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` Nottinghamshire Diabetes Guidelines June 2013 Title (hyperlinked – point and click) Background & Acknowledgements Referral to Community and Specialist Services Nottinghamshire Community Diabetes Services Diagnosing Diabetes /Glucose Intolerance Detection of people with Diabetes 75g Oral Glucose Tolerance Test (OGTT) Impaired glucose tolerance (IGT) Impaired fasting glycaemia (IFG) impaired fasting glycaemia during pregnancy Does the newly presenting patient need insulin? Type 1 Diabetes General advice on Insulin Treatment Insulin Pump Service for Adults Type 1 Diabetes Structured Education Type 2 Diabetes Monitoring and Complications Type 2 Diabetes Structured Patient Education Activity and Lifestyle Advice Basic Dietary Recommendations Dietetic Services for Patients with Diabetes Smoking Cessation Asian Diabetes Liaison Worker Treatment Algorithm for the Management of Type 2 Diabetes Treatment of Hyperglycaemia Monitoring Diabetic Control Self Monitoring Diabetes and Sick day Rules Hypoglycaemia Management in adults (aged 16 or older) Hypertension management in Diabetes Lipid management in Diabetes Renal Monitoring Diabetic Retinopathy Painful Neuropathy Management of Foot Complications in Diabetes Diabetes in Pregnancy Pre-existing Diabetes and pregnancy Gestational Diabetes Contraception Erectile Dysfunction in Diabetes Paediatric Diabetes Services Appendix A: Lucozade / OGTT Appendix B: Physical Activity Referral Schemes Appendix C: Patient Literature / Staff Training Courses Appendix D: Education checklist for insulin-treated diabetes Education checklist for diet/tablet treated diabetes Appendix E : Cardiovascular status and ED management Appendix F: Footcare management Nottinghamshire Diabetes Guidelines June 2013 version 3 Page 2 4 5 8 8 9 9 9 9 10 11 11 12 12 14 15 16 16 17 18 19 19 20 26 27 28 31 32 34 36 37 39 40 41 43 43 44 46 47 48 49 50 51 53 55 57 58 Last reviewed June 2013 1 Background These guidelines have been developed to support the delivery of high quality care for people with diabetes in Nottinghamshire. They are evidence-based wherever possible and have been developed in consensus across Nottinghamshire, incorporating national and international recommendations on standards of care. In the event of significant new research findings or national recommendation, specific areas may be updated on an ad hoc basis. Full revision will be undertaken every two years. Please remember: Guidelines provide guidance Good clinical practice always involves weighing the advantages and disadvantages of a clinical intervention depending on individual circumstances. Guideline Development These guidelines have resulted from the combination and updating of the previous Nottingham Diabetes Guidelines and the Central Notts Diabetes guidelines. If you have comments on the content of the guidelines, please contact: Dr Kamal Chokkalingam E-mail: [email protected] Diabetes and Endocrinology Department , C Floor, South Block, Queens Medical Centre, Nottingham, NG7 2UH Dr Is Idris E-mail: [email protected] Diabetes and Endocrinology Department, Kings Treatment Centre, Kings Mills Hospital, Sutton in Ashfield, NG17 4JL Next Review Due: April 2014 Nottinghamshire Diabetes Guidelines June 2013 version 3 2 KNOWLEDGEMENT TO THE FOLLOWING PEOPLE WHO HAVE CONTRIBUTED TO THIS VERSION OF THE DOCUMENT David Bailey Mr A Bazo Emma Bennett Diabetes Specialist Nurse Associate Specialist in Urology Diabetes Specialist Nurse Nicky Bird Dr Simon Brenchley Pharmacist Manager Commissioning Strategy GP Diabetes Lead Dr Kamal Chokkalingam Prof Devaka Fernando Andy Fisher Dr Fran Game Dr Tasso Gazis Marie Haynes Duncan Heaney Liz Houghton Dr Is Idris Dr Renee Page Sue Cox Consultant Physician Consultant Physician Podiatrist Consultant Physician Consultant Physician Nurse Practitioner Head of Specialist Podiatry Services Diabetes Specialist Nurse Consultant Physician Consultant Endocrinologist Support and Development Manager Rachael Rees Head of Primary Care Operations Charlotte Lawson-Braley Prof W Jeffcoate Sarah Kay Heather Lindsay Helen Marsh Suzanne Meredith Sylvia Miles Alison Musgrove Shailesh Panchmatia Gill Peck Dr Peter Prinsloo Helen Ramwell Dr Tabitha Randell Dr I Seetho Ann Spencer Prof George Thomson Dr Firial Al Ubaidi Francesca Meakin Mr Grenville Ward Karen Ward Hazel Wigginton Sheena Prentis Dr Manjusha Rathi Dr Simone Rueter Phyllis Bushby Support and Development Manager Consultant Physician Specialist Dietitian Public Health Manager Paediatric Diabetes Specialist Nurse, Health Improvement Principal Diabetes Specialist Nurse Podiatrist, Senior Pharmacist Diabetes Specialist Nurse, Consultant Metabolic Physician Specialist Community Dietitian (Diabetes) Consultant in Paediatric Endocrinology and Diabetes Specialist Register in Diabetes Patient Representative, Consultant Physician Consultant Chemical Pathologist, Senior Clinical Scientist Patient Representative Diabetes Specialist Nurse, Commissioning Manager - Long Term Conditions Lead Midwife Diabetes Consultant Locum Consultant in Contraception and Sexual Health Community Diabetic Specialist Nurse Sally Houltby Community Diabetic Specialist Nurse Debbie Page Dawn Jameson Community Diabetic Specialist Nurse Cluster Delivery & Performance Commissioning Manager - LTC GP Prescribing Lead Esther Gladman Sherwood Forest Hospital Foundation Trust Nottingham University Hospitals Trust Newark & Sherwood Clinical Commissioning Group NHS Nottinghamshire County Newark & Sherwood Clinical Commissioning Group Nottingham University Hospitals Trust Sherwood Forest Hospital Foundation Trust Community Health Partnership Nottingham University Hospitals Trust Nottingham University Hospitals Trust Churchside Medical Practice Community Health Partnership Nottingham University Hospitals Trust Sherwood Forest Hospital Foundation Trust Nottingham University Hospitals Trust Newark & Sherwood Clinical Commissioning Group Nottingham North & East Clinical Commissioning Group Principia Clinical Commissioning Group Nottingham University Hospitals Trust Nottingham University Hospitals Trust NHS Nottinghamshire County Sherwood Forest Hospital Foundation Trust NHS Nottinghamshire County Sherwood Forest Hospital Foundation Trust Community Health Partnership Nottingham CityCare Partnership Nottingham CityCare Partnership Nottingham University Hospitals Nottingham CityCare Partnership Nottingham University Hospitals Nottingham University Hospitals Greater Nottingham Diabetes Network Sherwood Forest Hospital Foundation Trust Sherwood Forest Hospital Foundation Trust Sherwood Forest Hospital Foundation Trust Central Notts Diabetes Network Sherwood Forest Hospital Foundation Trust NHS Nottingham City Sherwood Forest Hospital Foundation Trust Community Health Partnership Newark & Sherwood Clinical Commissioning Group Newark & Sherwood Clinical Commissioning Group Nottingham University Hospitals Trust Nottingham City Clinical Commissioning Group Nottingham City Clinical Commissioning Group Nottinghamshire Diabetes Guidelines June 2013 version 3 3 Referral to Community and Specialist Services The Central and Greater Nottingham Diabetes Networks do not recommend referral for adults with uncomplicated newly diagnosed Type 2 diabetes. Initial management (diagnosis, education, treatment Nottinghamshire Community Services and monitoring) is the responsibility of Diabetes Primary Care Teams. NUH QMC 0115 9249924 NCH 0115 9691169 EYE Sudden visual loss FOOT Hot foot – ulcer+cellulitus/ deep infection/ischaemia Chronic foot ulcer /deformity/persistent callus METABOLIC Newly diagnosed Type 1 Protracted vomiting or ketonuria (Type 1) Newly diagnosed (or suspected) Child or Young person Immediate (within 1 working day) Immediate (within 1 working day) Immediate (within 1 working day) Immediate (within 1 working day) Immediate Urgent/ Immediate PREGNANCY Pregnant Urgent Contemplating pregnancy Elective SFHT 01623 622515 To Eye Casualty 01623 622515 Ext 6035 (9am – 5pm) (Urgent weekend/out Vocera - Ask for Diabetic Foot of hours) Team Out of hours Urgent Refer to A & E (notify Diabetic Foot Team of admission via Vocera) 01623 622515 Ext 6035 (9am – Fax 0115 962 7959 5pm) (Urgent weekend/out of Vocera - Ask for Diabetic Foot hours) Team Out of hours Urgent Refer to A & E (notify Diabetic Foot Team of admission via Vocera) If Urgent Bleep In working hours contact Diabetes diabetes SpR Unit or Bleep diabetes SpR Out of hours Bleep on-call Medical Registrar Urgent admission via Urgent admission via on-call on-call medical team medical team Telephone referral to Paediatric Medical team the same day Fax 0115 962 7959 Next Joint Diabetes/Obstetric Clinic QMC Appointment Ext 61258 Fax 0115 8493331 City Appointment Ext 55240 Fax 0115 8402659 SFHT Appointment Ext 3740 MANAGEMENT Frequent hypoglycaemic episodes Problems achieving glycaemic, blood pressure or lipid targets Microalbuminuria / proteinuria / renal disease Insulin Pump Therapy Lipid Management Painful neuropathy, mononeuropathy and amyotrophy Erectile dysfunction Diabetes Specialist Nurses Elective Elective Elective To Diabetes Team Via Choose and Book or Direct Telephone Number Where Appropriate Elective Elective Elective Elective Nottinghamshire Diabetes Guidelines June 2013 version 3 4 Nottinghamshire Community Diabetes Services NHS Nottingham City Clinical Commissioning Group Community Diabetes Services The Community Diabetes Specialist Nursing service was established in Nottingham some time ago but was expanded in 2009 to provide a City wide service to primary care. The aim of the service is to improve the overall standard and quality of adult diabetes management in primary care through targeted provision of evidence based care, advice and support. Diabetes Structured Education Service (JUGGLE) This service was jointly commissioned by NHS Nottingham City and NHS Nottinghamshire County (Nottingham East, Nottingham West and Principia clusters) in July 2009. The aim of the service is to provide standardised, structured group education for adults with Type 2 diabetes. The curriculum has been designed and agreed locally by a working group of the Greater Nottingham Diabetes Network to meet both the requirements of the NICE Technology Appraisal and the diverse needs of local communities. The service is available to people diagnosed with Type 2 diabetes (aged 18 and over). Patients may selfrefer or are referred onto the programme when they are newly diagnosed (within the first 6 months of diagnosis) or if they have been identified as having a need for structured education. Personalised Care Planning NHS Nottingham City is working with the Year of Care Programme in order to embed personalized care planning across primary, community and secondary care. Training workshop for practices have seen a great uptake and further sessions for year of care training for practices are being planned. We are coordinating similar approach with NUH and by Diabetes Specialist Nurses. NHS Nottinghamshire County Mansfield and Ashfield Clinical Commissioning Group (CCG) The Mansfield and Ashfield CCG Community Diabetes service was launched in August 2010. It represents tier 2 of the defined care model and pathway, complementing existing services in primary and secondary care to offer integrated and seamless care for the patient. The service is available for adults with Type 2 Diabetes who might require additional management to bring their condition under control, where specialist secondary care services are not necessary. Patients meeting one or more of the following criteria can be referred into the service: Require Insulin Initiation services (where a service is not provided by the GP practice) Have poor diabetic control (whether taking tablets or Insulin) Have poor compliance to treatment or poor attendance for treatment Choose & Book referrals will be accepted from General Practices in Mansfield and Ashfield. Clinics are delivered by a consultant and community based diabetes specialist nurse from Sherwood Forest Hospitals Foundation Trust, using a range of venues within the community. In addition the community diabetes specialist nurses provide support to providers of healthcare in the community, e.g. GP practices and care homes, to discuss queries regarding diabetes care, either as part of support sessions or case review. Further information is available via the CCG intranet site or from the service or CCG team. Nottingham West Clinical Commissioning Group (CCG) The Nottingham West Diabetes Service was established to raise the consistency of standards of Diabetes care within General Practice at the same time as providing patients more convenient access to routine Nottinghamshire Diabetes Guidelines June 2013 version 3 5 Diabetes care. The service provides routine follow up of ‘stable’ patients and initiation of new therapies within the patients own registered practice. The service is delivered by practice nurses in each of the NWC registered practices and is supported by a GP Clinical Lead and a Diabetes Specialist Nurse (DSN) and Consultant from secondary care. Access to the service can be in one of two ways: A patient considered stable and suitable for discharge is reviewed by both the consultant and the lead GP in each practice and is effectively discharged to primary care A patient presents at the practice requiring a new therapy which can be initiated in primary care, either by the practice nurse, the DSN or the DSN and practice nurse jointly. NHS Rushcliffe Clinical Commissioning Group (CCG) Principia has developed a Community Diabetes Service, delivered within general practice for Principia patients. The service offers support for patients with sub-optimal control of Type 2 diabetes. The service targets patients requiring insulin initiation and also supports the repatriating into primary care patients who are routinely managed in secondary care. It was recognised that Principia’s desire to commission diabetes care in the community would impact on the services offered by the local secondary care trust. Principia worked in partnership with the secondary care trust from the outset of the project. This ensured a mutual understanding of the aims of the project and a common goal. The outcome of this collaboration is that the community Diabetic Specialist Nurse (DSN) who delivers the service is employed by the local acute trust. The DSN also receives weekly consultant mentorship. As well as managing newly-diagnosed Type 2 diabetics, the trust also actively discharges stable patients back to the community for management. This means that only the patients who need to be seen in hospital are seen in hospital; other patients receive care (subject to ‘Patient Choice’) at their local GP practice Newark and Sherwood Clinical Commissioning Group (CCG) Newark & Sherwood CCG are currently developing their existing Community Diabetic Specialist Nurse service working with GP practices and local acute trust to set out standardized and effective process for the care of patients receiving insulin initiation and diabetes management in primary care, that minimizes the associated risks. Practices will be commissioned to provide a level 1, 2 or 3 diabetes service. Service Level Level 1 Level 2 