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BARNSLEY

DIABETES CARE PATHWAY

VERSION 3 April 2014

BARNSLEY DIABETES CARE PATHWAY This Care Pathway is modified from the Enfield Diabetes Care Pathway, version 5, May 2010. The Barnsley Local Diabetes Service Advisory Group is most grateful to the clinicians responsible for the Enfield Care Pathway and, in particular, Debbie Hicks, Nurse Consultant, for permission to utilise their work. In turn, the pathway is based on: NICE CG 66 Type 2 diabetes guidelines for Diabetes 2008 and NICE CG 87 Type 2 diabetes: partial update 2009. Version 2 was launched in Barnsley in March 2013 and the Local Diabetes Service Advisory Group agreed an update (Version 3) in January 2013. Revisions will be issued every 2-3 years or as required. CONTRIBUTORS

Enfield Dr Chris Baynes Consultant Physician Barnet & Chase Farm Hospital Paul Gouldstone Head of Medicines Management NHS Enfield Debbie Hicks Nurse Consultant – Diabetes NHS Enfield Community Services Kit McAuley Diabetes Specialist Nurse NHS Enfield Community Services Dr Hilary Tindall Consultant Physician North Middlesex University Hospital Barnsley Dr Keith Sands Consultant Physician South West Yorkshire Partnership FT

DIABETES CARE PATHWAY TYPE 2 DIABETES1

* See laminated version appendix 1 & 2

MILESTONE 1

Diagnostic phase

a. Lifestyle changes*

b. Patient given information booklet

c. Patient given hand-held record

d. Referral to dietitian

e. Referral to group education sessions

f. Regular review (see Maintenance phase)

g. Assessment of emotional wellbeing

h. People with severe mental health diagnosis should be checked annually for diabetes

MILESTONE 2

Educative phase

a. Check and recheck understanding

b. Lifestyle issues incl smoking and exercise

c. Medication

d. Complications

e. Importance of regular review

f. Driving

g. Importance of good BP control

h. Importance of good BG control (HbA1c)

i. Retinal photography

j. Foot health

k. Sexual health

l. Travel

m. DUK/support groups

n. Offer structured education programme

MILESTONE 3

Treatment management phase

a. – Offer dietary advice – Trial of lifestyle Interventions including

increased activity

b. Treat all co-existent pathology eg BP, lipids

Arrange screening for complications • See Milestone 4

c. See medication algorithm

d. Continued education & support

e. 3-4 monthly HbA1c

f. Continue to follow medication algorithm

g. Once stabilised, regular review. See Maintenance phase

MILESTONE 4

Complication/risk management

a. Hypertension

b. Lipid management

c. Anti-platelet therapy for secondary prevention

d. Microalbuminuria

e. Management of CKD

f. Management of painful neuropathy

g. Retinopathy/foot care

h. Erectile dysfunction

i. Obesity

j. Peripheral arterial disease

MILESTONE 5

Maintenance phase

a. Regular review if unstable 2-3 monthly

b. 6 monthly review once stabilised

c. Annual review (see Appendix 2)

d. On-going review of educational needs

e. Review of dietary needs

f. People with existing diabetes should be monitored for depression

g. Information about monitoring and glucose meters where appropriate

MILESTONE 1: DIAGNOSIS OF DIABETES MELLITUS

PRESENTING SYMPTOMS

1. Patient presents with signs and symptoms suggestive of type 2 diabetes

Excessive thirst

Increased urination, especially at night

Lethargy

Weight loss

Blurred vision

Infections (eg pruritis, balanitis)

None of the above 2. At routine /ad hoc health review patient has glycosuria 3. Increased suspicion due to risk factors eg

Ethnicity

Family history >40 years of age

Previous gestational diabetes

Existing severe mental illness such as schizophrenia

WHO DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS

Most cases can now be diagnosed through a combination of clinical features, BG and HbA1c levels. OGTT is rarely required except during pregnancy. If

RBG 6.0–11.0 mmols/L check FBG. If RBG 11.1 mmols/L diabetes diagnosed (OGTT NOT required). If FBG < 6 mmols/L, diabetes is unlikely. Confirmation of diagnosis requires laboratory and not finger prick testing. Diagnosis should never be based on a single test result. Laboratory testing of HbA1c a useful diagnostic test in adults without conditions known to affect HbA1c measurement (ie anything that interferes with red cell or Hb turnover). Do not use in pregnancy or if type 1 diabetes is suspected. HbA1c<48mmol/mol (6.5%) is recommended as the cut-off point for diagnosing diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests, but one of greater than 48 mmol/mol (6.5%) should be regarded as indicating a high risk of diabetes. HbA1c 42-47 mmol/mol (6.0-6.4%): lifestyle advice, warn to report symptoms of diabetes, recheck in a year, HbA1c <42 mmol/mol (6.0%): may still be at high risk of diabetes. Review individual risk and manage accordingly.

NB: In the absence of osmotic symptoms 2 consecutive venous samples are required to diagnose diabetes mellitus

PLASMA DIABETES CONFIRMED IMPAIRED GLUCOSE TOLERANCE IMPAIRED FASTING GLYCAEMIA

FBG ≥7.0 <7.0 ≥6.1 <7.0

OGTT 2 hour value

≥11.1 ≥7.0

<11.1 Check HbA1c (as above)

NB: In the elderly and some ethnic minority groups fasting glucose levels may not be a reliable indicator of diabetes

MILESTONE 2: EDUCATION IN TYPE 2 DIABETES

STEP 4 Discuss

Complications

Eyes

CVD

Kidney

Erectile dysfunction

Neuropathy

PVD

Foot

STEP 1 Assess

Learning

Needs

Is English the first language?

Is the patient literate in English?

Is the patient literate in own

language?

Arrange appointments as necessary with

interpreter

Offer patient EPCT structured

diabetes education

programme

STEP 2 Review

Understanding

What is diabetes?

Importance of regular diabetes

checks

What to expect at an annual review

Barnsley support group

STEP 3 Discuss Lifestyle

Issues

Diet

Exercise

Smoking

Alcohol

Importance of medication

Social adjustments

Psychological wellbeing

Driving regulations

STEP 5 Facilitate Diabetic

Referral

Give ‘stop gap’ dietary advice

Has patient been referred to dietitian?

