Produced in conjunction with Calderdale and Huddersfield Foundation Healthcare Trust Calderdale Primary Care Trust Kirklees Primary Care Trust

Calderdale and Kirklees Diabetes Guidelines

Trustwide Guidelines for Calderdale Royal Hospital Huddersfield Royal Infirmary

Calderdale Primary Care Trust and Kirklees Primary Care Trust

For the management of diabetes in both Primary and Secondary care

These guidelines are based on the International Diabetes Federation Guidelines, NICE recommendations and the NSF

Prepared by Trudi Akroyd September 2007 Approved by Medicines Management Board Date Review date Date

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CONTENTS PAGE Core Guidelines for Diabetes Care 5

Early Identification of People with Type 2 Diabetes 7

Diagnosis of Diabetes 8

Management Guidelines for Impaired Glucose Tolerance and Fasting Glucose 11

Education of People with Diabetes 12

Dietary Management of Diabetes 14

Physical Activity in the Management of Diabetes 16

Diabetes and Smoking 20

Management of Cardiovascular Risk 22

Type 2 Diabetes – Key Messages 23

Management of Blood Glucose in Type 2 Diabetes 24

Insulin 27

Management of Hypertension 30

Management of Lipids 32

Management of Obesity 37

Retinal Screening Programme 39

Integrated Care Pathway for Footcare in Diabetes 41

Care Pathway for the Management of Renal Disease in People with Diabetes 56

Diabetes Surgical Guidelines 60

Intrapartum – Management of Diabetic Pregnancy 62

Management of Diabetes in Children 78

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Appendix I Classification and Terminology 83 Appendix II Guidelines for Screening and Diagnosis of Gestational Diabetes 84 Appendix III Recommended Testing for Individuals with Diabetes 85 Appendix IV Glucose Point of Care Testing 87 Appendix V Suggestions regarding Further Information for Individuals with Diabetes 98 Appendix VI Checklist for Diabetes Education 103 Appendix VII Footcare Advice Leaflets 108 Appendix VIII Blood Glucose Testing 115 Glossary of Terms 116 Acknowledgements 117 References 118

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The guidelines have been developed by the multidisciplinary diabetes team from primary and secondary care who are involved in the provision of diabetes care in Calderdale and Kirklees. There have been many changes recently affecting the clinical management of Type 2 Diabetes, including the publication of the National Service Framework (NSF) Delivery Strategy and NICE Guidelines and these guidelines incorporate these. We hope that the revised guidelines will continue to deliver the essential foundation of good quality diabetes care. These guidelines will be reviewed in line with Trust policy.

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CORE GUIDELINES FOR DIABETES CARE A firm foundation for good quality diabetes care would incorporate a commitment to the following: 1. REGISTER To have and keep up to date a register for all people with diabetes 2. CALL AND RECALL To ensure that systematic call and recall of patients is taking place, for regular

surveillance for ongoing care and detection of complications. It is our aim that in future this will be done through electronic call and recall.

3. PERSON CENTRED / EMPOWERMENT

To empower the individual to adopt a healthy lifestyle and to manage their own diabetes, through education and support which recognises the importance of lifestyle, culture and religion, and which, where necessary, tackles the adverse impact of material disadvantage and social exclusion

4. STRUCTURED EDUCATION FOR NEWLY DIAGNOSED PATIENTS To ensure that all newly diagnosed patients (Type 2) receive appropriate

structured education and where appropriate attend the DESMOND (Diabetes Education and Self-management for Ongoing and Newly Diagnosed) education programme. Modules for ongoing care and for Black Minority and Ethnic (BME) groups are in development

To ensure that people who decline to attend the DESMOND education are

provided with structured education on an individual basis 5. CONTINUING EDUCATION FOR PATIENTS To ensure that all patients receive appropriate structured continuing education

following locally agreed guidelines 6. CLINICAL HISTORY AND TESTS To ensure that on initial diagnosis and at least annually, a full review should be

performed including the following:

Measure: * weight and body mass index * blood pressure * Blood cholesterol HDL and LDL * microalbuminuria * glycosylated haemoglobin (HbA1C) * creatinine/eGFR

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Advise: * to stop smoking * to moderate alcohol consumption

* to take as much physical activity as possible – Consider referral to PALS (Kirklees)/Upbeat (Calderdale)

* regarding eye care in accordance with the retinal screening programme

* regarding foot care in accordance with Diabetes foot care integrated care pathway

Review patient's monitoring 7. REFERRAL POLICIES To refer patients promptly and appropriately to the relevant agencies using,

where issued, the appropriate referral guidelines. 8. RECORD KEEPING To maintain adequate records of performance and outcomes of the above

procedures. 9. AUDIT To audit the care of patients with diabetes against the above criteria and to audit

the integrated care pathways as appropriate 1st Retinal Screen are contracted with the PCT to deliver diabetic retinal screening. Please refer to the e-Referral Section of the ‘1st Retinal Screen Manual’ which describes how to enter a new patient. Please select ‘Screen asap’ in Section 5 Invitation Selection and for any queries, please ring the Helpdesk on 01270 527373.

EARLY IDENTIFICATION OF PEOPLE WITH TYPE 2 DIABETES

Diabetes is becoming more common

• The prevalence of those over 30 years old is 10% and rises with age, • The prevalence will be doubled by 2025 • There is generally a long asymptomatic stage of up to 10 years

Risk Factors • Suggestive symptoms

o Polyuria, nocturia, excess thirst o Fatigue o Weight loss

o Neuropathic symptoms o Recurrent infections especially thrush o Changes in visual acuity

• Macrovascular disease (Ischaemic Heart Disease, Peripheral Vascular Disease, TIA/Stroke) • All women with a history of a large baby (>4kg) • History of diabetes in pregnancy • Overweight and sedentary lifestyle • South Asian or Afro-Caribbean

The risk of diabetes is increased X 5 (if not already present) in The Metabolic Syndrome

Of which the 2005 International Diabetes Federation definition is:

Central Obesity Plus any two of

Waist circumference 1. Triglyceride>1.70mmol/L* Female >80cm (31.5 ins) 2. HDL-cholesterol <0.9mmol/L (M)*

<1.1mmol/L (F)* Europid Male >94cm (37 ins) 3. BP >130 systolic or >85 Diastolic* South Asian Male >90cm (35.5 ins) 4. Impaired fasting glycaemia or type 2 diabetes

* or on treatment for these

When to Screen

Targeted Opportunistic Screening • Routine health checks • Coronary heart disease clinics • Well women clinics • Health related events in the community

Annual Screening • Previous gestational diabetes • Impaired fasting glycaemia • Impaired glucose tolerance

Consider regular Screening (every 1 - 3 years) • Central Obesity* (ensuring waist measurements) • Macrovascular disease • Hypertension* • Hypertriglyceridaemia* *features of • Diabetes in a first degree relative metabolic • Long term steroid use syndrome • South Asian >30 years old

If fasting plasma glucose is >7mmol/l refer to the Newly Diagnosed Diabetes Integrated Care Pathway

How to Test For initial routine screening of the asymptomatic young (<65 years)

• Test post-prandial urine for glucose For all others and if glycosuria

• Check fasting plasma glucose (but fasting normal glycaemia does not exclude diabetes)

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Newly Diagnosed DiabetesNewly Diagnosed DiabetesIntegrated Care PathwayIntegrated Care Pathway

SelfNHS Direct/W alk in Centre

Community Pharm acistsOptic ians

Opportunistic ScreeningHospital Outpatients/Inpatients

PresentationSym ptom s, e.g. thirst, polyuria, weight loss, fatigue, visual disturbances

Diagnostic TestsPlasm a Glucose (Laboratory Test)

(mmol/l)Random >11.1Fasting >7.0If asymptomatic, confirm diagnosis with repeat test on another dayTest urine for ketones

Diagnostic Guidelines

• Enter details onto practice register• Refer to DESMOND education programm e for Type 2 diabetes (newly diagnosed m odule)• Refer to retinal screening programm e

Implem entation of self-managem ent planReview according to individual needsConsider earlier intervention w ith tablet medication if symptom atic & Type 2 Diabetes

To Care Pathway for Continuing Diabetes Care

(In developm ent)

•Discuss diagnosis and imm ediatepatient concerns

•Establish patients knowledge ofillness and education needs

•Give initial dietary lifestyle advice, including physical activity • Smoking cessation referral and

advice if required

Education

Negotiate and outline a self-managem ent plan to include:-•Individual targets•Support and M onitoring•Nam ed contact•Recall advice

Management

Type 2 Diabetes

Diagnosis

Following Diagnostic Guidelines

Type 1 Diabetes

Assessm ent of the person with newly diagnosed diabetes by a m em ber of the Prim ary Care Team•Physical examination to include

BMI waist m easurem ent and BP• Urine for microalbuminuria• Take blood sam ple for glucose,

HbA1c, U&E, LFT’s, TFT’s Lipids• Exam ine feet

Clinical Examination

• Symptom atic and acutely ill• Ketonuria

Refer by:Telephone call followed by a fax to the appropriate Diabetes Centre

Referral

Same Day Admission

• Dehydrationrequir ing IVfluids

• Requiringintensivemonitoring –ketotic

• Seriousintercurrent

problem

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Diagnosing Diabetes Diabetes is diagnosed on the basis of the following WHO criteria; Symptoms of hyperglycaemia (polyuria

polydipsia, unexplained weight loss. visual blurring, genital thrush, lethargy) plus raised venous plasma glucose level detected once fasting: 7.0mmol/L or higher or random 11.1 mmol/L or higher

OR In the absence of symptoms 2 abnormal

results are required for the diagnosis. A random glucose of 7 – 11 should be followed by a fasting blood glucose. If the result of the second test is not diagnostic, an oral glucose tolerance test (OGTT) should be performed

Impaired fasting glucose (FG >6.1mmol/l - 6.9mmol/l) should be followed by an OGTT to exclude a diagnosis of diabetes.

Impaired glucose tolerance (2 hour OGTT value of 7.8mmol/l – 11.1mmol/l) should be followed by lifestyle advice, education and repeat fasting blood tests in one year.

Initial Education and Management NICE guidelines (2003) recommend that

structured patient education is made available to all patients with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need.

Initial education should include: lifestyle advice including healthy eating, physical activity, smoking cessation and alcohol.

Refer newly diagnosed to DESMOND programme if appropriate

Appropriate leaflets should be given to support the initial advice given eg. First steps and a healthy eating leaflet

An explanation of targets, stressing that a multifactorial approach (eg. looking at BP and cholesterol alongside blood glucose control) is required when negotiating a self-management plan with the patient.

Test urine for microalbuminuria in Type 2 diabetes

Ensure that the person with newly diagnosed diabetes is referred to the retinal screening programme.

Review dates should be agreed according to each patients individual needs.

Link to the single assessment process where appropriate when managing complex long termconditions.

Refer to specialist dietitian if appropriate (see criteria in dietetic pathway) Ensure that a foot assessment takes place and appropriate education is given according to risk classification (see diabetic foot care ICP)

Referral Guidelines Admission

Admit to hospital if the person is at risk of a hyperglycaemic emergency (vomiting, abdominal pain reduced conscious level, heavy ketonuria, dehydration requiring IV fluids, hypotension, serious intercurrent problem)

Same day referral Refer to be seen on the same day if the patient is acutely ill, consider Type 1 Diabetes if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, polyuria)

Early Referral Diabetes and pregnancy requires referral to the hospital diabetes team please see pregnancy guidelines

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Diagnosing Diabetes Diabetes is diagnosed on the basis of the following WHO criteria; Symptoms of hyperglycaemia (polyuria polydipsia, unexplained weight loss.

visual blurring, genital thrush, lethargy) plus raised venous plasma glucose level detected once fasting: 7.0mmol/L or higher or random 11.1 mmol/L or higher

OR

In the absence of symptoms 2 abnormal results are required for the diagnosis. A

random glucose of 7 – 11 should be followed by a fasting blood glucose. If the result of the second test is not diagnostic, an oral glucose tolerance test (OGTT) should be performed

Impaired fasting glycaemia (FG >6.1mmol/l - 6.9mmol/l) should be followed by an OGTT to exclude a diagnosis of diabetes.

Impaired glucose tolerance (2 hour OGTT value of 7.8mmol/l – 11.1mmol/l) should be followed by lifestyle advice, education and repeat fasting blood tests in one year.

A diagnosis of diabetes has important legal and medical implications for the patient and it is therefore essential to be secure in the diagnosis. A diagnosis should never be made on the basis of glycosuria or a stick reading of a finger prick blood glucose alone, although such tests may be useful for screening purposes. HbA1c measurement is also not currently recommended for the diagnosis of diabetes.

MANAGEMENT GUIDELINES FOR IMPAIRED GLUCOSE TOLERANCE

AND IMPAIRED FASTING GLUCOSE Previous gestational diabetes

treated with insulin Confirmed diagnosis of impaired glucose tolerance or impaired fasting glucose – refer to newly diagnosed diabetes ICP

OR

1. Advice regarding lifestyle modification

• Physical Activity • Healthy eating • No smoking

2. Cardiovascular risk factor

assessment

Annual fasting blood glucose

Diabetes Mellitus

Above or equal to 7.0 mmol/l x 2

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EDUCATION OF PEOPLE WITH DIABETES The Diabetes National Service Framework (DH 2001) highlights structured education programmes as a key part of systematic care. It is recommended that structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal regular assessment of need. The aim of education for people with diabetes is to improve their knowledge and skills, enabling them to take control of their own condition and to integrate self management in their daily lives. The ultimate goal of education is improvement in the following areas: • Control of vascular risk factors, including blood glucose, blood lipids and blood

pressure • Management of diabetes associated complications, if and when they develop • Quality of life Education should be provided by an appropriately trained multidisciplinary team to groups of people with diabetes, unless group work is considered unsuitable for an individual. All people who are newly diagnosed with diabetes should be referred into the DESMOND programme if they are willing to participate in group education. THE DESMOND PROGRAMME DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) is a structured education programme for people with Type 2 diabetes. DESMOND provides 6 hours of structured group education over two half days no more than two weeks apart. Groups consist of 6 – 10 people newly diagnosed with Type 2 diabetes. The programme covers areas such as the patients’ story, main ways to manage diabetes, the risks and complications of diabetes, food choices and action planning. The philosophy underpinning DESMOND is essentially patient centred. Its aim is to support individuals to achieve their own goals for managing their diabetes. It is not about motivating people to do what health care professionals think they should do. Recognition that the person with diabetes is the expert in their own condition is therefore the driver for the programme and influences the style of how it is delivered. The style of delivery is crucial to enable all information to be made personally relevant and to promote individual problem solving and action planning which is then dovetailed with clinical management.

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The DESMOND programme should be ideally offered to people within two to three months of diagnosis. The overall aim is to ensure that people with diabetes are empowered to enhance their personal control over the day-to-day management of their diabetes in a way that enables them to experience the best quality of life. CARBOHYDRATE COUNTING PATIENT EDUCATION Education is provided for people with type 1 diabetes and people with type 2 diabetes who are using the basal bolus regime and wish to control their blood glucose by carbohydrate counting on a one to one basis by a dietitian from Calderdale Royal Hospital or Huddersfield Royal Infirmary. The education session helps the patient to understand how to adjust their own doses of insulin according to the amount of carbohydrate they are eating at each meal and also in relation to the amount and intensity of physical activity they are undertaking.

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DIET AND LIFESTYLE IN THE MANAGEMENT OF DIABETES All people with newly diagnosed diabetes should have access to a Registered Dietitian (RD) either via the DESMOND programme (type 2) or an individual consultation. In addition they should be offered the opportunity of referral to an ‘exercise referral scheme’. For those patients who have pre-existing diabetes and would benefit from weight reduction the treatment should be a referral into any in-house GP and/or local weight management schemes/exercise referral programme, namely Upbeat (for Calderdale) and PALS (for Huddersfield). For Calderdale, all people with diabetes and people with are eligible for referral to Upbeat which combines weight management and physical activity. Current criteria for referral to Upbeat are: Patients with a BMI greater than 30 Patients identified as ‘at risk of CVD’ with a risk score of >20% over the next 10 years Patients on a CVD ‘at risk’ register Patients on the CHD register Patients on the Diabetes register Patients who have completed Phase 3 Cardiac Rehabilitation Below is a summary of the main evidence based nutritional recommendations for everyone with diabetes:

eat regular meals planned around wholegrain starchy foods such as bread, chapattis, potatoes, yam, plantain, rice, pasta, dhal and wholegrain cereals.

aim to include more foods with a low glycaemic index, such as pulses (beans, peas, lentils), low fat milk and dairy products and starchy foods as listed above.

eat at least five portions of fruit and vegetables each day. if the patient is overweight or obese, they should aim to achieve and maintain a

healthy body weight if possible. A 5-10% weight loss will have significant health benefits for all overweight or obese patients if the former is not achievable and should be strongly emphasised.

reduce total dietary fat intake, particularly saturated fats. Monounsaturated fats are now promoted as the main type of fats but should still be used in moderation. E.g. Olive, rapeseed, groundnut oils and spreads.

try to eat oily fish (salmon, mackerel, sardines, pilchards, trout, kippers) twice a week.

limit the intake of sugary foods and drinks. reduce that intake of salt and salty foods/snacks. drink alcohol in moderation (<14 units a week for women and <21 units a week

for men). Binge drinking should be avoided. Intakes of alcohol should be evenly spread throughout the week, with at least 2-3 alcohol free days.

special diabetic foods are not necessary – they can be expensive and are often high in fat and calories.

aim to do 30 minutes of moderate physical activity a day. Connor, H. et al. The Implementation of Nutritional Advice for People with Diabetes. Diabetic Medicine (2003); 20: pp 786-807.

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The full version of the above paper can be downloaded from the information centre on the Diabetes UK website www.diabetes.org.uk It is vital that patients are given up-to-date, evidence based, consistent dietary advice to avoid confusion, especially when newly diagnosed, as this can be a difficult time when they are still coming to terms with the diagnosis.

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PHYSICAL ACTIVITY IN THE MANAGEMENT OF TYPE 2 DIABETES

BENEFITS AND RISKS Physical activity is important in the management plan of Type 2 diabetes as it not only improves short and long term glycaemic control, but has beneficial effects on blood pressure and dyslipidaemia. In addition, regular physical activity helps to lose and maintain weight, improves physical and psychological well being and may enhance quality of life; it may also help to reduce long term mortality. Despite these potential benefits, compliance with physical activity remains discouragingly poor. At present there is little evidence to suggest how the exercise habits and barriers to physical activity are assessed in patients with type 2 diabetes. To reap the multiple benefits of physical activity in patients with Type 2 diabetes, we need to educate our patients regarding the benefits of a healthy life style and being physically active. The brief guidelines which follow will help health professionals to understand the role of physical activity in the management of diabetes There is evidence, that regular physical activity benefits most patients with Type 2 diabetes and metabolic syndrome and the benefits generally far outweigh the risk associated with it. However, due to potentially detrimental effects of exercise on macro and micro vascular complications, careful selection of patients through a proper clinical evaluation and individualisation of exercise programmes is needed in those who wish to increase physical activity. BENEFITS OF PHYSICAL ACTIVITY The benefits are summarised in table 1: But remember • The best time to motivate your patients is around the time of diagnosis • Physical activity is much more likely to be beneficial during early years of Type 2

diabetes RISKS OF PHYSICAL ACTIVITY The risks of physical activity need to be considered carefully as newly diagnosed subjects with Type 2 diabetes frequently have micro and macro vascular complications. All subjects with newly diagnosed Type 2 diabetes: • should routinely be assessed for their leisure time and occupational activity as is the

current practice for dietary assessment. • target those who currently take no or little exercise. • develop and disseminate information leaflets to highlight the health benefits of

exercise to subjects with Type 2 diabetes. • screen for complications of diabetes prior to the initiation of any formal exercise

program.

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• give individualised advice to those who are ready for action about the kind of activities they can choose.

• encourage patients to keep a log book of their activities, as a willingness to do so is associated with better compliance.

• education regarding exercise need to be reinforced and should form an essential part of any ongoing educational programmes.

• Minor musculo-skeletal injuries are common and depend upon the intensity and duration. Wearing proper fitting shoes and exercising in a proper environment can minimise these risks.

• Those treated with sulphonylureas or insulin are at risk of hypoglycaemia during and up to 24 hrs after exercise.

• Exercise may also cause transient or prolonged hyperglycaemia after strenuous exercise in those who are insulin deficient.

EFFECTS ON SPECIFIC COMPLICATIONS OF TYPE 2 DIABETES Chronic complications of diabetes or other physical disabilities may be an impediment for exercise. However, none of these are an absolute contraindications for mild or moderate intensity exercise. • Sudden death is rare with an incidence of 0-2/1000,000 hours of exercise. • Precipitation of pre-existing CHD or unmasking of angina is another concern. But,

subjects should be carefully screened including a thorough history, a physical examination and a resting ECG should be considered. Follow safe tips for initiation of physical activity

MICROVASCULAR COMPLICATIONS Retinopathy: Moderate intensity physical activity has a no detrimental effect on non-proliferative retinopathy and the risk in those with proliferative retinopathy is low. • In those who have new vessel formation or vitreous haemorrhages, it is prudent to

avoid vigorous physical activities. • These include activities such pounding, repeated jarring, weight lifting, high impact

aerobics, and activities involving valsalva manoeuvre. Nephropathy: Exercise increases albumin excretion during and immediately after exercise although the long term implications on the natural history of diabetic nephropathy are unclear. Neuropathy: Patients with neuropathy and insensitive feet are more prone to foot ulceration and fractures. Therefore • screening for peripheral neuropathy, foot deformity or degenerative joint disease • limit or avoid weight bearing exercises such as step aerobics, prolonged jogging or

walking • Adequate advice about self foot care should be provided to all. • Subjects with autonomic neuropathy may have decreased exercise capacity.

