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Diabetes 28pp leaf (6798)

Maintain a practice register of people with diabetes with annual recall andclinical review.
Ensure all patients receive an adequate explanation of their condition, itsrisks and their management.
Provide health education on diet, physical activity, weight, blood pressure,foot care and blood glucose control.
Offer smoking cessation support and nicotine replacement to all smokers.
Aim to reduce raised blood pressure to below 140/80mmHg.
Aim to control HbA1c to 7.5% or below.
Offer statin treatment to people whose coronary heart disease risk is 15% Audit performance towards these objectives.
literature of overall good qualityand consistency addressing thespecific recommendation. conducted clinical studies but norandomised clinical trials on thetopic of recommendation.Orsystematic review of case-controlor cohort studies.
descriptive studies (e.g.
correlation or case controlstudies). committee reports or opinionsand/or clinical experiences ofrespected authorities. Indicates anabsence of directly applicableclinical studies of good quality.
The guidelines are designed for use in ambulatory care in primary, secondary and community settings to improve the management of people with type 2 diabetes.The guidelines aim to improve identification, organisation and quality of diabetes services including provision of information for patients and carers. These are set out as the primary objectives listed on the This work complements the National Service Framework (NSF) for diabetes. By April 2003 Primary Care Trusts should ensure that local priorities are identified and all practices have a protocol describing the systematic management and audit of type 2 These guidelines do not cover type 1 diabetes, gestational diabetes, diabetes in pregnancy or diabetes associated with endocrine disease.These guidelines have been agreed locally (see appendix 2 for details). They are based on the National Institute for Clinical Excellence (NICE) guidelines on management of type 2 diabetes (www.nice.org.uk), the National Service Framework for diabetes (www.doh.gov.uk/nsf/diabetes) and the Scottish SIGN guidelines.(www.sign.ac.uk). Additional sources To improve readability not all recommendations are graded by strength of evidence. However the major therapeutic The organisation of care : initial diagnosis, the diabetic register and annual review Appendix 2 How these guidelines were developed Appendix 4 Patient information services and benefits All laboratories in east London are Diabetes Control and Complications Trial (DCCT) aligned. This is the preferred Diagnosis
methods and the laboratory standards are based on those Symptoms: tiredness, polyuria, polydipsia, skin infections, used in the DCCT and the UK Prospective Diabetes Study Risk factors for diabetes: age >65years, Asian/African Caribbean, BMI >30, family history, previous gestational The International Federation of Clinical Chemistry (IFCC) has recently developed a new reference method, which measures true HbA1c and all laboratories will be required to The following indicative levels of HbA1c are based upon the North Thames and Eastern Region Survey and Audit for Diagnosis and Management of Diabetes Mellitus.
HbA1c: Indicative levels of control
Blood Pressure treatment thresholds
Treatment is recommend at all ages including over 75, whatever the initial cholesterol level.
Type 2 diabetes is often present several years before There is as yet no consensus on a population screening diagnosis and up to 50% of people already have programme. Such programmes have not been shown to be complications such as retinopathy, neuropathy or cost-effective or beneficial to outcome in people with type 2 cardiovascular disease at diagnosis.
diabetes. Population sub-groups at high risk have been identified for screening, though evidence of benefit is not Type 2 diabetes may present with polyuria, thirst, recurrent candida or skin infections or with dehydration often precipitated by infection. A significant number of people with 1. People who have pre-existing cardiovascular disease i.e.
diabetes are first identified on routine testing.
raised blood pressure, coronary heart disease, peripheral vascular disease and stroke, should have random blood Type 2 diabetes is now affecting an increasing number of glucose measured as part of their annual clinical review.
children/adolescents who should be managed in conjunction with paediatric and adolescent services.
2. Women with a history of gestational diabetes and people with impaired glucose tolerance or impaired fasting glucose are at high risk of developing diabetes. The diabetes NSF recommends sustained and regular follow up. However there is no consensus on how or whether this can be achieved and Blood glucose levels are continuously distributed and the no evidence of benefit to support it.
definition of diabetes is an arbitrary one, based on the risk associated with a particular level of blood glucose. The World 3. People with a family history of type 2 diabetes especially Health Organisation (WHO) has recently revised these at younger ages, or who are obese or from South Asian and African Caribbean population are all at increased risk of (http://whqlibdoc.who.int/hq/1999/WHO_NCD_NCS_99.2.pdf).
This classification also defines two intermediate groups, impaired fasting glucose and impaired glucose tolerance, both For groups 2 and 3, opportunistic case finding prompted by of which are at high risk of developing diabetes and symptoms or risk factors is a matter for clinical judgement and no formal screening programme is advocated. This may lead to identification of some individuals with previously Patient with a fasting glucose between 6.1 - 6.9mmol/l (impaired fasting glucose) should have an oral glucose 1. Diabetic symptoms: polyuria, thirst or weight loss plus
A fasting blood glucose concentration of ≥7.0 mmol/l Two hour blood glucose concentration of ≥11.1 mmol/l after an oralglucose tolerance test with the equivalent of 75g of anhydrous glucose or Blood glucose refers to a plasma venous sample 2. No symptoms of diabetes
The result in asymptomatic people requires at least two measurements One test in the diagnostic range should be followed by at least one additional glucose test result on another day.This may be either a random sample, a fasting sample or from the two hour post glucose load.
If the random or fasting values do not confirm the diagnosis the two hour glucose tolerance test value should be used.
The organisation of care : initialdiagnosis, the diabetic registerand annual review Practices and local diabetes services should have an agreed protocol and arrangements for the education of newly diagnosed diabetic patients or their carers, including: Education on diabetes and its risks.
Hazards and self management (NSF standard 7).
Availability of local services - chiropody, retinal screening, practice nurses or diabetes nurse specialists, diabetes dietitians, other dietitians where appropriate.
Benefits advice and where appropriate, mobility or Annual review (NSF standard 4)
Plan for follow-up including arrangements for the Review of blood glucose control/hypoglycaemia A disease register should be maintained with a mechanism for annual (or more frequent) follow-up.
Risk factors, advice and drug treatment should be GP or hospital responsibility for annual review should Liver Function Tests (if recently started on statin) Attendance at retinal screening should be recorded Responsibility for follow-up of non-attenders should be with the responsible physician. In practice, attendance often lapses and opportunistic vigilance by primary care and Foot examination including peripheral pulses 10 year coronary heart disease risk assessment At least one reminder should be sent to people who do not attend annual reviews. It is possible this may alter in the light (A template is available for EMIS computer systems - A variety of interventions to improve self-management, involved to provide structured education, metabolic and psychological outcomes have been used.
Education supplemented by continuing support for changes It should be recorded whether a patient has received: in behaviour. These should be based on valid theories that recognise the nature of behavioural change. Health Initial education on diabetes and its management professionals should receive training in patient centred including self-monitoring and diabetic emergencies.
A personal care plan, in an appropriate format and Education programmes, computer aided packages and telephone prompting may be of benefit as part of a multidisciplinary lifestyle intervention programme.
When appropriate, a patient held record to record Staff training will be required to provide these services. Smokers should be offered support to quit as part of a programme that includes nicotine replacement and intensive Patients with diabetes and their families provide 95% of their Smoking status should be recorded annually and smokers care themselves. In type 2 diabetes there is little evidence of should be offered support to quit at each review. For more benefit from self-monitoring of blood glucose but its use is widespread. If self-monitoring is used, it should be viewed as part of lifestyle change and concordance with medication and not as a stand-alone intervention.
