Download Grampian Guidelines for the Management of Diabetes Mellitus 2011

25 May 2011
Grampian Guidelines for the
Management of Diabetes Mellitus
2011
25 May 2011
Table of Contents
Section A: Classification, Diagnosis Initial Management,
Prevention and Screening ...................................... 5
Section B: Supporting Self-Management ................................ 36
Section C: Glycaemic Control .................................................. 11
Section D: Complications ......................................................... 70
25 May 2011
Introduction
These guidelines are designed to assist everyone involved in the care of
people with diabetes in planning and implementing their own local care plans,
and in dealing with specific common problems. They have been written by
local healthcare professionals in primary and secondary care with the aim of
supporting local practice within Grampian.
They will facilitate the development of a common standard of care for all
people with diabetes in the region, and provide guidance on access to the
various support services that are available.
The purpose of diabetes care is to empower patients to make informed
decisions about their lifestyle, self-management and health choices. Holistic
patient care requires that patients are involved in setting their own realistic
targets.
This 2011 update of the electronic guideline incorporates latest available
information including changes consequent upon the publication of SIGN 116
in 2010.
Useful Websites:
Throughout the Guideline chapters there will be important links to additional
information. A comprehensive list of these websites is available at the end of
the document. Some important websites are included below:
Grampian Diabetes Website
http://www.diabetes.grampian.org
The live version of these Guidelines is available through the Diabetes MCN
website at http://www.diabetes.nhsgrampian and this is a useful website for
diabetes in Grampian in general.
Scotland’s Health on the Web (SHOW)
http://www.show.scot.nhs.uk/
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/
NICE Guidelines – Home Page
http://www.nice.org.uk
My Diabetes My Way
http://www.mydiabetesmyway.scot.nhs.uk
Diabetes in Scotland
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http://www.diabetesinscotland.org.uk/
SCI-DC – home page
https://diabetes.mhs.scot.nhs.uk/Grampian/scidc/
25 May 2011
Section A: Classification,
Diagnosis Initial Management,
Prevention and Screening
A1.0 Types of Diabetes .............................................................................. 6
A2.0 Confirming the Diagnosis and Initial Management ............................... 8
A2.1 Confirming the diagnosis ............................................................. 8
A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l) .................... 8
A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO
2000) ............................................................................... 9
A2.2 Determine the risk of ketoacidosis and likely need for immediate
insulin therapy ............................................................................ 9
A2.2.1 Indications for immediate insulin therapy ........................ 9
A2.2.2 Patients not requiring immediate insulin ........................ 10
A2.3 Check list for recently diagnosed diabetes ................................ 10
A2.3.1 Checklist ....................................................................... 11
A2.4 Impaired glucose tolerance & impaired fasting glucose ............ 12
A2.5 Glycaemic control - management of the newly diagnosed patient:
................................................................................................. 13
A2.6 Performing a 75g Oral Glucose Tolerance Test ........................ 14
A3.0 Prevention of Diabetes .................................................................... 15
A3.1 Background ............................................................................... 16
A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle .. 18
A3.1.2 Key Facts – What is a healthy weight? ......................... 19
A3.1.3 Key Facts – Eating a Healthy Diet................................. 21
A3.1.4 Key Facts - Physical Activity ......................................... 22
A3.1.5 Key Facts: Healthy Lifestyle & Alcohol .......................... 25
A3.1.6 Key Facts: Medicines & Surgery as part of the
management of obesity ................................................. 26
A3.1.7 Sources of advice about how to achieve and maintain a
healthy weight & lifestyle ............................................... 28
A4.0 Screening for diabetes .................................................................... 30
A4.1 UK National Screening Committee (UK NSC) ........................... 30
A4.1.1 Summary of evidence regarding screening for diabetes30
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A1.0 Types of Diabetes
 Type 1 Diabetes: These patients usually present as children or young
adults, but it is important to be aware that they may present at any age. Their
hallmark is insulin deficiency due to autoimmune pancreatic β cell destruction,
resulting in weight loss and the presence of ketones in the urine. Such
patients are prone to ketoacidosis, and once diagnosed should be referred to
the Diabetes Service by telephone for treatment with insulin as a matter of
urgency, although emergency hospital admission is often unnecessary.
 Type 2 Diabetes: Although most present in middle and old age, an
increasing number present at younger ages. Many are obese. Peripheral
insulin resistance combined with relative insulin deficiency accounts for the
pathogenesis. Ketonuria is absent in the non-fasting state. Such patients are
not normally prone to ketoacidosis.
Those at Increased Risk of Diabetes:
 Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance
(IGT). IFG (fasting venous glucose >6.1<7.0mmol/l) and IGT (fasting venous
glucose <7.0mmol/l and 2 hours after OGTT venous glucose >7.8 <11.1
mmol/l) are associated with an increased risk of macrovascular disease and
require aggressive management of cardiovascular risk factors, dietary and
lifestyle advice. A fasting or random glucose level should be measured on an
annual basis to screen for development of diabetes.
 Syndromes Associated With Diabetes
Diabetes Mellitus: can be secondary to other conditions which cause
pancreatic destruction (haemochromatosis, cystic fibrosis, pancreatitis) or
associated with other syndromes which are characterised by insulin
resistance (acromegaly, polycystic ovarian syndrome, Cushing’s syndrome)
and drug therapy, particularly glucocorticoids. The table below illustrates
some of the conditions. It is important to remember that many of these
conditions are rare but a high index of suspicion may be needed to make such
a diagnosis.
Condition
Cushing’s syndrome
When to suspect
Centripetal obesity,
hypertension, hirsutism
Acromegaly
Coarse features,
prognathism, change in
ring / shoe size,
hypertension, sweating
Haemochromatosis
Pigmentation (“bronzed
diabetes”), abnormal
LFTs,
How to screen
First voided morning
urine sample for free
cortisol /creatinine ratio
Consider referral to
Endocrine clinic
Serum ferritin
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Polycystic Ovarian
Syndrome
Chronic pancreatic
destruction
hepatosplenomegaly
Irregular menstruation.
Features of the
metabolic syndrome.
History of alcohol
excess, recurrent
abdominal pain, cystic
fibrosis
Clinical history and
abdominal ultrasound.
Abdominal ultrasound,
amylase, consider
referral to GI specialist
Recognised Genetic Syndromes: including MODY (maturity onset diabetes
of youth), which is characterised by early onset diabetes and often no
requirement for insulin (non-ketotic). Patients are often of normal weight. The
condition is inherited in an autosomal dominant fashion and there is almost
always a family history. Family history is therefore important in people with
diabetes. Website: Diabetesgenes.org
Gestational Diabetes (see Section B 5.4.1) is defined as glucose
intolerance of variable severity with first onset or recognition during
pregnancy. The criteria for diagnosis of gestational diabetes are a fasting
venous plasma glucose of >5.5mmol/l or two hours after OGTT >9mmol/l. If
blood glucose levels are in the range for gestational diabetes specialist
management is needed. In most women the abnormality is reversible post
partum, but up to 50% develop Type 2 diabetes later in life. A small
proportion has coincidental Type 1 diabetes.
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A2.0 Confirming the Diagnosis and Initial
Management
A2.1 Confirming the diagnosis
In the symptomatic individual with dehydration or heavy ketonuria, a
presumptive diagnosis of diabetes may be made on the basis of urinalysis
and/or blood strip testing and urgent referral is likely to be appropriate.
Otherwise it is essential that a diagnosis of diabetes is confirmed before the
patient is advised that he/she has diabetes and before treatment with diet or
any other agent is commenced.
Symptoms of thirst and polyuria or the finding of glycosuria should prompt
blood glucose measurement using a laboratory method. The diagnosis of
diabetes should not be made on the basis of portable blood glucose meter
results alone. The diagnosis can be made on the basis of symptoms (thirst
and polyuria) and one diagnostic blood glucose measurement. The values of
blood glucose indicative of diabetes are as follows;



Random venous plasma glucose ≥ 11.1 mmol/l; or
Fasting plasma glucose ≥ 7 mmol/l; or
Venous plasma glucose ≥ 11.1 mmol/l at 2 hours after a 75g oral
glucose load (the oral glucose tolerance test
In the absence of symptoms the diagnosis is based on two diagnostic blood
glucose measurements on two separate days. On rare occasions therefore a
second oral glucose tolerance test may be needed before a diagnosis of
diabetes can be confirmed.
In the UK the 2000 WHO criteria were adopted from June 2000.
A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l)
Fasting
Venous
≥7.0
Capillary
≥ 7.0
Random
Venous
Capillary
≥ 11.1
≥ 12.2
Diabetic range
5.6 to 11.1
6.5 to 12.2
≤ 5.5
≤ 6.5
Check fasting glucose
Impaired Fasting Glucose
(IFG) - 75g OGTT
required
Borderline - 75g OGTT
required
Diabetes unlikely
≥6.1 to 7.0 ≥6.1 to 7.0
5.6 to 6.0
5.6 to 6.0
≤ 5.5
≤ 5.5
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A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO 2000)
Venous Plasma Glucose (mmol/l)
Fasting
2 Hour
Diabetes Mellitus
≥ 7.0
and/or
≥ 11.1
Impaired glucose
tolerance
<7.0
and/or
≥ 7.8, < 11.1
Capillary Plasma Glucose (mmol/l)
Fasting
2 Hour
Diabetes Mellitus
≥ 7.0
and/or
≥ 12.2
Impaired glucose
tolerance
<7.0
and/or
≥ 8.9, < 12.2
Capillary Whole Blood
Fasting
2 Hour
Diabetes Mellitus
≥6.0
and/or
≥ 11.1
Impaired glucose
tolerance
<6.0
and/or
≥ 7.8, < 11.1
A2.2 Determine the risk of ketoacidosis and likely need for
immediate insulin therapy
The most important decision once the diagnosis has been made is to decide
whether the patient is at risk of ketoacidosis and likely to require immediate
insulin therapy.
A2.2.1 Indications for immediate insulin therapy
 Persistent non-fasting ketonuria/ketonaemia
 Marked weight loss in the normal or underweight patient
 Vomiting and dehydration (will require immediate hospital admission for
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
intravenous therapy).
The initial blood glucose level or presence of primary symptoms of
thirst and polyuria are not good guides as to the need for insulin.
Hospital admission may be avoided in patients who clearly require
insulin, but are not dehydrated or in ketoacidosis, depending on the
logistics of arranging to start insulin at home as an out-patient or daycase on an urgent basis. Such patients should be discussed by
telephone with a member of the diabetes specialist team with a
view to starting insulin within 24 hours. These patients should receive
immediate care from the hospital diabetes team and may be seen or
admitted to hospital depending on the practicalities of starting insulin at
home. Patients with signs of ketoacidosis or dehydration should be
admitted to hospital under the emergency admissions system. Children
under the age of fourteen should be discussed urgently on the
telephone with a paediatrician, and will normally be admitted to
hospital.
A2.2.2 Patients not requiring immediate insulin
The majority of newly diagnosed patients have Type 2 diabetes, and the
management approach can be more relaxed in timescale. The initial blood
glucose level or presence of primary symptoms of thirst and polyuria are not a
good guide as to the long term need for hypoglycaemic drug therapy. Patients
do not normally require oral hypoglycaemic agents until they have completed
at least two or three months on diet alone.
Group education facilities are available at a variety of locations throughout the
region for the initial education of Type 2 patients. All such patients should
initially receive dietary advice aiming to optimise body weight (see diet
section). General advice and the provision of the Diabetes UK diet leaflet is
acceptable for initial management, but all patients should be referred to a
dietitian at an early stage for more detailed and personalised advice.
2
Obese patients (BMI > 30kg/m ) inadequately controlled after a trial of diet but
showing evidence of weight loss may be left on diet alone as glycaemic
control is likely to continue to improve. Overweight and obese patients (BMI
>25) not achieving weight loss may be most appropriately treated with
metformin (section 3) in a low starting dose to minimise gastrointestinal side
2
effects. Patients not overweight (BMI ≤ 25kg/m ) but inadequately controlled
may be commenced on a sulphonylurea (section 3.1). Employment and social
issues may also influence the choice of treatment.
A2.3 Check list for recently diagnosed diabetes
Once the immediate issue of glycaemic control has been addressed it is
important to consider further educational topics and to ensure an adequate
physical examination for detection of established complications, which are
often present at diagnosis in Type 2 patients. The following checklist is
suggested for completion over the first few clinical contacts.
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A2.3.1 Checklist
Comment/Recording
INITIAL
Decide on initial blood glucose management
and need for immediate insulin or otherwise
Provide initial dietary advice and arrange for
referral to a dietitian
CLINICAL RECORDINGS
Record weight and BMI
Blood pressure
Urinalysis for protein and ketones and glucose
Consider causes of secondary diabetes, see
Section A1 - Types of Diabetes
PODIATRY
Examine feet for signs of neuropathy,
peripheral vascular disease or active lesions.
Risk calculation available on SCI-DC.
Provide foot care information
Decide on need for referral to a podiatrist
RETINAL SCREENING
Perform, arrange and/or discuss need for
adequate retinal examination
Record visual acuity (pinhole corrected if
worse than 6/9)
Register with DRS programme.
LAB TESTS
Arrange biochemical assessment; serum
creatinine, LFTs, lipid profile, thyroid function,
HbA1c
Early morning urine for albumin/creatinine ratio
(microalbumin screen)
RISK
Record smoking status and advise as
appropriate
Assess cardiovascular risk status (smoking,
BP, family history, lipids,
proteinuria/microalbuminuria, established
Date/Signed
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macrovascular disease)
Consider ECG to assess evidence of previous
MI or left ventricular hypertrophy
FURTHER EDUCATION/MANAGEMENT
Decide on appropriate patient self monitoring
Determine individualised blood glucose
treatment targets
Discuss hypoglycaemia and its management
in all insulin and sulphonylurea treated patients
Provide support literature and web sites
Cover selected topics from the education
checklist with the patient and relevant
individuals
Discuss driving/DVLA/insurance
Consider referral to a Diabetes Specialist
Nurse or hospital diabetes clinic
Ensure patient is registered with practice and
regional diabetes register
A2.4 Impaired glucose tolerance & impaired fasting glucose





These patients, like those with established diabetes, have an increased
risk of macrovascular disease and require assessment and aggressive
management of cardiovascular risk factors, dietary and lifestyle advice
– See Section D2.0 and Section B3.5 Smoking and Diabetes.
Patients with impaired fasting glucose (IFG) (≥ 6.1mmol/l, <7.0mmol/l)
should have a 75g OGTT as some will fulfil the criteria for diabetes
mellitus on the two hour value.
Patients with IGT & IFG could be entered into the practice diabetes
register.
Five per cent per year may go on to develop Type 2 diabetes and will
then need appropriate diabetes care.
A fasting or random blood glucose level should therefore be measured
on an annual basis, or earlier in the event of symptoms in people with
IGT or IFG and the results interpreted according to Section A2.1.1.
Although not diagnostic an HbA1c level can give further information.
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A2.5 Glycaemic control - management of the newly diagnosed
patient:
Algorithm for management of the newly diagnosed patient
Newly diagnosed diabetics
Clinically unwell – vomiting,
dehydrated or suspected
acidosis
Yes
No
Heavy Ketonuria
Yes
Marked unintentional weight loss
No
No current indication for
insulin therapy
Lifestyle advice e.g. start on diet
Self-monitoring if appropriate
4 – 6 weeks later –
Adequate control
Yes
No
Continue diet
for 4 weeks
Yes
Improving
Control
No
Yes
Can dietary compliance be
improved?
No
Overweight
BMI >25
Yes
No
Diet &
Metformin
Diet &
Sulphonylurea
Diet
alone
Seek
experienced
advice re.
insulin therapy
within 24 hours
Emergency
admission
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A2.6 Performing a 75g Oral Glucose Tolerance Test
Indications for this test are discussed in Section 2. It can easily be performed
in primary care but a standardised protocol must be followed and laboratory
glucose analysis must be used. This test should not be performed during
intercurrent illness. On rare occasions two oral glucose tolerance tests may
need to be performed before a diagnosis of diabetes can be confirmed.
The patient should maintain an adequate carbohydrate intake (> 150g) for at
least three days prior to the test.
Fast overnight for a minimum of 10 hours (water only permitted).
75 g oral glucose dissolved in 250 to 300 ml water to be consumed in no more
than 5 minutes followed by a further 100 ml water.
Acceptable alternatives are;


Lucozade Energy Original 410 ml (73kcal/100 ml formulation)
Maltodextrins in appropriate volume to provide 75g carbohydrate (e.g.
Calsip 150 ml)
Blood for glucose estimation to be taken before (zero minutes) and 120
minutes after consumption of the drink.
Urine may also be tested for glucose to estimate the renal threshold, but this
does not contribute to the diagnosis of diabetes, which is based on the fasting
and two-hour blood glucose results.
The method of blood sampling is important and must be specified: venous or
capillary, plasma or whole blood.
Venous plasma is most commonly used. (Aberdeen Diabetes Clinic uses
whole blood capillary glucose).
The patient should remain sedentary and not smoke, eat or drink for the
duration of the test.
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A3.0 Prevention of Diabetes
A Healthy Weight – Summary
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A3.1 Background
In Grampian, there are currently more than 23,000 individuals with diabetes.
500 new people with diabetes were notified to the register in the last six
months alone. Type 2 diabetes accounts for 86.6% of cases. While the
cause of Type 1 diabetes is unknown, Type 2 diabetes mellitus is closely
associated with being overweight or obese. Over 80% of people with
diabetes in Scotland are obese or overweight.1
Prevention
Helping people to maintaining or achieve a healthy weight is the key
opportunity for prevention of diabetes. Approximately two out of every three
people in Scotland are overweight or obese. One in five is obese. One in
three children (under the age of 15) is overweight or obese. A ‘typical’ NHS
general practice with a list size of 6000 will have approximately 1200 adults
who are obese (BMI ≥ 30 kg/m2), and 50 adults who have severe obesity (BMI
≥ 40 kg/m2).2
Obesity is not just a consequence of an unhealthy lifestyle but is a disease
and a risk factor for other diseases. In adults, obesity is associated with an
increased risk of Type 2 diabetes, coronary heart disease, hypertension,
many cancers and osteoarthritis (see table 1).
Table 1: Risk of other diseases in obese adults2
Disease
Type 2 diabetes
Hypertension
Heart attack
Colon cancer
Angina
Gall bladder disease
Ovarian cancer
Osteoarthritis
Stroke
Relative risk
Women
Men
12.7
5.2
4.2
2.6
3.2
1.5
2.7
3
1.8
1.8
1.8
1.8
1.7
1.4
1.9
1.3
1.3
If you are male and obese you are 5 times more likely to develop diabetes
than if you were at a healthy weight; if you are female and obese, your risk is
increased 13 times.
If you lose weight you can not only improve the control and management of
your diabetes, reducing the need for insulin injections but, 2/3rds of Type 2
diabetes mellitus can be prevented by lifestyle and diet modification.3 You will
also reduce your risk of heart disease.
1
National Overview Follow up Report: Diabetes-March 2008, Diabetes UK & NHSQIS
NICE Guideline 43: Obesity NICE 2007
3
The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management, UK NSC 2007
2
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Screening for diabetes
Type 1 diabetes has a sudden onset and people present early for care but
because Type 2 diabetes has a gradual onset and presents with vague
symptoms, it can go unnoticed for many years. At the moment, an estimated
90001 people in Grampian may have Type 2 diabetes but will not know yet,
and they will not be known to healthcare teams. Diabetes can be detected by
a blood test and may be identified as an incidental finding or as part of
general health reviews by GPs, practice nurses or, increasingly, by
pharmacists.
Structure
This section of the guidelines aims to provide a summary of advice regarding:
 the prevention of Type 2 diabetes through the achievement & maintenance
of a healthy weight & lifestyle
 Screening for Type 2 diabetes
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A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle
NHS Grampian strategic framework for Healthy Eating, Active Living and
Healthy Weight (HEAL)
The NHS Grampian HEAL strategic framework is built on the policy context
set out in the ‘Better Health Better Care’ action plan4, which sets both nutrition
and physical activity firmly alongside healthy weight and also the national
action plan for Healthy Eating, Active Living and Healthy Weight 5.
This framework also builds on learning associated with the implementation of
existing policy including the Scottish Diet Action Plan6 and the National
Physical Activity Strategy7.
Nationally, obesity is also one of six priority areas which form part of the
health improvement performance management framework. Partners in
Community Planning Partnerships and Local Authorities are being
encouraged to include relevant outcomes and indicators focusing on healthy
eating and physical activity in Single Outcome Agreements.
Preventative work can be undertaken at three levels:



universal or public health prevention directed at everyone in a
community with the aim of stabilising or reducing the mean BMI in a
population
selective prevention directed at high-risk individuals or groups
targeted or secondary prevention, directed at those with existing
weight problems to prevent further weight gain and/or decrease body
weight
It is the combined effect of a wide range of interventions that is likely to make
the greatest impact.
The HEAL Framework makes a number of recommendations including the
development and implementation of a Grampian-wide integrated,
standardised approach for both adult weight management (including primary
care, specialist nutrition clinic and bariatric services) and child obesity. This
work is currently underway.
Implementation of the Integrated Care Pathway is happening in a staged
manner and now includes referrals to the ‘Healthy Helpings’ weight
management programme from the Diabetes Group Education Programme.
‘Healthy Helpings’ is a group based eight week weight management lifestyle
4
Better Health Better Care Action Plan http://www.scotland.gov.uk/Publications/2007/12/11103453/0
Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity
(2008- 11)
http://www.scotland.gov.uk/Publications/2008/06/20155902/0
6
Eating for Health: A Diet Action Plan for Scotland (1996)
http://www.scotland.gov.uk/Topics/Health/health/19133/17710
7
Physical Activity Task Force. Lets make Scotland more Active. A strategy for Physical Activity. Crown Copyright,
Edinburgh 2003. www.scotland.gov.uk/library5/culture/lmsa-00.asp
5
25 May 2011
intervention designed to support individuals to achieve and maintain a
healthier weight.
Factors affecting a person’s ability to maintain a healthy weight or lose
weight
Behavioural changes that include healthier eating, increased physical activity
and weight management would make an enormous difference to the burden
of chronic disease in Grampian. However, many people find it difficult to
implement healthy behaviours and maintain a healthy weight.
This is unlikely to change so long as the environmental factors that subtly
influence the daily decisions that lead to energy imbalance and weight gain
remain unaddressed.
In order to make a difference to the problem is important therefore to tackle
both individual behaviour and the environmental factors beyond an
individual’s control that influence their behaviour, through both a targeted and
population approach.
An environmental approach challenges the commonly held perception that an
individual’s behaviour and weight is simply a matter of personal responsibility
or indeed individual choice.
Many factors could therefore be affecting a person’s ability to stay at a healthy
weight or succeed in losing weight.
Barriers to lifestyle change should be explored:








lack of knowledge about how diet, exercise and sedentary
behaviour affect health, energy balance, food portion sizes
and buying and cooking food
the cost and availability of healthy foods and opportunities for
exercise
safety concerns, for example about cycling
lack of time
personal tastes
the views of family and community members
low levels of fitness, or disabilities
low self-esteem and lack of assertiveness.
Motivation: people choose whether or not to change their lifestyle or agree
to treatment. An individual’s readiness to alter their lifestyle can be enhanced
by engaging in a collaborative conversation about behaviour change. The
type of questions that could be asked to encourage client engagement
includes:
In what ways would it be good for you to…..?
If you decide to… how would you do it?
What would be the good things about…..?
Why would you want to……?
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If you don’t make any change what do you think will
happen?
Where would you like to be in…..years?
Tailored advice: Advice needs to be tailored for different groups. This is
particularly important for people from black and minority ethnic groups,
vulnerable groups (such as those on low incomes) and people at life stages
with increased risk for weight gain (such as during and after pregnancy, at the
menopause or when stopping smoking).
Children: treating children for overweight or obesity may stigmatise them and
put them at risk of bullying, which in turn can aggravate problem eating.
Confidentiality and building self-esteem are particularly important if help is
offered at school. It is important to consider these factors when supporting
people to maintain or achieve a healthy weight.
A range of services exist within Grampian where people can seek
opportunities to lose weight, improve their understanding of nutrition and
participate in physical activity. Patients can be referred, or self refer, to
Healthpoint to obtain health improvement advice, support and sign posting to
local services and facilities. In the next section, there are a series of key facts
and links to resources.
A3.1.2 Key Facts – What is a healthy weight?
Maintaining a healthy weight is important for many health conditions including
diabetes mellitus. A healthy weight is often defined by BMI (body mass index)
– this is a measure of weight taking into account a person’s height.
BMI
Underweight:
<18.5
Healthy weight:
18.5 -24.9
Overweight:
Obesity, class I
Obesity, class II
Obesity, class III
25.0-29.9
30.0-34.9
35.0-39.9
≥40
A BMI of 18.5 to 24.9 means that adults are a healthy weight for their height.
However, this is general advice for adults only. It does not apply to children,
pregnant women or women who are breastfeeding. Also, BMI may not be
accurate if the person:

does a lot of weight-training and is very muscular,

has a long-term health condition.
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A3.1.3 Key Facts – Eating a Healthy Diet








Base your meals on starchy foods that include breads, rice, potatoes
and pasta
Eat lots of fruit and vegetables
Eat more fish
Cut down on saturated fat and sugar
Try to eat less salt – no more than 6g a day
Get active and try to be a healthy weight
Drink plenty of water
Don’t skip breakfast
As an example, the following Healthy Eating leaflets are available at the
Healthpoint (in Aberdeen and Peterhead) and through Health Information
Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
Your Guide To Healthy Eating
The Balance of Good Health
The following websites provide useful sources of information about diet and
healthy eating:
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Take Life On – One Step At A Time
NHS Choices – Live Well Healthy Eating provides lots of guidance about
nutrition and healthy eating as well as diet related health issues
(obesity, diabetes).
A3.1.4 Key Facts - Physical Activity
Being physically active is important for health and contributes to maintaining a
healthy weight.
What Are The Benefits of Physical Activity?
 Helps to maintain an energy balance by increasing energy expenditure
(burning calories) and can help use up stored fat
 Builds muscle which will speed up metabolic rate. This increases the
amount of calories burnt even when the person is not exercising
 Reducing the amount of stored fat will help reduce the risk of
developing high blood pressure, diabetes and having a heart attack or
stroke
 Reduces the risk of certain cancers, osteoporosis, falling, levels of
stress and improves the person’s overall feeling of well-being and
quality of life
 If the person has diabetes, physical activity will help to maintain good
blood glucose control
How Much Physical Activity Should You Take?
The minimum recommended levels of physical activity to maintain good
health:
Adults should build up to at least 30 minutes of moderate intensity
activity on 5 or more days of the week.
Children to build up at least one hour of moderate intensity activity on 5
or more days of the week.
Moderate intensity means breathing a bit deeper, feeling warmer,
perhaps sweating a bit, but still able to carry out a conversation.
25 May 2011
Making It Happen - it is often perceived to be difficult fit activity into the day.
Here are some suggestions about how to do it (NICE guideline 43).
In Adults
Set realistic goals – don’t worry if the odd day is missed but try to make sure
physical activity is part of everyday life
Encourage the person to select activities that they enjoy – such as walking,
cycling, swimming, aerobics and gardening
Minimise sedentary activities, such as sitting for long periods watching
television, at a computer or playing video games.
Build activity into the day – for example, get off the bus a stop earlier and
walk, take the stairs instead of the lift, take a walk at lunchtime.
In Children
Encourage active play – for example, dancing and skipping.
Try to be more active as a family – for example, walking and cycling to
school and shops, going to the park or swimming.
Gradually reduce sedentary activities – such as watching television or
playing video games – and consider active alternatives such as dance,
football or walking.
Encourage children to participate in sport or other active recreation, and
make the most of opportunities for exercise at school.
Safety First!
 Seek advice from GP or practice nurse before starting an exercise
programme
 Start exercising slowly and build up to the recommended levels
 Wear appropriate clothing and footwear
 Stop exercising if you feel dizzy or unwell
Contacts and Further Information
Details of physical activity opportunities and leisure facilities in your area can
be found on the local authority websites:
Aberdeen City Council
Aberdeenshire Council
Moray Council
Click on heading ‘Sports and
Leisure’
Quick Links – ‘Sport and
Recreation’
click on heading ‘Leisure’
(contact details of local Active School Co-ordinators can also be found on
these sites)
25 May 2011
As an example, the following Physical Activity leaflets are available at the
Healthpoint (in Aberdeen and Peterhead) and through Health Information
Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
Get Active!
Hassle Free Exercise
Physical Activity and Weight Loss
Physical Activity and Diabetes
(British Heart Foundation)
(Health Scotland)
(HealthEx)
(HealthEx)
25 May 2011
A3.1.5 Key Facts: Healthy Lifestyle & Alcohol
Drinking alcohol regularly above the recommended guidelines has a number of
negative consequences for personal health and lifestyle:

Drinking to excess is linked with a rise in blood pressure. High blood pressure
increases the risk of heart disease and stroke

Drinking alcohol is the second biggest risk factor for cancers of the mouth and
throat. Drinking too much also increases risk of breast cancer

Excessive use of alcohol is linked to liver disease where alcohol turns some
liver cells into fat and damages others. Repeated heavy drinking scars the
liver (liver cirrhosis) and causes permanent damage which can lead to death

Even small amounts of alcohol can prevent the deep sleep we require to feel
alert and refreshed

Alcohol dehydrates the body, and this is partly responsible for ‘hangover’
symptoms

Alcohol is high in calories and therefore can contribute to weight gain; regular
mixers and some alcoholic drinks contain a lot of sugar

Alcohol should be avoided during pregnancy or if trying to conceive

Misuse of alcohol can in some cases lead to dependency and have adverse
effects on social networks and social functioning

Alcohol reduces inhibitions and affects decision making increasing risks from
preventable accidents (e.g. personal safety, sexual health and drink-driving)

There are no recommended drinking guidelines for children and young
people

Drinking regularly to excess with the purpose of getting drunk, or ‘storing up’ a
large number of alcohol units (weekends), is 'binge' drinking and increases
all of the above risks to health
A3.1.5.1 What is a unit of alcohol?
25 May 2011
1 Unit equals 10ml of pure alcohol.
Units = Volume (mls x % (ABV)
1000
35ml measure
of spirits (whisky, vodka, gin, rum etc)
1.4 units
330ml standard bottle lager/beer
1.7 units
1 pint of medium strength
lager/beer
2.8 units
1 pint of standard lager/beer
1 pint of strong cider
275ml bottle alcopop
One 175ml (standard) glass
of red wine
750ml bottle wine
Recommended Guidelines:
2.3 units
3.4 units
1.5 units
2.1 units
9.8 units
Women: No more than 2-3 units a day and no more than 14
units in one week
Men: No more than 3-4 units a day and no more than 21
units in one week
We all need at least 2 alcohol-free days per week
It takes approximately 1 hour for the body to safely process
1 unit of alcohol.
For more detailed information see SIGN Guideline 74 “The management of harmful
drinking and alcohol dependence in primary care” (2003).
For further detailed information, the following Alcohol Advice Leaflets are available
at the Healthpoint (in Aberdeen and Peterhead) and through the Health
Information Resource Service at Summerfield House, Aberdeen (Tel: 01224
558504).
What's in a Unit?
Sensible Drinking
Alcohol & Healthy Living
Alcohol & Stress
Women & Alcohol
Recognising Problem Drinking
A3.1.6 Key Facts: Medicines & Surgery as part of the management of obesity
Pharmacological treatment should be considered only after dietary, exercise
and behavioural approaches have been started and evaluated.
Drug Therapy
25 May 2011
Drug treatment should be considered for adults who have not reached their
target weight loss or have reached a plateau on dietary, activity and
behavioural changes alone and who have:


a BMI of 27.0 kg/m2 or more with associated risk factors
a BMI of 30.0 kg/m2 or more.
The decision to start drug treatment, and the choice of drug, should be made
after discussing with the patient the potential benefits and limitations. Drug
treatment should be offered only as part of a package of care and support.
Children
Medicine treatment is not generally recommended for children younger than
12 years. Treatment should be started in a specialist paediatric setting, by
multidisciplinary teams with experience of prescribing in this age group.
Surgical Therapy
Bariatric surgery is recommended as a treatment option for people with
obesity if all of the following criteria are fulfilled:





they have a BMI of 40 kg/m2 or more, or between 35 kg/m2
and 40 kg/m2 and other significant disease (for example,
Type 2 diabetes or high blood pressure) that could be
improved if they lost weight
all appropriate non-surgical measures have been tried but
have failed to achieve or maintain adequate, clinically
beneficial weight loss for at least 6 months
the person has been receiving or will receive intensive
management in a specialist obesity service
the person is generally fit for anaesthesia and surgery
the person commits to the need for long-term follow-up.
Children
Surgical intervention is not generally recommended in children or young
people. Bariatric surgery may be considered for young people only in
exceptional circumstances, and if they have achieved or nearly achieved
physiological maturity.
Only a multidisciplinary team that can provide the necessary expertise and
support should undertake surgery for obesity.
For more detailed information: NICE Guideline 43: Obesity (2006) & SIGN
115.
25 May 2011
A3.1.7 Sources of advice about how to achieve and maintain a healthy weight &
lifestyle
Below are some useful sources of advice about achieving and maintaining a
healthy weight and lifestyle.
For Everyone
Sources of information within Grampian
Healthpoint offers free advice and information on:






practical ways to improve your health;
your health concerns;
support groups and organisations;
how to access NHS services;
jobs in the NHS;
access to free condoms
Healthline is a free, confidential, telephone line that provides healthpoint
information.
Available: Monday - Friday 9.00am - 5.00pm.
Phone the free Healthline number on 0500 20 20 30
NHS Grampian website provides details of local sources of advice and
contacts for further information about healthy active living. Follow the links to
“About NHS Grampian” then “health improvement” and then select
“healthy living”.
Other sources of information
Take Life On – One Step At A Time provides a user friendly guide to healthy
eating and physical activity for all.
NHS Inform for a one-stop shop to quality assured health information for
patients, carers and the public.
Health Scotland provides information to support health improvement in
Scotland. It includes is information about food and nutrition and physical
activity.
NHS24 provides comprehensive up-to-date health information and self care
advice for people in Scotland.
NICE, the National Institute for Health and Clinical Excellence, has issued
new guidance to the health service about how to prevent obesity. This is a
summary of the evidence presented for the public (Preventing obesity and
staying a healthy weight).
NICE, the National Institute for Health and Clinical Excellence, has issued
new guidance to the health service about how to treat and manage
overweight & obesity. This is a summary of the evidence presented for the
public (Treatment for people who are overweight or obese).
25 May 2011
Active Scotland – find leisure activities by postcode.
For Healthcare Professionals
In addition to the resources above you can find more information here:
Sources of information in Grampian
Supporting the Professional: Several services provided by Public Health
work together under the ‘Supporting the Professional’ heading.
Health Information Resource Service can provide free information leaflets
and other resources for a range of topics – a few are recommended below.
Recommended leaflets:
Diet: Eating for Health; Hassle Free Food, Strive for 5; NHSG
Your Guide to Healthy Eating’
Alcohol: Sensible Drinking, Alcohol & Healthy Living
Physical Activity: The ‘Active Living’ series; Hassle Free
Exercise
The service can be accessed by telephone: 01224 558504 (ext. 58504), fax:
01224 558630 (ext. 58630), and email: [email protected]
However, the main access point is via the Health Information Resource
website as this is the service’s catalogue, as well as allowing online orders.

