grampian guidelines for the management of diabetes...
TRANSCRIPT
25 May 2011
Grampian Guidelines for the Management of Diabetes Mellitus
2011
25 May 2011
Table of Contents
Section A: Classification, Diagnosis Initial Management, Prevention and Screening........................................5
Section B: Supporting Self-Management.................................38
Section C: Glycaemic Control...................................................81
Section D: Complications........................................................129
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Introduction
These guidelines are designed to assist everyone involved in the care of people with diabetes in planning and implementing their own local care plans, and in dealing with specific common problems. They have been written by local healthcare professionals in primary and secondary care with the aim of supporting local practice within Grampian.
They will facilitate the development of a common standard of care for all people with diabetes in the region, and provide guidance on access to the various support services that are available.
The purpose of diabetes care is to empower patients to make informed decisions about their lifestyle, self-management and health choices. Holistic patient care requires that patients are involved in setting their own realistic targets.
This 2011 update of the electronic guideline incorporates latest available information including changes consequent upon the publication of SIGN 116 in 2010.
Useful Websites:
Throughout the Guideline chapters there will be important links to additional information. A comprehensive list of these websites is available at the end of the document. Some important websites are included below:
Grampian Diabetes Websitehttp://www.diabetes.grampian.orgThe live version of these Guidelines is available through the Diabetes MCN website at http://www.diabetes.nhsgrampian and this is a useful website for diabetes in Grampian in general.
Scotland’s Health on the Web (SHOW)http://www.show.scot.nhs.uk/
Scottish Intercollegiate Guidelines Network (SIGN)http://www.sign.ac.uk/
NICE Guidelines – Home Pagehttp://www.nice.org.uk
My Diabetes My Wayhttp://www.mydiabetesmyway.scot.nhs.uk
Diabetes in Scotland
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http://www.diabetesinscotland.org.uk/
SCI-DC – home page https://ctc6.tayside.scot.nhs.uk/scidc/
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Section A: Classification, Diagnosis Initial Management, Prevention and Screening
A1.0 Types of Diabetes..............................................................................2A2.0 Confirming the Diagnosis and Initial Management...............................4
A2.1 Confirming the diagnosis.............................................................4A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l)....................4
A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO 2000)...............................................................................4
A2.2 Determine the risk of ketoacidosis and likely need for immediate insulin therapy.............................................................................5A2.2.1 Indications for immediate insulin therapy.........................5A2.2.2 Patients not requiring immediate insulin..........................6
A2.3 Check list for recently diagnosed diabetes..................................6A2.3.1 Checklist..........................................................................6
A2.4 Impaired glucose tolerance & impaired fasting glucose...............8A2.5 Glycaemic control - management of the newly diagnosed patient:
....................................................................................................9A2.6 Performing a 75g Oral Glucose Tolerance Test........................11
A3.0 Prevention of Diabetes....................................................................12A3.1 Background...............................................................................13
A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle...15A3.1.2 Key Facts – What is a healthy weight?..........................15A3.1.3 Key Facts – Eating a Healthy Diet.................................17A3.1.4 Key Facts - Physical Activity..........................................19A3.1.5 Key Facts: Healthy Lifestyle & Alcohol..........................22A3.1.6 Key Facts: Medicines & Surgery as part of the
management of obesity.................................................23A3.1.7 Sources of advice about how to achieve and maintain a
healthy weight & lifestyle...............................................25
A4.0 Screening for diabetes.....................................................................27A4.1 UK National Screening Committee (UK NSC)...........................27
A4.1.1 Summary of evidence regarding screening for diabetes27
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A1.0 Types of Diabetes
Type 1 Diabetes: These patients usually present as children or young adults, but it is important to be aware that they may present at any age. Their hallmark is insulin deficiency due to autoimmune pancreatic β cell destruction, resulting in weight loss and the presence of ketones in the urine. Such patients are prone to ketoacidosis, and once diagnosed should be referred to the Diabetes Service by telephone for treatment with insulin as a matter of urgency, although emergency hospital admission is often unnecessary.
Type 2 Diabetes: Although most present in middle and old age, an increasing number present at younger ages. Many are obese. Peripheral insulin resistance combined with relative insulin deficiency accounts for the pathogenesis. Ketonuria is absent in the non-fasting state. Such patients are not normally prone to ketoacidosis.
Those at Increased Risk of Diabetes:
Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT). IFG (fasting venous glucose >6.1<7.0mmol/l) and IGT (fasting venous glucose <7.0mmol/l and 2 hours after OGTT venous glucose >7.8 <11.1 mmol/l) are associated with an increased risk of macrovascular disease and require aggressive management of cardiovascular risk factors, dietary and lifestyle advice. A fasting or random glucose level should be measured on an annual basis to screen for development of diabetes.
Syndromes Associated With DiabetesDiabetes Mellitus: can be secondary to other conditions which cause pancreatic destruction (haemochromatosis, cystic fibrosis, pancreatitis) or associated with other syndromes which are characterised by insulin resistance (acromegaly, polycystic ovarian syndrome, Cushing’s syndrome) and drug therapy, particularly glucocorticoids. The table below illustrates some of the conditions. It is important to remember that many of these conditions are rare but a high index of suspicion may be needed to make such a diagnosis.
Condition When to suspect How to screenCushing’s syndrome Centripetal obesity,
hypertension, hirsutismFirst voided morning urine sample for free cortisol /creatinine ratio
Acromegaly Coarse features, prognathism, change in ring / shoe size, hypertension, sweating
Consider referral to Endocrine clinic
Haemochromatosis Pigmentation (“bronzed diabetes”), abnormal LFTs,
Serum ferritin
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hepatosplenomegalyPolycystic Ovarian Syndrome
Irregular menstruation. Features of the metabolic syndrome.
Clinical history and abdominal ultrasound.
Chronic pancreatic destruction
History of alcohol excess, recurrent abdominal pain, cystic fibrosis
Abdominal ultrasound, amylase, consider referral to GI specialist
Recognised Genetic Syndromes: including MODY (maturity onset diabetes of youth), which is characterised by early onset diabetes and often no requirement for insulin (non-ketotic). Patients are often of normal weight. The condition is inherited in an autosomal dominant fashion and there is almost always a family history. Family history is therefore important in people with diabetes. Website: Diabetesgenes.org
Gestational Diabetes (see Section B 5.4.1) is defined as glucose intolerance of variable severity with first onset or recognition during pregnancy. The criteria for diagnosis of gestational diabetes are a fasting venous plasma glucose of >5.5mmol/l or two hours after OGTT >9mmol/l. If blood glucose levels are in the range for gestational diabetes specialist management is needed. In most women the abnormality is reversible post partum, but up to 50% develop Type 2 diabetes later in life. A small proportion has coincidental Type 1 diabetes.
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A2.0 Confirming the Diagnosis and Initial Management
A2.1 Confirming the diagnosis In the symptomatic individual with dehydration or heavy ketonuria, a presumptive diagnosis of diabetes may be made on the basis of urinalysis and/or blood strip testing and urgent referral is likely to be appropriate.
Otherwise it is essential that a diagnosis of diabetes is confirmed before the patient is advised that he/she has diabetes and before treatment with diet or any other agent is commenced.
Symptoms of thirst and polyuria or the finding of glycosuria should prompt blood glucose measurement using a laboratory method. The diagnosis of diabetes should not be made on the basis of portable blood glucose meter results alone. The diagnosis can be made on the basis of symptoms (thirst and polyuria) and one diagnostic blood glucose measurement. The values of blood glucose indicative of diabetes are as follows;
Random venous plasma glucose ≥ 11.1 mmol/l; or Fasting plasma glucose ≥ 7 mmol/l; or Venous plasma glucose ≥ 11.1 mmol/l at 2 hours after a 75g oral
glucose load (the oral glucose tolerance test
In the absence of symptoms the diagnosis is based on two diagnostic blood glucose measurements on two separate days. On rare occasions therefore a second oral glucose tolerance test may be needed before a diagnosis of diabetes can be confirmed.
In the UK the 2000 WHO criteria were adopted from June 2000.
A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l) Fasting Random
Venous Capillary Venous Capillary ≥7.0 ≥ 7.0 ≥ 11.1 ≥ 12.2 Diabetic range
5.6 to 11.1 6.5 to 12.2 Check fasting glucose
≥6.1 to 7.0 ≥6.1 to 7.0 Impaired Fasting Glucose (IFG) - 75g OGTT required
5.6 to 6.0 5.6 to 6.0 Borderline - 75g OGTT required
≤ 5.5 ≤ 5.5 ≤ 5.5 ≤ 6.5 Diabetes unlikely
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A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO 2000)
Venous Plasma Glucose (mmol/l)Fasting 2 Hour
Diabetes Mellitus ≥ 7.0 and/or ≥ 11.1
Impaired glucose tolerance <7.0 and/or ≥ 7.8, < 11.1
Capillary Plasma Glucose (mmol/l)Fasting 2 Hour
Diabetes Mellitus ≥ 7.0 and/or ≥ 12.2
Impaired glucose tolerance <7.0 and/or ≥ 8.9, < 12.2
Capillary Whole BloodFasting 2 Hour
Diabetes Mellitus ≥6.0 and/or ≥ 11.1
Impaired glucose tolerance <6.0 and/or ≥ 7.8, < 11.1
A2.2 Determine the risk of ketoacidosis and likely need for immediate insulin therapy The most important decision once the diagnosis has been made is to decide whether the patient is at risk of ketoacidosis and likely to require immediate insulin therapy.
A2.2.1 Indications for immediate insulin therapy Persistent non-fasting ketonuria/ketonaemia
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Marked weight loss in the normal or underweight patient Vomiting and dehydration (will require immediate hospital admission for
intravenous therapy). The initial blood glucose level or presence of primary symptoms of
thirst and polyuria are not good guides as to the need for insulin. Hospital admission may be avoided in patients who clearly require insulin, but are not dehydrated or in ketoacidosis, depending on the logistics of arranging to start insulin at home as an out-patient or day-case on an urgent basis. Such patients should be discussed by telephone with a member of the diabetes specialist team with a view to starting insulin within 24 hours. These patients should receive immediate care from the hospital diabetes team and may be seen or admitted to hospital depending on the practicalities of starting insulin at home. Patients with signs of ketoacidosis or dehydration should be admitted to hospital under the emergency admissions system. Children under the age of fourteen should be discussed urgently on the telephone with a paediatrician, and will normally be admitted to hospital.