YES

Recheck understanding

NO

Refer to dietitian

STEP 5 Review

Understanding

Importance of regular diabetes

checks

Review concordance with

medication

Review concordance with

healthy eating regimen

Assess gaps in knowledge and

provide education as appropriate

STEP 6 Understanding

the Annual

Review

Height, weight, BMI, waist

circumference

BP

Urine/blood tests

HbA1c

U&E

TFT

LFT

Lipid profile

eGFR

ACR

Foot Assessment

Pedal pulses

Neuropathy status

Retinopathy Status

Enrolment in Retinopathy Screening Programme

MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES

Consider first: Consider second when HbA1c >48 mmols/mol (6.5%), if sulfonylurea/metformin intolerance or hypoglycaemia with sulfonylurea :

(METFORMIN +) DPP-4 INHIBITORS (DPP4I)

In combination with metformin or a sulfonylurea or a glitazones

Sitagliptin and linagliptin can be used as monotherapy

Sitagliptin and saxagliptin can be added to insulin ( metformin)

Continue only if HbA1c reduction of at least 0.5 percentage point (5 mmol/mol) at 6 months, which is maintained

Discontinue if symptoms of acute pancreatitis

Dose of concomitant sulfonylurea or insulin may need reduction

Sitagliptin Saxagliptin Linagliptin

100mg od 5mg od 5mg od

= Alternative approach

Us

= Usual approach =

Us

INDIVIDUALISE THE HBA1c TARGET BUT, IN GENERAL, UNLESS THERE IS A CONTRAINDICATION, AIM FOR 48 mmols/mol (6.5%) INITIALLY

Review at least annually and, as diabetes progresses, the HbA1c target for intervention can be increased to 59 mmols/ml (7.5%)

INITIATE HEALTHY EATING PLAN AND INCREASED ACTIVITY FOR AT LEAST 12-16 WEEKS UNLESS SYMPTOMATIC

AGREE LEVEL OF HBA1c FOR INTERVENTION

METFORMIN

METFORMIN SHOULD NOT BE STARTED IF SERUM CREATININE (sCr) >150 mcmol/L &/OR eGFR <30 ml/min

Review response to medication using the step guidelines, within 28 days in the first instance, then 3-4 monthly using HbA1c

Commence 500mg bd/tds, with further increases over a few weeks as tolerated up to a maximum dose of 1g bd/tds

If unable to tolerate metformin, or concordance issues, consider reducing dose or change to mr metformin up to 2g od

Review metformin dose if sCr >130 mcmol/L &/or eGFR < 45ml/min

SEE CKD PATHWAY FOR LONG TERM MONITORING

SULFONYLUREAS If not overweight, metformin not tolerated or a rapid response is

required because of severe hyperglycaemia Consider a rapid-acting secretagogue (ie repaglinide, nateglinide)

for people with erratic lifestyles

GLICLAZIDE GLIPIZIDE GLIMEPIRIDE

80mg od/40mg bd 5mg od 1mg od

80mg bd 5mg bd 2mg od

160mg am/80mg pm 10mg bd max 4mg od

160mg bd max 6mg od max

(METFORMIN +) THIAZOLIDINEDIONES (TZD)

Only use pioglitazone

Avoid in those with active (or a history of) bladder cancer, heart failure or a higher risk of fractures

Licensed as monotherapy if control sub-optimal and intolerant of metformin

Can be added to metformin, sulfonylurea or both. Combination with metformin preferable, particularly in the overweight

Continue only if HbA1c reduction of at least 0.5 percentage point (5 mmols/mol) at 6 months, which is maintained

Caution when used with sulfonylurea as maximum response may not be evident for 6-12 weeks

MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES *Not approved by NHS Barnsley APC at time of writing

(METFORMIN +) SGLT2 INHIBITOR

Use as for DPP-4 inhibitors above

Dual combination with metformin

Can also be used with insulin ( metformin)

Not recommended as triple therapy

Use with caution in patients on diuretics or who are volume depleted

Avoid if <18 yrs or >75 yrs or eGFR <60 ml/min (does not apply to canagliflozin – avoid if eGFR<45 ml/min)

May cause genital thrush or UTI – treat conventionally; does not usually require discontinuation of SGLT-2 inhibitor

Dapagliflozin Canagliflozin*

10mg od 100-300mg od (100 mg od if eGFR 45-60 ml/min)

MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES Consider third when HbA1c >58 mmols/mol (7.5%): Consider fourth if HbA1c remains >58 mmols/mol (7.5%)

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT

GLUCAGON-LIKE PEPTIDE-1 AGONISTS (GLP-1)

If BMI ≥35kg/m2 and other

psychological/medical problem associated with raised BMI or if BMI <35kg/m

2 and insulin unacceptable for

occupational reasons or where weight loss would benefit other co-morbidities

Continue only if HbA1c reduction of at least 1 percentage point (11 mmols/mol) and weight loss of at least 3% at 6 months

Use exenatide before liraglutide

Avoid or stop if symptoms/history of acute pancreatitis

Avoid exenatide if eGFR <30ml/min and liraglutide if eGFR <60 ml/min

Dose of concomitant sulfonylurea or insulin likely to need reduction

The 1.8mg dose of liraglutide is not recommended

Exenatide licensed for addition to basal insulin; insulin detemir licensed for addition to liraglutide

‘

APPROVED AS ‘AMBER-G’ BY APC

NPH INSULIN

Ensure injectables care pathway is completed

OTHER INSULIN

Ensure injectables care pathway is completed

Consider if assistance required from a carer/HCP to administer

If lifestyle is restricted by recurrent hypoglycaemia

If would otherwise require bd insulin and OHAs

If cannot manage injection device for NPH insulin

ALPHA GLUCOSIDASE

INHIBITOR

ACARBOSE

50mg od

Increase to 50mg tds after 6

weeks

100mg tds

200mg tds

Insulin or GLP-1 agonists should only be initiated by: A. Practices that are currently receiving enhanced diabetes payments or B. Those who have attended an appropriate training course/update within the last 2 years.