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• These subjects may be more prone to episodes of extreme hypo or hypertension following vigorous exercise.

Table 1: Rationale for promoting physical activity in Type 2 diabetes

♥ As an adjunct to diet for initial weight loss

♥ Aid to help maintain the weight loss

♥ Loss and redistribution of abdominal fat

♥ Favourable effect on glycaemic control

♥ Management of hypertension in diabetes

♥ Management of dyslipidaemia

♥ Improvement in general well being

Table 2: Potential benefits of regular exercise in Type 2 diabetes

1 Lowers blood glucose during and after exercise

2 Increases insulin sensitivity

3 Lowers basal and post prandial insulin levels

4 Lowers glycated haemoglobin (HbA1c) over long term

5 Lowers systolic and diastolic blood pressures

6 Quantitative and qualitative changes in circulating lipids

- lower triglyceride, lower LDL-cholesterol, Higher HDL-cholesterol

- beneficial effects on LDL density?

7 Improves fibrinolysis, lowers plasma fibrinogen

8 Other Benefits

- Cardiovascular conditioning

- improves strength

- improves sense of well being (Physical and Psychological)

- better quality of life

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PHYSICAL ACTIVITY – GENERAL RECOMMENDATIONS • Any new physical activity should be discussed with the individual’s diabetes team. • When initiating physical activity, the amount and intensity of activity should be

increased gradually on an individual basis • People should aim to accumulate 30 minutes of moderate intensity physical activity

most days of the week, or at least five days a week. • A patient centred approach should be used to explore a person’s readiness to adopt

physical activity and to help the person formulate their personal physical activity strategies

• Education on methods to prevent exercise induced hypoglycaemia should be

provided, as well as information on hyperglycaemia and foot care.

Reference: Burr B, Nagi D (1999) Remember to ask the diabetes team about Upbeat (in Calderdale) or PALS (in Kirklees). These are specialist lifestyle services which will help increase activity levels and optimise diet. These are two very important aspects of diabetes care.

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DIABETES AND SMOKING

Tobacco is harmful to health and is of particular danger to people with diabetes. All late complications of diabetes such as cardiovascular disease, foot problems, kidney and eye disease are worsened by smoking. There is growing evidence that cigarette smokers are more prone to developing type 2 diabetes than the rest of the population. Smoking is associated with insulin resistance. While smoking, insulin absorption from subcutaneous tissue is delayed. In insulin treatment, smoking after meals will therefore be particularly untimely. When diabetes is already present, smoking increases the incidence of mortality and morbidity from cardiovascular and cerebrovascular complications such as myocardial infarction and stroke along with other complications that are explained in further detail below. Studies show that smoking shortens life on an average by 5 to 10 years; however this could be even more in people with diabetes. The effects of smoking on microvascular complications of diabetes The microvascular complications of diabetes include Nephropathy (kidney disease), neuropathy (nerve damage) and retinopathy (eye damage). These are strongly linked with metabolic control. However, it is likely that smoking increases the risk of microvascular complications. Nephropathy (kidney disease) has been shown to be common in type 1 diabetic patients who smoke and smoking increases the risk of microalbuminuria (the presence of protein in the urine which can indicate signs of kidney disease) in both type 1 and type 2 diabetes. Studies show that smoking cessation could slow the progression of kidney disease in people with diabetes. Smoking is also a risk factor for both the development and progression of various types of neuropathy (damage to the peripheral nervous system). A recent case study of type 1 and type 2 diabetic patients found that current or ex-smokers were significantly more likely to have neuropathy than diabetic patients that have never smoked. The study also found that cigarette smoking was associated with a 2-fold increase in risk of neuropathy. Generally, smoking has not been considered a serious risk factor for diabetes retinopathy. However, a number of studies involving people with type 1 diabetes suggest that tobacco smoking predisposes these people to eye damage.

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The effects of smoking on macrovascular complications of diabetes The multiple effects of smoking on the blood vessels have been established for several years. It seems that people with diabetes are particularly susceptible to some of these effects. In all people with diabetes, it has been shown that smoking is significantly associated with an increased risk of heart disease. The UK Prospective Diabetes Study clearly showed that in people with type 2 diabetes, cigarette smoking is a significant and independent risk factor for heart disease, stroke and peripheral vascular disease. Generally, tobacco smokers show various aspects of the metabolic syndrome – a cluster of features including abdominal obesity, high blood pressure insulin insensitivity and glucose intolerance. While these metabolic changes, which are often precursors to type 2 diabetes are generally correlated with the degree of nicotine use. Smoking cessation There is overwhelming evidence that stopping smoking reduces the risk of cardiovascular disease, lung disease, cancer and stroke. A large number of clinical and experimental studies and surveys have found evidence for significant associations between tobacco use, blood glucose control and diabetes complications. In diabetes care, smoking cessation is of the utmost importance in order to facilitate the effective control of blood glucose, and to limit the development of diabetes complications.

Nicotine addiction Cigarettes and some other products containing tobacco are highly engineered so as to create and maintain dependence to nicotine. It is not nicotine itself which is the most dangerous agent of smoking, but the many compounds that these products contain and the smoke they produce that cause the most damage: they are pharmacologically active, toxic, mutagenic and carcinogenic. The tobacco industry’s artful marketing, advertising and promotion are another obstacle to smoking cessation. Therefore, it is advised that smokers enlist the help and support of a specialist stop smoking service to aid them with their quit attempt. The stop smoking service in your area will offer free and confidential advice and support. Guidance will be given about products such as nicotine replacement therapy (NRT) that can be used to aid your quit attempt. How to access support Ask your doctor, nurse or pharmacist for help, or contact your local NHS Stop Smoking Service: Calderdale ℡ 01422 281505 Kirklees ℡ 0800 183 2056 If you use your local NHS Stop Smoking Services you are four times more likely to stop smoking than doing it alone. NHS Stop Smoking Helpline ℡ 0800 169 0 169 www.gosmokefree.co.uk

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MANAGEMENT OF CARDIOVASCULAR RISK Introduction Patients with diabetes are generally a very high risk group for Cardiovascular (CVD) disease and its clinical manifestations. The risk of CVD in patients with Type 2 diabetes is higher than patients without diabetes who already have IHD. Smoking, hypertension, dyslipidaemia and physical inactivity are major modifiable risk factors for IHD in diabetes. . Nephropathy manifest as microalbuminuria and retinopathy are strong predictions of CVD and total mortality. What are we Trying to Achieve? People with diabetes (type1 or type 2) are now all considered to be at high risk and therefore formal cardiovascular risk assessment is not required. The absolute risk can be effectively lowered by tackling multiple risk factors ie stopping smoking, treating hypertension adequately and lowering cholesterol levels.

Lifestyle and Risk Factor Targets

Discontinue smoking, make healthier food choices, increase physical activity and achieve optimal weight (BMI<25) and weight distribution (waist circumference <94cm in men [Asians <90cm] and <80cm in women Blood pressure target of <140mmHg systolic and <80 mmHg diastolic. In selected higher risk people (established atherosclerotic disease, diabetes and chronic renal failure) a new lower blood pressure target of< 130mmHg and, <75 mmHg may be more appropriate. A new lower total cholesterol target of <5.0 mmol/l and a new density lipoprotein (LDL) cholesterol < 3.0 mmol/l, or a 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol, whichever gets the person to the lowest absolute level The optimal fasting glucose is < 5.6 mmol/l for all people. The optimal target for glycaemic control in people with diabetes is a fasting or pre-prandial glucose value of 4.0 – 6.0 mmol/l and a HbA1c < 6.5%

Type 2 Diabetes – Key Messages

2 Stop smok

1 Control symptoms (diet, metformin)

• Although managementisolation.

• Tight control of bloo

intensive blood glucose

• Studies of hypertensiopressure control reduce

• Evidence shows that u

diabetes

• The effect on outcoexplained in terms of g

• Whilst there may be a p

of convincing outcome

• Blood glucose monitorpurpose in a patients swho receive appropriat

3 Control blood pressure

ing

5 Consider tight glucose control

4 Add statin and aspirin (and metformin)

of blood glucose is important, it should not be considered in

d pressure is at least as important if not more so than control.

n in patients with Type II diabetes show that tight blood s the risk of cardiovascular events and death.

se of metformin reduces the macrovascular complications of

mes obtained with metformin would not appear to be lycaemic control alone.

lace in therapy for the use of glitazones, there remains a lack data for their use.

ing by patients can be useful when it serves an identified elf-management programme. Impact is maximized in patients e education.

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Management of Blood Glucose in Type 2 Diabetes

Metformin

1st li

ne

This is the only hypoglycaemic drug that reduces mortality in Type 2 Diabetes Commonly causes gastrointestinal disturbances in the first few days of therapy; this usually settles after a few days. Side effects may be reduced by taking metformin with the largest meal of the day when initiating treatment. Increase dose slowly at a rate tolerated by patient. Contraindicated in severe heart failure and if prone to hypoxia. If eGFR <45ml/min reduce the dose by half. Stop if eGFR <.30ml/min. Initiation: Metformin 500mg daily for one week and then increase dose as tolerated by patient.

Sulphonylureas

2nd li

ne

Increase dose gradually. May cause hypoglycaemia. Do not prescribe two sulphonylureas concomitantly. Where glycaemic control is poor there is no advantage in switching from one sulphonylurea to another. Initiation: Gliclazide 40mg daily.

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Thiazolidinediones (glitazones)

Glitazones should only be initiated, if all lifestyle issues and management of cardiovascular risk factors have already been addressed. Glitazones are contraindicated in patients with cardiac failure or history of cardiac failure (NYHA stages I to IV). Glitazones may also precipitate cardiac failure in patients with no prior history of the cardiac disease. Glitazones are contraindicated in hepatic impairment. Check baseline liver function and repeat after 2 months and occasionally thereafter. Initiation: Pioglitazone 15mg daily

Insulin

3rd li

ne

Adding insulin should not be seen as a failure. Most patients with poorly controlled blood sugars will feel better on insulin. When starting insulin, metformin is routinely continued in all patients who tolerate it. Sulphonylureas are continued at the same dose for patients on basal insulin alone. The sulphonylurea dose should be reduced by approximately 25% in patients starting pre-mixed insulins and stopped for patients transferring to a basal bolus regimen. Insulin therapy should be individually tailored. Patients receiving insulin therapy need to be advised about the risk of hypoglycaemia and be alert to it. Inhaled insulin and insulin pump is reserved for initiation in secondary care.

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Meglinitides (Nateglinide and Repaglinide) These drugs are recommended for specialist use only as there is limited clinical data available They do not further increase insulin release if a person is already receiving a maximum dose of a sulphonylurea. May be useful in terminally-ill patients, alcoholism & shift workers.

Acarbose

Acarbose is an alpha-glucosidase inhibitor It is poorly tolerated and hence rarely used

Sitaglitpin & Vildagliptin

These drugs are generally not recommended for use, as there is a lack of information to accurately ascertain their place in therapy.

Exenatide

Add

ition

al A

gent

s

This is not recommended for general use, as the evidence for its effectiveness is still limited.

Additional Notes

1. It may occasionally be necessary to start newly diagnosed patients on insulin in addition to metformin +/- sulphonylurea if HbA1c is very high on diagnosis. This may be discontinued once the HbA1c returns to target levels.

2. Patients with a BMI less than 19 kg/m2 on diagnosis should be referred to secondary care for further investigation and treatment.

27

Insulin Initiation Pathway for People with Type 2 Diabetes The aim of insulin treatment is to improve glycaemic control and quality of life When to initiate insulin

Oral hypoglycaemic agent (OHA) prescription is to the maximum tolerated dose and desired HbA1c not achieved (<7.5%).

Generally the target HbA1C is <7.5% or <7% if there are complications present however each person should be assessed on an individual basis and targets set accordingly

OHA not tolerated/contra-indicated. Symptoms related to poor glycaemic control. Patient agrees to and understands the risks and benefits of insulin therapy.

Before Insulin Therapy

Check compliance with oral hypoglycaemic agent medication. Reinforce dietary advice and discuss lifestyle issues and employment i.e. Smoking

and physical activity. Refer to specialist diabetes dietitian if appropriate. Assess for diabetes related complications.

Check ability to administer own insulin or carers/district nurse involvement

Different Regimes that may be considered when initiating insulin therapy in people with diabetes

Basal insulin with hypoglycaemic

agents

Twice daily pre-mixed insulin with

oral hypoglycaemic agent

Basal Bolus Regimen

Patient Characteristics

Overweight (BMI>25)

Reluctance to start

insulin

Unable to inject themselves

Older person with no

complications but where hypoglycaemia

is unacceptable

Regular lifestyles.

Eat similar amounts at similar times of the day

OHAs are no longer stimulating efficient insulin production leading to post-

prandial high blood glucose level

Symptomatic

On daily/BD insulin

regimes without optimal control.

Requiring flexibility due to an erratic

lifestyle.

Shift work.

Regular travel across time zones

Regular sport

To optimise blood

glucose control because of

complications.

Notes

Continue metformin and sulphonylurea at same doses.

Continue metformin at same dose and sulphonylurea at approximately 25% lower dose.

Continue metformin at same dose – stop sulphonylurea.

28

Prescribing Points

• Insulins should be prescribed by brand name only.

• The evidence for the preferential use of analogue insulins is limited. The choice of insulin should be based on an assessment of the individual patient’s requirements and the most cost-effective option chosen.

Who may not benefit from insulin therapy?

• The target of 7.5% may not be appropriate for all and the risk of hypoglycaemia must be balance against this target. HbA1c is not always relevant if life expectancy is limited.

• Some obese people may not benefit from insulin therapy which can lead to further

weight gain with little or no improvement in HbA1c. In such patients consider whether a weight management programme and increased exercise may be explored.

• People whose oral hypoglycaemic therapy could be optimised.

Reasons patients may resist commencing insulin

• The decision to start insulin must be made in partnership with the patient.

• Lifestyle and employment issues must be discussed eg HGV drivers may not wish to or delay transfer to insulin as they will lose their HGV licence.

• Needle phobia. Accurate information may help people with needle phobia eg.

People may think that they need to find a vein to inject into or that the needle may be large. A demonstration of the pen device is therefore useful.

• Hypoglycaemia. People generally overestimate the risk of hypoglycaemia.

• Risk:benefit. Some asymptomatic people may believe their diabetes is well

controlled and that they are not at risk of complications. Training and Competencies

• Prior to initiating insulin in Primary Care it is essential that providers have:

o A health care professional who has already completed ENB 928 or the Diabetes Diploma or equivalent, AND

o Undertaken insulin initiation training via an accredited training programme.

• Health professionals involved in the initiation of insulin in primary care will be required to commit to attending at least 1 update session per year.

• The training will be linked to the Skills for Health Diabetes competencies which in turn

is linked to the KSF.

• In Secondary Care: all insulin-naïve patients should be referred to a Diabetes Specialist Nurse on admission

29

INSULIN INITIATION CHECKLIST 1. Aims of treatments Date:………… 2. Oral Medication Date:………… 3. Choice/use of pen Date:………… 4. Name and type of insulin Date:………… 5. Action of insulin Date:………… 6. Timing of injections Date:………… 7. Injection technique Date:………… 8. Site rotation Date:………… 9. Safe disposal of sharps Date:………… 10. Storage of insulin Date:………… 11. Self adjustment of insulin Date:………… 12. Hypoglycaemia – cause/symptoms/treatment Date:………… 13. Hyperglycaemia - Cause/symptoms/treatment Date:………… 14. Ketone testing Date:………… 15. Sick day rules Date:………… 16. Meter used Date:………… 17. Timing/frequency Date:………… 18. Recording results Date:………… 19. Interpreting results Date:………… 20. Basic dietary advice Date:………… 21. Alcohol Date:………… 22. Dietitian referral Date:………… 23. Physical Activity Date:………… 24. Smoking Date:………… 25. Driving-DVLA/insurance/hypoglycaemia Date:………… 26. Employment Date:………… 27. Prescription exemption Date:………… 28. Footcare/podiatry referral Date:………... 29. Contraception/pregnancy/pre-pregnancy counselling Date:………… 30. Holidays/travel Date:……… 31. ID card Date:………… 32. Local support groups Date………….

THE MANAGEMENT OF HYPERTENSION IN DIABETES

Blood Pressure Management

Type 1 Diabetes

All Patients <135/85 mmHg Target Blood Pressure Patients with nephropathy <130/80mmHg

All Patients ≥135/85 mmHg Threshold for

Treatment Patients with microalbuminuria or proteinuria or with metabolic

syndrome ≥130/80 mmHg

Type 2 Diabetes

All Patients <140/80 mmHg

Target Blood Pressure

Patients with

microalbuminuria or proteinuria

<130/80mmHg

All Patients ≥160/100 mmHg Threshold for

Treatment Patients with microalbuminuria or proteinuria and 10 year CVD

risk > 20%

≥140-159/80-90

mmHg

Treatment Notes Target Blood Pressure levels may be difficult to attain in some, but any BP

lowering reduces vascular risk with greatest benefit from reductions at higher end of BP scale.

Weight loss, salt restriction and exercise are all beneficial in reducing BP.

Treatment may sometimes require 4 or more drugs.

Remember – Compliance is all-important – a drug that is not taken won’t work!!!!

30

31

Treatment Algorithm

Under 55 or any age/race with microalbuminuria/

nephropathy

55 or over or any age if black

(Afro-Caribbean not mixed race, Asian or

Chinese)

Step 1 A D

Step 2 A + D

Step 3 A + C + D A + C + D

Step 4 Plus further diuretic therapy

Or β blocker or α blocker Or consider specialist advice

A= Ace Inhibitor (ACEI) ie. ramipril, lisinopril, or enalapril

Angiotensin II receptor antagonist (A2RA) if intolerant i.e. irbesartan or candesartan

C = calcium channel blocker i.e. amlodipine D = thiazide diuretic i.e. bendroflumethiazide 2.5mg daily Beta blockers are no longer first line choices in hypertension unless there is another compelling reason e.g. Ischaemic Heart Disease Monitor renal function before initiation and 2 weeks after introduction or dosage increase of ACEI/A2RA. See Product Summary of Product Characteristics or BNF for details Antiplatelets Aspirin Aspirin 75mg daily advised (if systolic BP<145) if have: manifest CVD (ie secondary prevention) , or no overt CVD but a10year CVD risk >20% (ie primary prevention) Co-prescribe a proton pump inhibitor (omeprazole or lansoprazole) with aspirin if dyspepsia problematic. Clopidogrel There are no trials specifically studying clopidogrel in patients with diabetes. Use only instead of aspirin for true aspirin hypersensitivity.

32

Lipid Lowering Please see the Calderdale and Kirklees Lipid Lowering Guidelines (2007)

DETECTION AND MANAGEMENT OF LIPID DISORDERS

•Diabetes with no complications (18-39 years) •People who DO NOT have cardiovascular disease •Total cholesterol >7.5* and familial hypercholesterolemia diagnosed or suspected refer to secondary care •Triglycerides >10 (see under fibrates)

n

LLIIPPIIDD MMAANNAAGGEEMMEENNTT GGUUIIDDEELLIINNEESS

Ensure all assessment outcomes are recorded on the clinical system in a retrievable format for audit

Take cardiovascular history and lifestyle assessment (refer to Box 1)

Use a cardiovascular risk assessment tool to assess level of risk

Measure FASTING lipid profile

n

co

Take cardiovascular history anassessment (refer to Bo

If risk ABOVE 20% start tr

Assessment Follow

If risk below 20% continue lifest

Continue lifestyle advice, and consider other

medications

If risk below 20% ntinue lifestyle advice

and review

Primary Preventio

Risk Assessment

If risk above 20% offerlifestyle advice and recheck in 3 months

33

FTSc

d lifestyle x 1)

eatment

Up

yle advice and review

Continue lifestyle advic

FASTING lipid profilCheck ALT as recomm

Box 3)

If cholesterol less than 5* anthan 3* or TC 20-25% low

30% lower (whichever resuabsolute level) continue wi

(Cardiovascular disease includes Coronary heart Disease, Stroke, Transient Ischaemic Attack, Peripheral Arterial Disease.) •People who DO have cardiovascular disease or •People with >20% Cardiovascular risk •Diabetes over 40 years of age •Diabetes (18-39 years) plus complications. See box 1 ‘lifestyle assessment’

ASTINGhyroid futart stationtraindifeeding)

e and ree annuaended

d LDL iser and Llts in lowth treatm

Secondary Preventio

t

lipinctin trecate– c

view lly (see

less DL est ent

Continue lifestyle advice and check ALT as recommended. Refer specialist lipid clinic if

target not achieved (accept and document treatment decline)

Treatment Follow Up

Treatment Follow Up Treatment Follow Up

Offer lifestyle advice d profile, glucose, creatine kinase, on tests, creatinine, liver function tests atment (refer to Box 2) unless d (liver disease, pregnancy, breast onsider other agents

Treatmen

If cholesterol more than 5* and LDL more than 3* review

compliance and statin dose (See Box 2)

At 8 weeks repeat FASTING lipid profile and alanine aminotransferase (ALT). NB–if patient reportsunexplained muscle pain check Creatine Kinase (CK)

Treatment Follow Up

ALT- 3 times upper limit or other abnormality stop statin or reduce

dose. Re-check full LFT within 4-6weeks

i

LLIIPPIIDD MMAANNAAGGEEMMEENNTT GGUUIIDDEELLIINNEESS

Calderdale PCT orth Kirklees PCT ascular risk, if t

py

34

BOX 3 Blood Tests [2] Baseline: Fasting (12 hour fast, water only) lipid profile, glucose, thyroid stimulating hormone (TSH), Creatinine, Creatine

kinase (CK)-as a baseline, then annually (except CK) as part of CVD review. Liver function tests (LFTs) as a baseline then alanine aminotransferase (ALT), lipid profile and CK - 8 weeks after starting statin and annually (except CK) thereafter.