Level 3 Practice Type Service Option Accreditation Practice not involved in insulin start/management Diabetic Skills for health evidenced diabetes Specialist Nurse capabilities level 1 DSN accredited (DSN) Caseload only Practices involved in supported insulin start/management (new insulin start. Lower confidence re-management of discharged patients) Practice provides own insulin start/management (experienced insulin management, confident discharge management) DSN/practice Skills for health evidenced diabetes lead joint case capabilities level 2. Basic insulin start load course (e.g. Merit) - PDP Practice lead Skills for health evidenced diabetes holds caseload capabilities level 3. full diabetes diploma (Warwick etc) holder manages clinic/case load, PDP Care will continue to be provided in practice and at DSN clinics based in local practices with Consultant support from secondary care. Nottinghamshire Diabetes Guidelines June 2013 version 3 6 Nottingham North East Clinical Commissioning Group (CCG) NNEC have commissioned a Community Diabetic Specialist Nurse to support Type 2 patients who have uncontrolled Diabetes and who require Insulin Initiation. The aim of the Diabetes Specialist Nursing Service is: To provide a specialist intermediate level service for adults with Type 2 diabetes who require insulin initiation and management. This service will be working within primary care services to provide a “step up” service and with secondary care services to provide a “step down” service, as required To provide a holistic specialist service for adult patients with diabetes and to support their families and carers within a localised clinical setting or, in exceptional circumstances, their own home or care home - whether residential or nursing To empower and improve the overall quality of life for people with diabetes, by providing care closer to home and by facilitating self care To support and educate GP practices in the care they provide for people with diabetes To work alongside other primary care services offering specialised support and advice as required To act as a resource for all health care professionals and associated healthcare services working within the area covered by the NNEC CCG Develop a structured education programme in consultation with the consortium that will meet the needs of the clinicians. This service commenced in September 2010. Nottinghamshire Diabetes Guidelines June 2013 version 3 7 Diagnosing Diabetes /Glucose Intolerance Detection of people with Diabetes Routine screening of non-pregnant, asymptomatic or low risk patient is not recommended. Recommended: Follow up and regular testing of individuals known to be at increased risk of developing diabetes. Opportunistic Screening of people with multiple risk factors. A high index of suspicion is needed as many cases remain undiagnosed. Women with risks for gestational diabetes should be screened at 24-28 weeks with an oral glucose tolerance test (OGTT) (Box 2 ) High Risk Patient Groups Age over 40 years Family history of diabetes Obesity especially with central distribution South Asians and Afro-Caribbeans History of gestational diabetes Patients with Impaired Glucose Tolerance / Impaired fasting glycaemia Patients with ischaemic heart disease, claudication, hypertension or stroke Patients with cataract People with multiple risk factors need advice and support to reduce their risk and information about the symptoms and signs of diabetes Symptoms Polyuria Polydipsia Weight loss Tiredness / Lethargy Blurred vision Urinary or genital infection Skin infection including pruritis Confirmation of the diagnosis requires a LABORATORY plasma glucose measurement. Fingerprick samples should not be used to diagnose diabetes Criteria for diagnosing diabetes mellitus Patient with symptoms of diabetes Random venous plasma glucose (RPG) Fasting plasma glucose 2 hour plasma glucose after 75g oral glucose (OGTT) A laboratory HbA1C>48mmol/mol >/= 11.1 mmol/l OR >/= 7.0 mmol/l OR >/= 11.1 mmol/l (OGTT) OR Asymptomatic patient Two samples, either random, fasting, or after OGTT are needed to confirm the diagnosis. Samples should be taken on different days Most cases can be confirmed with a random glucose measurement and an OGTT is often not necessary (WHO Recommendation 2011) Nottinghamshire Diabetes Guidelines June 2013 version 3 8 75g Oral Glucose Tolerance Test (OGTT) 1. 2. 3. 4. 12 hour fast prior to test (water only for comfort) Refrain from smoking/eating/drinking/exercise during the test Take baseline venous sample for glucose Give 75g oral anhydrous glucose equivalent to: Lucozade 410 ml based on a bottle of lucozade being 70 k/cals per 100 mls. Lucozade / OGTT 2 hours later take further venous plasma sample Send sample to laboratory (diagnostic criteria shown above) Appendix A: Other diagnostic categories: Impaired glucose tolerance (IGT) Fasting glucose less than 7 mmol/l 2-hour glucose between 7.8 and 11.1mmol/l Impaired fasting glycaemia (IFG) Fasting glucose between 6.1 and 6.9 mmol/l Impaired fasting glycaemia during Pregnancy Fasting glucose between >5.3mmol/l 1hr blood glucose >7.8mmol/l Refer immediately to the next Joint Diabetes/Obstetric Clinic IGT and IFG are not clinical entities but should be considered as continuum risk categories for cardiovascular disease and/or future diabetes. Assess the patient’s cardiovascular disease risk Patients with IGT/IFG should be recorded and receive: - Follow-up and regular testing (reviewed at least annually) - Education and advice on risk of diabetes / diet / lifestyle modification etc (e.g. weight loss of 5kg and 30 minutes of moderate exercise 5 times weekly reduces progression to Type 2 Diabetes by almost 60%) Patients with HbA1c 42- 48mmol/mol, are at risk and should receive demonstrably effective prevention strategies Nottinghamshire Diabetes Guidelines June 2013 version 3 9 Does the newly presenting patient need insulin? Does an adult patient need referral for insulin at diagnosis of diabetes Typical symptoms and a diagnostic blood sugar YES Is the patient ill (vomiting or semiconscious)? YES Admit to hospital NO Is there moderate/heavy ketonuria? YES Strong indication for insulin (Same day referral) NO Are two or more of the following present? Severe symptoms (nocturia x 3-4) Short history (weeks) Marked weight loss (irrespective of absolute weight) A first degree relative with type 1 diabetes A personal history of autoimmune disease Strong indication for insulin YES First degree relative diagnosed under 30 years of age on diet or tablets: consider Maturity Onset Diabetes of the Young (MODY) NO Is the patient under 30 years of age? (Same day referral) YES No immediate need for insulin Consider non-urgent referral NO No immediate need for insulin. Dietary advice based on healthy eating principles Referral details Newly diagnosed Type 1 Nottinghamshire Diabetes Guidelines June 2013 version 3 10 Type 1 Diabetes If Type 1 diabetes is suspected the patient should be referred to secondary care diabetes services urgently Most patients are young but insulin may be required at any age Check urine for ketones. Anything more than minimal ketosis is a strong indication for insulin Often associated with marked hyperglycaemia, rapid weight loss and rapid onset of severe symptoms Severely ill patients may show features of acidosis including deep, sighing respiration and alteration in conscious level and require urgent hospitalization Protracted vomiting or ketonuria (Type 1) Same day referral to secondary care diabetes services for insulin initiation Newly diagnosed Type 1 General advice on Insulin Treatment Types of Insulin (NB animal insulin – bovine and porcine are not routinely used) The following are the different types of available insulin • Very rapid onset and short duration of activity e.g. *Insulin Lispro (Humalog), *Insulin Aspart (NovoRapid), *Insulin Glulisine (Apidra) • Short-acting e.g. Soluble insulin (Human Actrapid, Humulin S, Insuman Rapid) • Medium-acting e.g. Isophane insulin (Humulin I, Human Insulatard, Insuman Basal) • Long-acting e.g. *Insulin Glargine (Lantus), *Insulin Detemir (Levemir) • Mixtures (Biphasic insulins) e.g. Humulin M3, Insuman Combi 15, 25 and 50, Humalog* Mix 25 and 50, Novomix 30*. The numbers define the content of short acting vs. intermediate acting insulin e.g. Humlin M3 contains 30% short acting and 70% medium acting *these are human analogue insulins and should not be used as first line, only use where appropriate NPH (intermediate acting insulin) is recommended as per NICE CG87 (CG87 Type 2 diabetes - newer agents (a partial update of CG66): short guideline) What quantity of insulin should be prescribed? Most of the preparations are available in vial, in cartridge form or in pre-loaded devices Each pack of insulin contains five 3ml cartridges where each cartridge contains 300 units of Insulin (A 10ml vial contains 1000 units). Therefore a patient using 20 units twice a day will use 4 cartridges per month (or 1 pack of 5 cartridges). Hypodermic Equipment Patients should be advised on the safe disposal of lancets, single use syringes and needles. Standard needle is 6mm (shorter ones are available 5,4mm). This includes the prescribing of sharps bins and information on local sharp disposal services. Patients must contact their General Practitioner for local procedures. Types of Pen Devices • Pen devices are available on prescription. Novo Nordisk, Lilly and Aventis each have their own ranges. Ensure that the insulin is prescribed with the compatible device. Owen Mumford Autopen is compatible with CP and Lily insulin devices (e.g.Hypurin Insulin) and the Autopen 24 is available for use with Aventis insulins (e.g. Lantus.) Nottinghamshire Diabetes Guidelines June 2013 version 3 11 • Pre-loaded devices are becoming more common • Insulin choice is often device driven; advantages / disadvantages and ease of use • All cartridge sizes are 3ml Lancets These are available on prescription and are compatible with specified finger pricking devices. NB fingerpricking devices are NOT allowed on prescription. Insulin Pump Service for Adults Supported by NICE guidance NICE Guidance TA 151 Suitable for people with type 1 diabetes only Referral to pump team via secondary care diabetes services Insulin Pump Therapy Suitable for people with type 1 diabetes who: Have attended an intensive Type 1 diabetes education programme (with carbohydrate counting) Type 1 Diabetes Structured Education Use a basal bolus (multiple injection) insulin regimen. Find it impossible to maintain optimal HbA1C individualised target < (64mmol/mol) 8% without disabling hypoglycaemia despite a high level of self care of diabetes and adequate trials of analogue (short and/or long acting) insulins. Have no medical, communication, psychological or personal problem which would prevent insulin pump use Need to ensure the patient is competent to use it effectively Requires: use of pager-sized insulin infusion pump 24 hours a day replacement of infusion set and subcutaneous cannula more commonly 2 days ongoing support from trained insulin pump team Type 1 Diabetes Structured Education Intensive education programmes to promote empowerment for people with Type 1 diabetes There are 3 programmes available in Nottinghamshire Suitable for people with type 1 diabetes who are prepared to manage diabetes intensively Blood testing four or more times daily Insulin four or more times daily Carbohydrate counting Referral is via the respective diabetes service All courses are facilitated by diabetes specialist nurses and specialist dietitians a. DAFNE – (Dose Adjustment For Normal Eating) Available on the QMC Campus Part of the national DAFNE collaborative Associated with long term reduction in HbA1c, weight stability and improved quality of life One week, non-residential course for up to 8 participants at Queens Medical Centre b. EDWARD – (Education for Diabetes Without A Restricted Diet) Available at Nottingham City Campus Based on the existing BERTIE Model of Patient Education A series of workshops held one day a week for four consecutive weeks at Dundee House with up to 8 participants improved well being Associated with long term reduction in HbA1c, weight maintenance and improved quality of life Nottinghamshire Diabetes Guidelines June 2013 version 3 12 K.A.R.E.N. – (Kings Mill Adjusting Regimes for Eating Normally) Available at Sherwood Forest Hospitals (Kings Mill and Newark) Based on the existing BERTIE Model of Patient Education, the patient receives intensive education on insulin dose adjustment and carbohydrate counting. A series of workshops held one day a week for four consecutive weeks with up to 8 participants improved well being c. Nottinghamshire Diabetes Guidelines June 2013 version 3 13 Type 2 Diabetes Type 2 diabetes has significant morbidity and requires good, systematic care at diagnosis. symptomatic and progressive and diagnosis is often only made after complications have developed. It is Many patients already have or are at high risk of developing microvascular and/or macrovascular complications. There is a very high mortality from coronary artery disease. Suggested Initial Management in Generalist (Primary) Care Good history to obtain cardinal features (including polyuria, polydipsia, nocturia, weight loss, lethargy, cramps, pruritus vulvae/balanitis, visual disturbance) FBC, urea and electrolytes, liver function tests, blood glucose, HbA1c Urinalysis (to look specifically for ketonuria and proteinuria) TSH (if indicated clinically) Initiate diabetic education and monitoring Dietary measures and physical activity Dietary Recommendations If hyperglycaemia is sustained consider medication Treatment of Hyperglycaemia Referral to Structured Education (Greater Nottingham, Juggle programme, Central Notts, TIIDE course. Referral to Specialist (Secondary) Care is not usually necessary The Central Nottinghamshire and Greater Nottingham Diabetes Networks do NOT recommend referral of patients with newly diagnosed Type 2 diabetes. Patients require intensive glycaemic control. The majority of patients can be controlled with dietary measures alone or in combination with an oral hypoglycaemic agent and urgent referral is not usually required (even if blood glucose high, providing the patient is well and not ketotic). Some will require insulin. It is expected that initial diagnosis and management, including education, dietary advice and monitoring will be undertaken within generalist care, supported by these management guidelines. Nottinghamshire Diabetes Guidelines June 2013 version 3 14 Monitoring and Complications Care plan An individual care plan to address issues of concern by both the person with diabetes and the health professional should be negotiated, within an agreed reasonable and achievable time frame, and should be regularly reviewed. Annual Review is an essential part of the planned diabetes management and it is recommended that it should be undertaken within Primary Care wherever possible (Adults Type 1 and Type 2). The elements of the annual review may need to be addressed at a number of appointments. (Underlined text is hyperlinked to further information – just point and click) Establish and review management plans and treatment targets for