A2.2.2 Patients not requiring immediate insulin The majority of newly diagnosed patients have Type 2 diabetes, and the management approach can be more relaxed in timescale. The initial blood glucose level or presence of primary symptoms of thirst and polyuria are not a good guide as to the long term need for hypoglycaemic drug therapy. Patients do not normally require oral hypoglycaemic agents until they have completed at least two or three months on diet alone.
Group education facilities are available at a variety of locations throughout the region for the initial education of Type 2 patients. All such patients should initially receive dietary advice aiming to optimise body weight (see diet section). General advice and the provision of the Diabetes UK diet leaflet is acceptable for initial management, but all patients should be referred to a dietitian at an early stage for more detailed and personalised advice.
Obese patients (BMI > 30kg/m2) inadequately controlled after a trial of diet but showing evidence of weight loss may be left on diet alone as glycaemic control is likely to continue to improve. Overweight and obese patients (BMI >25) not achieving weight loss may be most appropriately treated with metformin (section 3) in a low starting dose to minimise gastrointestinal side effects. Patients not overweight (BMI ≤ 25kg/m2) but inadequately controlled may be commenced on a sulphonylurea (section 3.1). Employment and social issues may also influence the choice of treatment.
A2.3 Check list for recently diagnosed diabetes Once the immediate issue of glycaemic control has been addressed it is important to consider further educational topics and to ensure an adequate physical examination for detection of established complications, which are often present at diagnosis in Type 2 patients. The following checklist is suggested for completion over the first few clinical contacts.
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A2.3.1 Checklist
Comment/Recording Date/SignedINITIALDecide on initial blood glucose management and need for immediate insulin or otherwise
Provide initial dietary advice and arrange for referral to a dietitian
CLINICAL RECORDINGSRecord weight and BMIBlood pressureUrinalysis for protein and ketones and glucoseConsider causes of secondary diabetes, see Section A1 - Types of Diabetes
PODIATRYExamine feet for signs of neuropathy, peripheral vascular disease or active lesions. Risk calculation available on SCI-DC. Provide foot care informationDecide on need for referral to a podiatrist
RETINAL SCREENINGPerform, arrange and/or discuss need for adequate retinal examinationRecord visual acuity (pinhole corrected if worse than 6/9)Register with DRS programme.
LAB TESTSArrange biochemical assessment; serum creatinine, LFTs, lipid profile, thyroid function, HbA1cEarly morning urine for albumin/creatinine ratio (microalbumin screen)
RISKRecord smoking status and advise as appropriateAssess cardiovascular risk status (smoking, BP, family history, lipids, proteinuria/microalbuminuria, established macrovascular disease)Consider ECG to assess evidence of previous MI or left ventricular hypertrophy
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FURTHER EDUCATION/MANAGEMENTDecide on appropriate patient self monitoringDetermine individualised blood glucose treatment targetsDiscuss hypoglycaemia and its management in all insulin and sulphonylurea treated patientsProvide support literature and web sitesCover selected topics from the education checklist with the patient and relevant individualsDiscuss driving/DVLA/insurance
Consider referral to a Diabetes Specialist Nurse or hospital diabetes clinic
Ensure patient is registered with practice and regional diabetes register
A2.4 Impaired glucose tolerance & impaired fasting glucose These patients, like those with established diabetes, have an increased
risk of macrovascular disease and require assessment and aggressive management of cardiovascular risk factors, dietary and lifestyle advice – See Section D2.0 and Section B3.5 Smoking and Diabetes.
Patients with impaired fasting glucose (IFG) (≥ 6.1mmol/l, <7.0mmol/l) should have a 75g OGTT as some will fulfil the criteria for diabetes mellitus on the two hour value.
Patients with IGT & IFG could be entered into the practice diabetes register.
Five per cent per year may go on to develop Type 2 diabetes and will then need appropriate diabetes care.
A fasting or random blood glucose level should therefore be measured on an annual basis, or earlier in the event of symptoms in people with IGT or IFG and the results interpreted according to Section A2.1.1. Although not diagnostic an HbA1c level can give further information.
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A2.5 Glycaemic control - management of the newly diagnosed patient:
Algorithm for management of the newly diagnosed patient
Newly diagnosed diabetics
Clinically unwell – vomiting, dehydrated or suspected
acidosis
Heavy Ketonuria
Marked unintentional weight loss
No current indication for insulin therapy
Lifestyle advice e.g. start on diet
Self-monitoring if appropriate
4 – 6 weeks later – Adequate control
Continue diet for 4 weeks
Improving Control
Can dietary compliance be improved?
Overweight BMI >25
Diet & Metformin
Diet & Sulphonylurea
Diet alone
Seek experienced
advice re. insulin therapy within 24 hours
Emergency admission
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
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A2.6 Performing a 75g Oral Glucose Tolerance Test Indications for this test are discussed in Section 2. It can easily be performed in primary care but a standardised protocol must be followed and laboratory glucose analysis must be used. This test should not be performed during intercurrent illness. On rare occasions two oral glucose tolerance tests may need to be performed before a diagnosis of diabetes can be confirmed.
The patient should maintain an adequate carbohydrate intake (> 150g) for at least three days prior to the test.
Fast overnight for a minimum of 10 hours (water only permitted).
75 g oral glucose dissolved in 250 to 300 ml water to be consumed in no more than 5 minutes followed by a further 100 ml water.
Acceptable alternatives are;
Lucozade Energy Original 410 ml (73kcal/100 ml formulation) Maltodextrins in appropriate volume to provide 75g carbohydrate (e.g.
Calsip 150 ml)
Blood for glucose estimation to be taken before (zero minutes) and 120 minutes after consumption of the drink.
Urine may also be tested for glucose to estimate the renal threshold, but this does not contribute to the diagnosis of diabetes, which is based on the fasting and two-hour blood glucose results.
The method of blood sampling is important and must be specified: venous or capillary, plasma or whole blood.
Venous plasma is most commonly used. (Aberdeen Diabetes Clinic uses whole blood capillary glucose).
The patient should remain sedentary and not smoke, eat or drink for the duration of the test.
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A3.0 Prevention of DiabetesA Healthy Weight - Summary
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A3.1 BackgroundIn Grampian, there are currently more than 23,000 individuals with diabetes. 500 new people with diabetes were notified to the register in the last six months alone. Type 2 diabetes accounts for 86.6% of cases. While the cause of Type 1 diabetes is unknown, Type 2 diabetes mellitus is closely associated with being overweight or obese. Over 80% of people with diabetes in Scotland are obese or overweight.1
PreventionHelping people to maintaining or achieve a healthy weight is the key opportunity for prevention of diabetes. Approximately two out of every three people in Scotland are overweight or obese. One in five is obese. One in three children (under the age of 15) is overweight or obese. A ‘typical’ NHS general practice with a list size of 6000 will have approximately 1200 adults who are obese (BMI ≥ 30 kg/m2), and 50 adults who have severe obesity (BMI ≥ 40 kg/m2).2
Obesity is not just a consequence of an unhealthy lifestyle but is a disease and a risk factor for other diseases. In adults, obesity is associated with an increased risk of Type 2 diabetes, coronary heart disease, hypertension, many cancers and osteoarthritis (see table 1).
Table 1: Risk of other diseases in obese adultsError: Reference source not found
Disease Relative risk Women Men
Type 2 diabetes 12.7 5.2Hypertension 4.2 2.6Heart attack 3.2 1.5Colon cancer 2.7 3Angina 1.8 1.8Gall bladder disease 1.8 1.8Ovarian cancer 1.7 Osteoarthritis 1.4 1.9Stroke 1.3 1.3
If you are male and obese you are 5 times more likely to develop diabetes than if you were at a healthy weight; if you are female and obese, your risk is increased 13 times.
If you lose weight you can not only improve the control and management of your diabetes, reducing the need for insulin injections but, 2/3rds of Type 2 diabetes mellitus can be prevented by lifestyle and diet modification.3 You will also reduce your risk of heart disease.
1 National Overview Follow up Report: Diabetes-March 2008, Diabetes UK & NHSQIS2 NICE Guideline 43: Obesity NICE 20073 The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management, UK NSC 2007
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Screening for diabetes Type 1 diabetes has a sudden onset and people present early for care but because Type 2 diabetes has a gradual onset and presents with vague symptoms, it can go unnoticed for many years. At the moment, an estimated 9000Error: Reference source not found people in Grampian may have Type 2 diabetes but will not know yet, and they will not be known to healthcare teams. Diabetes can be detected by a blood test and may be identified as an incidental finding or as part of general health reviews by GPs, practice nurses or, increasingly, by pharmacists.
Structure This section of the guidelines aims to provide a summary of advice regarding: the prevention of Type 2 diabetes through the achievement & maintenance
of a healthy weight & lifestyle Screening for Type 2 diabetes
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A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle
NHS Grampian strategic framework for Healthy Eating, Active Living and Healthy Weight (HEAL)
The NHS Grampian HEAL strategic framework is built on the policy context set out in the ‘Better Health Better Care’ action plan4, which sets both nutrition and physical activity firmly alongside healthy weight and also the national action plan for Healthy Eating, Active Living and Healthy Weight 5.
This framework also builds on learning associated with the implementation of existing policy including the Scottish Diet Action Plan6 and the National Physical Activity Strategy7.
Nationally, obesity is also one of six priority areas which form part of the health improvement performance management framework. Partners in Community Planning Partnerships and Local Authorities are being encouraged to include relevant outcomes and indicators focusing on healthy eating and physical activity in Single Outcome Agreements.
Preventative work can be undertaken at three levels:
universal or public health prevention directed at everyone in a community with the aim of stabilising or reducing the mean BMI in a population
selective prevention directed at high-risk individuals or groups targeted or secondary prevention, directed at those with existing
weight problems to prevent further weight gain and/or decrease body weight
It is the combined effect of a wide range of interventions that is likely to make the greatest impact.
The HEAL Framework makes a number of recommendations including the development and implementation of a Grampian-wide integrated, standardised approach for both adult weight management (including primary care, specialist nutrition clinic and bariatric services) and child obesity. This work is currently underway.