After dose increase repeat lipid profile, ALT and CK at 8 weeks. If muscle pain perform CK If < 5X ULN then monitor symptoms and CK regularly if continues to rise.

If >=5X ULN then stop treatment, check renal function and monitor CK fortnightly. ALT Raised? If ALT <3X ULN continue statin and re-check ALT in 4-6 weeks. If ALT >3X ULN STOP statin or reduce dose. Re-check full LFTs within 4-6 weeks.

N

BOX 1 Lifestyle Assessment Take a cardiovascular/ lifestyle history, and use an appropriate risk assessment tool to assess cardiov he risk is above 20% the patient should be treated the same as for secondary prevention after lifestyle intervention has been tried.

The JBS Statin therapy is recommended for people aged 18–39 years with either type 1 or 2 diabetes andwho have at least one of the following:

(a) retinopathy (pre-proliferative, proliferative, maculopathy) (b) nephropathy, including persistent microalbuminuria (c) poor glycaemic control (HbA1c >9%) (d) elevated blood pressure requiring antihypertensive thera (e) raised total blood cholesterol (> 6.0mmol/l) (f) features of metabolic syndrome (central obesity and fasting triglyceride >1.7mmol/l (non-fasting >2.0mmol/l) and/or HDL cholesterol <1.0mmol/l in men or <1.2mmol/l in women) (g) family history of premature CVD in a first degree relative

Risk assessment tools: www.hyp.ac.uk/bhs/risk.xis (Framingham) www.dtu.ox.ac.uk/riskengine (Diabetes UKPDS)

www.heartjnl.com (Joint British Societies cardiovascular disease (CVD) risk prediction chart) based on Framingham

BOX 2 Statin Treatment (always check compliance before treatment changes)

11st line Simvastatin 20-80*mg (aim for a 40mg dose)

If simvastatin is contraindicated eg. due to interactions (see BNF) then suitable alternative choices are atorvastatin 10mg or rosuvastatin 5mg.

nSimvastatin 80mg should be prescribed as 2 x 40mg. The increased risk of myopathy with the 80mg dose tends to occur in the elderly or those with undiagnosed or undertreated hypothyroidism. Patients on diltiazem should not receive more than 40mg simvastatin.

2nd line If higher risk patient is not to target on simvastatin 40mg then consider the use of alternative agents (not in any order of preference):

*Atorvastatin 40-80mg Rosuvastatin 10mg-20mg (20mg only after trial of 10mg for at least four weeks)

* NB – increased risks of myopathy with 80mg doses. If not to target check compliance and consider additional agents (see‘adjuncts and alternatives to statins’) or refer to specialist.

35

LIPIDLIPID MANAGEMENT GUIDELINESMANAGEMENT GUIDELINESLipid Lowering Agents

Statins

•Compliance or concordance should be checked when there is a failure to reach target. Statins work in a predictable way, therefore the most probable reason for failure to reach target is that the patient is not taking the treatment. •If a patient refuses to take a lipid lowering agent, then this should be accepted and documented in the patient’s notes.•Statins work by reducing LDL cholesterol (LDL-C) via the inhibition of the enzyme HMG Co-A reductase.•Simvastatin was the first statin to be launched in the UK and has been used since 1988. It has been taken by more than 35 million patients in 117 countries and is one of the world’s most widely used cholesterol-lowering drugs.•In a sub-analysis of the Heart Protection Study, simvastatin produced significant reductions in the risk of first major coronary events, stroke, or revascularisation in patients ≥40 years with (mostly) type 2 diabetes; even if they had normal cholesterol levels and/or no manifest CHD[1].•Adverse effects to be aware of are: effect on liver enzymes (hence monitoring of ALT required); and muscle pain or weakness along with the leakage of the muscle enzyme creatine kinase into the blood stream. If statins are continued in this condition, rhabdomyolysis and rarely death can occur.

Which Statin?

•Based on current evidence and cost, generic simvastatin at a dose of 40mg daily (od) at night is the statin of choice for the primary and secondary prevention of CHD[2].•Atorvastatin (10-80mg) daily is an alternative choice for most patients. A recent trial provides preliminary evidence to support the use of atorvastatin 80mg od for intensive lipid-lowering in certain high risk patients[3][4].•Rosuvastatin has no published long-term clinical outcome or safety data so care should be taken when prescribing this product[5]. Recent warnings have been issued by the Medicines and Healthcare Regulatory Agency (MHRA) and AstraZeneca regarding the use of rosuvastatin:

o Asian, Elderly (>=70) and patients with predisposing risk factors for myopathy initially 5mg od.oMaximum dose of 20mg od in Asian patientsoAll other patients to start on 10mg od with increase to 20mg od only after a four week trial at 10mgoSpecialist supervision is recommended when 40mg od dose is given, and is contraindicated in patients with predisposing risk factors for muscle toxicity[6

[1] Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 5963 people with diabetes: a randomised placebo controlled trial. Lancet 2002;360:7-22 [2] Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high risk individuals: a randomised placebo controlled trial. Lancet 2003;361:2005-16 [3] Cannon CP et al. Comparison of intensive and moderate lipid lowering with statins after acute coronary syndromes. (PROVE IT-TIMI22). NEJM 2004;350:15-25 [4] Regional Drug and Therapeutics Centre. Rapid Appraisal Number 1. April 2004[5] Regional Drug and Therapeutics Centre. New Drug Evaluation Rosuvastatin. June 2003 [6] MHRA: http://www.mhra.gov.uk/news/2004/crestor_9june04.htm . Accessed 06-09-05.

LIPID MANAGEMENT GUIDELINESLIPID MANAGEMENT GUIDELINES

Calderdale PCTHuddersfield Central and

South PCT

Adjuncts and Alternatives to Statins•The most likely reason that statin therapy does not achieve the target level for LDL-C is failure of concordance and this should be remedied before assuming the patient is resistant to a statin.•Adding a fibrate, nicotinic acid or ezetimibe lowers LDL-C by more than a statin alone but increases cost and the risk of adverse effects.•The combination of a statin with a fibrate or nicotinic acid is associated with an increased risk of severe muscle toxicity; in particular gemfibrozil should not be combined with a statin.•Resins are too inconvenient for routine use and more expensive than other options.•Combination therapy should therefore be reserved for patients with established atheroma or at high cardiovascular risk.•The relative long-term efficacy of these therapies is unknown.

Fibrates

•A combination of a statin with a fibrate may, under specialist supervision, be indicated for the treatment of severe hyperlipidaemia[1] or in patients with low HDL_C and low LDL-C.•Rarely on present evidence should combined treatment be used [2] For most people with a mixedhyperlipidaemia treatment should start with a statin. Where there is persistent hypertriglyceridaemia (TG >2.3) and a raised TC/HDL-C ration (>5) after the LDL-C target has been achieved a combination of a statin with fenofibrate may be considered.•Severe fasting triglyceridaemia (TG>10) may require treatment with a fibrate alone if no treatable underlying cause has been found. Common causes of marked hypertriglyceridaemia are obesity, poorly-controlled diabetes and alcohol excess.•Overall, fibrates reduce LDL-C by 7-11%; increase HDL-C by 10-15%, and lower triglycerides[3]. Adding a fibrate to a statin further lowers LDL-C by about 8% in patients with hypercholesterolaemia[4].

Nicotinic Acid

•Nicotinic acid lowers LDL-C by 5-25%, raises HDL-C by 15-35% and lowers triglyceride levels[5]. Adding nicotinic acid to a statin further lowers LDL-C in hypercholesterolaemia by 13% [4] and reduces the combined risk of coronary events [5].•Treatment is limited by a high frequency of adverse effects due to vasodilatation, especially flushing [1], this is less of a problem with the modified release (MR) formulation [5] but the long term efficacy of the MR product is unknown.•Nicotinic acid is associated with a dose-related worsening of glucose intolerance [5].

Anion Exchange Resins

•Colestyramine lowers LDL-C by an average of 12%[6] but it may worsen hypertriglyceridaemia [1].•Colestyramine and colestipol impair the absorption of vitamins and other drugs and are associated with a high frequency of GI effects [1].

[1] British National Formulary No.49. March 2005[2] FIELD Study Investigators. Effects of long-term fenofibrate on cardiovascular events in type 2 diabetes mellitus. Lancet, published online Nov 14 2005.[3] PRODIGY guidance- Hyperlipidaemia. July 2003 (www.prodigy.nhs.uk) Accessed 06-09-05.[4] Thompson GR. Management of dyslipidaemia. Heart 2004;90:949-55[5] UK Medicines Information Service. Nicotinic acid (modified release). New Medicines Profile 2004 No. 04/01[6] The Lipid Research Clinics Coronary Prevention Trials II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. J Am Med Assoc 1984;251:365-74[7] Regional Drug & Therapeutics Centre. Ezetimibe. New Drug Evaluation No. 60. August 2003

36

Adjuncts and Alternatives to Adjuncts and Alternatives to StatinsStatins continuedcontinued

Ezetimibe

• Ezetimibe is not recommended for routine use in primary or secondary care

• Given alone, ezetimibe reduces LDL-C by approximately 18% and slightly increases HDL-C; in combination with a statin it further lowers LDL-C by 12-20%[1].

• Common adverse effects in clinical trials were headache, abdominal pain and diarrhoea.

• There are no long term data on the efficacy of ezetimibe in preventing cardiovascular events and the drug is not licensed for this indication

• Consider adding ezetimibe 10mg daily if cholesterol not at target on atorvastatin 40-80mg or rosuvastatin 10-20mg in patients at high risk of cardiovascular events

Omacor

• Omacor is licensed for adjuvant treatment for secondary prevention post MI. It is alsolicensed for the treatment of hypertriglyceridaemia for monotherapy of type iv and in combination for type 11b/111 when a statin alone is inadequate [2]

• The Local Acute Coronary Care Management Guidelines do not currently recommend Omacor as a routine addition post-MI [3].

• Omacor is not routinely recommended for the treatment of hypertriglyceridaemia. When treatment of hypertriglyceridaemia is indicated (see under fibrates for further details) Omacor is not a first line choice.

Calderdale PCTNorth Kirklees PCT

LIPID MANAGEMENT GUIDELINESLIPID MANAGEMENT GUIDELINES

[1] Regional Drug & Therapeutics Centre. Ezetimibe. New Drug Evaluation No. 60. August 2003[2] Omacor Summary of Product Characteristics. Electronic Medicines Compendium. Available at http://emc.medicines.org.uk. Accessed December 14 2006[3] Calderdale and Huddersfield NHS Trust. Acute Coronary Syndromes Management Guidelines July 2006. Available at www.formulary.cht.nhs.uk Accessed December 14 2006.

37

The Management of Obesity in Patients with Diabetes

STEP 1 Diet, Lifestyle and Behavioural Modification. Please see the lifestyle section of the guidelines. Refer to a Dietician to develop an individual weight management plan where available and appropriate.

STEP 2 Anti-Obesity drug treatment should be reserved for patients with a BMI > 30kg/m2 (or >27kg/m2 if the patients have concomitant risk factors for cardiovascular disease) only after dietary, exercise and behavioural approaches have been started, evaluated and used as part of an individual weight management plan. NICE recommends that drug treatment should only continue after 3 months if the patient has lost at least 5% of their initial body weight since starting treatment. Less strict goals may be considered in some patients with type 2 diabetes as they may lose weight more slowly than the rest of the population. General Prescribing Information

• Counsel patients on the limitations of drug therapy and likely adverse effects before starting

• Do not use combinations of anti-obesity drugs

• Review drug treatment at 3 months. If there is no weight loss the drug should

be stopped. An alternative agent may be tried if appropriate.

Orlistat

Sibutramine

Lifestyle, Dietary and Behavioural

Changes

38

39

INDIVIDUAL DRUGS: See BNF/SPC for full prescribing details. Orlistat First line drug choice due to safety profile. Dose: 120mg three times a day with meals. If a meal is missed or contains no fat the dose of orlistat should be omitted. Patients may suffer from gastrointestinal side effects including oily leakage from rectum, flatulence, faecal urgency and incontinence. These side effects are minimised by reducing the amount of fat ingested in diet. Sibutramine Dose: 10mg daily initially increased to 15mg daily if inadequate response (<2kg weight loss over 4 weeks). Monitoring: Blood pressure and pulse – every 2 weeks for first 3 months then monthly for the next 3months and then at least 3 monthly. See BNF/Summary of Product Characteristics for full details. Treatment is not recommended for longer than 12 months. Rimonabant is not generally recommended for use due to safety concerns including an increased risk of depression and suicide. For further details see up to date Summary of Product Characteristics and MHRA Safety Alert July 2007.

40

RETINOPATHY – SCREENING AND EARLY MANAGEMENT

The programme, hosted by Kirklees PCT, is currently subject to a European tender process and it is anticipated that the contract will be awarded September 2007. Guidelines will be issued once the definitive scheme is in place. In the interim, the PCTs have commissioned 1st Retinal Screen to provide screening, grading and referral to specialist care as appropriate. Screening is undertaken at a number of locations across the patch including health centres, GP practices and a number of community optometrists who have subcontracted with 1st Retinal Screen. A flow diagram of the patient pathway is attached. The current provider allows access to the web-based system by GP practices for the purposes of obtaining results and for ensuring the centrally held list for call and recall is kept up-to-date. Training is provided by 1st Retinal Screen (contact: Helpdesk, 1st Retinal Screen on 01270 527373) The screening office function has been retained (contact: Screening Office on 01484 466149/466110).

41

Calderdale and Huddersfield DRS Patient Pathway

Existing patient previously screened

Newly diagnosed patient

Visual acuity and image capture by photography at preferred screening location

GOS sight test

Screening office sends recall invitation letter from database

GP requests screening

Optometrist advises patient to contact screening office or GP

Call invitation letter from screening office

Primary and secondary grading (arbitration if appropriate)

Slit lamp bio-microscopy and grading

Discharge from Ophthalmologist back to DRS

Referral to Ophthalmologist for treatment

Annual Recall

Report to patient and GP

Screening booked by patient either through the screening office or direct with participating Optometrists

Failed photographs

42

Management of the Diabetic Foot

Introduction The main driving force for the clinical guidance for the management of the diabetic foot is the Diabetes National Service Framework and the NICE clinical guidline No 10. Foot complications are common in people with diabetes. It has been suggested that overall, 20-40% of people with diabetes have neuropathy and 20-40% have peripheral vascular disease. Standards 10, 11 and 12 of the “National Service Framework for People with Diabetes” relate to the detection and management of long-term complications. Diabetic foot problems are a consequence of diabetic neuropathy. Foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered foot care education, podiatry and, where required, protective footwear. Prompt treatment of foot ulcers can reduce the risk of amputation. Key interventions are:

• Participation in a foot care programme that provides foot care education, podiatry and where required, protective footwear for people with diabetes identified as being at increased risk of developing lower limb complications.

• Prompt intervention for people with diabetes who develop foot ulceration.

The NICE Guidance states that around 5% of people with diabetes may develop a foot ulcer in any year, and amputation rates are often around 0.5% per year. The NICE Guidance aims to provide a standard set of recommendations for the prevention and management of foot problems. It covers the care of adults and children with type 1 and 2 diabetes by primary and secondary healthcare professionals. Operationally, the Podiatry service provides an annual review as part of a multi-disciplinary team approach (GP, Practice Nurse, Podiatrist, Dietitian). Patients are recalled annually by the practice and blood samples are taken prior to attendance so that results are available to the team. The intention is that each patient sees the practice nurse first and GP last with the dietitian and podiatrist in between as they become available. For 2004/5 and 2005/6, QOF includes 2 relevant clinical indicators DM 9 and DM 10 that relate to the ongoing management of people with diabetes; DM 9 relates to the percentage of patients with diabetes with a record of presence or absence of peripheral pulses in the previous 15 months and DM 10 relates to the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months. All people with diabetes who attend for a foot assessment are classified in accordance with NICE Guidance according to foot risk as: at low current risk, at increased risk, at high risk or ulcerated foot. This pathway outlines the proposed redesigned structure of the processes involved in podiatry assistants providing the annual diabetic foot review service to the diabetic population in Calderdale and Huddersfield. The key feature of the redesigned service is that

43

all the patients with diabetes will have an annual review provided by a healthcare professional appropriate to their needs in accordance with NICE clinical guidance. Aim For all patients with diabetes in Calderdale and Huddersfield to have the opportunity of an annual foot review including education that indicates the risk of foot ulceration and appropriate preventative action. Objectives • All patients with diabetes will receive an appointment for an annual review of their feet. • Foot review will be carried out by the appropriately trained staff. • Foot care education will be provided to individuals according to their clinical and

personal needs. • Patients will be allocated a risk factor for the possibility of foot ulceration based on

NICE guidance risk criteria. Process • Newly diagnosed patients will all be assessed by a Podiatrist at the Diabetes Centre,

Calderdale Royal Hospital or Princess Royal Community Health Centre (PRCHC), Huddersfield.

• The initial assessment will form the base line against which future reviews will be

compared. • Dependant on the findings of the review, every patient will be allocated a risk factor for

ulceration and appropriate footcare education provided. • Following the specific risk pathways the patient will be referred appropriately. • For every patient reviewed a report will be sent to their GP for entry onto EMIS.

44

Table 1 Risk Criteria of patients with Diabetes Mellitus Patients will be categorised into one of four risk groups based on NICE guidance.

Risk Definition Process Low Risk Normal sounding , regular foot

pulses AND Full sensation

Page 56

At Increased Risk Absent palpable foot pulses OR Reduced foot sensation PLUS Risk factors e.g. smoking, living alone, foot lesions and deformity, sight problems

Page 58

At High Risk Severe or Diabetic related foot deformity PLUS Reduced/absent foot sensations OR Absent/monophasic pulses OR History of previous foot ulceration

Page 60

Ulcerated Presence of an open wound on the foot

Page 62

Table 2 Overview of annual review according to risk group

Risk Level Assessment Frequency

Assessor Calderdale Site Huddersfield Site

Newly Diagnosed

Initial assessment

Podiatrist DMC, CRH PRCHC

Low Risk Annual Podiatry assistant GP surgery GP surgery At Increased Risk

6 - 12 month Podiatry assistant GP surgery GP surgery

At High Risk Annual Podiatrist Health Centre/ DMC

Health Centre/ PRCHC

Ulcerated At point of presentation with ulceration

Podiatrist Health Centre/ DMC

Health Centre/ PRCHC

45

The Newly Diagnosed Patient Referral process for foot review of a newly diagnosed patient GP surgeries presently refer patients to the Diabetes Medical Centre at CRH or Princess Royal Community Health Centre, Huddersfield to see a Podiatrist to provide a foot assessment. Initial review of the foot Examination will include:

• Inspection for foot deformity and associated foot lesions • 10mg monofilament sensation, pin prick, vibration. • Doppler examination of foot pulses • Examination of footwear • Identification of other risk factors including history of ulceration • Foot care education linked to the importance of stability of blood sugar in reducing

risk of developing complications Who will assess the newly diagnosed patient? A Podiatrist will undertake the initial assessment which forms the base line against which future screens are reviewed. What actions will follow from the initial review? The patient will be allocated a risk category and the appropriate education provided. A report of the review will be sent to the referring GP indicating when the patient next requires a review.

Flow chart of newly diagnosed patient pathway GP refers newly diagnosed patient to Diabetes Centre, CRH or PRHC, Huddersfield.

Low Risk o Normal

Sensation o Normal

Pulses

Feedback to GP

Annual review at GP surgery by podiatry assistant

Initial Assessment by Podiatrist

o Doppler foot pulses o Neurological tests o Inspect feet and footwear o Foot care education

46

At Increased Risk o Reduced

sensation Or

o Absent palpable pulses

Plus o Risk Factor/s

Ulceration Ulceration present in foot

At High Risk o Severe foot

Deformity Plus

o Absent sensation

Or o Pulses o Monophasic

with doppler Or

o Previous history of ulceration/ amputation

Feedback to GP

Trust Wound Formulary followed until ulcer healed

Feedback to GP

Feedback to GP

Annual review at GP surgery by podiatry assistant Referral for Podiatry treatment if lesions or deformity present

Annual review by podiatrist at Health Centre Referral for podiatry treatment

47

What is the low risk foot? A low risk foot has normal sounding, regular pulses detected by doppler, full sensation, no history of ulceration and no significant foot deformity. Annual review of the low risk foot Screening will include:

• Inspection for foot deformity and associated foot lesions • 10mg monofilament sensation, pin prick and vibration. • Doppler of foot pulses • Examination of footwear • Basic foot care education

Who will assess the low risk foot? A Podiatry assistant, competency trained to examine foot pulses and foot sensations will carry out the annual review. A patient with a low risk foot has no clinical need to see a Podiatrist. What actions will follow from the annual foot review? See flowchart on page 7. What will be done if foot pathologies are present? If additional risk factors are present i.e. foot lesions and functional foot deformities a referral will be made to the community Podiatry department for treatment and they will be re-assigned with a risk factor of at increased risk. Footwear If there is a problem with footwear, advice and leaflets will be provided for retail shoes. Education Foot care education will include:

• Nail care • . Emollient use• Footwear. • How to undertake daily self-examination of the feet. • What to do and who to contact if foot problems develop. Dispense appropriate leaflets to reinforce the education. •

48

low chart of the low risk foot pathway

F

Annual Review by Podiatry Assistant

ear o Foot care education

o Doppler foot pulses o Neurological tests o Inspect feet and footw

Normal Review in 12 months

Reduced sCheck for deformity, ca

ensation

llous

Absent Pulse Check pulseso with doppler

Uo referral to

o dress with dry dressing

Triphasic/BiphasiReview i

c o n 12

months

Reclassify as ulceratPodiatrist to provide woundcare as per Trust Wound Formulary. Once heale

ed.

d classify as at high risk

Monophasic o Reclassify as at High

o or

nt and annual

o Educate appropriately

Risk Refer to podiatrist at local health centreDiabetes Centre/ PRCHC for ABPI, treatmereview

lceration Immediatepodiatrist If ulcer uncovered or redness

o risk

o

o if

o Review 12 months

Re classify as atincreasedEducate appropriately Refer to podiatrist at local health centre, treatment required

49

50

The t Wh i

a Increased Risk Foot

at s the at increased risk foot? An at increased risk foot has either a reduction in foot sensation OR absent palpable pulses.

here will be other additional risk factors which may include smoking, high HbA1c, living ities or pathogenic nails.