NPH INSULIN Ensure injectables

care pathway is completed

OTHER INSULIN Ensure injectables care pathway is completed 1. Long-acting insulin analogue – see above and switch if

Target HbA1c not reached due to significant hypoglycaemia

Cannot manage insulin injection device

Requires assistance from carer/HCP to administer NOT to be initiated in pregnancy 2. Pre-mix insulin

DPP4I or SGLT2I See overleaf and

If insulin is not acceptable or inappropriate

TZD See overleaf and

If insulin is not acceptable or inappropriate

Consider pioglitazone or sitagliptin/saxagliptin with insulin if:

Pioglitazone or a DPP-4 inhibitor has previously had a marked glucose-lowering effect or

Blood glucose cannot be adequately controlled without high-dose insulin

HYPERTENSION

Step 1 Offer an angiotensin-converting enzyme (ACE) inhibitor or, if ACE not tolerated or not appropriate, a low-cost angiotensin-II receptor blocker (ARB)

Do not combine an ACE with an ARB to treat hypertension ACE: Lisinopril 5mg od initially, titrating up to usual dose of 10-20mg od or ramipril 2.5-5mg od ARB: Losartan 50-100mg od (>75yrs start with 25mg) or irbesartan 150-300mg od (>75yrs start with 75mg) Calcium-channel blocker (CCB) as alternative to above or as preferred treatment for black people of Afro-Caribbean origin (± diuretic) Amlodipine (caution with statin dose) 5-10mg od or felodipine 5-10mg od

Preferred choice if possibility of pregnancy

If CCB not suitable or evidence/high risk of heart failure offer a thiazide-like diuretic Chlortalidone 12.5-25mg od or indapamide 1.5mg mr od or 2.5mg od Continue treatment in those receiving conventional thiazide (bendroflumethiazide or hydrochlorothiazide) where BP stable and well controlled

IF BP REMAINS ABOVE TARGET

1. BP targets:

If NO microvascular complications ≤140/80 mm Hg

If microvascular complications (proteinuria, retinopathy, microalbuminuria) present aim for ≤130/80

If nephropathy(eg proteinuria >1g/day) is present aim for ≤125/75

2. Non-pharmacological measures:

Encourage healthy eating, including salt reduction

Increase physical activity

Stop smoking

Encourage weight reduction, including reducing excess alcohol intake

Stress management 3. Monitor patient monthly, titrating

medication upwards to maximum dose before adding the next anti-hypertensive agent

Step 2 Add CCB or diuretic (see above)


Step 3 Add diuretic or CCB (see above)


Step 4 Add alpha blocker Doxazosin 2-16mg od Add beta-blocker Metoprolol 50-200mg od or bisoprolol 2.5-20mg od

CONSIDER SPECIALIST REFERRAL IN CASES OF RESISTANT HYPERTENSION

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED …

LIPIDS Aims: To improve the lipid profile in order to :

Reduce the risk of cardiovascular disease (CVD)

Reduce the risk of pancreatitis in those with severe hypertriglyceridaemia 1. Offer a statin to all those with type 1 or type 2 diabetes aged 40 years or above (and to those under 40 years with a risk factor for CVD*) 2. Aim for total cholesterol (TC) ≤4.0 mmol/L and LDL-cholesterol ≤2.0 mmol/L, but consider each case individually. 3. If TC ≥4.0 mmol/L and/or LDL-C ≥2.0 mmol/L

Exclude hypothyroidism, excess alcohol intake, liver disease and pancreatitis 4. Encourage weight loss, healthy eating and increased activity 5. Optimise blood glucose control 6. Stop smoking

*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

Step 1. Simvastatin 40mg nocte (a lower dose of simvastatin, or pravastatin 40mg , may be considered if there are potential drug interactions or simvastatin 40mg is contraindicated)

Step 2. Simvastatin 80mg od (more cost-effective to prescribe 2 x 40mg tabs) or atorvastatin 40mg od Step 3. Atorvastatin 80mg od Step 4. If target not achieved and in presence of existing CVD consider the addition of ezetimibe or switching to rosuvastatin 10mg od Step 5. In patients failing to achieve target, unable to tolerate statins or who have a high CVD risk and triglycerides 2.3-4.5 mmol/L despite a statin,

consider the addition of a fibrate (first choice fenofibrate) on a case by case basis and consider specialist referral Elevated triglycerides (fasting lipid profile)

Assess and manage other possible causes (poor diabetes control, hypothyroidism, renal impairment, liver damage, particularly from alcohol)

If triglycerides >4.5 mmol/L initiate fibrate (first choice fenofibrate) either before or in addition to a statin

Only consider nicotinic acid or derivatives if intolerant to statins and fenofibrate

Omega-3-fish oils – only use as part of specialist management of hypertriglyceridaemia Monitoring

Check liver enzymes before starting a statin, then measure LFTs at 3 months and 12 months, and then annually if clinically indicated

Only exclude from statin treatment those with liver enzymes ≥3x upper limit(s) of normal

Do not measure creatine kinase routinely but only in those who develop muscle symptoms (pain, tenderness or weakness)

In case of unexplained peripheral neuropathy, statin should be discontinued and specialist advice sought


ANTI-PLATELET THERAPY

Aspirin is not licensed for the primary prevention of vascular events in people with diabetes. If aspirin is used in primary prevention, the balance of benefits and risks should be considered for each individual, particularly the presence of risk factors for vascular disease and the risk of gastrointestinal bleeding

Patients on existing low-dose aspirin for primary prevention of vascular events should be reviewed and the benefits and risks of the treatment discussed with them

Aspirin, 75mg od, should be given routinely and continued long term in patients with diabetes and established coronary heart disease, transient cerebral ischaemia or stroke or peripheral vascular disease

It may also be considered in people with diabetes at very high vascular risk (eg 2 or more risk factors - hypertension, smoking, dyslipidaemia)

In addition to long-term aspirin, clopidogrel 75mg od should be continued for 3 months in people with diabetes who sustain a non-ST elevation acute coronary syndrome and for up to 4 weeks in those who sustain an ST elevation acute coronary syndrome

First line Soluble aspirin 75mg daily

Second line For patients who are unable to tolerate soluble aspirin or have a history of ulceration add in either lansoprazole 15mg od or omeprazole 20mg od and continue either soluble or enteric coated aspirin

Third line If aspirin is still poorly tolerated or contraindicated or there are compliance issues favouring monotherapy, consider clopidogrel 75mg od