Hyperglycaemia Hypertension Lipid management Cardiovascular protection / Assessment Pre-conceptual advice / Erectile Dysfunction Lifestyle Activity and Lifestyle Advice Advise to stop smoking/refer to New Leaf Diet review Advise on exercise Clinical Weight / BMI / Waist Circumference ratio Blood Pressure Symptoms of hyperglycaemia / hypoglycaemia Injection site status Assessment of self-monitoring (including ketone testing where appropriate) Link: Monitoring Diabetic Control Psychological factors / Depression Medication problems Clinical waste/sharps Biochemical HbA1c and fasting glucose ● Urea and electrolyte levels Lipid Profile ● Liver function testing Consideration of FBC and TFT levels if relevant to medication use Diabetic Retinopathy Screening Annual eye screening by local programme Renal Monitoring Urine Albumin:Creatinine ratio (regardless of urine dipstick result) and eGFR Serum Calcium, phosphate and PTH in stage 4 and 5 CKD to identify anaemia. If Hb11g/dl check haematinics and exclude other causes. Foot care Deformity/callus Check dorsalis pedis and posterior tibial foot pulses Pinprick sensation Light touch -10g Seimes-Weinstein monofilament Foot ulcers Footwear Check risk levels (management of foot care complications) Nottinghamshire Diabetes Guidelines June 2013 version 3 15 Type 2 Diabetes Structured Patient Education Self-management is key to good diabetes care and patient education should be at the heart of any service (Diabetes UK, 2003). Education can be delivered in groups or on an individual basis but it is important to individualise to patient needs and requirements. A useful Education checklist is attached. There are 2 structured education programmes available to people with Type 2 Diabetes who are not on insulin held at various locations around Nottinghamshire. These courses are available to people with newly diagnosed Type 2 diabetes and to those with existing diabetes who would benefit from further diabetes education. The sessions cover a range of useful topics such as healthy eating, medication, monitoring and footcare and are delivered by trained educators. This offers the chance to have advice from a dietitian and nurses who specialise in diabetes. Juggle Juggle is available to residents from Nottingham City, Broxtowe, Gedling and Rushcliffe areas. Juggle is a structured education programme for people not on insulin therapy. It runs for 4 x 2.5 hour sessions facilitated by trained educators. Referral forms are available from the administrator and can be posted or faxed (details on form). Telephone referrals are accepted and the service is available on Choose and Book. Patients can also self refer by phoning 0300 300 0045 (local rate). For further information contact the administrator on 0300 300 0045 TIIDE (Type II Diabetes Education) TIIDE is available to patients from Ashfield, Mansfield and Newark and Sherwood areas. TIIDE is a structured education programme which runs over a 2 x 4 hour sessions. Some one day courses are also available. Referral forms should be completed available via GP Surgeries, the intranet or from the Administrator. Patients can also self refer for further information please contact the Administrator for Diabetes Groups on 01623 622515 ext 3528. Practices are encouraged to refer Type 2 Patients (newly diagnosed or with an identified educational need) for Type 2 Diabetes Structured Patient Education Activity and Lifestyle Advice General advice Advice on physical activity should be realistic and promote the inclusion of activity into everyday life; initially this may be by reducing sedentary behaviour at home and increasing walking such as taking the stairs not the lift, parking further away from the shop etc Benefits of increased physical activity include: Improved insulin sensitivity Lower blood glucose Increase HDL and lower LDL cholesterol Lower blood pressure Aids weight loss Provides stress relief Aims Current activity recommendations for people are to aim for either 30 minutes of moderate activity on at least 5 days of the week OR 10,000 steps a day This can be increased gradually depending on the individual’s current level of activity. There are a number of activity schemes throughout Nottinghamshire- see Appendix B: Physical Activity Referral Schemes Nottinghamshire Diabetes Guidelines June 2013 version 3 16 Basic Dietary Recommendations for People with Type 2 Diabetes These dietary principles are also appropriate for people with Impaired Glucose Tolerance and Impaired Fasting Glycaemia. The aims of dietary intervention are to: Minimise symptoms of hyperglycaemia and fluctuations in blood glucose Minimise the risk of hypoglycaemia Minimise the long term macro- and micro-vascular complication of diabetes Promote weight loss in people who are overweight Reduce the risk of coronary artery disease Advise on diet following assessment of: Readiness to make changes to diet and lifestyle Lifestyle Social circumstances Current dietary intake It is essential to negotiate realistic and achievable dietary changes with each patient. The recommended diet therapy for people with diabetes follows the Diabetes UK Healthy Eating Advice http://www.diabetes.org.uk/Guide-to-diabetes/Healthy_lifestyle/Eating_Well/ Some of the general principles are as follows (please use the link above for full details: Modify existing eating habits inline with the Eat Well Plate rather than attempt major changes to the patient’s pattern of eating Promote regular meals Consistent portions of carbohydrate at mealtimes in line with the eatwell plate guidance i.e. quarter to third of a plate depending on whether weight loss is the goal. When weight loss is advised please refer to the dietitian Increase: fruit and vegetables to at least 5 portions/day to achieve recommended antioxidant intakes fruit juice only counts once and is best taken with a meal Encourage: low glycaemic index foods at each meal as part of a balanced diet 2 x 100-150g portions of oily fish a week. Reduce: intake of refined carbohydrate, especially sugary foods and drinks total fat and replace saturated fat with monounsaturated and polyunsaturated fats dietary salt to less than 6g/day. Avoid salt substitutes alcohol. Men should not regularly drink more than 3 to 4 units of alcohol a day, and women should not regularly drink more than 2 to 3 units of alcohol a day. Stress the importance of 2-3 alcohol-free days per week. Special diabetic products are high in calories, cause gastrointestinal upset and are not recommended. Literature and training to support non-dietetic staff is available. Nottinghamshire Diabetes Guidelines June 2013 version 3 17 Dietetic Services for Patients with Diabetes All patients with diabetes should receive dietary education as part of their structured education programme at diagnosis and at appropriate intervals throughout their treatment. Type 1 Diabetes Structured Education Type 2 Diabetes Structured Patient Education It is not necessary to refer all patients with newly diagnosed type 2 diabetes for an individual appointment with a dietitian. Clinics for one to one consultations These are held in health centres and clinics throughout Nottinghamshire Health District. First line dietary advice for patients can be given in General Practice. One to one appointments with a registered dietitian are available throughout Nottinghamshire on referral when more specific advice is needed. Patients suitable for referral include: Those with CHD and diabetes Those with consistently poor control HbA1c>64mmol/mmol and other risk factors e.g. dyslipidaemia Those with a poor understanding of dietary management following first line advice Those who have co-existing conditions which require a special diet e.g. Coeliac Disease Those who have a poor appetite/nutritional intake and/or are underweight Those with type 2 diabetes that are unsuitable for group education due to communication difficulties or do not wish to attend a group session Patients where alternative injection therapies are being initiated e.g. Exenatide and Liraglutide. These patients may be seen on a one to one or within groups. Patients with IFG, or IGT should receive first line advice from the GP Surgery An appointment includes: detailed patient assessment care plan or dietary targets agreed referrer and GP informed follow up agreed on an individual basis Please ensure the referral letter includes the patient’s body mass index (BMI), relevant blood results, current medication and whether an interpreter is required and which language is spoken. Referrals for patients from Nottingham City, Referrals for patients from Newark Broxtowe, Gedling and Rushcliffe areas Sherwood, Ashfield and Mansfield areas Nottingham Community Dietitians Nottingham CityCare Partnership Community Nutrition and Dietetic Department Suite 6, 2nd Floor, Aspect House Aspect Business Park Bennerley Road Bulwell Nottingham NG6 8WR Central Admin Point Nutrition and Dietetics Department Kings Mill Hospital Mansfield Road Sutton in Ashfield Nottinghamshire NG17 4JL Tel: 0115 8834327 Fax: 0115 8834330 Support available from the dietetic service: telephone advice written information for non-dietetic staff training for non-dietetic staff Tel: 01623 676025 Nottinghamshire Diabetes Guidelines June 2013 version 3 18 and Smoking Cessation New Leaf is a free NHS service for any one that wants to stop smoking. . New leaf provides specially trained advisors in the local area who offer support, encouragement, information and friendly advice including advice on Nicotine Replacement Therapy and prescribed drugs Zyban and Champix. Community Pharmacies also offer this service It offers support from trained advisors at over 40 clinics across the City and Nottinghamshire. New Leaf Stop Smoking Service Nottingham City Tel: 0800 561 2121 Or text free “new” to 80800 Nottinghamshire County Tel: 0800 389 7712 Or text free “leaf” to 80800 Asian Diabetes Liaison Worker Preventative programmes of care Health Promotion -raise awareness of diabetes, incidence, recognition of symptoms and referral routes. Development of community initiatives to: - Promote healthy eating messages and increase intake of fresh fruit and vegetables. - Improve links between voluntary and statutory organisations. Working with diabetes specialist dietitian to deliver bi-lingual Juggle Programme Diabetes Education Role Group sessions amongst the Asian population at GP practices and other venues Allow patients to share experiences and practical ways of managing diabetes Participation in local events to raise awareness of diabetes. Asian Diabetes Liaison Worker, Radford Health Centre, Ilkeston Road, Radford, Nottingham. (Available to: Nottingham City, Nottingham West, Nottingham North & East and Principia Clinical Commissioning Groups only) Tel: 0115 883 4062 Fax: 0115 942 2672 Nottinghamshire Diabetes Guidelines June 2013 version 3 19 Nottinghamshire Health Community Treatment Algorithm for the Management of Type 2 Diabetes updated September 2012 Set individualised glycaemic target and review management every 2-6 months Remember to consider: Statin therapy Smoking Cessation First Line Treatment Diet & Lifestyle + Metformin Titrate slowly to maximum tolerated dose. Consider modified release metformin if poor GI tolerability prevents the person continuing with metformin. Review metformin dose if serum creatinine >130 micromole/litre or estimated glomerular filtration rate (eGFR) <45 ml/minute/1.73-m2. See diabetes in renal impairment Blood Pressure reduction Referral to education programmes Hints on 1st line treatment options Consider gliclazide instead of metformin if: Metformin not tolerated or contraindicated. Patient is not overweight. A rapid therapeutic response is required due to hyperglycaemic symptoms (consider metformin once stable). Gliclazide modified release is available if poor compliance with multiple daily dosing Metformin intolerant or contraindicated or patient is symptomatic of hyperglycaemia Gliclazide Individualised glycaemic target not reached BMI < 35 BMI > 35 Metformin + Gliclazide or Metformin + Pioglitazone or Metformin + Gliptin Metformin + Gliclazide or Metformin + Pioglitazone or Metformin + (GLP-1 Agonist or Gliptin) Gliclazide + (Pioglitazone or Gliptin) or GLP1 agonist Reinforce lifestyle advice Hints on 2nd line treatment options Gliclazide can cause hypoglycaemia and weight gain (few kilogrammes). Pioglitazone is contraindicated in heart failure or patients with increased risk of fractures or bladder cancer. Can cause weight gain. No long term safety data with the gliptins or GLP1 agonists. Risk of severe pancreatitis with GLP1 agonists and gliptins. Liraglutide (GLP1 agonist) 1.8mg dose should not be used. GLP1 agonists can be used in patients with a BMI <35kg/m2 where insulin is unacceptable as per NICE recommendations. Individualised glycaemic target not reached Continue pioglitazone or gliptin only if there is a reduction of ≥5.5mmol/mol in HbA1c in 6 months. Continue GLP1 only if there is a reduction of ≥11mmol/mol in HbA1c in 6 months Metformin + Gliclazide + Basal Insulin or Metformin + Gliclazide + Pioglitazone Metformin + Gliclazide + Pioglitazone or Metformin + Gliclazide + Basal Insulin or Metformin + Gliclazide + (GLP-1 Agonist or Gliptin) Gliclazide + Basal Insulin Hints on 3rd line treatment options Consider triple therapy if insulin is inappropriate or unacceptable. Human isophane insulin should be used first line. Individualised glycaemic target not reached Continue pioglitazone or gliptin only if there is a reduction of ≥5.5mmol/mol in HbA1c in 6 months. Continue GLP1 only if there is a reduction of ≥11mmol/mol in HbA1c and ≥3% loss in body weight in 6 months Metformin + Intensive Insulin therapy Intensive Insulin therapy Nottinghamshire Diabetes Guidelines June 2013 version 3 Hints on 4th line treatment options Long-acting insulin analogues (LAIAs) have no advantages over human isophane insulin in effects on HbA1c levels. 