The principles of healthy eating should be emphasised: a For self monitoring of glucose in type 2 diabetes there is no diet low in sugar, saturated fat and salt and high in starchy national consensus on the type (urine or blood) or method (visual or electronic reading of sticks) or frequency of self- monitoring. Local practice usually favours electronic meters See Appendix 1 on Healthy Eating for further details of an in those capable of using them, though patient preference Referral to a dietitian on a least one occasion, should be Patients require formal instruction in self-monitoring, the considered for all patients with diabetes. Overweight and recording of results in a patient held record and their obese people should be encouraged to modify their diet and reduce their calorie intake. Local resources for continuing support i.e. Weight Watchers or similar should be Patients should be taught about hypoglycaemia and its management and diabetic emergencies (see page 8).
All people should be encouraged to engage in moderate The objectives of treatment - target weight, blood pressure, levels of physical activity (e.g. daily walking for at least 20 smoking cessation where appropriate, blood glucose, minutes, 3 or more times a week) as part of their routine HbA1c, and serum cholesterol should be identified and activities (A). Local schemes - exercise on prescription, mechanisms for achieving these through exercise, diet and supported walks - should be considered. For more medication explained. Foot care should be discussed (for further details see page 14). Ideally each patient should have Patients with complications or associated disease should seek medical review before embarking on exercise programmes. However, graded increases in activity are Adherence to therapy should be discussed, together with the In people who have failed to achieve blood glucose control after lifestyle counselling and support, drug therapy should change and adherence with treatment(see lifestyle section).
NICE recommends 6 monthly HbA1c measurement (and no Metformin improves peripheral glucose uptake and more frequently than 2 monthly) depending on levels of control or changes in therapy. In east London it is more realistic to aim for a minimum of 12 monthly HbA1c Metformin has been shown to both improve glucose control and reduce mortality and morbidity (A) and is the first-line drug in people who are overweight (BMI 25 kg /m2 or more) A target HbA1c of between 6.5% and 7.5% is optimal (B).
(A). Metformin may also be first-line therapy in people who However, this target level is based on average levels are not overweight (A), including South Asian who have a achieved by patients taking part in trials - half of these failed 30% increased cardiovascular risk at BMI as low as 23.
to achieve these targets even on intensively supervised (Yusuf S 2000 J Hypertension 18 Supplement 35-65).
treatment. In UK diabetic clinics the level averages 7.5-8%. Start metformin 500mg (to be taken after meals) and build up In practice, individual targets may be more appropriate gradually over several weeks - see BNF for details.
depending upon initial HbA1c levels, response and Metformin is contraindicated in heart failure, alcohol adherence to treatment and in the elderly, risk of dependence and renal impairment (creatinine > 130mmol/l).
Lactic acidosis is a rare complication often associated with An HbA1c audit threshold of 7.5% is only a proxy measure of adequacy of control and below 6.5% is optimal.
Where glucose control remains unsatisfactory a sulphonylurea may be added (A). Although blood glucose Local laboratories are moving towards a common standard of control may improve, there is a lack of evidence that HbA1c measurement. See Major Thresholds for Diabetes on morbidity or mortality are improved by this combination.
page 3. The table below gives indicative thresholds for HbA1c. There is no general agreement about these thresholds, but they fit in with the NICE and Diabetes NSF Insulin secretagogues include the sulphonylureas (eg.
gliclazide, glibenclamide) and the rapid acting insulin secretagogues (nateglinide and repaglinide). These drugs augment insulin secretion and effectively lower blood glucose (A) though there is a lack of evidence of their effect on Sulphonylureas may also be used in people who are not overweight (A), and may be added to metformin where If haemoglobingopathy or abnormal red cell turnover prevents HbA1c estimation, blood glucose profiles or corrected serum Sulphonylureas may be used when metformin is not fructosamine should be used. Local diabetes specialists should be consulted for target level and predictors of control Hypoglycaemia is a risk with sulphonylureas, and clinicians and patients should be alert for symptoms and their Nateglinide or repaglinide may be useful in attaining tight When, despite metformin and a sulphonylurea, glucose control remains poor, a glitazone may be added either to Patients and professionals should be aware of the symptoms metformin or to a sulphonylurea. Weight gain and fluid and initial management of diabetic emergencies.
retention may be a problem. If there is no improvement in blood glucose control within 4 months, consider stopping them and re-consider other treatment options (D).
Glitazones should always be used in combination with other This may be the first manifestation of diabetes. It is oral agents, preferably with metformin or alternatively with a characterised by very high blood glucose and dehydration sulphonylurea. Diabetes specialists may use triple therapy - and is associated with high mortality.
glitazones in addition to both metformin and sulphonylureas - though this combination is not currently licensed.
Glitazones reduce peripheral insulin resistance. Though they improve control of blood glucose (A) there is no current Hypoglycaemia is associated with the use of insulin or evidence that these drugs improve mortality or morbidity.
sulphonylureas. Sweating, disturbed behaviour or confusion There is also no evidence that they confer any advantage may precede fits or life-threatening coma.
over insulin and there is less evidence about their long term safety. Their place in management remains controversial.
Patients on sulphonylureas or insulin should be encouraged (Gale EAM Lessons from the glitazones. Lancet 2001 357: to carry glucose at all times eg dextrosol tablets. Most hypoglycaemia can be managed by the patient and their carers, using the simple resources below, repeated after 10- Glitazones should not be used in combination with insulin.
Liver function tests should be measured at initiation, two monthly for the first year and thereafter annually.
Sugar 2-4 teaspoons, 3-6 lumps, solid or in water. 50ml of Lucozade, Coca Cola or similar sugary drink In type 2 diabetes, insulin therapy should be considered in (not ’diet’ type) which is approximately a quarter cup.
people whose blood glucose is inadequately controlled on Hypostop gel, 10g glucose per ampoule. (1-2 ampoules).
oral glucose lowering drugs. Bedtime insulin is sometimes combined with oral treatment to improve control.
Three dextrosol tablets (available commercially). Once recovered, a long acting carbohydrate such as a Appropriateness of insulin should be discussed with the sandwich needs to be eaten to prevent recurrence. patient and their carer. Choice of insulin and regimen should be determined by local preference and patient choice.
Severe hypoglycaemia causing coma or lack ofco-operation Formal education in the use of insulin, the management of raised blood glucose, infection and hypoglycaemia should be Glucagon 1mg intramuscularly (subcutaneously or IV) as first line treatment followed by oral glucose when patient rouses. Glucagon may not work in a fasted patient ie Acarbose may occasionally be considered as an alternative in people unable to use other oral drugs. Flatulence may be If no response to glucagon after 10 minutes, IV glucose may be given 50ml of 20% glucose or 25ml of 50% glucose (flushed with saline to reduce venous irritation).
More than 50ml of 50% glucose may cause cerebral There is no evidence that drug treatment of obesity with oedema in the very old or adolescents.
either orlistat or sibutramine reduces morbidity or mortality from diabetes, nor have studies specifically targeted people with diabetes for inclusion. There is evidence from studies in Hypoglycaemia from oral hypoglycaemic drugs may recur people without diabetes that their use is associated with a after treatment and if so continued monitoring would be small reduction in average weight. Their use in diabetes necessary, possibly under hospital supervision. remains uncertain and advice from NICE guidelines should be followed (NICE technology appraisal no 22,31.
Continuing treatment should be reassessed if hypoglycaemia Care for people with increased urine albuminexcretion ACE inhibitors in people withmicroalbuminuria or proteinuria reduce People who have microalbuminuria or proteinuria are at increased risk of renal and arterial disease and require more intensive investigation and treatment.
Full history, examination, urinalysis for culture and sensitivity, renal ultrasound if clinically indicated.
Definition
Optimal management of other cardiovascular risk factors and blood glucose control (A).
Microalbuminuria - albumin:creatinine ratio greater than
Start ACE inhibitor - see below (A).
or equal to 2.5 mg/mmol (men) or 3.5 mg/mmol
Maintain blood pressure below 125/75 mmHg (British (women), or albumin concentration greater than or