OBESITY ASSESSMENT

Body mass index (BMI) should be recorded at least annually in everyone with diabetes Classification of overweight and obesity (WHO, 2000)

Classification BMI (kg/m2) Risk of comorbidities

Underweight <18.5 Lowa

Healthy weight 18.5-24.9 Average

Overweight (or pre-obese) 25-29.9 Increased

Obesity, class I 30-34.9 Moderate

Obesity, class II 35-39.9 Severe

Obesity, class III ≥40 Very severe a Other health risks may be associated with a low BMI

Waist circumference (WHO, 2000) Waist circumference and waist-to-hip ratio, in addition to BMI, may be used to refine risk of obesity-related comorbidities

At increased risk Asian Caucasian

Men Women Men Women

Waist-to-hip ratio >1.0 >0.85 >1.0 >0.85

Waist circumference ≥90cm (35in) ≥80cm (31.5in) ≥102cm (40in) ≥88cm (35in)

Weight loss targets should be based on an individual’s comorbidities and risks rather than weight alone

5-10% weight loss may be adequate to achieve cardiovascular and metabolic risk reduction at lower starting BMIs, but >15-20% may be more appropriate for those with a BMI >35 kg/m2

Willingness to change and to alter different behavioural aspects (eg dietary and/or activity) should be discussed with the patient

Dietary interventions for weight loss should be tailored to the dietary preferences of the individual and calculated to produce a 600kcal/day energy deficit


OBESITY CONTINUED … TREATMENT OF OBESITY

Aim of treatment is to:

Reduce calorie intake

Increase physical activity

Increase self-awareness about day-to-day behaviours that affect calorie intake and activity levels

Discuss 5-10% reduction in weight in the first instance. Provide stop gap information* or relevant education / support materials for healthy eating (See Appendix 1)

Considerations:

Referral to health trainer

Referral to dietetic department

Encourage exercise to reduce sedentary behaviour: The goal being 30 minutes of moderately intensive activity (eg brisk walking at least 5 times a week)

Discuss behavioural strategies to enable patient to sustain weight loss

Review:

Review should be 1-3 monthly and assessment of weight loss carried out. If patient has not reached target weight loss after 6 months, refer to Health Trainer Department using appropriate referral form.

On discharge from Health Trainer department repeat HbA1c and BMI If Hba1c is not at target and BMI still >30kg/m2 see drug therapy recommendations below

DRUG THERAPY

Drug treatment should be considered for patients who are unable to reach their weight loss target or have reached a plateau on dietary, activity and behavioural changes alone after 3 months (NICE)

Discuss potential benefits, limitations, mode of action, adverse effects with patient: Orlistat (lipase inhibitor) 120mg tds with meals

GLP-1 agonist (incretin mimetic- exenatide or liraglutide) can be considered if HbA1c > 59 mmol/L (7.5%) and BMI >35 kg/m2. Refer to Community Diabetes Specialist Nursing Team using referral form

IF BMI IS > 40 kg/m2 CONSIDER BARIATRIC SURGERY

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED … MANAGEMENT OF PERIPHERAL ARTERIAL DISEASE (PAD)

Patient presents with

Intermittent Claudication (IC): A cramp-like pain in the legs when walking or exercising (can be experienced in calf or thigh muscles and buttocks)

Known arterial disease (coronary, carotid or renal artery disease)

Absent or diminished dorsalis pedis or posterior tibial pulses

Rest pain or gangrene of leg / foot

Poorly healing / non healing wounds on leg or foot

Increased risk of arterial disease (eg smokers, dyslipidaemia, hypertension)

Ankle:Brachial Pressure Index (ABPI) to be calculated. If this facility is not available ‘in-house’ please refer to specialist podiatrist for neurovascular assessment using referral form stating level of urgency

ABPI < 0.9 **Actively treat risk factors**

BP Aim for 130/ 80

Aim for good glycaemic control (see Milestone 3:Treatment management)

Commence antiplatelet therapy

If Cholesterol > 4mmol/L commence statin (See Milestone 4: Complications / Risk management)

Smoking cessation

Weight loss

Exercise therapy “ Keep walking” If lifestyle impairment

SEVERE IMPAIRMENT MILD IMPAIRMENT

Refer to Vascular Clinic via Choose and Book

Exercise therapy

Review 3 months

Consider cilostazol 100mg bd (stop if no improvement after 3 months)

Monitoring in community neurovascular clinic

ABPI > 0.9

The ABPI may be falsely elevated due to medial artery calcification. This may elevate the ABPI to > 1.3

If IC symptoms present, patient will need to be referred to the specialist podiatry clinic at Barnsley Diabetes Centre for more detailed assessment via referral form

If drop in ABPI post exercise occurs, PAD is diagnosed and patient to be treated as if ABPI is < 0.9 See text box opposite

If ABPI shows no reduction other causes for painful symptoms may need to be considered

Referral criteria to Specialist services (6Ps) Rapid onset of symptoms: Pain, pulselessness, pallor, paraesthesia, paralysis, perishingly cold = Emergency referral

Deterioration in chronic symptoms: Ischaemic rest pain, gangrene, non-healing wound or ulceration, infection = Urgent referral

There is rapid access to advice about foot problems at Barnsley Hospital Monday to Friday 0900-1700 hrs (01226 433173). If a patient has acute foot ulceration, infection, signs of acute ischaemia or penetrative foot injury: urgent queries working hrs (01226 43433173/432379; Out of hours Fax 01226 434406, refer to A&E

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED … TREATMENT OF ERECTILE DYSFUNCTION (ED)

Identify and treat curable causes of ED where possible: Endocrine: Poor control of DM, hypogonadism, hyperprolactinaemia, hypo / hyperthyroidism, Cushing’s syndrome (will need Endocrine referral)

Vascular: Peripheral vascular disease, chronic kidney disease

Urological: Previous injury, pelvic / prostatic surgery or radiation therapy (may need Urology referral)

Neurological: Multiple sclerosis, Alzheimer’s, Parkinson’s disease, spinal cord injury (may need Neurology referral)

Medications: Beta-blockers, alpha adrenergic antagonists, diuretics, sedatives, tranquillisers, anxiolytics, antidepressants, antipsychotics, corticosteroids, digoxin, NSAIDs, H2 antagonists etc