20 Treatment of Hyperglycaemia Only prescribe one agent from each class. Substituting agents is unlikely to improve glucose control – swapping metformin plus gliclazide for metformin plus pioglitazone is more likely to cause deterioration in glycaemic control. The addition of a third agent to a combination of two oral hypoglycaemic drugs taken at maximally tolerated doses may only lower HbA1c by 5.5mmol/mol*. Glycaemic Target In newly diagnosed patients tight control of HbA1c (i.e. 48 mmol/mol and fasting glucose 6 mmol/l) is to be aspired for most patients providing they are not having frequent hypoglycaemia. An individualised target should be discussed and agreed with each patient and reviewed every 2-6 months. This goal may not be appropriate or practical for some patients and clinical judgement needs to be applied. Lifestyle should be reviewed before every treatment escalation. The following factors should be taken into consideration when setting targets and choosing an appropriate agent: o weight, o cardiovascular risk factors, o occupation (e.g. HGV licence holders, train drivers, taxi drivers and machine operators where hypoglycaemia could have disastrous consequences), o frail elderly, o other medical co-morbidities (e.g. liver disease, renal impairment and arthritis), o visual impairment, o social isolation (i.e. home alone) o mental health disorders (including substance abuse). *Reporting Units for HbA1c Glycated haemoglobin (HbA1c) is the recommended method of measuring long term control of blood glucose in people with both type 1 and type 2 diabetes. Previously the results were reported as a percentage (%). This has changed to millimoles/mole (mmol/mol) where people with diabetes will receive their HbA1c measurement in mmol/mol only. A 0.5% difference in HbA1c is equivalent to a difference of about 5.5mmol/mol, and a 1% difference is equivalent to a difference of about 11mmol/mol. Note that these are rounded equivalents. HbA1c (new units) (mmol/mol) 20 31 42 48 53 59 64 75 86 HbA1c (old units) % 4.0 5.0 6.0 6.5 7.0 7.5 8.0 9.0 10.0 Nottinghamshire Diabetes Guidelines June 2013 version 3 21 Oral Hypoglycaemics Metformin Consider in all patients with Type 2 diabetes at the outset in conjunction with lifestyle advice. Step up metformin over several weeks to minimise risk of gastrointestinal (GI) side effects. Consider trial of modified release metformin if GI tolerability prevents the person continuing with metformin. Review metformin dose if serum creatinine >130 micromole/litre or estimated glomerular filtration rate (eGFR) <45 ml/minute/1.73-m2. Stop metformin if serum creatinine > 150 micromole/litre or the eGFR <30 ml/minute/1.73-m2. Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function, and those at risk of eGFR falling to <45 ml/minute/1.73-m2. If the person has mild to moderate liver dysfunction or cardiac impairment, discuss benefits of metformin so due consideration can be given to its cardiovascular-protective effects before any decision is made to reduce the dose. Gliclazide Prescribe gliclazide when a sulfonylurea is indicated. Educate the person about the risk of hypoglycaemia, particularly if they have renal impairment. Increase dose every 4-6 weeks to achieve glycaemic target or maximal dose is reached. Use gliclazide MR (modified release) if poor compliance. For Group 1 drivers (car/motorcycle) it may be appropriate to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia. Group 2 drivers (bus/lorry) on sulfonylureas are required by law to monitor glucose level at least twice daily and at times relevant to driving Gliptins/DPP-4 inhibitors (sitagliptin (Januvia®) first line, linagliptin (Trajenta®▼) second line) Low risk of hypoglycaemia and are weight neutral. Continue gliptin therapy only if there is a reduction of ≥ 5.5mmol/mol in HbA1c in 6 months. No long term safety data available for these agents. Discuss the benefits and risks of a gliptin with the person, bearing in mind that a gliptin might be preferable to a glitazone if; o further weight gain would cause significant problems, or o a glitazone is contraindicated, or o the person had a poor response to or did not tolerate a glitazone in the past. Glitazone (pioglitazone (Actos®▼) ONLY) Do NOT start or continue pioglitazone if the person has; o heart failure (NYHA class I-IV) o a higher risk of fracture o macula oedema o a history of bladder cancer or in patients with uninvestigated macroscopic or microscopic haematuria Continue pioglitazone therapy only if there is a reduction of ≥ 5.5mmol/mol in HbA1c in 6 months Cases of cardiac failure have been reported when pioglitazone was used in combination with insulin, especially in patients with risk factors for the development of cardiac failure. If the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain, and oedema. Nottinghamshire Diabetes Guidelines June 2013 version 3 22 Discuss the benefits and risks of pioglitazone, bearing in mind that a pioglitazone might be preferable to a gliptin if: o the person has marked insulin insensitivity, or o a gliptin is contraindicated, or o the person had a poor response to or did not tolerate a gliptin in the past. Acarbose (Glucobay®) Consider acarbose for a person unable to use other oral glucose-lowering medications. Injectable Hypoglycaemics GLP1 analogues (exenatide (Byetta®▼, exenatide modified release (Bydureon®▼), liraglutide (Victoza®▼)) Can be used as a treatment option in dual or triple therapy regimens when control of blood glucose remains or becomes inadequate (HbA1c ≥59 mmol/mol or agreed individualised target). Patient should be on maximally tolerated doses of oral hypoglycaemic agents and have a BMI; o ≥35kg/m2 in people of European descent and there are problems associated with high weight or o <35kg/m2 where insulin is unacceptable because of occupational implications or weight loss would benefit other co morbidities. Exenatide - DUAL and TRIPLE THERAPY - continue GLP1 only if the person has a reduction in HbA1c of ≥11mmol/mol and a 3% loss of initial bodyweight after 6 months. Exenatide MR or liraglutide – DUAL THERAPY - continue GLP1 only if the person has a reduction in HbA1c of ≥11mmol/mol2 after 6 months. Exenatide MR or liraglutide - TRIPLE THERAPY - continue GLP1 only if the person has a reduction in HbA1c of ≥11mmol/mol2 and a 3% loss of initial bodyweight after 6 months. Exenatide should be used first line in preference to liraglutide. Exenatide modified release can be considered if tolerability and compliance remains a major issue with conventional GLP-1 therapy among patients whose HbA1c remains suboptimal >59 mmol/mol and BMI>35kg/m2. Liraglutide should only be used second line if the patient has not tolerated exenatide or exenatide has been shown to be ineffective (after 6 months treatment). Liraglutide 1.8mg daily is NOT recommended for the treatment of people with Type 2 diabetes. Hypoglycaemia is only an issue if the GLP1 is combined with another agent likely to cause hypoglycaemia, therefore routine monitoring of blood glucose levels is not required. There have been reports of necrotising and haemorrhagic pancreatitis with exenatide, some of which were fatal. If pancreatitis is suspected, treatment with exenatide should be suspended immediately; if pancreatitis is diagnosed, exenatide should be permanently discontinued. (MHRA Drug Safety Update March 2009) Exenatide is not recommended for use in patients with an eGFR <30mL/min. Liraglutide is not recommended for use in patients with an eGFR <60mL/min. Insulin Therapy in Type 2 Diabetes Insulin treatment If other measures do not keep HbA1c to <59 mmol/mol (or other agreed target), discuss benefits and risk of insulin treatment. Initiate with a structured programme including patient education and management plan. Insulin therapy should be initiated from a choice of a number of insulin types and regimens by a practitioner with the appropriate knowledge, competencies and experience to choose the most appropriate starting regimen tailored to each patient. Begin with human NPH insulin (Isophane insulin e.g. Insulatard®, Humulin I®, Insuman®) taken at bedtime or twice daily according to need. Nottinghamshire Diabetes Guidelines June 2013 version 3 23 There is no evidence of a clinical benefit of analogue insulins over human insulins in type 2 diabetes. Consider twice-daily biphasic human insulin (pre-mix) regimens in particular where HbA1c >75 mmol/mol. A once-daily regimen may be an option when initiating this therapy. Insulin analogues rather than pre-mixed human insulin preparations should only be considered when: o immediate injection before a meal is needed, or o hypoglycaemia is a problem, or o there are marked postprandial blood glucose excursions. Recurrent symptomatic hypoglycaemia should prompt a re-examination of the current insulin regimen, injection sites, a search for other co-morbidities (such as liver or renal disease) and a review of the agreed HbA1c target. If tight control is still required, then consider a trial of analogue insulin. If a patient requires once a day insulin administration because a carer or healthcare professional is needed to administer the insulin injection, and once daily NPH insulin does not provide sufficient control, then consider a trial of basal analogue insulin. Monitor a person using a basal insulin regimen (NPH or a long-acting insulin analogue [insulin glargine/detemir]) for the need for mealtime insulin (or a pre-mixed insulin preparation). If blood glucose control remains inadequate (not to agreed target levels without problematic hypoglycaemia), move to a more intensive, twice/three times daily mixed insulin or mealtime plus basal insulin regimen. Human insulins (such as Humulin S®, Actrapid®, Insuman Rapid®, Isophane insulin, biphasic isophane insulin) should be considered as first line therapy before moving to analogue or analogue mixtures. Insulin analogues should only be considered if one of the criteria described above is met. Monitor a person using pre-mixed insulin once or twice daily for the need for a further pre-prandial injection or for an eventual change to a mealtime plus basal insulin regimen, based on human or analogue insulins, if blood glucose control remains inadequate. Oral agent combination therapy with insulin When starting basal insulin therapy: o Continue with metformin and gliclazide (and acarbose, if used) o Review the use of gliclazide if hypoglycaemia occurs. o When prandial quick or rapid acting insulin injections or mixed insulins are started, gliclazide should be discontinued, or tapered and then discontinued, since it is not considered synergistic when with administered insulin. When starting pre-mixed insulin therapy (or mealtime plus basal insulin regimens): o Continue with metformin o Consider combining pioglitazone with insulin therapy for: a person who has previously had a marked glucose-lowering response to thiazolidinedione therapy a person on high-dose insulin therapy whose blood glucose is inadequately controlled. This may need specialist guidance. Warn the person to discontinue pioglitazone if clinically significant fluid retention develops. Use of GLP1 analogues in combination with insulin Exenatide is licenced for addition to patients currently receiving insulin. Liraglutide does not currently have a licence for dual use. The patient group indicated to receive this combination must fulfil the following criteria; morbidly obese (BMI >35) and HbA1c >75mmol/mol and currently using insulin. This regimen must be initiated by a specialist. Continue the GLP1 in combination with insulin only if the person has a reduction in HbA1c of ≥11mmol/mol and a 3% loss of initial bodyweight in 6 months. Intensifying the insulin regimen Monitor those using basal insulin regimens for the need for short acting insulin before meals or pre-mixed insulin. Nottinghamshire Diabetes Guidelines June 2013 version 3 24 Monitor those using premixed insulin once or twice daily for need for further injections of short acting insulin before meals or change to mealtime plus basal regimen. Insulin delivery devices Offer education to a person who requires insulin about using an injection device (usually a pen injector and cartridge or a disposable pen) that they and/or their carer find easy to use. Appropriate local arrangements should be in place for the disposal of sharps. Only insulin detemir (Levemir®) and Insulatard® can be used with the Innolet® device. If a person has a manual or visual disability and requires insulin, offer a device or adaptation that: o takes into account his or her individual needs o he or she can use successfully. Type 2 Diabetes mellitus and renal impairment – dosing guidelines Worsening renal function (GFR range in ml/min) Drug CKD stage 1 (GFR>90) 2 (6090) 3a (59-45) 3b (44-30) 4 (29-15) 5 (< 15 or RRT) Metformin (review regularly) Gliclazide / Gliclazide MR (Use lowest effective dose) Pioglitazone Acarbose (GFR <25ml/min) Sitagliptin 100mg 100mg 50mg 50mg 25mg 25mg Linagliptin Liraglutide Exenatide Exenatide MR Insulin Requirements may be reduced in severe renal impairment – monitor and adjust dose accordingly 2 (Use lowest effective dose) 2 N.B. In patients at extremes of weight (BMI <18.5 kg/m or >30 kg/m ) or age (>70yr), calculate renal function using Cockcroft and Gault equation (see calculator available here) Nottinghamshire Diabetes Guidelines June 2013 version 3 25 Authors Nicky Bird, Senior Prescribing Advisor and APC Manager, NHS Nottinghamshire County James Sutton, Specialist Interface & Formulary Pharmacist, Nottinghamshire APC. In consultation with Dr Iskandar Idris (Sherwood Forest NHS Foundation Trust) Dr Kamal Chokkalingham (Nottingham University NHS Hospitals Trust) Comments received from Dr Renee Page (Nottingham University NHS Hospitals Trust) Dr Simon Page (Diabetes and Endocrinology Clinical Lead, Nottingham NHS Treatment Centre) Nottinghamshire County Clinical Commissioning Groups & Medicines Management teams Nottingham City Clinical Commissioning Group & Medicines Management team References Nottinghamshire Diabetes Guidelines MHRA Drug Safety Update March 2009 NICE Clinical Guideline 87 Type 2 Diabetes May 2009 NICE Technology Appraisal – Liraglutide for the treatment of Type 2 Diabetes Mellitus October 2010 Derbyshire JAPC Guideline – Glucose control in type 2 diabetes May 2011 NICE Technology Appraisal Diabetes (Type 2) – Exenatide (prolonged release) February 2012 Type 2 Diabetes mellitus and renal impairment – dosing guidelines Author; Dr Simon Page (Diabetes and Endocrinology Clinical Lead, Nottingham NHS Treatment Centre) References BMJ Publishing Group Ltd and RPS Publishing British National Formulary online March 2012: accessed via www.bnf.org.uk Summary of Product Characteristics on Electronic Medicines Compendium: accessed via www.medicines.org.uk Ashley C & Currie A [Ed.]