Download diabetic management protocol

The Oakwood Surgery
Clinical Protocols
Type II Diabetes
QoF topic
Author
Date Created
Date Reviewed
Review Date
Dr Dean Eggitt
November 2012
February 2015 (Dr Eggitt and Str Woodland)
February 2016
Diabetes is a serious lifelong condition, so making the diagnosis should not be made
lightly. Features suggestive of diagnosis include
Weight loss
Polydipsia (excessive thirst and drinking)
Polyuria (urinating a lot)
Fatigue
Frequent infections
Family history
If diabetes mellitis is suspected in an adult, then request fasting serum glucose and
HBA1C. Tell the patient that you will contact them with the result. It may be
efficient to also do a FBC, UE, LFT and cholesterol blood test at the saem time as
these will be required for risk stratification if the patient does turn out to have
diabetes.
Please note that children usually present with severe symptoms and should be
seen at the hospital the same day for diagnosis and management. A repeat sample
should not be taken for children < 18 years of age, they should be managed
immediately by the paediatric team if diabetes is a possibility. Failure to do so can
result in death.
Interpreting the results
 RANDOM blood glucose of
 FASTING blood glucose of
 OGTT 2hr result
> 11.1
> 7 (needs repeat)
> 11.1
Diagnosis should not be made on a single result. A fasting glucose should be
repeated to confirm the diagnosis along with a patient history.
When the result comes back through the path links, contact the patient with a phone
call to tell them the result and what this means. The patient should then be booked
in with a nurse who will discuss the diagnosis in more detail and start treatment if
this is indicated.
NEW Diabetes
At the first nurse appointment
1. Explain to the patient what diabetes is and what this means for them
2. Give the patient a leaflet about the condition
http://www.patient.co.uk/health/type-2-diabetes
3. Explain to the patient about the annual review process
a. List for annual retinopathy screening
4. Code the patient as TYPE 2 Diabetes Mellitus
5. If they require treatment, start this
a. Complete the prescription costs exemption certificate
6. Book the patient another appointment in a couple of weeks for a diabetes
annual review
Management
Oral treatment order.
Please remember that each diabetes treatment is quite unique to the patient’s
specific needs. Therefore, this order is a guide and it not prescriptive.
1. METFORMIN unless CI, is the first line choice for diabetes management
(Causes diarrhoea)
a. See protocol for use
2. GLICLAZIDE (Causes hypoglycaemia and weight gain)
a. See protocol for use
OR// Consider FORXIGA (Dapagliflozin 10mg OD) if…
 BMI>28
 Risk or HYPOglycaemia
 Patient does not want to monitor BM’s
 Other concerns regarding weight gain
 NB – reduced efficacy if CKD 3>
 Can be used with Metformin/ Linagliptin / Insulin
 NOT recommended for over 75 years of age
OR// Consider Linagliptin 5mg OD if
 BMI >30,
 Risk or HYPOglycaemia
 Patient does not want to monitor BM’s
 Other concerns regarding weight gain
3. PIOGLITAZONE (Can precipitate heart failure, ALSO increased risk of bladder
cancer)
a. See protocol for use
4. LINAGLIPTIN (Not safe in renal impairment CKD 5)
a. See protocol for use
5. Consider EXENATIDE (Bydureon once weekly)
a. Refer to DE or JW
Diabetic annual review
There is a template for this under OAKWOOD – Diabetes. Please complete the
template. This should be done at least annually and is necessary for QoF.
Blood pressure
Height, weight and body mass index
Signpost for smoking cessation if appropriate
Discuss blood results
- Aim for HBA1C < 7% with diet and exercise control
- Start statin if QRISK2 > 20%
- Start statin if >40 years of age
- see microalbuminuria protocol
Foot examination
- pulses
- sensation
- refer chiropody if needed or provide foot care advice
Discuss annual review process
Discuss annual diabetic retinopathy screening process
Discuss annual influenza / pneumonia vaccination
Arrange for indicated bloods and HBA1C review at 3 months.
Follow up with practice nurse review at 2 weeks following blood
investigations
Appendix - Medications
Metformin
Metformin is the first drug of choice for most patients with diabetes – particularly
those who are overweight where insulin resistance may be a problem. It is not
suitable for those with liver or kidney failure, so a recent UE and LFT should be
reviewed prior to starting the drug (within the last 3 months.)