Hypertension Society 1999 guidelines) or 135/75 (NICE equal to 20 mg/l
2002 guidelines) Most will require more than one drug Proteinuria - albumin:creatinine ratio greater than or
equal to 30 mg/mmol or albumin concentration greater
Aspirin and a statin will be appropriate in most cases.
than or equal to 200 mg/l.
Microalbuminuria (MCA) is the earliest sign of diabetic renal Starting ACE inhibitor therapy in people with disease (nephropathy). It is associated with increased mortality and cardiovascular disease or more rarely renal ACE inhibitors reduce blood pressure and progression of failure. Microalbuminuria describes a level of albumin in urine which while low, is above normal. Proteinuria describes a greater amount of albumin in the urine which can be ACE inhibitor therapy should be used with caution in those detected by standard urine dipstick.
with peripheral vascular disease, renovascular disease or There is a major resource issue in screening for MCA. In the absence of firm evidence of benefit, no firm recommendation Measure serum creatinine and electrolytes one to two weeks after initiating ACE inhibitor therapy and at each increase in dose. Some ACE inhibitors are not licensed for use at the blood pressure levels recommended in this Urinary protein and serum creatinine should be measured as See the BNF for starting dosages and titration to optimal part of the annual review (NICE recommends each visit).
dosages. Angiotensin II receptor blockers (A) are an alternative where cough limits the use of ACE inhibitors. First morning urine specimens are preferable. If not Urine dipstick for proteinuria. If positive, send for culture Positive results should be confirmed on at least two more Testing sticks for microalbuminuria are not available To obtain a quantitative estimation of proteinuria, a 24 If serum creatinine is 150 umol/l or more, discuss with specialist as to whether referral is appropriate. This will People with previous myocardial infarction, angina, stroke or peripheral vascular disease should either take simvastatin (A) or pravasatin, fluvastatin or atorvastatin. The aim of treatment is to reduce cholesterol below 5mmol/l or by 25% cardiovascular disease, as well as tothose without it but whose coronary The Heart Protection Study shows clear benefit below heart disease risk is 15% or more over10 years. It also applies to people over 5mmol/l and a statin should be started in this group of people. It is no longer necessary to restrict statins to people whose cholesterol is above 5mmol/l. The patient s risk, not (Heart Protection Study. Lancet 2002;360:7-21) their serum cholesterol,should determine who receives Monitoring of serum cholesterol and HDL cholesterol does not require a fasting sample and may be performed on a random sample. (Serum triglycerides and LDL cholesterol 1. In people without pre-existing cardiovascular disease, need fasting samples). Serum cholesterol and HDL estimate 10 year coronary heart disease risk using Coronary cholesterol should be measured annually as part of the Heart Disease Risk tables or Framingham calculator (template for EMIS is available from the CEG, or see back of 2. If 10 year coronary heart disease risk is 15% or more give The Heart Protection Study (Lancet 2002; 360: 7-21) intensive advice on weight loss, diet, physical activity and reported after national guidelines were finalised. The trial is optimise blood glucose and blood pressure control and large and of high quality and three main findings are repeat total cholesterol:HDL ratio and risk estimation after 3 incorporated into these guidelines, which therefore differ slightly from the current national recommendation. The 3. If 10 year CHD risk remains 15% or more, start treatment with simvastatin (A) or pravastatin, fluvastatin or atorvastatin 1. The recommendation to treat with a statin applies to all people at high risk, including those over 75 years of age (and not simply to people under 75 years).
See Major Thresholds for Diabetes on page 3 2. Treatment in high risk groups should be started whatever the level of serum cholesterol even if it is below 5 mmol/l.
(People with serum cholesterol < 5mmol/l were previously Before starting treatment, consider other risk factors (for 3. Simvastatin (A) or another statin with trial evidence of Optimise smoking cessation (B), blood pressure (A) and Support dietary change, with a diet high in fruit, It is not clear whether a fixed statin dose (irrespective of final vegetables and oily fish, a low saturated to serum cholesterol) - the fire and forget strategy - or titration polyunsatuated fat ratio and low in salt and alcohol (B).
of statin dose, to maintain serum cholesterol below 5mmol/l, is more cost effective. There is evidence for both.
Particular emphasis should be laid on physical activity - regular walking is effective in reducing risk. Exercise on prescription may encourage more physical activity (A).
At least one lipid sample should be fasting and include triglycerides and LDL cholesterol before starting treatment.
Examine cardiovascular system and peripheral pulses.
Check for renal disease (serum creatinine, urinary Liver function tests should be measured within 1-3 months of starting and do not need repeating unless there is a two-fold rise in ALT (alanine aminotransferase) (HPS study). If there is a persistent 4-fold rise consider referral. Rises in enzymes less than 2-fold are common and not clinically important.
Patients should be warned to report muscle pain or weakness because of the rare risk of rhabdomyolysis. This is more common at high dosage or in combination with a Evidence from the Heart Protection Study now makes simvastatin 40mg one drug of first choice. Alternatively other drugs with trials including diabetic subgroups - pravastatin, fluvastatin and atorvastatin at comparable dosage or lower doses of simvastatin might also be considered. Statins should be taken at night (except atorvastatin).
National guidelines recommend that people with coronary heart disease are offered a fibrate in addition to a statin, if triglycerides remain higher than 2.3mmol/l, despite treatment with a statin (D). This is because raised triglycerides independently increase the risk of coronary events. We await the reporting of current trials in progress to determine the role of fibrates in diabetes. The combination of fibrates with statins may cause side effects such as muscle and/or abdominal pain and has been associated with In the rare event that fasting triglycerides are extremely raised (>10mmol/l) refer to lipid clinic.
NICE (2002) recommend treatment of blood pressure if:
First line
140/80 mmHg or more AND 10 year coronary heart
Low dose thiazide diuretics, ACE inhibitors and beta- disease risk is 15% or more
blockers are all considered effective as first line therapy in people with diabetes. Combination therapy with two or more 160/100mmHg or more irrespective of 10 year coronary
heart disease risk
ACE inhibitors should be offered as first line therapy in 140/80 mmHg or more AND previous stroke, myocardial
people with increased urine albumin excretion infarct or angina
135/75 mmHg AND proteinuria >1g per 24 hours
These recommendations differ from the 1999 British
Second line
Hypertension Society recommendations. See below.
In the event that blood pressure is not controlled on a combination of first line drugs, once daily long acting calcium Treatment should be based on the average of at least three channel blockers may reduce blood pressure but there is readings within three months, and if either the mean systolic conflicting evidence of benefit in people with diabetes (B).
or the mean diastolic is above treatment thresholds, Twice daily calcium channel blockers should not be used.
Peripherally acting alpha blockers (such as doxazosin) have shown an absence of benefit and possible adverse actions when used as first line agents. They can be used as fourth line agents where the risk of continued hypertension outweighs any possible harm from doxazosin.
If on treatment, aim to maintain blood pressure below 140/80mmHg (B) The NICE (2002) recommendations differ from the 1999 British Hypertension Society (BHS) Guidelines (see page 3) which are still used by some local physcians.
People with pre-existing cardiovascular disease should take For people with renal disease, the BHS target is aspirin 75mg daily (A). For true aspirin intolerance, 125/75mmHg or less. However NICE recommend that in people with proteinuria >1g per 24 hours or renal disease this People with a 10 year coronary heart disease risk of 15% or more should take 75mg of aspirin providing their systolic People who have a blood pressure above 140/80 but below blood pressure is controlled below 145mmHg (B).
160/100mmHg who do not have renal disease, or cardiovascular disease and where 10 year CHD risk is below 15%, do not require blood pressure treatment but should be People with diabetes who additionally have raised blood *Only half of those intensively treated in the UKPDS study pressure should be supported to stop smoking and improve their diet, physical activity and reduce obesity. Salt restriction (A) and a diet high in fruit and vegetables have both been See Major Thresholds for Diabetes on page 3 shown to reduce the likelihood of stroke (B).
Blood pressure and risk factor assessment should be part of the annual assessment with more frequent review where Referral and review criteria for retinopathy Annual review (routine care)