Refer a patient to Healthpoint – for advice, support and direction to
local services. You can refer a patient by using the “Healthpoint
referral pads” which can be ordered from Resources
([email protected]).
.
The Grampian Health Improvement Network (Hi-Net) provides a web based
resource full of health improvement information. You can access:
Physical Activity Strategy and Action Plan
Focus is Grampian’s Nutrition Health Promotion Strategy
Grampian Healthy Weight Strategy
Other sources of information
SIGN 115 – A new SIGN Guideline on Obesity was launched in spring 2010.
NICE 43 (Full Guideline – Obesity) – includes guidance on prevention of
obesity, lifestyle advice and interventions for the treatment of overweight and
obesity, and medical or surgical interventions.
25 May 2011
A4.0 Screening for diabetes
A4.1 UK National Screening Committee (UK NSC)
The UK National Screening Committee is chaired by the Chief Medical Officer
for Scotland and advises Ministers and the NHS in all four UK countries about
all aspects of screening policy and supports implementation. Using research
evidence, pilot programmes and economic evaluation, it assesses the
evidence for programmes against a set of internationally recognised criteria.
Assessing programmes in this way is intended to ensure that they do more
good than harm at a reasonable cost. In 1996, the NHS was instructed not to
introduce any new screening programmes until the UK NSC had reviewed
their effectiveness.
More information about the UK NSC can be obtained here
(http://www.nsc.nhs.uk).
More information about the criteria used by the NSC to judge whether to
introduce a screening programme can be found here
(http://www.screening.nhs.uk/criteria).
A4.1.1 Summary of evidence regarding screening for diabetes
There have been no national screening programmes in place for:



Diabetes
Impaired Glucose Tolerance (IGT)
Obesity
March 2008) saw the publication of the “Handbook for Vascular Risk
Assessment, Risk reduction and Risk Management” A report prepared for
the UK National Screening Committee to, as outlined in a Press statement by
Dr Anne Mackie, Director of the NSC, “help us identify what is desirable, and
realistic, to provide…and inform primary care and public heath professionals
who are already providing risk assessment and risk management.”
It provides an interesting summary of the evidence and suggested ways
forward for incorporation of screening and intervention for the main vascular
risk factors including obesity and diabetes.
You can access the document here
(http://www.screening.nhs.uk/vascular/VascularRiskAssessment.pdf).
During 2010, the Scottish Public Health network published a draft document
on the prevention of and screening for Type 2 diabetes in Scotland. The draft
report has advised that HbA1c be used as the preferred screening test for
diabetes. This approach has been cleared by the National Screening
Committee as being consistent with the vascular screening programme
across the rest of the UK and with international work. The best alternative is
25 May 2011
fasting glucose. Random blood glucose is not recommended for screening for
diabetes and SIGN Guideline 97 on risk estimation and prevention of
cardiovascular disease should be updated accordingly. Random glucose
measurement remains a satisfactory way of confirming a clinical diagnosis in
a symptomatic patient. The report has also recommended that in
asymptomatic individuals an HbA1c ≥ 48 mmol/mol (6.5%) should be
repeated. A repeat level of ≥ 48 mmol/mol confirms Type 2 diabetes mellitus.
Those with an elevated HbA1c ≥39 mmol/mol (5.7%) but not meeting
diagnostic criteria for diabetes should be classified as having non-diabetic
hyperglycaemia (NDH) and should be offered intensive lifestyle intervention.
In those with initial HbA1c <39 mmol/mol screening with an HbA1c should be
repeated every five years as part of cardiovascular screening. These
recommendations are under review (November 2010). This section will be
updated as further information becomes available.
25 May 2011
APPENDIX 1: HEALTHPOINT & HEALTH LINE
Healthpoint is a walk in service which offers free and confidential advice and
information from trained staff on a wide range of topics:
 practical ways to improve your health;
 your health concerns;
 support groups and organisations;
 how to access NHS services;
 jobs in the NHS; access to free condoms
Visit healthpoint at:
Aberdeen Indoor Market (In Shops)
8 - 10 Market Street
Aberdeen
Open Monday to Saturday 10.00am to
4.00pm
This healthpoint is manned by trained staff
Healthpoint information is also available at:
Aberdeen Royal Infirmary Concourse
David Anderson Building, Foresterhill Road
Torry Neighbourhood Centre
The Point, St Nicholas House
Dr Gray's Hospital, Elgin
Healthy Hoose, Middlefield
Lhanbryde Community House
Denburn Health centre, Aberdeen
ASDA Pharmacy, Portlethen
Baird's Pharmacy, Huntly
Tarland Pharmacy, Tarland
Summers Chemist, Fraserburgh
Marywell Healthcare centre, Aberdeen
Buchanhaven Pharmacy, Peterhead
& SCP Management Unit at Spynie, Elgin
Denburn Health Centre, Aberdeen
Please note that these healthpoints are unmanned.
Alternatively, you can contact the healthpoint team for information by email:
[email protected] or call on the free Healthline on 0500 20 20 30
25 May 2011
Healthline is a free local telephone line available Monday - Friday 9.00am 5.00pm. Any information requested is sent by post free of charge. All calls
are confidential and are answered by trained health advisers.
You can access these services with or without referral from a healthcare
professional.
25 May 2011
APPENDIX 2: Measuring overweight & obesity
Adults BMI (body mass index)
To take account of the expected differences in weights in adults of different
heights, an index of weight-for-height has been devised as the BMI. This is
calculated as:
BMI = Weight (Kg)/Height (m2)
Example: An adult of 70 kg with a height of 175 cm has a BMI of:
BMI = 70 (Kg)/1.75 x 1.75(m2) = 22.9
Interpreting BMI
Underweight:
<18.5
Healthy weight:
18.5 -24.9
Overweight:
Obesity, class I
Obesity, class II
Obesity, class III
25.0-29.9
30.0-34.9
35.0-39.9
≥40
Waist circumference
Excess abdominal fat carries particularly elevated health risks. Waist
circumference is the most practical marker of abdominal fat. (Many people
understand this concept as ‘apple’ versus ‘pear’ shaped.). If the BMI is <35
then waist circumference is a useful marker for additional health risks.
Interpreting the waist circumference:
Substantially increased
risk
Men >102 cm (~40 inches)
Women > 88 cm (~35
A waist circumference of less than 94cminches)
in a man, and less than 80 cm in a
Increased risk
Men > 94 cm (~37 inches)
Women > 80 cm (~32
inches)
woman, means that their abdominal fat accumulation is not excessive.
Children
Body mass index (BMI) (compared to a reference population of children of the
same age and sex) is recommended as a practical estimate of overweight and
obesity in children and young people, but needs to be interpreted with caution
because it is not a direct measure of fat tissue.
For clinical use, SIGN recommends that obesity should be defined as those
with a BMI >=98th centile of the UK 1990 reference chart for age and sex. For
overweight, a BMI >=91st centile should be used.
25 May 2011
For more detailed information see SIGN Guideline 115.
25 May 2011
Section B: Supporting SelfManagement
B 1.0 Structured Review Schedules ....................................................... 37
B1.1 Regular Review Schedules ....................................................... 37
B1.2 Every structured diabetic review ............................................... 37
B1.3 Content of Annual Checks ........................................................ 38
B 2.0 Education ........................................................................................ 38
B2.1 Newly Diagnosed Diabetes ...................................................... 39
B2.2 Ongoing Diabetes Management ............................................... 40
B2.3 Diabetes Courses & Resources ............................................... 42
B3.0 Lifestyle ........................................................................................... 43
B3.1 Driving ....................................................................................... 43
[DVLA website: www.dvla.gov.uk] ..................................................... 47
B3.2 Occupations .............................................................................. 48
B3.3 Physical Activity ........................................................................ 51
B3.4 Psychological Wellbeing ........................................................... 55
B3.4.1 Introduction ................................................................... 55
B3.4.2 Depression .................................................................... 55
B3.4.3 Anxiety .......................................................................... 55
B3.4.4 Screening for Anxiety and Depression .......................... 56
B3.4.5 Other Psychological Issues ........................................... 56
B3.4.6 Behaviour Change ........................................................ 58
B3.5 Smoking .................................................................................... 61
B3.5.1 Smoking cessation ........................................................ 61
B3.6 Travel ........................................................................................ 62
3.6.1 Travel Letter for Patients Using Insulin ............................ 63
B4.0 Information Technology .................................................................. 65
B4.1 Appendix 1 – SCI-DC Back-Population: Diabetes-Related GMS
Contract Indicators ................................................................... 76
B5.0 Contraception, Pregnancy and the Management of Gestational
Diabetes Mellitus ............................................................................. 81
B5.0.1 Patient information ........................................................ 81
5.0.2 Introduction ...................................................................... 81
B5.1 Contraception ............................................................................ 82
B5.2 Planning pregnancy .................................................................. 83
B5.3 Confirmed pregnancy ................................................................ 84
B5.4 Management of Gestational Diabetes ....................................... 86
B5.4.1 Follow up of Patients with Previous Gestational Diabetes
...................................................................................... 88
B6.0 Children’s Services ......................................................................... 89
25 May 2011
B 1.0 Structured Review Schedules
B1.1 Regular Review Schedules
Patient empowerment through education to encourage optimal selfmanagement should be central to each review. Regular review of individuals
with diabetes should address both metabolic control and diabetic complication
screening. Reviews will involve metabolic management, education, health
promotion, and detection and management of diabetic complications. This
care must be structured, locally agreed and documented and may involve a
variety of professionals in various locations carrying out different parts of this
programme.

Interim metabolic and troubleshooting checks at three to six month
intervals are usually appropriate.

Systematic screening for the early detection of the microvascular
and associated macrovascular complications of diabetes is also an
essential component of structured diabetes care.

Effective interventions are available at an early or latent stage of the
disease processes which can slow or prevent further progression,
and which would not be as effective if delayed until the problem had
become clinically obvious.

Complication screening is usually performed on an annual basis,
either as a formal annual review or on a rolling programme basis,
unless problems have been previously identified.
B1.2 Every structured diabetic review
The patient should be assessed and advised regarding:
 The impact of diabetes on lifestyle and psychological well-being.
 Symptoms of hyperglycaemia (where relevant)
 Occurrence and warning symptoms of hypoglycaemia
 Results of home monitoring if available.
 Episodes requiring hospital admission
 Medication
The following parameters should usually be recorded and discussed with the
patient at each visit:
 Blood pressure (particularly if hypertensive or previous recording
elevated).
 HbA1c (not more often than every 3 months).
 Weight and BMI.
 Urinalysis for ketones, protein and glucose.
An individual care plan and goals should be reviewed, agreed with the patient
and updated as appropriate. Additional interim visits may be required to
address specific problems.
25 May 2011
B1.3 Content of Annual Checks
B 2.0 Education
Education of the person with diabetes about their condition and its
management is a key component in the promotion of successful self-care.
Healthcare professionals can make a major contribution by helping those with
diabetes to understand their disease and the potential for intervention to
improve outcomes. In particular, emphasis on the beneficial effects of lifestyle
management should never be neglected. Similarly, facilitation of appropriate
learning with respect to administration of medications and self-monitoring are
essential parts of effective medical management of diabetes.
Educational input at diagnosis of the condition will need to be substantial and
will usually need ongoing reinforcement. The ‘correct’ amount of information
to present at any encounter is problematic and should not greatly exceed the
patient’s current needs or capacity to take new knowledge on board. It is
important to be aware that people learn best when physically and emotionally
‘comfortable’ and to remember how stressful many individuals find
interactions with healthcare professionals. In attempting to enlighten, it is
more important to check understanding regularly than to continue to impart
ever more information; in this context less is often more. Also note that
different issues will be most appropriately addressed at different stages of the
patient experience. In facing the challenge of selecting topics to be
addressed, the healthcare professional must always attempt to recognise and
acknowledge the patient’s current agenda.
Skilled educators will understand the need to combine factual knowledge and
skills training with appropriate empathy and reassurance and will be able to
improvise on the breadth and depth of material appropriate to a given
consultation or enquiry. They will be aware of the variety of methods that
different people prefer to learn by and will use relevant combinations of
spoken, written and demonstrated material as well as leaflets, video
recordings, websites etc., that most appropriately match the patient’s needs.
Ideally they will have had the opportunity of some training in various methods
of teaching, including individual and group work.
Many different media, texts and courses are available for diabetes education,
particularly in relation to commonly recurring situations. It is important to have
a broad range of resources and skills to respond to patients’ various needs
and preferred learning styles. It is also useful to seek opportunities to
customise or develop training materials in line with local demands and
patterns of service provision and support.
More specific information follows on:
i)
The educational approach to the newly diagnosed patient
ii)
Ongoing education
iii)
Introduction of insulin therapy
25 May 2011
iv)
Diabetes Courses and Resources
B2.1 Newly Diagnosed Diabetes
Attention needs to be paid to the manner in which information about the
diagnosis and its implications are delivered to the patient. As diabetes is so
prevalent, most individuals already have some ideas about, and experience
relating to, diabetes that may well be incomplete or misleading and thus
cause undue distress upon diagnosis.
Diabetes UK (Grampian Voluntary Group) provides Education packs for those
newly diagnosed with Type 2 Diabetes that are currently distributed to
practices around the region; these cover a wide range of issues of potential
relevance. Group Education sessions with specialist nurse, dietetic and
podiatry input for newly diagnosed Type 2 patients (+/- partners) are available
at various localities throughout Grampian. Additional opportunities may be
required for one to one follow-up consultations with diabetes team members.
Information for those with Type 1 diabetes is also available from Diabetes UK,
but the need for early initiation of insulin therapy means there is an even
greater need for education time and timely education. Early, and perhaps
serial, follow-up is particularly important in this situation.
It is essential that adequate instruction is given on the use of any equipment
supplied (e.g. injection devices, blood testing equipment). The effectiveness
of such tuition needs to be assessed sensitively, recognising differences in
engagement, aptitude and application among patients.
All material considered for presentation to newly diagnosed patients should be
considered again at subsequent follow-up in recognition of the common need
for reinforcement, and the evolution of the patients understanding and
immediate focus of engagement.
A checklist of some of the commoner items to be considered in the early
period following the diagnosis of diabetes is reproduced below. This list is
neither exhaustive nor is coverage of many items obligatory. Furthermore, it
should be used at a pace and to an extent commensurate with achieving the
aim of equipping the patient to cope more effectively with diabetes and its
management, and not to simply to record coverage of a list.
DIAGNOSIS
What is diabetes?
How has the diagnosis been confirmed?
What are the implications of the diagnosis on health?
LIFESTYLE ISSUES
Diet: quality, quantity and distribution through the day
25 May 2011
Activity and exercise
Alcohol intake and health
Smoking and resources to aid cessation
Conception, contraception and sexual health
Travel and holidays
MONITORING
What to expect (glucose, HbA1c, weight, blood pressure, eyes, feet, urine)
Meaning and implications of results
Self-monitoring: whether, why, how and when?
Effects of intercurrent illness
MEDICATION
As an adjunct to self-management/ lifestyle modification
Evolving disease and treatment plans
Range and nature of glucose-lowering treatments
Use of non-hypoglycaemic, risk-modifying drugs
OTHER ISSUES
Driving
Employment
Footwear and foot care
ID cards/ bracelets etc
Free prescriptions and eye tests
B2.2 Ongoing Diabetes Management
Education in various aspects of diabetes management will be a continuing
component of good diabetes care which will make considerable demands on
the knowledge, skill, experience and professionalism of those involved in its
provision. Several issues will often need to be revisited with patients; topics
for discussion will sometimes be introduced proactively during review
consultations, and sometimes be in reaction to a patient’s current particular
concerns. Once again a range of educational approaches and resources will
allow for the requirements of each patient to be best met. Some situations will
have a particular set of topic areas that require to be covered. Prominent
among these will be the introduction of insulin therapy and a second indicative
table of items to consider discussing with the patient at this stage is produced
below.
INTRODUCING INSULIN
What is insulin and what does it do?
Insulin types
Insulin injections
Doses and dose adjustment
Supplies and disposal
Hypoglycaemia: causes, recognition, management, avoidance
Sick day rules
25 May 2011
Driving, DVLA and employment issues
25 May 2011
B2.3 Diabetes Courses & Resources
The MCN has an Education Advisory Group (contactable via the MCN Office)
that meets quarterly and is available to advise the MCN, and individuals or
groups across the region involved in diabetes care, on matters concerning
educational strategy and delivery. It produces an Annual Report viewable on
the MCN website. There is also local representation on the national Diabetes
Education Advisory Group, a subgroup of the Scottish Diabetes Group.
Many diabetes educational opportunities are available for both professionals
and their patients. Training needs and course provision naturally vary over
time and anyone looking for something specific, or more general, will always
do well to consult colleagues about current or recent experience of what is
available. There is a strong history of locally developed and delivered
educational initiatives within Grampian. Forthcoming courses and events are
advertised on the Grampian Diabetes MCN website.
Among the local events for health care professionals on offer recently are the
Lilly GP Diabetes Scholarship, Managing the Change to Insulin in Type 2
Diabetes and Diabetes: Helping Nurses to Help Patients to Help Themselves.
The Grampian Diabetes Managed Clinical Network also hosts an Annual
Professional Conference in early summer.
More substantial courses, some including distance learning, are provided by
various Higher Education Institutions across the UK. Advice on diabetes
education for professionals and patients also appears on the Diabetes in
Scotland website.
Among the current organised educational activities for patients in Grampian
are New Patient Groups, Exercise Classes and DAFNE (Dose Adjustment for
Normal Eating) with further information available via the Grampian Diabetes
website or through health care professionals.
A wide variety of leaflets and literature are available from a number of sources
and these are often being reviewed and updated. The internet is well
established as a potential source of information for all, although one must
always be aware of commercial influences that could direct contents or
emphasis. A substantial amount of good quality information has been
available for some time on the Diabetes UK website. NHSG Health
Information Resource Service can provide free information leaflets and other
resources for a range of topics.
In 2008, NHS Scotland launched ‘My Diabetes My Way’, an interactive
website designed to help anyone with an interest in diabetes. Its partner
website comprises the ‘NHS Inform’ e-Library of quality assured information.
The respective web addresses of these NHSS websites are:
http://www.mydiabetesmyway.scot.nhs.uk and http://www.nhsinform.co.uk.
25 May 2011
Useful and interesting resources for patients and professionals can be found
at Diabetes Stories, featuring 100 oral histories of patients, relatives and
health care workers and at Healthtalkonline, which features a series of texts
and recordings of individual experiences of Type 2 Diabetes.
B3.0 Lifestyle
B3.1 Driving
Full guidance on medical rules is available on the DVLA website:
www.dvla.gov.uk

Patients with diabetes treated with insulin must inform the DVLA of their
diagnosis and type of treatment.

Patients with diabetes treated by diet or tablets no longer need to inform
the DVLA unless they develop other complications or have frequent
episodes of hypoglycaemia (see patient information sheet in “At a glance
guide”).

All patients are advised to inform their car insurance company at
diagnosis and if their type of treatment changes.

From August 2010 the Driving Regulations changed in keeping with
European changes. The main change currently under consultation is to
allow insulin-treated patients to hold Group 2 licences if specialist review
considers this appropriate. However the mechanisms and organisational
processes surrounding these changes have yet to be confirmed.
For the individual patient information sheets please look at the “At A Glance
guide” on the DVLA website and download and give to patients as
appropriate:
Diet and tablet treated diabetes
Insulin treated diabetes
C1 licensing and insulin
Types of driving licence:
Group 1 entitlement allows the driving of vehicles up to 3.5 tonnes or with up
to 8 passenger seats, including motorcycles and mopeds. For patients on diet
or oral hypoglycaemic agents a licence lasting until age 70 will be issued in
the absence of other complications. Drivers whose diabetes is treated with
insulin will be issued with a 1, 2 or 3 year licence, provided they are able to
25 May 2011
recognise warning symptoms of hypoglycaemia and have no other
complications which would affect driving including recurrent hypoglycaemia.
Group 2 entitlement (see note at beginning of 3.1 concerning new
regulations in August 2010) allows the driving of vehicles over 3.5 tonnes or
more or with more than 8 seats. This includes medium sized lorries (3.5-7.5
tonnes, C1), minibuses (D1), lorries (C), buses (D). Before January 1997
drivers who obtained a normal car driving licence were automatically awarded
C1 and D1 entitlement. These holders of C1/D1 entitlement retain it until their
licence becomes due for renewal, when they must meet the medical
standards prescribed for all lorry and bus drivers. Group 2 drivers treated with
oral hypoglycaemic agents must inform the DVLA and group 2 entitlement will
continue as long as they can meet all group 2 medical standards. New
applicants on insulin or existing drivers starting insulin are barred in law from
driving HGV or PCV vehicles (C and D) from 1/4/91. Drivers licensed before
1/4/91 on insulin are dealt with individually and licensed subject to satisfactory
annual Consultant assessment. Regulation changes in April 2001 allow
“exceptional case” drivers to apply for or renew their entitlement to C1/C1E to
drive small lorries with or without a trailer subject to meeting all “Qualifying
Conditions”. Regular review by a consultant Diabetologist is required.
Patients on insulin are not allowed to hold a D1 licence (minibus).
Taxi drivers
The licensing of taxi-drivers is undertaken by individual local authorities and
therefore different standards are applied in different parts of the country.
However current best practice advice recommends that Group 2 medical
standards are applied to taxi drivers although this does not currently seem to
take place in Grampian.
Emergency response vehicles
The DVLA has recommended that drivers with insulin treated diabetes should
not drive emergency vehicles. This takes account of the difficulties for an
individual, regardless of whether they may appear to have exemplary
glycaemic control, in adhering to the monitoring processes required when
responding to an emergency situation. .
How are driving licences renewed?
At the time of licence renewal or at initial declaration of insulin treatment
patients on insulin will be required to complete a self-declaration form about
their diabetes with particular reference to hypoglycaemia and glucose
monitoring. If no problems are identified it is usual for the licence to be
renewed without requesting a medical report. However in all cases where
specific issues are identified then a medical report will be required and will be
sent to the doctor identified by the patient. Information required includes
whether the patient knows about the driving advice, monitors appropriately,
any recent episodes of severe hypoglycaemia (in last 12 months) or has lost
awareness of hypoglycaemia.
25 May 2011
Diabetes related complications and driving
All drivers are required by law to be able to read a standard size car number
plate in good light at 20.5 metres. The advantage of this test is that it is easily
self-administered. Problems which affect the field of vision must be notified to
the DVLA. Drivers who have had laser treatment to both eyes for retinopathy
or suffer other conditions affecting both eyes must inform the DVLA so that
the extent of the problem can be assessed.
Drivers who develop problems with either the nerves or the circulation in the
lower limbs, sufficient to prevent safe operation of the foot pedals, must inform
the DVLA. This is unlikely to prevent driving as problems may be overcome
by either restricting driving to certain types of vehicles e.g. those with
automatic transmission, or by appropriate adaptations such as hand operated
accelerator / brake.
Insulin Treated Diabetes and Driving
Drivers who have any form of diabetes treated with any insulin
preparation must inform DVLA.
At the time of starting insulin patients should be advised not to drive
until their blood glucose levels are stable.
Hypoglycaemia
The risk of hypoglycaemia (low blood sugar) is the main hazard to safe
driving. Many of the accidents caused by hypoglycaemia are because drivers
continue to drive even though they are experiencing warning signs of
hypoglycaemia.
A patient must inform DVLA :
• If he / she develops impaired awareness of hypoglycaemia
• If he / she suffers disabling hypoglycaemia at the wheel
• If he / she suffers more than 1 episode of disabling hypoglycaemia within the
last 12 months.
However in some circumstances the patient will be allowed to drive by the
DVLA and it is up to individual health professional to advise if the patient if fit
to drive whilst awaiting to hear from the DVLA.
If a patient drives against medical advice then his / her insurance and
driving licence are deemed not valid and the patient is therefore driving
without insurance or a valid driving licence.
Precautions advised for Drivers with insulin treated diabetes:
• Do not drive if you feel hypoglycaemic or if your blood glucose is less than
4.0 mmol/l.
25 May 2011
• If hypoglycaemia develops while driving stop the vehicle as soon as possible
in a safe location, switch off the engine, remove the keys from the ignition and
move from the drivers seat.
• 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.
• Always keep an emergency supply of fast-acting carbohydrate such as
glucose tablets or sweets within easy reach in the vehicle.
• Carry your glucose meter and blood glucose strips with you. Check blood
glucose before driving (even on short journeys) and test regularly (every 2
hours) on long journeys. If blood glucose is 5.0mmol/l or less, take a snack
before driving.
• Carry personal identification indicating that you have diabetes in case of
injury in a road traffic accident.
• Particular care should be taken during changes of insulin regimens, changes
of lifestyle, exercise, travel and pregnancy.
• Take regular meals, snacks and rest periods on long journeys. Always avoid
alcohol.
Hypoglycaemic seizures
If a patient has a seizure which is hypoglycaemia related they may be allowed
to drive after notification to the DVLA. However, before this occurs clear
evidence will be required by the DVLA that hypoglycaemia was the cause of
the seizure and that there is very low risk of recurrence. Pending an
investigation / report the patient should be advised not to drive and to inform
the DVLA immediately.
C1/C1E Entitlement
Any C1 or other Group 2 licence reports must be completed by a consultant in
diabetes and require annual review.
Qualifying Conditions:
 No hypoglycaemic attacks requiring assistance whilst driving within the
previous 12 months.
 Regular monitoring at least twice daily and at times relevant to driving.
The use of a memory chip meters for such monitoring is strongly
recommended.
 Examination every 12 months by a hospital consultant, who specialises
in diabetes. At the examination the consultant will require sight of blood
glucose records and preferably the meter for the last 3 months.
 No other condition, which would render you a danger when driving C1
vehicles.
25 May 2011

required to sign an undertaking to comply with the directions of
doctors(s) treating the diabetes and to report immediately to DVLA any
significant change in your condition.
Exenatide, liraglutide or gliptins and driving
Exenatide and liraglutide are available as treatments for use in Type 2
diabetes, in combination with metformin and/or with sulphonylureas. Trials
published to date show a small but significant increased risk of hypoglycaemia
when exenatide is used in conjunction with a sulphonylurea. It would appear
that when the gliptins (DPP4 inhibitors) are used with sulphonylureas, the
hypoglycaemia risk is similarly raised.
The increased risk of hypoglycaemia from exenatide, liraglutide or gliptins
when used in combination with sulphonylureas is such that these are felt to
be a potentially high risk treatment for drivers holding Group 2 (LGV or
PCV) licences and that individual assessment will be required. Therefore
any patient who holds a Group 2 licence and who is commenced on either a
gliptin, exenatide or liraglutide in combination with a sulphonylurea must
report this to the DVLA (combination with metformin alone does not require
reporting). The use of gliptins, exenatide or liraglutide carries no specific
driving restrictions for Group 1 (car or motorcycle) licences.
[DVLA website: www.dvla.gov.uk]
25 May 2011
B3.2 Occupations
An occupational history is essential at diagnosis in order to help patients
adjust their diabetes to fit with their work routine. Some occupations may be
considered hazardous for patients with diabetes. Patients at particular risk of
hypoglycaemia ie those on insulin or sulphonylureas should be given advice
about appropriate detection and management of hypoglycaemia to minimize
risks which may occur. They should also be advised to consider carefully the
risks they may be exposed to if working unsupervised and the effect that
unstable shift patterns may have on their diabetes control.
Hazardous occupations

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Many occupations involve an element of hazard or risk. This could
involve anything from working near heavy machinery to being an active
fire fighter.
Regular monitoring of blood glucose is advised and disabling
hypoglycaemia and loss of warning signs of impending hypoglycaemia
should be discussed at each clinic review.
Patients undertaking physically active work should also be aware of
their carbohydrate requirements and insulin adjustment to prevent
hypoglycaemia.
The presence of other diabetes related complications may pose
additional risk eg advanced retinopathy, nephropathy or severe
neuropathy or coronary heart disease.
The role of the health professional and the employer

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Patients should be encouraged to declare their diabetes when applying
for employment.
The Disability Discrimination Act (updated 2005) provides legal
grounds for people with diabetes to address the issue of discrimination.
Within organisations that are not exempt from the Act, an employer is
no longer able to dismiss a person because they have developed
diabetes. Employment cannot be refused on the grounds of having
diabetes – indeed employers need to prove why they could not employ
an individual with diabetes.
Employer’s knowledge of diabetes may be minimal and health
professionals should be willing to liaise with employers to try and dispel
the myths that are commonly associated with diabetes.
People with diabetes should be encouraged to tell their work
colleagues and the first-aider about their diabetes so they know how to
recognise and treat hypoglycaemia.
Health professionals should ensure that people requiring insulin are on
the most appropriate insulin regimen to fit in with the patients work
schedule e.g. multiple injection regimen for shift workers.
Patients wishing to work overseas should be advised to ascertain the
availability of appropriate medical support if required.
25 May 2011
In October 2004 the DDA was extended to include the emergency services
and other potentially hazardous occupations. The only occupation that still
enforces a blanket ban for people with diabetes is the armed forces.
Diabetes UK have produced the following guidelines to help employers decide
whether a person with diabetes can work safely in a hazardous occupation:

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“You should be as physically and mentally fit as people without
diabetes.
You should visit your diabetes care team for regular (at least
annual check ups.
Your diabetes should be well controlled.
You should test your blood glucose levels and be well informed
and motivated to care for your condition.
There should be no cases of disabling hypos and you should be
aware of your own hypo warning signs.
You should have no advanced diabetes-related eye disease
(retinopathy), kidney disease (nephropathy) nor severe nerve
damage (neuropathy).
You should have no significant circulation disorders of the heart
(eg coronary heart disease), legs or brain
Your suitability for employment should be reviewed annually by
both an occupational physician and diabetes specialist. The
review should be based on previous criteria.
You may find that if you develop diabetes whilst in employment,
the organisation may change the nature of your job. This could be
sensible and may be worth considering.”
It is anticipated that there will be new legislation – the Equality Act - towards
the end of 2010 which is likely to affect employment for people with diabetes.
However as the law stands, some occupations that have their own medical
standards and if reasonable can limit employment in certain areas and
detailed occupational health review may be required.
Occupations which may be limited for people with insulin treated
diabetes:
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Armed forces
Airline pilot or airline cabin crew (certain airlines)
Air traffic control
Police
Emergency services
Train driver
Deep sea diving
Prison service
Jobs requiring a Large Goods Vehicle (LGV), Passenger Carrying
Vehicle (PCV) licence or a minibus (D1) licence. If a person drives a
C1 class vehicle for a living, and develops Type 1 diabetes or starts
25 May 2011
insulin treatment, they will have to be medically assessed on their
fitness to drive.
o These rules are to change in August 2010 with the introduction
of new driving legisltation which will allow well-controlled insulintreated patients to hold a Group 2 licence for larger vehicles.
Working offshore eg on oilrigs
Regulations concerning this work were relaxed in May 2008.
Patients requiring insulin may be given restricted certification of fitness to
work offshore if the following requirements are met:

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There is a report from the individual treating physician
The patient has been assessed and not considered to be at excess risk
of hypoglycaemia
The patient must be fit to respond to any emergency situation on the
platform
There has been good control of their diabetes for a minimum period of
6 months
The patient can self-manage their insulin requirements
The patient does not have impaired awareness of hypoglycaemia
The operator’s medical advisor must be consulted regarding the
individual case and must agree with the proposal to allow the individual
offshore
There must be a supply of glucagon and iv dextrose on the platform
Certification is restricted to a named platform and restricted to a
maximum of 1 year.
Individuals require annual review
Patients on diet or oral agents will be assessed for their risk of hypoglycaemia
and presence of complications which may affect mobility and ability to
respond to emergency situations.
Seafarers
On a UK registered ship the following regulations apply:
For patients with diabetes not on insulin:
 Deemed unfit for distant waters (ie > 150 miles from safe haven in UK
waters) and for watchkeeping until stabilized but then may be fit for all
areas.
For patients with diabetes requiring insulin:
 Deemed unfit for all duties until stable and then permanently unfit for
distant waters and watchkeeping and emergency duties.
25 May 2011
B3.3 Physical Activity
All people with diabetes should be asked about physical activity and most
should be encouraged to increase activity. Suitable educational material is
available on the NHS Scotland website mydiabetesmyway.
Improving health
 All people (including health professionals) should be advised to
increase their level of physical activity to achieve current
recommendations and be supported to maintain this level across their
lifespan.

People with Type 2 diabetes should be encouraged to participate in
physical activity or structured exercise to improve glycaemic control
and cardiovascular risk factors.

People with Type 1 diabetes should be encouraged to participate in
physical activity or structured exercise to improve cardiovascular risk
factors.

A gradual introduction and initial low intensity of physical activity should
be recommended for sedentary people with diabetes.

Exercise and physical activity is best undertaken regularly i.e.
preferably daily or on alternate days. Once a week is of limited benefit.
As a rough guide the first stage would be to encourage an
accumulation of 30 minutes of moderate activity (e.g. walking) on most
days of the week. The second stage is to encourage those who are
motivated. These individuals could be encouraged to engage in more
vigorous activity at least three days per week.

Advice about physical activity and exercise should be individually
tailored and diabetes specific and should include implications for
glucose management and footcare.

Patients with complications should seek medical advice before
embarking on exercise programmes.

If patients have problems with mobility there are easy exercise
programmes which they could do, e.g. chair exercises

Above all encourage patients to choose an activity which they will
enjoy.

Health professionals should discuss barriers to increasing physical
activity and likely causes for relapse with patients.

Patients should be encouraged to set realistic targets for increasing
physical activity.
25 May 2011

Appropriate footwear and socks should be encouraged and patients
with neuropathy may need to discuss their needs with a podiatrist.
Exercise and blood glucose control
(also see section C4.0 hypoglycaemia)

For patients who routinely monitor blood glucose and/or are insulin
treated, it is advisable to monitor blood glucose before and after
exercise.