– 12 month review of the at increased risk foot

Talone, sight problems, foot lesions, functional foot deform 6

creening will include:

• Inspection for foot deformity and associated foot lesions • 10mg monofilament sensation, pin prick and vibration.

r of foo u• Examination o o• Enhanced foot care education

ho will assess the at increased risk foot?

S

t p lses. f f otwear

• Dopple

W

y assista y tra ine fo d foo out the annu

hat actions w

A Podiatrcarry

nt, competencal review.

ined to exam ot pulses an t sensations will

W ill follow from the annual foot review?

ee flow chart on page 9.

hat will be done if foot pathologies are present?

S W

additional risk factors are prese ot lesions and functional foot deform l ill be made to the community Podiatry department for treatment. If diabetic eformity is present, the risk factor will be re-assigned to at high risk.

ootwear

Ifw

ities a referrarelated

nt i.e. fo

d F

there is a pro ion and advice will be provided at thppointment. I t Orthotics ill e required.

ducation

If blem with footwear, educat at review

department wa f re ail footwear is inappropriate a GP referral to theb E

oot care education will include:

• Nail care. • Emollient use. • Footwear. • Checking footwear and hosiery before putting them on. • Checking bath temperature. • Not walking with bare feet. • “Breaking shoes” in gradually. • Avoidance of home remedies e.g. corn plasters.

F

daily self-examination of the feet. • What to do and who to contact if foot problems develop.

flets to reinforce the education. • Ensure patient has emergency contact details.

oot pathway

• How to undertake

• Dispense appropriate lea

Flow chart of the at increased risk f

oooo

NoReview in 12 mo

new findings

nths

Newcalloredne

o Reco Eduo Refe

revie

Annual Review by Podiatry Assistant

footwear tion

Doppler foot pulses

ical tests Neurolog Inspect feet and

Foot care educa

51

deformity, us or ss

Changes in sensation

Changes in pulses

Ulcer o Immediate referral to

podiatrist o If ulcer uncovered

dress with dry dressing

lassify as at High Risk cate appropriately r to Podiatrist for treatment and future annual w

Reclassify as ulcerated. Podiarist to provide woundcare as per Trust wound

s at high risk

formulary. Once healed classify a

52

The t

hat is the at high risk foot?

a High Risk Foot

W

n at high risk foot has a diabetes related deformity plus either a reduction in monofilament ensation OR pulses tion. If there is a istory of previous ulc as at high risk.

nnua

As that are monophasic following Doppler examina

eration the foot will automatically be classified h A l review of the at high risk foot Examination will include:

• Inspection for foot deformity and associated foot lesions • Inspection for foot ulcer• 10mg monofilament sensation, pin prick and vibration. • Doppler examination of• Examination of footwear •

the at increased risk foot?

ation

foot pulses

Enhanced foot care education Who will assess

y Podiatrist will re igh risk foot annually. This will be undertaken when e patie attends their regula appointment at arest health centre.

hat actions will follow from the annual foot review?

A communit view the h

r clinical th their nent W

he nd a report of the review to the GP fo ecords. See age

ha one if foot pathologies are present?

T Podiatrist will se

11.

t will be d

r their r flow chart on p W

ulceration is present, treatment will automatically be provided at the appointment with ferral to the DMC, CRH or PRCHC, Huddersfield if ac quired to the multi-

isciplinary team.

ootwear

Ifred

cess is re

F

accommodative footwea oles are required, a GP referral to the rthotics department will be requested.

ducation

If r with pressure relieving insO E

oot care education will include: • Nail ca• Emollient use. • Footwear. • Checking footwear and hosiery before putting them on. • Checki g b h• Not wa in• “Break g • Avoidance of home remedies e.g. corn plasters. • How to undertake daily self-examination of the feet.

F

re.

nlk

at temperature. g with bare feet. shoes” in gradually. in

d who to contact if foot problems develop. • Dispense appropriate leaflets to reinforce the education.

low chart of the at high risk foot pathway

• What to do an

• Ensure patient has emergency contact details. F

All at high risk

o Treat o Revie

o Annu

o Feed

Diabetes related deformity

Podiatrist receives referral from Podiatry assistant

Referral to Orthotist for appropriate footwear

Annual review by Podiatrist

tests oo Foot care education

o Doppler foot pulses o Neurological

Inspect feet and footwear

p

me

w

al

ba

Symptomatic circulatory status

Ulceration

Absent sensation

53

atients to be offered regular podiatry treatment.

nt every 4 – 6 weeks.

feet for any changes at each treatment.

review by Podiatrist at treatment appointment.

ck to GP

Referral to vascular surgeon

Follow Trust wound Formulary Feedback to GP ABPI

54

he Ulcerated Foot

ll patients with foot ulceratio he nearest cal Podiatry department by ee appen

Patients will be seen within 2 the next working da If there are clinical signs of infection, antibiotics should be started immediately.

nce a foot ulcer has occurr in in the H h Risk category.

oundcare Management

T A ns will be referred to t lotelephone or fax. (S

dix 1 on Page 13).

4 hours or on y.

O ed the patient will rema ig W Woundcare management regimens will be compliant with the Calderdale and Huddersfield

HS Trust wound Formulary

• Control of infection • Regular woundcare de dressing properties an• Multidisciplinary woundcare management Vascular status with referral to vascular surgeon following ABPI as appropriate

lief and off- otics • Footwear • Glycaemic control • Education Prevention of future ulc

N and will include:

pendant on d healing stage

•• Pressure re loading using orth

• eration occuring

55

eferr

odiatry Hospital Base

R al Information P Specialist Podiatry

iabetes Team

Podiatry Department

Calderdale Royal Hospital Salterhebble Halifax HX

22 224375

Fax: 01422 222035

DDiabetes Medical Centre Tel: 014

3 0PW Podiatry Community Bases Laura Mitchell H.C

PodLauGre

Tel: 01422 305537

iatry Department ra Mitchell HC at Albion Street

Halifax HX1 1YR

Fax: 01422 305562

Brighouse HC

Lawson Road

HD6 1NY

Tel: 01484 712515

84 728953

Podiatry Department Brighouse HC

Brighouse Fax: 014

Todmorden HC

Podiatry Department Todmorden HC Rose Street Todmorden OL14 5AT

Tel: 01706 815717

Fax: 01706 819646

Orthotics Department

Community Support Centre

Halifax HX3 0QB

306708

Fax: 01422 350900

Salterhebble Hill Tel: 01422

Podiatry Manager Calderdale

Debbie Wolfe St Johns HC Lightowler Road Gibbet Street Halifax HX1 5NB

Tel: 01422 307310 Fax: 01422 330918

Diabetes Lead Huddersfield

Tracy Baines Department of Foot Health

ersfield

Tel: 01484 344231 Fax: 01484 344338

Princess Royal CHC Greenhead RoadHuddHD1 4EW

Orthotics Department ary Tel: 01484 342402 Fax: 01484 347089

Huddersfield Royal InfirmLindley Huddersfield HD3 3EA

56

FOOTCARE PATHWAY FLOW CHART OF THE AT HIGH RISK FOOT PATHWAY - AT A GLANCE

Podiatrist receives referral from Podiatry assistant

Diabetes related deformity

Annual review by Podiatrist -- e Doppler foot pulses N urological tests

- Inspect feet and footwear - Foot care education

Referral to Orthotist for appropriate

footwear

Absent sensation Symptomaticcirculator

y status

ABPI

Referral to va

All at highoffered retreatment: - Treatment every 4-6 weeks - Review feet for any changes

at each treatment − Annual review by Podiatrist

at treatment appointment − Feedback to GP

-risk patients to be gular podiatry

scular surgeon

Ulceration

Follow Trust wound Formulary

Feedback to GP

57

FOOTCARE PATHWAY FLOW CHART OF THE AT INCREASED RISK FOOT PATHWAY - AT A GLANCE

No new findings eview in 12months

Reclassify as ulcerated. Podiatrist to provide care as per Trust wound formulary. Once

healed classify as at high risk

New deformity, callous or redness

Changes in sensation

Changes in pulses

Ulcer - Immediate

referral to podiatrist

ss essing

- If ulcer uncovered drewith dry dr

− Reclas− Educate

sify as at High Risk appropriately

− Refer to Podiatrist for treatment and future annual review

Annual Review by Podiatrist

− Inspect feet and footwear

Assistant: - Doppler foot pulses − Neurological tests

- Foot care education

R

58

CARE PATHWAY FOR THE MANAGEMENTIN PEOPLE WITH DIABETES

OF RENAL DISEASE

Test urine for microalbuminuria Screen for microalbuminuria by me

albumin/creatinine ratio on overnight If positive, confirm by demonstrating at

tests in 1 mo

All newly diagnosed type 2 patients Type 1 patients 5 years after diagnosis

asuring the first void samples t pe

least 2 pnth.

Exclude other causes i.e. urinary tract infections, other

y ositive of 3

kidney disease etc.

Routine care Arrange recall and annual review

Is microalbuminuria present? No

Yes

• Document it and identify the patient as high cardiovascular risk g (accepting that many patients are unable to blood pressure lowering medication - ACE-

antagonists if not tolerated) as the first choice irrespective of blood pressure

• Tighten glycaemic control (below 7% HbA1c according to individual’s target) • Stop metformin if creatinine > 140 mcmol/l • Intensive management of cardiovascular risks smoking cessation, dyslipidaemia and

physical inactivity

• Aim for a blood pressure of 130/75 mmH

achieve this target) by using aggressive inhibitors (or angiotensin II receptor

Consider Referral to Diabetes Specialist

If targets are not reached • Intensify treatment • Consider insulin therapy if HbA1c >7.5mmol/l and rising • Reassess in 3 – 6 months

Diabetic Nephropathy with one of the following • eGFR < 30 • Plasma creatinine >200 mcmol/l or plasma urea>20

mmol/l • Plasma potassium>6 mmol/l on a non-haemolysed

(hospital ) sample • Hyperphosphataemia or hypocalcaemia • Heavy proteinuria (1g in 24 hours) • Renal impairment with haemoglobin<10g/dl and normal

haematinic values • Uncontrollable hypertension (>150/90 on 3 agents) • Suspected non-diabetic renal disease • Suspected renal artery stenosis

Refer to Nephrologists

Dr Mark Wright Leeds General Infirmary

It is impgroup oespeciafirst detection of any diabeticnephropathy, that any risk fact rs should be addressed ie: Glycaemic

control (HbA1c<7%)

Control f hypertension (<130/75 mmHg)

Lipid assessment Total Cholesterol <5, LDL <3

Smokin cessati(advised)

Following reassessment • Blood pressure targets not

achieved • Glycaemic control remains poor • Creatinine levels are elevated

and rising

Microalbuminuria in diabetes is a key marker of cardiov risk ascular

ortant in this f people lly at the

o

o

gon

59

Definitions Diabetic Renal Disease The presence of raised urine albumin levels or raised serum creatinine in type 2 diabetes indicates an increased risk of premature cardiovascular events and, to a lesser extent, end stage renal disease. If the person has also signs of

disease. If retinopathy is not present, the probability of

Lower-risk ur

protei ria low Higher-risk uMicroalbuminequal to 2.5mg/mmol (men) or 3.5mg/mmol (women), or albumin conceand/or Proteinuria –to 30mg/mmol or albumin concentration greater than or equal 200m

retinopathy, it is likely that the raised urine albumin and raised serum creatinine is resulting from diabetes-related renal another renal disease increases.

ine albumin excretion People who have levels of microalbuminuria and/or

nu er than those indicated below.

rine albumin excretion uria – albumin:creatinine ratio greater than or

ntration greater than or equal to 20mg/l

albumin; creatinine ratio greater than or equal

to g/l.

Screening for Nephropathy • Screen when free of acute, intercurrent

illness

ly morning urine sample dipstick

Check for urinary tract infection

If dipstick negative

) itive, confirm by

demonstrating at 2 positive of 3

• Collect an ear• Check for protein using a

oo Obtain a laboratory urine protein :

creatinine ratio (PCR)

o Check for microalbuminuria usinglaboratory urine albumin : creatinine ratio (ACR

o If pos

tests in 1 month

60

(DKA) and Hyperosmolar Non-Ketotic Coma (HNKC)

Management of Diabetic Ketoacidosis

DKA and HNKA are life threatening conditions requiring prompt diagnosis and treatment and should be excluded in all diabetics who are hyperglycaemic, dehydrated, drowsy or vomiting or presenting with abdominal pain, myocardial infarction or stroke. DIAGNOSIS: Blood glucose >11.1 mmol/L (or known diabetic), Blood gas analysis mandatory (pH <7.30, Bicarbonate <15 mmol/l), Urine ketones >++. (Rarely DKA presents in acidotic, ketostix – ve patients). In non-acidotic patients consider HNKC. Osmolality (= 2xNa+ + 2xK+ + Glucose and Urea) > 350 mosmole, Bicarbonate >15 mmol/l, Urine ketones <++. INVESTIGATIONS: Lab blood glucose, U&E, serum bicarbonate, urine ketostix, blood count, ECG, CXR, msu, blood cultures. INITIAL MANAGEMENT: Initial management of DKA/HNKC is identical. Management must be started in casualty without delay and the medical registrar contacted promptly. Consider ITU/HDU if patient confused / unconscious , Hypotensive (BP<90) or bicarbonate < 10 mmol/l INSULIN: Start insulin infusion 6 unit/h (50u Actrapid in 50 ml saline (discard 10 ml through connecting tubing before

attaching to patient because insulin binds to plastic). If no fall in blood glucose at 4 hours, increase to 10 unit/h. When blood glucose - <20 mmol/L, reduce dose according to the sliding scale overleaf.

FLUIDS: KEEP PATIENT NIL BY MOUTH – IVI N Saline in the following sequence: (Litre : hour) 1:1,1:2, 1:4, 1:8 (repeat 1:8).

Hypovolaemic patients who remain hypotensive (systolic <100) after 2 litres of fluid, consider plasma expansion with 1 or 2 additional units of 4.5% human albumin or Haemacell. Elderly/cardiac/renal disease patients – Exercise great caution. Reduce rate (4 litres in 24 hours) and monitor CVP. If Sodium high and remains >160 mmol/L 2 hours after onset of therapy consider ½ N saline. (No more than 2 litres). Bicarbonate: RARELY NEEDED: If life threatening acidosis (pH<7.0) not responding by 2 hours of above fluid management consider 200 ml, 2.74% HC03 + 20 mmol KCI over 30 minutes (contact consultant on-call first).

Nurses should check pump/connections every hour and document remaining volume. POTASSIUM: No K+ in the first litre. Subsequently add as follows:- Serum K+ <3.5 3.5 – 5.5 >5.5 KCL (mmol) per litre bag of fluid 40 20 0 ANTIBIOTICS: Consider using broad spectrum. Note, normal markers of infection unreliable, ie pyrexia – patient often

hypothermic, WBC – usually high even in absence of infection. HEPARIN: Use sc low molecular weight Heparin – prophylactic dose in DKA and therapeutic dose in HNKC. CATHETER: If npu in 4 hours. NG TUBE: Avoid unless patient comatose and vomiting. If required, insert in head-down, left lateral position and

aspirate hourly. MONITORING ECG monitor. Blood glucose (BM stix)/obs, fluid balance hourly. VENOUS SERUM BICARBONATE, U&E, LAB BLOOD GLUCOSE 2 HOURLY UNTIL pH AND K+

NORMAL. CVP in elderly/cardiac/renal patients. RECOVERY PHASE: FLUIDS When blood glucose < 15 mmol/L; change ivi to 5% dextrose. (Note: There is rarely a need to change the

ivi back to N Saline: If the blood glucose raises, increase the insulin as per sliding scale). If glucose runs low change to 10% dextrose – do not stop insulin.

Blood glucose target range 5 – 10 mmol/L. DIET Commence oral fluids when pH normal and patient alert and not vomiting. Allow food after 24-36 hours. SC INSULIN Once blood sugar stable and ketones clear for 24 hours, consider sc Insulin. Patients previously on insulin,

increase usual total daily dose by 10%. Give in 4 equally divided doses of short acting insulin (Actrapid) before the 3 main meals and intermediate acting insulin (Insulatard) at night. Patients not previously on insulin, estimate the total daily insulin requirement as the stable hourly insulin infusion rate x 24 and give in 4 divided doses as above. Remember to continue the IV insulin /dextrose infusion for 1 hour after the first sc insulin dose.

ADMISSION: ITU if the patient is in a coma / HDU if patient confused / unconscious , Hypotensive (BP<90) or bicarbonate < 10 mmol/l otherwise keep in MAU whilst in “Initial management” phase. To ward 5a, 5b, 5c, 5d (Dr Bangar/Dr Mousa). REFER Diabetes Registrar, Diabetes Specialist Nurse and Dietician, via Diabetes Centre

61

HRI refer to Dr Burrows or Dr Mandour’s Teams

INTENSIVE DIABETIC THERAPY RECORD NB – Insulin must be prescribed on m ne prescripti t i normal ma

BMS <4.0 4.0 - 1 1 12 - 15 16 - 19.9 20+

edici

9.9

on ch

1.9

ar n nner

– 6.9 7 0 - .9 RATE - (mmol/L) 0.5 3 5 6 1 2 4

Date

Time

Blood Glucose (mmol/L)

Insulin Infusion (unit/h)

I.V. Fluids (Additi

K U HA

E )

& ves)

UrinKet

e ones

Na rea PH CO-

BG(

SOR RUM

LS

ab ug

ar

CVP Signature

00.00 01.00 * * * * * 02.00 03.00 * * * * * * 04.00 * 05.00 * * * * * * 06.00 * 07.00 * * * * * * 08.00 * 09.00 * * * * * * 10.00 * 11.00 * * * * * * 12.00 * 13.00 * * * * * * 14.00 * 15.00 * * * * * * 16.00 * 17.00 * * * * * * 18.00 * 19.00 * * * * * * 20.00 * 21.00 * * * * * * 22.00 * 23.00 * * * * * * 24.00

60

CALDERDALE AND HUDDERSFIELD NHS TRUST

SURGICAL GUID A

DIABETES ELINES

t Preoperative Assessment All patients to have an HbA1C test A

rov agemic

betics to diabetes nurses if not a

P

of su. Co

P

rn to or

intake is less operatively and plan

dar p ho are type II on insulin toh)deer

ll patients with an HbA1C of more than 7.5%

Look at trend of HbA1C results – no action if imp If type II dia

ing betic on single oral hypoglycaemic

If type II diabetic on maximum oral hypoglycaent, refer to GP agents, refer to diabetic nurses

If on insulin, refer to diabetic nurses

Refer all type 1 dia lready on Glargine

lanning for Day of Operation

Stop Metformin 48 hours before surgery Omit other oral hypoglycaemic agents on day rgery

mmence Sliding scale if BM > 10 Measure blood glucose on arrival and 4 hourly(see sliding scale guidelines)

atients Who are Taking Insulin

Patients should be first on the list if possible If surgery is day surgery presume rapid retu al intake post operatively

likely post For major surgery presume rapid oral for sliding scale (see guidelines)

In each case give insulin as normal the previous y atient w

1

For day surgery cases patients taking Glargine oaim to avoid sliding scale by empowering patientpost operative

take a dose of insulin with food ly (like a delayed breakfast or lunc

For all diabetic patients, hypoglycaemia may be Ribena, non-fizzy Lucozade up to 2 hours pre-op

alt with by oral sugary fluids (e.g atively)

61

For diabetics on insulin

Morning surgery fwith an HbA1C of less than 8.5%

eryor minor operations on patients Morning surg for major surgery or patients with an HbA1C of more than 8.5%

Patient to take normal insulin day before surgery ds / non-clear fluids from 12

Blood sugar monitoring on arrival at hospital, If blood

s possible post operatively

frequency as required.

surgery1 unless having bowel prep gar

monitoring on arrival. Starve patient of solid foods / non-clear fluids 12 midnight the night before

o 6am 0am or earlier if

glucose>10. (see sliding scale guidelines) , monitor blood sugars

Patient to progress to diet and subcutaneous insulin as soon as possible post-operatively.