If there is no retinopathy or there is only minimal or mild background retinopathy or low risk background Refer for or perform an appropriate and acceptable retinopathy screening test for all people with type 2 diabetes (D) (locally provided by either retinal Early review (three to six months)
photography delivery by trained opticians or as part of a If there is a new occurrence, or worsening of the lesions locally agreed and validated screening programme or by since last examination. ( A worsening of lesions since last indirect opthalmoscopy using a slit-lamp).
examination will occur to a modest degree in many Check visual acuity, corrected with glasses or pinhole patients due to time. This only needs earlier eye review if the worsening of lesions is unexpectedly marked).
Patient is at high risk of progression (where there is rapid change in blood glucose control, severe hypertension or Use methods of retinal examination that have been NICE also recommends early referral of patients with demonstrated to achieve a sensitivity of 80% or higher, a scattered exudates more than 1 disc diameter from the specificity of 95% or higher and a technical failure rate of fovea but most local clinicians feel that this is unnecessary and would involve so many patients as to Use tropicamide to achieve midriasis, unless contraindicated (glaucoma, etc) (C).
Document attendance for retinopathy screening.
Referral (within 4 weeks)
If there is unexplained drop in visual acuity.
If macular oedema is suspected.
Hard exudates within 1 disc diameter of the fovea.
There are unexplained retinal findings.
Pre-proliferative or more advanced (severe) retinopathy.
Cataracts are interfering with the patient’s vision. Retina is obscured on examination.
Urgent Referral (within one week)
If new vessels are present.
Pre-retinal and/or vitreous haemorrhage.
Rubeosis iridis is present.
Emergency (immediate)
If there is sudden loss of vision. Retinal detachment.
Foot at low current risk
Normal sensation and palpable pulses
Agree a management plan, including foot care education, with each person and maintain on annual review (B).
of annual review to detect riskfactors for ulceration (A) Foot at risk
Recall annually and review for complications and risk factors Evidence of neuropathy or absent foot pulses or other
by trained personnel (trained personnel will usually be the risk factors present
podiatrist or member of the diabetes team, but may also be Risk factors include plantar callus, poor footwear, social deprivation or isolation, cigarette smoking, old age, footdeformities, long duration diabetes and poor vision.
Test foot sensation using a 10g monofilament and Ensure that foot care education is reviewed and vibration sense using a tuning fork or biothesiometer.
Refer to Foot Health for inspection of the person’s feet 3 Inspection of foot shape, skin condition and footwear. Advise on appropriate footwear (B).
Review the need for vascular assessment and referral.
Special care arrangements may be required for older Foot at high risk
The foot at risk and a history of ulceration or peripheral
vascular disease or amputation or Charcot disease
The addition of these factors significantly increases the risk of episodes of complications beyond that of the foot at risk.
Arrange frequent review as necessary, with a maximum of 3 monthly intervals from specialist podiatry/foot care Ensure special care arrangements for those people with At each review, evaluate the provision of intensified foot Provide specialist footwear and insoles.
Skin and nail care, according to the individual’s needs.
Ulcerated Foot
Current ulceration, infection, cellulitis or discoloration
Arrange urgently foot ulcer care with a specialist podiatry /multidisciplinary foot care team. They should ensure as a Investigation and referral for treatment of vascular Local wound management, appropriate dressings and Systemic antibiotic therapy for cellulitis or bone infection Effective means of distributing foot pressures, for instance using specialised footwear or casts or bed rest.
Monitoring of blood glucose control.
Dietary fat should be limited to 35% total energy (saturated fat no more than 10%; polyunsaturated fat not exceeding 10%; monounsaturated fat making up the balance). Patients who are The principles of healthy eating should be emphasised. The diet overweight or obese should pay particular attention to reducing dietary fat by: avoiding fried foods; decreasing use of spreading fat and oil in cooking; using lower fat diary products (semi- skimmed milk, reduced fat cheese, low fat yoghurt); choosing lean meats, (including lean cuts of beef and pork, as well as High in fibre (especially soluble fibre) chicken and fish), while avoiding/limiting processed meats (sausages, burgers, salami); limiting or avoiding high fat snacks (crisps, nuts, cake, chocolate) and other high fat foods (pastry, Overweight or obese patients should be encouraged to lose weight by a combination of changes in diet and physical activity.
Referral to a dietitian should be considered as well as appropriate use of reputable local slimming groups and Exercise The Balance of Good Health leaflet is available in several languages from Health Information East London (HIEL) Patients should: use an artifical (intense) sweetener in place of sugar in drinks, foods and on cereals; choose sugar free drinks Reduce dietary salt intake (particularly if they are ( diet fizzy drinks and sugar free squashes/cordials), avoiding large volumes of pure unsweetened fruit juice; limit or avoid Avoid special diabetic food products (they confer no benefit sweets, confectionery and high sugar foods.
If they drink alcohol, take in moderation (with no need to The diet overall need not be sugar-free to achieve good blood change beer to special pils lager, since this confers no glucose control. Patients may take up to 10% total energy benefit, and may be harmful with its higher alcohol content).
(calories) as sugar by choosing foods such as cereals (All Bran, Fruit n Fibre), baked beans, plain biscuits and bakery items (Rich Tea, Garibaldi biscuits, teacakes, crumpets).
Starchy carbohydrate foods should form the base of each meal and contribute up to 50% of the total energy in the diet. Patients should be encouraged to choose carbohydrate foods which are slowly absorbed (those with a low Glycaemic Index), such as pasta, long grain rice (e.g. Basmati rice), wholegrain/granary bread, porridge oats, pulses (lentils, beans, dahl) and fruit.
Patients should be encouraged to include 5 portions per day of fruit and vegetables, since the soluble fibre in these - as well as that found in oats (porridge), rye, barley and pulses - will help to smooth out peaks in post-prandial blood glucose levels.
1. They were based on evidence based guidelines developed with clear criteria for evidence and consensus: the National Institute for Clinical Excellence guidelines on management of type 2 diabetes (www.nice.org.uk) and the Scottish SIGN guidelines (www.sign.ac.uk). These guidelines are also in line with the National Service Framework for diabetes 2. Some more recent evidence has been added where indicated.
3. They were sent to all major stakeholders in east London who were asked to comment on three drafts. Full list of The final draft was agreed by an editorial group (those marked with an asterix below) The work was coordinated by Jo Law, Sarah Mott, Dr John Robson, Dr Ricardo Cabot, Dr Jean-Michel Wendorff and typeset by Gladys Fordjour, Clinical Effectiveness Group. It is intended that this work should complement any existing protocols, guidelines and services already in use in both the primary and secondary sectors.
Any correspondence should be to Dr John Robson at Clinical Effectiveness Group, Department of General Practice and Primary Care, Barts and the London Queen Mary s School of Medicine and Dentistry, Mile End Road, London, E1 4NS or email j.robson@qmul.ac.uk Dr John Anderson, Consultant Diabetologist* Dr Peter Freedman, Consultant Diabetologist Prof Gene Feder, Professor of Primary Care Dr Tahseen Chowdhury, Consultant Physician Ms Helen Noakes, Diabetes Nurse Specialist* Ms Esther Beasley, Chair, City & Hackney PN Dr David Sloan, Director of Health Improvement Ms Theresa Berry, Director of Nursing and Quality Ms Valerie Escudier, Diabetes Nurse Specialist Ms Janet Reid, Diabetes Nurse SpecialistDr Sam Everington, Clinical Governance Lead Dr Susan Gelding, Consultant Diabetologist* Ms Sara Davenport, Director of Commissioning Dr Gopinathan, GPMr Steve Dean, Head PodiatristMs Jayne Brotherdale, Diabetic Podiatrist Ms Susan McKay, District DietitianMs Yvonne Canel, Lead Primary Care Dietitian Prof Magdi Yaqoob, Consultant Nephrologist Ms Lisa Brown, Acting Head of Primary Care Ms Anne MacDonald, Diabetes Nurse Specialist Prof Jo Martin, Clinical Director of Pathology * Ms Teresa O’Shea, Diabetes Nurse Specialist Ms Jothi Christian, Joint Chair - Newham PN Mr Jonathon O’Sullivan, Public Health Strategist Ms Lesley Pavitt, Patient Representative* Ms Alice Ford, Joint Chair - Newham PN Forum Dr Sheila Adam, Director of Public Health Dr Prasanta Bhowmik, Clinical Governance Lead Dr Jeremy Allgrove, Consultant Paediatrician Dr Barry Strickland Hodge, Prescribing Advisor*Ms Jan Tomes, Chief Pharmacist Newham H T City and Hackney
For more information about diabetes services please consult “Diabetes Service Directory 2002” available from the Hackney
Diabetes Centre 020 8510 5000, www.the-Homerton.demon.co.uk