It is usually unnecessary to reduce oral hypoglycaemic agents although
regular activity resulting in weight loss and improved glycaemic control
may require adjustments in medication.

Hypoglycaemia related to exercise may occur at the time of exercise or
up to 24 hours after when glycogen stores are being replenished.

The risk of hypoglycaemia is related to the intensity and duration of
exercise and also how used to exercising the patient is (those with little
experience may be more likely to go hypo compared with those
exercising regularly).

Patients should be advised to consider reducing insulin doses before
and after exercise (including the day afterwards), increase dietary
carbohydrate and alter injection sites, e.g. avoiding legs if running or
arms if kayaking as this will increase absorption of insulin.

It is advisable for patients to have easy access to rapid-acting
carbohydrate (e.g. orange juice / jelly babies (2=8g)) when exercising.
Additional advice for people with Type 1 diabetes taking part in high intensity
or endurance sporting activities
Referral to a specialist should be considered.
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Ideally blood glucose at the start of exercise should be 7-12mM.
Extra CHO should be ingested if glucose < 7mM.
If glucose >12 mM and ketone free glucose replacement should not
occur until glucose falls.
Blood glucose should be monitored every 30 minutes.
25-75% reduction in prandial insulin may be required if exercising
within 2 hours of injecting.
Carbohydrate should be consumed at 1g/kg/hour of exercise from 20
minutes after start of exercise. Lower intensity activities and
25 May 2011
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intermittent high intensity activities are likely to require less.
Additional hydration is essential.
Where possible individuals should be advised not to exercise alone.
Exercise within 24 hours following an episode of hypoglycaemia carries
a high risk of further hypoglycaemia.
Additional nutritional advice, particularly for those engaging in more
vigorous physical activity is available on the Runsweet.com website.
Other ways of helping motivate patients to increase physical activity
It is helpful for each diabetes clinic (in primary or secondary care) to be able
to provide information to patients on local facilities. Each locality will have
various opportunities for exercise. Local councils can provide details of
classes running in the area and also details of opening times of swimming
pools etc. Details of walking routes are also available from Health Point.
Pedometers
 These have been shown to help people increase physical activity
levels.
 The reliability of pedometers varies greatly and people wishing to use
one should be advised to purchase it from a reliable outlet rather than
the back of a cereal packet!
 Pedometers should be attached to the hip belt for best accuracy.
 Pedometers are most effective when a “step goal” is agreed with the
patient. When first using a pedometer it is recommended that people
wear it for a week and document the average number of steps per day.
If they wish to increase physical activity an appropriate goal may be to
consider trying to increase the number of steps by 1000 - 1500 on 3
days of the week. After 2-4 weeks the target could be increased to an
additional 3000 steps on 3 days of the week.
 For many patients the frequently cited target of 10000 steps per day is
unrealistic.
Exercise Classes
Some patients enjoy the social interaction and motivation of exercise classes.
Diabetes exercise and information classes have been running in Grampian for
2 years.
At the present there are six classes (including an aqua-aerobics class) which
run for 1.5 hours with about 1 hour of exercise followed by 30 minutes of
group discussion. Further details including information sheets and referral
forms can be found on the Patient Information page of the Diabetes MCN
website.
Although many patients attend other exercise classes at various venues
throughout Grampian, patients new to exercise classes may find some
classes too strenuous. This can be de-motivating for patients.
25 May 2011
Some patients may be suitable for referral to Grampian Cardiac Rehabilitation
Classes although, again some patients may find this too strenuous if they
have not been through the earlier stages of the Cardiac Rehab programme
(see GCRA website).
25 May 2011
B3.4 Psychological Wellbeing
B3.4.1 Introduction

Self-care relates to the way that people choose to lead their lives and
to their psychological wellbeing.

Psychological wellbeing of patients is important to those working
in diabetes services because it has a profound effect on the
efforts of people with diabetes to self-care.

It is important to ascertain when significant psychological issues are
present because this will influence management decisions (for
example, whether or not we encourage lifestyle change), and can help
when to advise patients to get additional help if necessary (eg visit their
GP for management of depression)

Regular assessment of a broad range of psychological and behavioural
problems in children and adults with diabetes is recommended. The
most common issues are clinical depression and anxiety in adults
and eating disorders should also be considered. It is best to think
of peoples’ experience of depression and anxiety as occurring along a
continuum (ie you can have a little or lots of it) rather than it simply
being present or absent.
B3.4.2 Depression

Significant levels of depression, for example, are present in about 20%
of people with diabetes, and are associated with poorer glucose control
and more severe illness course (de Groot et al, 2001). That is not
surprising in view of the fact that key characteristics of depression
include: lack of motivation & energy; disrupted eating patterns, and
negative thinking styles particularly about being a failure and about
being unable to make positive changes.

Because of beliefs about being a failure and general reduced levels of
resourcefulness, great care needs to be taken if setting goals with
people who have significant levels of depression. Almost always, it is
wiser to postpone an attempt to implement efforts to change
behaviour until the depression has been successfully treated.
B3.4.3 Anxiety

Clinical anxiety too is more prevalent among people with diabetes than
in the general population with a point prevalence of about 15 %
25 May 2011
although about double this number will have borderline clinicallysignificant levels. There is a biological component to anxiety, namely
the release of stress hormones such as cortisol and adrenaline. These
hormones in turn cause other biological responses including the
release of glucose into the bloodstream, and other somatic symptoms
which overlap with symptoms experienced during hypoglycaemia.

Because of the release of glucose into the blood and because
commonly people with diabetes misinterpret symptoms of anxiety as
indications of low blood glucose (so they take unneeded action to raise
blood glucose), clinical anxiety is also associated with poorer control
(Anderson et al, 2002).

Anxiety is associated with thoughts about future disasters occurring (in
minutes, days, months or years) and these recurring worries could be
about health-related or non-health-related events. Thus, health
professionals should be careful when providing information to
anxious people because they have a strong tendency to
superimpose a future “disaster-type” message, which will further
fuel worry and disturb blood glucose control.
B3.4.4 Screening for Anxiety and Depression

Identifying depression and anxiety in people with diabetes is
notoriously difficult (CMO Psychology Advisory Committee, 2003). This
is especially true in the case of those with significant but mild to
moderate levels because they can easily mask their difficulties over the
course of consultations. These are the very people who can be helped
most easily by self-help; psychological therapy, or medications. They
are also the very people that are unwittingly asked by health
professionals to make changes that are most probably not possible
until their psychological difficulties are resolved.

If it is deemed appropriate to investigate whether someone might have
significant levels of depression or anxiety, the use of a screening
questionnaire may be helpful. The Scottish Diabetes Group
recommends the Hospital Anxiety & Depression Scale (HADS)1
which takes patients about five minutes to complete and us about two
minutes to score. If other common inventories are used such as the
PHQ-9, Beck’s Anxiety Scale, or Beck’s Depression Inventory it is
important to bear in mind that more false positives will be identified
than if the HADS is used.
B3.4.5 Other Psychological Issues
Cognitive problems
25 May 2011
Dementia (including the early stages of) is more common as people age
(prevalence among over 65s: 5-8%; over 75s: 15-20%; over 85s: 25-50%).
Non-dementia related cognitive changes can also occur particularly in the
presence of cardiovascular risk factors. Key factors to bear in mind include
possible difficulties with memory and learning; planning, and organising all
of which can impair significantly self-care.
Eating disorders
These are more common among people with diabetes than the general
population and like the other issues above typically impair self-care, for
example, because they can involve manipulation of insulin. Anorexia and
bulimia nervosa are both characterised by preoccupations with food and
body image (dread of weight gain and beliefs about being overweight and
so on). Those with anorexia engage in deliberate weight loss strategies
and have a BMI < 17.5. Bulimics have an irresistible craving for food which
is consumed in large amounts over short periods: this is typically followed
by vomiting. There is an Eating Disorder Clinic in Aberdeen which
specialises in the treatment of people experiencing these types of
problems.
25 May 2011
B3.4.6 Behaviour Change
The guidance below provides brief, general information and some advice
about helping patients to change behaviours, which staff will need to adapt to
suit their specific model of working.
Those who attend adult diabetes services in primary and secondary care have
lifestyle habits that have been present for many years. Unsurprisingly then,
key areas of concern to professionals working with people who have diabetes
have been repeatedly highlighted as notoriously difficult to influence over
extended periods of time, and this is especially true of behaviours targeted at
prevention of future health problems.
Key ways to approach changing lifestyle behaviour that make success more
probable.

Good general clinical skills are imperative ie the ability to establish and
maintain a good working relationship with patients and to encourage
them to make changes in a warm, sensitive and considered manner.
There is about 40 years of research that indicates that how health
professionals get on with patients plays a much more important
role in helping people to make changes than technical skill &
knowledge.

Education and information alone are rarely sufficient to change
long-standing lifestyle behaviours. They generally do however play
an important part in behavioural changes programmes. So, the best
way to think about information provision is as necessary but not
sufficient.

The job of helping people to make changes to the way they live their
lives is really about encouraging, building confidence, and
motivating.

Existing behaviours tend to serve a function (purpose). In general,
people are trying to be happy and their efforts are often focused on the
shorter-term. So what might seem like odd behaviours or ideas are
often idiosyncratic efforts to either increase happiness or decrease
unhappiness. One example might be a person with Type 1 diabetes
who is extremely fearful of nocturnal hypoglycaemic episodes so loads
up on biscuits and toast before bed. She is trying (successfully) to
avoid immediate, very uncomfortable thoughts (about dying) and
feelings (fear, anxiety). The pattern is similar for people who frequently
comfort eat when distressed.

The same behaviour serves a different function in different
people. For example, one person might avoid testing blood glucose
levels because he cannot face the uncomfortable thoughts and feelings
(eg about being a failure or future health complications) that occur if
25 May 2011
readings are higher than he would like, whereas another might do so
because she doesn’t want others to know she has diabetes.

The function or purpose of existing behaviours are the
maintaining factors, i.e., it explains why the current situation
continues. So, for example, loading-up on biscuits before bed in people
with significant fear of hypoglycaemia continues because it serves a
purpose (successful avoidance of negative thoughts and feelings).
Similarly, many people who (like most of us) have tried and failed to
lose weight or maintain weight loss are seemingly disinterested in
trying again. The purpose of this apparent inactivity is often to avoid the
typical feelings of frustration, disappointment and so on which are
typically associated with not losing the amount of weight desired /
putting weight back on. In both cases, to these people the outcome
is positive, in the shorter-term at least.

Helping change behaviour means patients are moved toward what they
find difficult and means focusing on the pay off between shorter and
longer-term outcomes. So in helping people overcome hypoglycaemic
fear they may be advised to eat and drink gradually less before bed,
thereby exposing them to their uncomfortable thoughts and feelings,
building their confidence in their ability to deal with this uncomfortable
ness, whilst helping them become mindful of the longer-term gains of
addressing this problem.

It is worth bearing in mind that often health alone is not a great
motivator for people to make significant changes to the way they lead
their lives. All of us could spend every hour of every day in efforts to
maximise health but few would choose to do so, even those with
serious medical conditions.

Generally, change is more likely if health gains can be linked to
what people feel is important compared to if change is only linked
to health outcomes. People do tend to be motivated by their values,
that is, those things in life which are important to them. Commonly,
values include intimate relationships; children and grandchildren;
extended family; friendships; enjoyable hobbies, pastimes and sports,
and work.
Goal Setting
This is an important aspect of helping patients to improve self-care. Although
seemingly simple, it is inevitably harder in practice.
o Think SMART: goals should be Specific; Measurable; Achievable;
Relevant, and Timely.
o Be active in negotiating goals because typically people will have
unrealistic expectations of themselves ie try to ensure goals are
achievable.
o Nothing de-motivates like failure so early successes are especially
imperative.
25 May 2011
Write down goals and methods for achieving them – a copy for
patients to take away and for clinical records is often helpful.
o Diary keeping can help track progress for people with diabetes and
their clinicians.
o Link diaries of behaviour or outcomes to the fact that change is rarely
linear; more often we tend to do well perhaps one week and not so
well the next (they can look back to baseline for example and note
overall progress).
o It is normal to have setbacks.
o You can strengthen the likelihood of new behaviours becoming
established by helping patients link behaviours to existing parts of
their daily routines. So, examples might include walks after the TV
news; blood glucose tests after showering, and so on.
o
It is generally best to have more regular contact initially with people trying to make
changes (this includes emails, telephone calls etc). This is because the early success
is generally imperative. It is also during this period that people make common
mistakes which can lead to them discontinuing their efforts like: remembering
incorrectly agreed goals and plan of action; becoming very disheartened by small or
infrequent failures; boosted by early success set themselves large goals which they
fail to achieve.
Remember, people often try on a number of occasions to change lifestyle
behaviours before they succeed (sometimes they never will), and often the fact
that things remain the same is an achievement (weight for example).
1
We have copies of the HADS in the Diabetes Service. Please contact Andy Keen
(mailto:[email protected] telephone: 55507), Consultant Health Psychologist, if you
would like to know how to use the HADS.
25 May 2011
B3.5 Smoking






All people with diabetes should be strongly counselled against smoking.
Smoking is a significant reversible risk factor for cardiovascular disease
(macrovascular and microvascular).
Patients with diabetes are already at increased risk of cardiovascular
disease.
Smoking increases the risk of development and progression of most
complications, e.g. retinopathy, microalbuminuria.
Smoking potentiates the risks during pregnancy in women with diabetes.
Smoking increases the risk of developing diabetes.
B3.5.1 Smoking cessation
Patients who wish to stop smoking should have access to motivational
support as this will increase the chances of quitting. Nicotine replacement
therapy, bupropion and varenicline are effective aids to smoking cessation for
patients smoking more than 5-10 cigarettes per day and who are nicotine
dependent.
Nicotine replacement therapy (NRT) (sublingual, chewing gum, patches,
nasal spray, inhaler). The form of nicotine replacement therapy chosen should
take into account clinical conditions, (e.g. pregnancy, skin disorders)
individual preference and tolerance of side-effects. NRT is available from
most community pharmacies conforming to a NHS pharmacy service
specification, where staff have undergone training in counselling and smoking
cessation support. Patients who are exempt from prescription costs receive
treatment free of charge, and patients who pay prescription charges will be
charged the equivalent of the prescription charge for each month of treatment.
Bupropion Tablets (Zyban®) must be used in conjunction with a programme
of counselling and cessation support. It should not be used in patients with a
history of seizures, eating disorders, a CNS tumour or who are experiencing
acute withdrawal from alcohol or benzodiazepines.
Varenicline tablets (Champix®▼) must be used in conjunction with a
programme of counselling and cessation support. Uptake of varenicline has
been high and research demonstrates it to be very successful. There have
been recent safety concerns and prescribers should be aware that symptoms
of depression, which may include suicidal ideation and suicide attempt, have
been reported in patients taking varenicline.
Counselling and smoking cessation support is available through the NHS
Grampian Smoking Advice Service (SAS). The SAS can be contacted, free of
charge, on 0500 600 332. Our web address is http://www.nhsgrampian.org.
Professionals wishing to find out more about the SAS may wish to log onto
our section on Hi-net (http://www.hi-netgrampian.org/sas).
25 May 2011
A GP Decision Flow Chart and referral information is available at:
http://cgi.grampian.scot.nhs.uk/
Other Support Available:
Patients can access support by calling Smokeline (provided on behalf of
Health Scotland) 0800 84 84 84. The Health Scotland “Can Stop Smoking”
website (http://www.canstopsmoking.com/) offers advice and e-mail and text
message support.
B3.6 Travel
It has become increasingly easy in recent years to travel all over the world
offering exciting opportunities to many. For most patients diabetes mellitus
should not be a bar to travel but certain factors have to be taken into
consideration to ensure a healthy, hassle free trip.
General Advice










Those on tablets or insulin should pack extra snacks in case of delays
in travel arrangements.
Additional supplies of medication should be taken in case of delay etc.
Hot / cold climates may affect blood glucose control and additional
blood glucose monitoring may be appropriate.
Diet may be very different in some countries – particularly in the type
and quantity of carbohydrate.
It is not necessary to order special diabetic meals for flights. The
diabetic meals provided by the airlines do not contain enough
carbohydrate.
The water in many countries is not safe to drink so food and water
hygiene are very important as illnesses causing diarrhoea and vomiting
may have a serious adverse effect on diabetes control and may
precipitate the need for urgent medical review or even hospital
admission.
It is important to protect the feet from sunburn. Footwear should be
worn at all times including on the beach to avoid injury to the foot and
the risk of infection.
It is useful to carry some kind of information stating that you have
diabetes mellitus and are on medication, especially if travelling alone.
Various items are available such as cards or bracelets.
Patients on long-haul flights should be given advice concerning
minimising the risk of DVT.
Accidents and ill health can occur to any traveller and good travel
insurance with repatriation cover if necessary should be taken out by
all. The European Health Insurance card (EHIC) does not cover
repatriation to the UK only medical costs incurred in countries in the
EU. Diabetes UK can be helpful in this regard as can companies such
as SAGA and Freespirit.
25 May 2011
Specific advice for insulin-treated patients
 Hot climates can affect insulin absorption and activity levels and diet on
holiday often differ from those at home so doses may have to be
altered. Therefore it is advisable to test blood glucose more frequently
on holiday to keep good control and avoid unexpected hypoglycaemia.
 Any illness acquired while travelling could precipitate ketoacidosis.
Ketostix should be taken on holiday so that urine can be tested for
ketones if these illnesses arise.
 Insulin adjustment may be required for long haul flights. For some the
use of a short-acting insulin before meals while travelling may be
added to the normal regimen.
 Insulin should not be stored in the hold as it can freeze, thereby making
it permanently less effective. It should be carried in hand luggage. For
those travelling to very cold climates, special storage bags are
available to insulate the insulin so that it does not freeze. These are
available from companies such as Diabetes UK and Frio. High
temperatures can also affect insulin and again storage bags can help
to protect it but insulin will keep well at room temperature for periods of
up to one month.
 A letter from a doctor for those on insulin should be carried to avoid
any problems with customs at airports both here and abroad. These
are available from the diabetic clinic for those who attend Woolmanhill
or from GPs. An example follows:
3.6.1 Travel Letter for Patients Using Insulin
To Whom It May Concern
Date
Dear Sir/Madam
Patients details
The above patient attends my Diabetic Clinic and is on insulin treatment.
Insulin, equipment for its administration including needles and equipment for
blood glucose monitoring have to be carried at all times. Insulin should be
kept in the flight cabin as it can be destroyed by the potentially low
temperatures of an aeroplane hold. Lest there are any mishaps, it is also
recommended that supplies are carried in more than one bag with some,
where possible, being carried by a friend or partner.
Yours faithfully
25 May 2011
A useful check list for holiday packing can be found in the Diabetes UK
booklet on travel.
Additional information can be found on the following websites:
Travax (for health professionals)
Fit For Travel (for patients)
25 May 2011
B4.0 Information Technology
National and Regional Diabetes IT Overview
SCI-DC – Introduction
SCI-DC (Scottish Care Information – Diabetes Collaboration) is a national
system that allows access to data regarding all people with diabetes in NHS
Grampian. It aims to deliver an integrated diabetes record to diabetes health
care providers in NHS Scotland. This was set up on the basis of the
recommendations in the ‘Scottish Diabetes Framework’; which identified that
well-managed, integrated diabetes care must be underpinned by effective
information technology systems. The principal aim of SCI-DC is to deliver a
shared electronic record for use by all involved in the provision of diabetes
care.
SCI-DC brings support information and clinical data together from a variety of
sources including general practice, hospital clinics and retinal screening. The
SCI-DC project comprises two key products, namely SCI-DC Clinical and SCIDC Network. The SCI-DC products are complementary, each with a different
focus. SCI-DC Clinical is designed to provide hospital clinic-based support,
delivering such features as the automatic generation of GP letters. An
interface has been developed to take the clinical data captured by SCI-DC
Clinical for automatic update of the patient record held on SCI-DC Network.
SCI-DC Network allows for the identification of all people with recorded
diagnoses of diabetes in the General Practice computer systems, and
provides full support for the Scottish Diabetes Survey. Its regionally
customisable web pages allow access to standardised treatment guidelines
for decision support, and provide access to patient leaflets.
The SCI-DC Network website is available to all General Practices regardless
of what GP system an individual practice uses and SCI-DC holds a diabetes
register of patients for all practices. SCI-DC Network allows for automated
practice audit in support of clinical governance, and contains such features
as graphical representation of laboratory results over time, allowing for
longitudinal risk to be gauged and providing a focus for discussion with
patients. In Grampian all practices have access to the system.
In Grampian the Diabetes Centre used PROTOS until Feb 2011 as its IT
system, afterwhich the conversion to SCI-DC Clinical commenced.
25 May 2011
Figure 1 – Diagram of SCI-DC linkages with other systems
Accessing SCI-DC Network
The address for accessing SCI-DC is:
https://diabetes.mhs.scot.nhs.uk/Grampian/scidc/
Access to SCI-DC is available to registered users from within NHS computer
networks.
You can access SCI-DC Network through the GP Portal (see figure 2) from
the Grampian Intranet pages.
25 May 2011
Click here
Figure 2 – Accessing SCI-DC Network through the GP Portal
In order to gain access to the information contained within SCI-DC Network
you must enter your SCI-DC Network username and password from the login
page (see figure 3).
25 May 2011
Figure 3 – SCI-DC Network Login Page
Once you have successfully logged into SCI-DC, the screens and options you
will be presented with will vary slightly depending on whether you are working
in primary or secondary care (see figures 4+5).
25 May 2011
PRACTICE NAME
Dr James, GP
Figure 4 – SCI-DC Primary Care Page
SCI-DC Network – Overview (Primary Care)
From this screen you can access a range of further screens that allow you to
both enter and view information on individual patients at your practice from
the practice overview screens such as biochemistry, cardiovascular and
lifestyle data (HbA1c, cholesterol, blood pressure, height, weight and BMI for
instance).
25 May 2011
Figure 5 – SCI-DC Secondary Care Page
SCI-DC Network – Overview (Secondary Care)
From this screen you can access a range of further screens that allow you to
both enter and view information on individual patients at your clinic from the
clinic overview screens such as biochemistry, cardiovascular and lifestyle
data (HbA1c, cholesterol, blood pressure, height, weight and BMI for
instance). Any patient who attends the clinic, and is registered with a GP
Practice in NHS Grampian, can be viewed as appropriate.
Leaflets
You can also access and print off relevant leaflets irrespective of whether you
work in primary or secondary care, such as foot screening leaflets for example
(see figure 6). Shown below is a snapshot of the foot screening form that can
be accessed from an individual patient summary screen and where you can
access the foot screening leaflets.
25 May 2011
Click on the appropriate form and
print as required
Figure 6 – Foot Screening Leaflet Screen
In SCI-DC Network you can also enter and view foot screening data and view
results and images obtained from Diabetes Retinal Screening from the patient
summary screen for individual patients (see figure 7).
25 May 2011
Figure 7 – Patient Summary Screen
If you work in the primary care sector you can gain information on the retinal
screening status of all patients at your practice as well as their next
appointment details (see figure 8). Additionally, you can also request
suspensions for patients if required from retinal screening.
25 May 2011
PRACTICE NAME
Dr James, GP
Click here
to access
Diabetes
Retinal
Screening
pages
Figure 8 – Accessing Diabetes Retinal Screening Results
Furthermore, if you work in primary care, you are also able to perform practice
audits in a range of areas that allow you view patients with certain readings,
patients with deteriorating readings or patients who have not had certain tests
carried out or results recorded (see figure 9).
In addition you are also able to view summary information in a range of areas
for your own practice and compare this with regional figures for NHS
Grampian as a whole.
25 May 2011
Figure 9 – Performing a General Audit Using SCI-DC
SCI-DC Network – Back Population of GMS Contract
Indicators
The functionality now exists for GMS Contract Indicators information to be
back-populated into primary care systems (see appendix 1 for full list of items
that can be back-populated).
Currently, this functionality is in place for practices with EMIS primary care
system and work is in progress to include practices with Vision primary care
system in 2011.
25 May 2011
SCI-DC – Help / Contacts
Should you require a user name and password for SCI-DC Network, forget
your username or password, require additional training or have any other
query please use the numbers or email below as a contact. There is a SCInetwork user guide that can be e-mailed to assist you.
Contact Names
Robert O’Donnell
MCN Support Officer
Diabetes Centre
Woolmanhill Hospital
t: 01224 555393
e: [email protected]
25 May 2011
B4.1 Appendix 1 – SCI-DC Back-Population: Diabetes-Related GMS
Contract Indicators
Data Item
Relevant
Indicators
Recommended/Agreed READ Code(s)
Diabetes
Diagnosis
Date of Birth
Body Mass
Index
HbA1c
All
Type 1 Diabetes (C10E. – Type 1 diabetes mellitus)
Type 2 Diabetes (C10F. – Type 2 diabetes mellitus)
9155. – Patient date of birth
22K.. – Body Mass Index
Retinal
Screening
All
DM 2
DM 5, DM
20, DM 7
DM 21
42W.. – Hb. A1C - diabetic control
No Retinopathy – Left Eye (2BBK. – O/E - no L diabet
retinopathy)
No Retinopathy – Right Eye (2BBJ. – O/E - no R diabet
retinopathy)
Background Diabetic Retinopathy (BDR) Mild – Left Eye
(2BBQ. – O/E - left eye back diab ret)
Background Diabetic Retinopathy (BDR) Mild – Right Eye
(2BBP. – O/E - right eye back diab ret)
Previously Background Diabetic Retinopathy (BDR) Mild:
(F4200)
BDR Moderate – Left Eye (2BBS. – O/E - L eye preprolif
diab ret)
BDR Moderate – Right Eye (2BBR. – O/E - R eye preprolif
diab ret)
BDR Severe – Left Eye (2BBS. – O/E - L eye preprolif diab
ret)
BDR Severe – Right Eye (2BBR. – O/E - R eye preprolif
diab ret)
Previously BDR Moderate / Severe: (F4202)
Proliferative Retinopathy – Left Eye (2BBV. – O/E - L eye
prolif diab ret)
Proliferative Retinopathy – Right Eye (2BBT. – O/E - R eye
prolif diab ret)
Previously Proliferative Retinopathy (F4201)
(2BBX. – O/E - L eye diab maculopathy)
(2BBW. – O/E - R eye diab maculopathy)
Previously Diabetic Maculopathy (F4204) and Advanced
Diabetic Maculopathy (F4203)
Not Adequately Visualised – Left (2BBC. – O/E - Left retina
not seen)
Not Adequately Visualised – Right (2BBB. – O/E - Right
retina not seen)
25 May 2011
Peripheral
Pulses
DM 9
Neuropathy
Testing
DM 10
Pulse Present – Left (24FB. – O/E - left foot pulses
present)
Pulses Absent – Left (24FA. – O/E - Absent left foot
pulses)
Pulse Present – Right (24EB. – O/E - right foot pulse
present)
Pulses Absent – Right (24EA. – O/E - Absent right foot
pulses)
Foot Sensation to Monofilaments Normal – Left (29BC. –
10g monofil sens L foot normal)
Foot Sensation to Monofilaments Normal – Right (29BB. –
10g monofil sens R foot normal)
Previously Foot Sensation to Monofilaments Normal
(29B7.)
Foot Sensation to Monofilaments Impaired – Left (29BA. –
10g monofil sens L foot abnorm)
Foot Sensation to Monofilaments Impaired – Right (29B9.
– 10g monofil sens R foot abnorm)
Previously Foot Sensation to Monofilaments Impaired
(29B8.)
Foot Vibration Sensation Normal – Left (29H7. – O/E-Vibr
sens Lt foot normal)
Foot Vibration Sensation Abnormal – Left (29H6. – O/EVibr sens Lt foot abnorm)
Foot Vibration Sensation Normal – Right (29H5. – O/EVibr sens Rt foot normal)
Foot Vibration Sensation Abnormal – Right (29H4. – O/EVibr sens Rt foot abnorm)
Low Risk of Foot Ulceration – Left (2G5I. – O/E - L diab
foot at low risk)
Low Risk of Foot Ulceration – Right (2G5E. – O/E - R diab
foot at low risk)
Moderate Risk of Foot Ulceration – Left (2G5J. – O/E - L
diab foot at mod risk)
Moderate Risk of Foot Ulceration – Right (2G5F. – O/E - R
diab foot at mod risk)
High Risk of Foot Ulceration – Left (2G5K. – O/E - L diab
foot at high risk)
High Risk of Foot Ulceration – Right (2G5G. – O/E - R
diab foot at high risk)
Active Foot Ulceration – Left (2G5L. – O/E - L diab foot ulcerated)
Active Foot Ulceration – Right (2G5H. – O/E - R diab foot ulcerated)
Foot Risk
–
Attending
Podiatry
Blood Pressure
–
Under care of podiatrist (9NN0.)
DM 11, DM
12
DM 13, DM
15
Systolic (2469. – O/E – Systolic BP reading)
Diastolic (246A. – O/E – Diastolic BP reading)
MA Value – mg/l (46N4. – Urine albumin)
MA Value – mg/mmol (46TC. – Urine albumin:creatinine
ratio)
MA Value – mg/24hrs (46N6. – 24 hour urine albumin
output)
44J3. – Serum creatinine
Microalbuminuria
Testing
Serum
Creatinine
DM 22
25 May 2011
Estimated
Glomerular
Filtration Rate
(eGFR)
Total Cholesterol
Smoking Status
Smoking
Cessation
Advice
DM 22
451F. – Glomerular filtration rate
DM 16, DM
17
Smoking 1,
Smoking 2
44PH. – Serum cholesterol
Smoking 2
Current Smoker (137R. – Current smoker)
Ex Smoker (137S. – Ex smoker)
Never Smoked (1371. – Never smoked tobacco)
8CAL. – Smoking cessation advice
25 May 2011
The following data items to be reviewed and included at a later date…
Data Item
Relevant
Indicators
Recommended/Agreed READ Code(s)
Proteinuria
DM 13, DM
15
ACE Inhibitor
Treatment
DM 15
AIII Antagonist
Treatment
DM 15
Influenza
Immunisation
DM 18
General
Depressed
Wellbeing
Diabetes
Depressed
Wellbeing
Depression
1
Urine Protein Test Not Done (4671.)
Urine Protein Test Negative (4672.)
Urine Protein Test = Trace (4673.)
Urine Protein Test = + (4674.)
Urine Protein Test = ++ (4675.)
Urine Protein Test = +++ (4676.)
Prescribed (8B6B.)
Contraindicated (8I28.)
Declined (8I3D.)
Adverse Reaction (U60C4)
Prescribed (8B6E.)
Contraindicated (8I2H.)
Declined (8I3P.)
Adverse Reaction (U60CB)
Given (65E..)
Contraindicated (8I2F.)
Declined (9OX5.)
3884.
Depression
1
3882.
Information supplied by SCI-DC Support Team on 10/08/2010
25 May 2011
Useful Links
The following websites provide a mixture of local and national information and
are suitable for all with an interest in diabetes and diabetes care.
Grampian Diabetes Centre – this website provides a range of information
about services in NHS Grampian and contains lots of useful information for
both patients and those involved in patient care.
http://www.diabetes.nhsgrampian.org
My Diabetes My Way – this website is designed to help support people who
have diabetes as well as their family and friends and provides a host of
resources with regards to all aspects of diabetes.
http://www.mydiabetesmyway.scot.nhs.uk
Diabetes UK – this website provides information guides for people with
diabetes as well as extensive information about research into diabetes and
fundraising activities. The website also provides local and national
information and information about professional conferences and diabetes
campaigns.
http://diabetes.org.uk
Active Scotland – this website allows you to enter your postcode and see
what activities are available in your local area, from the easy to the extreme,
to help people lead a more active lifestyle.
http://www.activescotland.org.uk
25 May 2011
B5.0 Contraception, Pregnancy and the Management
of Gestational Diabetes Mellitus
B5.0.1 Patient information
The national website mydiabetesmyway allows access to a range of
information for people with diabetes who are pregnant or who are planning
pregnancy. The “My Body” section has a link to general pregnancy leaflets
and a DVD. Hard copies of the leaflets and DVD are available form combined
clinics in Aberdeen and Elgin. Other locally produced leaflets are reproduced
here on:
Type 1 and Type 2 Diabetes and Pregnancy (detailed information) information for women
Gestational Diabetes – information for women
Pre-Pregnancy and Antenatal care for women with diabetes mellitus
These are also available on the Grampian Diabetes MCN website.
5.0.2 Introduction
Type1 diabetes is one of the most common medical conditions during
pregnancy and increasing numbers of women with Type 2 diabetes are
having pregnancies. Thus discussion of contraception and pre-pregnancy
care is important for all women with diabetes during their childbearing years.
Successful outcome of pregnancy can usually be anticipated in women with
pre-existing diabetes. However, diabetic pregnancy is statistically a high-risk
pregnancy with regard to foetal morbidity and mortality. In order to achieve an
optimal foetal outcome major efforts and attention to detail are required on the
part of the patient and her carers. Meticulous blood glucose control before
and during pregnancy is the cornerstone of management. In addition to
metabolic supervision, mothers require close clinical surveillance since there
are increased risks with regard to progression of diabetic retinopathy and
nephropathy, pregnancy-induced hypertension and intrapartum complications.
The congenital abnormality rate in diabetic pregnancy is at least double that of
the background population. There is convincing evidence that good
glycaemic control prior to and after conception during the period of
organogenesis reduces the increased risk of congenital abnormality that is
associated with poor control.
For these reasons diabetic pregnancy should always be planned and reliable
contraception is therefore important.
25 May 2011
B5.1 Contraception
The importance of avoiding unplanned pregnancy should be an essential
component of diabetes education for young women with pre-existing diabetes
from adolescence. The failure rate of the condom is relatively high, however
many of the other methods of contraception are safe for use by the majority of
people who have diabetes.
For all those recently diagnosed as having diabetes mellitus all methods are
suitable provided there are no other medical reasons why a particular method
is unsuitable.
For those who have vascular complications such as diabetic eye disease or
kidney problems the combined oral contraceptive pill may be contraindicated
and most other methods would be suitable. Advice has to be tailored to each
individual depending on the presence of complications and other medical
problems. Expert advice is available at the diabetic clinic or at Sexual and
Reproductive Health Service at Denburn Health Centre.
Contraceptives available are:
Contraceptive
Combined contraceptive pill (COC) –
Depo Provera Injection
Implanon subcutaneous implant
Progesterone only pill (POP)
Intrauterine system or Mirena
Intrauterine device (IUD)
Sterilisation
Vasectomy
Condom
Persona
Diaphragm or Cap
Natural family planning methods
Failure Rate
0.3%
0.3%
almost 0%
1 to 2%
<1%
<1%
1 in 200 and gets worse over time
1 in 2000
2 to 15%
6% at best
2 to 12%
Can be around 25% if not followed
every day and requires a high degree
of motivation
Long acting methods such as the IUD, IUS, and Implanon are best as they
require no further thought once fitted until they need replaced.
Emergency contraception - failure rate of around 5% mid-cycle, 2% over the
whole cycle. Need to obtain it within 72hrs of risk episode and the sooner it is
taken the more effective it is. The copper IUD can be inserted as an
emergency contraceptive up to 5 days after a risk episode and is nearly 100%
effective but due to other considerations such as the risk of infection is not
first choice. Other tablet methods are used on a trial basis under license from
the Scottish Office and are available up to 5 days after the risk episode from
The Sexual and Reproductive Health Department at Denburn Health Centre.
25 May 2011
B5.2 Planning pregnancy
Prior to conception
Refer to a hospital or combined obstetric diabetic clinic for pre pregnancy
assessment, where the following steps are taken:













Review treatment regimen. For intensive blood glucose control most
women with Type 1 diabetes are best treated with a multiple injection
regimen.
Provide blood glucose meter and test blood glucose four to six times
daily Blood glucose targets should be individualised and will depend on
factors such as hypoglycaemia unawareness or the residual maternal
beta cell function. General targets are fasting and pre meal 4.0-6.0
mmol/l, one hour post-prandial <8 mmol/l, two hour post prandial <7.0
mmol/l and over 6 mmol/l before bed for women with Type 1 Diabetes.
Achieve optimal glycaemic control aiming for an HbA1c result within or
as near to the non-diabetic range as is possible without inducing
disabling hypoglycaemia A general target for HbA1C of <7% is
advised for women with Type 1 diabetes although the ideal target
quoted in NICE is < 6.1%. This lower value may be feasible in patients
with Type 2 diabetes but cannot be achieved in many women with
Type 1 diabetes because of the risk of severe hypoglycaemia.
Patients with Type 2 diabetes should be considered for insulin therapy
with treatment targets as above. Women with pre existing diabetes
may use metformin as an adjunct or alternative to insulin in the
preconception period and during pregnancy when the likely benefits
from improved glycaemic control outweigh the potential for harm. All
other oral hypoglycaemics should be discontinued before pregnancy
and insulin substituted.
Discuss lifestyle issues which may affect glycaemic control, e.g.
o Difficulty with shift work
o Encourage appropriate exercise
Review all medications and other potential teratogens. Statins, ACE
inhibitors and ARBs should be discontinued before pregnancy or as
soon as pregnancy is confirmed. Alternative antihypertensive agents
suitable for use during pregnancy, eg methyl dopa, should be
substituted.
Arrange dietetic review and reinforce antismoking advice
Commence folic acid 5mg daily. (High dose recommended in view of
high risk of neural tube defects)
Ensure complication screening is complete and take action as
appropriate – See 10.2 -Content of Annual checks
Check rubella status
Assess general health, fitness for pregnancy, and screen for factors
which could disturb glycaemic control, e.g. urinary infection and thyroid
status
Review menstrual and gynaecological factors which could impair
fertility
An intensive education update to self management should be offered. If
available, a place on a structured education programme prior to
25 May 2011

pregnancy provides this level of education.
Continuous glucose monitoring (CGMS) may be considered in women
with Type 1 and Type 2 diabetes before and during pregnancy to
optimise control.
B5.3 Confirmed pregnancy
All diabetic women in whom pregnancy has been confirmed should be
referred immediately by telephone or fax to a hospital combined obstetric /
diabetic clinic for intensive education and multidisciplinary supervision.
Clinics are held weekly in Aberdeen and Elgin, where women will be seen at
one to four weekly intervals depending on metabolic control and obstetric
progress. Admission is not routine but may be recommended for
stabilisation of blood glucose control, management of diabetic complications
or associated obstetric problems. There is a low threshold for admission in
these relatively high-risk pregnancies.
Hypoglycaemia (see section C4.0)
Strict blood glucose control increases the risk of hypoglycaemia and warning
signs are often lost in early pregnancy. All women should be provided with
glucogel and a glucagon emergency kit, and their partner should be instructed
in their use. Ideally women should not sleep in a house alone in early
pregnancy because of the risk of hypoglycaemia. Women who lose
awareness of hypoglycaemia in pregnancy should be advised to stop driving
until warning symptoms return to normal.
Ketosis
The foetus tolerates maternal hypoglycaemia well, but is very sensitive to
ketosis. Established ketoacidosis in pregnancy results in a very high incidence
of foetal loss at all gestations, and is usually potentially avoidable. Pregnant
women should all have facilities to check blood or urine for ketones. Elevation
of blood glucose (> 10mmol/l) together with persistent non-fasting ketonuria is
an indication for increased insulin doses and urgent further assessment
usually involving hospital admission for intravenous insulin and dextrose.
Women must be advised to contact either their DSN, hospital team or GP in
such circumstances without delay. The most common cause of ketosis in
pregnancy is urinary tract infection, which should be treated on a
presumptive basis.
Delivery
Women should be delivered where there are facilities for intensive neonatal
care. Ideally delivery should be vaginal and at term (but not beyond). An
individual decision will be made for each patient, and in practice the
caesarean section rate remains much higher than that of the non-diabetic
population (around 67%).
All women on insulin receive an infusion of dextrose and insulin during labour
25 May 2011
to maintain normoglycaemia.
Post partum insulin requirements usually fall to between 30% and 50% of
that immediately prior to delivery. Breast-feeding is encouraged.
25 May 2011
B5.4 Management of Gestational Diabetes
Background and definition
Gestational diabetes mellitus (GDM) has been defined as carbohydrate
intolerance of variable severity with onset or first recognition during
pregnancy.
During pregnancy the normal range for fasting blood glucose is much lower
than in non-pregnant women and glycosuria with normal blood glucose levels
is common due to a lowering of the renal threshold for glucose.












The optimal methods to screen for, diagnose and treat GDM are under
review. The National Screening Committee is considering screening for
GDM. NICE guidelines recommend use of risk factors for screening
and SIGN, considered the topic as part of the updated Guideline 116.
Women with a history of gestational diabetes, who have not
progressed to diabetes in the interim, should have an OGTT around
16-18 weeks during subsequent pregnancies.
o
Risk factors for gestational diabetes326 (SIGN 116)
BMI more than 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or more
Previous gestational diabetes
Family history of diabetes (first degree relative with diabetes)
Family origin with a high prevalence of diabetes:
ƒ. South Asian (specifically women whose country of family origin is
India, Pakistan or Bangladesh)
ƒ. Black Caribbean
ƒ. Middle Eastern (specifically women whose country of family origin is
Saudi Arabia,
United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait,
Lebanon or Egypt).
Recommended population screening protocol for gestational diabetes
mellitus
Recommendations from Grampian guidelines 2009 (current screening
process)
 Urine should be tested for glycosuria at every antenatal visit (preferably
fasting)
 Timed or random venous plasma glucose measurements should be
made:
o Whenever glycosuria (2+ or more) is detected
o At 28 weeks gestation
 A 75g oral glucose tolerance test (OGTT) should be carried out if the
venous plasma glucose is:
o >5.5 mmol/l 2 hours or more after food
o >7.0 mmol/l within 2 hours of food
25 May 2011

Midwifery, obstetric and medical staff in Grampian are reviewing the
recommendations of SIGN 116 on gestational diabetes to consider how
they could be implemented across the region. The recommendations
from SIGN are given in SIGN 116 (pages 63-65).
Management
Women diagnosed as having gestational diabetes should be seen by a
physician and obstetrician with a special interest in diabetes and should
receive intensive management with diet and/or insulin if macrosomia is
suspected or if blood glucose levels are in the range for established diabetes.
Post-natal follow up
Up to 50% of women may go on to develop Type 2 diabetes later in life and
this group presents an excellent opportunity for screening and intervention.
Studies have shown that lifestyle intervention can reduce the incidence of
diabetes in at risk patients by over 50%. A local patient leaflet explaining
this risk and measures to reduce the risk of diabetes is available on the
MCN website. All patients with gestational diabetes are invited for a glucose
tolerance test at 6 months after delivery.
Women with a history of gestational diabetes who have developed IGT, IFG
or DM should be referred to the pre-pregnancy clinic or to the Combined
Obstetric Diabetic clinic when pregnancy is confirmed. Some women will
need active management from early pregnancy.
25 May 2011
B5.4.1 Follow up of Patients with Previous Gestational Diabetes
25 May 2011
B6.0 Children’s Services
There are services available for children and adolescents across Grampian
based at RACH, Dr Gray’s Hospital and Woolmanhill.
Any child up to the age of 14 with suspected diabetes should be referred the
same day to the receiving Paediatric Medical team at either RACH or
Dr Gray’s Hospital. Older children and adolescents should be referred to adult
services.
Local guidelines for the management of children with diabetes can be
accessed via the Grampian diabetes website at:
http://nhsgrampian.org/grampianfoi/files/RACHDiabeticChildrenManagement.
doc
Further information about the service and the children’s team can also be
obtained from Grampian Children’s Diabetes Service (http://www.diabetesscotland.org/grampian/home.html)
25 May 2011
Pre-pregnancy
and antenatal care
for women with diabetes mellitus
(General information)
Information for women
25 May 2011
25 May 2011
Planning a pregnancy?
Planning ahead for pregnancy is important for all, but for
women with diabetes we recommend extra care and
advice before conception and throughout pregnancy. This
will help to ensure a safe and successful pregnancy.
Before you become pregnant




If possible, blood glucose levels should be kept
between 4 to 6 mmol/l before meals and HbA1c should
have been stable and as near target as possible for
3 months before you stop using contraception.
If your blood glucose is not well controlled in early
pregnancy, the risk of stillbirth and miscarriage is
increased. It may also affect your baby’s early
development.
The target for most women for pre-pregnancy
glycaemic control should be an HbA1c of 42 to 53mmol/l
(around 6 to 7%) for 3 months before pregnancy.
Discuss your current medicines with your diabetes team
– you may have to stop or change medicines in
preparation for pregnancy (such as medicines for high
blood pressure).
Make sure you are up to date with routine retinal
screening.
Start taking folic acid 5mg each day (you need a
prescription for this strength). This helps normal
development in the very early weeks of pregnancy.
1
25 May 2011



Stop smoking. Your diabetes team or GP can refer you
to a cessation specialist.
Eat a healthy and balanced diet. A dietitian is on hand
for advice at the specialist clinic.
Arrange a specialist pre-pregnancy consultation.
Your specialist care team
At your pre-pregnancy consultation you will see a specialist
team comprising of:





Obstetrician
Diabetologist (doctor who specialises in diabetes)
Dietitian
Specialist diabetes midwife
Lab technician
What will happen at a
pre-pregnancy appointment?
You can discuss any questions you have about diabetic
pregnancy and receive advice.
We will test your blood for anaemia, immunity to rubella
(German measles), thyroid and kidney function as well as
an HbA1c test.
We will offer screening for any complications of your
diabetes such as problems with your eyes, feet and kidney
function (including microalbumin).
2
25 May 2011
Why should I keep my blood glucose normal?
Early pregnancy
From the time of conception (usually about 2 weeks after
the first day of your last menstrual period) until about
10 weeks, the developing baby is sensitive to very high
blood glucose levels. During this time, the major organs
are being formed.
Later in pregnancy
If blood glucosesugar is high, your baby can grow larger
than normal. This can lead to more difficult birth and may
be a reason for needing a caesarean section.
Haemoglobin A1c (HbA1c)
This is a measure of the average blood glucose over the
preceding two months or so. Ideally, it should be less than
53 mmol/l ( 7%) although this can be challenging to
achieve.
3
25 May 2011
Contact telephone numbers
If you have any questions about your health or care, you
can call us on:
Diabetic Clinic
Woolmanhill Clinic
 (01224) 555443 
Antenatal Clinic
Aberdeen Maternity Hospital
 (01224) 552743 
Useful websites
www.mydiabetesmyway.scot.nhs.uk
Provides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medical
Provides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable
for the quality of the information, resources or maintenance
of external websites. Any advice on external websites is
not intended to replace a consultation with an appropriately
qualified medical practitioner.
4
25 May 2011
25 May 2011
This leaflet is also available in large print
and on computer disk.
Other formats and languages can be
supplied on request. Please call Quality
Development on (01224) 554149 for a
copy. Ask for leaflet 0535.
Feedback from the public helped us to develop this leaflet.
If you have any comments or suggestions about how we
can improve this leaflet, please let us know.
Department of Diabetes
Aberdeen Royal Infirmary
Leaflet supplied by:
revised November 2010
©NHS Grampian
Quality Development, Foresterhill
25 May 2011
Type 1 and Type 2
diabetes and
pregnancy
(Detailed information)
Information for women
Department of Diabetes
Aberdeen Royal Infirmary
25 May 2011
25 May 2011
As a woman with Type 1 or Type 2
diabetes, what do I need to know
aboutbefore considering pregnancy?
Over 95% of babies born to diabetic mothers are healthy
and well. During pregnancy women are encouraged to
take as much responsibility for their diabetic care as
possible.
Both mums and infants need very intensive input before,
during and after pregnancy. Good glucose control is
especially important before and throughout your
pregnancy. Ideally your HbA1c should have been stable
and as near target as possible (42 to 53mmol/l, 6.0 to
7.0%) for 3 months before considering pregnancy.
We will offersee you an appointment for pre pregnancy
councelling regularly at our specialist Combined Diabetic
Antenatal Clinic (CDANC) and once pregnant you will be
most women are advised to attend for early review. early in
pregnancy. At the clinic, you may see an obstetrician,
diabetologist, diabetic specialist nurse, midwife, dietitian
and lab technicians.
As a rough guide, you will be seen every 2 to 4 weeks until
you are 28 weeks pregnant, fortnightly until 36 weeks and
then weekly until you have your baby. You can fax your
home blood glucose monitoring charts to the clinic and
discuss them over the phone.
Please be advised that these clinic visits can take
1 to 2 hours as there is a lot to discuss.
We will give you a copy of the care plan for your pregnancy
at your first our diabetes protocol at your booking visit. We
arrange your scans in line with the recommendations in
this protocol.
1
25 May 2011
During your pregnancy retinal screening, your eyes will be
checked more often. Retinal screening will be arranged for
you on three occasions. times during your pregnancy. This
is because occasionally there can be changes in your eye
during pregnancy which may need to be investigated
further. Your kidney and thyroid function will also be
monitored. by blood tests.
What about glucose control?
It is important to keep your blood glucose levels within the
normal range (fasting around 4 to 6mmol/l and 2 hours
after a meal less than 7.0mmol/l) for as much of the day as
possible. You should do this both before you become
pregnant and throughout your pregnancy.
Please be aware that this involves very regular blood
testing (often over 4 times a day), keeping to dietary
recommendations and having regular insulin (usually
4 times a day).
If you have Type 2 diabetes you may need a change to
your medication and may be advised to start insulin
treatment before you become pregnant. if required This
should help to improve your blood glucose control. Most
women with Type 2 diabetes will need to be on insulin
during their pregnancy. Some may manage excellent
control with diet and tablets.
2
25 May 2011
What about hypos in pregnancy?
For women with Type 1 diabetes, hypoglycaemia (blood
glucose less than 4mmol/l) is common in pregnancy. It can
happen more often and be more severe than it was before
you were pregnant. You should warn family members of
this and let them know how to treat hypoglycaemia.
Symptoms of hypoglycaemia include:
 Sweating

Anxiety

Palpitations

Poor concentration

Turning pale

Feeling hungry

Dizziness

Odd behaviour

Tingling of the lips or fingers

Headache.
During pregnancy, women may find that their warning
symptoms of hypoglycaemia become more difficult to
recognise. This may mean you cannot drive temporarily.
Please discuss this regularly with your diabetes team.
How to avoid hypos
Eat regularly
Missed or late meals are the most common cause of
hypos.
3
25 May 2011
Testing your blood glucose
Test at least 4 times a day and adjust your food intake or
insulin levels as advised by your care team.
Avoid spending long periods alone
Make sure you are in regular contact with people during
the day and that you are not alone overnight if possible.
Carry your dextrose energy tablets, Lucozade® or fruit
juice
Carry one of these at all times and tell family and friends
how to help you. You will also be given a glucagon kit with
instructions for your partner or family member on when and
how this should be used.
Take care when driving
Check your blood glucose before you drive, carry extra
glucose with you and try not to drive before a meal.
4
25 May 2011
What if my tests are high?
If your glucose levels are raised (over 10mmol/l) it is
important to monitor your urinary ketones.
Ketones can increase quickly during pregnancy. They can
harm your baby as well as making you ill.
Contact Ashgrove Ward for advice if you develop ketones.
See “How to contact us” at the end of this leaflet for more
details.
Please do not hesitate to contact your GP or the ward if
you are unwell.
Will my delivery be normal?
In Scotland one third of diabetic women have a vaginal
delivery and two thirds have caesarean sections. No matter
what type of delivery you have, we will monitor and
maintain your blood glucose closely throughout labour.
We will discuss delivery with you in the later stages of your
pregnancy. You should have your baby in hospital and
most will be delivered between 38 and 39 weeks (full term
is 40 weeks). We may need to induce labour at this point if
it shows no sign of beginning itself.
Once labour is established, you will need an insulin and
glucose drip to keep your blood glucose normal during
labour.
We will monitor your baby continuously during labour. This
is usually done by a machine called a cardiotocograph
(CTG). You will have two straps round your abdomen
which are connected to the CTG machine which picks up
the baby’s heartbeat.
All women with diabetes have their babies in hospital with
access to a neonatal unit. This is because your baby needs
5
25 May 2011
to have regular blood glucose measurements to make sure
these are not in the low range.
We will discuss delivery with you in the later stages of your
pregnancy. You should have your baby in hospital and
most will be delivered between 38 and 39 weeks (full term
is 40 weeks). We may need to induce labour at this point if
it shows no sign of beginning itself.
Once labour is established, you will need an insulin and
glucose drip to keep your blood glucose normal during
labour.
We will monitor your baby continuously during labour. This
is usually done by a machine called a cardiotocograph
(CTG). You will have two straps round your abdomen
which are connected to the CTG machine which picks up
the baby’s heartbeat.
Will the health of my baby be affected?
Most pregnancies in women with diabetes have a very
good outcome. Compared with the population as a whole
however, there is a very slightly increased risk of stillbirth
neonatal death and malformations in the infant. By making
sure that your blood glucose is controlled as well as
possible before and throughout your pregnancy, you can
reduce these risks near to the levels for non-diabetic
women.
Babies of mothers with diabetes tend to be bigger than
other babies. This is sometimes called macrosomia. The
blood glucose level of the mother is one of the major
factors affecting this growth. This is another reason why it’s
important to keep your blood glucose as near the normal
range as possible.
6
25 May 2011
Will my baby have diabetes?
Compared to non-diabetic women, there is only a very
slightly increased risk of your child developing diabetes in
later life.
No, not at birth. In fact, babies of mothers with diabetes
tend to have low blood glucose. For this reason your
baby’s glucose levels will be monitored around the time of
delivery.
What happens after my baby’s born?
Generally your experience will be the same as other
mothers. You will be able to hold your baby and begin
breastfeeding, if you choose to, as soon after delivery as
possible.
Babies go with their mums to the postnatal ward following
birth and are only admitted to the neonatal unit if blood
glucosesugar levels become difficult to maintain.
After delivery of your placenta, your insulin requirements
drop dramatically.
 In Type 2 diabetes, if insulin was used temporarily in
pregnancy this may be discontinued after delivery.

With Type 1 diabetes, you will be kept on a reduced
insulin infusion for a few hours after delivery and once
eating, your insulin requirements normally return to pre
preganacy levels.dose will be adjusted as needed.
Your blood sugars will be checked regularly until your
levels stabilise. When you resume your normal diet, you
should also be able to return to approximately your
7
25 May 2011
pre-pregnancy dose of insulin (a care plan will be written in
your notes before you have your baby).
Is breastfeeding possible
if I’ve got diabetes?
Yes. Just like for all other women, breastfeeding is
recommended for women with diabetes. It provides the
best nutrition for your baby and gives extra protection
against infection through your antibodies. Please be aware
that breastfeeding can reduce your blood glucose level and
that you may need to adjust your diet or insulin to prevent
hypoglycaemia.
Try keeping a snack nearby in case your blood glucose
levels drop during the feed. Following delivery, early
breastfeeding is recommended as this helps to prevent low
blood glucose levels in the baby.
What happens after I’ve had my baby?
A postnatal check up is arrangeddone 6 weeks after your
delivery. This check up is done at the antenatal clinic by
the specialist team you saw during pregnancy. Please
bring your blood glucose charts with you to discuss your
insulin requirements. At this check up, you can also
discuss contraception and any issues about your delivery.
8
25 May 2011
How to contact us
If you have any questions about your health or care, you
can talk to one of our staff on the numbers listed below:
Antenatal Clinic
Aberdeen Maternity Hospital
 (01224) 552743 
Ashgrove Ward
Aberdeen Maternity Hospital
 (01224) 554939 
Diabetic Clinic
Woolmanhill Hospital
 (01224) 555443 
Useful websites
www.mydiabetesmyway.scot.nhs.uk
Provides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medical
Provides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable
for the quality of the information, resources or maintenance
of external websites. Any advice on external websites is
not intended to replace a consultation with an appropriately
qualified medical practitioner.
9
25 May 2011
This leaflet is also available in large print
and on computer disk.
Other formats and languages can be
supplied on request. Please call Quality
Development on (01224) 554149 for a
copy. Ask for leaflet 0536.
Feedback from the public helped us to develop this leaflet.
If you have any comments or suggestions about how we
can improve this leaflet, please let us know.
Department of Diabetes
Aberdeen Royal Infirmary
Leaflet supplied by:
revised November 2010
©NHS Grampian
Quality Development, Foresterhill
25 May 2011
Gestational diabetes
Information for women
Department of Diabetes
Aberdeen Royal Infirmary
25 May 2011
25 May 2011
What is gestational diabetes.
Some women develop diabetes during pregnancy. This is
called gestational diabetes.
Gestational diabetes usually starts in the later stages of
pregnancy. It happens when the body can’t control its own
blood glucose level (this can also be called the blood sugar
level).
The hormone insulin is responsible for controlling blood
glucose levels. The hormones produced during pregnancy
block the action of insulin in the body. In women who
develop gestational diabetes, there is not enough extra
insulin produced to overcome the blocking effect.
Gestational diabetes can usually be controlled by changes
to your diet but some women may need to take tablets or
insulin therapy as well.
Why do I need to keep my
blood glucose down?
It is important to control the level of glucose in your blood
during pregnancy and keep it within the normal range.
Normal ranges in pregnancy are:
 Fasting - less than 5.5mmol/l
 2 hours after food - less than 7.0mmol/l (up to 35
weeks)
 2 hours after food - less than 8.0mmol/l (over 35
weeks).
1
25 May 2011
If there’s too much glucose in your blood, your baby’s body
may start to make extra insulin to try to cope with it. This
extra insulin can make the baby grow larger, making
delivery more difficult and so could cause injury to you and
your baby.
Also a baby who is making extra insulin may have low
blood glucose after they are born, which can affect them in
the first few hours of life.
How do I check my blood glucose?
At the Combined Diabetic Ante Natal Clinic (CDANC) we’ll
give you the equipment you need to do this and show you
how and when to do it. Your GP willcan provide repeat
prescriptions.
How can I control my blood glucose levels?
Healthy eating is very important to help you control your
blood glucose levels and help your baby get the nutrients
they need. A dietitian at CDANC will offer you personal
dietary advice.
Regular exercise such as 30 minutes walking a day, if you
are able, is also very beneficial.
2
25 May 2011
Aim to:
 Eat regular meals and have a variety of foods. Include
carbohydrate foods (such as bread, pasta, rice,
potatoes and cereal) at each meal but be careful to
avoid large portion sizes of these foods.

Higher fibre choices are best such as wholemeal bread
and pasta.

Eat 3 pieces of fruit and 2 portions of vegetables each
day.

Avoid sweet foods, biscuits and sugary drinks.
Include milk in your diet as part of your carbohydrate
allowance. Other good sources of calcium include cheese
and diet yoghurts (not low fat yoghurts as these are high
in sugar).
Include some oily fish 2 to 3 times a week (such as
mackerel, sardines, herring, pilchards or salmon).
Include foods rich in iron every day (such as lean red meat,
chicken, turkey, eggs, peas, beans, lentils and green leafy
vegetables). Avoid liver.
3
25 May 2011
Your specialist diabetic team
A specialist team is a group of healthcare professionals
with experience of supporting people with diabetes. In the
team there is:
 Obstetrician

Diabetologist (doctor who specialises in diabetes)

Dietitian

Specialist diabetes midwife

Lab technician
This team will provide you with routine care (such as
regular urine tests for protein and blood pressure checks)
during your pregnancy. You may also be offered a late
scan to check the size of your baby.
Will I need to take medication?
If you follow the advice of your specialist diabetes team but
your blood glucose levels are still too high, you may need
to start taking tablets or insulin. Your specialist diabetes
team will explain how to take the insulin and what its
effects will be.
4
25 May 2011
What happens during labour?
During labour, your blood glucose levels will be monitored
closely by an experienced team. If your diabetes is
controlled just by your diet, your labour will be managed as
normal., but Iif you need insulin during your pregnancy you
will have an insulin infusion during labour to ensure your
blood glucose remains normal. This is where a continuous
amount of insulin, balanced with glucose, is fed into your
blood through a drip.
Women with gestational diabetes sometimes have larger
than average babies. If this is the case, you may need to
be induced before your due date or have a caesarean
delivery. We will discuss this with you in the final weeks of
your pregnancy.
What happens after my baby is born?
Your baby is at risk of a low blood glucose after birth which
can be serious. Because of this, they will have a heel prick
test to check their blood glucose level. Your team will want
to monitor your baby’s blood glucose levels closely for the
first 24 hours. This may mean that your baby is taken to
the special care baby unit. Your baby isn’t being tested for
diabetes during this time, but is being monitored to see if
extra feeds are needed to stabilise their blood glucose
levels.
You probably won’t have diabetes after you’ve given birth
but we may ask you to monitor your blood glucose. If
you’ve been taking insulin, you should be able to stop after
your baby’s birth.
5
25 May 2011
You should be offered an oral glucose tolerance test
(OGTT) 6 months after birth to check that your blood
glucose levels have gone back to normal.
Can I breastfeed?
Breastfeeding is generally thought to be the best start for
babies and there’s no reason why you shouldn’t breastfeed
your baby if you have had gestational diabetes. It provides
the best nutrition for your baby and gives extra protection
against infection through your antibodies.
What happens if I get pregnant again?
If you’ve had gestational diabetes, it is more likely that
you’ll develop it again in future pregnancies. You will be
offered early screening by an oral glucose tolerance test in
future pregnancies.
You also have a higher chance of developing type 2
diabetes in later life if you’ve had gestational diabetes. To
help reduce your risk, eat healthily, aim to keep your
weight down and include some physical activity in your
day.
6
25 May 2011
Who is at particular risk of developing
gestational diabetes?GDM?
The factors below increase the risk of developing
gestational diabetes:

Being overweight (body mass index more than 30).

Having a previous large baby weighing 4.5kg or more.

Gestational diabetesGDM in a previous pregnancy.

Family history of diabetes (in first degree relatives such
as your parents, brother, sister).

Family origin with a high prevalence of diabetes (South
Asia, Black Caribbean, Middle Eastern).
7
25 May 2011
How to contact us
If you have any questions about your health or care, you
can talk to one of our staff on the numbers listed below:
Antenatal Clinic
Aberdeen Maternity Hospital
 (01224) 552743 
Ashgrove Ward
Aberdeen Maternity Hospital
 (01224) 554939 
8
25 May 2011
Useful websites
www.mydiabetesmyway.scot.nhs.uk
Provides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medical
Provides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable
for the quality of the information, resources or maintenance
of external websites. Any advice on external websites is
not intended to replace a consultation with an appropriately
qualified medical practitioner.
9
25 May 2011
This leaflet is also available in large print
and on computer disk.
Other formats and languages can be
supplied on request. Please call Quality
Development on (01224) 554149 for a
copy. Ask for leaflet 1250.
Feedback from the public helped us to develop this leaflet.
If you have any comments or suggestions about how we
can improve this leaflet, please let us know.
Department of Diabetes
Aberdeen Royal Infirmary
Leaflet supplied by:
November 2010
Grampian
Quality Development, Foresterhill
©NHS
25 May 2011
Section C: Glycaemic
Control
C1.0 Targets for Glycaemic Control .............................................
C1.1 Glycosylated haemoglobin..............................................
C1.2 Conversion Table for HbA1c % to mmol/mol ..................
C2.0 Monitoring ..............................................................................
C2.1 Patients with Type 2 Diabetes controlled by
diet or oral medication ....................................................
C2.2 Patients with Insulin-treated Diabetes.............................
C2.3 Adjustment of insulin dose ..............................................
C2.4 Ketone testing in insulin-treated patients ........................
C2.4.1 Management of results: ......................................
C2.5 BLOOD GLUCOSE METERS / LANCERS/
LANCETS.......................................................................
. C3.0 Hypoglycaemic Drug Therapy ............................................
C3.0 Hypoglycaemic Drug Therapy ..............................................
C3.1 Oral hypoglycaemic drugs ..............................................
C3.1.1 Comparative Costs of Treatments for
Type 2 Diabetes..................................................
C3.2 Insulin regimens ..............................................................
C3.3 Types of Insulin ..............................................................
C3.4 Summary of insulin classification ....................................
C3.4.1 Insulin costs ........................................................
C4.0 Hypoglyaemia ........................................................................
C4.1 Causes of hypoglycaemia...............................................
C4.2 Symptoms of hypoglycaemia ..........................................
C4.3 Hypoglycaemia unawareness .........................................
25 May 2011
C4.4 Treatment of hypoglycaemia ..........................................
C4.5 Hypoglycaemia and sulphonylureas ...............................
C4.6 Nocturnal hypoglycaemia ...............................................
C4.7 Rebound Hyperglycaemia ..............................................
C4.8 Avoidance of hypoglycaemia ..........................................
C4.9 Driving and hypoglycaemia.............................................
C4.10 Exercise related hypoglycaemia ...................................
C5.0 Management of Diabetic Emergencies in the
Community ............................................................................
C6.0 Management of Diabetes in Hospital ...................................
C6.1 Introduction .....................................................................
C6.2 Diabetic emergencies ....................................................
C6.2.1. Diabetic Keto Acidosis (DKA) ............................
C6.2.2 Hyperosmolar Hyperglycaemic Non
Ketotic syndrome (HHNS)...................................
C6.2.3 Hypoglycaemia in hospital ..................................
C6.2.4 Prevention of Hypoglycaemia during
Hospital Admission .............................................
C6.2.6 Prevention of Hypoglycaemia during
Hospital Admission .............................................
C6.3 Management of Diabetes during intercurrent
illness .............................................................................
C6.3.1 Type 1 diabetes ..................................................
C6.3.2 Type 2 diabetes ..................................................
C6.3.3 Variable rate intravenous insulin
infusion ...............................................................
6.3.4 PROTOCOL FOR VARIABLE RATE
INTRAVENOUS INSULIN
INFUSIONS ........................................................
C6.4 Guidelines for diabetes management during
procedures requiring fasting ...........................................
25 May 2011
C1.0 Targets for Glycaemic Control
Epidemiological studies show that the risks of arterial
disease and micro vascular complications in people with
diabetes are related to the extent of hyperglycaemia.
The Diabetes Control and Complication Trial (DCCT) and
UK Prospective Diabetes Study (UKPDS) have shown that
optimal blood glucose control in the early years after
diagnosis substantially reduces the risk of development
and progression of complications in people with diabetes.
The overall goal should therefore be the optimisation of
blood glucose without undue hypoglycaemia. The extent
to which this is pursued by the individual patient will
depend on motivation, practical aspects of diabetes
management (e.g. insulin delivery and self-monitoring),
risks related to hypoglycaemia and concomitant comorbidity. Long term outcome studies are not available for
some of the newer therapeutic agents and their long term
benefits are uncertain.
C1.1 Glycosylated haemoglobin
Overall glycaemic control is best measured by HbA1c,
which provides an index of the average blood glucose
concentration over the preceding two months. Reference
ranges for HbA1c vary according to method of assay.
From June 2009 HbA1c assays were standardised and
reported in mmol/mol as well as %. Dual reporting in both
units will continue for around 2 years to allow the diabetes
community and others to adapt to the new units.
25 May 2011
Educational leaflets for patients, lab staff and clinical staff
are available at Diabetes in Scotland
The range for HbA1c in people who do not have diabetes
is up to 42 mmol/mol (6%). The DCCT and UKPDS
intensively treated groups achieved HbA1c levels of 53
mmol/mol (7%) but this may not be achievable without
undue adverse effects. Any reduction of elevated
glycosylated haemoglobin will produce a significant
reduction in microvascular complication risk.
To achieve optimal HbA1c levels the following blood
glucose targets are likely to be required:
• Fasting plasma glucose in Type 2 patients ≤ 5.9 mmol/l
• Pre-prandial blood glucose 4-7 mmol/l
• 2 hours postprandial blood glucose 7-9 mmol/l
A single target figure may be unhelpful as this may vary
between individuals depending on the:
 Quality of life that would have to be sacrificed to
reach that target.
 Extent of side effects
 Resources available for management
In order to set realistic targets that patients can relate to
and are motivated to achieve people with diabetes should
be:
 Involved in decisions as to their individual HbA1c
level, which may be above or below that set for the
general population of people with diabetes
 Offered therapy (lifestyle and medication) to assist
in achieving and maintaining their HbA1c target
 Informed that any reduction in HbA1c towards the
agreed target is advantageous to future health
25 May 2011
In conclusion patients with diabetes should be
encouraged to maintain an HbA1c less than 53
mmol/mol (7%) unless the resulting side effects of their
efforts in achieving this significantly impair their quality
of life.
An HbA1c target of 53 mmol/mol (7.0%) among people
with Type 2 diabetes is reasonable to reduce risk of
microvascular and macrovascular disease. A target of
48 mmol/mol (6.5%) may be appropriate at diagnosis.
Targets should be set for individuals in order to balance
benefits with harm, in particular hypoglycaemia and
weight gain. Recent evidence suggests that tight control
may increase overall mortality:
25 May 2011
25 May 2011
C1.2 Conversion Table for HbA1c % to mmol/mol
%
4.0
5.0
6.0
6.5
7.0
7.5
8.0
9.0
10.0
mmol/mol
20
31
42
48
53
59
64
75
86
Information for patients and for healthcare professionals
can be found via the following factsheets:
Change In HbA1c Reporting – Information for People with
Diabetes Factsheet
Change In HbA1c Reporting – Information for Healthcare
Professionals Factsheet
25 May 2011
C2.0 Monitoring
Self Monitoring of blood glucose (SMBG) has an important
role in the management of some individuals with diabetes.
It should certainly not be seen as essential for everyone
with diabetes. The evidence of value in improving HbA1c
patients is limited (SHTG Evidence Note 26). Indeed,
when used inappropriately, it can lead to added stress to
the patient with no benefit.
No matter what the type of diabetes or the treatment
modality being utilised SMBG will only be of value if used
by a motivated, well educated patient. It should only be
initiated as part of a package of care that should include
structured education.
In these circumstances SMBG is an integral part of
effective patient education packages and enhances the
effective use of many therapies and lifestyle interventions.