Patient to take normal insulin day before

Starve patient of solid foomidnight the night before Patients can have clear fluids up to 6am

Admit day before surgery. Blood su

sugar is satisfactory, monitor 2 hourly Patient to be first on list, anaesthetic technique to avoid nausea.

Patients can have clear fluids up tStart sliding scale at 7.3

Patient to eat as soon aInsulin given with late Breakfast or early lunch. Check blood sugars 2 hourly at first and adjust

Patient to be first on listhourly

Afternoon surgery for minor operations on patients with an HbA C of les1

s than 8.5% Afternoon surgery for major surgery or patients with an HbA1C of more than 8.5%

sulin day before surgery

bt of long acting insulin

y, monitor 2 hourly esthetic technique

Insul te lunch or early evening mealBlood sugar monitoring 2 hourly at first, adjust frequency as required

Patient to take normal insulin day before rgery1 unless having bowel prep

Starve patient of solid foods / non clear fluids

Patient to take ½ the normal dose of Mix insulin with breakfast To take normal amount of long acting insulin analogue / Actrapid, NovoRapid / Humalog with

Clear fluids up to 11.30am Admit 9:00am Blood sugar monitoring on arrival Start sliding scale at 12 midday or earlier if

0. (see sliding guidelines) Patient to be first on list, monitor blood sugars hourly at first. Adjust blood sugar monitoring as required Patient to progress to diet and subcutaneous insulin as soon as possible post-operatively

Patients who are nil by mouth and who are undergoing bowel preparation would need sliding scale from the start of the bowel preparation1.

Patient to take normal inStarve patient of solid foods / non clear fluids from su7.30am Patient to take ½ normal dose of Mix insulin with

reakfast. from 7.30am

To have normal amounanalogue / Actrapid, NovoRapid / Humalog with breakfast Patient to have Clear fluids up to 11.30am breakfast

Blood sugar monitoring on arrival at hospital, If blood sugar satisfactorPatient to be first on the list, anato avoid nausea. Patient to eat as soon as possible post operatively glucose>1

in to be given with la.

scale

62

ND HUDDERSFIELD NHS FOUNDATION TRUST

Women’s Services Intrapartum Guidelines

c Patient

r, r induction of labour or for elective caesarean section.

of

cope of the guideline

Page

CALDERDALE A

Intrapartum Management of the Diabeti

Purpose of the guideline Guidance to the management of diabetic pregnant patients admitted in spontaneous laboufo Locations where this guideline applies The guideline applies to all midwifery, medical staff and support staff involved in the care pregnant women at Calderdale Royal Hospital and Huddersfield Royal Infirmary. SThe guideline will cover the management of diabetic patients who are admitted in spontaneous labour; are admitted for induction of labour or for caesarean section.

Table of contentsName and purpose of guideline 1 Location where guideline applies 1 1. Definitions of diabetes 2 2. Guidance at a glance 2 Algorithm Glycaemic Control of diabetic patient intrapartum 7 Details of recommendations and supporting evidence 8 1. General points intrapartum management of women receiving insulin

tre8

atment 2. Sp 9 ontaneous labour 3. ucInd tion of labour. 10 4. Sliding scale regimen for the management of spontaneous / induction

labour 11

5. Elective LSCS. 12 6. Emergency Caesarean Section 12 7. Postpartum Management 13 8. Em

b. Hypoglycaemia

14 15 15

ergency admission of diabetic pregnant women not in labour a. Hyperglycaemia

References 1Guideline development group

List of interested groups Distribution details

Training

18 18 18 19

7

63

Type 1Usually diagnosed less than 30 yrs of age and often in childhood and the only treatment option is insulin therapy. Ketonuria will develop rapidly if insulin is omitted. Type 2 Diabetes: Predomtreatment Gestational Diabetes (GDM) Abnormality of glucose metabolism first identified during pregnancy. The Diagnosis of true GDM is always made in retrospect following a normal Oral Glucose Tolerance Test (OGTT) after delivery, as occasiona t can occur or be detected just by chance during pregnancy. All women with diabetes in pregnancy should have been managed at the antenatal diabetic clinic. A plan for the management of labour will have been decided and inserted in the hand held records and/or h pformulated the follow 2. GUIDANCE AT A a) Spontaneous labour

Tight blood glucose control during labour reduces the risk of neonatal hypoglycaemia. Aim to maintain blood sugars between 4 - 7 mmols during intra -partum period.

Level 3

ld be allowed to eat normally and should take their usual insulin dose until established in labour.

Monio B / litre @ rate of 125mls per hour. o B

e insulin when labour is established (i.e. regular contractions

and c The registrar should be informed of all diabetic patients admitted to the delivery suite.

Paed Women should be offered continuous electronic fetal monitoring in labour.

Labo w

caesarean section if there is delay in labour with a large baby. Registrar should be livery suite at delivery because of the risk of shoulder dystocia.

Level 3

1. DEFINITIONS

Diabetes:

inately affects the obese or overweight person. In the non-pregnant state several options are available but insulin therapy is the only treatment option in pregnancy.

lly ype 1 or type 2 Diabetes

os ital case notes. If the woman presents prior to the plan being ing guideline can be used.

GLANCE

.

Women admitted in spontaneous labour shou

tor capillary blood glucose (BG) 2 hourly if not established in labour. G <4 commence 5% dextrose 20mmol potassiumG >10 commence sliding scale.

Level 3

Commence IV sliding scalervix dilated > 3 cms.).

iatrician should be advised and should attend for delivery.

Level 3

ur ard staff should be aware of the possibility of shoulder dystocia, consider

present on the de

64

a)

1. Induction of labour- there are no RCTs to give clear evidence for the optimum ng

basis.Level 3

2. The patient will usually have been assessed in the antenatal clinic or on the ward

so the method of induction should be documented and an induction of labour form pl

Level √ Patients who need prostaglandins:-

To have normal morning insulin and breakfast.

in labour abour give usual

P planned for amniotomy reakfast at 07.00hours and usual dose of rapid acting insulin.

o it to delivery suite at 07.30 hours. o IV line and infuo Following amniotom

er 1 hour in sence of ute activity commence enous oxytocin using normal saline vehicle for oxytocin h a separate IV line. Follow the norm regime as for uctions.

b) Elective Caesarean Section

The day before planned caesarean section:

o Normal diabetic meal and insulin the day before caesarean section.

o Admit th ning before the d

o Fast from 12 Midnight if any episodes of hypoglycaemia can be given Lucozade.

rly If <2 or >17 must check laboratory blood glucose and

o Commence 5% Dextrose with 20 mmol potassium /litre at a rate of

o Maintain the glucose infusion constant throughout.

o Aim to keep blood glucose between 5- 6 mmol

Induction of labour

timi of delivery. The timing of delivery should be determined on an individual

com eted.

oo Monitor BG 2 hourly. o Reassess at time of next insulin dose/ meal if established

commence sliding scale, if not established in linsulin and meal.

atients who areo Light b

and oxytocin:-

Adm Site sion with normal saline at 125 mls. /hour.

y commence sliding scale. the abo If aft

intravrine as

throug al oxytocin all ind

e eve ay of LSCS.

The morning of delivery:

o Omit morning (pre breakfast) insulin.

o Chart BG levels houU&E.

125mls/hour.

o Commence sliding scale regime 1 hour prior to theatre (see table above fordose regime).

During delivery:

65

for the glycaemic control of diabetic patients admitted either in spontaneous labour, for induction of labour or caesarean section

% dextrose with 20 mmol potassium chloride /litre at a rate of

125mls/hour.

U insulin).

ng bedside monitoring. If Blood glucose < 2mmol/l or >17mmol/l send blood sample to the laboratory for blood

6 hours.

d) Sliding scale regimen

Commence 5

Commence 50units of Human Actrapid or Humulin S mixed with 50 ml of 0.9% saline via a syringe driver. (1ml = 1 I

Monitor blood sugars hourly usi

glucose estimation.

Check urea & electrolytes (U&E) every 4-

Adjust insulin infusion rate based on blood sugar results.

Blood Sugar (mmols)

Insulin Rate (units/hr)

0- 4.0 0.5 change to 10% dextrose solution at 200mls /hour

4.1-5.9 0.5

6.0 -7.9 1

8.0-9.9 2

10.0-11.9 3

12.0-14.9 4

15.0-16.9 5

>17 6.0 contact the diabetic team or on call medical

registrar check urea and electrolytes

Note: If the sliding scale above does not produce desirable effect, seek advice from

ions on treatment chart and patient notes.

im to keep blood glucose to between 4 – 7 mmol/l.

.B. Do not omit insulin as there is a risk of rapid ketoacidosis, if unsure, seek emeror the c pm till 9

the diabetes team to modify the sliding scale and note alterat

A N

gency advice. For diabetes related issues contact the diabetes specialist nurse onsultant diabetologist during the day and the medical registrar on call from 5 am.

66

e) Po

Po r induction of labour) for insulin dependent diabetics (Type 1&2)

the placenta is delivered immediately halve the insulin infusion rate and

insulin and adjust the insulin rate using the sliding scale according to the blood glucose.

3. Give pre-pregnancy insulin dose next time subcutaneous insulin would be due (e.g. ucose infusion and

sliding scale one hour after s/c insulin injection.

5. Breastfeeding mothers need to increase carbohydrate intake and possible need for o avoid hypoglycaemia.

ther and need only to be admitted to the Special Care Nursery if there is a specific medical indication.

7. The neonatal blood glucose should be measured soon after birth (within 30 min), urs.

8 ement of hypoglycaemia of the baby, follow Hypoglycaemia Care Pathways for Newborn Infant.

Gestational Diabetes

Non insulin dependent diabetics/ Insulin dependent diabetics (Type 1&2)

1. When the placenta is delivered immediately halve the insulin infusion rate and continue with the intravenous glucose and insulin and adjust the insulin rate using the sliding scale according to the blood glucose.

2. Oral fluids may be given 4 hours post delivery and solid food 6 hours provided the patient is not vomiting and observations are stable.

3. Continue the sliding scale insulin infusion until the following morning. Monitor blood sugars hourly for 6 hours post operation if blood sugars between 4 – 11mmol/l reduce to 2 hourly blood sugars.

stpartum management

st vaginal delivery (spontaneous o

1. When continue with the intravenous glucose and

2. Can eat normal diabetic diet and drink

delivers 2pm insulin given pre evening meal). Discontinue IV gl

4. Monitor blood sugars pre-meals and liaise with the diabetic team.

reduced insulin doses t

6. The baby should remain with mo

hourly for 3 hours and regularly thereafter for 24 ho

. For manag

1. Discontinue insulin pump and glucose infusion immediately post delivery.

2. Monitor blood sugars pre-meals for 24hrs if <8 mmols discontinue, if high contact the consultant diabetologist.

3. OGTT to be arranged 6 weeks post-delivery.

4. Arrange for outpatient review in diabetic clinic following OGTT.

Post Caesarean Section

4. If at this time patient is tolerating food and fluids, give subcutaneous insulin (pre-pregnancy insulin regime) and discontinue IV glucose infusion and Sliding Scale one hour after s/c insulin injection.

5. Follow guidelines above for after vaginal delivery from 3 onwards

6. Gestational diabetes as described above.

Post natal contraceptive advice to be given post-delivery and reviewed at 6 week post-natal check (at GP surgery). Patients return to routine diabetes care following delivery. f) Emergency admission of diabetic pregnant women not in labour

All diabetic patients who have unscheduled admission to the labour ward must be discussed with the on call consultant.

History and examination

Urinalysis for ketones and protein.

Maternal blood for:

a. Haemoglobin, haematocrit and white cell count.

b. Glucose

c. Urea & electrolytes + bicarbonate

d. Other blood tests that may be indicated from history and examination.

Confirm fetal viability and perform fetal cardiotocograph.

Plan of management must be documented prior to discharge home or transfer to the ward.

Note diabetic women are more prone to infection in pregnancy. Any signs of infection should be treated early and diabetic control monitored carefully as there is a risk of ketoacidosis.

Call the medical registrar for management of profound hypoglycaemia or ketoacidosis.

67

68

Algorithm: Glycaemic control of diabetic patient intrapartum

69

taiwith 1. Ge

re nd during pregnancy. Type 1 diabetes is associated with

increased risk of complications of diabetes, such as ketoacidosis,

ications. There is also

increased risk of obstetric complications, such as pre-ecalmpsia, prematur

spontaneous miscarriage, obstructed labour, polyhydramnios and maternal infection.

distress syndrome and

jaundice.1,3,5,9.

All women with diabetes should be delivered in the consultant-led unit and a co

physician and neonatologist should be available. The consultant obstetrician should be

informed of all diabetic patients admitted to the delivery suite/LDRP.

In the intrapartum period tight blood glucose control during labour reduces th

mia. Aim to maintain blood sugars between 4 - 7 mmols during

Level 3

Be aware of development of obstetric complications and early involvement of a

cons

risk in pregnancies with maternal complications of diabetes (e.g., vascular disease or 3,4,9

Level 3

to inform the optimal timing for delivery and the timing is based on individual patient 2,4,5,6

Level 3

De l of recommendations and supporting evidence (and reasons for not complying national guidance). neral points of management intrapartum

An optimal outcome may be obtained in diabetic pregnancy if excellent glycaemic

control is achieved befo a

severe

hypoglycaemia and progression of any microvascular compl

e labour,

Fetal complications include late intrauterine death, fetal distress, congenital

malformation, neonatal hypoglycaemia, respiratory

Refer to the antenatal management of diabetic pregnancy for details of

recommendations for management.

nsultant

1,3

e risk of

n onatal hypoglycaee

intra -partum period.3

ultant obstetrician is essentially in the overall management. The fetus is at greater

renal disease) or obstetric complications (e.g. pre-ecalmpsia).

Delivery is usually expedited within 40 weeks gestation and there is no clear evidence

progress during the antenatal period.

70

e

When steroids are indicated there should be in patient supervision of blood glucose

a slid g

Women

Level 1b

Estimated fetal weight >4.5kg is generally regarded as an indication for delivery by

elect

These patients are high risk and the progress in labour should be

conti

inform t of fetal heart

Grade √

nt in the

management intrapartum should be vigilant to any signs of delay in progress.3,5,9

2. Spontaneous labour

Women with diabetes in pregnancy who are at risk of preterm delivery should receiv

antenatal steroids, using betamethasone as detailed in preterm labour guidelines.

control and it is essential to regulate the diabetic control which may involve the use of

in4,5.8.

scale regime.

Level 2 with diabetes have a higher rate of caesarean section.

ive caesarean section.

Level 2

monitored along with

nuous electronic fetal monitoring of the fetus. The consultant should be kept

of any deviations from normal progress or developmened

abnormalities.

Shoulder dystocia is a significant risk factor and all staff involveme

Level 3.

Women should be allowed to eat normally and should take their usual insulin regime

o B e 5% dextrose 20mmol po of 125mls per hou

o BG >10 commence sliding scale.

The progress in labour should be reassessed at time of next insulin dose/ meal and if they are established in labour commence a sliding scale, if not established in labour give usual insulin and meal.

Commence IV sliding scale insulin when labour is established (i.e. regular contractions and cervix dilated > 3 cms.)

3. Induction of la

until they are established in labour.

Monitor capillary blood glucose (BG) 2 hourly.

G <4 commencr.

tassium/ litre @ rate

bour.

Normal diet and insulin day prior to induction of labour.

Induction of labour in a diabetic patient must be treated as priority.

71

the method of induction should be documented on the induction of labour forms and in th

P

ove. labour

commence sliding scale, if not established in labour give usual insulin and

xytocin:-

o Light breakfast at 07.00hours and usual dose of rapid acting insulin. ours.

g scale insulin regime and change IV of

125mls/hour. ur in the absence of uterine activity commence intravenous

vehicle for oxytocin through a separate IV

. Slid r for caesarean section

5% Dextrose with 20 mmol potassium chloride /litre at a rate of

Commence 50u of Human Actrapid or Humulin S mixed with 50 ml of normal saline via

The patient will usually have been assessed in the antenatal clinic or on the ward so

e maternity records. A risk assessment form should also be completed.

atients who need prostaglandins

o To have normal morning insulin and breakfast. o Monitor BG 2 hourly and manage as detailed abo Reassess at time of next insulin dose/ meal if established in

meal.

Patients who are planned for amniotomy and o

o Admit to delivery suite at 07.30 ho Site IV line and infusion with normal saline at 125 mls/hour. o Following amniotomy commence slidin

infusion to 5% dextrose with 20 mmol potassium chloride /litre at a rate

o If after 1 hooxytocin using normal saline asline. Follow the normal oxytocin regime as for all inductions.

4 ing scale regimen for the management of diabetic patients in labour/ induced o

Commence125mls/hour.

a syringe driver. (1ml = 1 IU insulin).

Monitor blood sugars hourly using bedside monitoring.

Check urea & electrolytes (U&E) every 4-6 hours.

Adjust insulin infusion rate based on blood sugar results.

Blood Sugar (mmols)

Insulin Rate (u/hr)

0- 4.0 0.5 Change to 10% dextrose solution at 200mls/hour

4.1-5.9 0.5

6.0 -7.9 1

8.0-9.9 2

10.0-11.9 3

12.0-14.9 4

15.0-16.9 5

>17 6.0 Contact the diabetic team or on call medical registrar.

Check urea and electrolytes

72

Note tthe

NB Do seek em For diabetes related issues contact the diabetes specialist nurse or the consultant diabetologist during the day and the medical registrar

ncontact Dr Hamilton @ CRH and Miss Bhabra @ HRI during the day or the on

al 5. El iv

If he sliding scale above does not produce desirable effect, seek advice form diabetes team to modify the sliding scale and make a note of it. not omit insulin as there is a risk of rapid ketoacidosis, if unsure, ergency advice.

o call from 5 pm till 9 am. For emergency advice for obstetric issues, please

c l consultant obstetrician if either not available.

ect e LSCS (Aim for the elective CS to be done in the morning) The day b N A • Fast from 12 Midnight if any episodes of hypoglycaemia can be given Lucozade.

e m O

C C

regim During delivery

aesarean planned for the afternoon her fore

the operation contact the Consultant diabetologist /registrar or the diabetic specialist nurse to discussregime for 6. Em ge If the patient is in labour or has been induced the sliding scale will be in progress and this shoul e If the patient is admitted with other complication necessitating emergency caesarean section, an IV should be sited, bloods taken for FBC, GSS U&E glucose and commence the sliding scale d 7. Postpa Post gi

n endent diabetics (Type 1&2)

scale according to the blood glucose.

efore planned caesarean section • ormal diabetic meal and insulin the day before caesarean section. • dmit the evening before the day of LSCS.

h orning of delivery T

• mit morning (pre breakfast) insulin. • Chart BG levels hourly If <2 or >17 must check laboratory blood glucose and U&E. • ommence 5% Dextrose with 20 mmol potassium /litre at a rate of 125mls/hour. • ommence sliding scale regime 1 hour prior to theatre (see table above for dose

e).

• Maintain the glucose infusion constant throughout. • Aim to keep blood glucose between 4-7 mmol.

anagement if elective cM

If t e are no instructions in the notes regarding the dose of insulin for the morning be

. At midday commence glucose infusion together with insulin infusion as in the normal labour. Measure blood sugar hourly.

er ncy Caesarean Section

d b continued.

as etailed above.

rtum management

va nal delivery (spontaneous or induction of labour)

No insulin dependent diabetics/ Insulin dep

• When the placenta is delivered immediately halve the insulin infusion rate and continue with the intravenous glucose and insulin and adjust the insulin rate using the sliding

73

uld be given when sub-cutaneous insulin would be due (e.g. delivers 2pm insulin given pre evening

liaise with the diabetic team.

e carbohydrate intake and possible need for reduced insulin doses needs to be considered to avoid hypoglycaemia.

• The baby should remain with mother and should only to be admitted to the l indication.

be measured soon after birth (within 30 min),

emia Care Pathways for Newborn Infant.

onal Diabetes

ood sugars pre-meals for 24hrs if <8 mmols discontinue, if high contact the consultant diabetologist.

arranged 6 weeks post-delivery.

Post caesarean section

pe 1&2)

the

he sliding scale insulin infusion until the following morning. Monitor blood sugars hourly for 6 hours post-operative if blood sugars between 4 – 11mmol/l reduce to 2 hourly blood sugars.

•pregone insulin injection.

• oll

• Gestational diabetes as described above.

contraceptive advice to be given post-delivery and reviewed at 6 week Patients return to routine diabetes care following

• Can eat and drink normally and pre-pregnancy insulin dose sho

meal). Discontinue IV glucose infusion and Sliding Scale one hour after s/c insulin injection.

• Monitor blood sugars pre-meals and post-meals and

• Breastfeeding mothers need to increas

Special Care Nursery if there is a specific medica

• The neonatal blood glucose should hourly for 3 hours and regularly thereafter for 24 hours.

• For management of hypoglycaemia, follow Hypoglyca

Gestati

• Discontinue insulin pump and glucose infusion immediately post- delivery.

• Monitor bl

• OGTT to be

• Arrange for outpatient review following OGTT.

Non insulin dependent diabetics/ Insulin dependent diabetics (Ty• When the placenta is delivered immediately halve the insulin infusion rate and

continue with the intravenous glucose and insulin and adjust the insulin rate using the sliding scale according to the blood glucose.

• Oral fluids may be given 4 hours post delivery and solid food 6 hours providedpatient is not vomiting and observations are stable.