Hackney Diabetes Centre
Diabetologist
Diabetes Nurse Specialist Team
Sarah Ambrose Willson (Diabetes Team Leader) Helen Noakes (Diabetes Nurse Facilitator) Bridgit Parkinson (Diabetes Nurse Facilitator) Dietitians
Diabetes Foot Service
Retinal screening
Profile of services - City and Hackney
Diabetes Clinics
New patient Clinic (recently diagnosed type 2 diabetes)
Assessment by diabetes nurse and dietitian
Medical assessment by physician (including eye examination), feet examined by podiatrist
2 x 2 hours group education sessions
Diabetes Clinic
Annual review, starting insulin, assessment of treatment, complications, review of medication
Problem Clinic
Specific issues: nephropathy, erectile dysfunction, neuropathies

Antenatal Clinic
For new or existing diabetes in pregnant women: urgent referral by fax/letter to ante natal dept, Homerton Hospital,
Tel 020 8510 7175, Fax 020 8510 7682

Nurse and Dietitian Reviews
One-to-one patient review by diabetes nurse specialist and or diabetes dietitian
Eye Screening Clinic
Ophthalmology done and photographs taken of the retina, assessed by optometrist and diabetologist
Standard referral form for Diabetes Eye Screening is located in “Diabetes Service Directory 2002”
Three levels of support depending on GP’s skills or request
1. GP skilled: referral for a one off opinion from Eye Screening Clinic
2. GP reasonably skilled, but wishing regular crosscheck: referral for alternate year appointment at Eye Screening Clinic