Home blood glucose monitoring may help an
individual to take control of their condition and
can inform patients of the effects of eating certain
foods or exercise on blood glucose. Conversely it
may have no impact on control and has been
associated with negative psychological outcomes.
It should only be utilised in conjunction with an
appropriate educational package.
25 May 2011
C2.1 Patients with Type 2 Diabetes controlled by
diet or oral medication



For most patients regular home blood glucose
testing is not be appropriate. Patient choice and
clinical need should be taken into account. When
glycaemic control is stable and HbA1c on target,
regular testing may not be essential but may help
some patients maintain optimal control.
SMBG needs to be initiated by the clinician and
patient in conjunction with a structured education
package and in the context of clear outcome
benefits.
Home blood glucose monitoring may help an
individual to take control of their condition and can
inform patients of the effects of eating certain foods
and exercise on blood glucose. Some individuals
will monitor blood glucose to empower them to
make changes to lifestyle and thus improve
glycaemia.
How often and when should patients monitor blood
glucose?


When HbA1c is rising or when treatment is
changing, eg to insulin or when there is intentional
lifestyle change, blood glucose monitoring 2-3 times
per week at different times of day (e.g. fasting, 2
hours after eating) may be helpful up to a maximum
of 4 tests every fourth day or one test per day.
Patients should be encouraged to record and
understand the results of their blood testing and
take action as agreed with their diabetes team.
Situations which may require more intensive blood glucose
25 May 2011
monitoring:
Patients should be advised to test blood glucose at least
daily and possibly up to 4 times per day in the following
situations:
 During significant illness or if ketonuria present
 During times of psychological / emotional stress
(e.g. exams, driving tests) If the patient is on
sulphonylurea and is at increased risk from
hypoglycaemia (e.g. taxi / lorry driver / operating
heavy machinery)
 During pregnancy or pre-pregnancy planning
 To assess changes in glucose control due to
medications and lifestyle changes
 Before / After moderate physical activity
QIS Evidence note on clinical and cost-effectiveness of
self-monitoring of blood glucose (SMBG) for non-insulin
treated Type 2 diabetes – see link below.
SHTG Evidence Note 26
Blood glucose targets – these vary between individuals –
(See section C1.1)
Urine Ketone Testing
This is not usually required in patients with Type 2 diabetes
but where there is concern that the patient may have
evolving Type 1 diabetes or becoming "insulin-requiring"
the diabetes team may recommend urine ketone
monitoring.
C2.2 Patients with Insulin-treated Diabetes
Patients with diabetes who utilise insulin need to practice
25 May 2011
SMBG so as to titrate insulin dose and avoid the extremes
of glycaemia. By correctly interpreting SMBG and making
adjustments to insulin dose and lifestyle control can be
maximised and long term outcomes improved. For this to
be affected then the individual with diabetes utilising insulin
needs to be well educated and empowered to make
changes.
Home blood glucose monitoring is strongly recommended
for people with insulin-treated diabetes, as it enables the
individual to take control of their condition and can help
highlight situational changes requiring insulin adjustment.
How often should patients monitor blood glucose?
A blood glucose test should only be taken if it is to be used
in decision making.
Monitoring should be encouraged at a frequency that is
useful to the particular individual with diabetes
remembering that:



Frequency of monitoring will vary between patients
depending on lifestyle, motivation and need.
Patients should be encouraged to do at least one
test per day at different times or 4 times a day every
3rd or 4th days.
At times some patients wishing to have greater
control or flexibility may choose to test up to 4 times
per day (also see below for situations where more
testing may be required)
When should patients test blood glucose?
Recommended times of testing would be before meals (i.e.
breakfast, lunch and tea), before bed and sometimes 2
25 May 2011
hours after eating. Patients should be encouraged to keep
a record of results including details such as time of day,
activity and dietary intake.
Situations which may require more intensive blood glucose
monitoring









Therapeutic change
During illness or ketonuria
Before /After physical activity
Before driving (any distance not just long journeys)
Psychological / emotional stress (e.g. exams, driving
tests)
Impaired hypoglycaemic awareness or recurrent
hypoglycaemia.
Changes in lifestyle – job / shift patterns
Pregnancy or pre-pregnancy planning
Using an insulin pump
C2.3 Adjustment of insulin dose
Individuals with diabetes should be empowered by their
team of professionals to interpret the results of SMBG and
be able to make changes to their insulin regime.
C2.4 Ketone testing in insulin-treated patients
Patients on insulin should be advised to keep an “in date”
supply of urine ketone-testing strips. They may have
access to blood ketone testing strips for use in specialised
circumstances.

If blood glucose 17 or above or during intercurrent
illness (e.g. cold /flu/ UTI etc) urine should be tested
25 May 2011
for ketones.
Routine ketone monitoring is not required however it
is advised to monitor during periods of sustained
hyperglycaemia.
C2.4.1 Management of results:
Urine Ketones:
1. If TRACE or SMALL - observe.
2. If MODERATE or LARGE – extra insulin is probably
required.

If blood glucose still 17 or above after 3 hours – retest for ketones. If ketones are still present (i.e.
moderate or large), further extra insulin may be
required and if any uncertainty with the best course
of action specialist help should be sought.
If blood glucose and urine/blood ketones are
persistently elevated the patient is at significant risk of
developing diabetic ketoacidosis and specialist advice
will be required
25 May 2011
C2.5 BLOOD GLUCOSE METERS / LANCERS/ LANCETS
Recommendations DSN Group June 2010 (Review Date June 2011)
METER NAME
AVIVA
CONTOUR
FREESTYLE ONE TOUCH
NANO
FREEDOM
ULTRAEASY
LITE
Will not accept No coding
No coding
Small in size
A ADVANTAGES
POSSIBLE
DISADVANTAGES
wrong batch or
out of date test
strips
required
required
Multiclik lancet
reduces risk of
needlestick
injury
Various
colours
Large window
displaying
results
Small in size
Unsuitable for
patients on
renal dialysis
Requires
manual coding
Aviva
Usually for short
term use and not
normally put on
repeat
prescription
Useful situations:
Steroid therapy
Chemo therapy
Illness
Holidays
Accessory kit with
lancer device and
carry case required
Care needed
when placing
strip in meter
Requires
coding by chip
STRIP NAME
Various
colours
TRUE ONE
Meter/strips all
in one
Contour
FreeStyle Lite One Touch
TRUEone
25 May 2011
Ultra
£14.53 / 50
STRIP COST
£14.49 / 50
£14.74 / 50
£14.62 / 50
LANCER
Multiclik
Microlet
Freestyle
One Touch
Ultrasoft
LANCETS
MULTICLIK
BOX = (204)
MANUFACTURER
ROCHE
ASCENCIA
MICROLET2
or BD
Microfine
BAYER
FREESTYLE
LANCET
or BD
Microfine
ABBOTT
ONE TOUCH
ULTRASOFT
or BD
Microfine
LIFESCAN
CARELINE
0800 701000
0845 006030
0500 467466
0800 121200
£14.36 / 50
TRUEone
Accessory Kit order via
manufacturer
BD Microfine
HOME
DIAGNOSTICS
0800 0858808
Alternative meters could be considered for patients in these categories:
Type 1
Diabetes
Meter Name
Advantages
Test Strips
Optium Xceed
Checks blood glucose
Optium Plus
£14.53 /
B.G. strips
50
Optium Ketone £19.55 /
Checks blood ketones
Cost
Contact Details
Abbott
0500 467466
25 May 2011
Useful in pregnancy
test strips
10
Visual
Cleverchek
Gives verbal
Cleverchek
£16.30 / BBI Healthcare
Impairment
commands and results
50
01792 229333
Poor
Compact Plus
Can be operated with
Compact Plus £14.88 / Roche
Dexterity
one hand
51
0800 701000
National procurement of blood glucose meters and test strips is currently being undertaken
by NHS Scotland.
The meters listed are recommended for home blood glucose monitoring in NHS Grampian.
It is recommended that patients use one type of meter only as results can vary from one
meter to another.
When test strips are changed please ensure previous ones are discontinued and removed
from the repeat prescription. Some meters will accept other test strips which will
produce inaccurate results.
Please ensure patients are aware if their meter requires re-coding for each new batch of
test strips.
Blood sample size and range of results differ with each meter.
25 May 2011
It is recommended that patients register their meter with the manufacturing company. This
can be done by telephone or completing and posting the registration card.
Most Company Carelines will support patients with simple queries regarding their blood
glucose testing equipment. They also supply software to download test results, free
replacement batteries and new meters in the event of product recall.
It is recommended that meters be quality controlled regularly. Quality control solution is
available on request from the manufacturing company.
Health care workers / others involved with blood glucose monitoring
The Unistix 3 single use lancets are recommended for use by any care worker involved
with blood glucose monitoring. They can be ordered as follows:
 PECOS 052233 Blood lancet disposable Unistik3 (FZT069)
or
 On stock order GP10a for practices
or
 On GP10 for a named patient
25 May 2011
The Multiclik lancer device supplied with the Accuchek Aviva Nano meter can be used by
others involved with blood glucose monitoring e.g. family members. The lancets for this
device are contained within a drum, therefore reducing the risk of needlestick injury.
25 May 2011
25 May 2011
C3.0 Hypoglycaemic Drug Therapy
C3.1 Oral hypoglycaemic drugs
These drugs are suitable for people with Type 2 diabetes
when blood glucose control through lifestyle measures
alone proves inadequate. Even when taking
hypoglycaemic drugs lifestyle issues remain of key
importance.
Since in practice the majority of patients are overweight,
metformin is usually the drug of first choice.
Sulphonylureas would be the usual second choice due to
cost and safety factors. Pioglitazone or DPP 4 inhibitors
may be an alternative in obese patients. However, recent
safety concerns re: the glitazones (heart failure and
reduced bone density) and the limited clinical experience
with DPP 4s (as well as cost factors) place these agents as
third choice for possible use as triple combination therapy
(in addition to metformin and sulphonylureas), in patients
who are reluctant to go on to insulin.
Early sulphonylurea treatment may be appropriate in the
thin symptomatic patient without ketonuria.
Patients should be educated about their drugs and should
carry documentation of any risk of hypoglycaemia. The risk
of hypoglycaemia is present when using sulphonylureas
alone or with any combination of oral agents with
sulphonylureas.
25 May 2011
The new treatments for Type 2 diabetes on the market at
the present time have limited long term outcome data to
support them and should be used with a degree of caution.
Oral medication is often continued once insulin therapy has
been commenced in the treatment of Type 2 diabetes. The
SIGN algorithm is attached over and each of the drug
classes will be considered in the following pages.
25 May 2011
Algorithm for Glucose-Lowering in People with Type 2 Diabetes
25 May 2011
Metformin
Action
Metformin works principally by reducing insulin resistance.
Indications
Primary drug treatment of overweight Type 2 diabetes. As an adjuvant to
other hypoglycaemic therapy in Type 2 patients. Metformin may be continued
in some obese patients with Type 2 diabetes who ultimately require insulin
therapy, to maximise insulin sensitivity and minimise weight gain on insulin.
Side Effects
Diarrhoea, lethargy, anorexia, malabsorption of B12 and folate. Lactic
acidosis is a very rare but often fatal side effect. It occurs almost exclusively in
alcoholics, patients with renal or severe cardiac failure, liver disease, sepsis,
shock or recent myocardial infarction.
Caution
Contraindicated in renal impairment (creatinine >150µmol/l or eGFR <30
ml/min/1.73 m2), severe liver disease and alcoholism. Discontinue temporarily
during severe inter-current illness. Discontinue for 48-hours following the
injection of x-ray contrast media.
Dose
Initially 500mg daily with or after main meal, increasing gradually in 500mg
increments to a maximum of 1g tds as required for good glycaemic control.
The dose is often limited by diarrhoea.
Extended Release Metformin (Glucophage SR, dose 500mg to 2gram daily) is
restricted for use to patients intolerant to immediate release metformin or for
patients for whom a once daily preparation offers a clinically significant
advantage over immediate release metformin. This new formulation appears
to have similar short-term efficacy to immediate-release metformin. Evidence
of improved gastrointestinal tolerability is not convincing and it is more
expensive than the immediate-release formulation. However, it may be useful
in those who are poor at remembering tablets as a once daily dose may aid
compliance.
Metformin is also available in combination tablets with pioglitazone
(Competact). The use of these tablets is not recommended unless essential to
aid compliance in certain patients
Metformin and intravenous contrast studies
Contrast studies such as peripheral or coronary angiography and CT head
scan with iv contrast, are associated with a small risk of acute renal failure
that could result in the development of lactic acidosis in patients on Metformin
therapy. Therefore, Metformin should be discontinued after such contrast
studies for 48 hours or until renal function returns to normal. It is essential
25 May 2011
that the Radiology Department is aware of Metformin therapy and current
eGFR in advance. In patients with significant renal impairment, (eGFR <50)
ensure adequate hydration (eg normal saline 100 ml/hr 4 hours before and 24
hours afterwards) and discontinue any potential nephrotoxic drugs such as
ACE inhibitor for 24-48 hours after the procedure.
25 May 2011
Sulphonylureas
Sulphonylureas remain a very important drug in the treatment of Type 2
diabetes and should be considered at an early stage after Metformin.
Action
Potentiates the pancreatic β cell insulin release in response to
glucose.
Indications Primary drug treatment of non-obese patients with Type 2
diabetes. Primary drug treatment of overweight Type 2 patients
unable to take usual first line agents. As adjuvant therapy with
other agents.
Side Effects Hypoglycaemia, weight gain, Other side effects are rare.
Drugs
The three most commonly used sulphonylureas in Grampian are
Gliclazide, Glipizide and Glimepiride, the last having the
advantage of a once daily single tablet dose. Gliclazide is also
available in a once daily dosage version which may aid
compliance in some patients. Chlorpropamide and
Glibenclamide are particularly prone to cause hypoglycaemia
and should not be initiated, and their continued use should be
reviewed periodically.
Doses
It is usually appropriate to start with a small dose before
breakfast, increasing progressively according to blood glucose
response. The drug should always be taken before meals,
ideally 20 to 30 minutes before eating.
Glimepiride 1-6 mg as a single daily dose.
Gliclazide
40-320mg daily (doses > 160mg should be
divided). Also available as a 30mg modified
release tablet (equivalent to 80 mg of standard
preparation) – to achieve maximum dose range
(120mg), patient required to ingest up to 4 tablets
before breakfast.
Glipizide
2.5-20 mg (doses >10 mg should be divided).
Maximum daily dose 10mg twice daily.
25 May 2011
Thiazolidinediones
Action:
Acts at the level of the PPAR-gamma receptor to promote
insulin sensitivity. To be effective, patients require to have
sufficient endogenous insulin production. The maximum
therapeutic benefit may not be apparent until after eight weeks.
Pioglitazone is used to treat adult patients who have Type 2
diabetes, particularly in those who are overweight.
Pioglitazone, can also be used in combination with insulin.
Contra-indicated in patients with left ventricular impairment,
heart failure or high risk of fractures. Warn a person prescribed
a thiazolidinedione about the possibility of significant oedema
and consider alternatives if this develops. (Rosiglitazone has
had its marketing authorization withdrawn in Europe)
Indications Thiazolidinediones can be used as monotherapy although
Metformin is the drug of first choice
Thiazolidinediones may be added to
 the combination of metformin and a sulfonylurea where
insulin would otherwise be considered but is likely to be
unacceptable or of reduced effectiveness because of
employment, social or recreational issues related to
putative hypoglycaemia
– barriers arising from injection therapy or other personal
issues such as adverse experience of insulin in others
– those likely to need higher insulin doses or with barriers
to insulin arising from particular concerns over weight
gain (namely those with obesity or abdominal adiposity)
 a sulfonylurea if metformin is not tolerated
 metformin as an alternative to a sulfonylurea where the
person’s job or other issues make the risk of
hypoglycaemia with sulfonylureas particularly significant.
Side-effects Significant weight gain and fluid retention; associated with loss
of bone mass and are associated with significantly higher risk of
distal fractures in women.
Caution
Avoid in hepatic impairment – Do not initiate if AAT≥ 2.5 x upper
normal limit and therefore worth checking LFT’s before initiating
therapy and as BNF states “periodically” thereafter.
Liver toxicity is however rare.
If AAT is ≥ 3x upper normal limit, therapy should be
discontinued.
Dose
Pioglitazone (Actos) - 15-45mg once daily. Pioglitazone 15mg
is available in combination with Metformin 850mg (Competact)
25 May 2011
and can be used as 1 tablet twice daily. Pioglitazone should be
continued only if a HBA1c reduction of 5.5 mol/mol is achieved
at 6 months.
Drugs that affect the incretin system
Incretin hormones [eg, glucagon-like peptide-1 (GLP-1) and glucosedependent insulinotropic polypeptide (GIP)] regulate glucose homeostasis by
increasing insulin synthesis and release from pancreatic beta cells and
decreasing glucagon secretion from pancreatic alpha cells. Decreased
glucagon secretion results in decreased hepatic glucose production. Under
normal physiologic circumstances, incretin hormones are released by the
intestine throughout the day and levels are increased in response to a meal;
incretin hormones are rapidly inactivated by the Dipepidyl Peptidase 4 (DPP4) enzyme.
GLP-1-based therapies affect glucose control through several mechanisms,
including slowed gastric emptying, regulation of postprandial glucagon,
reduction of food intake, and enhancement of glucose-dependent insulin
secretion. These agents do not cause hypoglycaemia, in the absence of
therapies that otherwise cause hypoglycaemia
DPP-4 Inhibitors
Dipeptidyl peptidase 4 (DPP-4) Is a ubiquitous enzyme that deactivates a
variety of other bioactive peptides, including GIP and GLP-1; therefore, its
inhibition could potentially affect glucose regulation through multiple effects.
Sitagliptin is the only agent licensed for use in the UK and approved by the
Grampian Joint Formulary Committee. Vildagliptin (twice daily dosing and
liver function test monitoring) and Saxagliptin (SMC approved only for 2nd line
use with metformin; modest efficacy and marginal unit cost advantage) were
both currently deemed unworthy of inclusion when considered by the
Grampian Joint Formulary Committee.
Action:
Inhibits dipeptidyl peptidase 4 (DPP-4) enzyme resulting in
prolonged active incretin levels.
Indications:
1
May be used in combination with metformin when diet and
exercise, plus metformin, do not provide adequate glycaemic
control. It should be restricted to use in patients only when the
addition of sulphonylureas is not appropriate (intolerance or
significant risk of hypoglycaemia or its consequence – certain
jobs like heavy machinery use, working at heights etc.
25 May 2011
2
In combination with thiazolidinediones or sulphonylurea when
diet and exercise and maximum tolerated dose do not prove
adequate and metformin contraindicated or not tolerated.
3
Sitagliptin only is licensed for triple therapy in combination with
Metformin and sulphonylurea when dual therapy is
inadequate to maintain glycaemia control (as an alternative to
other agents such as thiazolidinediones)
4.
Sitagliptin can be used as monotherapy in exceptional cases
when metformin and sulphonylurea use is inappropriate due to
contraindications or intolerance.
Efficacy:
As assessed by measurement of HbA1c, is similar to
sulphonylurea and thiazolidinedione drugs added at this stage in
therapy. It appears to have minimal effects on body weight.
Consider withdrawing DPP-4 inhibitor therapy if the person has
not had a beneficial metabolic response (a reduction of at least
5.5 mmol/mol points in HbA1c at six months.
Side effects: Seems to be well tolerated with minor headaches and nausea in
<5%. Hypoglycaemia risk is minimal with Metformin but
significant when used with sulphonylurea.
Cautions:
Gliptins are not recommended in patients with moderate to
severe renal failure (GFR <50ml/min). Not recommended in
severe hepatic failure.
Additional cautions for Vildagliptin:
Not recommended in hepatic impairment, including patients with ALT >3x
upper limit of normal. It is recommended that LFTs are monitored three
monthly in the first year and periodically thereafter. Not recommended in
patients with moderate cardiac failure (NYHA class III-IV). Due to rare reports
of skin lesions in animal studies, monitoring of skin disorders such as
blistering or ulceration is recommended.
GLP-1 Analogues:
Exenatide and Liraglutide
Action:
Exenatide and Liraglutide are analogues of the hormone incretin
(glucagon-like peptide 1 or GLP-1) which increases insulin
secretion, slows gastric emptying, and may decrease food
intake
Indications: Both agents may be used with metformin and/or sulphonylureas
in patients who have not achieved adequate glycaemic control
on maximally tolerated doses of these oral therapies. Liraglutide
25 May 2011
may also be used in combination with metformin and
pioglitazone. These are considered as a third line
hypoglycaemic agent e.g. where a history of significant cardiac
problems, or a fear of adverse cardiac risks, mitigates against
use of other agents. These are injectable agents and could be
considered at the point where insulin therapy would be suitable
in selected individuals who have a BMI >30 and there are
specific psychological, biochemical or physical problems due to
the high weight. Continue exenatide/liraglutide therapy only if a
beneficial metabolic response (at least 5.5 mmol/mol points
HbA1c reduction in 6 months and a weight loss of at least 5% at
1 year) occurs and is maintained.
“Careful clinical judgement must be applied in relation to people
with long duration of Type 2 diabetes on established oral
glucose-lowering drugs with poor glycaemic control (>10 years,
these individuals being poorly represented in published studies)
to ensure insulin therapy is not delayed inappropriately for the
perceived benefits of GLP-1 agonists.”(SIGN 116 6.9.2.)
Side effects: Hypoglycemia (with concurrent sulfonylurea therapy 14% to
36%; frequency similar to placebo with metformin therapy). See
advice on Driving - in Section B3.1.
Significant Nausea 40% - may be dose-related and may
decrease in frequency/severity with gradual titration and
continued use.
2
Contraindicated in severe renal failure (eGFR <30 ml/min/1.73 m )
Dose:
Exanatide
Initial: 5 mcg subcutaneous injections twice daily within 60
minutes before main meals at least 6 hour apart; after 1 month,
may be increased to 10 mcg twice daily as a maximum.
Liraglutide
A starting dose of liraglutide 0.6mg daily is recommended to i
mprove gastro-intestinal tolerability. After at least one week, the
dose should be increased to 1.2mg daily. Liraglutide is
administered once daily at any time, independent of meals, and
can be injected subcutaneously in the abdomen, in the thigh or
in the upper arm.
The Grampian Formulary does not recommend Liraglutide
1.8mg daily for the treatment of people with Type 2 diabetes
mellitus.
25 May 2011
Prandial glucose regulators
Action:
These agents act as insulin secretagogues, potentiating the
post-prandial secretion of insulin that is impaired in the Type 2
diabetes. May be considered rarely for people with non-routine
daily lifestyle patterns (creating difficulty with sulphonylureas) to
assist in attaining glucose control to their individual target.
Indications: Repaglinide – As monotherapy or in combination with metformin
`
Nateglinide – In combination with metfomin
Side effects: Both agents can precipitate hypoglycaemia
Caution:
Avoid in severe hepatic impairment
Dose
Repaglinide (Novonorm) -initially 500mcg within 30 minutes
before main meals (1mg if transferring from another oral
hypoglycaemic), adjusted according to response at 1-2 week
intervals. Up to 4 mg as single dose; max daily dose 16mg.
Nateglinide (Starlix) - initially 60 mg 3 times daily within 30 minutes before
main meals; adjust according to response to maximum 180mg 3 times daily.
Acarbose
Action
An alpha-glucosidase inhibitor which acts within the gut to slow
digestion and absorption of carbohydrates.
Indications Primary drug treatment of patients with Type 2 diabetes
(especially the obese) if other drugs are contraindicated. As an
adjuvant to other oral agents or insulin.
Side effects Flatulence and GI disturbance. As mono therapy it does not
cause hypoglycaemia.
Caution
Insulin or sulphonylurea induced hypoglycaemia in patients
taking acarbose must be treated with glucose (dextrose)
Dose 25-50mg daily increased very gradually to 50-100mg tds according to
tolerance.
25 May 2011
C3.1.1 Comparative Costs of Treatments for Type 2 Diabetes
Comparative 28 Day Treatment Costs for Type 2
Diabetes
Gliclazide 80mg x 1
Glimepiride 2mg x 1
Metformin 1g x 2
Gliclazide MR 60mg x 1
Humulin I 20 units x 1
Metformin MR 2g x 1
Insulatard 20 units x 1
Lantus 20 units x 1
Levemir 20 units x 1
Pioglitazone 15mg x 1
Sitagliptin 100mg x 1
Exenatide 10mcg x 2
Liraglutide 1.2mg x 1
0
10
20
30
40
50
60
70
80
£
Figures are taken from MIMs March 2011 and Scottish Drug Tariff March 2011. They do not
consider any costs of additional materials, education, monitoring, wastage etc. It should also
be noted that ‘typical’ daily doses are only indicative and somewhat arbitrary, and drugs are
frequently used in combinations rather than as straight alternatives.
The price of metformin 1g twice daily used in the above graph is the cost if a pack size of 84
is used to dispense from. The price would be greater (£4.24) if a pack size of 28 was used.
The reality is that metformin is dispensed in both 84’s and 28’s and the actual cost to NHS
Grampian was £3.76 for the period Oct – Dec 2010 (PRISMs).
Insulin costs are all based on the prices of 5 x 3ml cartridges.
25 May 2011
C3.2 Insulin
regimens
Initiation of insulin
Patients with Type I diabetes are normally commenced on human insulin or
an insulin analogue, in either a twice daily or a multiple injection regimen. The
choice of the initial regimen and subsequent modifications should be made in
consultation with the patient, taking due regard of the patient’s occupation and
lifestyle. The precise insulin formulation may be determined by the patient’s
preferred insulin delivery device. Most patients prefer to use pen devices.
Insulin Treatment in Type 2 Diabetes
Patients with Type 2 diabetes may need insulin when oral agents are
insufficient to achieve satisfactory glycaemic control due to progressive beta
cell failure. It is expected that almost 50% of patients with Type 2 diabetes will
eventually require insulin and patients should be counselled about this early in
their management.
Once daily injections
Single daily injections do not usually result in good glycaemic control, and are
relatively rarely used. Such a regimen may be appropriate for patients where
the therapeutic goal is only to prevent ketosis or suppress symptomatic
hyperglycaemia, and where there are practical problems with insulin delivery,
or particular concern over the risks of nocturnal hypoglycaemia. Elderly
patients living alone and patients requiring injections to be given by a
community nurse may fall into this category.
Once daily bedtime NPH insulin is the basal insulin of choice when adding
insulin to metformin and/or sulphonylurea therapy. Long acting basal
analogue insulins (Insulin Glargine and Levemir) may be considered if there
are concerns regarding hypoglycaemic risk.
Patients and carers should recognise that if good glycaemic control is needed
most cases will eventually need to move onto a more frequent injection
regime (either by adding prandial insulin or switching to a twice daily insulin
regime as per patient choice).
Twice daily injections
This is a commonly used regimen, and suitable for patients starting on insulin.
A combination of short and intermediate acting insulins is taken before
breakfast and before the evening meal.
Multiple injections
This arrangement, involving up to 4 injections a day, has the main advantage
of increased flexibility with regard to exercise, meal timing and meal size. It is
most likely to work effectively in a well-motivated patient, prepared to do
regular and frequent blood glucose testing
The majority uses an insulin analogue or soluble insulin before each meal,
and an injection of an intermediate, or long acting insulin usually before tea or
bedtime to provide background cover.
25 May 2011
Continuous subcutaneous insulin infusion (Insulin Pump Therapy):
CSII therapy is available as a treatment option for patients with Type 1
diabetes mellitus provided that
 Multiple daily injections (MDI) therapy (including, if appropriate, the
use of long-acting insulin analogues) has failed to provide adequate
control of diabetes mellitus as defined below, and
 those receiving the treatment have the commitment and competence
to use the therapy effectively
MDI therapy is considered to have failed when, despite a high level of care of
their diabetes mellitus:
 it has been impossible for the individual to maintain a haemoglobin A1c
(HbA1c) level of less than 8.5%, or
 the person is experiencing disabling hypoglycaemia, which, means the
repeated and unpredictable occurrence of hypoglycaemia that results
in persistent anxiety about recurrence and is associated with a
significant adverse effect on quality of life.
Patients may be referred to the insulin pump service for assessment if they
fulfil the above criteria and are on the basal bolus insulin regimen and reliably
monitor their blood sugars at least four times a day. They should be able to
count the carbohydrate content of meals (and been for a course such as the
DAFNE – Dose Adjustment for Normal Eating). Funding for pumps is limited
and presently priority is given to those patients who have documented severe
hypoglycaemia. Patients will be considered by the Insulin Pump Panel.
Insulin pump therapy is a complex therapy relying upon not just the hardware
of the insulin pump but also the educational package associated with it.
C3.3 Types of Insulin
There are a large and confusing number of insulin preparations available. If
patients are satisfied with their treatment and achieving satisfactory control in
the absence of hypoglycaemia, no modification of their regimen is required.
Most insulin currently in use is biosynthetically manufactured of human
sequence or analogues with altered pharmacokinetic properties. Many
patients prefer the ultra short-acting analogues/mixtures for convenience.
Some patients prefer to use animal derived insulin in the belief that use of
human sequence insulin may cause loss of awareness of hypoglycaemia.
Although such a conviction is quite widespread among the users, carefully
conducted scientific studies have consistently failed to provide evidence to
support this hypothesis.
Some preparations are available in both human and porcine versions (e.g.
human and porcine actrapid) which can result in confusion in prescribing and
dispensing. It is important to realise that such preparations although similar in
their characteristics are not interchangeable, and patients should not be
inadvertently changed from one to the other. When patients are deliberately
changed from animal to human/analogue insulin a dose reduction of 25% is
advised.
25 May 2011
Please refer to the Diabetes and Emergencies sections for management of
insulin therapies during illness.
Insulins are most conveniently classified by duration of action as shown in the
following table.
25 May 2011
C3.4 Summary of insulin classification
Ultra short acting
Short acting analogues
Immediate onset Duration
Insulin Lispro (Humalog), Insulin Aspart (Novorapid),
up to 4 hours Peak action
Insulin Glulisine (Apidra)
60 minutes
Short acting
Soluble insulin
Onset 30 minutes
(Human) Actrapid 10ml Vial only, Humulin S, Insuman
Rapid
Duration up to 5 hours
Hypurin Bovine Neutral*, Hypurin Porcine Neutral*.
Peak action 3 hours
Intermediate acting a:
Isophane insulin (contains protamine) Human Insulatard,
Onset 90 minutes
Humulin I, Insuman Basal, Hypurin Bovine Isophane*,
Duration: 16-20 hours
Hypurin Porcine Isophane*.
Peak action: 4-12 hours
Intermediate acting b:
Insulin Zinc Suspension
Onset 120 minutes
Hypurin Bovine Lente*
Duration: 24 hours
Peak action: 6-18 hours
Long acting (a)
Protamine Zinc Insulin*
Onset 4 hours
Hypurin Bovine Protamine Zinc 10ml Vial
Duration up to or greater
than 24 hours
Long acting (b)
Insulin Glargine (Lantus)
Duration up to or greater
Insulin Detemir (Levemir)
than 24 hours
Mixed preparations
Fixed mixtures of soluble and isophane insulin
Humulin M3 [Humulin S / Humulin I in ratios of 30/70]
Biphasic onset and
duration of action
Insuman Comb 15, 25 or 50, [Insuman Rapid / Basal in
ratios of 15/85, 25/75, 50/50].
25 May 2011
Biphasic Insulin Lispro
Humalog Mix 25 or 50 [Lispro/LisproProtamine in ratios of
25/75 or 50/50]
Biphasic Insulin Aspart
Novomix 30 [Aspart/Aspart Protamine in a ratio of 30/70]
Biphasic Isophane Insulin
Hypurin Porcine 30/70 Mix*
*: These insulins are rarely used and would not usually be part of a new
insulin start.
Note
Ultra short-acting insulins (e.g. Humalog, Novorapid, Apidra and mixtures ie
Humalog Mix 25 or 50 and Novomix 30) should be injected immediately
before eating or after food. Other insulins should be injected
subcutaneously 30 minutes before eating. Long acting insulins are
usually taken once daily at the same time, eg bb or bt or bbed.
25 May 2011
C3.4.1 Insulin costs
INSULIN COSTS: 5 x 3ml Cartridges
Humulin M3
Novomix 30
Humlaog 25 Mix
Humulin I (isophane)
Insulatard (isophane)
Lantus (Glargine)
Levemir (Detemir)
Humulin S (soluble)
Apidra (Glulisin)
Novorapid (Aspart)
Humalog (Lispro)
0
5
10
15
20
25
30
35
40
45
£
Prices taken from MIMs March 2011
The graph shows the cost of insulin provided in boxes of 5x3ml cartridges for
use with insulin pens. The insulin pens used with the cartridges cost between
£15.55 and £26.86.
Pre-filled insulin pens are also very popular, and cost only slightly more (£0 £2.62 per box of 5 pre-filled pens) than the 5x3ml cartridges.
Figure 1 - Insulin Costs
25 May 2011
C4.0 Hypoglyaemia
This section deals with hypoglycaemia in general. Some additional notes
pertaining particularly to hypoglycaemia occurring in in-patient situations
appear in section C6.0.
Clinical hypoglycaemia refers to any episode of low blood glucose (usually
<3.5 mmol/l) with or without symptoms and may occur in patients taking
insulin, sulphonylureas or prandial glucose regulators. To reduce
hypoglycaemic risk, such patients are normally advised to avoid blood
glucose levels below 4.0 mmol/l. Mild hypoglycaemic episodes may not only
be inconvenient for the patient, but may predispose to more severe episodes
which are associated with significant morbidity as well as the development of
fear of hypoglycaemia. While prompt recognition and treatment of
hypoglycaemia obviates the risk of progression, even if untreated, most
isolated episodes recover spontaneously and are not associated with
permanent damage. It is reasonable to reassure patients accordingly. Fear
of hypogycaemia is such that many patients avoid tightening blood glucose
control to minimise risk of its occurrence.
ALL PATIENTS PRESCRIBED SULPHONYLUREAS OR INSULIN MUST
BE ADVISED ON THE OCCURRENCE, AVOIDANCE, RECOGNITION AND
MANAGEMENT OF HYPOGLYCAEMIA.
C4.1 Causes of hypoglycaemia
Hypoglycaemia occurs when there is an imbalance between:



Carbohydrate intake
Insulin or oral hypoglycaemic drug dose
Exercise/activity.
Additional factors that may contribute to the risk of hypoglycaemia include
lumpy injection sites (leading to erratic absorption of insulin), inappropriate
injection site / technique (including intramuscular injection eg caused by using
too long a needle or using arms as injection site), alcohol excess (particularly
if combined with exercise and reduced carbohydrate intake), gastroparesis in
patients with autonomic neuropathy and adrenal insufficiency (increased
frequency in patients with Type 1 diabetes).
C4.2 Symptoms of hypoglycaemia
The symptoms of hypoglycaemia vary between patients and the same patient
may experience different symptoms in different circumstances. Symptoms
are sometimes classified as:


autonomic, due to activation of the autonomic nervous system
(sweating, tremor, anxiety, palpitations etc)
neuroglycopenic due to reduced glucose delivery to the brain (poor
25 May 2011
concentration, odd behaviour, dizziness)
non-specific (headache, tingling lips etc)

.
Symptoms of hypoglycaemia may be non-specific and vague (eg dizziness,
feeling “wobbly”), especially in the elderly. Hypoglycaemia should always be
considered as a possible cause of such symptoms, or collapse, in any patient
taking sulphonylureas or insulin.
Symptoms generally develop when the blood glucose falls to around 3.5
mmol/l. In most patients the autonomic symptoms occur before the
neuroglycopenic symptoms and provide a useful warning. Sometimes
autonomic symptoms are a reflection of anxiety about possible hypoglycaemia
rather than a reflection of a truly low blood glucose level; capillary glucose
testing can be useful in differentiating. Patients with poor control and chronic
hyperglycaemia may report symptoms of hypoglycaemia at higher blood
glucose levels; this situation is an indication for negotiating a gradual stepwise approach if there is to be progress in achieving improvement in blood
glucose control.
C4.3 Hypoglycaemia unawareness
In some patients the autonomic warning features may not provide effective
warning e.g. those with long-duration of diabetes, very tight glycaemic control
or recurrent episodes of hypoglycaemia. This may result in hypoglycaemia
unawareness when the patient is unable to recognise the onset of problems,
with potentially serious physical and psychological consequences.
Hypoglycaemia unawareness due to very tight control is generally reversible
through meticulous avoidance of hypoglycaemia and relaxation of targets e.g.
three months with a minimum blood glucose level of 6 mmol/l.
C4.4 Treatment of hypoglycaemia
All patients treated with insulin or sulphonylureas (or prandial glucose
regulators) should be advised to carry carbohydrate with them. As soon as
symptoms are recognised or if a low blood glucose value is recorded (with or
without symptoms), the patient should be advised to take one of the following:



5/6 Dextrose sweets (containing 3g CHO in each) or 4/5 Glucotabs
(containing 4g CHO in each) or sugar lumps
Fruit juice – 1 glass (200 ml)
Half of a small bottle (150ml) of sugary drink e.g cola, lemonade, or
similar – (not diet or lite varieties)
If the patient’s medication includes acarbose (Glucobay), then glucose e.g.
Dextrosol must be used for treatment of hypoglycaemia (not a disaccharide
such as sucrose (table sugar) or lactose (milk sugar)).
If symptoms and / or metered glucose are not improving after 10 minutes this
should be repeated. If the patient is too drowsy to cooperate, “Glucogel”
(formerly known as Hypostop) may be applied to the inside of the cheek and
massaged from the outside. It may be advisable for patients to keep Glucogel
25 May 2011
at home/work and instruct family members/ friends/colleagues how to use it.
If the patient is unresponsive, 1 mg of glucagon (“Glucogen”) should be given
subcutaneously or intramuscularly (once only per episode). It may be also
appropriate to instruct partners, close relatives, friends or colleagues of
susceptible insulin-treated people in the use of glucagon and to ensure that
they keep a kit available.
Alternatively 25g (50ml) of 50% dextrose can be given intravenously by
professional help.
During the initial treatment of hypoglycaemia, high fat foods (eg chocolate) or
long acting carbohydrates (bread, plain biscuits) are not the best choice as
these will treat be slow to raise the blood glucose and may impair absorption
of ingested fast acting carbohydrate.
After the initial treatment (once metered glucose is >4mmol/l), it is essential
for the patient to take long acting carbohydrate such as biscuits and milk or a
sandwich to prevent the hypoglycaemia from recurring.
C4.5 Hypoglycaemia and sulphonylureas
Hypoglycaemia may occur in patients taking sulphonylureas and is often
underreported in the elderly when the symptoms are non-specific and are
confused with other conditions e.g. TIAs. Hypoglycaemia may recur following
initial treatment and occasionally admission to hospital may be required.
Newer long-acting sulphonylureas e.g. Glimepiride and modified release
Gliclazide seem much less likely to cause hypoglycaemia than obsolescent
long acting agents such as chlorpropamide.
In the frail or elderly, when patients are eating less due to intercurrent illness /
hospitalisation, dose reduction or cessation of sulphonylurea may need to be
considered to avoid hypoglycaemia. The dose can be increased again once
normal eating patterns are restored. Progressive renal impairment also
potentiates the risk of hypoglycaemia with sulphonylureas (and insulin).
C4.6 Nocturnal hypoglycaemia
This is a common occurrence in insulin-treated patients. Patients may or may
not wake up during the night with symptoms, or sometimes wake up the
following morning feeling “hung-over”. In the great majority of circumstances
moderate levels of hypoglycaemia will wake the patient; ready access to
appropriate fast acting carbohydrate by the bedside will facilitate corrective
action. Nocturnal hypoglycaemia may contribute to the development of
hypoglycaemia unawareness. The risk of nocturnal hypoglycaemia can be
minimised by ensuring a snack containing complex carbohydrate is taken at
bedtime (irrespective of blood glucose reading), and allowing the blood
glucose to be between, say, 7 and 9 at bedtime. Patients who take a twicedaily regimen of mixed insulin, or isophane insulin at night should be advised
to have a bedtime snack. However this is may not be so important for patients
on a basal-bolus regimen using the newer long-acting analogues as these
25 May 2011
have a flatter action profile.
The following measures may also reduce the risk of nocturnal hypoglycaemia:



With basal/bolus regimens long acting insulin analogues, i.e. insulin
glargine (Lantus®) or insulin detemir (Levemir®) appear to be
associated with a lower incidence of hypoglycaemia than long acting
human sequence insulins.
With twice-daily pre-mixed regimens those containing a short-acting
analogue such as Humalog Mix 25® or Novomix 30® are associated
with less nocturnal hypoglycaemia than those containing human
sequence soluble insulin eg Humulin M3®.
Replacing human sequence soluble insulin at teatime with a shorter
acting insulin analogue e.g. Lispro® or Novorapid®
C4.7 Rebound Hyperglycaemia
After an episode of hypoglycaemia patients may experience marked
hyperglycaemia, which can be prolonged (12-20 hours). This is only partly
related to carbohydrate consumption to treat hypoglycaemia. A greater
contribution is made by release of so-called counter-regulatory hormones that
act by various means to raise glucose (and thus try to prevent early
recurrence of hypoglycaemia); counter-regulatory hormones will raise glucose
levels following hypoglycaemia whether or not the episode was detected at
the time (e.g. during sleep). It must be remembered that hyperglycaemia may
follow an earlier period of hypoglycaemia and that reducing the
hypoglycaemic risk may be the action required to prevent recurrence of the
rebound hyperglycaemia.
C4.8 Avoidance of hypoglycaemia
The risk and recognition of hypoglycaemia can be reduced by self-monitoring
of blood glucose, review of insulin / drug regimen, quantity and timing of
carbohydrate intake and injection sites. Patients should be advised to “Make
4 the floor” with respect to their targets for glucose control i.e. try to avoid
glucose values below 4. The targets for glycaemic control may need to be
relaxed in patients who do not have awareness of low glucose levels and for
those who have had problems with severe hypoglycaemia.
C4.9 Driving and hypoglycaemia
Patients should be advised to check their blood glucose before and during
long car journeys (at least every 2 hours) and should always carry
carbohydrate in the car. If they have hypoglycaemic symptoms while driving
they should stop the car as soon as safely possible, remove the keys from the
ignition, leave the driver’s seat and take oral carbohydrate. Driving should not
be resumed for at least 45 minutes. Patients who have lost their warning
symptoms of hypoglycaemia or those experiencing recurrent hypoglycaemia
should be advised not to drive until the problem has been resolved. It should
25 May 2011
be documented in clinical records when such advice has been given.
C4.10 Exercise related hypoglycaemia
Exercise is to be encouraged in those with diabetes and due care must be
taken to give advice on observance of appropriate precautions for avoidance
of problems. Hypoglycaemia related to exercise may occur at the time of
exercise or up to 24 hours afterwards while the body’s glycogen
(carbohydrate) stores are being replenished. The risk of hypoglycaemia is
related to the intensity and duration of exercise. Where possible individuals
should be advised not to exercise alone. Those less accustomed to regular
exercise need to exercise particular caution. Patients should be advised to
consider reducing insulin doses before and after exercise (including the day
afterwards) and/or increase dietary carbohydrate and alter injection sites, e.g.
avoiding legs if running/ cycling or arms if rowing/kayaking as such exercise
will increase absorption of insulin. It is advisable for patients to have easy
access to rapid-acting carbohydrate (eg orange juice / glucose tablets) when
exercising. Exercise within 24 hours following an episode of hypoglycaemia
carries a high risk of further hypoglycaemia.
Additional nutritional advice, particularly for those engaging in more vigorous
physical activity is available on the following website: Runsweet.com
.
25 May 2011
C5.0 Management of Diabetic Emergencies in the
Community
Acute illness in insulin-treated patients






Encourage blood glucose checks 2-4 hourly. Ensure monitoring
equipment and technique satisfactory.
Never stop insulin. Increase dose according to blood glucose. Give
e.g. 4 units of quick acting insulin every 2 hours until blood glucose
less than 10
Check for ketones. Ketostix in urine (or Medisense Optium meter in
blood). If moderate to high levels are detected, an increase in
insulin may be necessary with subsequent check for ketones later
same day.
Ensure continued fluid intake.100-200ml / hour (approx 1 glass) or
an egg cupful /10 minutes. If vomiting prevents fluid intake,
consider buccal or parenteral anti-emetic. Admission may be
required.
Carbohydrate intake must be maintained by fluids if unable to eat.
See 10g CHO Guidance below.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE.
Acute illness in Non-Insulin-treated patients



Provided not severely dehydrated or showing features of
Hyperosmolar Coma ( drowsiness) then high blood glucose levels
can be tolerated for a short illness
Markedly dehydrated hyperglycaemic patients should be admitted
for IV fluids.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE
Consider admission if:







Inability to swallow or keep fluids down
Persistent vomiting
Persistent diarrhoea
Persistently raised blood glucose greater than 28 despite increased
insulin
Strongly positive ketones
No improvement 24-48 hours
When ketoacidosis clinically obvious (dehydration, thirst, polyuria,
abdominal pain, intractable vomiting, rapid or laboured breathing)
10g CHO Guidance
25 May 2011
Milk
Fruit juice unsweetened
Lucozade
Coca Cola (not diet)
Lemonade (fizzy/sweetened)
Ice cream
Jelly (ordinary)
Yoghurt (fruit)
Yoghurt (plain)
1 cup (200ml)
1 small glass (100ml)
50ml
150ml
150ml
1 scoop
2 table spoons
½ small carton (60g)
1 small carton (120g)
If admission definitely necessary contact the relevant medical admitting
team at ARI or Dr Gray’s as appropriate.
If advice or discussion appropriate first then contact (for ARI) the Diabetes
Specialty Registrar who is available 9am – 9pm; 7 days (0845 456 6000
and ask for Bleep 2543) or, outwith these hours, the on-call Consultant for
Diabetes can be contacted via Wards 27/28 ARI (01224 552004/552104).
For Dr Gray’s, during office hours contact the NHS Grampian switchboard
0845 456 6000 or 67998 and ask to speak to Dr Strachan or Dr Park.
Alternatively ask to speak to the DSN covering Dr Gray’s.
25 May 2011
C6.0 Management of Diabetes in Hospital
C6.1 Introduction
In first considering this subject, it is important to differentiate between people
in hospital with acute metabolic decompensation, those with established
diabetes that is an incidental or contributory issue in their hospitalisation, and
those newly found to have a high glucose. The last group need to receive all
the due consideration of any new patient with diabetes (see Section A2) –
with additional attention paid to modifications occasioned by the nature of the
hospital admission and input from the inpatient diabetes team as required.
For those with prior diabetes, the patient’s level of engagement and
experience in self-management must always be borne in mind. Every
encouragement should be given to preserve patient autonomy, but it should
be remembered that the lack of familiarity with a particular clinical
circumstance may compromise the patient’s coping strategies.
Glycaemic control may deteriorate in the hospital setting due to stress of
intercurrent illness, changes in dietary intake and decrease in physical
activity. Interruptions to accustomed dietary intake or enforcement of
medication and dietary concordance may also considerably alter the patient’s
circumstances. The circumstance of clinical decision making in hospital can
also limit the skilled patient’s opportunity to apply appropriate flexibility in selfmanagement. As a consequence, both hyperglycaemia and hypoglycaemia
are common in the hospital setting. It is often therefore appropriate to alter
interim glucose targets to a broader (and safer) range than would apply in the
chronic out-patient situation (e.g. 6-14mmol/l) to prevent problems with
hypoglycaemia and hyperglycaemia. However, persistent and significant
hyperglycaemia (>17mmol/l) should be prevented/treated to avoid
dehydration, caloric loss, infection and ketoacidosis.
Both hypoglycaemia and hyperglycaemia are common in the hospital setting.
Factors that contribute to this include the stress of intercurrent illness,
changes in dietary intake, enforcement of medication and decrease in
physical activity.
The circumstance of clinical decision making in hospital can also limit the
skilled patient’s opportunity to apply appropriate flexibility in self-management.
It is often therefore appropriate to alter interim glucose targets to a broader
(and safer) range than would apply in the chronic out-patient situation (e.g. 614mmol/l) to prevent problems with hypoglycaemia and hyperglycaemia.
However, persistent and significant hyperglycaemia (>17mmol/l) should be
prevented/treated to avoid dehydration, caloric loss, infection and
ketoacidosis.
Hospitalised patients may benefit from opportunistic specialist review and
appropriate education. Timely liaison with the specialist diabetes team can
25 May 2011
reduce the risk of glucose management problems during admission and can
facilitate early discharge.
Hospitalised patients may benefit from opportunistic specialist review and
appropriate education. This is of importance in those whose hospital
admission is the only time some patients make contact with healthcare
professionals. Timely liaison with the specialist diabetes team can reduce the
risk of glucose management problems during admission, help to optimise
patient’s long term diabetic care and can facilitate early discharge.
25 May 2011
C6.2 Diabetic emergencies
If admission definitely necessary contact the relevant medical admitting
team at ARI or Dr Gray’s as appropriate.
If advice or discussion appropriate first then contact:
1 (for ARI) the Diabetes Specialty Registrar who is available 9am – 9pm;
7 days (0845 456 6000 and ask for Bleep 2543) or, outwith these hours,
the on-call Consultant for Diabetes can be contacted via Wards 27/28 ARI
(01224 552004/552104).
2 For Dr Gray’s contact the switchboard 0845 456 50000 or 67998 and
ask to speak to Dr Strachan, Dr Park or the DSN covering Dr Gray’s.
C6.2.1. Diabetic Keto Acidosis (DKA)
DKA is a potentially life threatening complication of diabetes that while
often preventable, must be dealt with as a matter of urgency once
established. Diagnosis of DKA is only appropriate in the presence of
diabetes AND ketosis AND acidosis.
A national protocol for management of confirmed DKA in adults only is
being rolled out in spring 2011; it can also be down loaded from the
intranet link below. A separate paediatric protocol is available for children
under the age of 16 years. The paediatric protocol may also be
appropriate in adults of low body weight (BMI < 16kg/m2), as it reduces the
risk of fluid overload.
The Diabetes specialist team should be contacted as appropriate for
advice regarding management of DKA
Consideration must be given to the cause of DKA for example, infection,
myocardial infarction or insulin administration difficulties and the
underlying cause appropriately treated.
The Diabetes specialist team should be contacted as appropriate for
advice regarding management of DKA and, once the patient is stable, for
education to try to prevent recurrence.
Adult DKA Care Pathway
Paediatric DKA Protocol
25 May 2011
C6.2.2 Hyperosmolar Hyperglycaemic Non Ketotic syndrome (HHNS)
Hyperosmolar Hyperglycaemic Non Ketotic syndrome formally known as
HONK is a life threatening condition, which mainly occurs in older people
with Type 2 diabetes. HHNS is characterized by dehydration, very high
blood glucose and high serum osmolality (>320mosm/l) but without
ketoacidosis or heavy ketonuria; modest ketonuria and lactic acidosis may
sometimes occur. Mortality is very high (up to 50%). Early diabetic
specialist review is recommended. Management is similar to DKA but the
fluid replacement should be less rapid. Some advocate rehydration with
0.45% saline claiming it reduces the risk of hypernatraemia. Blood glucose
should be reduced gradually to avoid precipitating cerebral oedema.
Patients with HHNS should also be considered for subcutaneous heparin
prophylaxis due to increased risk of thrombo-embolism. Once treated,
most patients can be managed on diet with or without oral hypoglycaemic
agents.
Investigation into the underlying cause should also be given and treated as
appropriate.
C6.2.3 Hypoglycaemia in hospital
This section focuses on the treatment and prevention of hypoglycaemia in
hospitalised patients. Further details regarding hypoglycaemia can be found in
Section C4.
Hypoglycaemia is a lower than normal level of blood glucose. Patients with
diabetes experience more frequent hypoglycaemia in the hospital setting than
the community. Hypoglycaemia is the commonest side effect of insulin and
sulphonylurea therapy (e.g. gliclazide, glipizide or glimepiride) and results
from an imbalance between glucose supply, glucose utilisation and current
insulin levels.
Hypoglycaemia should be excluded in any person with diabetes who is
acutely unwell, drowsy, unconscious, unable to co-operate, presenting with
aggressive behaviour or seizures. Any blood glucose of less than 4.0 mmol/L
in people with diabetes on sulphonylurea or insulin therapy should be treated,
whether symptomatic or not.
People experiencing hypoglycaemia require quick acting carbohydrate (1520g) to return their blood glucose levels to the normal range. The quick acting
carbohydrate should be followed up by giving long acting carbohydrate either
as a snack or as part of a planned meal. All patients experiencing
hypoglycaemia should be treated without delay. Where it is safe to do so, a
blood glucose measurement should be taken to confirm hypoglycaemia. If
measurement is difficult (e.g. in a patient undergoing a seizure) then
treatment should not be delayed.
25 May 2011
The majority of patients will be able to ingest oral glucose. Patients unable to
take things by mouth will require parenteral administration of glucose.
Intravenous glucose in 10% or 20% concentrations is now preferred than the
previous commonplace use of 50% glucose which is hyperosmolar and may
increase the risk of extravasation injury.
All adults with a blood glucose level less than 4.0mmol/L with or without
symptoms of hypoglycaemia should be treated as outlined below. Each ward
should have a ‘hypo box’ which contains treatment for hypoglycaemia.
C6.2.4 Prevention of Hypoglycaemia during Hospital Admission
C.6.2.4 Treatment of hypoglycaemia:
Treatment of hypoglycaemia in adults who are conscious, orientated and able
to swallow:
1) Give 15-20g of quick acting carbohydrate:
a. 150-200 ml pure fruit juice (e.g. orange)
b. 90-120ml of original Lucozade® (preferable in renal patients)
c. 5-7 Dextrosol® tablets (or 4-5 Glucotabs®)
d. 3-4 heaped teaspoons of sugar dissolved in water
2. Repeat capillary blood glucose measurement 10-15 minutes later. If it
is still less than 4.0mmol/L, repeat step 1 up to 3 times
3. If blood glucose remains less than 4.0mmol/L after 45 minutes or 3
cycles, contact a doctor. Consider 1mg of glucagon IM (may be less
effective in patients prescribed sulphonylurea therapy) or IV glucose
(10 or 20%)
4. Once blood glucose is above 4.0mmol/L and the patient has recovered,
give a long acting carbohydrate. Patients given glucagon require a
larger portion of long acting carbohydrate to replenish glycogen stores
Some examples are:
a. Two biscuits
b. One slice of bread/toast
c. 200-300ml glass of milk (not soya)
d. Normal meal if due (must contain carbohydrate)
5. DO NOT omit insulin injection if due (However, dose review may be
required)
6. Document event in patient’s notes. Ensure regular capillary blood
glucose monitoring is continued and ask the patient to continue this at
25 May 2011
home if they are to be discharged. Refer to the diabetes specialist
nurse (DSN)
If the patient is too drowsy to co-operate, Glucogel® (2 tubes) should be
applied to the inner cheeks and then massaged from the outside. This
treatment can also be given to the fasting patient without compromising their
fasting status.
If the patient is unresponsive - 125 mls of 20% Glucose or 250 mls of 10%
glucose should be given intravenously as a bolus over a few minutes. This
can be repeated if the patient remains unresponsive. More concentrated
glucose preparation such as 50% Glucose should be avoided where possible
due to the risk of extravasation injury. If there is no alternative then a
generous saline flush both before and after the 50% glucose should be given,
ideally through a large bore cannula.
If unable to obtain venous access – 1mg of Glucagon (Glucagen®) can be
given intramuscularly or subcutaneously (once only per episode); patients
frequently experience nausea and vomiting after this treatment so it should
not be used unless essential.
C.6.2.5: When hypoglycaemia has been successfully treated








Take measures to avoid hypoglycaemia in the future, the Diabetes
Specialist Nurses or on-call Diabetes Registrar can be contacted to
discuss this.
Consider completing an incident (DATIX®) form if appropriate.
If “hypo boxes” were used then replenish as appropriate.
Identify the risk factor or cause resulting in hypoglycaemia.
Unless the cause is easily identifiable and both the nursing staff and
patient are confident that steps can be taken to avoid future events
then a review by the diabetes team should be considered. If the
episode of hypoglycaemia was severe or recurrent, or if the patient
voices concerns, then a review is indicated.
Please DO NOT omit the next insulin injection or start variable rate
intravenous insulin infusion to ‘stabilise’ blood glucose. If unsure of
subsequent diabetes treatment, discuss with the diabetes team.
Medical team responsible for the patient may consider reducing the
dose of insulin prior to the time of previous hypoglycaemia events. This
is to prevent further episodes of hypoglycaemia occurring.
Please DO NOT treat isolated spikes of hyperglycaemia with ‘stat’
doses of short/rapid acting insulin. Instead maintain regular capillary
blood glucose monitoring and adjust normal insulin regimen if a
particular pattern emerges.
25 May 2011
C6.2.6 Prevention of Hypoglycaemia during Hospital Admission





Avoid giving unopposed insulin infusion (i.e. without iv glucose – unless
during early iv management phase of hyperglycaemia)
Avoid disconnecting or stopping intravenous fluids while on an
intravenous insulin pump
If any concern, e.g. blood glucose levels suddenly dropping,
temporarily reduce interval between capillary glucose checks to 30 or
15 minutes
Ensure patients treated with s/c insulin have carbohydrate-containing
snacks available, especially for bedtime
Be aware that after episodes of hypoglycaemia patients typically have
REBOUND hyperglycaemia perhaps lasting several hours. These
high levels of blood glucose should be allowed to return to normal
without intervention (unless developing significant ketonuria).
Resisting the temptation to give extra insulin may avoid
recurrence of the primary hypoglycaemic event!
For further information please see the national guidelines entitled “The
Hospital Management of Hypoglycaemia in Adults”, published March 2010,
available from NHS Diabetes (look under “publications and resources”)
25 May 2011
C6.3 Management of Diabetes during intercurrent illness
C6.3.1 Type 1 diabetes
Patients with Type 1 diabetes are regarded as being continuously
dependent on external insulin for their survival. Whenever possible,
patients should be involved in decision making concerning management of
their glycaemia. If there is reasonable likelihood of patients being able to eat
and drink, then the ‘sick day’ rules should be followed (chapter C5). If blood
glucose levels are high, it may be appropriate to use increased insulin doses
for patients on basal-bolus insulin therapy, and additional supplementary
doses of quick acting insulin (before lunch and before bed) for patients on
twice daily pre-mixed insulin.
A Variable Rate Insulin Infusion Protocol (C6.3.3) is available for use when
oral intake is compromised.
C6.3.2 Type 2 diabetes
Patients, who are on diet alone, may need no specific therapy during
intercurrent illness apart from monitoring, to ensure blood glucose is
reasonably stable. Patients on oral hypoglycaemic agents may need
increased oral therapy or may need insulin temporarily (especially, for
example, with steroid therapy). If blood glucose levels are high (> 17 mmol/l
before meal times), consider adding subcutaneous soluble insulin (e.g.
Actrapid, Humulin S 4 units). Management of insulin treated Type 2 diabetic
patients is usually similar to that of Type 1 diabetes. It is important to consider
discontinuation of increased hypoglycaemic treatment on recovery.
Intercurrent or new chronic illness may alter safety of some OHAs and there
is potential for adverse interaction with newly introduced medications; this
should be borne in mind when managing in-patients. Certain oral
hypoglycaemic agents may be contraindicated in the acutely ill patient, e.g.
Metformin should be discontinued in impaired renal function (eGFR < 30)
severe sepsis and acute left ventricular failure. Similarly, glitazones are
contraindicated in patients with unstable ischaemic heart disease and cardiac
failure. Deteriorating renal function reduces insulin clearance and so may
increase the hypoglycaemic potential of given doses of insulin or
sulphonylureas.
Deteriorating renal function reduces insulin clearance and so may increase
the hypoglycaemic potential of given doses of insulin, GLP1 analogues,
DPPIV inhibitors or sulphonylureas.
C6.3.3 Variable rate intravenous insulin infusion
25 May 2011
This protocol is used in several circumstances:
 1. For controlling glucose levels when patients are not able to take their usual
insulin and diet e.g. peri-operative fasting;
 2. Intercurrent illness where blood glucose levels are insufficiently controlled
on usual diabetic medication;
 3. For 48 hrs after diagnosis of acute myocardial infarction, if admission
glucose is over 11mmol/l.
The protocol aims at maintaining blood glucose levels in a safe range (814mmol/l) avoiding risks of significant hypo/hyperglycaemia. Circumstances
necessitating the use of this protocol should be regularly reviewed and
patients should be switched back to their usual diabetic medications as soon
as possible.
6.3.4 PROTOCOL FOR VARIABLE RATE INTRAVENOUS INSULIN
INFUSIONS
When to use this protocol:

Peri-operative management of patients with insulin-treated diabetes /
patients on near maximum dose oral hypoglycaemic agents undergoing
major surgery. This includes patients who are clinically well but who have
a high glucose requiring stabilisation
peri-operatively

Management of insulin-treated patients who are unable to take a normal
diet (eg fasting for investigations / nausea and vomiting etc)

On rare occasions for the continuing management of patients who remain
unable to take a full diet following initial treatment for diabetic ketoacidosis
and hyperosmolar coma (ie bicarbonate has normalised and blood glucose
less than 14 mmol/l)
When not to use this protocol:

For patients with DKA ie elevated glucose / ketonuria and acidosis (use
DKA protocol)

For patients who are clinically well, not peri-operative and presenting with
high glucose (ie > 14 mmol/l) with or without ketonuria. Please consider if
insulin infusion is really required or whether subcutaneous insulin would be
more appropriate

Control of blood glucose in patients who are eating and drinking, whether
or not they require IV fluids for other reasons (such patients should be
treated with their normal oral hypoglycaemic agents or sc insulin)

Pregnancy – please contact the maternity hospital for diabetes in
pregnancy protocol.
25 May 2011

High dependency/ intensive care situations – specific wards may have
their own protocols to aim at tighter control

Patients on nasogastric feed. Although, Variable Intravenous insulin
infusion can be used temporarily, subcutaneous insulin therapy is more
appropriate in these circumstances (e.g. Isophane insulin twice daily).
Please liaise with the diabetes team.

Patients on TPN – TPN team will usually advise.
25 May 2011
GRAMPIAN UNIVERSITY HOSPITAL NHS TRUST
SURNAME
SYRINGE PUMP PRESCRIPTION SHEET
[
]
………………………………………………………….
HOSPITAL
WARD/DEPARTMENT
FIRST NAMES
…………………………………………………………………
ADDRESS
…………………………………………………………………
UNIT NO
…………………………………………………………………
CONSULTANT
POST CODE
BAR CODE
………………………………………………………………..
SEX
MARITAL STATUS
……………………………………………………………….
DATE OF BIRTH
[
PLACE LABEL WITHIN BRACKETS
]
DATE:
CODE LETTER FROM MAIN PRESCRIPTION SHEET:
MEDICINE: Human Actrapid 50 Units
DILUENT: 0.9 % Sodium Chloride
CONCENTRATION:
TOTAL VOLUME:
1unit in 1ml
50ml
INTRAVENOUS FLUIDS (GLUCOSE MUST ALWAYS RUN CONCURRENTLY WITH INSULIN)
4 % Glucose + 0.18 % Sodium chloride + 0.15 % Potassium chloride at 100ml/hour
OR
5 % Glucose + 0.15 % Potassium chloride at 100 ml / hour
In patients who are at risk of fluid overload (e.g cardiac failure) use 10% glucose +0.15% potassium chloride and
run at 50 ml / hour
If K>4.5mmol/L give above fluids without added K
Dialysis dependent patients: use 10 % glucose (with no added potassium) and run at 50 ml/hour
Fluids to be prescribed separately on fluid prescription sheet.
INSTRUCTIONS FOR VARIABLE RATE INFUSIONS
Please note-Capillary Glucose to be checked prior to starting insulin
infusion and then hourly
INITIAL SETTINGS:
If capillary glucose between 8-14mmols/l start at 2ml/hour
If capillary glucose greater than 14mmol/l start at 4 ml/hour and check glucose again in 30 minutes
If capillary glucose less than 8mmol/l start infusion at 1ml/hour
If capillary glucose less than 4mmol/l discuss with medical staff or diabetes team
DATE:
ROUTE: IV
INSTRUCTIONS FOR CHANGING RATE:
RATE(ml/hr):
IF CAPILLARY GLUCOSE:- Between 8-14mol/l leave at present rate
IF CAPILLARY GLUCOSE:Greater than 14 mmol/l: increase infusion rate by 2 units/hour (if infusion rate at 6ml/hour
and capillary glucose remains >14mmol/l inform medical staff). If within 2 hours of a meal
do not increase dose.
Greater than 17 mmol/l: increase infusion as above and check for ketones and inform
medical staff if positive.
Between 6 and 8 mmols/l halve rate of insulin infusion, (Round down to nearest 0.1 decimal place). Continue to
monitor glucose hourly and if glucose still between 6 and 8 mmols/l continue to halve rate of insulin infusion (do not
reduce rate below 0.5ml/hour).
Between 3.5 and 6mmols/l :

If patient normally on diet +/- oral hypoglycaemics, stop insulin infusion, and continue to monitor glucose hourly. If
blood glucose rises to greater than 14 mmol/l restart infusion at 0.5ml/hour and follow protocol as above.