1. Discuss the use and side effects metformin
2. Start metformin and titrate the dose over a few weeks. It should be taken
with or after food to minimise the common gastrointestinal side effects.
a. 500mg once daily for a week
b. 1g in the morning and 500mg at night for a week
c. 1g twice daily thereafter
3. Check the UE 1 month after starting the metformin to ensure no renal
damage has occurred as a result of starting it. Stop the metformin and
discuss the management with a doctor if the eGFR has dropped by > 5 or if
the eGFR is < 45
Contraindications
Renal impairment
Creatinine >150
eGFR < 30
Liver disease
Alcohol abuse
Heart failure
Advanced arterial disease
Common side effects
Diarrhoea
Heartburn
Abdominal discomfort
Reduced appetite
Reduce the dose or withdraw the drug if the patient is not tolerating the side effects.
If this is the case. Do not forget to document in the patient’s notes the reason for
stopping the drug. If the patient is not tolerating the gastrointestinal side effects of
the Metformin, then consider changing to METFORMIN MR (Glucophage) 500mg OD
and titrate as above.
Notes
Metformin may be used in combination with all other oral agents or in combination
with insulin therapy
Advice patient when initiating treatment to inform DVLA / insurance
Appendix - Medications
Gliclazide
Initially 40-80mg daily adjusted accordingly to response
1. Start GLICLAZIDE at 40mg once daily
2. Explain to the patient how to recognise hypoglycaemia and what to do if this
occurs.
http://www.patient.co.uk/health/dealing-with-hypoglycaemia-low-bloodsugar
3. Give the patient their own blood glucose monitor (whichever is in stock at
the time – we have them in the practice to give away) and teach the patient
how to use it. The patient should check their BM’s before driving and if they
feels hypoglycaemic.
4. Advise the patient to inform DVLA /insurance if not already done so.
5. Review HBA1C at 3 months
Contraindications
Renal impairment
Hepatic impairment
Breast feeding
Try to avoid the use of gliclazide
in patients with BMI >30
in those at risk of complications from HYPOglycaemia (elderly)
in those who do not wish to monitor their BM’s
in those who do not want to gain weight
Common side effects
Nausea
Vomiting
Diarrhoea
Constipation
Weight gain
HYPOglycaemia
Titrating
If HBA1C remains above patient target, then titrate the dose upwards
in increments of 40mg at 3 monthly intervals until the HBA1C target is
achieved or the patient can no longer tolerate the drug.
The maximum dose if 160mg in a single dose, or 320mg spread over a
day.
Appendix - Medications
Pioglitazone
1. Check LFT prior to initiating (within the last 3 months)
2. Discuss the use and side effects of pioglitazone
3. Start PIOGLITAZONE 15mg once daily
4. Review HBA1C and LFT at 3 months
Contraindications
Refer for GP review if the patient has a history of ischaemic heart disease
Heart failure
Osteoporosis
Hepatic impairment
Pregnancy
Breast feeding
Common side effects
Gastrointestinal disturbance
Weight gain
Fluid retention
Anaemia
Headaches
Dizziness
Joint pains
Visual disturbances
Titrating Drug
Ask about side effects, in particular fluid retention, gastrointestinal
disturbances and yellow discolouration of the skin. If any - refer to
GP.
If derangement of the LFT, refer to GP
If HBA1C remains above the patient’s target and the patient is
tolerating the drug, then increase the dose of Pioglitazone by 15mg at
3 monthly intervals until the maximum tolerated dos, a maximum
daily dose of 45mg daily or until the NBA1C target is achieved.
Linagliptin 5mgs OD
Monotherapy
Dual therapy with-
Triple therapy -
Metformin
Gliclazide
Pioglitasone
Insulin
Dapagliflozin
Metformin, Gliclazide
Metformin, Dapagliflozin
Dapagliflozin licence
Monotherapy
Dual therapy with -
Triple therapy with
Metformin
Gliclazide
Gliptin
Insulin
Metformin, Gliclazide
Metformin, Gliptin
Bydureon licence
Monotherapy
Dual therapy with -
Triple therapy with -
Metformin
Gliclazide
Pioglitazone
Metformin, Gliclazide
Metformin, Pio