• Continue t

If at this time patient is tolerating food and fluids, give subcutaneous insulin (pre-nancy insulin regime) and discontinue IV glucose infusion and Sliding Scale

hour after s/c

F ow guidelines above for after vaginal delivery form 3 onwards

• Post natal post-natal check (at GP surgery).delivery.

74

All diabetic patients who have unscheduled admission to the labour ward must be

discusse

History and examination of maternal and fetal condition.

Urinalysis for ketones, protein and nitrites.

ematocrit and white cell count. • Glucose • Urea & electrolytes + bicarbonate • Other blood tests that may be indicated from the history and examination findings.

Confirm

Plan of management must be documented prior to discharge home or transfer to the w

Note diabetic women are more prone to infection in pregnancy. Any signs of infection should be treated early and diabetic control monitored carefully as there is risk of ketoacid

a) Hyperglyc

Definitio

8. Emergency admission of diabetic pregnant women not in labour.

d with the on call consultant.

Maternal blood for:

• Haemoglobin, ha

fetal viability and perform fetal cardiotocograph.

ard.

osis.

aemia

n: Blood glucose of 12 mmol/l or over on 2 consecutive occasions on routine ndial testing. post pra

Signs and symptoms: thirst/unwell/weak.

Cause: not enough insulin/missed dose/ too much food /wrong type of food. Decrease in usual activity. Steroid therapy. Infection.

Dangers: Untreated high blood glucose can lead to ketoacidosis. A sudden rise in

Action

maternal glucose can cause fetal hypoxia and acidaemia.

: reduce the blood glucose to normal levels (4 -7mmol/l) and correction of

i. Call the medical team/ diabetic team

dosis

nal subcutaneous doses of insulin or by starting sliding

Hy

ketoacidosis.

ii. Identify and treat the cause of the poor control e.g infection. iii. Close monitoring of the blood glucose levels and check U&E. If ketoaci

present will need also to check blood gases. Urine should be tested regularly for ketones.

iv. Bring blood glucose levels back to normal by increasing the usual dose of insulin by giving additioscale regime.

b) poglycaemia

Definition: blood glucose < 3 mmol/l

75

Signs and symptoms: these may be present even iof glucose > 3 mmol/l in acses where there is a sudden fall in the blood sugar form a relatively high level.

Double vision/ confusion/mood swings/aggression/irritability/lack of concentration/ loss of consciousness/ slurred speech.

Sweating/tachycardia/anxiety/ panic/tremor/ pins and needles/ nausea / hunger/ headaches.

Cause: not enough food, too much insulin/ hot weather/ alcohol/ breast feeding.

Action: If conscious:

Give 10-15g of fast acting sugar ( eg Sweet tea, lucozade, ribena,dextrosol,

t. Check bolld glucose 30 minutes after initial diagnosis.

If not conscious:

man into recovery position to maintain airway. Call medical registrar.

on 1mg (1unit) can be given subcutaneously, intramuscular or intra venous.

ucose.

can also be used

R

. Diabetes UK (2000). Recommendations for the management of pregnant women with ional Diabetes)

l service Framework for Diabetes Standards dels/pregnancy.htm)

nal

cy: The Scottish Intercollegiate Guidelines

ds for Care of Diabetes in Pregnancy Enquiry

6. Williams G, Pickup JC (1999) Handbook of Diabetes, Blackwell Science (UK)

7. HTA Technology Assessment 2002; Vol 6: N0 11

8. RCOG PACE Review No 97/03 Dr MJA Maresh

Check blood sugar

hypostop Gel) Follow with next meal early, or a snadwixh , biscuit or toas

Put wo

Glucag

If not effective within 10 minutes need to give intravenous glSite large IV cannula. Give 50 mls of 20% glucose infusion. 10% glucose solutionbut need a larger volume.

9. eferences and Strength of recommendations

1diabetes (including Gestat

2. Department of Health (2001) NationaService models. (doh.gov.uk/nsf/diabetes/ch2/servicemo

3. Dornhurst A, Hadden DR (Eds.) (1996). Diabetes and Pregnancy. An Internans Ltd, England.

tioApproach to Diagnosis and Management. John Wiley & So

4. Management of Diabetes in PregnanNetwork. (December 1996).

5. Multidisciplinary Resource Group StandarProgramme C.E.S.D.I. (2002).

76

In Handbook of Obstetric Medicine. ISIS Medical Media 2000. Chapter 5:45-79.

(Based upon SIGN the Scottish Intercollegiate nes Net fication

d randomised controlled trials and ctly ap

d or co t studies or s stematic eviews and n or evide extra olated from meta-analysis or

uality case controlled or cohort studies directly applicable to the idence extrapolated from high lity ca e controlled or c ort studies.

al evidence such as case reports or expert opinion or evidence r quality case-controlled cohor tudies.

guidance for C

best practice based on the clinical experience of the guideline

view or meta-analysis of randomised controlled trials. 1b

2b quasi-experimental study such as cohort study

10. Guideline developed by:

trapartum Clinical guidelines group:

ister K Morgan Sister CRH LDRP Ward

ife Led Unit CRH Supervisor of Midwives

Dr V Bangar Consultant Physician/ Diabetologist/ Endocrinologist CRH

9. Nelson-Piercy C. Diabetes.

Guideli work classi )

A Based on meta-analyses an

population. dire plicable to the

B Based on high quality case controlle hor y rdirectly applicable to the populatio

ls nce p

randomised control tria

C Based on lower qpopulation or ev qua s oh

D Based on non-analyticolated from loweextrap or t s

GPP Good Practice Points from NICE S.

Recommended evelopment group. d

L

evels of evidence

1a Systematic reAt least one randomised controlled trial.

2a At least one well designed controlled study without randomisation. At least one well designed

3 Well designed non-experimental descriptive study, such as comparative studies,correlation studies, case-control studies and case series.

4 Expert committee reports, or opinions and/or clinical experience of respected authorities.

In Miss K Bhabra Consultant O&G Intrapartum Obstetric Lead Mrs E Rollinson Matron Maternity Inpatient Services CRH Supervisor of Midwives Mrs J Hinchliffe Matron Maternity Inpatient Services HRI Supervisor of Midwives Sister M Bell Sister HRI Delivery Suite Supervisor of Midwives SSister J Whittaker Community HRI

ister S Townsend Community / MidwSAnn Coleman Senior Clinical Pharmacist for CWS Directorate. Dr Mandour Consultant Endocrinologist HRI.

77

11. List of Intereste Group Name

only sign- off Date signed off

d Groups

Information Requires

Labour Ward forum October 2004 Women’s services directorate October 2004 Trust Clinical Effectiveness Group October 2004 Children’s & Women’s Divisional Board Consultant Obstetricians CRH & HRI Supervisors of midwives Children’s directorate Head of midwifery List of Groups Consulted Pharmacy Medicines Management committee Clinical guidelines steering group Director of nursing 12. Distribution list

Internet site

Typed copies of guidelines to be available in red ring binders in all maternity ward

Guideline to be on computers in all maternity ward areas for all staff to access.

Thethe will be notified and be expected to read the guideline. The supervisors of midwives will

nsure that the individual midwives have read the guidelines as part of regular review. The

raining coordinator for midwives: Brenda Alderson. Matron CWS

Training coordinators for medical staff: Dr T Naeem CRH & Mr B. Onyeka HRI.

areas for all staff to read.

CD-rom with all guidelines to be given to all junior medical staff on joining organisation.

All Consultant Obstetricians and associate specialists Women’s services division.

Arrangements for dissemination of guideline and training

responsibility of dissemination of the guideline will be with Alison Lodge to ensure that guideline is present in all clinical areas of the maternity units as detailed above. All staff

emaster copies will be held with research and development midwife

T

78

MANAGEMENT OF DIABETES IN CHILDREN GOOD PRACTICE GUIDELINES FOR CALDERDALE AND KIRKLEES

his paper is intended to outline the current practice for the management of children t.

care of the adult physicians in their te teens as healthy individuals. Our aim is that they should have a comprehensive

IAGNOSIS

iabetes in childhood can present in a number of ways:

n therefore often present in DKA.

hile often obvious, this diagnosis should be considered in cases of vomiting, dehydration, drowsiness, tachypnoea. Ketosis frequently causes

ber has diabetes

s when blood or urine is tested for another reason

henever diabetes mellitus is suspected check an instant blood sugar with a

INFORMATION FOR GENERAL PRACTITIONERS INTRODUCTION Twith diabetes in this distric As diabetes occurs in only about 1 in 1000 children, most practices will have very few children with this condition and treatment and follow up is largely hospital based. The General Practitioner however, is the key figure in the initial recognition of the condition and may be called upon for advice about complications or incurrent illness. The family doctor is also responsible for much of the ongoing prescribing for the life long condition. One purpose of this paper is to improve liaison between primary and secondary health care. Our philosophy of care is to deliver children to thelaunderstanding of all aspects of diabetes, normal growth and development, good biochemical control and be free of complications including emotional and psychological disturbance. To achieve this we believe requires the efforts of a multidisciplinary team providing care to a high standard in a supportive and educational environment. D D • Classical symptoms of polydipsia, polyuria, weight loss and lethargy. New onset of

bedwetting is not uncommon. Remember diabetes in children can present at any age. In infants and toddlers the diagnosis may not be obvious in the early stages and these childre

• Diabetic ketoacidosis – w

abdominal pain. Consequently diabetes appears in the differential diagnosis of gastroenteritis, pneumonia, appendicitis, meningitis etc.

• sometimes parents make the diagnosis by testing themselves when another family

mem • sometimes the diagnosis is fortuitou

Wblood glucose meter or dipstick urine for glucose and ketones.

79

EFERRAL

Sa urs) is portant, however well the child is, as children can decompensate rapidly.

min

e tted for a few days but, if well, may be discharged early and, in ome cases, treatment may be initiated without overnight stay. Initiating treatment

withou r re is some evidence that families learn to cope better and are less likely to require re-admission to hospital at a later date. This approach, however, is very dependent on adequate staff availability to provide the necessary support at home. During this time there will be close liaison with members of the Paediatric Diabetes Team. LONG LIAISON

ut-patient appointments are scheduled 3 monthly. Children with problems may be quently or be reviewed by the paediatric diabetes specialist nurse

DSN) between clinic appointments. Families who fail to attend clinic appointments PDSN via a telephone call and another appointment or a home

isit will be arranged as soon as possible.

ROUBLE SHOOTING All families are given contact numbers for the paediatric diabetes team, the children’s wards and ‘on call’ mobile numbers to enable emergency advice to be sought. Please feel free to use the contact numbers provided for advice about a particular patient, or diabetes in children in general. Protocols for illness management and hypoglycaemia re outlined below.

LNESS MANAGEMENT During illness blood sugars tend to rise in response to increased metabolic demands. Consequently, it is often necessary to take more insulin during illness than usual. Many children are reluctant to eat when they are unwell but must be encouraged to take at least as much carbohydrate as on a normal day. Basic advice should therefore be as foll • ever stop insulin even during illness

drink plenty of fluids

•

test the urine also for ketones even if blood sugars acceptable

R

me day referral to the paediatric diabetes team (on call team if out of hoimUrgent referral will enable them to be seen within 24 hours of presentation and

imize hospital stay. EARLY MANAGEMENT Th child may be admis

t fo mal admission is the preferred option as the

ER TERM MANAGEMENT AND Oseen in clinic more fre(Pare contacted by the v T

a IL

ows:

n •

If reluctant to eat usual diet give carbohydrate in alternative form – eg Lucozade, milk, fruit juice, soup, jelly, yoghurt, biscuits, toast etc.

• test the blood sugar at least four times each day more frequently if necessary

•

80

•

Extra insulin may need to be repeated after a few hours ( 3-4 hours if soluble insulin,

• •

emains strongly positive for ketones o Dehydration

s level

HYPOGLYCAEMIA Signs and symptoms Autonomic activation

• Trembling /shaking • Pallor • Sweating • Hunger • Palpitations

Neuroglycopenia

• Impaired thinking • Change of mood • Irritability • Dizziness • Headache • Tiredness • Confusion

Later convulsions and coma • In a co-operative child, give oral glucose 5 -15 grams e.g. 1, 2 or 3 dextrose tablets

(depending on the age of the child) or other sugars e.g., a cup of Lucozade (50 mls), 100mls of non diet cola

if the blood glucose is 11 mmol/l or higher with moderate or large ketones contact the diabetes team for advice on how much extra rapid acting insulin to give.

•~2 hours if rapid acting insulin) if high sugars or ketones persist.

Family to contact diabetes team for further advice at this stage if not already done so

Refer to hospital if:

o Urine r

o Vomiting o Abdominal pain o Rapid breathing o Troublesome hypoglycaemia (typically in younger children with D&V) o Depressed consciou

, or table sugar (two teaspoons). • Glucogel (hypostop) can be used in the less co-operative or drowsy child as it can

be rubbed into the buccal mucosa

81

• In an unconscious child giv unit) for children over 8 years and adults, 0.5mg for children under 8 years. Children who require glucagon injection may need to be admitted to the hospital for ongoing assessment until condition imp

s a ital

iet can be n for IV glucose infusion may be required if there is an ongoing

tional literature. If changes of treatment need to be initiated promptly, the new drugs or formulations will also be provided from out-patients. If the GP agrees with the recommended treatment, we would be grateful if they would accept responsibility for prescribing ongoing therapy.

e glucagon IM – 1mg (one

roves

• On recovery, oral glucose must be followed by more starchy carbohydrate such asandwich, a packet of crisps or biscuits to prevent rebound hypoglycaemia. Hospadmission is not necessary if there is full recovery and a normal dtolerated. Admissioproblem such as gastroenteritis.

PRESCRIBING Initial treatment and equipment will be provided from the hospital along with educa

82

TRANSITIONAL CLINIC

THE PHILOSOPHY OF TRANSITIONAL CARE

itional care clinic is a monthly clinic which is run jointly A tr ns with both the paediatric and dfaci • Pro

app •

a a ult services to ensure that a smooth transition between the services is litated. The clinic will:

vide comprehensive, coordinated and uninterrupted health-care that is age ropriate and developmentally appropriate with respect to all persons involved

Promote skills in communication, decision-making, assertiveness and self-care

Algorithm for diabetes transitional care from paediatric to adult services

NB This applies to Calderdale and

those attending Mid Yorks at present

Thsch

e concept of transitional care should be introduced during year 10 or 11 of the ol years o

Cli • • dult consultant and adult diabetes specialist nurse (DSN) present • Patient introduced to the adult team • Paediatric dietitian present • Podiatrist present • If patient DNAs paediatric team to follow up

nic:

Led by the paediatric consultant and paediatric diabetes specialist nurse (PDSN)

A

83

CLASSIFICATION AND TERMINOLOGY • Impaired Glucose T glucose regulation

(Fasting plasm value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l)

Impaired Fasting Glycaemia (IFG) has been introduced to classify individuals who stic

now encompasses the groups formerly ional ealth

glucose pregnancy, the gestation at which the

ester, the d glucose

begnosis sh single raised blood glucose result, as

above. Immediate referral to a Paediatric Diabetes Team should not be delayed.

T and IFG are n igh r risk or ardiovascular disea future diabetes (IF

t legal and med ationse re in the diagno is. A diagnos

be made on the basis of glycosuria or a stick reading of a finger prick blood glucose lone, although such tests may be useful for screening purposes. HbA1c

APPENDIX I

olerance (IGT) is a stage of impaireda glucose less than 7.0 mmol/l and OGTT two hour

•

have fasting glucose values above the normal range but below those diagnoof diabetes. (Fasting plasma glucose greater than or equal to 5.6 mmol/l but less than 7.0 mmol/l). Diabetes UK recommends that all those with IFG should have an OGTT to exclude the diagnosis of diabetes.

Gestational diabetes is retained but•

classified as Gestational Impaired Glucose Tolerance (GIGT) and GestatDiabetes Mellitus (GDM). Diabetes UK endorses the use of the World HOrganisation definition to allow for comparative studies. However, sincetolerance changes with the duration ofdiagnosis was made should be recorded and, if made in the third trimclinician should be cautious about the clinical implication of impairetolerance.

• It should noted that children usually present with severe symptoms and

dia ould then be based on a

IG ot clinical entities in their own r t but rathe categories fc

se (IGT) and/or G).

A diagnosis of diabetes has imand it is therefore

portanssential to be secu

ical implic for the patient is should never s

ameasurement is also not currently recommended for the diagnosis of diabetes.Diabetes UK recommends that the diagnosis is confirmed by a glucose measurement performed in an accredited laboratory on a venous plasma sample.

84

GUIDELINES FOR SCREENING AND

ROUTINE SCR Recent NICE guidelines, recommends that routine screening for GDM is not cost effective. A routine urine test for glycosuria at every antenatal visit is undesirable and

and therefore not to be performed.

ORS FOR GDM AND INDICATIONS FOR ORAL GLUCOSE OLERANCE TEST (OGTT)

APPENDIX II

DIAGNOSIS OF GESTATIONAL DIABETES (GDM)

EENING

unnecessary SELECTIVE SCREENING We recommend selective screening for Gestational diabetes based on high risk characteristics, based on history at booking and clinical assessment during pregnancy, as indicated in the table below: RISK FACTT From history at Booking

Maternal obesity: BMI > 35

*TRBG at booking

OGTT at 28weeks

First degree relative with Diabetes

TRBGbooki

at ng

OGTT at 28 weeks

Polycystic Ovarian Syndrome TRBG at Booking weeks

OGTT at 28

Previous GDM

TRBG at Booking

Refer Combined ANC

During pregnancy Polyhydramnios OGTT at time of diagnosis

*TRBG = timed random blood glucose in relation to last meal. A TRBG valuhan 6.0 mmols/l

e of less (more than 2 hrs after last meal) or less than 7 mmols/l (within 2 hrs

bove this will indicate the need for full tof last meal) is considered normal. Values aOGTT.

Blood glucose > 11.0 mmols/l, refer direct to Diabetes Team without OGTT

8

APPENDIX III

iabetes is a chronic metabolic disorder caused

oood glycaemic control along with careful contro

ent and progression of diabetic compl

atient Education is considered to be a fundam

• Self-monitoring can be used in conjunction

One of the most important outcome measurema Glycated Haemoglobin (HbA1c) Monitoring

Introduction Dimpaired insulin effect results in increased levelscan, if prolonged, cause microvascular and mac

Two landmark studies, the Diabetes Control andPr spective Diabetes Study (UKPDS) have demgdevelopmrespectively. Peducation for people with diabetes is to improvetake control of their own condition and to integra NICE (2002) has issued guidance on self-mon • Self-monitoring should not be considered a • Self-monitoring should be taught if the n

patient.

self-care.

nagement is:

Blood glucose levels as measured by glycdicatilycaemic control. Daily blood glucose teseterminations give a much broader picture.

The target should reflect individual needs, but Hgenerally recommended. (Lower values represeachieve the target range in some patients) Monitoring - Clinical Need & Practice

in on of blood glucose control over the pgd

For self-monitoring of blood glucose to be utraining in self-monitoring techniques and caeducated to enable them to reflect on their re

BLOOD GLUCOSEADULTS WITH NON

TYPE II D

MONITORING FOR -INSULIN TREATEDIABETES

5

by defects in insulin secretion and action. An ose in the blood (hyperglycaemia) which

d the United Kingdom of maintaining

l of lipids and blood pressure on the ications in Type 1 and Type 2 diabetes,

ental part of diabetes care. The aim of to

ment into their daily lives.

tes:

d agreed with the

with appropriate therapy as part of integrated

ments to assess overall diabetes

of glucrovascular damage.

Complications Trial anonstrated the beneficial effects

their knowledge and skills, enabling themte self-manage

itoring that sta

s a stand-alone intervention.

eed or purpose is clear an

ated haemoglobin (HbA1c) give an accurate evious 12 weeks and are the best indicator of ting gives just a snapshot whereas HbA1c

bA1c levels of between 6.5% and 7.5% are nt better glucose control and it is not possible to

r

seful, patients should be given adequate libration of meters. They should be sults and take appropriate action.

86

Diet and Exercise Controlled Type II Diabetics • No need to self-monitor if stable.

r HbA1c m

ics Co Oral Medication

• Regula onitoring required on a 3-6 monthly basis. Type II Diabet ntrolled with• In adults taking su

those on other agents there is no specific need to self-monitor routinely if stable. pogly are changed or introduced, during intercurrent illness,

nancy e prescribed then self-monitoring up mes we ng blood glucose levels are the most h the od

6mont cks of HbA1c are essential to monitor overall control.

Insulin Dependent Diabetics-for information only

lphonylureas there may be a need to self-monitor blood glucose. For

aemic agents • After oral hyduring preg

c and if systemic glucocorticoids ar

ded. Fastito three tiwit

ekly may be recommenprandial test. useful d post -

che• Regular 3-

hly

Patients on a multi-dose regimen require self-monitoring up to four times a day with

pre-prandial, bedtime and prior to driving or operating machinery readings advised. Patients on daily dosing r ing. Regular 3monthly checks of HbA1c essential to monitor overall control.

All ie s with n ra to kee e testing Rec m nded fr iocha es ing p Rep at crib

•

••

egimens require daily self-monitor

NOTE:

pat nt on-insulin treated type-2 diabetes that self-monitor should be encou gedp s lf- to a minimum during periods of stability.

omg

e equency of self-testing may alter if patients become unwell, medicat n n , dur regnancy or if test results markedly change.

e Pres ing of Blood Glucose Monitoring Strips There may be significant wastage of blood glucose monitoring strips through over prescribing, ove rd by rec m tion

T mov pr cribing should be on an acute basis only to control the supply of blood glucose testing strips in l ith t

T a hese d ions t and w d co

The diabetes review should include discussion of the frequency and usefulness of t g an an keep t clea

A patient

r-o ering patients and unnecessary blood glucose testing. The following are om enda s to reduce waste and should be adopted at practice level:

• o re e blood glucose testing strips from repeat prescription. Further es

ine w his guideline. • he full

rectnd specific directions for use should be stated on each prescription. T

i will then be added to the label produced by the Community Pharmacisill ai mpliance.