If patient normally on insulin, provided patient is fully conscious, reduce insulin infusion to 0.5 ml/hour, recheck
glucose in 30 minutes and continue protocol. If patient not fully conscious stop insulin infusion and contact doctor
immediately. (Consider changing to 10% glucose if insulin rate already 0.5 ml/hour (see over)).
25 May 2011
Less than 3.5 mmol/L: Stop insulin infusion and give 100mls of 10% glucose IV over 5 – 10 minutes. (If patient’s
conscious level reduced call medical staff). Repeat blood glucose after 10 minutes and if glucose still less than
3.5mmol/l give another 100 mls of 10% glucose and call medical staff for advice. Once glucose > 3.5 mmol/l follow
instructions as above for “between 3.5 and 6 mmol/l”.
Prescriber’s signature: ……………………………………….(for 100mls 10%glucose)
Administration of 100 mls Glucose 10 %
Date/Time:
:
:
:
:
Administered by:
:
:
:
:
PRESCRIBER’S NAME (PRINT)
SIGNATURE:
DATE DISCONTINUED:
KNOWN DRUG / MEDICINE SENSITIVITY
:
:
:
:
GRADE
BLEEP NO:
TIME (24 hour clock)
INITIALS:
25 May 2011
Protocol for Variable Rate Intravenous Insulin Infusions
When to use this protocol:

Peri-operative management of patients with insulin-treated diabetes / patients on near maximum
dose oral hypoglycaemic agents undergoing major surgery. This includes patients who are
clinically well but who have a high glucose requiring stabilisation peri-operatively

Management of insulin-treated patients who are unable to take a normal diet (eg fasting for
investigations / nausea and vomiting)

On rare occasions for the continuing management of patients who remain unable to take a full diet
following initial treatment for diabetic ketoacidosis and hyperosmolar coma (ie bicarbonate has
normalised and blood glucose less than 14 mmol/l)
When not to use this protocol:

For patients with DKA / HONK ie elevated glucose / ketonuria and acidosis (use DKA protocol)

For patients who are clinically well, not peri-operative and presenting with high glucose (ie > 14
mmol/l) with or without ketonuria. Please consider if insulin infusion is really required or whether
subcutaneous insulin would be more appropriate

Control of blood glucose in patients who are eating and drinking, whether or not they require IV
fluids for other reasons (such patients should be treated with their normal oral hypoglycaemic
agents or sc insulin)

If patient on TPN (contact nutrition team )

If patient on naso-gastric feeds (contact diabetes team )
IF YOU ARE NOT SURE WHICH PROTOCOL YOU SHOULD USE PLEASE CONTACT THE
DIABETES TEAM FOR ADVICE (ALL BASED AT ARI)
Diabetes specialist nurse:
Bleep 3334 (Monday-Friday, 9-5)
Diabetes registrar:
Bleep 2543 (Monday-Sunday 9-9)
Renal registrar:
Bleep 2451
Or contact ward 27/28 ARI and where senior nursing staff may be able to help you or give you
the contact number for the ward registrar / SHO or diabetes consultant on-call.
IMPORTANT INFORMATION






Insulin infusion (50 units Human Actrapid in 50ml 0.9% Sodium Chloride, ie 1 unit/ml) by
syringe pump according to the scale overleaf.
Aim to keep blood glucose between 8 and 14 mmol/l, check capillary glucose hourly using ward
meter.
If the blood glucose is persistently below target and insulin infusion rate has been reduced to
0.5ml/hour, a change to 10% glucose may be required at a rate of 100ml/hour
Patients who are insulin-treated should not be left off iv insulin for more than 30 minutes as there
may be a risk of developing ketosis.
Check U & E daily whist patient on infusion
The presence of this additonal prescription sheet must be highlighted (by placing a tick in the
special prescription sheets box on the main prescription sheet) to indicate that a fluid prescription
sheet and variable rate iv insulin sheet is in use.
Patients at risk of fluid overload or cardiac failure ( eg post MI) or
dialysis dependent patients
To avoid volume overload start the intravenous infusion at a rate of 50ml/hr as follows:
10% Glucose + 0.15% Potassium Chloride

Omit potassium if dialysis dependent patient or K 4.5 or greater

Insulin infusion as above (50 units Actrapid in 50ml 0.9% saline, ie 1 unit /ml).
Changing back to normal insulin / oral hypoglycaemic regimen

For patients on human or pork soluble insulin, when the patient is able to eat, the usual dose of
subcutaneous insulin should be given 30 minutes prior to eating and the insulin infusion
discontinued 30 minutes after the subcutaneous injection.
25 May 2011


For patients on Humalog, Humalog Mix, Novorapid, Novomix, when the patient is able to eat, the
usual dose of subcutaneous insulin should be given 5 minutes prior to eating and the insulin
infusion can be discontinued immediately after the subcutaneous injection.
Patients who take oral hypoglycaemic agents should have their drugs recommenced at this stage.
 Once usual treatment has recommenced capillary blood
glucose testing is required at a maximum of 4 times per
day with additional 2am blood tests for those on insulin
considered at risk of hypoglycaemia
NOTE: Separate sheets are available for:
PCA Pumps
Fluid (Additive Medicines)
Pumps calibrated in mm
APRIL 2004
IF YOU ARE NOT SURE WHICH PROTOCOL YOU SHOULD USE PLEASE
CONTACT THE DIABETES TEAM FOR ADVICE:
Diabetes specialist nurse:
Diabetes registrar:
Bleep 3334 (Monday-Friday 9-5)
Bleep 2543 (Monday-Sunday 9-9)
Or contact Ward 27/28 and where senior nursing staff may be able to help
you or give you the contact number for the ward registrar / SHO or diabetes
consultant on-call.
C6.4 Guidelines for diabetes management during procedures
requiring fasting
These guidelines help both health care professionals and diabetic patients
manage diabetes safely without significant hypoglycaemia or hyperglycaemia
during various procedures that require fasting. While it is difficult to include
every possible scenario in detail, guidelines have been developed keeping
colonoscopy as a general example (with as many variations as possible) and
these guidelines can also be used in similar circumstances.
Those on diet alone need no specific intervention but patients on insulin
therapy and on OHAs need some adjustments in their medications. In
general, patients on basal-bolus therapy need 50% reduction in their basal
insulin on the previous day and should omit quick acting insulin while fasting.
Patients on twice daily pre-mixed insulin should omit their morning insulin on
the day of the procedure. Once able to eat and drink, normal insulin doses
should be resumed at the earliest opportunity (e.g. if on twice daily insulin,
after the procedure take half the usual morning insulin dose at lunch time).
Frequent capillary glucose monitoring is essential to avoid
hypo/hyperglycaemia which may often go unnoticed especially after
administration of sedation.
25 May 2011
Occasionally, some patients (with particularly unstable diabetes or limited
capability for safe self-management) may need to be admitted for intravenous
insulin infusion during these procedures and the use of variable rate
intravenous insulin infusion protocol (see section C6.3.3) is recommended.
The following specific patient information leaflets are available for certain
hospital procedures:
i) Guidelines for people with insulin treated diabetes undergoing
outpatient colonoscopy / flexible sigmoidoscopy (morning and
afternoon)
ii) Guidelines for people with tablet treated diabetes undergoing outpatient
colonoscopy / flexible sigmoidoscopy
iii) Guidelines for people with diabetes undergoing outpatient upper GI
endoscopy
25 May 2011
Section D: Complications
Section D: Complications ......................................................... 70
D2.0 Cardiovascular disease and diabetes ............................................ 72
D2.1 Screening .................................................................................. 73
D3.0 Eye Care, Screening and Treatment .............................................. 76
D3.1 Eye screening ........................................................................... 76
D3.2 Mydriasis ................................................................................... 77
D3.3 Medical treatment ..................................................................... 77
D3.4 Laser treatment ......................................................................... 78
D3.5 Diabetic eye screening guidelines - classification and action .... 78
D3.5.1 Visual acuity .................................................................. 78
D3.6 Fundoscopy .............................................................................. 78
D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1 ....... 79
D3.8 Obtaining individual patient results ........................................... 82
D4.0 Foot Care, Screening and Treatment ............................................. 84
D4.1 Foot Screening.......................................................................... 84
D4.1.1 SCI-DC Foot Screening Tool ........................................ 85
D4.1.2 Annual Diabetic Foot Screening.................................... 86
D4.2 Management guidelines for Charcot neuroarthropathy in people
with diabetes ............................................................................ 88
D4.3 Diabetic Foot Ulceration and Wound Management................... 89
D4.3.1Care Pathway for Active Diabetic Foot Ulceration ......... 89
D4.3.2 Referral Pathway for Pressure Relief ............................ 91
D4.4 Good practice guidance for the use of antibiotics in patients with
diabetes foot ulcers .................................................................. 94
D4.5 Diabetic Foot Care Patient Education ..................................... 106
D5.0 Neuropathy - Autonomic ............................................................... 107
D6.0 Renal Disease ................................................................................ 109
D6.1 Screening for diabetic renal disease ....................................... 109
6.2 Definitions .................................................................................. 109
D6.2.1 Assessment of dipstick positive patients .............................. 110
D6.2.2 Assessment of dipstick negative patients ............................ 110
D6.2.3 Algorithm for microalbuminuria screening in the
community ................................................................... 112
D6.3 A simple guide to eGFR interpretation and nephrology referral
guidelines. .............................................................................. 113
D6.4 Management of Diabetic Renal Disease ................................. 116
D6.5 Referral for specialist renal advice .......................................... 116
25 May 2011
D1.0 Blood Pressure
Blood pressure control is extremely important. It is as important, if not more
so, than blood sugar control. Tight blood pressure control in patients with
hypertension and Type 2 diabetes achieves a clinically important reduction in
the risk of deaths related to diabetes, complications related to diabetes,
progression of diabetic retinopathy, and deterioration in visual acuity.
(Conclusion of UKPDS 38 1998)
Reducing blood pressure needs to have high priority in caring for
patients with diabetes. The target BP in diabetes is ≤ 130/80.
In patients with diabetes and kidney disease blood pressure should be
reduced to the lowest achievable level to slow the rate of decline of
glomerular filtration and reduce proteinuria.
The ‘standard’ guidance of blood pressure management as described by the
British Hypertension Society applies to all patients
(http://www.bhsoc.org/Latest_BHS_management_Guidelines.stm).
Management specific to diabetes is contained in:
NICE clinical guideline 66 - Management of Type 2 diabetes (Section 1.8)
SIGN 116 – Management of diabetes 2010 (sections 8.3.2 and 9.5.3)
D1.1 SIGN 116 Antihypertensive therapy
Blood pressure (BP) lowering in people with diabetes reduces the risk of
macrovascular and microvascular disease.
Hypertension in people with diabetes should be treated aggressively
with lifestyle modification and drug therapy.
The lowering of blood pressure to 80 mm Hg diastolic is of benefit in people
with diabetes. In the Hypertension Optimal Treatment (HOT) study, the lowest
incidence of major cardiovascular events in all patients occurred at a mean
achieved diastolic blood pressure of 82.6 mm Hg and further reduction below
this blood pressure was safe in patients with diabetes. There was a 51%
reduction in major cardiovascular events in the BP target group ≤80 mm Hg
compared with the target group ≤90 mm Hg (p=0.005).
Target diastolic blood pressure in people with diabetes is ≤80 mm Hg.
In the HOT study, although diastolic BP was accurately measured, systolic BP
was consistently underestimated. The reported achieved systolic BP of 139.7
mm Hg in patients with a diastolic target of ≤80 mm Hg is likely to have been
closer to 146 mm Hg. In the UKPDS, the achieved systolic BP of 144 mm Hg
in patients allocated to ‘tight control’ was observed when aiming for a systolic
BP of <150 mm Hg. The long term follow up of these patients emphasised the
need for maintenance of good blood pressure control. In an epidemiological
analysis, lowest risk was observed in those with a systolic BP <120 mm Hg.
SIGN 97 recommends that the target systolic blood pressure for patients with
diabetes should be <130 mm Hg.
Target systolic blood pressure in people with diabetes is <130 mm Hg.
When starting antihypertensive treatment, calcium channel blockers, diuretics
and ACE inhibitors are equally effective. There was no significant difference in
25 May 2011
outcome among the three treatment groups in the Antihypertensive and LipidLowering Treatment to Prevent Heart Attack Trial (ALLHAT). A subgroup
analysis of ALLHAT found an increase in heart failure in the patient group
treated with alpha blocker as first line compared to a diuretic although this
may simply reflect an increase in ankle swelling prevalence (RR of heart
failure in patients with diabetes 1.85, 95% CI 1.05 to 2.55).
The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) found that
amlodipine (a calcium channel blocker) based treatment (with an ACE
inhibitor as an add-on treatment) reduced the incidence of total cardiovascular
events and procedures compared with an atenolol (beta blocker) regimen
(with a thiazide diuretic as an add-on treatment) (HR 0.86, CI 0.76 to 0.98,
p=0.026).
This study is also included in a meta-analysis of eight trials comparing beta
blockers and other antihypertensive agents on cardiovascular outcomes
which showed increased CV mortality in those treated with beta blockers in
comparison with those treated with renin-angiotensin blockade agents.
There is evidence from two studies for the use of a combination of ACE
inhibitor and diuretic. Compared to placebo, ACE inhibitor and diuretic in one
study reduced blood pressure (5.6/2.2 mm Hg) and the relative risks of all
deaths, cardiovascular deaths and major vascular events by 14% (p=0.025),
18% (p=0.027) and 9% (p=0.041) respectively, no matter the initial BP level.
A second study found that ACE inhibitor and diuretic reduced BP by 9.5/4.6
mm Hg compared to placebo. The reduction in risk of further stroke for those
with diabetes was 38% (95% CI 8 to 58%) equivalent to one stroke avoided
for every 16 patients treated for five years.
Angiotensin-II receptor blockers (ARBs) are equally effective alternative
antihypertensive agents in patients with ACE inhibitor-induced cough or rash.
They also have similar renal benefits in patients with microalbuminuria.
The British Hypertension Society A/CD algorithm has been accepted as the
best method of defining combination drug therapy. It specifies the use of ACE
inhibitors (or ARBs if intolerant), calcium channel blockers and thiazide-type
diuretics. The A/CD algorithm can be found in SIGN 97: Risk estimation and
the prevention of cardiovascular disease.
Patients with diabetes requiring antihypertensive treatment should be
commenced on:
o an ACE inhibitor (ARB if ACE inhibitor intolerant), or
o a calcium channel blocker, or
o a thiazide diuretic.
Beta blockers and alpha blockers should not normally be used in the
initial management of blood pressure in patients with diabetes.
D2.0 Cardiovascular disease and diabetes
Atherosclerotic macro-vascular disease is the major cause of morbidity and
mortality in people with diabetes mellitus. The increased risk of angina,
myocardial infarction, transient ischaemic attacks (TIAs), stroke disease and
25 May 2011
peripheral arterial disease is related to relative hyperglycaemia over a prolonged
period of time.
For example diabetes is associated with a two to three-fold increased risk of
coronary heart disease in men and in pre-menopausal women with longstanding
diabetes the risk is increased four to five-fold.
Any additional risk factor further magnifies the risk i.e. smoking, hypertension,
hyperlipidaemia, microalbuminuria/ proteinuria, obesity, ethnicity or family
history of premature vascular disease.
D2.1 Screening
All people with diabetes aged over 18 should have their risk factors for
cardiovascular disease assessed as part of the annual screening process:
 History and examination as appropriate.

Smoking habit – SectionB3.5

Blood pressure –Section D1

Lipid levels – Section D2.3 page 135

Urinary microalbumin / proteinuria screen – Section D6

Diet/ Weight /BMI or waist circumference – Section A4.1

Physical activity level – Section B3.3

Glycaemic control – Section C
Intervention for these modifiable risk factors should be discussed with all
patients and implemented as appropriate – see relevant sections.
D2.2 Specific cardio-protective therapy
General guidance on cardiovascular risk reduction is covered in depth in:
JBS 2: Joint British Societies’ Guidelines On Prevention Of Cardiovascular
Disease In Clinical Practice (Prepared by: British Cardiac Society, Diabetes
UK, British Hypertension Society, HEART UK, Primary Care Cardiovascular
Society, The Stroke Association)
http://www.bcs.com/download/651/JBS2final.pdf
SIGN 97 – Risk reduction and the prevention of cardiovascular disease 2007
Management specific to diabetes is contained in:
SIGN 116 – Management of diabetes 2010
NICE Clinical Guideline 66 - Management of Type 2 diabetes (Section 1.9)
25 May 2011
As well as addressing lifestyle risk factors , specific therapies to reduce the
cardiovascular risk should be offered to the following individuals, after
informed discussion between the individual and responsible clinician, unless
contraindicated:
D2.3 Lipids
JOINT STATEMENT ON THE USE OF LIPID REGULATING DRUGS IN
GRAMPIAN - November 2010
GENERIC SIMVASTATIN 40mg IS THE PREFERED INITIAL AGENT
THE OPTIMUM DOSE IS REGARDED AS 40MG AT NIGHT
Why has guidance otherwise changed?
Whilst simvastatin remains the preferred agent Atorvastatin can be used after
initial treatment failure or unacceptable side effects with simvastatin.
Rosuvastatin should be reserved for third line use.
The risks and benefits of treatment should be discussed with the patient
including the risk of side effects that can be increased by some drugs (see
BNF) and medical conditions (e.g. renal failure). In such cases closer
monitoring may be required.
FOR PATIENTS WITH ESTABLISHED VASCULAR DISEASE:





An initial dose of simvastatin 40mg at night is recommended for
most patients. Simvastatin 80mg is routinely not recommended in
view of significant adverse effects.
If patients are complying with therapy and targets cannot be
achieved on 40mg simvastatin, then a switch to atorvastatin 20
mgis recommended. .
Fibrates can be used when a patient is intolerant of any statin.
Ezetimibe is not on the Grampian formulary but can be used as
monotherapy where patients cannot tolerate either statin or fibrate.
It is not licensed for addition to fibrates.
If triglycerides (or initial total cholesterol) are >10mmol/litre then
expert advice should be obtained.
IN PRIMARY PREVENTION


Diabetic patients over the age of 40 should be treated following the
'established disease' recommendations in the previous section;
younger diabetic patients should be considered for primary
prevention.
Drug therapy should now be routinely used for individuals with a
risk >20% over 10 years. This assessment should be based on risk
tables and not on cholesterol levels alone. Simvastatin 40mg at
night is the recommended therapy.
25 May 2011




There is no evidence for further dose titration and it is not a
requirement of QoF.
Focused attention to improving general lifestyle measures is always
an essential component of primary prevention.
There is currently no robust outcome data for the use of either
fibrates or ezetimibe although pragmatically they could be used with
discretion.
If cholesterol or triglycerides are >10mmol/l then expert advice
should be obtained.
Lipid Management specific to diabetes is contained in:
SIGN 116 – Management of diabetes 2010 (Section 8.3.2 and 8.4.7)
NICE clinical guideline 66 – Management of Type 2 diabetes (Section 1.10)
25 May 2011
D3.0 Eye Care, Screening and Treatment
D3.1 Eye screening
The Grampian Diabetes Retinal Screening Programme undertakes screening
for diabetic retinopathy within Grampian Region. Any patient registered with
diabetes on a GP software system in NHS Grampian will be
automatically called for eye screening. Any person with diabetes can be
excluded from eye screening through SCI-DC. All patients with diabetes
are offered appointments at the discretion of their General Practitioner.
Patients unable to co-operate with examination or who have no perception of
light in either eye should not be offered screening. However it may be
appropriate that these patients are referred directly to the ophthalmology
department for review. All other patients should be invited to attend, including
those registered blind as, despite the terminology, many still have useful
remaining vision. In particular the commonest causes of blindness in people
with diabetes are age-related macular degeneration and diabetic macular
oedema. Screening is still essential to look for new-vessel formation that
could affect their remaining peripheral vision.
Patients who attend Ophthalmology Clinics for reasons other than monitoring
or management of their diabetic eye disease should still be encouraged to
attend for retinal screening.
Screening criteria
Who
When
Where
By Whom
How
People with diabetes aged 12 years or over
Refer at diagnosis. Screen at least annually*.
Will vary according to local arrangements.
Routine screening by Diabetes Retinal Screening Programme.
Digital retinal imaging
*Ophthalmologists or the Retinal Screening Programme may undertake
repeat examination more frequently in certain high-risk groups. In pregnancy
retinal examination should be undertaken in each trimester.
Defaulters
Screen opportunistically by whoever sees them diabetologist, optometrist, general practitioner.
Should have visual acuity (with glasses or pinhole) recorded
and either non-mydriatic retinal photography or direct
ophthalmoscopy with mydriasis (1% tropicamide).
Documentation Methodology and findings should be reported according to
the Scottish Diabetic Retinopathy Grading System – details in
Appendix 5.
25 May 2011
Frequency of screening Patients will be recalled at least on an annual basis
for screening for diabetic retinopathy. Those with referable retinopathy or
referable maculopathy will be referred on to the ophthalmology service.
Those patients will moderate retinopathy or observable maculopathy will be
rescreened at a 6 month interval.
Obtaining individual patient results
Patients diabetic retinal screening outcomes and retinal images may be
accessed and shown to your patients via the SCI-DC Network system – see
section on Information Technology (B 4.0, Figure 8; D 3.8).
D3.2 Mydriasis
Patients who are attending the Grampian Diabetes Retinal Screening
Programme will not routinely have their pupils dilated unless it is not possible
to get a gradeable image with digital photography. If dilation is required, 1%
Tropicamide should be used. This may cause blurring of vision and affect the
ability to drive or operate machinery for up to four hours, and patients should
be appropriately warned.
Glaucoma, whatever form, is not a contraindication to mydriasis.
Contact lenses do not need to be removed.
D3.3 Medical treatment
Tight blood pressure control has a dramatic effect on the progression of eye
disease and the prevention of visual impairment. It is always strongly advised.
Tight glycaemic control also has a beneficial effect on the progression of eye
disease and the prevention of visual impairment. In some patients however if
control is tightened up too quickly this can lead to progression of retinopathy.
In patients with no retinopathy or only mild background changes this usually
manifests itself as the development of cotton wool spots. These are of no
consequence and will often disappear. In patients with severe background or
worse retinopathy rapid tightening of glycaemic control can lead to rapid
progression to high-risk proliferative retinopathy.



If the patient’s retinopathy status is unknown and they are poorly
controlled then they should be referred to the Grampian Diabetes
Retinal Screening Programme for assessment, if possible, prior to
tightening up of glycaemic control.
As it takes years for the complications of diabetes to occur, it would
seem prudent for glycaemic control to be improved gradually over 6-12
months in such at risk patients.
Opportunistic retinal examination for chronic defaulters from Retinal
Screening/Ophthalmology review, should be undertaken prior to
discharge from hospital.
25 May 2011
D3.4 Laser treatment
Laser treatment is very effective at treating proliferative (new vessels)
retinopathy and will prevent the majority of people developing significant
visual impairment.
Laser treatment is less effective at treating patients with maculopathy
(changes affect the centre of vision) but attention to blood pressure and
glucose control can make a significant impact in preventing deterioration.
D3.5 Diabetic eye screening guidelines - classification and action
D3.5.1 Visual acuity


Normal corrected visual acuity
Action Review visual acuity annually

Visual acuity worse than 6/9 in the worst eye

Stable or previously explained

Action Review visual acuity annually

Deteriorating (by 2 or more lines) or previously unexplained

Action Ask patient to attend their own Optometrist for refraction and if
vision cannot be improved then consider reason unrelated to diabetic
retinopathy (e.g., cataract, chronic amblyopia, senile macular
degeneration). Refer to ophthalmologist as appropriate

Diabetic retinopathy. Macular oedema may present with no specific
fundoscopic change.

Action Refer to ophthalmologist
D3.6 Fundoscopy
Ophthalmoscopy is an alternative method to photography for examining the
retina. The Health Technology Board for Scotland recognises that indirect
ophthalmoscopy using a slit-lamp is sensitive and specific enough for retinal
screening but notes that it carries the disadvantage that there is no permanent
record of the image for quality assurance or for monitoring progressive
changes. However, this technique will be essential for screening failures of
digital photography. Direct ophthalmoscopy has high specificity but its
sensitivity is too low to form the basis of a national screening programme.
Direct ophthalmoscopy still has a role though in opportunistic screening for
those who persistently default from the systematic national programme.
25 May 2011
D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1
This system is used for screening by the Grampian Retinal Screening
Programme or opportunistically. The Grampian Retinal Screening Programme
will initiate appropriate onward referrals or review schedules.
Retinopathy
Description
Outcome
R0
(no visible
retinopathy)
No diabetic retinopathy anywhere
Rescreen 12
months
R1 (mild)
Background diabetic retinopathy BDR –
mild
The presence of at least one of any of the
following features anywhere
 dot haemorrhages
 microaneurysms
 hard exudates
 cotton wool spots
 blot haemorrhages
 superficial/ flame shaped
haemorrhages
Rescreen 12
months
R2
(observable
background)
Background diabetic retinopathy BDR observable
Four or more blot haemorrhages (ie _AH
standard
photograph 2a – see below) in one hemifield only (Inferior
and superior hemi-fields delineated by a
line passing
through the centre of the fovea and optic
disc)
Rescreen 6
months (or refer
to ophthalmology if
this is not feasible)
R3 (referable
background)
Background diabetic retinopathy BDR –
referable
Any of the following features:
 Four or more blot haemorrhages (ie
AH standard
 photograph 2a – see below) in both
inferior and superior
 hemi-fields
 Venous beading (AH standard
photograph 6a – see
 below)
 IRMA (AH standard photograph 8a –
see below)
Refer
ophthalmology
These patients
may
be kept under
surveillance and
will
not necessarily
receive immediate
laser treatment.
25 May 2011
R4
(proliferative)
Proliferative diabetic retinopathy PDR
Any of the following features:
Active new vessels
Vitreous haemorrhage
Refer
ophthalmology
These patients are
likely to receive
laser treatment or
another
intervention.
R5
(enucleated)
Enucleated eye
R6
(inadequate)
Not adequately visualised :
Retina not sufficiently visible for
assessment
Rescreen 12
months (other
eye)
Technical failure
Arrange alternative
screening
examination. This
will be automatic
within the
screening
programme.
25 May 2011
Photo 2a
Photo 6a
Photo 8a
All photographic images in relation to Diabetic Retinopathy grading outcomes
can be viewed at
http://eyephoto.ophth.wisc.edu/ResearchAreas/Diabetes/DiabStds.htm
Maculopathy
M1
(Observable)
Description
Lesions within a radius of > 1 but ≤ 2 disc
diameters of the centre of the fovea
 Any hard exudates
M2
(Referable)
Lesions within a radius of ≤ 1 disc diameter
of the centre of the fovea
 Any blot haemorrhages
 Any hard exudates
Coincidental
Description
findings
PhotoLaser photocoagulation scars present
coagulation
Other
Other non-diabetic lesion present
 Pigmented lesion (naevus)
 Age-related macular degeneration
 Drusen maculopathy
 Myelinated nerve fibres
 Asteroid hyalosis
 Retinal vein thrombosis
Outcome
Rescreen 6
months (or refer
to ophthalmology if
this is not feasible)
Refer
ophthalmology
These patients
may
be kept under
surveillance and
will
not necessarily
receive immediate
laser treatment.
Outcome
Grading note
This grading scheme is not intended to be done by levels. It is meant to be
done by features. The grader reports the presence or absence of each of the
following features for each hemisphere and then derives the level for the
25 May 2011
individual eye:
.
.
.
.
.
.
• Dot haemorrhages or microaneurysm
• 4 or more blot haemorrhages (i.e. ≥ standard photography 2a)
• Venous Beading (≥ AH standard photograph 6a)
• IRMA (≥ AH standard photograph 8a)
• New vessels
• Vitreous haemorrhage
D3.8 Obtaining individual patient results
Retinal screening results and images may be accessed using SCI-DC.
Click on ‘eye screening images to access retinal images
Click here to view patient’s retinal images
Grading outcomes at top of page, scroll down to see retinal image
25 May 2011
Please refer to IT section regarding call/recall process.
25 May 2011
D 4.0 Foot Care, Screening and Treatment
D 4.1 Foot Screening
The chief factors responsible for foot problems in the diabetic foot are
neuropathy and ischaemia, often a combination of the two, with infection as
both a provoking and complicating factor. Diabetic foot screening is beneficial
in identifying the level of risk of developing foot ulceration in patients with
diabetes. It is important to enable appropriate management patients with
diabetes; Absence of symptoms should not be taken as an indication of
absence of risk.

All patients with diabetes should be screened at diagnosis and
annually thereafter to assess their level of risk. (SIGN 116)

The result of foot screening examination should be entered onto SCI
DC foot screening tool. This will provide automatic risk stratification
and a recommended management plan. See appendix 1 (SIGN 116)

Foot screening in Grampian will be provided by NHS Grampian
Integrated Screening Service or at practice level.

Only suitably-trained healthcare professional will carried out foot
screening. Training will be provided by NHS Grampian podiatry
department using the SCI DC foot screening tool. Contact details from
NHS Grampian Diabetes MCN website.

The use of a calibrated 10g Monofilament is essential.
25 May 2011
D4.1.1 SCI-DC Foot Screening Tool
25 May 2011
D4.1.2 Annual Diabetic Foot Screening
Draft Guideline – 25 September 2008
D4.1.3 Diabetic Foot Risk Stratification and Triage “Traffic Lights”
Draft Guideline – 25 September 2008
D4.2 Management guidelines for Charcot neuroarthropathy in
people with diabetes
Charcot neuroarthropathy of the foot is a neuroarthropathic process with
osteoporosis, fracture, acute inflammation and disorganisation of foot
architecture, During the acute phase it can be difficult to distinguish from
infection (SIGN 116, 2010)
Clinical features
Diabetes patient presents with red, oedematous, hot and possibly painful foot
in the absence of infection.
Usually bounding pedal pulses with evidence of impaired neurological testing.
Diagnosis / Investigations
Diagnosis should be made by clinical examination.
(SIGN 116, 2010, Frykberg et al 2000; Jeffcoate et al 2000)
Post-diagnosis thermography can be used to monitor the disease activity.
(SIGN 116, 2010)







Usually a good blood supply to lower limb with degree of neuropathy
Observe foot for obvious signs of tissue trauma, cellulites or systemic
toxicity to rule out infection
History of trauma to limb may be present
Heat differentiation between limbs -affected limb often 2-8 degrees
higher than the contra lateral foot
Blood test- HbA1c, ESR and C-reactive protein
X-Ray for baseline and to exclude diabetic neurophathic fracture
MRI can be used to detect early changes of Charcot neuroarthropathy
which cannot be detected by x-ray
Management
Suspected Charcot neuroarthropathy is an emergency and should be
referred immediately to the Multidisciplinary Foot Clinic.
(SIGN 116, 2010, NICE 2004)




Total Contact Casting or a prefabricated walker rendered irremovable
with a total contact insole and non weight bearing are effective
treatment for patients with Charcot neuroarthropathy.
Off loading device usually worn until inflammation settles, heat
differentiation disappears and bone activity reduces.
Patients require comprehensive education on the causes, management
and prevention of complications associated with Charcot
neuroarthropathy
There is insufficient evidence to support the routine use of
Bisphosphonates in the acute Charcot neuroarthropathy (SIGN 116,
2010)
Draft Guideline – 25 September 2008
Contact details of the Multidisciplinary Foot Clinics are available on the
NHS Grampian Diabetes MCN website. Alternatively referral can be made
via local Diabetes Podiatrist.
PHIL 1 Charcot Foot Leaflet .PDF
D4.3 Diabetic Foot Ulceration and Wound Management
5-7% of all people with diabetes will by affected by a foot ulcer at some point
during their lives. Diabetic foot ulcers are a major reason for hospitalisation
and account for more than two-thirds of non-traumatic lower limb amputations
performed. A unified approach to foot care management is essential. No one
health care professional should deal with this problem. It continues to be a
challenge to diabetic medicine and requires a multi-disciplinary approach.
(SIGN guideline 116, 2010,Section 11)
Urgent referral to a Diabetes Podiatrist (by telephone or fax followed by a
written referral) is the most appropriate route for patients with a diabetic foot
ulcer and possible soft tissue infection.
(Please refer to NHS Grampian Diabetes MCN website for contact details of
Diabetes Podiatrist).
D4.3.1 Care Pathway for Active Diabetic Foot Ulceration
Patients with active diabetic foot disease should be referred to a
multidisciplinary diabetic foot care service. (SIGN 116, 2010)
If the referral is urgent please contact by telephone or fax followed by a
written referral to the multidisciplinary diabetic foot care service via the
diabetes podiatry team.
(Please refer to NHS Grampian Diabetes MCN website for contact details of Diabetes
Podiatrist).
Draft Guideline – 25 September 2008
Care pathway for Active Diabetic Foot Disease
Active foot disease - Def: Active foot disease may be either of recent onset
or chronic but deteriorating. The term refers to anyone with diabetes who
has:
o An ulcer, blister or break in the skin of the foot
o Inflammation or swelling of any part of the foot, or any sign of
infection
o Unexplained pain in the foot
o Fracture or dislocation in the foot with no preceding history of
significant trauma
o Gangrene of all or part of the foot
Determine the cause e.g. trauma, neuropathic, ischaemic or neuroischaemic.
Determine current vascular and neurological status. Assess wound and
record all findings e.g. duration of wound, size, depth, appearance etc.
Is infection present?