Implementation of the Integrated Care Pathway is happening in a staged manner and now includes referrals to the ‘Healthy Helpings’ weight management programme from the Diabetes Group Education Programme. ‘Healthy Helpings’ is a group based eight week weight management lifestyle 4 Better Health Better Care Action Plan http://www.scotland.gov.uk/Publications/2007/12/11103453/05 Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008- 11) http://www.scotland.gov.uk/Publications/2008/06/20155902/06 Eating for Health: A Diet Action Plan for Scotland (1996)http://www.scotland.gov.uk/Topics/Health/health/19133/17710
7 Physical Activity Task Force. Lets make Scotland more Active. A strategy for Physical Activity. Crown Copyright, Edinburgh 2003. www.scotland.gov.uk/library5/culture/lmsa-00.asp
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intervention designed to support individuals to achieve and maintain a healthier weight.
Factors affecting a person’s ability to maintain a healthy weight or lose weight
Behavioural changes that include healthier eating, increased physical activity and weight management would make an enormous difference to the burden of chronic disease in Grampian. However, many people find it difficult to implement healthy behaviours and maintain a healthy weight.
This is unlikely to change so long as the environmental factors that subtly influence the daily decisions that lead to energy imbalance and weight gain remain unaddressed.
In order to make a difference to the problem is important therefore to tackle both individual behaviour and the environmental factors beyond an individual’s control that influence their behaviour, through both a targeted and population approach.
An environmental approach challenges the commonly held perception that an individual’s behaviour and weight is simply a matter of personal responsibility or indeed individual choice.
Many factors could therefore be affecting a person’s ability to stay at a healthy weight or succeed in losing weight.
Barriers to lifestyle change should be explored:
lack of knowledge about how diet, exercise and sedentary behaviour affect health, energy balance, food portion sizes and buying and cooking food
the cost and availability of healthy foods and opportunities for exercise
safety concerns, for example about cycling lack of time personal tastes the views of family and community members low levels of fitness, or disabilities low self-esteem and lack of assertiveness.
Motivation: people choose whether or not to change their lifestyle or agree to treatment. An individual’s readiness to alter their lifestyle can be enhanced by engaging in a collaborative conversation about behaviour change. The type of questions that could be asked to encourage client engagement includes:
In what ways would it be good for you to…..?If you decide to… how would you do it?What would be the good things about…..?Why would you want to……?
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If you don’t make any change what do you think will happen?
Where would you like to be in…..years?
Tailored advice: Advice needs to be tailored for different groups. This is particularly important for people from black and minority ethnic groups, vulnerable groups (such as those on low incomes) and people at life stages with increased risk for weight gain (such as during and after pregnancy, at the menopause or when stopping smoking). Children: treating children for overweight or obesity may stigmatise them and put them at risk of bullying, which in turn can aggravate problem eating. Confidentiality and building self-esteem are particularly important if help is offered at school. It is important to consider these factors when supporting people to maintain or achieve a healthy weight. A range of services exist within Grampian where people can seek opportunities to lose weight, improve their understanding of nutrition and participate in physical activity. Patients can be referred, or self refer, to Healthpoint to obtain health improvement advice, support and sign posting to local services and facilities. In the next section, there are a series of key facts and links to resources.
A3.1.2 Key Facts – What is a healthy weight?Maintaining a healthy weight is important for many health conditions including diabetes mellitus. A healthy weight is often defined by BMI (body mass index) – this is a measure of weight taking into account a person’s height.
BMIUnderweight: <18.5Healthy weight: 18.5 -24.9Overweight: 25.0-29.9Obesity, class I 30.0-34.9Obesity, class II 35.0-39.9Obesity, class III ≥40
A BMI of 18.5 to 24.9 means that adults are a healthy weight for their height. However, this is general advice for adults only. It does not apply to children, pregnant women or women who are breastfeeding. Also, BMI may not be accurate if the person:
does a lot of weight-training and is very muscular, has a long-term health condition.
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A3.1.3 Key Facts – Eating a Healthy Diet Base your meals on starchy foods that include breads, rice, potatoes
and pasta Eat lots of fruit and vegetables Eat more fish Cut down on saturated fat and sugar Try to eat less salt – no more than 6g a day Get active and try to be a healthy weight Drink plenty of water Don’t skip breakfast
As an example, the following Healthy Eating leaflets are available at the Healthpoint (in Aberdeen and Peterhead) and through Health Information Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504) Your Guide To Healthy Eating The Balance of Good Health
The following websites provide useful sources of information about diet and healthy eating:
Take Life On – One Step At A Time
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NHS Choices – Live Well Healthy Eating provides lots of guidance about nutrition and healthy eating as well as diet related health issues (obesity, diabetes).
A3.1.4 Key Facts - Physical Activity Being physically active is important for health and contributes to maintaining a healthy weight.
What Are The Benefits of Physical Activity? Helps to maintain an energy balance by increasing energy expenditure
(burning calories) and can help use up stored fat Builds muscle which will speed up metabolic rate. This increases the
amount of calories burnt even when the person is not exercising Reducing the amount of stored fat will help reduce the risk of
developing high blood pressure, diabetes and having a heart attack or stroke
Reduces the risk of certain cancers, osteoporosis, falling, levels of stress and improves the person’s overall feeling of well-being and quality of life
If the person has diabetes, physical activity will help to maintain good blood glucose control
How Much Physical Activity Should You Take?The minimum recommended levels of physical activity to maintain good health:
Adults should build up to at least 30 minutes of moderate intensity activity on 5 or more days of the week.
Children to build up at least one hour of moderate intensity activity on 5 or more days of the week.
Moderate intensity means breathing a bit deeper, feeling warmer, perhaps sweating a bit, but still able to carry out a conversation.
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Making It Happen - it is often perceived to be difficult fit activity into the day. Here are some suggestions about how to do it (NICE guideline 43).
Safety First! Seek advice from GP or practice nurse before starting an exercise
programme Start exercising slowly and build up to the recommended levels Wear appropriate clothing and footwear Stop exercising if you feel dizzy or unwell
Contacts and Further InformationDetails of physical activity opportunities and leisure facilities in your area can be found on the local authority websites:
Aberdeen City Council Click on heading ‘Sports and Leisure’
Aberdeenshire Council Quick Links – ‘Sport and Recreation’
Moray Council click on heading ‘Leisure’
(contact details of local Active School Co-ordinators can also be found on these sites)
As an example, the following Physical Activity leaflets are available at the Healthpoint (in Aberdeen and Peterhead) and through Health Information Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
In AdultsSet realistic goals – don’t worry if the odd day is missed but try to make sure physical activity is part of everyday life
Encourage the person to select activities that they enjoy – such as walking, cycling, swimming, aerobics and gardening
Minimise sedentary activities, such as sitting for long periods watching television, at a computer or playing video games.
Build activity into the day – for example, get off the bus a stop earlier and walk, take the stairs instead of the lift, take a walk at lunchtime.
In ChildrenEncourage active play – for example, dancing and skipping.
Try to be more active as a family – for example, walking and cycling to school and shops, going to the park or swimming.
Gradually reduce sedentary activities – such as watching television or playing video games – and consider active alternatives such as dance, football or walking.
Encourage children to participate in sport or other active recreation, and make the most of opportunities for exercise at school.
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Get Active! (British Heart Foundation)Hassle Free Exercise (Health Scotland)Physical Activity and Weight Loss (HealthEx)Physical Activity and Diabetes (HealthEx)
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A3.1.5 Key Facts: Healthy Lifestyle & AlcoholDrinking alcohol regularly above the recommended guidelines has a number of negative consequences for personal health and lifestyle:
Drinking to excess is linked with a rise in blood pressure. High blood pressure increases the risk of heart disease and stroke
Drinking alcohol is the second biggest risk factor for cancers of the mouth and throat. Drinking too much also increases risk of breast cancer
Excessive use of alcohol is linked to liver disease where alcohol turns some liver cells into fat and damages others. Repeated heavy drinking scars the liver (liver cirrhosis) and causes permanent damage which can lead to death
Even small amounts of alcohol can prevent the deep sleep we require to feel alert and refreshed
Alcohol dehydrates the body, and this is partly responsible for ‘hangover’ symptoms
Alcohol is high in calories and therefore can contribute to weight gain; regular mixers and some alcoholic drinks contain a lot of sugar
Alcohol should be avoided during pregnancy or if trying to conceive
Misuse of alcohol can in some cases lead to dependency and have adverse effects on social networks and social functioning
Alcohol reduces inhibitions and affects decision making increasing risks from preventable accidents (e.g. personal safety, sexual health and drink-driving)
There are no recommended drinking guidelines for children and young people
Drinking regularly to excess with the purpose of getting drunk, or ‘storing up’ a large number of alcohol units (weekends), is 'binge' drinking and increases all of the above risks to health
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What is a unit of alcohol? 1 Unit equals 10ml of pure alcohol.
Units = Volume (mls x % (ABV)
100035ml measureof spirits (whisky, vodka, gin, rum etc)
1.4 units
330ml standard bottle lager/beer 1.7 units
1 pint of medium strength lager/beer
2.8 units
1 pint of standard lager/beer 2.3 units1 pint of strong cider 3.4 units275ml bottle alcopop 1.5 unitsOne 175ml (standard) glass of red wine
2.1 units
750ml bottle wine 9.8 units Recommended Guidelines:
Women: No more than 2-3 units a day and no more than 14 units in one week
Men: No more than 3-4 units a day and no more than 21 units in one week
We all need at least 2 alcohol-free days per weekIt takes approximately 1 hour for the body to safely process
1 unit of alcohol.
For more detailed information see SIGN Guideline 74 “The management of harmful drinking and alcohol dependence in primary care” (2003).
For further detailed information, the following Alcohol Advice Leaflets are available at the Healthpoint (in Aberdeen and Peterhead) and through the Health Information Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504).
What's in a Unit?Sensible DrinkingAlcohol & Healthy LivingAlcohol & StressWomen & AlcoholRecognising Problem Drinking
A3.1.6 Key Facts: Medicines & Surgery as part of the management of obesityPharmacological treatment should be considered only after dietary, exercise and behavioural approaches have been started and evaluated.
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Drug TherapyDrug treatment should be considered for adults who have not reached their target weight loss or have reached a plateau on dietary, activity and behavioural changes alone and who have:
a BMI of 27.0 kg/m2 or more with associated risk factors a BMI of 30.0 kg/m2 or more.