. Renal Drug Handbook [3rd edition] London: Radcliffe Publishing (2009) Nottinghamshire Diabetes Guidelines June 2013 version 3 26 Monitoring Diabetic Control General patient assessment Symptoms Glycaemic Control Hyperglycaemia / hypoglycaemia) HbA1c target Weight: Weight gain may indicate over-treatment; weight loss may indicate deteriorating control. Well being Glycaemic Target Tight control [HbA1c 48mmol/mol / fasting glucose 6 mmol/l] is to be aspired for most patients providing they are not having frequent hypoglycaemia. An ideal target should be discussed and agreed with each patient and reviewed every 2-6 months. This goal may not be appropriate or practical for some patients and clinical judgement needs to be applied. NICE CG87 (Update of NICE CG 66) The following factors should be taken into consideration when setting targets and choosing an appropriate agent: weight, cardiovascular risk factors, occupation (e.g. HGV licence holders, train drivers, taxi drivers and machine operators where hypoglycaemia could have disastrous consequences), frail elderly, other medical co-morbidities (e.g., liver disease, renal impairment and arthritis), visual impairment, social isolation (i.e., home alone) and mental health disorders (including substance abuse). Pregnancy (see separate section Diabetes in Pregnancy) HbA1c General points Any improvement in HbA1c is beneficial in reducing the risk of diabetic complications. If 10mmol/mol above target consider adjusting treatment HbA1c testing should be carried out every 6 months In pregnancy advise women to aim for HbA1c <43mmol/l if safe to do so (see separate section Diabetes in Pregnancy) Switch to IFCC units The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and International Diabetes Federation (IDF) have agreed that in the future HbA1c is to be reported in the International Federation of Clinical Chemistry (IFCC) units. IFFC reporting was introduced in Europe except for the UK in 2003, and the UK has as of 1st June 2009 introduced dual reporting until 1st June 2011. IFCC-HbA1c (new) DCCT – HbA1c (old) (mmol/mol) 20 31 42 48 53 59 64 75 86 % 4.0 5.0 6.0 6.5 7.0 7.5 8.0 9.0 10.0 Conversion between the units is by the following equation: IFCC-HbA1c (mmol/mol) = [DCCT-HbA1c (%) - 2.15] × 10.929. Nottinghamshire Diabetes Guidelines June 2013 version 3 27 Approximate relationship between HBA1c and average glucose levels HBA1c result (%) 37 53 75 97 130 Average blood sugar levels over 6-8 weeks Less than 6 mmol/mol Around 6-8 mmol/mol Around 12-13 mmol/mol Around 15-16 mmol/mol Over 20 mmol/mol Self Monitoring Self-monitoring may prove useful to people in their overall approach to self-care. Type 1 and Type 2 diabetes on insulin Most patients in this group should be taught self-blood glucose monitoring. Guidance on the different meters will be available. Patients vary in how often they test. See guidance table re frequency of testing More frequent testing in certain circumstances may be indicated: - illness, pregnancy, changes in treatment, driving, hypo awareness. Testing is only part of the process of improving glucose control. Unless results are interpreted and diet or insulin adjusted glycaemic control will not improve. More frequent monitoring may be required during pregnancy Patients should be reminded to check regular performance regular calibration of the meters 50% of self-monitored glucose measurements are inaccurate, usually due to operator error. Patients, doctors and nurses using blood glucose monitoring with or without a meter MUST RECEIVE APPROPRIATE EDUCATION Blood glucose meters used should be subject to regular quality control Type 2 diabetes not on insulin Urine or blood glucose testing may be considered in this patient group. Please refer to the Frequency of Blood Glucose self-monitoring in Type 1 and Type 2 diabetes table. The National Institute for Clinical Excellence (CG 87) recommends that: ‘Self-monitoring should not be considered as a stand alone intervention’ and ‘self-monitoring should be taught if the need / purpose is clear and agreed with the patient’ When considering whether testing is appropriate, the following points should be considered: A clear indication should be given on why, when and how to test A clear indication should be given on when testing is not required A clear reason for monitoring i.e. Intention to provide the patient with information about their day to day glycaemic control to inform decision making, particularly in relation to illness, strenuous activity or when driving Intention to provide the clinician with information about day to day control, enabling them to give appropriate advice Aim to detect/confirm hypoglycaemia Aim to confirm symptoms of hyperglycaemia and poor control NB Obsessional testing occurs in some individuals and can cause anxiety and lifestyle disruption. Any individual who tests inappropriately should be supported to reflect on their monitoring habits. Will the result change the management of the patient? If not, why do it? Nottinghamshire Diabetes Guidelines June 2013 version 3 28 DVLA Guidance The risk of hypoglycaemia is the main hazard to safe driving and can occur with diabetes treated with insulin or tablets. Treated with tablets: Drivers are advised to monitor their blood glucose regularly and at times relevant to driving, particularly if taking medication likely to cause hypoglycaemia, such as a sulphonylurea Treated with insulin: Drivers are advised to carry their glucose meters and test strips with them. They are advised to check blood glucose before driving (even on short journeys) and test every 2 hours on long journeys. Drivers with insulin treated diabetes who wish to apply for C1/C1E Entitlement (small lorries) These drivers must regularly monitor their blood glucose levels at least twice daily and at times relevant to driving. The DVLA advise the use of a memory chip meter for such monitoring. Full guidance for people with diabetes is available at www.dvla.gov.uk Urine Tests vs. Blood Tests Urine tests are inexpensive relative to Serum Monitoring of Blood Glucose. Urine tests are non-invasive. Research has shown that blood glucose testing is not superior to Urine testing. Neither was shown to have a significant impact on HbA1c control, decreased body weight and reduced incidence of hypoglycaemia. Urine tests are an unreliable guide to the current blood glucose level and may therefore be misleading. Urine tests are influenced by a high renal threshold (often seen in the elderly and patients with renal impairment) or a low renal threshold (as seen in pregnancy). Urine tests identify hyperglycaemia but not hypoglycaemia Nottinghamshire Diabetes Guidelines June 2013 version 3 29 Frequency of Blood Glucose self-monitoring in Type 1 and Type 2 diabetes Diabetes Type Type 1 Diabetes All patients Insulin pump In Pregnancy Diabetes Insulin Diet Type 2 Diabetes Multi-injection insulin therapy (more than 2 times per day) Type 2 Diabetes Insulin Therapy including oral agents Fasting glucose Testing frequency Up to 4 times a day* Specific Considerations Greater risk of hypoglycaemia and hyperglycaemia More frequent testing indicated in certain circumstances e.g. Illness, undertaking Type 1 Education, drivers Approximate number of strips needed (1 box contains 50 strips) NB may increase in certain circumstances 3-4 boxes per month Minimum 4 times a day Including fasting state and postprandial blood glucose Up to 7 times a day* Up to 7 times a day under specialist advice 4-5 boxes per month (re-assess after delivery) Up to 4 times a day* Greater risk of hypoglycaemia and hyperglycaemia 3-4 boxes per month Frequency may vary for each individual Vary testing times to identify hypoglycaemia At least once a day Plus either: Additional once a day (twice in total) Or Additional twice a day (three in total) Vary testing times to include preprandial, postprandial and prebedtime 2 boxes per month Vary according to individual need Plus either If on daily insulin and stable Or If on twice-daily Insulin Or More frequent testing Unstable glycaemic control Type 2 Diabetes HbA1c main outcome measure Testing may be appropriate in certain circumstances i.e newly Diet and exercise diagnosed, where need and purpose is clear and agreed with Metformin only patient. This should be supported by educational support. See Metformin plus Exenatide Not routinely required* NICE guidelines here. or Liraglutide only Drivers may also need to test more frequently. Glitazone only Type 2 Diabetes About 3 times a week Hypoglycaemia is common so vary testing times during the day to for non driver identify hypoglycaemia Sulphonylurea alone (or in 1 box every 3 months combination with ANY other At least 3 times a week for driver* Drivers may require more frequent testing antidiabetic agents) This guidance reflects recommended best practice. Concurrent illness or medication e.g. steroids, chemotherapy may increase the frequency of testing It may be appropriate to test less frequently in stable patients. *Please refer to the DVLA ‘At a glance’ guide to the current medical standards of fitness to drive, Chapter 3 Diabetes Mellitus. Available to download here Nottinghamshire Diabetes Guidelines June 2013 version 3 30 Diabetes and Sick day Rules Key points: Intercurrent illness is likely to cause deterioration in blood glucose control and in those with Type 1 diabetes, increases the risk of diabetic ketoacidosis. All patients with diabetes, whether Type 1 or Type 2 should be familiar with the ‘Sick Day Rules’. www.nottinghamdiabetes.nhs.uk Patients with Type 1 diabetes should be provided with test strips (e.g. Ketostix) to test their urine for ketones during illness. Blood Ketone test strips are available on NHS prescription for patients using the Optium Xceed and GlucoMen LX Plus blood glucose / ketone meters only. Checking the blood glucose level and for ketones in the urine is an important part of the assessment of any patient with diabetes who is unwell. Blood glucose levels are likely to be higher than normal even if the patient is not eating, is vomiting or has diarrhoea. Seek medical advice if: Vomiting and unable to keep down fluids. Hyperglycaemia (blood glucose level above 17.0 mmol/l) + Ketones in urine (trace to small amount) or blood ketones 1.5 mmol/l or higher (consider hospital admission). Unsure of what to do. Admit to hospital if: Persistent vomiting. Not able to tolerate oral fluids. Dehydrated (or risk of dehydration). Hyperglycaemia (blood glucose level above 17.0 mmol/l) + Ketones in urine (moderate to large amount) or blood ketones 3.0 mmol/l or above. Suspected diabetic ketoacidosis. Nottinghamshire Diabetes Guidelines June 2013 version 3 31 Hypoglycaemia Management in adults (aged 16 or older) Hypoglycaemia is the commonest side effect of insulin and sulphonylureas in the treatment of diabetes and presents a major barrier to satisfactory long term glycaemic control. Hypoglycaemia should be considered in the differential diagnosis in any person with diabetes presenting acutely unwell, altered consciousness or behaviour and seizures. Definition A Hypoglycaemic episode occurs when any blood glucose level falls below 4mmol/L in a patient with diabetes. This is classified into mild if the episode is treated by the person alone and severe if the assistance of a third party is required for treatment. Risk factors for hypoglycaemia Too much insulin or inappropriately high doses of oral hypoglycaemic agents (sulphonlyureas) Hot weather Exercise Alcohol Patients with very tight glycaemic control Severe or frequent hypoglycaemia history Frequent nocturnal hypoglycaemia or unrecognized nocturnal hypoglycaemia Longstanding diabetes Early Pregnancy and breast feeding Poor insulin administration technique Impaired hypoglycaemia awareness Impaired renal function and renal dialysis Severe Hepatic Dysfunction A prior episode of hypoglycaemia which has been inadequately treated Patients with terminal illness Patients with lipohypertrophy Possible Causes of Hypoglycaemia in hospitals Inappropriate use of stat doses or PRN doses of quick acting insulin Discontinuation of long term steroid therapy or reduction in steroid treatment Recovery from acute illness Inappropriately timed diabetes medications in relation to meals/feeds Change in size of meals Incorrect insulin dose prescribed/administered Insufficient blood glucose monitoring Poor compliance at home Nil by mouth or reduced oral intake or missed meals No bedtime snack Clinical Features of Hypoglycaemia Adrenergic: Pallor, tachycardia, sweating, tremor Neuroglycopenic: Poor concentration, hunger, double vision, irritability, lips and tongue tingling, confusion, aggressive behaviour, poor judgement, altered personality, altered speech, altered consciouness, seizures, coma. Management Treatment of acute hypoglycaemia should be carried out without delay. Please refer to algorithm. (see separate section frequent hypoglycaemic episode) Nottinghamshire Diabetes Guidelines June 2013 version 3 32 Management of Hypoglycaemia BM check < 4mmol/l Patient conscious, orientated and able to swallow Patient not capable and/or uncooperative but can swallow Patient is unconscious, having seizures, very aggressive or uncooperative 10-20g or oral fast acting carbohydrate Examples: -115 mls original Lucozade - 5-7 Dextrose Tablets -150-200mls natural fruit juice Check ABCDE Call for help Either 1.5 - 2 tubes of Glucogel/Dextrogel (Hypostop) squeezed into mouth or between teeth (but may not be effective) Or Glucagon 1mg IM Check ABCDE Call for help Either Glucagon 1mg IM Or IV Dextrose (50 mls of 10% dextrose initially and repeat at 5 minute intervals to max of 250mls) Check blood sugar after 10-15 minutes BM > 4 mmol/l BM < 4 mmol/l Conscious and able to swallow Unconscious/ oral route not possible Repeat oral glucose Seek help Glucagon 1mg IM if not had or further IV 10% Dextrose (100 ml/hr) Eat snack or meal with long acting carbohydrate 10-20g carbohydrate (2 x digestive biscuits, diet yoghurt, slice of toast) Give normal meal with carbohydrates if due Determine cause Hypoglycaemia education Refer to diabetes nurse for review of glycaemic control (if deemed necessary) Ensure regular blood glucose monitoring for 24-48 hours Measures to avoid future episodes Notes: 1. If a severe hypoglycaemic episode occurs when insulin/tablets doses are due the tablet should be omitted, treat the hypoglycaemic episode, give the patient a meal and then give insulin/tablet. Seek help urgently if hypoglycaemia is not responding to treatment. 2. Hypoglycaemia can be prolonged with large doses of insulin or with sulphonylurea therapy. Therefore, need for regular BM monitoring after a hypoglycaemia episode has occurred. 