Lifestyle / habit / addiction: Substance abuse, smoking, alcoholism, anabolic steroids, heroin, marijuana

Psychological

Lifestyle changes and risk factor modification

Send blood for hormone levels

Counselling for patients and partners

Refer for psychosexual therapy

Education for patients and partners

Describe treatments available

Assess current CV risk & medication history (eg nitrates)

PRESCRIBE PDE5 INHIBITORS TRIAL: The prescribing physician should be aware of mode of action, cautions, contraindications, side-effects as per BNF Frequency of treatment needs to be considered on a case by case basis. One treatment per week is usually appropriate (DoH)

DRUG DOSE MINIMUM INFORMATION FOR PATIENTS

SILDENAFIL Viagra

50-100 mg. Start at 50 mg and titrate according to response and side-effects

Effective 30-60 mins in presence of sexual stimulation

Effect reduced by fatty meal

Half-life 4 hours

VARDENAFIL Levitra

5-20 mg Start at 10mg and titrate according to response and side-effects

Effective 25-60 mins in presence of sexual stimulation (can be as early as 10 mins)

Effect reduced by fatty meal

Half-life 4.5 hours

TADALAFIL Cialis

5-20 mg Start at 10mg and titrate according to response and side-effects

Effective after 30 mins in presence of sexual stimulation

Effect not reduced by food and alcohol

Half-life 17.5 hours

ALTERNATIVE THERAPIES: NB: PATIENT NEEDS TO BE REFERRED TO UROLOGY CLINIC TO BE TRAINED IN USE OF THESE PRODUCTS Intracavernosal injections: Caverject, Viridal Duo

Intraurethral alprostadil: Muse

Vacuum devices

Penile implants

ASSESS THERAPEUTIC OUTCOMES

IT IS ESSENTIAL TO ADVISE PATIENTS TO TAKE ORAL

MEDICATION APPROXIMATELY 4 HOURS PRIOR TO SEXUAL ACTIVITY AS IT HAS BEEN OBSERVED THAT ONSET OF ACTION MAY BE DELAYED IN MEN WITH DIABETES

IF SILDENAFIL IS INEFFECTIVE CHANGE TO ANOTHER PDE5

IF INEFFECTIVE, REFER TO ED/UROLOGY CLINIC


RENAL COMPLICATIONS / MICROALBUMINURIA SCREENING

PLEASE NOTE THAT THESE TESTS ARE IN ADDITION TO THE eGFR

IF NEGATIVE

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 Interpretation Action

<2.5 <3.5 Normal Repeat in 1 year

2.5 3.5 Possible microalbuminuria (MA)

Repeat test at the next two clinic appointments and within 3-4 months and MA is confirmed if at least one out of two or more results is also abnormal

If positive for MA treat to target as for frank proteinuria, but aim for BP target of 130/80

IF POSITIVE

If 1st specimen is abnormal exclude UTI (collect MSU)

If 2nd specimen is abnormal quantify proteinuria by ACR

Treat to target

BP (Aim < 125/75)

Glycaemic control HbA1c 53 mmol/mol (7.0%)

Commence ACE inhibitor or ARB if intolerant to ACEI (irbesartan has licence in microalbuminuria)

Manage CV risk factors aggressively

Repeat ACR after 6 months

If specimen is abnormal, refer to specialist care according to local CKD guidelines

SEE eGFR GUIDELINES

DIPSTICK URINE FOR PROTEIN USING MULTISTIX / ALBUSTIX

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED … REFERRAL FOR CKD USING eGFR IN DIABETES MELLITUS

Chronic Kidney Disease (CKD) and the estimated Glomerular Filtration Rate (eGFR)

Chronic Kidney Disease (CKD) describes abnormal kidney function and/or structure. It is common (10% of the population), frequently unrecognised, usually asymptomatic, commonly exists with other conditions such as diabetes and cardiovascular disease (CVD), carries a higher risk of mortality and is often asymptomatic until renal function is severely impaired.

There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of cardiovascular disease and tests for detecting CKD are both simple and freely available.

Serum creatinine has traditionally been the mainstay for the initial identification of renal disease but, on its own, does not detect minor degrees of kidney impairment and is not directly related to the glomerular filtration rate (GFR), which is a much more accurate measure of renal function.

eGFR can be calculated using a mathematical formula forms using serum creatinine, age, gender and race. It can then be used to classify the severity of CKD and, hence, aid in the selection of the most appropriate management. Normal eGFR is about 100 mls/min/1.73m2 (body surface area)

CKD staging and management below only apply to stable renal function. Declining eGFR may need urgent assessment.

eGFR is only an estimate and can be significantly inaccurate, particularly in people at extremes of body mass (eg malnourished, amputees) and in pregnancy (do not use the eGFR)

Afro-Caribbean black patients have a higher eGFR for any given creatinine and a clinician should therefore apply a correction factor of 1.21

The formula (MDRD) used to predict eGFR in adults is not valid for under 18s, for which there is a separate calculator.

Stage eGFR Severity of CKD Frequency of testing Referral to renal team Type of referral

1 >90 Normal Annually Only if specifically

indicated See table 1

See below

2 60-89 Mild impairment

60-90% renal function Annually

As for stage 1 See table 1

See below

3A 45-59 Moderate impairment 45-59% renal function

3-6 monthly NO – ONLY if

deteriorating function See table 2

Routine referral See below

3B 30-44 Moderate impairment 30-44% renal function

3-6 monthly YES

See table 3 Referral or discussion

4 15-29 Severe impairment

15-30% renal function 3 monthly

YES See table 4

Urgent referral or discussion

5 <15 Established CKD 3 monthly YES

See table 4 Immediate referral or

discussion


MANAGEMENT OF CKD

YOU HAVE FOUND THAT YOUR PATIENT HAS A HIGH CREATININE (LOW eGFR)

In all cases initial assessment of high creatinine / low eGFR should include:

Is the patient well? Is there a history of significant disease?