Contact GP for
commencement of antibiotic
cover
Take a wound swab and
send to microbiology
Refer to Diabetes Podiatrists
for
(Contact details available from NHS
Grampian Diabetes MCN website
www.diabetes.nhsgrampian.org )




Assessment of patient
Immediate pressure relief
Referral to members of the
multidisciplinary foot team
Referral to M.A.R.S. for a managed
program of pressure relief.
Draft Guideline – 25 September 2008
D4.3.2 Referral Pathway for Pressure Relief
Active Diabetic Foot
Disease
Refer to Diabetes Podiatrist for

Initial Pressure relieving device

Appropriate referral to Orthotist at Mobility
and Rehabilitation Service (MARS) for
Assessment of a managed program of
pressure relief
(Contact details for Diabetes Podiatrist’s are available
from NHS Grampian Diabetes MCN website
www.diabetes.nhsgrampian.org)
Draft Guideline – 25 September 2008
D4.3.3Painful Diabetic Neuropathy
Symptoms of neuropathy or neuropathic symptoms present at annual check (e.g. Pain (burning, shooting or electrical
quality), dysthesia and paraesthesia (e.g. crawling, itching, numbness, tingling), sensory loss or allodynia)
Investigations- Check Vitamin B12 , Immunoglobulin, Thyroid function, Creatinine,. Optimise HBA1c and blood pressure
Encourage all patients with diabetes who smoke to stop.
Assess severity of symptoms. Severe symptoms can cause e.g. sleep
disturbance, interference with normal activity etc
Non-severe
Consider trial of:
- Simple analgesia
- Capsaisin Cream 0.075%
(under specialist supervision)
- Opsite, bed cradle
Consider referral to
Diabetes Podiatrist
Uncontrolled
Severe
Consider Medication
(see following page)
Controlled
Controlled
Continue annual checks.
Monitor for worsening or
remission.
Uncontrolled
Refer to Consultant Diabetologist
Draft Guideline – 25 September 2008
MEDICATION FOR PAINFUL DIABETIC NEUROPATHY
AMITRIPTYLINE
Unlicensed for this indication, but adult dose initially of 10 mg at night,
gradually increased if necessary to 75mg; higher doses under specialist
supervision.1
GABAPENTIN
Adult dose: 300mg once daily on day 1, then 300mg twice daily on day 2, then
300mg three times daily of day 3 or initially 300mg three times daily on day 1,
then increased according to response in steps of 300mg (in 3 divides doses)
every 2-3 days up to max 3.6g daily. 1
TRAMADOL
In combination with gabapentin should be considered for the treatment of
patients with painful diabetic neuropathy 1,3
Adult dose: 50-100mg not more than every 4 hours, total of more than 400mg
daily not usually required. 1
DULOXETINE
60mg once daily, increased to a max of 120mg in divided doses. 1 May be
initiated under specialist supervision as second or third line therapy.2
PREGABALIN
It should be restricted to use in patients who have not achieved adequate pain
relief from, or have not tolerated, conventional first- and second-line
treatments for peripheral neuropathic pain. Treatment should be stopped if
the patient has not shown sufficient benefit within 8 weeks of reaching the
maximally tolerated therapeutic dose. Available for restricted use under
specialist supervision.2
Dose for adult over 18 years of age: initially 150mg daily in 2-3 divided doses,
increased if necessary after 3-7 days to 300mg daily in 2-3 divided doses,
increased further if necessary after 7 days to max. 600mg daily in 2-3 divided
doses . 1
References
1. BNF 61, March 2011
2. Grampian Joint Formulary
3. SIGN Guideline 116: Management of Diabetes
Draft Guideline – 25 September 2008
D 4.4 Good practice guidance for the use of antibiotics in patients
with diabetes foot ulcers
This document has been endorsed by the Scottish Diabetes Group on behalf
of the Scottish Government, and is recommended for use as National
guidance.
D 4.4.1 INTRODUCTION
The following is guidance to help health-care professionals to make decisions
that will improve outcomes for their patients. This is a consensus document
based on limited available clinical trial evidence, review of international
guidelines and expert opinion. There may be circumstances where alternative
courses of action may be appropriate.
Guidance about antibiotic choice is primarily dependent on local
microbiological epidemiology and susceptibility patterns. However, the
consensus group felt that the pathogens causing infection in Scotland for the
various diabetic foot infection clinical syndromes are unlikely to vary
substantially within Scotland. Therefore there is some merit in providing
broad practical guidance about antibiotic choice but this should be subject to
local adaptation if necessary.
D 4.4.2 GENERAL APPROACH TO FOOT ULCERS
Team Approach
 All patients with diabetes and foot ulcers should be managed in a
multidisciplinary foot-care setting. Previous ulceration is the strongest
predictor for further ulceration. Thus, after healing, preventative
measures need to be addressed. Attention to aggressive treatment of
macrovascular risk factors in patients with foot ulcers has been shown
to prolong survival.
Specimens for Culture
 It is debated whether ulcers with clinical signs of infection should have
a specimen taken for culture at outset. If not then cultures should be
taken if there is clinical failure of empirical antibiotics. Aspiration of
purulent secretions, curettage of debrided wound base, punch biopsy
and exuded bone are the best specimens to obtain. Keep in mind that
in foot ulcers what maybe cultured as mixed growth, doubtful
significance , unusual organisms maybe of great significance and
warrant therapy to achieve healing.
Loose Bone
 Loose bone exuded from an ulcer, or any bone debrided should be
sent for bone culture and microbiological assessment. The extrusion of
a bone fragment (sequestrum) is highly suggestive of underlying
Draft Guideline – 25 September 2008
osteomyelitis although the infection may have arrested coincident on
the passage of the sequestrum.
Investigation of Osteomyelitis
 If concerned about osteomyelitis, Plain X-ray is the usual initial
investigation of choice. However, the X-ray can be normal for 2 weeks
before any changes are seen, and thus serial X-rays may be required.
If there is ongoing concern then the secondary investigations of choice
are (in order of preference): MRI > Isotope White cell Scan > Triple
phase Bone scan. The isotope bone scan is relatively sensitive at
diagnosing osteomyelitis, but is not specific, and can remain positive
for over one year. The white cell scan may be difficult to obtain in
some areas. Choice of test may be dictated by local availability.
“Probe to Bone”
 Inability to touch bone when probing a wound with a sterile metal
probe, makes osteomyelitis very unlikely, with a negative predictive
value of about 90%. The positive predictive value of a positive probe to
bone test is only around 50%, which means that ulcers that probe to
bone frequently do not have osteomyelitis.
“Sausage Digit”
 The presence of a red swollen “sausage” digit is suggestive, of
osteomyelitis, but can be consistent with other causes such as fracture.
Differentiating Osteomyelitis and Charcot
 This can be difficult, and is based on taking a good history and
examination with supplementary evidence from MRI and other
investigations. Osteomyelitis and Charcot foot can frequently occur
simultaneously.
Foot Ulcer Classification
 Various Ulcer classification schemes can be used (Wagner, Texas,
SINBAD, PEDIS). The SCI-DC electronic ulcer management
programme is based on the Texas scheme (figure 1)
Classification of Infection
 It is recommended that the presence and severity of infection can be
classified according to the Infectious Disease Society of America
(IDSA)/ International Working Group for the Diabetic Foot (IWGDF)
classification (table 1).
Table 1 (Lipsky et al, Clinical Infectious Diseases 2004: 39: 885-910: IDSA
guidelines)
SEVERITY OF INFECTION DESCRIPTION
1. NO INFECTION
2. MILD (GRADE 2)
Either:
a) 2 or more features of inflammation:
Pus; Erythema; Pain; Tender; Warmth; Induration
Or
b) Cellulitis < 2cm. Confined to skin or subcutaneous tissue.
No systemic illness.
Draft Guideline – 25 September 2008
3. MODERATE (GRADE 3). Above with
Either
a) lymphatic streaking, deep tissue infection (subcutaneous, fascia,
tendon, bone), abscess,
Or
b) Cellulitis >2cm
(but with no systemic illness)
4. SEVERE (GRADE 4). Any infection with systemic toxicity (fever, shock,
vomiting, confusion, metabolic instability). Presence of critical
ischaemia may make the infection severe.
Draft Guideline – 25 September 2008
D 4.4.3. GENERAL PRINCIPLES OF ANTIBIOTIC USE (see below for specifics)








Antibiotic choice is primarily dependent on local microbiological
susceptibility and epidemiology. However antibiotics often need to be
started before this information is available. As the pathogens in
diabetic foot infections do not vary significantly in Scotland, the
consensus group recommends broad practical guidance about
antibiotic use. These are however subject to changing local
epidemiology and prescribing policy.
Initial treatment is frequently empirical based on the presumed
pathogen; see table 2 and 3.This guidance is of value until
microbiological and clinical response shed further light.
The choice of antibiotic, agent and route of delivery, should reflect the
severity of infection as reflected by the IDSA/IWGDF definition– see
table 1.
The duration of antibiotic use should be adjusted according to the
severity of infection (table) and can be guided by monitoring clinical
improvement. In general duration of antibiotic therapy should be kept
short, but the dose used should be high dose.
In light of international concerns over the risk of C.difficile associated
with broad spectrum antibiotics (especially clindamycin, co-amoxiclav,
cephalosporins and quinolones) and MRSA risk (associated with coamoxiclav, cephalosporins and quinolones and macrolides) narrow
spectrum therapy should be used wherever possible. C.difficile is a
particular risk for patients aged over 65years and in-patients.
Adjustment of therapy based on microbiology results, when available,
is important. These agents should be used where indicated empirically
I this specialist foot ulcer advice or by sensitivities to achieve foot ulcer
healing, even if conflicting with general advice on antibiotic selection.
Allergies to antibiotics refer to skin rash or anaphylaxis. This does not
include minor side-effects such as nausea.
Enterococci, Pseudomonas and anaerobes are frequently grown as
colonising organisms, rather than infecting organisms. If however there
is a chronic persisting infection or they are the predominant organisms,
they may be more important, and need treatment.
This document provides general advice, but direct contact with local
specialists may be necessary in certain circumstances for advice with
regard to more specialised use of these or other antibiotics.
Draft Guideline – 25 September 2008
Figure 1.
Draft Guideline – 25 September 2008
D4.4 SPECIFIC ANTIBIOTIC GUIDANCE (see Table 2 for summary)
For different clinical syndromes the likely microbiology and therefore initial
antibiotic can be predicted with some degree of confidence although there will
on occasions be unusual circumstances. We emphasize the importance of
getting good quality specimens (see above) for microbiology and of close
liaison with the local infection specialist. Main choice antibiotics in blue and
alternatives in green are provided. The advice given is for empirical choices of
antibiotics. If there is local guidance based on local sensitivities, then this
should take precedent.
4.4.1 Mild infection (IDSA) or (PEDIS 2) and the patient is antibiotic naïve.
Likely pathogens are S.aureus (coagulase-negative
Staphylococcus) or beta-haemolytic streptococci. If previously
treated with antibiotics, enterococci and gram negative rods
(GNRs) are likely to be present.
Oral flucloxacillin 1g qds.
Oral Alternatives
Doxycyline 100mg bd
Clindamycin 300-450mg qds, if the patient is allergic to or intolerant of
flucloxacillin.
A second course of flucloxacillin is rarely effective if the first course has been
unsuccessful, assuming that the first course was given in high dose and for a
full 5-7 days. There is an increased prevalence of resistant organisms after
the first exposure to flucloxacillin.
Treat for 5-7 days and then decide about further antibiotics depending on
clinical response and microbiological culture. Ensure microbiological culture if
unusual organism suspected, or initial treatment fails.
4.4.2a Moderate (IDSA) or PEDIS 3 and the patient is antibiotic naïve.
Good quality microbiological culture is usually helpful in these
circumstances. Likely pathogens are S.aureus or betahaemolytic streptococci. Those with limb ischaemia, gangrene,
necrosis or a foul odour from the wound often have obligate
anaerobic pathogens.
Oral flucloxacillin 1g qds
Oral Alternatives:
Co-trimoxazole 960mg bd
Co-amoxiclav 625mg tds
Clindamycin 300-450mg qds or co-trimoxazole, if the patient is allergic to
penicillins.
Add in oral metronidazole 400mg tds if anaerobes suspected
Draft Guideline – 25 September 2008
IV flucloxacillin 1g qds.
If IV route for clindamycin is needed then use 450-600mg qds.
Draft Guideline – 25 September 2008
4.4.2b Moderate (IDSA) (or PEDIS 3) and the patient is NOT antibiotic naïve.
Patients with chronic infections, especially if they have received antibiotics
previously often have polymicrobial infections, including aerobic gramnegative bacilli among the flora.
a) IV co-amoxiclav 1.2gtds – especially if anaerobes or coliforms suspected
Oral switch option is
oral co-amoxiclav 625 tds or
Co-trimoxazole 960mg bd
If the patient is allergic to penicillins consider:
b) IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds ± vancomycin (if
MRSA considered likely)
Or
IV gentamicin* and IV metronidazole ± vancomycin (if MRSA considered
likely)
The choice will depend on the relative risks of C.difficile versus those of renal
impairment.
* The dosing of gentamicin is high dose once daily and should be determined
by local practice and will require close monitoring of serum levels and renal
function. Gentamicin dosing for more than 48 hours should only be continued
with specific advice from the infection specialist.
Oral switch option is
oral ciprofloxacin 500- 750mgbd with oral metronidazole 400mg tds, or
oral ciprofloxacin 500- 750mg bd and clindamycin 300-450mg qds
 Treat for 7 days. Adjust therapy in light of clinical response and results
of culture and sensitivity results.
4.4.3a Severe infection (IDSA) (or PEDIS 4), antibiotic naïve.
High quality culture (see section 2) is usually helpful in these circumstances.
The likely pathogens are S.aureus or beta-haemolytic streptococci but may
need to cover also for anaerobes and enterobacteriacea and Pseudomonas
aeruginosa. Caution: Pseudomonas is usually a coloniser rather than being
an infecting organism. As grade 4 infection implies systemic toxicity, it is
generally advised that such patients should be admitted to hospital for the
initial phase of management.
IV co-amoxiclav 1.2gtds +/- gentamicin 5-7mg/kg once daily or as per local
practice. . Gentamicin dosing for more than 48 hours should only be
continued with specific advice from the infection specialist
If the patient is allergic to penicillins or there is concern about renal function
consider
IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds. ± vancomycin (if
MRSA considered likely)
 Treat for a minimum of 10-14 days
Draft Guideline – 25 September 2008
4.4.3b Severe infection (IDSA) (or PEDIS 4) and the patient is not antibiotic naïve
and has risk factors for drug resistant infection
Previous antibiotics within last 90 days, recent hospitalisation/s for more than
2 days within last 90 days, previous colonisation or infection with resistant
organism e.g MRSA or Extended Spectrum Beta-Lactamase (ESBL)
producing E.coli or Klebsiella spp) or proven resistant infection
IV piperacillin/tazobactam (tazocin) 4.5g tds ± vancomycin if MRSA suspected
(consult pharmacy for dose but aim for a trough vancomycin level of 1520mg/l). If penicillin allergy IV ciprofloxacin 400mg bd and add IV
metronidazole 500mg tds.
Oral switch options in these patients are best guided by microbiology where
possible. Otherwise, try oral ciprofloxacin 500- 750mg bd and metronidazole
400mg tds.
 If extended spectrum beta-lactamase (ESBL) producing coliform is
proven then seek specialist infection advice.
 Treat for minimum of 10-14 days, then review need for antibiotic.
If continuing MRSA cover is required and the patient can be discharged from
hospital we suggest
either outpatient and home parenteral antimicrobial therapy (OHPAT) if
available (usually given iv teicoplanin)
or oral linezolid is an option but treatment beyond two weeks needs to be
monitored closely for bone marrow toxicity, particularly thrombocytopenia or
leucopenia, and lactic acidosis, which are usually reversible on
discontinuation of the drug
Rifampicin 300mg bd AND
oral doxycycline 100mg bd OR fusidic acid 500mg tds OR trimethoprim
200mg bd
The rifampicin may offer difficulties related to drug interaction [eg warfarin]. All
these agents can be used in penicillin allergic patients.
At all times advice can be sought from your local podiatry team:
Contact numbers on Grampian Diabetes MCN website
Draft Guideline – 25 September 2008
4.4.5. OSTEOMYELITIS
Early local surgery to excise infected bone can help accelerate healing and
reduce the length of time antibiotics are required. For other cases, antibiotic
therapy will lead to resolution of infection in up to 60% to 80% of cases. The
exact role of local surgery remains controversial.
The evidence base for antibiotic choice for these infections is poor. However,
in general terms the group recommends that where there is evidence of
osteomyelitis the treatments outlined above should be continued for at least 46 weeks, and sometimes longer depending on clinical response. Sometimes
measurement of serial CRP’s and White cell count may help, but not more
than once per week. Various antibiotics require monitoring of liver function
tests, full blood count and/or serum drug levels. Rationalisation of therapy
should be discussed with an infection specialist.
For MRSA osteomyelitis there is some evidence that adding rifampicin 600mg
bd or Sodium Fusidate to other treatments can be beneficial
There is no evidence that IV therapy is superior to oral therapy, although in
certain infections like MRSA IV therapy delivered in the OHPAT setting is
attractive to enhance compliance and reduce hospitalisation.
In osteomyelitis tolerability of oral antibiotics is a significant issue and therapy
may need to be tailored accordingly. If considering the use of linezolid for
osteomyelitis the prescriber must be aware of its unlicensed status for this
indication and of the risks of bone marrow toxicity, peripheral or optic
neuropathy and lactic acidosis.
Draft Guideline – 25 September 2008
Table 2. Summary of Good practice statement on Antibiotic choice for the
diabetic foot.
Choices should always be guided by deep culture results when available.
Treatment should be for 5-7 days (mild/moderate) to 10-14 days (severe) and
then review the need for longer treatment. If osteomyelitis present then treat
for at least 4-6 weeks and then review the need for longer treatment. IV
antibiotics may be switched to oral preparations after an appropriate interval
(see main text)
MILD
Either 2 or more features
of inflammation (pus,
erythema, pain, tender,
warmth, induration),
OR Cellulitis < 2cm.
Confined to skin or
subcutaneous tissue. No
systemic illness
ANTIBIOTIC NAIVE
Oral Flucloxacillin 1g
qds*
Alternatives:
Doxycycline 100mg bd
Clindamycin 300-450mg
qds
MODERATE
Either two or more
features lymphatic
streaking, deep tissue
infection (subcutaneous,
tendon, fascia, bone),
abscess, OR b) Cellulitis
>2cm
SEVERE
Systemic toxicity (fever,
shock, vomiting, confusion,
metabolic instability)
ANTIBIOTIC NAIVE
Oral Fluxcloxacillin 1g qds*
(for MSSA, ß-H Strep)
Alternatives:
Cotrimoxazole 960mg bd
Coamoxiclav 625mg tds
Clindamycin 450mg bd
+/-metronidazole 400mg
tds
ANTIBIOTIC NAIVE
(Oral therapy
inappropriate)
IV Co-amoxiclav 1.2g tds ±
Gentamicin* 5-7mg/kg
If allergic to penicillin: IV
Ciprofloxacin 400mg BD &
IV metronidazole 500mg
tds ± Vancomycin
If NOT antibiotic naïve:
See alternatives above
If NOT antibiotic naïve:
IV CoAmoxiclav 1.2g tds
Alternatives:
IV Ciprofloxacin 400mg tds
& IV Metronidazole 500mg
tds
±IV Vancomycin* (if
MRSA)
or
IV Gentamicin & IV
Metronidazole 500mg tds ±
IV Vancomycin* (if MRSA)
Oral switch: Ciprofloxacin
750mg bd & Metronidazole
400mg tds or
Ciprofloxacin 750mg bd &
Clindamycin 300-450mg
qds
If NOT antibiotic naïve:
IV Tazocin 4.5g tds + IV
Vancomycin if MRSA.
If allergic to penicillin see
alternatives opposite
MRSA
IV Vancomycin*
IV Teicoplanin* (Home IV
service)
Oral switch: Rifampicin*
with trimethoprim or
MRSA
IV Vancomycin*
IV teicoplanin* (Home IV
service)
Oral switch: Rifampicin*
with trimethoprim or
Draft Guideline – 25 September 2008
doxycycline or fusidic acid* doxycycline or fusidic acid*
Linezolid 600mg bd#*
Linezolid 600mg bd#*
* Require monitoring. Add rifampicin 600mg bd or Sodium Fusidate if osteomyelitis
#
Note concerns about linezolid toxicity with protracted therapy
Table 3. Empirical guide as to which organisms are likely to be the infecting
organism and which antibiotics are likely to be effective.
INFECTING
ORGANISM
Staphylococcus
(aureus)
MRSA
-Haemolytic
Streptococcus
Enterococcus
Pseudomonas
(Gm negative bacillus)
Anaerobic
PRIMARY GROUP OF
ANTIBIOTICS
Penicillinase resistant
Penicillin
Eg Flucloxacillin
Vancomycin
Teicoplanin
(for other options
discuss with infection
specialist)
ALTERNATIVE
Doxycycline
Clindamycin
Amoxicillin
Rifampicin combined
with trimethoprim or
doxycycline or fusidic
acid,
Cotrimoxazole,
Linezolid
Clindamycin
Amoxicillin/co-amoxiclav
Quinolones eg high
dose Ciprofloxacin
Metronidazole
Vancomycin, Linezolid
Piperacillin-tazobactam
(tazocin), meropenem
Clindamycin
Bibliography
Lipsky BA, Berendt AR, Deery HG. IDSA guidelines: diagnosis and
treatment of diabetic foot infection. Clin Infect Dis 2004; 39: 885-910.
Lipsky BA. Empirical therapy for diabetic foot infections: are there clinical
clues to guide antibiotic selection. Clin Microbiol Infect. 2007: 13: 351-3
Lipsky BA. New developments in diagnosing and treating diabetic foot
infections. Diab Met Res Rev 2008; 28 (suppl 1) S66-71
Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing
osteomyelitis in diabetes. Clinl Inf Dis2004; 39 (Suppl 2): S115-22.
Game FL, Jeffcoate WJ. Primarily non-surgical management of osteomyelitis
of the foot in diabetes. Diabetologia 2008; 51: 962-7.
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ,
Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Specific guidelines
for treatment of diabetic foot osteomyelitis Diabetes Metab Res Rev. 2008; 24
Suppl 1:S190-1
Draft Guideline – 25 September 2008
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ,
Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Diabetic foot
osteomyelitis: a progress report on diagnosis and a systematic review of
treatment Diabetes Metab Res Rev. 2008; 24 Suppl 1:S145-61
D4.5 Diabetic Foot Care Patient Education
Foot care education is an integral part of any treatment plan and is recommended as
part of a multidisciplinary approach in all patients with diabetes. (SIGN 116, 2010).
Education is an essential element in the empowerment of people with diabetes.
Patient education/information should be tailored to meet each individuals needs and
should be timely, appropriate and consistent.
A patient with diabetes should be given the appropriate NHS Scotland foot
leaflet (according to their foot risk stratification) at their foot screening
appointment.
NHS Scotland foot care leaflets include






Low Risk
Moderate risk
High Risk
Holiday Feet
Looking after your diabetic foot ulcer
Advice about your footwear
Draft Guideline – 25 September 2008
D5.0 Neuropathy - Autonomic
Patients with long-standing diabetes may develop neuropathy affecting
autonomic function, which may produce a number of different difficult clinical
and management problems. Symptoms are often non-specific and other
diagnoses should be considered and excluded, if appropriate. As many of
these problems are fortunately uncommon it is appropriate to consider
seeking specialist advice. The following notes give some basic advice on
therapeutic approaches to a range of problems that can result from diabetic
autonomic neuropathy.

Erectile dysfunction: the advent of selective inhibitors of
phosphodiesterase-5 in erectile tissue has revolutionised the initial
management of this relatively common problem in diabetic men.
Treatment is said to be successful in more than 50% of patients.
Sildenafil, Vardenafil and Tadalafil are all available on prescription for
patients with diabetes; their use should be avoided in cases of severely
compromised cardiovascular function and when nitrates are being
taken. Where oral therapies are unsuccessful, referral can be made to
a specialist ED clinic (run in Aberdeen by the Urology Department and
Mr Gunn in Elgin) for consideration of intracavernosal injection of
prostaglandin or vacuum devices.

Intermittent diarrhoea: especially occurring nocturnally, this problem
may be a direct result of gastrointestinal neuropathy in which codeine
phosphate or other antidarrhoeal agents can be helpful. Alternatively,
gut dysmotility can lead to atypical bacterial overgrowth and short
courses of antimicrobial agents such as tetracycline or metronidazole
can be rapidly effective. [Remember also other possible causes of
diarrhoea, including Metformin therapy, the possibility of coeliac
disease or exocrine pancreatic dysfunction in cases of secondary
diabetes].

Postural hypotension: advice on rising/standing cautiously, and
avoidance of over-enthusiastic use of diuretics and hypotensive agents
may be most effective. Fludrocortisone can be useful in severe cases
but may lead to oedema.

Vomiting due to gastroparesis: metoclopramide or domperidone may
help by promoting gastric emptying. Alternatively, Erythromycin may
benefit some patients.

Gustatory sweating: fortunately uncommon; best managed by
avoidance of foods found by the sufferer to exacerbate the problem.
Agents, such as propantheline, may be beneficial but often have
marked anticholinergic adverse effects.
Draft Guideline – 25 September 2008


Neuropathic oedema: damage to control of capillary blood flow can
lead to accumulation of fluid in dependent extremities in the presence
of a normal serum albumin and the absence of fluid overload.
Ephedrine, an alpha-adrenergic agonist may be useful but care is
required in the presence of hypertension and angina.
Bladder hypotonia: drug treatment with alpha blocking agents is difficult
due to the risk of precipitating symptomatic postural hypotension.
Draft Guideline – 25 September 2008
D6.0 Renal Disease
Renal impairment is important in patients with chronic diseases or on multiple
drug therapy and serum creatinine should be checked annually. Diabetic
nephropathy is an important long-term complication of diabetes, which is
characterised by persistent proteinuria, hypertension and a progressive
decline in renal function. The absence of retinopathy or the presence of
haematuria should prompt investigation for other possible forms of renal
disease. A definitive diagnosis of diabetic nephropathy can be made by renal
biopsy, although this is unnecessary in most cases.
Persistent proteinuria confers eighty to one hundred fold increased mortality
due largely to cardiovascular disease and such patients often succumb before
the need for renal support arises. Survivors with persistent proteinuria
eventually progress to end stage renal failure requiring dialysis or
transplantation.
Microalbuminuria is an early marker of diabetic renal disease and predicts the
onset of overt nephropathy in both Type 1 and Type 2 diabetes.
Microalbuminuria is also a significant independent risk factor for the
development and progression of cardiovascular disease.
Aggressive management of blood pressure can retard the progression of
diabetic renal disease at all stages.
SIGN 103 – Diagnosis and Management of CKD covers updated guidance for
all patients. SIGN 116 has a section on diabetic renal disease.
D6.1 Screening for diabetic renal disease
Who
People with diabetes aged 12 years or over
When
At diagnosis and annually
How
Dipstick for proteinuria (Albustix or equivalent)
Microalbumin estimation if dipstick negative
eGFR
Outcome
Dipstick positive – see 6.2.1 – Assessment of dipstick positive patients
Dipstick negative – see 6.2.2 – Assessment of dipstick negative patients
D6.2 Definitions
Spot urine samples (for screening)
Albustix
Dipstick one plus or greater (>200mg/l) indicates proteinuria.
Draft Guideline – 25 September 2008
Albumin/creatinine ratio (ACR)
The ratio of urinary albumin to creatinine concentration. This is a screening
test for microalbuminuria.
Normal values – female <3.5mg/mmol, male <2.5mg/mmol
Timed overnight urine collections
Normoalbuminuria
Normal albumin excretion rate <20 µg/min
Microalbuminuria
Albumin excretion rate 20- 200µg/min
Proteinuria
Albumin excretion rate > 200µg/min
Spot protein/creatinine ratio (PCR) > 70mg/mmol
24hr urinary protein > 500mg
Patient Information Sheet: Urine Testing And Microalbuminuria
D6.2.1 Assessment of dipstick positive patients
 Consider urinary infection or other non diabetic causes
 Repeat test
 Persistent proteinuria, when confirmed on two consecutive occasions,
should be quantified using a protein / creatinine ratio measurement on a
spot sample.
 In individuals with significant proteinuria, a PCR on a first pass morning
urine specimen is preferable to a timed collection.
 Review result of recent serum creatinine and blood pressure
 Persistent “dipstick positive” proteinuria negates the need for
measurement of microalbuminuria
D6.2.2 Assessment of dipstick negative patients
 Screen for microalbuminuria
 First voided urine sample after sleep, for albumin/creatinine ratio (ACR).
 Reject samples with evidence of infection.
 Normal (male < 2.5, female < 3.5 mg/mmol). Repeat in twelve months.
 Abnormal – Re-test.
 Urinary albumin excretion may be temporarily increased by other factors
such as intercurrent illness and exercise. Therefore it is usual to request
multiple positive tests, usually two out of three, over a period of months,
before microalbuminuria is confirmed.

ACR levels persistently in excess of 10 mg/mmol always indicate an
Draft Guideline – 25 September 2008
AER > 20µg/min.

Result from Klinitek 50 – both ACR <3.5 and urinary albumin
concentration <10 mg/l = normal albuminuria. Repeat in 12 months.

Result from Klinitek 50 –ACR >3.5 and/or urinary albumin concentration
>10 mg/l = send first voided urine to Lab for further analysis.
Patient information sheet – urine testing and microalbuminuria
Draft Guideline – 25 September 2008
D6.2.3 Algorithm for microalbuminuria screening in the community
Official annual screening from
diagnosis for patients
•
Albustix negative
First voided urine sample after sleep
Evidence
of infection
Yes
Reject
No
Measure Albumin /
Creatinine Ratio (ACR)
No
ACR > 2.5 men
or > 3.5
women
Normal – re-screen in
one year
Yes
Re-test first voided urinary ACR
ACR > 2.5 men
or > 3.5
women
No
Yes
No
Repeat ACR on 3 occasions. ACR +ve
on at least 2 out of 3.
Yes
Persistent microalbuminuria confirmed
Reassess cardiovascular risk
Contraindication for
ACE inhibitor or
AIIA?
BP > 125 / 75 (Type 1) ?
BP > 140 / 80 (Type 2) ?
Yes
No
Start ACE/AIIA inhibitor, irrespective of BP
Aim for BP < 125 / 75 (Type 1)
Aim for BP < 140 / 80 (Type 2)
No
Yes
Yes
Start non-ACE antihypertensive
Aim for BP < 125 / 75 (Type 1)
Aim for BP < 140 / 80 (Type 2)
Monitor BP
Draft Guideline – 25 September 2008
D6.3 A simple guide to eGFR interpretation and nephrology referral
guidelines.
What Is eGFR?
Glomerular Filtration Rate is the most
useful measure to describe kidney
function in adults. Direct measurement
of GFR is involved and expensive.
However serum Creatinine can be used
together with age and gender to give a
calculated estimate which is reasonably
accurate, particularly in those with
impaired function. A correction factor of
1.212 should be applied to AfricanCaribbean individuals. The calculation is
not applicable in acute renal failure and
gives poor results in those at the
extremes of weight. The GFR is around
100ml/min/1.73m2 in health, so the
eGFR effectively describes % kidney
function.
The introduction of eGFR In Grampian
From June 2006, the Biochemistry
department will report an estimated
GFR (eGFR) alongside reports for
serum creatinine. The calculations
being used nationally depend on the
creatinine assay used, so GFR should
not be estimated outside the laboratory.
The eGFR will not be reported in
delayed samples (>24h), or in children.
All values above 60 will all be reported
as >60 ml/min/1.73m2. Patient
information required by the
Biochemistry department to determine
eGFR include date of birth and sex.
Chronic Kidney Disease Classification
GFR can be used to classify patients
with chronic kidney disease (CKD). The
system in current use was developed by
the National Kidney Foundation in the
USA.
Stage
Description
GFR
1
Kidney damage and normal GFR
>90
2
Kidney damage and mild decrease
60 to 89
in GFR
3
Moderate decrease in GFR
30 to 59
4
Severe decrease in GFR
15 to 29
5
Kidney failure (dialysis or kidney
< 15
transplant needed)
Kidney damage refers to the additional
finding of either direct evidence (eg
ultrasound showing polycystic kidneys)
or indirect evidence (eg persisting
proteinuria) of kidney disease.
For further Information and a guide to
the management of CKD see
www.renal.org/CKDguide/ckd.html
An eGFR guide is also available at
http://www.renal.org/eGFR/
How to Interpret the eGFR result
eGFR > =60 ml/min/1.73m2
On its own an eGFR result of 2 60
ml/min/1.73m2 indicates normal kidney
function and requires no specific action.
Clearly there are however many other
indicators of kidney disease (eg nephrotic
syndrome, severe hyperkalaemia and
malignant hypertension) and a normal
eGFR should not prevent or delay
appropriate referral to a specialist.
eGFR 30—- 59 ml/min/1.73m2 ( Stage 3
CKD )
Draft Guideline – 25 September 2008
If this is the first time an abnormal result
has been identified then it should be
repeated within the week to ensure this is
not acute renal failure which should be
urgently assessed and referred. The
majority of patients with this level of
kidney disease will have already been
recognised as having an associated risk
factor (most commonly diabetes,
hypertension or cardiovascular disease in
the older patient). The patient should be
reviewed with specific note of past
results, current medications, BP,
cardiovascular risk factors, family history
of renal disease and urinary symptoms.
Most patients will be asymptomatic and
have no specific complications of CKD
(Anaemia and Renal Bone Disease).
Management should include the
following:








Advice on smoking, weight, exercise,
salt and alcohol intake.

Cause of CKD not obvious

Progressive declining kidney function

Persisting abnormalities on urine
dipstick testing (Proteinuria and/or
Haematuria).

Suspected underlying systemic
disease (eg SLE or Vasculitis)

Anaemia, cause not identified on
standard investigation

Persisting abnormalities in Potassium,
Calcium or Phosphate.

Difficult or uncontrolled hypertension

Consider urological referral if
indicated by urinary symptoms,
ultrasound findings or haematuria.
eGFR < 30 ml/min/1.73m2 ( Stage 4+ 5
CKD )
This indicates advanced or severe
chronic kidney disease. The majority of
Check drug doses, avoid or stop
patients in this group will already be
nephrotoxic agents.
known to the renal service or are
Cardiovascular risk reduction with
receiving renal replacement therapy.
consideration of aspirin and statin
Patients who have not previously been
therapy
assessed by a nephrologist should be
Strict BP control target 130/80 in most urgently referred or discussed by
telephone. There will be some situations
and 125/75 in those with Proteinuria
where this is clearly inappropriate due to
ACEI or ARB is first line
the coexistence of other significant
antihypertensive therapy (check
pathology but again where there is doubt
bloods after introduction to ensure
telephone advice can be sought.
GFR does not fall > 15%)
Management is broadly similar to that
outlined in stage 3 CKD but there are
Request renal ultrasound in those
likely to be specific problems associated
with urinary symptoms
with Anaemia or Renal bone disease
Check Hb, Potassium, Calcium and
which warrant specialist advice.
Phosphate and monitor bloods 4 - 6
Discussing renal replacement therapy
monthly.
options (dialysis, transplantation or
conservative) should also be undertaken
Offer Influenza and Pneumococcal
at this time by the specialist renal
vaccination
multidisciplinary team
Stage 3 CKD Nephrology Referral
Guidelines
Around 5% of the population will have
stage 3 CKD and many will remain stable
and can be managed in primary care as
detailed above. Criteria for referral are
listed below:
Further referral advice available from
consultant staff
[email protected]
[email protected]
[email protected]
[email protected]
01224 553536
01224 552122
01224 559502
01224 559503
Draft Guideline – 25 September 2008
Draft Guideline – 25 September 2008
D6.4 Management of Diabetic Renal Disease
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Patients with diabetic renal disease require frequent and intensive
monitoring.
Microalbuminuria and proteinuria confirm diabetic renal disease and
aggressive management of blood pressure and other risk factors is
essential to preserve renal function.
These patients are also at high risk of retinopathy, autonomic
neuropathy and cardiovascular disease.
All patients with microalbuminuria or proteinuria should be commenced
on ACE inhibitor therapy. The dosage should be gradually increased
to the maximum tolerated dose. Those intolerant of ACE inhibitors
should be given Angiotensin II antagonists. Annual measurements of
creatinine and albumin/creatinine ratio (protein/creatinine ratio if
proteinuric) should be continued.
Lowering blood pressure in relatively hypertensive microalbuminuric
patients reduces albumin excretion and progression to nephropathy.
All agents which lower blood pressure reduce albumin excretion,
although ACE inhibitors and AIIAs probably have a class specific effect
independent of their hypotensive effect and are the drugs of choice for
initial therapy.
Blood pressure should be maintained to the lowest achievable level
and certainly <130/80 mm Hg in all patients (SIGN 116). In Type 1
patients with microalbuminuria or proteinuria the target blood pressure
should be lower. The Aberdeen Renal Clinic currently recommend
<125/75.
Insulin or sulphonylurea requirements usually decrease with advancing
renal impairment. Metformin should be discontinued when serum
creatinine is > 150 µmol/l.
Reducing proteinuria should be a treatment target regardless of
baseline urinary protein excretion. The greater the reduction from
baseline urinary protein excretion, the greater effect on slowing the rate
of loss of GFR.
Patients with diabetic renal disease have a high risk of cardiovascular
co-morbidity and should be managed aggressively.
D6.5 Referral for specialist renal advice
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Consider referral to specialist renal services when creatinine >150
µmol/l (male), >130 µmol/l (female) or protein/creatinine ratio >300
mg/µmol, eGFR <30.
Referral should also be considered for features suggestive of nephrotic
syndrome or if persistent proteinuria is not thought to be explained by
diabetes (considering the duration of diabetes and absence of other
microvascular complications).
The presence of both blood and protein may also be indicative of an
alternative renal pathology and in cases where this is persistent i.e.
detected on more than 2 occasions a referral should be considered.
Isolated haematuria will require separate evaluation and is not a
feature of diabetic nephropathy.
Draft Guideline – 25 September 2008
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Specialist renal assessment will include assessment for non-diabetic
renal conditions if necessary, assessment of GFR and estimation of
likely progression of renal disease. Patients with stable renal disease
will be discharged back to routine diabetes care (primary or secondary
care) with advice on a threshold for further referral.