3. Glucagon may be less effective in sulphonylurea therapy and with repeated doses. Glucagon should not be used in a person with liver disease. Nottinghamshire Diabetes Guidelines June 2013 version 3 33 Hypertension Management in Diabetes Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes. Hypertension is associated with an increased risk of many complications of diabetes, including cardiovascular disease and the findings from the UKPDS trial indicate that any reduction in a person’s average blood pressure reduces the risk of complications (from Type 2 Diabetes). Recommended Blood Pressure Targets No microvascular complications less than (mmHg) 140 / 80 Microvascular complications 130 / 80 (Proteinuria, Retinopathy, Microalbuminuria) Proteinuria>1g 125 / 75 General Comments on Hypertension Management in Type 2 Diabetes The UKPDS trial showed clear benefit of lowering blood pressure to 142/84 mmHg in middle-aged patients with type 2 diabetes and hypertension To achieve this approximately one third of patients required one anti-hypertensive agent, one third needed two and one third needed three or more agents A target of 140/80 or less may be difficult, impossible or unnecessary to achieve in certain patients (i.e. the elderly). Individual targets should be established for each patient Systolic hypertension is common in diabetes and the recommended targets may be difficult to attain. Aim to lower the systolic pressure by 20mmHg in the first instance and then review. Aim to minimise ALL vascular risk factors, especially in patients with established endorgan damage. Offer lifestyle management advice re smoking, weight loss, physical activity etc How to measure blood pressure British Hypertension Society recommendations; Patient should be seated and relaxed for 5 minutes with the arm supported. Ensure no tight clothing constricts the arm The rubber bladder should encircle between three quarters and the whole arm. The cuff must be level with the heart. The alternative adult cuff (12.5 – 13.0 x 35) is recommended for use in all adults For arm circumference over 42cm large bladders may be required. Cuff sizes Normal Alternative adult Width (cm) 12.0 –13.0 12.5 – 13.0 Length (cm) 23 35 arm arc (cm) up to 33 up to 42 Blood pressure measurements should be taken on a minimum of three separate occasions and averaged Electronic monitors should only be used if there is published evidence of accuracy. If used upper arm automated machines are preferable and all machines should be appropriately calibrated. More information available at http://www.bhsoc.org/blood_pressure_list.stm Nottinghamshire Diabetes Guidelines August 2012 34 Blood Pressure Management Algorithm Targets If kidney ,eye or cerebrovascular damage, set a target < 130/80 mmHg Others, set a target <140/80 mmHg If on antihypertensive therapy at diagnosis of diabetes Review BP control and medication use. Make changes only if BP is poorly controlled or current medications are inappropriate because of microvaascular complications or metabolic problems. If the person’s BP reaches and consistently remains at the target Monitor every 4-6 months and check for possible adverse effects of antihypertensive therapy (including those from unnecessarily lo blood pressure) Measure BP annually if not hypertensive or with renal disease. If BP > target, repeat measurement within: 1 month if > 150/90 mmHg 2 months if >140/80 mmHg 2 months if > 130/80 mmHg and kidney, eye or cerebrovascular damage BP above target Monitor BP 1 - 2 monthly until consistently below target Maintain lifestyle measures Advice on lifestyle measures See dietary advice on page 14 and the NICE clinical guideline on hypertension (www.nice.org.uk/CG127) BP above target Offer ACE inhibitor (titrate dose) For people of African-Carribean descent, offer ACE Inhibitor plus diuretic, or CCB BP above target If there is a possibility of the person becoming pregnant, start with a CCB If continuing intolerance to ACE inhibitor (other than renal deterioration or hyperkalaemia), change to an A2RB. Add CCB or diuretic (usually bendroflumethiazide 2.5 mg daily) BP above target Add other drug (diuretic or CCB – see above) BP above target Add alpha-blocker, beta- blocker or potassium-sparing diuretic Use a potassium-sparingdiuretic with caution if already taking ACE inhibitor or A2RB Antihypertensive medications can increase the likelihood of side effects such as othostatic hypotension in a person with autonomic neuropathy. A2RB, angiotensin II receptor blocker; AER, albumin excertion rate; BP blood pressure; CCB, calcium-channel blocker Nottinghamshire Diabetes Guidelines August 2012 35 Lipid management in Diabetes To improve the lipid profile to: Reduce the risk of cardiovascular disease Reduce the risk of pancreatitis in patients with severe hypertriglyceridaemia NICE recommended targets Total Cholesterol < 4 mmol/l or LDL-C <2 mmol/l (NICE CG66 and CG67 May 2008) http://www.nice.org.uk/guidance/index.jsp?action=download& o=40804 http://guidance.nice.org.uk/CG67/PublicInfo/doc/English Lifestyle The importance of weight reduction, limit alcohol consumption, exercise and smoking cessation should be emphasised and continually monitored. Treatment Patients 40 years or older Consider a person to be at high premature cardiovascular risk if he or she is Overweight, tailoring this with an assessment of body weight Has associated risk according to ethnic group Is hypertensive (>140/80 mmHg in the absence or presence of antihypertensive therapy) Has microalbuminuria Smokes Has a high-risk lipid profile Has a history of cardiovascular disease Has a family history of premature cardiovascular disease Patients less than 40 years old With CVD risk factors: Multiple features of the metabolic syndrome Presence of conventional risk factors Microalbuminuria / Nephropathy Retinopathy At-risk ethnic group Strong family history of premature CVD If the person is considered not to be at high cardiovascular risk, estimate cardiovascular risk annually. If > 20% over 10 years or at high premature cardiovascular risk due to any of the risk factors above Initiate therapy with generic Simvastatin 40mg If potential drug interaction or intolerance, use lower dose of Simvastatin or another statin of low acquisition cost Targets TC <4mmol/l (audit level <5 mmol/l) Or LDL-C <2mmol/l (audit level <3mmol/l) Not met - intensify statin therapy (using a statin of low acquisition cost) consider adding other agents such as fibrates or ezetimibe Elevated Triglycerides (fasting lipid profile) Samples Assess and manage secondary causes of high triglycerides: Poor blood glucose Hypothyroidism Renal impairment Liver inflammation particularly from alcohol. If Triglyceride remain >4.5 mmol/l initiate fibrate (first choice fenofibrate). Either before or in addition to statin). Nicotinic acid or derivatives: Do not use routinely. May be considered if intolerance to statins or fenofibrate. Omega-3-fish oils: Do not use in primary prevention of CVD (unless as part of specialist treatment of hypertriglyceridaemia). There is no post prandial rise in total and LDLcholesterol A non-fasting sample is suitable for initial screening only. A fasting sample should be obtained if triglyceride is raised and for future monitoring. Referral to specialist care should be considered: If control remains poor • If there is drug intolerance Severe mixed hyperlipidaemia, with triglycerides >4.5 mmol/l When combination therapy is necessary If there is concern about liver function tests and the advisability of starting a statin If there is a family history of premature cardiovascular disease and familial hypercholesterolaemia. Nottinghamshire Diabetes Guidelines August 2012 36 Renal Monitoring Microalbuminuria: Proteinuria (or macroalbuminuria): Excess albumin in the urine but not detectable using protein dipstick. The earliest indicator of renal disease (nephropathy). Is predictive of total mortality, cardiovascular mortality and cardiovascular morbidity. Is an important finding in patients with type 1 and type 2 diabetes Represents progression of urine albumin excretion from microalbuminuria Is associated with a high probability of progressive renal impairment due to diabetic nephropathy and an increased risk of macrovascular disease An albumin:creatinine ratio >30mg/mmol is overt proteinuria Renal monitoring for patients with diabetes Annual urine dipstick test for protein (Boerhinger 5L or Albustix test strips). If urine dipstick negative for protein measure urinary albumin creatinine ratio (ACR). Annual serum creatinine and estimation of GFR Microalbuminuria laboratory screening 10ml early morning 'first pass' urine sample in a 'Universal' specimen container. Clinical chemistry form for albumin/creatinine ratio ('ACR' in mg/mmol). Male Female <2.5 <3.5 Interpretation Normal Action Repeat in 1 year ≥2.5 ≥3.5 Possible microalbuminuria Repeat test at the next two clinic appointments and within 3 – 4 months, and microalbuminuria is confirmed if at least one out of two or more results is also abnormal Renal Management for Patients with Diabetes Routine management Maintain good blood glucose control Maintain good blood pressure control see algorithm on next page Stop smoking Advice on salt, exercise Immunize against influenza and pneumococcus Drug reviews Persistently raised ACR or proteinuria Maintain good blood glucose control (HBA1c < 53 mmol/mol if possible). Maintain good blood pressure control (target < 130/80 mmHg for microalbuminuria, <125/75 if proteinuria >1g – ACR >100mg/mmol). Start ACE inhibitor or ARB Check eGFR +7-10 days after starting/ dose change Use combination anti-hypertensive therapy to reach target. Manage CV risk factors aggressively Referral is advised: To investigate for non-diabetic renal disease – suspect if: Heavy proteinuria / nephrotic syndrome with: -short duration diabetes -little or no retinopathy -haematuria/microscopic haematuria Raised creatinine with little or no proteinuria Rise in creatinine >20% or fall in estimated GFR >15% following initiation of ACE/ARB (possible renovascular disease) Possible systemic illness – e.g.vasculitis/myeloma Acute renal failure For management of: Persistent fluid retention Hypertension Secondary hyper parathyroidism Rapidly decline GFR >4% per year irrespective of CKD stage GFR <30mls/min (CKD stage 4) Hb<10g/dl in absence of any other cause for anaemia apart from chronic kidney disease Nottinghamshire Diabetes Guidelines August 2012 37 Renal Disease Screening Algorithm Positive Result Screen newly diagnosed patients for Proteinuria Negative result Screen for microalbuminuria after 3 months of improved glycaemic control Screening method Morning urine specimen for albumin: creatinine ratio (ACR) Yes Result >2.5mg/mmol in a male? >3.5mg/mmol in a female? Establish the cause Exclude other causes of a positive result e.g. urinary tract infection, severe hyperglycaemia, cardiac failure, contamination with blood, and other renal disease MSU with microscopy for casts should be performed to aid diagnosis (the presence of red cell and other casts may indicate other renal pathology) Ultrasound of the renal tracts may also be appropriate in some cases Incipient nephropathy is diagnosed if 2 out of 3 tests are positive and other causes excluded No Screen annually Management Optimise glycaemic control Check serum creatinine. If normal then check annually. Referral if GFR <30mls/min or a progressive fall in GFR (fall >5ml/min for 2 successive years even if the absolute GFR is >30mls/min) Optimise blood pressure control. Target is 130/80 for microalbuminuria and 125/75 for proteinuria >1g Drugs of choice ACE-I or ARB, followed by long acting calcium channel blockers (avoiding short acting dihydropyridine ca channel blockers such as nifedipine) Manage the other cardiovascular risk factors aggressively Nottinghamshire Diabetes Guidelines August 2012 38 Diabetic Retinopathy The commonest cause of blindness in adults of working age in the UK Asymptomatic in the early stages when treatment is most effective More common and more severe with increasing duration of diabetes Smoking, renal disease and uncontrolled hypertension are the biggest risk factors Screening for diabetic eye disease has been shown to prevent loss of sight Laser therapy will reduce the risk of visual loss in more than 70% of patients with proliferative retinopathy Laser therapy will salvage vision in 50-60% of patients with maculopathy. Suggested Management in Primary Care Ensure good diabetic control, give lifestyle advice (i.e. smoking) and control hypertension All patients age 12 and over should be referred for screening for diabetic retinopathy on diagnosis and annually thereafter (irrespective of where their routine care is managed). There are two Retinopathy Screening Programmes covering Nottinghamshire. The Greater Nottingham Diabetic Eye Service provides a Diabetic Retinopathy Screening for patients registered with a GP practice in Nottingham City, and in Greater Nottingham including Broxtowe, Gedling and Rushcliffe areas. Contacts details are: The Nottingham Diabetic Eye Screening Service, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH. Telephone: 0115 9194411 Fax: 0115 9701080 The North Nottinghamshire Diabetic Eye Screening Programme provides a service for patients living in the Ashfield, Mansfield, Newark and Sherwood and Bassetlaw areas. Contact details: North Nottinghamshire Diabetic Eye Screening Programme, Sherwood Forest Hospital Trust, King’s Mill Hospital, Trust Administration, Level 2, Mansfield Road, Sutton in Ashfield, Notts, NG17 4JL Telephone: 01623 676134 Fax: 01623 672203 Referral Guidelines to Secondary Care The following circumstances require urgent referral: Sudden deterioration of vision in one eye New vessels (within 14 days). The following require early referral (within a few weeks): Pre-proliferative retinopathy (severe background + cotton wool spots) Exudates near to the macula. Nottinghamshire Diabetes Guidelines August 2012 39 Painful Neuropathy Definition The presence of positive symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes. Typical positive symptoms include burning, pricking pain, electric feelings, tightness, and hypersensitivity to touch. Special Points Vastly underdiagnosed and a potential source of debilitation in a person with diabetes Occurs in both type 1 and type 2 diabetes and more common with increased duration of diabetes. Often co-exists with other microangiopathy. Small fibre neuropathy is a more common variant and responds poorly to treatment. In large fibre neuropathy; proprioception, vibration strength, tendon reflexes and muscle strength may be affected Even if successful, treatment may not relieve pain for many months or longer Suggested Management in Primary Care Exclusion of other causes of pain; e.g. fasciitis, nerve entrapment, arthritis etc Aim for good glycaemic and blood pressure control, angiopathy and foot screening Trial of tricyclic antidepressants (e.g. amitriptyline), dose titration to a maximal tolerable dose. If no response, consider gabapentin or phenytoin again titrating to a maximum tolerable dose Other treatments: Tramadol (non-opioid analgesics), Duloxetine (in place of amitriptyline), Topical capsaicin, Opioid based analgesics, accupunture, spinal cord stimulators can be tried with variable results in various small trials. Monotherapy generally results in 30-50% reduction of pain at best and multi-drug treatment may be indicated in patients with intractable pain http://guidance.nice.org.uk/CG96/NICEGuidance/ Referral Guidelines to Secondary Care Patients should be referred to the hospital to see a diabetologist if: 1) Intractable pain (despite amitriptyline and/or gabapentin) 2) Concerns about alternative diagnosis where electrodiagnostic investigation may be indicated. 3) Associated with significant glycaemic control or vascular complications of diabetes where secondary input is necessary. The following circumstances require urgent referral: If the painful foot is also noted to be either hot or swollen or both. Associated with a non healing neuropathic ulcers Nottinghamshire Diabetes Guidelines August 2012 40 Management of Foot Complications in Diabetes KEY POINTS 1. INTEGRATED CARE Management of the foot in diabetes requires closely integrated care which crosses conventional professional boundaries. 