(with GP screening intervening year)
3. GP can opt for patient screened yearly at Eye Screening Clinic
Sight threatening eye disease: Fax Urgent Referral to 020 8510 5015 or page Dr Anderson/Registrar through Homerton
Switchboard or refer to Moorfields Eye Hospital

St Bartholomew’s Hospital Clinics
Young Adult Clinic (type 1 diabetes) at Diabetes Clinic
Evening clinic at St Bartholomew’s Hospital
Annual review, insulin starts, assessment and treatment of complications
Children and Adolescents
Contact Consultant Paediatrician Dr Jeremy Allgrove (Royal London Hospital on 020 7377 7000, ext 3455 or Diabetic Nurse
Specialist Clarie Wyatt (RLH), ext 3938) or Dietitian Maddy Leriti (RLH, bleep 1079). Joint Adolescent clinic held monthly
with Dr Jeremy Allgrove and Professor Hitman at Whitechapel Hospital.

Diabetes Nurse Facilitator
Supporting GP practice in diabetes care: please call 020 8510 5005 for help with:
Organising diabetes care: appointments, diabetes register, recall system, equipment
Setting up and running a diabetes clinic
Assisting with diabetes audit, annual reviews, case discussions, educational support
Supporting Practice Nurses and GPs starting patients on insulin
Promoting quality control of blood glucose meters
Participate in community events to raise awareness about diabetes
Promoting appropriate referral of patients to specialised services

Diabetes Eye Screening In C&H PCT
Eye screening should be carried out through one or more of the three follow routes:
1. Fundoscopy by GP
2. Retinal photography at Eye Screening Clinic at Hackney Diabetes Centre following above protocol
3. Secondary care ophthalmology, Moorfields Eye Hospital, Royal London Hospital

Diabetes Foot Service (based at St Leonard’s Hospital)
Daily emergency clinic (020 7301 3347); registration only between 9.00am - 9.30am
Urgent referrals sent to emergency clinic at St Leonard’s Hospital
Non-urgent referrals sent to St Leonard’s Hospital for routine appointment
Substantive foot surgery referrals sent to Trevor Prior, Homerton Hospital Outpatients
Advice on Glucose Monitoring Meters
Contact Hackney Diabetes Centre
Education
Hackney Diabetes Centre
1. For patients

Group education sessions for recently diagnosed type 2 diabetes
Group education sessions for people with type 2 diabetes starting insulin
2. For health professionals
3 x half days “Insulin Management Course”
5 x half days “Diabetes in Primary Care Course”
Other resources
Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group
Clinical priorities in diabetes care in City and Hackney PCT
Chair: Dr Clare Highton, contact through Hackney Diabetes Centre 020 8510 5000
Please see Patient Information Services and Benefits on P24 for further information about local resources.
Diabetes Centre
Diabetologist
Dr Niyi Sonibare (Community Diabetic Consultant) Diabetes Specialist Nurse (DSN)Team
(Newham General Hospital DSN Team Leader) Dietitians
Podiatrist
Retinal screening Scheme
Barry Blackman Optician
Profile of services - Newham
Diabetes Clinics
Shrewsbury Road Diabetes Centre
All routine diabetes referrals via unified Diabetes Referral Form to Shrewsbury Road Diabetes Centre

Stable, uncomplicated type 2 (according to Incentive Scheme):
Level 1/non participating - may refer all patients
- may refer all type 2 diabetics, who are insulin requiring, need to commence insulin or <40 yrs
- may refer type 2 diabetics, who need to commence insulin or <40 years old
Type 2 diabetes, uncontrolled or with complications /complex needs
All levels may:

Refer to diabetologist, Shrewsbury Road
DSN referrals
Please contact Shrewsbury Road Diabetes Centre on 0202 8586 5240 for complete referral criteria for level 1, 2 & 3 practices
Newly diagnosed type 1
Bleep Medical Registrar on call at Newham General Hospital

