelines (refer direct to renal specialist)
  • complex peripheral vascular disease
  • complex macrovascular disease
  • necrosis
  • eye complications (refer direct to retinopathy services)
People who are planning pregnancy or have become pregnant

*If orthotist employed at level 2 these people could be referred to level 2

DIRECTORY OF SERVICES

The Somerset Diabetes Service is currently provided through a locality structure.

The practice catchment for each of the currently defined localities is provided on Page 85.

The Directory of Services, including contact details for all main services, is set out by locality as follows:

The above locality catchments may change following the transition to GP commissioning.

It is anticipated that patients will prefer to use services closest to where they live but they have the right to take up services located in other localities provided they meet the eligibility criteria.

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