History of significant associated disease: Referral may need to be considered if indicators present eg urinary abnormalities

Review previous results: Assess whether stable or deteriorating. If patient appears well, repeat within 2 weeks, sooner if there is any doubt. NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings

Clinical assessment: Look for signs of sepsis, heart failure, hypovolaemia, bladder enlargement

Medication review: Look for recent additions (eg ACEIs, ARBs, NSAIDS, antibiotics, diuretics, mesalazine, PPIs)

Blood tests: HbA1c, Ca2+, PO4, FBC, CRP. Hypercalcaemia may cause acute renal impairment or deterioration

Urine tests: Dipstick for blood and protein

BP/ cardiovascular assessment (including peripheral circulation) : accelerated hypertension and Grade 4 retinopathy need immediate referral to the on call medical team

Imaging: Required if function is deteriorating and of unknown origin. Urgency will be ascertained by speed of deterioration

REFER TO RELEVANT TABLE:

Stage 1 &2 Table 1

Stage 3A Table 2

Stage 3B Table 3

Stage 4 & 5 Table 4


Table 1: Management of Stage 1 and 2 CKD in diabetes mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT

Almost all patients can be managed in primary care

Patients have normal or near normal eGFR, but have other evidence of renal disease ie: o Proteinuria or haematuria o A genetic diagnosis of kidney disease (eg

known to be have a disease such as polycystic kidney disease)

o Evidence of structurally abnormal kidneys (eg reflux nephropathy, renal dysgenesis).

o Microalbuminuria in diabetes

Aim is to identify individuals at risk of progressive renal disease and reduce associated risks

In most patients risk of cardiovascular death much more likely than progression to dialysis

Referral to diabetes or renal clinic is not required unless o Heavy proteinuria (ACR >70mg/mmol or

protein creatinine ratio [PCR] > 100mg/mmol) o Haematuria of renal origin o Declining GFR

o Young age

Initial assessment to include: Blood tests: HbA1c, TFTs, Ca2+, PO4, FBC, CRP Urinalysis: Dipstick for blood and protein (if positive quantify proteinuria) BP/cardiovascular assessment (including peripheral circulation) : Ensure BP within target range (<130/80 mm/ Hg)

On-going management:

Blood tests annually for: o HbA1c o Creatinine o Potassium

o Cholesterol.

Urinalysis: Annually for blood and protein

Meticulous control of BP (<130/ 80 mm Hg)

Smoking, exercise and lifestyle advice (see Diabetes Care Pathway Appendix 1)

Consider aspirin (see anti platelet therapy Milestone 4: Diabetes Care Pathway)

Cholesterol lowering therapy (Milestone 4: Diabetes Care Pathway)

Haematuria a) Visible (macroscopic)

Usually fast track Urology referral for imaging and cystoscopy, unless strong pointers to acute renal disease

Refer to Renal Clinic if urological investigations negative b) Invisible (microscopic) without proteinuria and eGFR >60 ml/min

Age >40, usually refer to Urology

Age <40, or >40 with negative urological investigations, manage as Stage 1/2 CKD

c) Microscopic haematuria with PCR >50mg/mmol

Refer to Renal Clinic, otherwise manage as Stage 1/2 CKD

http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/Stage1-2CKD.aspx




Table 2: Management of Stage 3A CKD in diabetes mellitus


Almost all patients can be managed in primary care

Patients have stable renal function (eGFR and/or creatinine)

As for Stage 1 and 2 (see above), including referral criteria plus referral if eGFR<40ml/min

Initial assessment to include:

Review of previous results: Assess whether stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2 days. NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings

An assessment of the following: o Is the patient well? Is there a history of significant associated disease which involves kidneys (eg urinary abnormalities)? o Clinical assessment for heart failure, sepsis, hypovolaemia, examination for bladder enlargement (may need imaging if obstruction suspected) and rectal

examination for prostate enlargement o Medication review. Look for recent additions (eg ACE inhibitors, ARBs, NSAIDS, mesalazine, antibiotics, diuretics) o Blood tests: HbA1c, haemoglobin, bone profile, lipids, PTH o Urinalysis: Dipstick urine for blood and protein (and quantification, if required, by ACR/PCR) o Cardiovascular assessment: BP and peripheral vascular system

o Imaging: If obstruction a possibility

On-going management: If creatinine is >150 mcmol/L or eGFR <30 ml/min (if discrepancy between two, use eGFR) stop metformin. Refer to community DSNs via diabetes referral form if necessary

Blood tests initially to be done 3 monthly then 6-12 monthly when stable for: o HbA1c, creatinine and potassium (consider unexplained fall in eGFR of >25% to be acute renal failure. Seek specialist advice for a loss of GFR over 1y of

5ml/min or a loss of GFR in 5y of 10ml/min) o Haemoglobin (if low consider non-renal cause. ‘Renal’ anaemia rarely significant before stage 3B or 4)

o Bone profile, PTH, lipids

Urine tests: o Protein estimation if proteinuria o If MICROSCOPIC haematuria – Urology referral if > 40 years old, if < 40 years old Renal Clinic referral. All MACROSCOPIC haematuria needs urology

referral

Blood pressure. Meticulous control <125/ 75 mm Hg (see Milestone 4: Diabetes Care Pathway)


Consider aspirin (see anti-platelet therapy Milestone 4: Diabetes Care Pathway)

Cholesterol lowering therapy (Milestone 4: Diabetes Care Pathway)

Immunisation for influenza and pneumococcus

Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Exercise caution with bisphosphonates.

MILESTONE 4: COMPLICATIONS/RISK MANAGEMENT CONTINUED … Table 2: Management of Stage 3B, 4 & 5 CKD in diabetes mellitus


Patent will be cared for on a shared care basis

Refer to Renal Clinic

If severe renal impairment is part of another terminal illness

Those patients for whom further investigation and management is clearly inappropriate

There is a clear and understood pathway of care already in place

Management is similar to Stage 3A, but referral to Renal Clinic will usually be required

Pre-referral considerations:

Clinical Assessment and Medication Review as per stage 3A CKD

Assess whether values are stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2 days.