•estin d patients should be reminded to have meters regularly calibrated d to hem n.

information leaflet is available.

87

APPENDIX IV

OP no. QF 800 201 glucose meter includes Class/Code/No SEdition no. [1] (This edition replaces all previous editions) Date of issue 23/02/2005 Review To be reviewed before 22/02/2006 or after significant change in

procedure. Authorised by

Signed Date Prepared by F Beckett / V Knaggs Copy no. 1 of 3 Copy location 1.

2. 3.

Glucose Point Of Care Testing

Standard Operating Procedure

…………………………. 8 8

n…………………………………………………………….. 8

………………………………….. 10 8 ……………………… 11 9 10 ………………………… 14

1 Introduction…………………………………………………………… 2 2 Limitations of Meter……………………………………………….. 3 3 Role of the Diabetes Link Nurse………………………………. 5 4 Operators……………………………………………………………… 5 5 Health and Safety Considerations……………………………. 6 5.1 Cleaning……………………………………………………………….. 6 6 Materials……………………………………………………………….. 7 6.1 Workstation and Contents………………………………………. 7 6.2 Storage and Stability………………………………………………. 7 7 Principles…………………………………… 7.1 Advantage Quality Control Record Book…………………… 7.2 Calibratio 7.3 Electronics Check…………………………………………………… 9 7.4 Internal Quality Control………………………………………….. 9 7.5 External Quality Control………………………………………….. 10 7.6 Audit…………………………………

Methods………………………………………………………………... 11 8.1 Calibration……………………………………………………………… 11 8.2 Electronics Check……………………………8.3 Quality Control………………………………………………………. 12 8.4 Patient Testing………………………………………………………. 12 Maintenance…………………………………………………………. 14

Meter Problems……………………………10.1 Quality Control Errors……………………………………………… 14 10.2 Other Problems……………………………………………………… 14

88

. Introduction

he Roche Advantage is a battery-powered device designed for the measurement of glucose c betes. The meter uses single-use test strips (Advantage ll) to measure the g of whole blood by biamperometry using the enzyme glucose dehydrogenase. Point of care testing (POCT) refers to those a s provided within t nity, but performed outswith all current standards for laboratory accredit This Standard Operating Procedure explains the protocol for monitoring blood glucose c r. in mt ures must be Health Care Professionals and staff they are themselves at risk of litigation if they fail to adhe The Trust has a responsibility to ensure that the performance meters and the competence of the operators Therefore, the POCT glucose co-ordinator or a designated deputy from Biochemistry Department will audit use of the meters and p monthly. Users who do not y Control procedures r from he database of Autho of a meter not being u propriately a letter will beClinical Area advising them of a problem. If the unsafe practice is, or ultimately the meter may be withdrawn from use. The Glucose Point Of Care Testing Co-

y has the authority to withdraw meters from service, though in the future this ecision may rest with a multidisciplinary POCT committee.

owing points are made:

1 Toncentrations in dialucose concentration in 4µL

nalytical patient-testing activitiehe hospital or commu ide the central laboratory. POCT must comply

ation, regardless of the scope of testing.

oncentrations using the Advantage mete This relates to the nursing responsibility onitoring blood glucose concentrations and e

he meter is used. These procednsuring the quality of results in addition to how followed to protect the welfare of the patient. All responsible for, are accountable, and may put re to this SOP.

is regularly assessed. Quality Control

rocedures once 3 ved

regularly take part in Qualitnt isk being remo rised Users. In the eve

sed or cared for ap sent from the Biochemistry Department to the cannot, be resolved then

ordinator currentld

. Limitations of Meter 2 All point of care testing devices have limitations, this should be remembered at all times. The Medical Devices Safety Notice MDA SN 9616 deals specifically with the matter of glucose

OCT. In particular, the follP

The glucose meter alone must not be used to make a diagnosis of diabetes, a confirmatory sample must be sent to the laboratory.

All results need to be inte

rpreted in the light of the patient’s condition. If an

complex in neonates due to high Haematocrit levels. However

unexpectedly high or low glucose concentration is obtained then a repeat test should be performed and a sample sent to the laboratory.

The situation is morethe Roche Advantage can be used on neonates.

There are many instances where use of the Roche Advantage (and other glucose POCT devices) may produce erroneous results. Please see the table on the next page for a summary of these.

89

Contra-indications Associated with Point of Care Testing Glucose Measurement

ources: MDA SN 9616 and Roche Literature) (S Contra-indication Examples and limits for Roche Advantage Peripheral circulatory failure Severe dehydration, hyperglycaemic-

hyperosmolar states, with or without ketosis (i.e. including DKA), hypotension, shock, peripheral vascular disease.

Severe dehydration Vomiting of diarrhoea, prescription drugs e.g. diuretics, inability to recognise or respond to thirst sensations, sustained uncontrolled diabetes.

Rapid variations in blood oxygen tension Patient receiving intensive oxygen therapy. High concentrations of non-glucose reducing substances in blood.

Intravenous infusion of ascorbic acid, xylose absorption test. Galactose and maltose may cross react, (galactose >0.56mmol/L, maltose >0.89mmol/L).

High bilirubin levels Jaundice – Bilirubin >342umol/L Extremes of Haematocrit Haematocrit values <20% or >65% if glucose

<11.1mmol/L, or Haematocrit values >55%glucose >11.1mmol/L.

if

Hyperlipidaemia Triglycerides >57mmol/L. Some drugs Paracetamol >80mg/L Dialysis treatment Peritoneal dialysis solutions containing

icodextrin. Misc High uric acid concentrations (>590µmol/L) ellaneous

3. Role of the Diabetes Link Nurse Each clinical area should have a designated Diabetes Link Nurse who must be a Registered Nurse. The Diabetes Link Nurse has the following responsibilities with regards to the Roche Advantage Glucose Meter:

Training: The Diabetes Link Nurse must ensure that members of staff from his/her clinical area are trained before using the glucose meter. A Training Form must be completed and sent to the Biochemistry Department for the staff member to be entered onto the operator database.

Meter care: The Diabetes Link Nurse is responsible for the day to day care of the

meter system and ensuring that test strips and Internal Quality Control solutions are within their shelf-life.

Quality Assurance Checks: The Diabetes Link Nurse is responsible for ensuring that

staff perform Internal Quality Control checks. The Diabetes Link Nurse is also responsible for ensuring staff complete the External Quality Control test that is sent from the biochemistry Department three monthly and that the results obtained for each meter are documented on the sheet provided and returned to the Biochemistry Department.

Update training: The Diabetes Link Nurse must ensure that staff members in the

clinical area continue to use the meters appropriately, giving update training where necessary, this would be expected to occur on an annual basis.

90

On quently registered on the Operator Database in the iochemistry Department are authorised to use the Roche Advantage glucose meter. The

Database will be periodically reviewed; operators who do not regularly participate in Quality Control procedures will be removed. After a prolonged absence (more than 4 months) refresher training from the Diab efore names are re entered onto the operator database. 5. Health and afet The COSHH a essm is a separate document. All perators should familiarise themselves with this before using the instrument. Particular care

should be taken to ensure that lancets and used tests strips are disposed of in a sharps bin.

with consequent reduction in spill risk. However should the eter become contaminated then the following instructions should be followed:

The outside of the meter should be cleaned with warm water and soap.

cument that the meter has been cleaned in the Quality Control Record Book.

4. Operators

ly staff who are trained and subseB

etes Link Nurse will be required b

S y Considerations

ss ent for the use of the Roche Advantageo

5.1. Cleaning

The Advantage meter should not require much cleaning as blood is dosed to the side of the test strip externally to the instrumentm

Ensure that no liquid gets into the test strip insertion area, as the internal working of

the meter will be damaged by moisture.

Do

91

. Materials

• Advantage Glucose Meter ntage Chek Strip

• Advantage ll Glucose Test Strips

ivalent • Advantage Users Manual

Control Record Book

6.

6.

In accordance with manufacturers recommendations the meter should be stored between 14°C nd 40°C away from moisture.

e a rmacy. In accordance with manufacturers °C at less than 85% humidity in the

me p must be replaced

6.5. Advantage Control Solutions

e of charge. They must be stored t room temperature. The control solutions are stable until the expiry date printed on the vial, or

3 months after opening, whichever comes first. The date the control solutions are opened must e written on the vial along with the new expiry date.

.

ll Internal and External Quality Control results should be recorded in the Quality Control Record Book (please note, if Quality Control performed but the results are not recorded in the Quality

ontrol Book then it will be deemed that no Quality Control has been preformed when the glucose mete stem Any other relevant comments should also be recorded in the Quality Control Record Book e.g. new vial strips opened, meter cleaning, out of range Quality Control results or other meter problems. If the meter is returned to the Diabetes Centre for any reason then the Quality Control Record

6

6.1. Workstation Contents

• Adva

• Advantage ll Control 1 and Control 2 • Lancing Device • Lancets • Cotton Wool, gauze or equ

• Advantage Quality

2. Storage and Stability

3. Advantage Meter

a

6.4. Advantage test strips Th dvantage test strips are supplied by Pharecommendations they must be stored between 14°C and 40sa tightly capped vial in which they are packaged. The vial caimmediately after removing a test strip. The test strips are stable until the expiry date printed on the vial.

The advantage control solutions are supplied by Pharmacy frea

b 7. Principles

7.1. Advantage Quality Control Record Book The Quality Control Record Book documents the history of the meter e.g. whether a particularmeter functions correctly and whether internal Quality Control checks are regularly performed A

Cr sy is audited).

92

Book should a ompa For legal reasons, the Quality Control Record Book must be kept for 12 years once it has been

m ill then be i

7

h of

y

Before a meter is used for the first time Routinely before a new vial of strips is used on the meter

number displayed does not match the code number printed on the test strip vial

eck

tronics within the meter are functioning correctly. This should be carried out:

Before a meter is used for the first time

Routinely before a new vial of strips is used on the meter

On any occasion where there is a suspicion that the meter is not operating correctly

Please note that using the Chek strip does not replace Internal and External Quality Control checks, it should be carried out in addition to these activities.

ternal Control

In order to do this, samples with known glucose concentrations are run through the usual test procedure and the results are recorded in the Quality Control Record Book.

There are two Internal Quality Control solutions, Control 1 (low glucose concentration, purple pped bottle) and Control 2 (high glucose concentration, blue topped bottle). If the Quality

proceed to patient testing. If the Quality Control values are not of the acceptable range then please refer to the section on problems – Control Errors.

ontrol 1 and 2 should be run:

• Daily, before it is used for glucose monitoring in patients.

• Before a meter is used for the first time.

• Routinely when a new vial of strips is used.

cc ny it.

co pleted. Please send completed books to the Diabetes Centre, a replacement book wssued.

.2. Calibration

There may be batch-to-batch variations in test strips. Calibrating the meter for each batcstrips ensures that the accuracy of the system is unaffected by this variation. Each box of test strips has a code key that contains the information needed to calibrate the instrument. The kecode is left in the instrument between calibrations. The Advantage meter must be calibrated:

If the code

7.3. Electronics Ch The blue Advantage Chek Strip is used to check that the elec

Routinely after changing the meters batteries

If the code number displayed does not match the code number printed on the test strip vial If the meter has been dropped

7.4. Internal and Ex

Internal Quality Control checks ensure that the meter is working correctly at the time of testing.

toControl values are within the acceptable range printed on the test strip vial then the user can

C

• After any unexpected result.

• Routinely after changing the meters batteries.

• If the meter has been dropped.

93

• On any occasion when there is a suspicion that the meter is not working

Completed Quality Control record books should legally be kept for 7 years. It is the responsibility for individual wards and departments to ensure this happens.

External Quality Controls differ from Internal Quality Controls in that the accuracy of the procedure is not known until after the results have been issued. As the user does not know the

e results are assessed independently, it allows confidence that the performance of the meters and operators is not varying with time and

aremo

8. Methods

2. Compare the 3-digit number on the code key with the number on the test strip vial.

3. the Advantage meter is turned OFF.

owards the meter) into the code key slot.

on the

vial of test strips used.

7. I ter does not match that on the test strip vial the meter must be recoded (recalibrated).

g the above.

If calibration is unsuccessful do not use the meter, call the Biochemistry Department on 01484 342362 and ask to speak to Frank Beckett

8

1. Make sure the Advantage meter is turned OFF.

2. Insert the blue Chek Strip into the test strip aperture at the bottom of the meter.

3. Th

Thin the Quality Control section below.

properly.

*

7.5. External Quality Control

glucose concentration at the time of analysis, and th

that the results are similar in different clinical areas. Vials of External Quality Control material distributed from the Biochemistry Department to all clinical areas approximately three nthly.

8.1. Calibration

1. Remove the key code from the Advantage test strip box.

Make sure

4. Remove the old code key from the Advantage meter and snap the new code key (slots facing t

5. Leave the code key in the Advantage meter and turn the meter on (press the blue power button).

6. Verify that the code number on the meter display corresponds to the code number

f the code number on the me

8. Recalibrate the Advantage meter by opening a new vial of test strips and repeatin

process 9.

.2 Electronics Check

e meter will display √ and OK if the Electronics Check is successful.

4. e meter will then prompt the user to perform Quality Control checks. Continue from No. 3

94

If D

8.3 Quality Control

1. Oopm

P

3. The date, time and code number (test strip lot number) are displayed on the LCD panel lodoes not correspond with that of the test strips being used the meter needs recalibrating.

5. A flashing strip icon appears on the meter display, gently insert the test strip (silver bar end) in

6. A flashing drop icon appears on the meter display. Apply a drop of control solution to the edge of the yellow target area. Ensure that the whole of the yellow target area is filled.

. A small box flashes on the meter display. After 25 seconds the blood glucose value is

rd

trol results fall outside the stated reference range please refer to

Problems – Quality Control Errors, section 10.1 of this SOP.

8.4

indications section earlier in the SOP. If you are in any doubt please send a sample to the boratory.

1.

2.

the code number does not correspond with the test strips being used the meter needs

3. em eplace the cap.

4. fla (silver bar

end) into the bottom of the meter with the yellow target area facing upwards.

5. A flashing drop icon appears on the meter display. Obtain a blood sample using the appropriate lancing device.

5. the Electronics check is unsuccessful do not use the meter and call the Biochemistry epartment on 01484 342362

nce opened, the control solutions have a shelf life of 3 months. When a new bottle is ened the pre-printed expiry date on the bottle should be crossed out, and the date 3 onths later written on.

2. ress the blue power ON button on the meter.

cated above the number keypad. The meter is now ready for use. If the code number

4. Remove a test strip from the vial and replace the cap.

to the bottom end of the meter. The yellow target area should face upwards.

7

displayed.

8. Record the Quality Control value and appropriate lot number in the Quality control RecoBook.

9. If either of the Quality Con

10. Remove the test strip from the meter and dispose of in an appropriate biohazard bin.

Patient Testing All POCT devices have limitations. Ensure you are familiar with the Limitations and Contra-

la

Press the blue power ON button.

The date, time and code number (test strip lot number) are displayed on the LCD panel. If

calibrating. If the code number does correspond then the meter is ready for use.

R ove a test strip from the vial and r

A shing strip icon appears on the meter display, gently insert the test strip

95

of blood to the curved edge of the yellow target area. The blood will

be drawn into the strip by capillary action. Hold the finger to the curve until the yellow area

d

blood drops then the test result may be erroneous, the strip should be discarded and the test procedure repeated.

8. Once sufficient blood has been added to the test strip, a small box flashes on the meter

display, 25 seconds later the blood glucose result is displayed.

9. If LO of HI is displayed then medical attention should be sought, a Venepuncture performed and the sample sent to the laboratory for analysis.

10. Remove the test strip from the meter, dispose of the strip and lancet in an appropriate

biohazard bin.

riate documentation for the clinical area. The record should include unequivocal patient identity, date and time of test and the identity of the person performing the test.

The advantage meter will display a small battery icon when it is necessary to change the batteries (after approx. 1000 tests). The meter requires 2x AAA batteries. Battery changes hould be recorded in the Quality Control record Book. Batteries should be changed every 3

Never use a meter for monitoring patients if there are concerns as to its accuracy or function. Use another meter and contact the Diabetes Centre. If another meter is not available send samples to the laboratory. 11. Quality Control Errors

Most Quality Control errors can be resolved in the clinical area. Before phoning the Biochemistry Department about a Quality Control error.

• Carry out an electronics check with the blue Chek Strip. • Check that the correct calibration chip is being used for the strips in use. • Check the expiry date and that the lid has not been left off the vial. • Check that the Quality Control bottles are within their expiry date and were opened

less than 3 months ago. • Invert the Quality Control bottle 6 times (the Quality Control solution may sometimes

crystallise around the neck of the bottle). • Repeat the Quality Control test.

• If the Quality Control error persists contact the Biochemistry Department.

6. Briefly touch the drop

is completely filled with blood.

7. If after the initial drop of blood has been applied, the yellow area is not completely fille(yellow colour still visible), then a second drop of blood may be applied within 15 secondsof the first. If more than 15 seconds has passed between

11. Record the patient’s glucose result on the approp

9. Maintenance

smonths irrespective of use. 10. Meter Problems

96

blems

ete Meter Erro described in the Advantage Users Manual. If any blem wi ann t be resolved in the clinical area then it should be referred to the betes C epa ment carries a limited number of replacement meters that can be

xchanged r faulty meters Meters sent to the Diabetes Centre must be accompanied by the uality Con ol Record Boo and a brief description of the fault.

For Patients Use

0800 701000 For Healthcare Professionals

0800 3282676

iaries, Batteries, Replacement Meters, Finger pricking Devices, Quality Control Books and olution can all be obtained by contacting this number.

10.1. Other Pro A compl list of r Codes is pro

iath the meter c

ntre. The Do

D e rteQ

fotr

. k

Roche Help line Numbers

DS Diaries, Quality Control Books and Advice regarding Meters can also be obtained from the

betes Specialist Nurses. Dia

tes Centre - 01422 222025

i and signed each page is ndorsed with the Pathology Department stamp, in red ink. A member of staff may only

Princess Royal CHC - 01484 344269/70 CRH Diabe

Th s document comprises 13 pages and is only valid if authorisedeperform the procedure described when trained and authorised.

97

Revision history

dition Date E Comment

1 23/02/2005 PROCEDURE AMENDMENT RECORD

Amendment Authorised by Number Date Page 1 2 3 4 5

An amendment must be authorised by the author of the procedure

e new information must be clear and legible. Correction fluid must not be used.

margin (no correction fluid please)

The document must be reviewed after 5 minor amendments.

Amendments must be made by simple striking through of the change to be made. Th

The amendment must be underlined in the document and an asterisk added to the

The document must be reviewed if major procedural change is necessary.

98

ENDIX V

GGESTIONS REGARDING FURTHER INFORMATION FOR INDIVIDUALS WITH DIABETES

of background reading and information are important aids in reinforcing creasing patient awareness. Below are some suggestions of

sources that are currently available.

ITERATURE

• Type 1 diabetes

alance Magazine

iabetes UK also produce a vast selection of leaflets and information which are listed in

Diabetes for those treated with insulin) Dr JL Day ) Susan Brenchley

Association

rtips Peter Sonksen, Charles Fox and Sue Judd 1991, Class Publishing Ltd, cost approx £10.00

Charles Fox and Anthony Pickering, Class Publishing

nderstanding your Diabetes for People with PH Wise, Foulsham the Publishing House

nderstanding your Diabetes for People with PH Wise

APP

SU The provisionverbal advice and inre L Balance for Beginners

• Type 2 diabetes

Available from Diabetes UK - currently at a charge of £3.00 B Bi-monthly "news and views" publication by Diabetes UK to subscribing members. Dtheir catalogue and order form booklet. Can be ordered and purchased at Newsagents. Books Living with Living with Diabetes for those treated with diet ) and Suzanne Redmond and tablets ) Medicos 1992 British Diabetic

Diabetes at your finge

Diabetes in the Real World

UType 1 Diabetes UType 2 Diabetes

99

Azhina Gouindji and Jill Myers published with BDA

iabetes UK

7AA

Calderdale and Kirklees. Further details om the Diabetes Centres in Wakefield.

ork in collaboration with colleagues in Primary Care offer support, information and education to people with diabetes in this area, and to

ur multi-disciplinary team work together to offer a “One Stop Shop” approach to

on the third Tuesday of each month, where staff from both adult and children’s

ns to the centre are clearly displayed roughout the hospital.

tion

etes Centre Secretary 01422 222036

nhs.uk

r Vijay Bangar

onsultant Diabetologist

Recipes for Health Diabetes

Support Group D10 Parkway LONDON NW1 Telephone: 020 7323 1531 Local branches of Diabetes UK are active in are available fr Calderdale Diabetes Service The Diabetes Team in Calderdale wtoensure that they have access to a high quality and comprehensive diabetes service. Odiabetes. Here people can access the services they need at one clinic appointment. Diabetes clinics are held twice weekly at the centre. Regular clinics are held for specific groups; for example the young persons’ clinic, which isservices are available for help and advice, and the ante natal clinic for women with diabetes held each Wednesday attended by staff from obstetric and adult diabetes services. Calderdale Diabetes Centre can be found within Calderdale Royal grounds and is at the Dudwell Lane boundary of the hospital. Directioth Contact Informa Sue Vardy Diab℡

sue.vardy@cht. Key Personnel Consultant Diabetologist D CDr Abdu Mousa

100

rvices anet Baxendale

s.uk

2032 mandy.stocks@cht.nhs.uk

01422 341611

wide range of educational opportunities and a variety of media are offered. Staff will

iabetes Specialist Nurses – Calderdale

he Diabetes Specialist Nurses are based in the Diabetes Centre and work closely with ietitians and Podiatrists, GPs and Practice Nurses to

rovide a service to people with diabetes in Calderdale.

h quality, expert education and clinical support is provided on both a one one consultation and through group sessions.

cialist Nurse service is available Monday – Friday, 9.30 – 4.30 (except ank holidays).

ointments can be made by contacting the Diabetes Centre receptionist n:

lternatively you can leave a short message stating your name, telephone number es Specialist Nurses answerphone, ℡ 01422 222025, and a

ir earliest convenience.

to individual consultations, the service also offers supermarket tours and ssions.