2. PREVENTION OF ACTIVE FOOT DISEASE All people with diabetes should have their feet examined annually to detect those at risk. Those at increased risk are those with peripheral arterial disease, neuropathy, or deformity. Those at greatest risk are those who have had a previous foot problem, and those with end stage renal failure. Those at increased risk should remain under surveillance by a specialist with attempts made to reduce onset of new disease – by regular examination, podiatry, education and provision of orthoses (when appropriate). Foot care guidance Appendix F 3 MANAGEMENT OF NEW (OR DETERIORATING) ULCER, OR THE HOT RED SWOLLEN FOOT All newly occurring disease whether in the community or hospital should be referred to the MDT within one working day. Telephone or fax referrals to MDT at hospitals: City Hospital Campus: Fax 0115 962 7959 Sherwood Forest Hospitals: 01623 622515 Ext 6035 (9am – 5pm), Vocera - Ask for Diabetic Foot Team. Out of hours Urgent Refer to A & E (notify Diabetic Foot Team of admission via Vocera) 4 MANAGEMENT OF THE PERSON WHOSE FOOT DISEASE HAS HEALED The risk of a new problem is 40% within 12 months The overall mortality of people with foot disease is 50% at 5 years. Strenuous steps should be taken to minimiseCARE cardiovascular risk. INTEGRATED Disease of the foot is complex and multifactorial, with different people having different dominant problems. Each person with foot disease must have access to professionals with skills and resources necessary to assess and correctly manage any infection, peripheral arterial disease and any requirement for off-loading arising from neuropathy. It is for this reason that most foot disease requires the input of a number of professionals with the necessary complementary skills who work either together or in close communication with each other. Management of the foot in diabetes requires closely integrated care which crosses conventional professional boundaries. This care is shared between: Generalist Practitioner or Practice Nurse with the skills necessary to identify the foot at increased risk. Community Podiatrist - A Health Professions Council registered podiatrist working primarily in a community setting. Diabetes Specialist Podiatrist – A highly specialised podiatrist with a relevant post, and graduate qualification in the podiatric care of patients with diabetes. Multidisciplinary Footcare Team (MDT) – A team of highly expert diabetes specialist physicians, podiatrists, orthotists and nurses who together have the necessary skills to assess and manage diabetic foot disease. The team must have ready access to input from vascular and orthopaedic surgeons, plaster casting, microbiological support, appropriate imaging and in-patient beds. Because of the multiple skills and resources required, the MDT will usually be located in secondary care. Nottinghamshire Diabetes Guidelines August 2012 41 ROLES AND RESPONSIBILITIES The appropriately trained generalist practitioner will be responsible for providing at least annual foot screening, education and information for all ‘low risk’ patients. Patients found to be at increased risk should be referred to the Podiatry service. All newly occurring disease of the foot should by referred by phone or fax to the expert MDT. The Community Podiatry service will be responsible for providing assessment and appropriate foot care, including education and information, to all patients identified as being at ‘increased or high risk’. They will be responsible for ensuring appropriate ongoing monitoring, with a focus on prevention and early intervention. They will refer on to the Multidisciplinary Footcare team in a timely manner if ‘risk’ increases. They will also refer any newly occurring disease to the expert MDT by phone or fax. The Diabetes Specialist Podiatrist will be responsible for providing expert diabetes podiatric input to the Multidisciplinary Footcare Team, usually based in acute organisations. They will also be responsible for setting and maintaining clinical standards and providing expert advice and support to podiatric colleagues The Multidisciplinary Footcare Team will be responsible for providing care for all foot care emergencies and coordinating the care of those at ‘high risk’ who are referred to them. PREVENTION OF ACTIVE FOOT DISEASE Classification of risk People with diabetes should have their degree of foot risk classified, and their routine surveillance adjusted on the result. 1 Low Current Risk – Normal sensation, palpable pulses and no other risk factors Those at low risk require basic footcare education, including action to be taken if they develop an active foot problem. 2 Increased Risk – One risk factor present, e.g. loss of sensation or signs of peripheral vascular disease without callus or deformity Those at increased risk require assessment by a podiatrist who will formulate a management plan dependent on individual needs, and including ongoing regular expert review and education. 3 High Risk – Previous ulceration or amputation or more than one risk factor present e.g. loss of sensation or signs of peripheral vascular disease with callus or deformity The management plan and education will emphasise the need for early expert assessment of new disease ACTIVE FOOT DISEASE Presence of active ulceration, spreading infection, critical ischaemia, gangrene or unexplained hot, swollen foot with or without the presence of pain All patients with active foot disease must be referred to the MDT within one working day (NICE 2004), or as an emergency. For contact details please go to: Referral to Community and Specialist Services Nottinghamshire Diabetes Guidelines August 2012 42 Diabetes in Pregnancy Key Priorities Pre Conceptual Care Women with diabetes who are planning to become pregnant should establish good glycaemic control before conception. Continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death. It is important to explain that risks can be reduced but not eliminated. The importance of avoiding unplanned pregnancy should be an essential component of diabetes education from adolescence for women with diabetes. Pre Pregnancy All women with diabetes who are known to be planning a pregnancy should be referred to the Joint Diabetic/Obstetric Clinic QMC appointment Ex 61258 Fax 0115 8493331 City appointment Ex 55240 Fax 0115 8402659 SFHT appointment Ex3740 Information and Advice Encourage the woman’s partner or a family member to attend pre conception appointments Give advice on risks of diabetes in pregnancy and how to reduce them with good glycaemic control. Aim towards HbA1c <43mmol/mol if safe Advise women with HbA1c >86mmol/mol to avoid pregnancy Discuss diet, body weight and exercise including weight loss with women with BMI >27kg/m2 Discuss hypoglycaemia and hypoglycaemia awareness Retinal and renal assessment When to stop contraception and smoking cessation support Offer folic acid 5mg/day 3 months before a planned pregnancy and continue up to 12 weeks gestation Review medication (Box 1) and self monitoring routine (Self monitoring of blood glucose will be frequentideal parameters <5.5mmols/l pre-meal, <7.8mmols/l 1 hour after meals and 6-7mmols/l before bedtime). Box 1 Safety of medications before and during pregnancy Metformin may be used before and during pregnancy. Data from clinical trials and other sources do not suggest that the rapid-acting insulin analogues (aspart and lispro) adversely affect pregnancy or the health of the fetus or newborn baby. Isophane (NPH) insulin is the first-choice long-acting insulin during pregnancy. Before or as soon as pregnancy is confirmed: Stop oral hypoglycaemic agents, apart from metformin. If on a sulfonylurea ‘dovetail’ reduction to prevent hypoglycaemeia Stop angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists and consider alternative antihypertensives Stop statins (ideally 3 months before a planned pregnancy) A confirmed pregnancy should be immediately referred to Consultant led care (as above). Inform women they will have frequent ongoing input from the Joint Diabetes/Obstetric Teams Pre-existing Diabetes and Pregnancy If it is safely achievable, women with diabetes should aim to keep pre-meal blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose <7.8 mmol/litre during pregnancy. During pregnancy, women who are suspected of having diabetic ketoacidosis should be admitted immediately where they can receive both medical and obstetric care. Nottinghamshire Diabetes Guidelines August 2012 43 Gestational Diabetes 2-5% of all pregnancies are complicated by gestational diabetes Women with risks for gestational diabetes should be screened at 24-28 weeks (Box 2) with an oral glucose tolerance test (OGTT) Box 2 Risk factors for screening BMI above 30 kg/m2. Previous macrosomic baby weighing 4.5 kg or above. First-degree relative with diabetes. Family origin with a high prevalence of diabetes: South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh), Black Caribbean, Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt). Clinical Consideration should be given to undertaking OGTT with individual situations e.g. Current pregnancy measuring above 97th Centile Polyhydramnios Recurrent glycosuria (on 2 occasions within 7 days) Pre-existing endocrine disorders Polycystic ovarian disease 75g Oral Glucose Tolerance Test (OGTT) Obtain laboratory results within 24-48hrs Pregnancy Impaired fasting glycaemia (IFG) Fasting blood glucose > 5.3mmols/l 1hr blood glucose >7.8mmols/l Refer immediately to next Joint Diabetes/Obstetric Clinic (as above) Further advice can be sought from: Lead Midwife Diabetes City 0115 9691169 Ex 55244 QMC 0115 9249924 Ex 64280 Midwife for Diabetes SFHT 01623 622515 Ex 3740 Midwife Pregnancy Day Care SFHT 01623 622515 Ex 3071 Women with previous gestational diabetes who have had an impaired fasting glucose test between pregnancies can be referred directly to Consultant led care. They should plan their pregnancy. Offer a fasting glucose once pregnancy confirmed and refer if >5.3mmols/l . All other women with previous gestational diabetes should be screened with OGTT 16-18 weeks gestation followed by OGTT at 28 weeks if first test normal Information and advice before screening and testing Advise that: there is a small risk of birth complications (Box3) if gestational diabetes is not controlled gestational diabetes will respond to changes in diet and exercise in most women oral hypoglycaemic agents or insulin injections may be needed if diet and exercise do not control blood glucose levels After diagnosis inform women they will have frequent ongoing input from the Joint Diabetes/Obstetric Team Self monitoring of blood glucose will be frequent-ideal parameters <5.5mmols/l pre-meal, <7.8mmols/l 1 hour after meals and 6-7mmols/l before bedtime. Nottinghamshire Diabetes Guidelines August 2012 44 Box 3 Risks of gestational diabetes fetal macrosomia birth trauma (to mother and baby) induction of labour or caesarean section transient neonatal morbidity neonatal hypoglycaemia perinatal death obesity and/or diabetes developing later in the baby’s life. Post Partum Management women with pre-existing diabetes are referred back to routine care women with diabetes who breastfeed continue to avoid drugs for complications that were discontinued in pregnancy (Metformin safe with breastfeeding) Gestational diabetes advice a 75g OGTT should be performed 6 weeks post partum lifestyle advice and contraception advice offered discuss symptoms of hyperglycaemia annual fasting blood sugar taken counselling on subsequent pregnancy and gestational diabetes Nottinghamshire Diabetes Guidelines August 2012 45 Contraception Contraception must be discussed at annual review with all women of childbearing age. Condom use is encouraged to help prevent sexually transmitted infection There are no contraceptive methods specifically contraindicated in women with diabetes, however methods with proven high degrees of effectiveness are preferable. It is advisable to plan ahead for pregnancy and contraception is a key factor in the planning process. Type of contraception Advantages Combined Hormonal Contraceptives (CHC) Generally safe in younger patients with Type 1 Diabetes. Alternative methods should be considered in patients with 2 or more risk factors (i.e. diabetes plus other e.g. vascular disease, neuropathy and retinopathy). Progestogen only pill (POP) Safe and effective if reliable in taking medication. Pill needs to be taken at same time every day. Useful for patients with risk factors Injectable progestogen Suitable for patients with diabetes (except those with risk factors (i.e. (Depo) diabetes plus other e.g. vascular disease, neuropathy and retinopathy). Injection administered every 12 weeks. Non-contraceptive effects (e.g. bleeding disturbance) can last for up to 18 months, but contraception only lasts for maximum of 14 weeks after last injection! Implanon (Implant) Intrauterine device (progesterone) (IUS, Mirena) and IUD (copper) Diaphragm/condom Sterilisation Small, flexible rod, which is inserted under the skin on the inside of the upper arm. A small amount of progestogen is released each day. It lasts for 3 years, and is more effective than sterilisation. Suitable for women with diabetes. IUS/IUDs are safe to use in women with diabetes. The IUS is helpful for women suffering from menorrhagia These methods provide a lower degree of effectiveness Emergency contraception may be required if the methods have not been used consistently or the method has failed (e.g. condom split). This may be appropriate for the male partner, if the female partner has diabetes as surgery poses potential risks for people with diabetes. Male sterilisation (vasectomy) is very effective, female sterilisation is not as effective. UK Medical Eligibility Criteria for Contraceptive Methods 2009 History of gestational disease Type 2 Diabetes, non vascular disease Type 1 Diabetes, non vascular disease Nephropathy/retinopathy/neuropathy Other vascular disease COC 1 2 POP 1 2 Depo 1 2 Implant 1 2 IUS 1 2 IUD 1 1 2 2 2 2 2 1 3/4 3/4 2 2 3 3 2 2 2 2 1 1 Category 1 – a condition for which there is no restriction for the use of the contraceptive method Category 2 – a condition where the advantages of using the method generally outweigh the theoretical or prove risks Category 3 – a condition where the theoretical or proven risks usually outweigh the advantages of using the method Category 4 - a condition which represents an unacceptable health risk if the contraceptive method is used. Nottinghamshire Diabetes Guidelines August 2012 46 Erectile Dysfunction in Diabetes - ED - inability to obtain and/or maintain an erection good enough for satisfactory intercourse Affects 40% of men aged 40-70 years More prevalent in men with diabetes, tends to occur at an earlier age and incidence increases with disease duration and co-existence of peripheral neuropathy - Undertake Cardiovascular assessment Cardiovascular status and ED management check if hypoleric Address lifestyle issues (alcohol, smoking, obesity, stress etc) Examination for any obvious abnormality (genital malformation, penile acute inflammatory conditions, when indicated digital rectal examination Baseline investigations – Lipids, Thyroid Function, Liver Function, Testosterone, Sexual Hormone Binding Globulin (SHBG), Prolactine and urine dip-stick. The use of questionnaires can help with the diagnosis and monitoring of ED. Such questionnaires are the International Index of Erectile Function (IIEF) and the Sexual Health inventory for Men - Consider Aid tools: IIEF questionnaire Full Sexual History & Examination SHIM Score Perform baseline investigations as above Check Testosterone, SHBG, Prolactin. PSA should be checked in those patients over 40 years Normal Results Psychogenic Cause? - Sudden onset - Early collapse of erection - Good quality spontaneous /self stimulation/waking erections - Relationship problems - Major life events Consider psychosexual referral Consider short trial of PDE5 Refer for endocrine opinion if testosterone, prolactin or PSA abnormal refer Organic Cause? - Gradual onset - Normal libido - Risk factors - Operations/radiotherapy or trauma to pelvis/scrotum - Current medication - Smoking - Alcohol Cardiovascular status grading Low Risk High and Intermediate Risk Consider referral to Cardiologist and/or ED services Discuss Treatment options - Arrange a