Is the patient well? Is there significant associated disease? If yes, consider urgent referral

Blood tests: HbA1c, bone profile, PTH, lipids, haemoglobin

Urinalysis: Dipstick urine for blood and protein (and quantify)

BP/cardiovascular assessment

Consider imaging to exclude obstruction

Dietary assessment

On-going management: Metformin should be stopped in all patients with an eGFR 30 ml/min

Blood tests 3 monthly for: o HbA1c, creatinine, potassium and bicarbonate o Haemoglobin (if low consider non-renal cause), ferritin, B12 and folate

o Bone profile (oral phosphate binders will often be required), PTH, lipids Urine tests:

o Protein estimation if proteinuria o Haematuria – as Stage 3A

Correction of acidosis. Oral bicarbonate after discussion with diabetes/renal team

Blood pressure. Meticulous control <125/75 mm Hg (see Milestone 4: Diabetes Care Pathway)


Consider aspirin (see anti-platelet therapy Milestone 4: Diabetes Care Pathway)

Cholesterol lowering therapy (Milestone 4 Diabetes Care Pathway)

Immunisation for influenza and pneumococcus. In Stage 4 & 5 CKD Hepatitis B is added if renal replacement therapy is being considered

Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Exercise caution with bisphosphonates (specialist advice should generally be sought before use of agents reducing bone turnover in patients with potential renal osteodystrophy).

Section derived from NICE (CG73, 2008), SIGN (103, 2008) and Renal Association guidelines (revised 2009).


Painful Neuropathy

DIAGNOSIS

HISTORY o Consider differential diagnosis (eg alcohol excess, B12 deficiency, malignancy, nerve compression) o Sometimes acute, sometimes insidious onset and progression o Paraesthesia in toes, feet and shins o Anaesthesia/hyperaesthesia

o Symptoms often worse at night or at rest PAIN

o A wide variety of descriptions of peripheral symptoms can be present. o Careful patient questioning is necessary as symptoms can be confusing o Consider use of Pain Pictures or S-LANNS assessment questionnaire

Neurological symptoms may include: o Numbness o Tingling o Prickling o ‘Pins and needles’ o Aching o Dull pain o Burning o Buzzing o Cold o Sharp o Knife-like

o ‘Electric shocks’ – or may be very unpleasant but difficult to describe

The severity of individual patient symptoms will influence which step of the care pathway is appropriate for commencement of treatment

SIGNS

WEAKNESS (motor loss) o Distal and/or proximal o Loss of reflexes

NEUROLOGICAL EXAMINATION (sensory loss) o 10g monofilament o Vibration perception (tuning fork 128 Hz), calibrated tuning fork, Bio/neurothesiometer) o Proprioception o Light touch (‘glove and stocking’ sensory loss very common)

http://www.nice.org.uk/Guidance/CG73

http://www.sign.ac.uk/guidelines/fulltext/103/index.html

http://www.renal.org/PageArchive/CKD.aspx


Management of Painful Neuropathy

NICE Guidance (CG 96, 2010)

STEP 2

Review symptoms, pain and glycaemic control

If pain still present, reassure. Check concordance with drug(s) previously prescribed in Step 1

If pain is still present, add in: o Gabapentin 300mg bd initially (600mg tds often required before any benefit achieved)

Review in 1 month

STEP 3


If pain still present or there is no symptomatic relief, refer for specialist advice

Monitor therapy and increase up to maximum tolerated and/or licensed dose

Consider prescribing, in place of previous therapy: o Duloxetine 60mg daily in place of amitriptyline or pregabalin 75-300mg bd in place of gabapentin o Consider the addition of tramadol 50-150mg tds

STEP 4


If pain still present or there is no symptomatic relief, refer to diabetic or specialist pain clinic

STEP 1

Improve glycaemic control. Liaise with diabetes nursing team/dietician if appropriate. Aim for normoglycaemia.

Trial of tricyclic antidepressants (eg amitriptyline), with dose titration from 10mg nocte to a maximal tolerable dose (contraindicated in patients with prostatism, glaucoma, dysrhythmias or serious heart disease). NOTE: Tricyclics and anticonvulsants usually need to be initiated at a low dose and gradually increased to the maximally effective/tolerated dose in order to minimise side-effects. Patients should be warned that relief of pain may not begin to occur until a therapeutic threshold is reached

Duloxetine 60mg daily (not recommended in under 18’s) is a second line alternative to amitriptyline

If patient is experiencing night time cramps only consider prescribing: o Quinine sulphate 200-300 mg nocte (inform patient that improvement may take up to a month to occur) o May benefit from low calorie Indian tonic water (not available on FP10)

Reassure (use of pain diary may be useful)

Review in 1 month If patient is reluctant to take oral medication consider capsaicin cream 45g, noting that initially there may be an intense burning sensation


FOOT CARE 1. Ensure that feet are assessed including foot pulses, vibration, sensation by a competent practitioner annually (See also Milestone 4: Peripheral Arterial

Disease – [PAD]) 2. Record results 3. Ensure that principles of good foot care are reiterated at each review 4. Refer for podiatry treatment as appropriate 5. Refer URGENTLY TO ACUTE ASSESSMENT CLINIC if any of the following problems occur:

Acute foot injury (including any penetrating foot injury)

Foot ulceration

Signs of infection

Evidence of ischaemia or gangrene

Acute Charcot foot Complete an Acute Assessment Referral and fax to the Diabetes Centre on 01226 434406 (queries 433173 or 432379). Out of hours: Refer urgently to the Accident & Emergency Department, Barnsley Hospital. 6. Refer to Painful Neuropathy Care Pathway if symptoms of painful neuropathy are present

RETINOPATHY 1. Ensure that patient understands the importance of annual retinopathy screening 2. Ensure that patient is enrolled on the Barnsley Retinopathy Screening Programme for digital photography. The Barnsley Retinopathy Screening

Department is based in the Diabetes Centre at Barnsley Hospital. It is open between 08:00 and 17.00, Monday to Friday, and weekend and evening clinics are also available. In addition, sessions take place at locations throughout the community and, wherever possible, screening will be arranged as close as possible to a patient’s home. Please contact the Diabetic Eye Screening Service on 01226 434577/434576

3. At annual review, check that a result is present in the patient records dated within the last 12 months 4. Results of retinal screening should be discussed with patient 5. If retinopathy is present ensure appropriate referral is made according to NICE guidelines

MILESTONE 5: MAINTENANCE

1. Regular review if unstable 2- 3 monthly

BP

Lipids

Glycaemic control (there is no benefit to repeating HbA1c reading more frequently than 3 monthly)