The decision to start drug treatment, and the choice of drug, should be made after discussing with the patient the potential benefits and limitations. Drug treatment should be offered only as part of a package of care and support.
ChildrenMedicine treatment is not generally recommended for children younger than 12 years. Treatment should be started in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group.
Surgical TherapyBariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled:
they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, Type 2 diabetes or high blood pressure) that could be improved if they lost weight
all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
the person has been receiving or will receive intensive management in a specialist obesity service
the person is generally fit for anaesthesia and surgery the person commits to the need for long-term follow-up.
ChildrenSurgical intervention is not generally recommended in children or young people. Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity.
Only a multidisciplinary team that can provide the necessary expertise and support should undertake surgery for obesity.
For more detailed information: NICE Guideline 43: Obesity (2006) & SIGN 115.
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A3.1.7 Sources of advice about how to achieve and maintain a healthy weight & lifestyle
Below are some useful sources of advice about achieving and maintaining a healthy weight and lifestyle.
For EveryoneSources of information within Grampian
Healthpoint offers free advice and information on: practical ways to improve your health; your health concerns; support groups and organisations; how to access NHS services; jobs in the NHS; access to free condoms
Healthline is a free, confidential, telephone line that provides healthpoint information.Available: Monday - Friday 9.00am - 5.00pm. Phone the free Healthline number on 0500 20 20 30
NHS Grampian website provides details of local sources of advice and contacts for further information about healthy active living. Follow the links to “About NHS Grampian” then “health improvement” and then select “healthy living”.
Other sources of informationTake Life On – One Step At A Time provides a user friendly guide to healthy eating and physical activity for all.
NHS Inform for a one-stop shop to quality assured health information for patients, carers and the public.
Health Scotland provides information to support health improvement in Scotland. It includes is information about food and nutrition and physical activity.
NHS24 provides comprehensive up-to-date health information and self care advice for people in Scotland.
NICE, the National Institute for Health and Clinical Excellence, has issued new guidance to the health service about how to prevent obesity. This is a summary of the evidence presented for the public (Preventing obesity and staying a healthy weight).
NICE, the National Institute for Health and Clinical Excellence, has issued new guidance to the health service about how to treat and manage overweight & obesity. This is a summary of the evidence presented for the public (Treatment for people who are overweight or obese).
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Active Scotland – find leisure activities by postcode.
For Healthcare Professionals
In addition to the resources above you can find more information here:
Sources of information in Grampian
Supporting the Professional : Several services provided by Public Health work together under the ‘Supporting the Professional’ heading.
Health Information Resource Service can provide free information leaflets and other resources for a range of topics – a few are recommended below.
The service can be accessed by telephone: 01224 558504 (ext. 58504), fax: 01224 558630 (ext. 58630), and email: [email protected]
However, the main access point is via the Health Information Resource website as this is the service’s catalogue, as well as allowing online orders.
Refer a patient to Healthpoint – for advice, support and direction to local services. You can refer a patient by using the “Healthpoint referral pads” which can be ordered from Resources ([email protected]).
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The Grampian Health Improvement Network (Hi-Net) provides a web based resource full of health improvement information. You can access:Physical Activity Strategy and Action PlanFocus is Grampian’s Nutrition Health Promotion StrategyGrampian Healthy Weight Strategy
Other sources of informationSIGN 115 – A new SIGN Guideline on Obesity was launched in spring 2010.
NICE 43 (Full Guideline – Obesity) – includes guidance on prevention of obesity, lifestyle advice and interventions for the treatment of overweight and obesity, and medical or surgical interventions.
Recommended leaflets: Diet: Eating for Health; Hassle Free Food, Strive for 5; NHSGYour Guide to Healthy Eating’Alcohol: Sensible Drinking, Alcohol & Healthy LivingPhysical Activity: The ‘Active Living’ series; Hassle FreeExercise
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A4.0 Screening for diabetes
A4.1 UK National Screening Committee (UK NSC)The UK National Screening Committee is chaired by the Chief Medical Officer for Scotland and advises Ministers and the NHS in all four UK countries about all aspects of screening policy and supports implementation. Using research evidence, pilot programmes and economic evaluation, it assesses the evidence for programmes against a set of internationally recognised criteria. Assessing programmes in this way is intended to ensure that they do more good than harm at a reasonable cost. In 1996, the NHS was instructed not to introduce any new screening programmes until the UK NSC had reviewed their effectiveness.
More information about the UK NSC can be obtained here (http://www.nsc.nhs.uk).
More information about the criteria used by the NSC to judge whether to introduce a screening programme can be found here (http://www.screening.nhs.uk/criteria).
A4.1.1 Summary of evidence regarding screening for diabetes There have been no national screening programmes in place for:
Diabetes Impaired Glucose Tolerance (IGT) Obesity
March 2008) saw the publication of the “Handbook for Vascular Risk Assessment, Risk reduction and Risk Management” A report prepared for the UK National Screening Committee to, as outlined in a Press statement by Dr Anne Mackie, Director of the NSC, “help us identify what is desirable, and realistic, to provide…and inform primary care and public heath professionals who are already providing risk assessment and risk management.”
It provides an interesting summary of the evidence and suggested ways forward for incorporation of screening and intervention for the main vascular risk factors including obesity and diabetes.
You can access the document here (http://www.screening.nhs.uk/vascular/VascularRiskAssessment.pdf).
During 2010, the Scottish Public Health network published a draft document on the prevention of and screening for Type 2 diabetes in Scotland. The draft report has advised that HbA1c be used as the preferred screening test for diabetes. This approach has been cleared by the National Screening Committee as being consistent with the vascular screening programme across the rest of the UK and with international work. The best alternative is
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fasting glucose. Random blood glucose is not recommended for screening for diabetes and SIGN Guideline 97 on risk estimation and prevention of cardiovascular disease should be updated accordingly. Random glucose measurement remains a satisfactory way of confirming a clinical diagnosis in a symptomatic patient. The report has also recommended that in asymptomatic individuals an HbA1c ≥ 48 mmol/mol (6.5%) should be repeated. A repeat level of ≥ 48 mmol/mol confirms Type 2 diabetes mellitus. Those with an elevated HbA1c ≥39 mmol/mol (5.7%) but not meeting diagnostic criteria for diabetes should be classified as having non-diabetic hyperglycaemia (NDH) and should be offered intensive lifestyle intervention. In those with initial HbA1c <39 mmol/mol screening with an HbA1c should be repeated every five years as part of cardiovascular screening. These recommendations are under review (November 2010). This section will be updated as further information becomes available.
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APPENDIX 1: HEALTHPOINT & HEALTH LINE
Healthpoint is a walk in service which offers free and confidential advice and information from trained staff on a wide range of topics:
practical ways to improve your health; your health concerns; support groups and organisations; how to access NHS services; jobs in the NHS; access to free condoms
Alternatively, you can contact the healthpoint team for information by email: [email protected] or call on the free Healthline on 0500 20 20 30
Healthline is a free local telephone line available Monday - Friday 9.00am - 5.00pm. Any information requested is sent by post free of charge. All calls are confidential and are answered by trained health advisers You can access these services with or without referral from a healthcare professional.
Visit healthpoint at:Aberdeen Indoor Market (In Shops) 8 - 10 Market Street Aberdeen Open Monday to Saturday 10.00am to 4.00pm This healthpoint is manned by trained staff
Healthpoint information is also available at:
Aberdeen Royal Infirmary ConcourseDavid Anderson Building, Foresterhill Road
Torry Neighbourhood CentreThe Point, St Nicholas House
Dr Gray's Hospital, ElginHealthy Hoose, Middlefield
Lhanbryde Community HouseDenburn Health centre, Aberdeen
ASDA Pharmacy, PortlethenBaird's Pharmacy, Huntly
Tarland Pharmacy, TarlandSummers Chemist, Fraserburgh
Marywell Healthcare centre, AberdeenBuchanhaven Pharmacy, Peterhead & SCP
Management Unit at Spynie, ElginDenburn Health Centre, Aberdeen
Please note that these healthpoints are unmanned.
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APPENDIX 2: Measuring overweight & obesity
Adults BMI (body mass index) To take account of the expected differences in weights in adults of different heights, an index of weight-for-height has been devised as the BMI. This is calculated as:
Example: An adult of 70 kg with a height of 175 cm has a BMI of:
Interpreting BMI
Underweight: <18.5Healthy weight: 18.5 -24.9Overweight: 25.0-29.9Obesity, class I 30.0-34.9Obesity, class II 35.0-39.9Obesity, class III ≥40
Waist circumferenceExcess abdominal fat carries particularly elevated health risks. Waist circumference is the most practical marker of abdominal fat. (Many people understand this concept as ‘apple’ versus ‘pear’ shaped.). If the BMI is <35 then waist circumference is a useful marker for additional health risks.
Interpreting the waist circumference:
A waist circumference of less than 94cm in a man, and less than 80 cm in a woman, means that their abdominal fat accumulation is not excessive.
ChildrenBody mass index (BMI) (compared to a reference population of children of the same age and sex) is recommended as a practical estimate of overweight and obesity in children and young people, but needs to be interpreted with caution because it is not a direct measure of fat tissue.
For clinical use, SIGN recommends that obesity should be defined as those with a BMI >=98th centile of the UK 1990 reference chart for age and sex. For overweight, a BMI >=91st centile should be used. For more detailed information see SIGN Guideline 115.