Diabetes in Pregnancy
Contact Newham General Hospital, Theresa Joseph 020 7476 4000 bleep 909
Dr Carol Gayle and Miss Jamna Saravanamuthu hold a weekly joint obstetric diabetes clinic at Newham General Hospital

Children and Adolescents
Children under 16yrs of age
In case of emergency, bleep Paediatric SHO at Newham General Hospital
Or refer to Consultant Paediatrician Dr Jeremy Allgrove at the Newham General Hospital on 020 7363 8462,or fax 020
7363 8081, contact Diabetic Nurse Specialist Teresa O’Shea 020 8586 5240 or Dietitian Helen Fermor 020 7363 8788
A joint adolescent diabetes clinic is held monthly with Dr Allgrove and Dr Vijayaraghavan

Diabetes Eye Screening
Eye examination at annual reviews
Routine eyes: refer to Optometrist on the retinal screening scheme for visual acuity, dilated fundoscopy and retinal
photographs
Non-routine eyes (failing vision, retinopathy, macular abnormality, loss of vision): refer to ophthalmology at Newham
General Hospital eye clinic or Moorfield’s Eye Hospital

Diabetes Foot Service
Routine foot, foot at risk and at high risk: refer to the Foot Health Service
Ulcerated foot: contact diabetes specialist podiatrist on 020 8586 6271/6270 or 07903 271263

Education
1. For patients
New diabetic patients and any patient with genuine need: refer to Shrewsbury Road for formal education. Available in
several languages. See Patient Information Services and Benefits on page 24
Group education sessions for people with type 2 diabetes starting insulin
2. For health professionals
Regular seminars and workshops for all GPs and Primary Care staff contact Naru Majevadia on 020 8586 5200
Updates for trained nurses contact Jackie O’Gara (DSN) 020 8586 5240
Updates for residential homes staff contact Rebecca Smeed (DSN) 020 8586 5240
Newham University of Warwick Diabetes Care Course for level 2 & 3 practices contact Jacqui Chapman 020 8586 5240

Community Liaison
Please contact Niru Majevadia at Shrewsbury Road Diabetes Centre for advice regarding the following:
Level 1 practices help with setting up and running a structured diabetes care clinics
Level 2 practices support and advice to progress to level 3
Training and support to become a GP with Specialist Interest in diabetes
Visits by the specialist team to GP practices or by primary care staff to the Shrewsbury Road Diabetes Centre
Access to locality clinics, GPs with Specialist Interest in diabetes and the community specialist diabetes team

Other resources
Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group
Clinical priorities in Diabetes Care in Newham Chair: Dr Niyi Sonibare, 020 8586 5255
Health Improvement (HIMP) Diabetes Working Group
Chair: Clare Davison (PCT Clinical lead for Diabetes Care), 020 8548 2200
Diabetes National Service Framework (NSF) Implementation Manager
Contact Felicia Robinson at West Beckton Health Centre, 020 7445 7046
Diabetes IT/Diamond Manager
Mahmoud Nassir-Deen, 020 8586 5244
Diabetes patients representatives
Represents patients at (LDSAG)/Diabetes National Service Framework Implementation Group, talk to patients at GP
practices, talks to community groups/press - Mr Solanki or Clare Mehamet: clarediabetes@talk21.com

Please see Patient Information Services and Benefits on P24 for further information about local resources.
Tower Hamlets
For more information about diabetes services and referral pathways please consult “Tower Hamlets Diabetes Service
Directory ” available from the Mile End Diabetes Centre 020 7377 7836, www.thpct.nhs.uk

Mile End Diabetes Centre
Diabetologist
Dr Tahseen A Chowdhury (Advice/Community liaison) Diabetes Nurse Team
Dietitian
Podiatrist
Retinal screening
Alison Powling (Retinal Screening Co-ordinator) Profile of services - Tower Hamlets
Diabetes Clinics
Mile End Diabetes Centre Clinics
Please write to the diabetes centre at the above address. For standard referral letter please see the Diabetes Service
Directory

Consultant led Diabetes Clinics
Patients with poor control on insulin
Poor diabetic control on maximum oral hypolglycaemics (HbA1c>8.0%), in patients who agree to go on to insulin and who
have other problems
Patients with proteinuria (not necessary to refer patients with microalbuminuria)
Patients with active foot ulceration
Patients with painful neuropathy
Diabetic patients who are pregnant

Diabetes Nurse Clinics
Education
Commencement of insulin therapy for patients with poor diabetic control on maximum oral hypoglycaemics
HbA1c>8.0%) who agree to go on to insulin and have no other problems
Stabilisation of insulin therapy

Diabetes Dietetic Clinic
One to one dietetic advice
Meter Sessions
Distribution of blood glucose meters to patients
Diabetes Foot Clinic
Ulceration/blister/infection
Non Urgent
Patient requires education on foot care (e.g. has neuropathy)
Nail care if has high-risk feet (neuropathy or vascular disease)

Retinal Screening Clinic
Run by Moorfields Eye Hospital
Digital fundal photography at Mile End Hospital, reading by ophthalmologists at Moorfields Hospital
If significant diabetic retinopathy is present, the patient is automatically referred to Moorfields Hospital

Diabetes Antenatal Clinic
Held in the antenatal outpatients department, Royal London Hospital, Whitechapel
Newly discovered pregnant women with diabetes should be referred urgently by letter or fax. (Miss Anita Sanghi,
Consultant Obstetrician, Department of Obstetrics, Royal London Hospital, Whitechapel, London E1 1BB,
Tel: 020 7377 7395; Fax: 020 7377 7055)

Community Diabetes Liaison
Community Diabetologist - Dr Tahseen Chowdhury
A weekly session in primary care helping GPs and nurses to provide diabetes care in the community
1. Joint (with GP or nurse) problem patient clinics
2. Problem/case discussion sessions
3. Helping to set up and run a diabetes clinic
4. Sitting in diabetes clinic to support the practice nurse and GP
5. Interactive group discussion sessions with patients invited to the practice
6. Organising Educational Sessions for Tower Hamlets GPs/nurses on diabetes

