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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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Appendix F: Footcare management
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