BMI = Weight (Kg)/Height (m2)
BMI = 70 (Kg)/1.75 x 1.75(m2) = 22.9
Increased risk Men > 94 cm (~37 inches) Women > 80 cm (~32 inches)
Substantially increased riskMen >102 cm (~40 inches)Women > 88 cm (~35 inches)
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Section B: Supporting Self-Management
B1.0 Structured Review Schedules.........................................................39B1.1 Regular Review Schedules.......................................................39B1.2 Every structured diabetic review................................................39B1.3 Content of Annual Checks.........................................................40
B2.0 Education..........................................................................................41B2.1 Newly Diagnosed Diabetes.......................................................42B2.2 Ongoing Diabetes Management...............................................43B2.3 Diabetes Courses & Resources................................................44
B3.0 Lifestyle............................................................................................45B3.1 Driving.......................................................................................45B3.2 Occupations...............................................................................50B3.3 Physical Activity.........................................................................52B3.4 Psychological Wellbeing............................................................55
B3.4.1 Introduction....................................................................55B3.4.2 Depression....................................................................55B3.4.3 Anxiety...........................................................................55B3.4.4 Screening for Anxiety and Depression..........................56B3.4.5 Other Psychological Issues...........................................56B3.4.6 Behaviour Change.........................................................58
B3.5 Smoking.....................................................................................61B3.5.1 Smoking cessation........................................................61
B3.6 Travel.........................................................................................62
B4.0 Information Technology..................................................................64B4.1 National and Regional Diabetes IT Overview............................64
B4.1.1 SCI-DC – Introduction....................................................64B4.1.2 Accessing SCI-DC Network...........................................65B4.1.3 SCI-DC Network - Overview..........................................68B4.1.4 SCI-DC – Help / Contacts..............................................71
B5.0 Contraception, Pregnancy and the Management of Gestational Diabetes Mellitus.............................................................................73B5.1 Contraception............................................................................73B5.2 Planning pregnancy...................................................................74B5.3 Confirmed pregnancy................................................................75B5.4 Management of Gestational Diabetes.......................................77
B5.4.1 Follow up of Patients with Previous Gestational Diabetes......................................................................................79
B6.0 Children’s Services.............................................................................80
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B 1.0 Structured Review Schedules
B1.1 Regular Review Schedules Patient empowerment through education to encourage optimal self-management should be central to each review. Regular review of individuals with diabetes should address both metabolic control and diabetic complication screening. Reviews will involve metabolic management, education, health promotion, and detection and management of diabetic complications. This care must be structured, locally agreed and documented and may involve a variety of professionals in various locations carrying out different parts of this programme.
Interim metabolic and troubleshooting checks at three to six month intervals are usually appropriate.
Systematic screening for the early detection of the microvascular and associated macrovascular complications of diabetes is also an essential component of structured diabetes care.
Effective interventions are available at an early or latent stage of the disease processes which can slow or prevent further progression, and which would not be as effective if delayed until the problem had become clinically obvious.
Complication screening is usually performed on an annual basis, either as a formal annual review or on a rolling programme basis, unless problems have been previously identified.
B1.2 Every structured diabetic review The patient should be assessed and advised regarding:
The impact of diabetes on lifestyle and psychological well-being. Symptoms of hyperglycaemia (where relevant) Occurrence and warning symptoms of hypoglycaemia Results of home monitoring if available. Episodes requiring hospital admission Medication
The following parameters should usually be recorded and discussed with the patient at each visit:
Blood pressure (particularly if hypertensive or previous recording elevated).
HbA1c (not more often than every 3 months). Weight and BMI. Urinalysis for ketones, protein and glucose.
An individual care plan and goals should be reviewed, agreed with the patient and updated as appropriate. Additional interim visits may be required to address specific problems.
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B1.3 Content of Annual Checks
The following parameters should usually be considered +/- recorded and discussed with the patient at each visit: Blood pressure (particularly if hypertensive or previous recording elevated). HbA1c (not more often than every 3 months). Weight and BMI. Urinalysis for ketones, protein and glucose.
The patient should be assessed and advised regarding:
The impact of diabetes on lifestyle and psychological well-being. Symptoms of hyperglycaemia Occurrence and warning symptoms of hypoglycaemia Results of home monitoring if available. Episodes requiring hospital admission Medication
The patient should be assessed and advised regarding the following: Exercise and physical activityDiet. Access should be available to dietetic specialist advice as required.Smoking habits Symptoms or other evidence of cardiovascular disease Symptoms suggestive of peripheral vascular disease Alcohol consumption Contraception and pregnancy planning if appropriate (remember the increasing number of women with Type 2 diabetes in this group)Symptoms of erectile dysfunctionSymptoms of depressionImmunisation (especially seasonal influenza vaccination)
The following parameters should be measured or examined on a minimum of an annual basis, and are selectively further expanded in the following sections.
Blood pressure (sitting after 5 minutes rest) Visual acuity (corrected with pin hole if worse than 6/9) and retinal screening. Patients once referred to the Grampian Diabetes Retinal Screening Service will be invited annually for retinal screening. Inspection of feet for callus, active lesions, colour and foot pulses. Foot sensation using 10g monofilament. Calculation of foot risk.Injection sites (in insulin treated people) Urine for protein First morning urine for microalbumin screen if proteinuria negative. (Persistent proteinuria, when confirmed on two consecutive occasions, should be quantified using a protein/creatinine ratio)Glycosylated haemoglobin (HbA1c) Serum lipid profile Serum creatinine and eGFR Consider screening for Thyroid and Coeliac Disease, especially in Type 1 DM.
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B 2.0 EducationEducation of the person with diabetes about their condition and its management is a key component in the promotion of successful self-care. Healthcare professionals can make a major contribution by helping those with diabetes to understand their disease and the potential for intervention to improve outcomes. In particular, emphasis on the beneficial effects of lifestyle management should never be neglected. Similarly, facilitation of appropriate learning with respect to administration of medications and self-monitoring are essential parts of effective medical management of diabetes.
Educational input at diagnosis of the condition will need to be substantial and will usually need ongoing reinforcement. The ‘correct’ amount of information to present at any encounter is problematic and should not greatly exceed the patient’s current needs or capacity to take new knowledge on board. It is important to be aware that people learn best when physically and emotionally ‘comfortable’ and to remember how stressful many individuals find interactions with healthcare professionals. In attempting to enlighten, it is more important to check understanding regularly than to continue to impart ever more information; in this context less is often more. Also note that different issues will be most appropriately addressed at different stages of the patient experience. In facing the challenge of selecting topics to be addressed, the healthcare professional must always attempt to recognise and acknowledge the patient’s current agenda.
Skilled educators will understand the need to combine factual knowledge and skills training with appropriate empathy and reassurance and will be able to improvise on the breadth and depth of material appropriate to a given consultation or enquiry. They will be aware of the variety of methods that different people prefer to learn by and will use relevant combinations of spoken, written and demonstrated material as well as leaflets, video recordings, websites etc., that most appropriately match the patient’s needs. Ideally they will have had the opportunity of some training in various methods of teaching, including individual and group work.
Many different media, texts and courses are available for diabetes education, particularly in relation to commonly recurring situations. It is important to have a broad range of resources and skills to respond to patients’ various needs and preferred learning styles. It is also useful to seek opportunities to customise or develop training materials in line with local demands and patterns of service provision and support.
More specific information follows on:i) The educational approach to the newly diagnosed patientii) Ongoing educationiii) Introduction of insulin therapyiv) Diabetes Courses and Resources
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B2.1 Newly Diagnosed Diabetes
Attention needs to be paid to the manner in which information about the diagnosis and its implications are delivered to the patient. As diabetes is so prevalent, most individuals already have some ideas about, and experience relating to, diabetes that may well be incomplete or misleading and thus cause undue distress upon diagnosis.
Diabetes UK (Grampian Voluntary Group) provides Education packs for those newly diagnosed with Type 2 Diabetes that are currently distributed to practices around the region; these cover a wide range of issues of potential relevance. Group Education sessions with specialist nurse, dietetic and podiatry input for newly diagnosed Type 2 patients (+/- partners) are available at various localities throughout Grampian. Additional opportunities may be required for one to one follow-up consultations with diabetes team members.
Information for those with Type 1 diabetes is also available from Diabetes UK, but the need for early initiation of insulin therapy means there is an even greater need for education time and timely education. Early, and perhaps serial, follow-up is particularly important in this situation.
It is essential that adequate instruction is given on the use of any equipment supplied (e.g. injection devices, blood testing equipment). The effectiveness of such tuition needs to be assessed sensitively, recognising differences in engagement, aptitude and application among patients.
All material considered for presentation to newly diagnosed patients should be considered again at subsequent follow-up in recognition of the common need for reinforcement, and the evolution of the patients understanding and immediate focus of engagement.
A checklist of some of the commoner items to be considered in the early period following the diagnosis of diabetes is reproduced below. This list is neither exhaustive nor is coverage of many items obligatory. Furthermore, it should be used at a pace and to an extent commensurate with achieving the aim of equipping the patient to cope more effectively with diabetes and its management, and not to simply to record coverage of a list.
DIAGNOSISWhat is diabetes?How has the diagnosis been confirmed?What are the implications of the diagnosis on health?
LIFESTYLE ISSUESDiet: quality, quantity and distribution through the dayActivity and exerciseAlcohol intake and health Smoking and resources to aid cessationConception, contraception and sexual health
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Travel and holidays
MONITORINGWhat to expect (glucose, HbA1c, weight, blood pressure, eyes, feet, urine)Meaning and implications of resultsSelf-monitoring: whether, why, how and when?Effects of intercurrent illness
MEDICATIONAs an adjunct to self-management/ lifestyle modificationEvolving disease and treatment plansRange and nature of glucose-lowering treatmentsUse of non-hypoglycaemic, risk-modifying drugs
OTHER ISSUESDrivingEmploymentFootwear and foot careID cards/ bracelets etcFree prescriptions and eye tests
B2.2 Ongoing Diabetes Management
Education in various aspects of diabetes management will be a continuing component of good diabetes care which will make considerable demands on the knowledge, skill, experience and professionalism of those involved in its provision. Several issues will often need to be revisited with patients; topics for discussion will sometimes be introduced proactively during review consultations, and sometimes be in reaction to a patient’s current particular concerns. Once again a range of educational approaches and resources will allow for the requirements of each patient to be best met. Some situations will have a particular set of topic areas that require to be covered. Prominent among these will be the introduction of insulin therapy and a second indicative table of items to consider discussing with the patient at this stage is produced below.
INTRODUCING INSULINWhat is insulin and what does it do?Insulin typesInsulin injectionsDoses and dose adjustmentSupplies and disposalHypoglycaemia: causes, recognition, management, avoidanceSick day rulesDriving, DVLA and employment issues
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B2.3 Diabetes Courses & Resources
The MCN has an Education Advisory Group (contactable via the MCN Office) that meets quarterly and is available to advise the MCN, and individuals or groups across the region involved in diabetes care, on matters concerning educational strategy and delivery. It produces an Annual Report viewable on the MCN website. There is also local representation on the national Diabetes Education Advisory Group, a subgroup of the Scottish Diabetes Group.