Community Diabetes Nurse
Shortly to be appointed senior DSN, facilitating diabetes care in the community
1. Helping to organise diabetes care - appointments, diabetes register, recall, equipment and assisting with diabetes audit
2. Helping to set up and run a diabetes clinic
3. Sitting in diabetes clinic to support the practice nurse and GP and case discussion with the practice team
4. Promoting quality control of blood glucose meters
5. Interactive group discussion sessions with patients invited to the practice
6. Educational sessions with the practice team and provision of educational material
7. Promoting appropriate referral of patients to specialised services
8. Support practice nurses and GPs starting patients on insulin
9. Participate in community events to raise awareness about diabetes
Contact Dr Chowdhury or Diabetes Specialist Nurse, Mile End Diabetes Centre, 020 7377 7000 ext 4384; Fax: 020 7377 7806;
E-mail: Tahseen.Chowdhury@bartsandthelondon.nhs.uk

Children and Adolescents
Contact Consultant Paediatrician Dr Jeremy Allgrove (Royal London Hospital on 020 7377 7000, ext 3455 or Diabetic Nurse
Specialist Clarie Wyatt (RLH), ext 3938 or Dietitian Maddy Leriti (RLH, bleep 1079). Joint adolescent clinic held monthly
with Dr Jeremy Allgrove and Professor Hitman at Whitechapel Hospital.

Diabetes Eye Screening in Tower Hamlets PCT
1. Screening of all diabetic patients in Tower Hamlets, who are not attending hospital diabetic or ophthalmology clinics, at
the Digital Retinal Screening Service, Mile End Diabetes Centre; referral to retinal screening co-ordinator via Retinal
Screening Referral form
2 If significant diabetic retinopathy or other problems direct referral to ophthalmologist at Moorfields Eye Hospital, Tel: 020
7253 3411; Fax 020 7566 2052 or Royal London Hospital, Ophthalmology Clinic, Tel: 020 7377 7426; Fax:020 7377 7112
Advice on Glucose Monitoring Meters
Contact Mile End Diabetes Centre
Education
Mile End Diabetes Centre
1. For patients

Group education sessions in English or Bengali
“Diabetes and Ramadan” session
Bengali diabetes leaflets and Bengali diabetes video

2. For health professionals
5 x half days “Diabetes in Primary Care Course”, Hackney Diabetes Centre, Homerton Hospital
Regular study afternoons on diabetes - commencing March 2003, Mile End Diabetes Centre
Visits to practices for advice and education input by Community DSN and Dr Chowdhury

Other resources
Local Diabetes Service Advisory Group (LDSAG)/Diabetes National Service Framework Implementation Group
Clinical priorities in Diabetes Care in Tower Hamlets PCT
Chair: Dr Isabel Hodkinson, fax: 020 8983 7131 or Isabel.Hodkinson@gp-F84696.nhs.uk
For information, contact Darren Summers, Tel: 020 7377 7929 or Darren.Summers@thpct.nhs.uk

Please see Patient Information Services and Benefits on P24 for further information about local resources.
Patient information services and benefits Diabetes UK
Diabetes UK is the leading charity working for people with diabetes.
They carry out research and help people to live with the condition by producing factually accurate information, supported by They can provide information about the following: Reducing the risk of serious health problems.
Help yourself to stay fit and healthy.
To access information and support on any aspect of managing diabetes via the Diabetes UK Careline either: Telephone 020 7472 1030 (voice) or 020 7424 1888 (text) Or you can visit their website on www.diabetes.org.uk Diabetes UK Local Groups For more information contact:
Tower Hamlets
Social and community services for patients and carers Urgent medical advice for your GP or out of hours
Tower Hamlets
Urgent medical advice out of hours Benefits
Tower Hamlets
Social services One stop shop Citizens advice Forms from social security/social services Diabetes Education Groups
Tower Hamlets
type 2 diabetes (in English, type 2 diabetes Exercise
Tower Hamlets
Dietary Services
Tower Hamlets
If you would like to see a dietitian to discuss your diet you will need a referral from either your GP, practice nurse other Eye Screening
Tower Hamlets
If you are being seen by the hospital out patient department they will carry out the eye examination Foot Health
Tower Hamlets
Tower Hamlets
If you would like information about or help with giving up smoking you can contact one of the following: the National Smoking Helpline on 0800 169 0169 or the local Smoking Clinic on 0800 169 1943 Advocacy and other Local Resources
If English is not your first language and you need help in the following languages the diabetes specialist health advocates speak Gujarati, Urdu, Hindi, Tamil and Bengali. The specialist health advocates are available only for diabetic appointments at Shrewsbury Road Centre or for a diabetes specialist nurse. Telephone: either 020 8586 5240 Shrewsbury Diabetes Centre (Other languages are available with general health advocates) If English is not your first language and you need help please telephone: 020 7337 7934 for appointments at your GP surgery 020 7337 7280 for appointments at the Homerton or St Leonard s Hospital Tower Hamlets
If English is not your first language and you need help please telephone: 020 7337 7934 for appointments at your GP surgery 020 7337 7280 for appointments at the London or Mile End Hospital This is a programme for all people with a long-term medical condition, not just diabetes. It provides a chance to help people to gain confidence, knowledge and skills so they can manage their condition better.
For information telephone Amita Shakya on 020 7377 7919.
A facilitated, self-sustaining patient group of older Bangladeshi women with diabetes, from the central Stepney area, with a Bengali facilitator. For more information contact: Anna Collard New Deal for Communities Project on the Ocean Estate This project facilitates diabetes care and raises awareness of diabetes and its complications in the Ocean Estate community.
It is run by a diabetes specialist nurse and Bengali diabetes link worker. For more information contact the Mile End Diabetes Further copies can be obtained from:
Clinical Effectiveness GroupDepartment of General Practice & Primary CareBarts and the LondonQueen Mary’s School of Medicine and DentistryMile End RoadLondon E1 4NSTel: 020 7882 7954 Contact details:
Jo Tissier - Tower Hamlets FacilitatorTel: 020 7882 7925 Jo Law - Hackney FacilitatorTel: 020 7882 7952 Anne-Marie Maher - Primary Care Audit FacilitatorTel: 020 7882 7908 Keith Prescott - IT FacilitatorTel: 020 7882 6974 John Robson - Clinical LeadTel: 020 7882 7958 Kambiz Boomla - IT LeadTel: 020 7882 7958 Sally Hull - Mental Health Clinical LeadTel: 020 7882 7961 Gladys Fordjour - SecretaryTel: 020 7882 7954

Source: http://ses.sp.bvs.br/local/Image/diabetes.pdf

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