Diet

Lifestyle

2. 6 monthly review

As above

3. Annual review

Weight/BMI

BP

Review of medication

Review of diet

Review of glycaemic control

Review of investigations o HbA1c o Lipids o U&E including eGFR o TFT o LFT if taking glitazone or statin o Albumin/creatinine ratio (ACR)

Foot examination o Shoes, socks, stockings MUST be removed o Observation of colour, warmth, sensation, symptoms, general appearance of nails, skin, callus etc o Pedal pulses: dorsalis pedis and posterior tibial o 10gm monofilament on BOTH feet

Lifestyle issues o Driving o Activity levels o Smoking o Alcohol o Sexual activity o Stress (assess for depression)

APPENDIX 1: LIFESTYLE CHANGES

HEALTHY EATING (STOP GAP INFORMATION)

ADVICE TO BE GIVEN EXAMPLES

Regular meals that include carbohydrates This will help to control blood glucose levels*

High fibre low salt and low fat breakfast cereals

Wholemeal/whole grain breads, including pitta, crackers, crisp breads

Pasta and noodles

Potatoes

Rice

Foods that are high in fibre* Beans

Lentils

Bran

Wholemeal and wholegrain breads and cereals

Fruit and vegetables

Cut down/eat less saturated fat* Less animal fats and fatty foods

Choose olive oil, rapeseed oil or other vegetable oils

Grill, steam ,bake food

Use less butter, margarine, cheese and fatty meats

Use low fat dairy foods like skimmed or semi skimmed milk, low fat yoghurt

Reducing salt* Less processed food

Leave out salt in cooking

Buy reduced salt versions of food

Use herbs and spices instead of salt

Five a day* Try to eat five portions of fruit or vegetables a day, but limit fruit intake to no more than 3-4 portions a day

A portion is a handful of fruit or vegetables

Cut down on sugar and sugary foods* This does NOT mean a sugar-free diet

Sugar can be used as an ingredient in foods in small quantities

Use sugar-free, diet or low-sugar squashes and fizzy drinks

APPENDIX 1: LIFESTYLE CHANGES CONTINUED …

INCREASING ACTIVITY


Increase exercise levels gradually until exercising for at least 30 minutes a day 5 x per week*

Walking daily

Increase distance and speed

Once exercising regularly, try cycling, swimming etc.

Housework/gardening if mobility is limited

If immobile teach armchair exercises

STOPPING SMOKING


Assess smoking status

Advise to stop*

ASK and record information about smoking

Give information about smoking cessation service

ADVISE patient to stop smoking

ACT on patient’s response, including referral to Barnsley NHS Stop Smoking Service on 01226 737077 or EMAIL www.quitsmoking.uk.com

ALCOHOL ADVICE


There is no harm in drinking in moderation* 1 unit of alcohol = half a pint of beer or lager, 1 small glass of wine or 1 single measure

Men should drink no more than 3 units a day

Women should drink no more than 2 units a day

*Diabetes UK Patient information www.diabetes.org.uk

APPENDIX 2: PATIENT EDUCATION After diagnosis it is essential that education is given at a level appropriate to individual needs

Introduction Date Signature Comment

What is diabetes?

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

Name of meter

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

Referrals

Structured education

APPENDIX 2: PATIENT EDUCATION CONTINUED …

Retinal screening

Information on Change for Life

Exercise

Hypoglycaemia if treated with sulfonylurea

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

APPENDIX 3: BLOOD GLUCOSE MONITORING IN PRIMARY CARE

FREQUENCY OF TESTING

APPENDIX 3: BLOOD GLUCOSE MONITORING IN PRIMARY CARE CONTINUED …

In the interests of safety and value for money, it is the intention of Barnsley LDSAG to promote some standardisation of blood glucose meters available for patient use. The range is likely to include 2-3 blood glucose meters, at least one of which is also capable of measuring blood ketones. All patients monitoring blood glucose levels should be advised to check the accuracy (quality assurance) of the blood glucose meter on a monthly basis. Control solutions used to carry out this procedure are, in most cases, available free of charge from the manufacturer.

Type 1 diabetes

Blood glucose testing is essential for ALL people with type 1 diabetes

If taking basal bolus regimen this could be up to 6 times a day

Frequency may be increased during intercurrent illness

Ketone testing equipment should be available for times of acute illness

Drivers should maintain a record (as per DVLA recommendations) and test prior to all journeys

Pre-pregnancy and pregnancy – may be necessary to test up to 6 times daily

Type 2 diabetes

If on diet and exercise

Daily monitoring of blood glucose levels unnecessary. Ensure 3 monthly HbA1c

If people wish to test, 1-2 times a week before breakfast is sufficient, aiming for a

blood glucose level of 7.0 mmol/L (plus 3 monthly HbA1c)

If on diet, exercise and metformin ( glitazones and/or GLP-1 agonist)

As above If on sulfonylurea/insulin secretagogue

Increased risk of hypoglycaemia. Testing may be necessary to confirm or avoid

Type 2 on conventional insulin therapy

If stable, 2-3 times a week at different times If unstable, once daily testing at different times of the day until stability achieved

See Type 1 diabetes for DVLA recommendations

Type 2 on intensive insulin therapy

May be necessary up to 6 times daily

See Type 1 for DVLA recommendations

Pre-pregnancy and pregnancy

May be necessary up to 6 times daily PTO…

Approximate usage

Six tests per day = 48 boxes (50 strips each) per year = 4 boxes per month

One test per day = 8 boxes per year

Three tests per week = 4 boxes per year

(This includes extra strips for testing when ill as well as accidental wastage)

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

Reviewed and updated April 2014

When considering suitability for blood glucose monitoring the following points should be considered:

Visual acuity

Manual dexterity

Ability to use a blood glucose meter

Willingness of patient to perform tests

When initiating blood glucose monitoring the following process should take place:

Offer choice from standardised range of meters ONLY according to patient needs

Demonstrate chosen meter and finger pricking device, identifying procedure for patient to follow

Give information on the safe disposal of sharps

Issue blood glucose monitoring diary indicating agreed individual target range and frequency of testing (See previous page)

Give information to patient regarding what to do with self-testing results

Ensure patient has a contact number for access to HCP advice

Arrange to review self-testing results at a suitable interval

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