Many diabetes educational opportunities are available for both professionals and their patients. Training needs and course provision naturally vary over time and anyone looking for something specific, or more general, will always do well to consult colleagues about current or recent experience of what is available. There is a strong history of locally developed and delivered educational initiatives within Grampian. Forthcoming courses and events are advertised on the Grampian Diabetes website.
Among the local events for health care professionals on offer recently are the Lilly GP Diabetes Scholarship, Managing the Change to Insulin in Type 2 Diabetes and Diabetes: Helping Nurses to Help Patients to Help Themselves. The Grampian Diabetes Managed Clinical Network also hosts an Annual Professional Conference in early summer.
More substantial courses, some including distance learning, are provided by various Higher Education Institutions across the UK. Advice on diabetes education for professionals and patients also appears on the Diabetes in Scotland website.
Among the current organised educational activities for patients in Grampian are New Patient Groups, Exercise Classes and DAFNE (Dose Adjustment for Normal Eating) with further information available via the Grampian Diabetes website or through health care professionals.
A wide variety of leaflets and literature are available from a number of sources and these are often being reviewed and updated. The internet is well established as a potential source of information for all, although one must always be aware of commercial influences that could direct contents or emphasis. A substantial amount of good quality information has been available for some time on the Diabetes UK website. NHSG Health Information Resource Service can provide free information leaflets and other resources for a range of topics.
In 2008, NHS Scotland launched ‘My Diabetes My Way’, an interactive website designed to help anyone with an interest in diabetes. Its partner website comprises the ‘NHS Inform’ e-Library of quality assured information. The respective web addresses of these NHSS websites are: http://www.mydiabetesmyway.scot.nhs.uk and http://www.nhsinform.co.uk.
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Useful and interesting resources for patients and professionals can be found at Diabetes Stories, featuring 100 oral histories of patients, relatives and health care workers and at Healthtalkonline, which features a series of texts and recordings of individual experiences of Type 2 Diabetes.
B3.0 Lifestyle
B3.1 Driving
Full guidance on medical rules is available on the DVLA website: www.dvla.gov.uk
Patients with diabetes treated with insulin must inform the DVLA of their diagnosis and type of treatment.
Patients with diabetes treated by diet or tablets no longer need to inform the DVLA unless they develop other complications or have frequent episodes of hypoglycaemia (see patient information sheet in “At a glance guide”).
All patients are advised to inform their car insurance company at diagnosis and if their type of treatment changes.
From August 2010 the Driving Regulations changed in keeping with European changes. The main change currently under consultation is to allow insulin-treated patients to hold Group 2 licences if specialist review considers this appropriate. However the mechanisms and organisational processes surrounding these changes have yet to be confirmed.
For the individual patient information sheets please look at the “At A Glance guide” on the DVLA website and download and give to patients as appropriate:
Diet and tablet treated diabetesInsulin treated diabetesC1 licensing and insulin
Types of driving licence:
Group 1 entitlement allows the driving of vehicles up to 3.5 tonnes or with up to 8 passenger seats, including motorcycles and mopeds. For patients on diet or oral hypoglycaemic agents a licence lasting until age 70 will be issued in
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the absence of other complications. Drivers whose diabetes is treated with insulin will be issued with a 1, 2 or 3 year licence, provided they are able to recognise warning symptoms of hypoglycaemia and have no other complications which would affect driving including recurrent hypoglycaemia.
Group 2 entitlement (see note at beginning of 3.1 concerning new regulations in August 2010) allows the driving of vehicles over 3.5 tonnes or more or with more than 8 seats. This includes medium sized lorries (3.5-7.5 tonnes, C1), minibuses (D1), lorries (C), buses (D). Before January 1997 drivers who obtained a normal car driving licence were automatically awarded C1 and D1 entitlement. These holders of C1/D1 entitlement retain it until their licence becomes due for renewal, when they must meet the medical standards prescribed for all lorry and bus drivers. Group 2 drivers treated with oral hypoglycaemic agents must inform the DVLA and group 2 entitlement will continue as long as they can meet all group 2 medical standards. New applicants on insulin or existing drivers starting insulin are barred in law from driving HGV or PCV vehicles (C and D) from 1/4/91. Drivers licensed before 1/4/91 on insulin are dealt with individually and licensed subject to satisfactory annual Consultant assessment. Regulation changes in April 2001 allow “exceptional case” drivers to apply for or renew their entitlement to C1/C1E to drive small lorries with or without a trailer subject to meeting all “Qualifying Conditions”. Regular review by a consultant Diabetologist is required. Patients on insulin are not allowed to hold a D1 licence (minibus).
Taxi driversThe licensing of taxi-drivers is undertaken by individual local authorities and therefore different standards are applied in different parts of the country. However current best practice advice recommends that Group 2 medical standards are applied to taxi drivers although this does not currently seem to take place in Grampian.
Emergency response vehiclesThe DVLA has recommended that drivers with insulin treated diabetes should not drive emergency vehicles. This takes account of the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation. .
How are driving licences renewed?At the time of licence renewal or at initial declaration of insulin treatment patients on insulin will be required to complete a self-declaration form about their diabetes with particular reference to hypoglycaemia and glucose monitoring. If no problems are identified it is usual for the licence to be renewed without requesting a medical report. However in all cases where specific issues are identified then a medical report will be required and will be sent to the doctor identified by the patient. Information required includes whether the patient knows about the driving advice, monitors appropriately, any recent episodes of severe hypoglycaemia (in last 12 months) or has lost awareness of hypoglycaemia.
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Diabetes related complications and drivingAll drivers are required by law to be able to read a standard size car number plate in good light at 20.5 metres. The advantage of this test is that it is easily self-administered. Problems which affect the field of vision must be notified to the DVLA. Drivers who have had laser treatment to both eyes for retinopathy or suffer other conditions affecting both eyes must inform the DVLA so that the extent of the problem can be assessed.
Drivers who develop problems with either the nerves or the circulation in the lower limbs, sufficient to prevent safe operation of the foot pedals, must inform the DVLA. This is unlikely to prevent driving as problems may be overcome by either restricting driving to certain types of vehicles e.g. those with automatic transmission, or by appropriate adaptations such as hand operated accelerator / brake. Insulin Treated Diabetes and Driving
Drivers who have any form of diabetes treated with any insulin preparation must inform DVLA.
At the time of starting insulin patients should be advised not to drive until their blood glucose levels are stable.
Hypoglycaemia The risk of hypoglycaemia (low blood sugar) is the main hazard to safe driving. Many of the accidents caused by hypoglycaemia are because drivers continue to drive even though they are experiencing warning signs of hypoglycaemia.
A patient must inform DVLA :
• If he / she develops impaired awareness of hypoglycaemia
• If he / she suffers disabling hypoglycaemia at the wheel
• If he / she suffers more than 1 episode of disabling hypoglycaemia within the last 12 months.
However in some circumstances the patient will be allowed to drive by the DVLA and it is up to individual health professional to advise if the patient if fit to drive whilst awaiting to hear from the DVLA.
If a patient drives against medical advice then his / her insurance and driving licence are deemed not valid and the patient is therefore driving without insurance or a valid driving licence.
Precautions advised for Drivers with insulin treated diabetes:
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• Do not drive if you feel hypoglycaemic or if your blood glucose is less than 4.0 mmol/l.
• If hypoglycaemia develops while driving stop the vehicle as soon as possible in a safe location, switch off the engine, remove the keys from the ignition and move from the drivers seat.
• Do not resume driving until 45 minutes after blood glucose has returned to normal. It takes up to 45 minutes for the brain to fully recover.
• Always keep an emergency supply of fast-acting carbohydrate such as glucose tablets or sweets within easy reach in the vehicle.
• Carry your glucose meter and blood glucose strips with you. Check blood glucose before driving (even on short journeys) and test regularly (every 2 hours) on long journeys. If blood glucose is 5.0mmol/l or less, take a snack before driving.
• Carry personal identification indicating that you have diabetes in case of injury in a road traffic accident.
• Particular care should be taken during changes of insulin regimens, changes of lifestyle, exercise, travel and pregnancy.
• Take regular meals, snacks and rest periods on long journeys. Always avoid alcohol.
Hypoglycaemic seizuresIf a patient has a seizure which is hypoglycaemia related they may be allowed to drive after notification to the DVLA. However, before this occurs clear evidence will be required by the DVLA that hypoglycaemia was the cause of the seizure and that there is very low risk of recurrence. Pending an investigation / report the patient should be advised not to drive and to inform the DVLA immediately.
C1/C1E Entitlement
Any C1 or other Group 2 licence reports must be completed by a consultant in diabetes and require annual review.
Qualifying Conditions: No hypoglycaemic attacks requiring assistance whilst driving within the
previous 12 months. Regular monitoring at least twice daily and at times relevant to driving.
The use of a memory chip meters for such monitoring is strongly recommended.
Examination every 12 months by a hospital consultant, who specialises in diabetes. At the examination the consultant will require sight of blood glucose records and preferably the meter for the last 3 months.
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No other condition, which would render you a danger when driving C1 vehicles.
required to sign an undertaking to comply with the directions of doctors(s) treating the diabetes and to report immediately to DVLA any significant change in your condition.
Exenatide, liraglutide or gliptins and driving
Exenatide and liraglutide are available as treatments for use in Type 2 diabetes, in combination with metformin and/or with sulphonylureas. Trials published to date show a small but significant increased risk of hypoglycaemia when exenatide is used in conjunction with a sulphonylurea. It would appear that when the gliptins (DPP4 inhibitors) are used with sulphonylureas, the hypoglycaemia risk is similarly raised. The increased risk of hypoglycaemia from exenatide, liraglutide or gliptins when used in combination with sulphonylureas is such that these are felt to be a potentially high risk treatment for drivers holding Group 2 (LGV or PCV) licences and that individual assessment will be required. Therefore any patient who holds a Group 2 licence and who is commenced on either a gliptin, exenatide or liraglutide in combination with a sulphonylurea must report this to the DVLA (combination with metformin alone does not require reporting). The use of gliptins, exenatide or liraglutide carries no specific driving restrictions for Group 1 (car or motorcycle) licences.