trial of PDE5 inhibitors (e.g. Sildenafil) - Vacuum device - Trans Urethral Alprostadil (MUSE) - Intracavernosal injection of Alprostadil If failure refer to ED service References: BSSM Guidelines for Erectile Dysfunction. http://www.bssm.org.uk/downloads/BSSM_ED_Management_Guidelines_2007.pdf EAU Guidelines for Erectile Dysfunction. http://www.uroweb.org/gls/pdf/Male%20Sexual%20Dysfunction%202010.pdf Nottinghamshire Diabetes Guidelines August 2012 47 Paediatric Diabetes Services Newly diagnosed (or suspected) patients aged 18 years and under Urgent (same day) telephone referral to Paediatric Medical Teams at Nottingham University Hospitals or Sherwood Forest Hospitals Emergencies Families are encouraged to seek prompt medical or specialist nurse advice in order to anticipate and prevent problems of hypoglycaemia, illness induced ketoacidosis and persistent poor control Nottingham Hospitals Contact details: Dr T Randell, Dr L Denvir and Dr J Drew secretary Tel: 0115 9249924 ext 62331/62336 Fax: 0115 9709419 Newark Hospital: Dr T Randell 01636 685719 Paediatric DSNs Vreni Verhoeven 0115 9346411 Karen Cuttell 0115 9346412 Glyn Feerick/Matt Williams 0115 9345951 Emergency pager For urgent medical advice only 8am -6pm Monday – Friday 0765 913 2445 – leave short message including name and number – if no reply after 15 minutes please try again 6pm – 8am (also Weekends and Bank Holidays) Contact on-call Paediatric Medical Registrar at relevant hospital Sherwood Forest Hospitals Contact details: Dr U Ngwu Secretary Tel: 01623 622515 ext 6292 Diabetes Specialist Nurses Helen Marsh 9-5 Monday – Friday Full Time, Mobile: 07764 897941 or if switched off, via hospital switchboard or office ext: 6879 Advice out of hours and weekends/ bank holidays can be obtained from Robin Hood Ward Ext: 3063 Children/adolescents with diabetes have open access to Robin Hood Ward for urgent medical advice/treatment that is diabetes related Regular clinic reviews Patients are reviewed in clinic between 2-6 monthly depending on individual needs, often at least 3 or 4 reviews per year. HbA1c is checked at every review. An annual review incorporates retinal examination (patients over 12 years advised to attend local screening programme) blood pressure management, screening for microalbuminuria, coexistant autoimmune thyroid disease and coeliac disease. General Information All children and young people aged 18 years and under with diabetes are managed for their diabetes within specialist services either at Nottingham University Hospitals or Sherwood Forest Hospitals Children and young people are managed on insulin regimens via a pen injection device or continuous subcutaneous insulin via an insulin pump. All children are now started on basal bolus regimens from diagnosis, with only a small number of patients with established diagnoses remaining on bds or tds regimens. The specialist teams include consultant paediatricians with a special interest in diabetes, paediatric diabetes specialist nurses, specialist dietetic support and emotional health and wellbeing support. The diabetes specialist nurses facilitate close liaison with all carers, schools and work to promote education and the gradual transfer of responsibility and management as the child grows and becomes more capable of self-management. General Practitioners are kept informed of management and progress Transfer arrangements are made to the adult team as geographically appropriate. Close liaison with the adult team and a transitional clinic aim to promote a smooth transition to adult services. Nottinghamshire Diabetes Guidelines August 2012 48 Appendix A: Lucozade / OGTT Lucozade Energy Original and the Oral Glucose Tolerance Test (OGTT) 70kcal/100ml variant The sole source of carbohydrate (CHO) in Lucozade Sparkling Glucose Drink is glucose syrup (liquid 1 glucose) with a dextrose equivalent of approximately 52.5 . The glucose syrup used is a solution, in water, of a mixture of CHO’s, obtained by the hydrolysis of starch, ranging from glucose to high molecular weight polysaccharides. The precise CHO composition is controlled to give the optimum balance of taste and performance. The body’s digestive processes convert all the sugars quickly and easily to glucose. Please note: Due to manufacturing changes in the production of Lucozade the volume of Lucozade required for a Glucose Tolerance Test (GTT) has changed. Lucozade: Sparkling Glucose Energy Drink, 70kcal/100ml formulation Volume of Lucozade to provide the equivalent of 75g anhydrous glucose or 82.5g glucose monohydrate 410ml Weight of Lucozade to provide the equivalent of 75g anhydrous glucose or 82.5g glucose monohydrate 438g N.B. For children the recommended test load is 1.75g glucose per kg body weight up to a total of 75 g of glucose, this is equivalent to 9.564ml Lucozade per kg body weight up to a total of 410ml of Lucozade. The ingredients of Lucozade Sparkling Glucose Energy Drink are given below. Single and multi-serve bottles: Carbonated Water, Glucose Syrup, Citric Acid, Lactic Acid, Flavouring, Preservatives (Potassium Sorbate, Sodium Bisulphite), Caffeine, Antioxidant (Ascorbic Acid), Colour (Sunset Yellow). Cans: Carbonated Water, Glucose Syrup, Citric Acid, Lactic Acid, Acidity Regulator (Sodium Citrate), Flavouring, Preservative (Potassium Sorbate), Caffeine, Antioxidant (Ascorbic Acid), Colour (Sunset yellow). Volume of Lucozade equivalent to 75g anhydrous glucose = 410ml Nottinghamshire Diabetes Guidelines August 2012 49 Appendix B: Physical Activity Referral Schemes There are a number of activity schemes throughout Nottinghamshire: Patients’ residential Name of scheme Contact number area Ashfield Broxtowe Borough Exercise Referral Scheme Vitality Referral 0162-345-7233 0115-917-3508 Gedling Positive Moves 0115-901-3601 Mansfield Get Active 0162-346-3470 Newark and Sherwood GP referral scheme 0163-665-5707 Nottingham City YMCA Active4Life 0115-855-3316 Rushcliffe GP referral Contact local leisure centre Website http://www.ashfielddc.gov.uk/ccm/navigation/he alth-and-socialcare/exercise-referralscheme/ http://www.broxtowe.gov.uk/i ndex.aspx?articleid=4654 http://www.gedling.gov.uk/in dex/leisure/ls-getfit/ls-erho.htm http://www.mansfield.gov.uk/ index.aspx?articleid=1572 http://www.newarksherwooddc.gov.uk/pp/gold/ viewGold.asp?IDType=Page &ID=8136 http://www.nottsymca.com/w ellbeing/active4life.html None available Arts on Prescription is a scheme for people who are experiencing stress, depression and anxiety. Patients can self refer by contacting the scheme on 0115 978 2463 and then the co-ordinators will contact the health care professional concerned. This scheme can help reduce sedentary behaviours. Further details at www.city-arts.org.uk Nottinghamshire Diabetes Guidelines August 2012 50 Appendix C: Dietetic Information for Non-Dietetic Staff Patient Literature – The following information should be given to all patients with diabetes: Eating, Drinking and Diabetes. This is a booklet of comprehensive dietary advice on the dietary management of diabetes. 4th edition 2009 Booklets are free to GP Practices within Broxtowe, Gedling, Rushcliffe and City Nottinghamshire are available from: Community Nutrition and Dietetic Department, Nottingham CityCare Partnership Suite 6, 2nd Floor, Aspect House, Aspect Business Park, Bennerley Road, Bulwell, Nottingham, NG6 8WR. Tel: 0115 8834327 Fax: 0115 8834330 Type 2 Diabetes Resource and Information Booklet This is distributed to all GP’s and relevant health professionals by the local PCT in the Newark and Sherwood, Ashfield and Mansfield areas Healthy Eating for Diabetes This is an A4 sheet of basic guidance on dietary management of diabetes. This advice sheet can be downloaded via the Nottinghamshire Health Community intranet. On the health community portal there is a drop down list under a heading of community resources. Nutrition and Dietetics can be selected from this list and once on our site select Community Nutrition Pack. This gives access to the sheet entitled healthy eating for Diabetes. http://www.nottscommunityhealth.nhs.uk/index.php/services/nutrition-a-dietetics Further dietary information is available from :www.bda.uk.com www.bdaweightwise.com www.diabetes.org.uk Staff Training Courses Facilitated by Specialist Dietitians and Public Health Nutritionists from Nottingham CityCare Partnership and County Health Partnerships Suitable for anyone whose role includes discussion on food and nutritional related issues: Practice Nurses, School Nurses, District Nurses, Health Visitors, Community Health Doctors, General Practitioners, Family Support Workers, Children’s Centre workers, All courses are half day workshops facilitated by Specialist Dietitians or public health nutritionists from Nottingham CityCare Partnership and Nottinghamshire Community Health.: Eat Well Training This training is mandatory before being eligible to attend other sessions detailed below Current evidence based healthy eating messages The use of the National Food Guide “Eat Well Plate” as a teaching tool for different client groups Dietary Management of Diabetes and Hyperlipidaemia Current evidence based dietary advice for diabetes and hyperlipidaemia Reinforce the use of the Eat Well Plate model as a tool for education Eliminate misconceptions concerning dietary advice for these conditions Nottinghamshire Diabetes Guidelines August 2012 51 A holistic approach to obesity management is now replaced with the following courses – Raising Awareness (Eat Well session must have been completed before attending this session) Define obesity Describe the current trends in obesity Describe the health consequences of obesity Identify factors contributing to the increasing prevalence of obesity Plot BMI and interpret the result Identify common barriers to changing health related behaviour First Line Advice (The Eat Well session must have been completed before attending this session) This is a full day session that covers specific first line advice. Define obesity Describe the current trends in obesity Describe the health consequences of obesity Describe the importance of waist circumference Identify factors contributing to the increasing prevalence of obesity Plot BMI and interpret the result Identify common barriers to changing health related behaviour Recommend appropriate ways for clients to increase physical activity levels Be aware of co morbidities which might require more specialised obesity management services These courses are advertised through flyers; emails and in newsletters. For further details or to book a place, please contact: NHS Nottingham City Wendy Swinson, Community Nutrition and Dietetic Department, Nottingham CityCare Partnership, Suite 6, 2nd Floor, Aspect House, Aspect Business Park Bennerley Road, Bulwell, Nottingham, NG6 8WR Tel: 0115 8834324, Fax: 0115 8834330 NHS Nottinghamshire County Sarah Hind, Clerical Officer, Nutrition and Dietetic department, Mansfield Community Hospital, Stockwell Gate, Mansfield, NG18 5QJ Tel: 01623 785183 [email protected] The training is free of charge for staff employed by the PCTs in City and County. Nottinghamshire Diabetes Guidelines August 2012 52 App D: TO BE PHOTOCOPIED Patient label Education checklist for insulin-treated diabetes Date Introduction Signature Comment What is diabetes? What is good control? - short term (blood glucose levels) long term (HBA1) Injections Insulin administration Pen devices Storage of insulin Safe disposal of needles Timing of injections Name and type of insulin Action of insulin Site rotation Dose adjustment Honeymoon period Diet Basic dietary advice Detailed dietary advice Advice on weight management Alcohol Blood glucose testing Timing/frequency Recording results Interpreting results Safe disposal of lancets Quality control of meter Nottinghamshire Diabetes Guidelines August 2012 53 Education checklist for patients with insulin-treated diabetes cont….. Date Hyperglycaemia Signature Comment Signs, symptoms Causes Prevention Ketones Ketoacidosis Illness Sick day rules Hypoglycaemia Causes Recognition Avoidance Treatment with diet Treatment with Hypostop Treatment with Glucagon Effect of exercise General Driving - DVLA - Insurance - Hypos Employment Retinopathy screening Benefits Free prescriptions NHS podiatry services Foot care information Smoking cessation advice Erectile dysfunction Contraception Pregnancy Pre-pregnancy counselling Holidays/travel Complications Annual review Exercise HBA1c Diabetes UK Nottinghamshire Diabetes Guidelines August 2012 54 TO BE PHOTOCOPIED Patient label Education checklist for diet/tablet treated diabetes Date Introduction What is diabetes? Signature Comment Explanation of disease process Tablet Treatment Action of tablets Dose When to take Side effects Diet Basic dietary advice Detailed dietary advice Advice on weight management Alcohol Testing Urine testing Timing/frequency Blood glucose testing Timing/frequency Recording results Interpreting results Safe disposal of lancets Quality control of meter Hyperglycaemia Signs/symptoms Causes Prevention Illness Sick day rules Nottinghamshire Diabetes Guidelines August 2012 55 Education checklist for diet/tablet treated diabetes cont….. Hypoglycaemia if treated with Sulphonylurea Date Signature Comment Causes Recognition Avoidance Treatment with Glucogel Effect of exercise General Driving - DVLA - Insurance - Hypos Employment Retinopathy screening Benefits Free prescriptions NHS podiatry services Foot care information Smoking cessation advice Erectile dysfunction Contraception Pregnancy Pre-pregnancy counselling Holidays/travel Complications Annual review Exercise HBA1c Diabetes UK Version 7 Nottinghamshire Diabetes Guidelines August 2012 56 Appendix E : Cardiovascular status and ED management Low risk • Controlled hypertension • Asymptomatic ≤3 risk factors for CAD - excluding age and gender • Mild valvular disease • Minimal/mild stable angina • Post successful revascularisation • CHF (I) • Manage within the primary care setting • Review treatment options with patient and his partner (where possible) Intermediate risk • Recent MI or CVA (i.e., within last 6 weeks) • Asymptomatic but >3 risk factors for CAD – excluding age and gender • LVD/CHF (II) • Murmur of unknown cause • Moderate stable angina • Heart transplant • Recurrent TIAs • Specialised evaluation recommended (e.g., exercise test for angina, Echo for murmur) • Patient to be placed in high or low risk category, depending upon outcome of testing High risk • Severe or unstable or refractory angina • Uncontrolled hypertension (SBP>180 mmHg) • CHF (III, IV) • Recent MI or CVA (i.e. within last 14 days) • High risk arrhythmias • Hypertrophic cardiomyopathy • Moderate/severe valve disease • Refer for specialised cardiac evaluation and management • Treatment for ED to be deferred until cardiac condition established and/or specialist evaluation completed CAD, coronary artery disease; MI, myocardial infarction; CVA, cerebral vascular accident; CHF, congestive heart failure, LVD, left ventricular dysfunction; SBP, systolic blood pressure; ED, erectile dysfunction; TIA, Transient Ischaemic Attack Nottinghamshire Diabetes Guidelines August 2012 57 Appendix F: Footcare management Nottinghamshire Diabetes Guidelines August 2012 58