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