Acting Lead Nurse Diabetes SeJ℡ 01422 222023

janet.baxendale@cht.nh Senior Diabetes Dietitian Mandy Stocks ℡ 01422 22

Diabetes Podiatrist/Podiatry Service Manager Debbie Wolfe ℡

Debbie.wolfe@cht.nhs.uk Education and Support Services The diabetes service has been developed to ensure people with diabetes, their families and carers, have access to current information, education and support they need. Abe happy to assist you in finding the information you require. D Tthe Diabetes Consultants, Dp Up to date, higto The Diabetes Speb Enquires and appo ℡ 01422 222257 Aand GP on the Diabetnurse will contact you at the Dietitians In additiongroup education se

101

aediatric Diabetes Service

hildren with diabetes in Calderdale are cared for by members of the Calderdale

r Y A Oade Consultant Paediatrician n Paediatric Diabetes Specialist Nurse

isa Holmes Paediatric Dietitian.

hildren’s Diabetes Clinics are held on the first and third Friday of each month at the le Royal Hospital. Young people are

e team every three months, or more frequently if necessary.

in the community and support people ith diabetes and their carers in their home environment. They work closely with,

to, secondary care services to ensure that all have access to high uality diabetes care.

he weekly consultant clinics are held on Wednesday mornings at Huddersfield

Director of Diagnostics and Therapeutic Services

urse Michelle Kain 44270

tian anessa Henry ℡ 01484 342749 Podiatry Senior I Podiatrist Tracey Baines Princess Royal Health Centre ℡ 01484 344336

P CChildren’s Diabetes Team: DNancy HarrisoL CPaediatric Outpatient Department, Calderdaseen in clinic by th Diabetes Services in Kirklees The Diabetes Specialist Nurse Service is based at Princess Royal Health Centre, Huddersfield. The diabetes nurses are basedwand are a linkq TRoyal Infirmary. Weekly ante-natal clinics are held each Tuesday morning. Key Personnel Core Multidisciplinary Team Consultant Diabetologist Dr A Burrows Divisional Dr Huw Griffiths Clinical Assistant Dr Huw Griffiths Lead Diabetes Specialist N℡ 01484 3 Dietetic Department Senior I Diabetes DietiV

102

Children and Young

Sarah Schorah Paediatric Diabetes Specialist Nurse ℡ 55 Carol Dobrowski Paediatric Da The Outpatients Clinics are held every Tuesday afternoon with an adolescent clinic once a month on a Wednesday evening. The children are seen initially on a weekly basis on diagnosis, decreasing eventually to three monthly once stabilised. All patients are seen more frequently if required. Other Links Calderdale Diabetes Support Group Meets on the first Thursday of the month at the Maurice Jagger Centre, Halifax (between the Bus Station and Sainsbury’s) from 7.30 pm – 9.00 pm. C 240528 or Peggy Bruce ℡ 01422 240427 Huddersfield Diabetes Support Group

eets twice monthly at Huddersfield Methodist Mission. ontact suesudsd571@myway.com

People with Diabetes Children with Diabetes in Huddersfield are cared for by members of the Huddersfield Paediatric Diabetes Team. Dr M A Stills Consultant Paediatrician

01484 3442

ietitians nd Lisa Holmes

ontact Anne Lees ℡ 01422

MC Mobile 07769775243 Honeyzz St John’s Resource Centre 29 St John’s Road Huddersfield Meet the first and third Tuesday of each month from 2.00 pm – 3.30 pm. ℡ 01484 223001 Health Contact Dorothy Clayton 15 Greenhead Road ℡ 01484 344255 DIL Group Asian Mens Group Meets weekly on Monday 10.00 am – 12.00 pm Contact: Suraj Uddin ℡ 01484 223001

103

APPENDIX VI CHECKLIST FO BETES TION

The following checklists can be used gu ing the important points that an individual with diabetes and their family should know. Section One - Guidelines for all Individuals with Diabetes

Date Discussed

Date(s) Reviewed

Comments

R DIA EDUCA

ide in cover

as a helpful

Topic

What is diabetes?

symptoms eatment

o explanation of conditionoo rationale of tr Treatment Plan Dietary Requirements Physical Activity Oral hypoglycaemic agents

check patient knows:

oo type, length of action, dose,

when to take, side effectsincluding hypoglycaemia

104

Topic Date discussed

Date(s) Reviewed

Comments

Insulins (see section two)

trol

yperglycaemia and ketoacidosis

Warning signs of poor con

H

symptoms

Hyp

oo causes and prevention

oglycaemia

mptoms

carrying of glucose n

awareness of family/friends

o cagon/hypostop

o signs and syo causes and prevention oo patient identificatiooo Driving

need for glu

M nitoring of conditio on ol

why and when to test

icance record keeping

Urine testing: technique k n

to test

What it means frequency of

Blood testing: technique when

of blood glucose) to test ance

record keeping afe disposal of sharps efer to Appendix III for

recommended testing)

* Importance of good contr* Urine testing: technique

signif * ( etones) why and whe

* HbA1c

testing

* (self-monitoring why and signific S(R

105

Topic iscussed eviewed

Comments Date D

Date(s) R

Identification * Patient hand held record

Information regarding talismans/medicalerts etc

s More frequent testing of

When to consult doctor/nurse

lf

* – PALS (Kirklees)

Obesity

r retinal screening

Foot Care * Importance of regularly

checking your feet Other Possible Problems * Erectile Dysfunction * Neuropathy

*

Illness and Diabetes * Never stop insulin/tablet*

blood/urine for glucose (and ketones if appropriate)

* Vomiting * Look After Yourse * Importance of regular diabetes

check ups * Effects of alcohol * Effects of smoking

Physical activity Upbeat (Calderdale) * * Holidays * Employment/jobs Eye Care * Importance of regula

106

Discussed Reviewed Topic Date(s) Date(s) Comments

• CHD • Retinopathy

caemia

ps

Diabetes UK Local branches

Prescription Charges/Benefits • Prescription exemption • Availability of benefits How to get Help • Contact numbers

riving and Diabetes D

* Notify DVLC and

Insurance * Dangers of hypogly

es Pregnancy and Diabet * Preconception counselling* Contraception * Pregnancy advice Support Grou •

me • Expert patient program• Local Support groups • PALS (Patient advice and

liaison service

107

Section Two - Additional Information for Individuals with treated wit

ate Discussed

Date(s) Reviewed

Comments

h Insulin

Topic D

Treatment Plan - Insulins The action of insulin injection techniques

* Name and type of insulin

* *

* of insulin

* * Counselling

* Choice/use of pen

* Action of insulin Timing of injections Injection technique

* Site rotation * Storage of insulin

Self adjustment Employment

Shift work adjustments

* Encouragement and support

108

X VII

ause foot problems. These usually occur ecause of damage to nerves (affecting feeling) and blood vessels (affecting

eeping good control of your diabetes and having an annual foot examination can help to

ADVIC

pers and no hard or bulky seams. Lace ups are good because they hold your feet firmly in place.

•

Socks should be made from cotton or wool, be free from bulky seams and have

eams rubbing the skin.

Dry skin can be treated with a moisturising cream such as Diprobase or E45

• s which may develop.

il healed. If these

or corns.

ined podiatry assistant at

APPENDIFootcare Advice Leaflets AT LOW RISK INFORMATION SHEET Diabetes is a lifelong condition, which can cbcirculation). Kprevent damage. The following advice will help you.

E TO HELP PREVENT PROBLEMS: • Shoes are a common cause of damage to feet because you may not feel if they are

‘rubbing’. Always wear well-fitting shoes with soft up

Have your feet measured before you buy. Buy shoes that are the correct length, width and depth.

•non elasticated tops. Before putting on socks and shoes check inside them for anything which may rub (stones, bulky seams, etc). Wearing socks inside out helps to prevent the s

•

(available at the chemist, supermarket or on prescription). Avoid using it between the toes, as this can make the skin too moist and prone to infection.

Examine your feet daily to detect any problem • Cut nails straight across and not too short. If in doubt file nails.

Any minor cut or blister should be covered by a sterile plaster unt•are slow to heal seek advice from your GP.

• Do not use home remedies, such as corn plasters or verruca treatments.

Do not use razor blades to remove hard skin• It is not necessary for you to see a podiatrist regularly just because you have •

diabetes. Your routine foot checks will be done by a trayour GP surgery and they can refer you to a Podiatrist if needed.

• If you notice any signs of infection, swelling, heat, redness or pain contact your

GP or your local Podiatry Department URGENTLY. Additional advice AT INCREASED RISK INFORMATION SHEET Diabetes is a lifelong condition, which can cause foot problems. These usually

e e of damage to nerves (affecting feeling) and blood vessels (affecting tion).

occur b causcircula

109

without

l of your diabetes and having an annual foot examination can help to prevent damage. You will also need to take extra care of your feet to prevent future

roblems. The following advice will help you. ADVICE TO HELP PREVENT PROBLEMS: • Shoes are a common cause of damage to feet because you may not feel if they are

‘rubbing’. Always wear well-fitting shoes with soft uppers and no hard or bulky seams. Lace ups are good because they hold your feet firmly in place.

• Have your feet measured before you buy – remember you cannot ‘feel’ if they fit. Buy

shoes that are the correct length, width and depth. • Socks should be made from cotton or wool, be free from bulky seams and have non-

elasticated tops. Before putting on socks and shoes check inside them for anything which may rub (stones, bulky seams, etc). Wearing socks inside out helps to prevent the seams rubbing the skin.

• Check your feet for any signs of damage when you take your shoes and socks off. If

you have poor eyesight ask a friend or relative to do this for you, daily if possible (at least weekly).

It is important not to walk barefoot and risk damaging your feet. • Keep your feet clean by washing them every day. Dry them carefully with a soft

towel, pay particular attention to drying between the toes this helps to prevent problems. Do not soak your feet for too long.

• Dry skin can be treated with a moisturising cream such as Diprobase or E45

(available at the chemist, supermarket or on prescription). Avoid using it between the toes, as this can make the skin too moist and prone to infection.

• Cut nails straight across and not too short. If in doubt file nails. • Any minor cut or blister should be covered by a sterile plaster until healed. If these

are slow to heal seek advice from your GP. • Do not use home remedies, such as corn plasters or verruca treatments. • Do not use razor blades to remove hard skin or corns. • You may not be able to feel heat or cold so be very careful when bathing. Test the

water with your elbow, in case the nerves in your hands are also affected, or alternatively ask someone to test the temperature for you.

• Remove hot water bottles from the bed before getting in. • Avoid sitting close to fires and heaters, they can burn your skin without you noticing. • It is not necessary for you to see a podiatrist regularly just because you have

Once sensation is lost it means that you may develop callouses, blisters, cuts or ulcers

being aware that your feet are being damaged. Keeping good contro

p

110

diabetes. Your routine foot checks will be done by a trained podiatry assistant at your you to a Podiatrist if needed.

dditional advice

GP surgery and they can refer • If you notice any signs of infection, swelling, heat, redness or pain contact your

GP or your local Podiatry Department URGENTLY. A

111

GH R Diabet se foot problems. These usually occur

ecause of damage to nerves (affecting feeling) and blood vessels (affecting

can he amage. You may need to wear special shoes to keep your feet safe. ou will also need to take extra care of your feet to prevent future problems. The following vice

dvice to help prevent problems:

• Shoes are a common cause of damage to the feet. You will not feel if they are ‘rubbing’ and the shape of your feet may make it difficult to buy suitable shoes.

• If you do buy shoes have your feet measured before you buy – remember you cannot

‘feel’ if they fit. Buy shoes that are the correct length, width and depth with soft uppers and no hard seams.

• If you have difficulty finding shoes to fit, you may need special shoes. The Podiatrist

will discuss this with you and make a referral as appropriate. • If you are given special shoes they are to protect your feet and should be the only

ones you wear, even at home. • Socks should be made from cotton or wool, be free from bulky seams and have

non-elasticated tops. Before putting on socks and shoes check inside them for anything which may rub (stones, bulky seams etc). Wearing socks inside out helps prevent the seams rubbing the skin.

• Check your feet for any signs of damage when you take your shoes and socks off. If

you have poor eyesight or cannot reach down to look at your feet ask a friend or relative to do this for you, daily.

• It is important not to walk barefoot and risk damaging your feet. • Remove hot water bottles from the bed before getting in. • Keep your feet clean by washing them every day. Dry them carefully with a soft

towel, pay particular attention to drying between the toes, this helps to prevent problems. Do not soak your feet for long periods.

• Dry skin can be treated with a moisturising cream such as Diprobase or E45

(available at the chemist, supermarket or on prescription). Your Podiatrist will instruct you how often this should be applied. Avoid using it between the toes as this can make skin too moist and prone to infection.

• Any minor cut or blister should be covered with a sterile plaster until you can be seen

at clinic. • Do not use home remedies, such as corn plasters or verruca treatments.

HI ISK INFORMATION SHEET

es is a lifelong condition, which can caubcirculation). Keeping good control of your diabetes and having an annual foot examination by a podiatrist

lp to prevent dYad will help you.

A

112

• Do not use razor blades to remove hard skin or corns. • You cannot feel heat or cold so be very careful when bathing. Test the water with

your elbow in case the nerves in your hands are also affected or alternatively ask temperature

• Avoid sitting close to fires and heaters, they can burn your skin without you noticing. • Your Podiatrist will decide who s enails and advise you

accordingly. • If you notice any signs of infec g, heat, redness or pain contact your

GP or your local Podiatry Department URGENTLY. Additional advice

for you.

hould care fo

tion, swellin

r your to

someone to test the

115

APPENDIX VIII

Summary Good control of blood glucose is important for all patients with diabetes to reduce complications. A balanced diet and exercise play a very important part in maintaining or improving your health. Contact your surginformation. If you do not use insulin, there is not alwayclear benefit fromglucose test strips. Local diabetes experts advise that there masome special circumstances where y o need to monitor your blood glucose (e.g. pregnancy, poor control and during illness)

I want to know more

If you require any further advice or information regarding your diabetes or blood glucose testing, please ask at your local surgery or pharmacy for advice. It is important to keep your blood glucose levels under control. Please check with your practice nurse or GP if you don’t know how to arrange for your regular blood test or how often to have one done.

d by: derda eld Diabete twor

ber 2006 Clinical Audit and Effectiveness Group

ober 2006

Approved by: Calderdale and Huddersfield Diabetes Network

21st September 2006

19th October 2006

lood ose M ters and Test Strips

No nsulin Treated Type 2 Diabetes

ery

the routine use of blood

for

o

fur

u d

ther

s a

y bestill

oversfiem

ApHust S

9th

prddeept

Oct

Cal le and 21

1

s Ne k

Clinical Audit and Effectiveness Group

ucB G

n-I

l e

116

T Weight

revious 8-12 weeks

r

reakdown when the body ss or lack of insulin)

y. Normal range:

GFR Blood test for kidney function

rine test to identify risk of diabetic kidney problems the blood sugar

DSN Diabetes Specialist Nurse GP General Practitioner PN Practice Nurse

GLOSSARY OF TERMS

WHT Height Blood Tests

BS Fasting blood sugars FRBS Random blood sugar HbAlc Indicator of average blood sugar over p Urine Tests Sugar SugaProtein Protein Ketones Ketones (toxin produced by fat b

cannot use glucose. May indicate illne Eyes Visual acuity Ability to read distant sight chart BP Blood Pressure BMI Body Mass Index. Indicator of obesit

men 20-25 women 19-24

Lipids These tests give an indication of types of fat present Chol Cholesterol – high cholesterol levels are bad HDL High density cholesterol – high levels are good LDL Low density cholesterol – high levels are bad TG Triglycerides – high levels are bad Kidney Tests eCreatinine Blood test for kidney function Microalbuminuria UOral Therapy Tablets taken to help lowerInsulin Type of insulin injected and doses

iet Your healthy eating plan D

117

ACKNOWLEDGEMENTS

alderdale Royal Hospital r A Burrows Consultant Diabetologist Huddersfield Royal infirmary

uddersfield Royal Infirmary

e Huddersfield

r Wright Consultant Nephrologist St James’s Hospital Leeds

Diabetes Specialist Nurse Calderdale Royal Hospital ngela Sealeaf Diabetes Specialist Nurse Calderdale Royal Hospital

yal Hospital ichelle Kaine Lead Nurse Diabetes Princess Royal HC Huddersfield

yal HC Huddersfield

kroyd Business Change Manager Diabetes Long erm Conditions Project

Public Health Commissioning Diabetes

We would like to acknowledge and thank Wakefield District and North Kirklees Diabetes Network for their contribution in developing this pathway. The following professionals were involved in the development of these guidelines: Dr Vijay Bangar Consultant Diabetologist Calderdale Royal Hospital Dr A Mousa Consultant Diabetologist CDDr H Griffiths Consultant Chemical Pathologist and Clinical assistant in Diabetes HDr Robin Marks Consultant Chemical Pathologist and Clinical Assistant in Diabetes Calderdale Royal Hospital

r S Rana Staff Grade Diabetes Calderdale Royal Hospital DDr A Anbazhan Staff Grade Diabetes Calderdale Royal Hospital Dr Shona Hamilton Consultant Obstetrician Calderdale Royal Hospital

r D Anderson General Practitioner The Grange PracticDDr S Gardiner General Practitioner Plane Trees Practice Halifax Dr S Cleasby Spring Hall Surgery Halifax Dr P Knight Consultant Anaesthetist Calderdale Royal Infirmary DJanet Baxendale Acting Lead Nurse in Diabetes Calderdale Royal Hospital Vickie Knaggs AKathryne Healey-Allsop Diabetes Specialist Nurse Calderdale RoMAdele Sharpe Diabetes Specialist Nurse Princess Royal HC Huddersfield Sandra Readman Diabetes Specialist Nurse Princess Royal HC Huddersfield

arolyn Eastwood Diabetes Specialist Nurse Princess RoCDebbie Wolfe Podiatry Manager Calderdale and Huddersfield NHS Foundation Trust Mandy Stocks and Vanessa Henry Dietitians Calderdale and Huddersfield NHS Foundation Trust Calderdale and Kirklees Medicines Management Team The process was facilitated by Trudi AT Thanks are expressed to the following for their input:

aynor Scholefield ManagerG

118

K Prospective Diabetes Study Group (1998) Intensive blood-glucose control with

in patients with type 2 diabetes (UKP DS 33) The Lancet

REFERENCES Usulponylurea or insulin compared with conventional treatment and risk of complications 352 837-851

lar complications in type 2 diabetes (UKPDS 38) ritish Medical Journal

UK Prospective Diabetes Study Group (1998) tight blood pressure control and risk of macrovascular and microvascuB 317 703-713

iabetes National Service Framework Delivery Strategy 2002 Department of Health

oint British Societies’ Guidelines on Prevention of Cardiovascular Disease in Clinical ractice (2005) Heart

D JP British Cardiac Society 91 supplement V

The National Service Framework for Renal Services 2005 Part two: Chronic Renal Failure and End of Life Care Department of Health Management of Type 2 Diabetes Renal Disease – prevention and early management Clinical Guideline F (2002) National Institute for Clinical Excellence (NICE) Type 2 Diabetes Prevention and Management of Foot Problems Clinical Guideline 10 (2004) NICE Anglo Scandinavian Cardiac Outcomes (ASCOT) trial 2003 Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in Children, Young People and Adults Clinical Guideline 15 (2004) NICE Management of Type 2 Diabetes: Retinopathy – screening and early management Clinical Guideline E (2002) NICE Management of Type 2 Diabetes: Management of Blood Pressure and Blood Lipids Clinical Guideline H (2002) NICE Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in Adults Clinical Guideline 15 (2004) NICE Guidance on the use of Patient Education Models for Diabetes: Technology Appraisal Guidance (TAG) – No.60 (2003) NICE Management of Type 2 Diabetes: Management of Blood Glucose Clinical Guideline G (2002) NICE Guidance on Rosigltazone for Type 2 Diabetes Mellitus: TAG – No. 9 (2000) NICE Guidance on the use of Long-acting Insulin Analogues for the Treatment of Diabetes – Insulin Glargine: TAG – No. 53 (2002) NICE

119

Recommendations of the St Vincent Task Force for the Management of Diabetes Pregnancies – 1996 (September 1999) International Diabetes Federation; new worldwide definition of metabolic syndrome (April 2005) British National Formulary; British Medical Association, Royal Pharmaceutical Society of Great Britain (2007)