[DVLA website: www.dvla.gov.uk]
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B3.2 Occupations
An occupational history is essential at diagnosis in order to help patients adjust their diabetes to fit with their work routine. Some occupations may be considered hazardous for patients with diabetes. Patients at particular risk of hypoglycaemia ie those on insulin or sulphonylureas should be given advice about appropriate detection and management of hypoglycaemia to minimize risks which may occur. They should also be advised to consider carefully the risks they may be exposed to if working unsupervised and the effect that unstable shift patterns may have on their diabetes control.
Hazardous occupations
Many occupations involve an element of hazard or risk. This could involve anything from working near heavy machinery to being an active fire fighter.
Regular monitoring of blood glucose is advised and disabling hypoglycaemia and loss of warning signs of impending hypoglycaemia should be discussed at each clinic review.
Patients undertaking physically active work should also be aware of their carbohydrate requirements and insulin adjustment to prevent hypoglycaemia.
The presence of other diabetes related complications may pose additional risk eg advanced retinopathy, nephropathy or severe neuropathy or coronary heart disease.
The role of the health professional and the employer
Patients should be encouraged to declare their diabetes when applying for employment.
The Disability Discrimination Act (updated 2005) provides legal grounds for people with diabetes to address the issue of discrimination. Within organisations that are not exempt from the Act, an employer is no longer able to dismiss a person because they have developed diabetes. Employment cannot be refused on the grounds of having diabetes – indeed employers need to prove why they could not employ an individual with diabetes.
Employer’s knowledge of diabetes may be minimal and health professionals should be willing to liaise with employers to try and dispel the myths that are commonly associated with diabetes.
People with diabetes should be encouraged to tell their work colleagues and the first-aider about their diabetes so they know how to recognise and treat hypoglycaemia.
Health professionals should ensure that people requiring insulin are on the most appropriate insulin regimen to fit in with the patients work schedule e.g. multiple injection regimen for shift workers.
Patients wishing to work overseas should be advised to ascertain the availability of appropriate medical support if required.
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In October 2004 the DDA was extended to include the emergency services and other potentially hazardous occupations. The only occupation that still enforces a blanket ban for people with diabetes is the armed forces. Diabetes UK have produced the following guidelines to help employers decide whether a person with diabetes can work safely in a hazardous occupation:
“You should be as physically and mentally fit as people without diabetes.
You should visit your diabetes care team for regular (at least annual check ups.
Your diabetes should be well controlled. You should test your blood glucose levels and be well informed
and motivated to care for your condition. There should be no cases of disabling hypos and you should be
aware of your own hypo warning signs. You should have no advanced diabetes-related eye disease
(retinopathy), kidney disease (nephropathy) nor severe nerve damage (neuropathy).
You should have no significant circulation disorders of the heart (eg coronary heart disease), legs or brain
Your suitability for employment should be reviewed annually by both an occupational physician and diabetes specialist. The review should be based on previous criteria.
You may find that if you develop diabetes whilst in employment, the organisation may change the nature of your job. This could be sensible and may be worth considering.”
It is anticipated that there will be new legislation – the Equality Act - towards the end of 2010 which is likely to affect employment for people with diabetes.
However as the law stands, some occupations that have their own medical standards and if reasonable can limit employment in certain areas and detailed occupational health review may be required.
Occupations which may be limited for people with insulin treated diabetes:-
Armed forces Airline pilot or airline cabin crew (certain airlines) Air traffic control Police Emergency services Train driver Deep sea diving Prison service Jobs requiring a Large Goods Vehicle (LGV), Passenger Carrying
Vehicle (PCV) licence or a minibus (D1) licence. If a person drives a C1 class vehicle for a living, and develops Type 1 diabetes or starts insulin treatment, they will have to be medically assessed on their fitness to drive.
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o These rules are to change in August 2010 with the introduction of new driving legisltation which will allow well-controlled insulin-treated patients to hold a Group 2 licence for larger vehicles.
Working offshore eg on oilrigs
Regulations concerning this work were relaxed in May 2008.
Patients requiring insulin may be given restricted certification of fitness to work offshore if the following requirements are met:
There is a report from the individual treating physician The patient has been assessed and not considered to be at excess risk
of hypoglycaemia The patient must be fit to respond to any emergency situation on the
platform There has been good control of their diabetes for a minimum period of
6 months The patient can self-manage their insulin requirements The patient does not have impaired awareness of hypoglycaemia The operator’s medical advisor must be consulted regarding the
individual case and must agree with the proposal to allow the individual offshore
There must be a supply of glucagon and iv dextrose on the platform Certification is restricted to a named platform and restricted to a
maximum of 1 year. Individuals require annual review
Patients on diet or oral agents will be assessed for their risk of hypoglycaemia and presence of complications which may affect mobility and ability to respond to emergency situations.
Seafarers
On a UK registered ship the following regulations apply:
For patients with diabetes not on insulin: Deemed unfit for distant waters (ie > 150 miles from safe haven in UK
waters) and for watchkeeping until stabilized but then may be fit for all areas.
For patients with diabetes requiring insulin: Deemed unfit for all duties until stable and then permanently unfit for
distant waters and watchkeeping and emergency duties.
B3.3 Physical Activity All people with diabetes should be asked about physical activity and most should be encouraged to increase activity. Suitable educational material is
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available on the NHS Scotland website mydiabetesmyway.
Improving health All people (including health professionals) should be advised to
increase their level of physical activity to achieve current recommendations and be supported to maintain this level across their lifespan.
People with Type 2 diabetes should be encouraged to participate in physical activity or structured exercise to improve glycaemic control and cardiovascular risk factors.
People with Type 1 diabetes should be encouraged to participate in physical activity or structured exercise to improve cardiovascular risk factors.
A gradual introduction and initial low intensity of physical activity should be recommended for sedentary people with diabetes.
Exercise and physical activity is best undertaken regularly i.e. preferably daily or on alternate days. Once a week is of limited benefit. As a rough guide the first stage would be to encourage an accumulation of 30 minutes of moderate activity (e.g. walking) on most days of the week. The second stage is to encourage those who are motivated. These individuals could be encouraged to engage in more vigorous activity at least three days per week.
Advice about physical activity and exercise should be individually tailored and diabetes specific and should include implications for glucose management and footcare.
Patients with complications should seek medical advice before embarking on exercise programmes.
If patients have problems with mobility there are easy exercise programmes which they could do, e.g. chair exercises
Above all encourage patients to choose an activity which they will enjoy.
Health professionals should discuss barriers to increasing physical activity and likely causes for relapse with patients.
Patients should be encouraged to set realistic targets for increasing physical activity.
Appropriate footwear and socks should be encouraged and patients with neuropathy may need to discuss their needs with a podiatrist.
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Exercise and blood glucose control (also see section C4.0 hypoglycaemia)
For patients who routinely monitor blood glucose and/or are insulin treated, it is advisable to monitor blood glucose before and after exercise.
It is usually unnecessary to reduce oral hypoglycaemic agents although regular activity resulting in weight loss and improved glycaemic control may require adjustments in medication.
Hypoglycaemia related to exercise may occur at the time of exercise or up to 24 hours after when glycogen stores are being replenished.
The risk of hypoglycaemia is related to the intensity and duration of exercise and also how used to exercising the patient is (those with little experience may be more likely to go hypo compared with those exercising regularly).
Patients should be advised to consider reducing insulin doses before and after exercise (including the day afterwards), increase dietary carbohydrate and alter injection sites, e.g. avoiding legs if running or arms if kayaking as this will increase absorption of insulin.
It is advisable for patients to have easy access to rapid-acting carbohydrate (e.g. orange juice / jelly babies (2=8g)) when exercising.
Additional advice for people with Type 1 diabetes taking part in high intensity or endurance sporting activities Referral to a specialist should be considered.
Ideally blood glucose at the start of exercise should be 7-12mM. Extra CHO should be ingested if glucose < 7mM. If glucose >12 mM and ketone free glucose replacement should not
occur until glucose falls. Blood glucose should be monitored every 30 minutes. 25-75% reduction in prandial insulin may be required if exercising
within 2 hours of injecting. Carbohydrate should be consumed at 1g/kg/hour of exercise from 20
minutes after start of exercise. Lower intensity activities and intermittent high intensity activities are likely to require less.
Additional hydration is essential. Where possible individuals should be advised not to exercise alone. Exercise within 24 hours following an episode of hypoglycaemia carries
a high risk of further hypoglycaemia.
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Additional nutritional advice, particularly for those engaging in more vigorous physical activity is available on the Runsweet.com website.
Other ways of helping motivate patients to increase physical activity
It is helpful for each diabetes clinic (in primary or secondary care) to be able to provide information to patients on local facilities. Each locality will have various opportunities for exercise. Local councils can provide details of classes running in the area and also details of opening times of swimming pools etc. Details of walking routes are also available from Health Point.
Pedometers These have been shown to help people increase physical activity
levels. The reliability of pedometers varies greatly and people wishing to use
one should be advised to purchase it from a reliable outlet rather than the back of a cereal packet!
Pedometers should be attached to the hip belt for best accuracy. Pedometers are most effective when a “step goal” is agreed with the
patient. When first using a pedometer it is recommended that people wear it for a week and document the average number of steps per day. If they wish to increase physical activity an appropriate goal may be to consider trying to increase the number of steps by 1000 - 1500 on 3 days of the week. After 2-4 weeks the target could be increased to an additional 3000 steps on 3 days of the week.
For many patients the frequently cited target of 10000 steps per day is unrealistic.
Exercise ClassesSome patients enjoy the social interaction and motivation of exercise classes. Diabetes exercise and information classes have been running in Grampian for 2 years.
At the present there are six classes (including an aqua-aerobics class) which run for 1.5 hours with about 1 hour of exercise followed by 30 minutes of group discussion. Further details including information sheets and referral forms can be found on the Patient Information page of the Diabetes MCN website.
Although many patients attend other exercise classes at various venues throughout Grampian, patients new to exercise classes may find some classes too strenuous. This can be de-motivating for patients.
Some patients may be suitable for referral to Grampian Cardiac Rehabilitation Classes although, again some patients may find this too strenuous if they have not been through the earlier stages of the Cardiac Rehab programme (see GCRA website).
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B3.4 Psychological Wellbeing
B3.4.1 Introduction
Self-care relates to the way that people choose to lead their lives and to their psychological wellbeing.
Psychological wellbeing of patients is important to those working in diabetes services because it has a profound effect on the efforts of people with diabetes to self-care.
It is important to ascertain when significant psychological issues are present because this will influence management decisions (for example, whether or not we encourage lifestyle change), and can help when to advise patients to get additional help if necessary (eg visit their GP for management of depression)
Regular assessment of a broad range of psychological and behavioural problems in children and adults with diabetes is recommended. The most common issues are clinical depression and anxiety in adults and eating disorders should also be considered. It is best to think of peoples’ experience of depression and anxiety as occurring along a continuum (ie you can have a little or lots of it) rather than it simply being present or absent.
B3.4.2 Depression
Significant levels of depression, for example, are present in about 20% of people with diabetes, and are associated with poorer glucose control and more severe illness course (de Groot et al, 2001). That is not surprising in view of the fact that key characteristics of depression include: lack of motivation & energy; disrupted eating patterns, and negative thinking styles particularly about being a failure and about being unable to make positive changes.
Because of beliefs about being a failure and general reduced levels of resourcefulness, great care needs to be taken if setting goals with people who have significant levels of depression. Almost always, it is wiser to postpone an attempt to implement efforts to change behaviour until the depression has been successfully treated.
B3.4.3 Anxiety
Clinical anxiety too is more prevalent among people with diabetes than in the general population with a point prevalence of about 15 %
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although about double this number will have borderline clinically- significant levels. There is a biological component to anxiety, namely the release of stress hormones such as cortisol and adrenaline. These hormones in turn cause other biological responses including the release of glucose into the bloodstream, and other somatic symptoms which overlap with symptoms experienced during hypoglycaemia.
Because of the release of glucose into the blood and because commonly people with diabetes misinterpret symptoms of anxiety as indications of low blood glucose (so they take unneeded action to raise blood glucose), clinical anxiety is also associated with poorer control (Anderson et al, 2002).
Anxiety is associated with thoughts about future disasters occurring (in minutes, days, months or years) and these recurring worries could be about health-related or non-health-related events. Thus, health professionals should be careful when providing information to anxious people because they have a strong tendency to superimpose a future “disaster-type” message, which will further fuel worry and disturb blood glucose control.
B3.4.4 Screening for Anxiety and Depression
Identifying depression and anxiety in people with diabetes is notoriously difficult (CMO Psychology Advisory Committee, 2003). This is especially true in the case of those with significant but mild to moderate levels because they can easily mask their difficulties over the course of consultations. These are the very people who can be helped most easily by self-help; psychological therapy, or medications. They are also the very people that are unwittingly asked by health professionals to make changes that are most probably not possible until their psychological difficulties are resolved.
If it is deemed appropriate to investigate whether someone might have significant levels of depression or anxiety, the use of a screening questionnaire may be helpful. The Scottish Diabetes Group recommends the Hospital Anxiety & Depression Scale (HADS)1 which takes patients about five minutes to complete and us about two minutes to score. If other common inventories are used such as the PHQ-9, Beck’s Anxiety Scale, or Beck’s Depression Inventory it is important to bear in mind that more false positives will be identified than if the HADS is used.
B3.4.5 Other Psychological Issues
Cognitive problems
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Dementia (including the early stages of) is more common as people age (prevalence among over 65s: 5-8%; over 75s: 15-20%; over 85s: 25-50%). Non-dementia related cognitive changes can also occur particularly in the presence of cardiovascular risk factors. Key factors to bear in mind include possible difficulties with memory and learning; planning, and organising all of which can impair significantly self-care.
Eating disorders
These are more common among people with diabetes than the general population and like the other issues above typically impair self-care, for example, because they can involve manipulation of insulin. Anorexia and bulimia nervosa are both characterised by preoccupations with food and body image (dread of weight gain and beliefs about being overweight and so on). Those with anorexia engage in deliberate weight loss strategies and have a BMI < 17.5. Bulimics have an irresistible craving for food which is consumed in large amounts over short periods: this is typically followed by vomiting. There is an Eating Disorder Clinic in Aberdeen which specialises in the treatment of people experiencing these types of problems.
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B3.4.6 Behaviour Change
The guidance below provides brief, general information and some advice about helping patients to change behaviours, which staff will need to adapt to suit their specific model of working.
Those who attend adult diabetes services in primary and secondary care have lifestyle habits that have been present for many years. Unsurprisingly then, key areas of concern to professionals working with people who have diabetes have been repeatedly highlighted as notoriously difficult to influence over extended periods of time, and this is especially true of behaviours targeted at prevention of future health problems.
Key ways to approach changing lifestyle behaviour that make success more probable.
Good general clinical skills are imperative ie the ability to establish and maintain a good working relationship with patients and to encourage them to make changes in a warm, sensitive and considered manner. There is about 40 years of research that indicates that how health professionals get on with patients plays a much more important role in helping people to make changes than technical skill & knowledge.
Education and information alone are rarely sufficient to change long-standing lifestyle behaviours. They generally do however play an important part in behavioural changes programmes. So, the best way to think about information provision is as necessary but not sufficient.
The job of helping people to make changes to the way they live their lives is really about encouraging, building confidence, and motivating.
Existing behaviours tend to serve a function (purpose). In general, people are trying to be happy and their efforts are often focused on the shorter-term. So what might seem like odd behaviours or ideas are often idiosyncratic efforts to either increase happiness or decrease unhappiness. One example might be a person with Type 1 diabetes who is extremely fearful of nocturnal hypoglycaemic episodes so loads up on biscuits and toast before bed. She is trying (successfully) to avoid immediate, very uncomfortable thoughts (about dying) and feelings (fear, anxiety). The pattern is similar for people who frequently comfort eat when distressed.
The same behaviour serves a different function in different people. For example, one person might avoid testing blood glucose levels because he cannot face the uncomfortable thoughts and feelings (eg about being a failure or future health complications) that occur if
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readings are higher than he would like, whereas another might do so because she doesn’t want others to know she has diabetes.
The function or purpose of existing behaviours are the maintaining factors, i.e., it explains why the current situation continues. So, for example, loading-up on biscuits before bed in people with significant fear of hypoglycaemia continues because it serves a purpose (successful avoidance of negative thoughts and feelings). Similarly, many people who (like most of us) have tried and failed to lose weight or maintain weight loss are seemingly disinterested in trying again. The purpose of this apparent inactivity is often to avoid the typical feelings of frustration, disappointment and so on which are typically associated with not losing the amount of weight desired / putting weight back on. In both cases, to these people the outcome is positive, in the shorter-term at least.
Helping change behaviour means patients are moved toward what they find difficult and means focusing on the pay off between shorter and longer-term outcomes. So in helping people overcome hypoglycaemic fear they may be advised to eat and drink gradually less before bed, thereby exposing them to their uncomfortable thoughts and feelings, building their confidence in their ability to deal with this uncomfortable ness, whilst helping them become mindful of the longer-term gains of addressing this problem.
It is worth bearing in mind that often health alone is not a great motivator for people to make significant changes to the way they lead their lives. All of us could spend every hour of every day in efforts to maximise health but few would choose to do so, even those with serious medical conditions.
Generally, change is more likely if health gains can be linked to what people feel is important compared to if change is only linked to health outcomes. People do tend to be motivated by their values, that is, those things in life which are important to them. Commonly, values include intimate relationships; children and grandchildren; extended family; friendships; enjoyable hobbies, pastimes and sports, and work.
Goal Setting
This is an important aspect of helping patients to improve self-care. Although seemingly simple, it is inevitably harder in practice.
o Think SMART: goals should be Specific; Measurable; Achievable; Relevant, and Timely.
o Be active in negotiating goals because typically people will have unrealistic expectations of themselves ie try to ensure goals are achievable.
o Nothing de-motivates like failure so early successes are especially imperative.
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o Write down goals and methods for achieving them – a copy for patients to take away and for clinical records is often helpful.
o Diary keeping can help track progress for people with diabetes and their clinicians.
o Link diaries of behaviour or outcomes to the fact that change is rarely linear; more often we tend to do well perhaps one week and not so well the next (they can look back to baseline for example and note overall progress).
o It is normal to have setbacks.o You can strengthen the likelihood of new behaviours becoming
established by helping patients link behaviours to existing parts of their daily routines. So, examples might include walks after the TV news; blood glucose tests after showering, and so on.
It is generally best to have more regular contact initially with people trying to make changes (this includes emails, telephone calls etc). This is because the early success is generally imperative. It is also during this period that people make common mistakes which can lead to them discontinuing their efforts like: remembering incorrectly agreed goals and plan of action; becoming very disheartened by small or infrequent failures; boosted by early success set themselves large goals which they fail to achieve.
Remember, people often try on a number of occasions to change lifestyle behaviours before they succeed (sometimes they never will), and often the fact that things remain the same is an achievement (weight for example).
1 We have copies of the HADS in the Diabetes Service. Please contact Andy Keen (email: [email protected] telephone: 55507), Consultant Health Psychologist, if you would like to know how to use the HADS.
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B3.5 Smoking
All people with diabetes should be strongly counselled against smoking. Smoking is a significant reversible risk factor for cardiovascular disease
(macrovascular and microvascular). Patients with diabetes are already at increased risk of cardiovascular
disease. Smoking increases the risk of development and progression of most
complications, e.g. retinopathy, microalbuminuria. Smoking potentiates the risks during pregnancy in women with diabetes. Smoking increases the risk of developing diabetes.
B3.5.1 Smoking cessation Patients who wish to stop smoking should have access to motivational support as this will increase the chances of quitting. Nicotine replacement therapy, bupropion and varenicline are effective aids to smoking cessation for patients smoking more than 5-10 cigarettes per day and who are nicotine dependent.
Nicotine replacement therapy (NRT) (sublingual, chewing gum, patches, nasal spray, inhaler). The form of nicotine replacement therapy chosen should take into account clinical conditions, (e.g. pregnancy, skin disorders) individual preference and tolerance of side-effects. NRT is available from most community pharmacies conforming to a NHS pharmacy service specification, where staff have undergone training in counselling and smoking cessation support. Patients who are exempt from prescription costs receive treatment free of charge, and patients who pay prescription charges will be charged the equivalent of the prescription charge for each month of treatment.
Bupropion Tablets (Zyban®) must be used in conjunction with a programme of counselling and cessation support. It should not be used in patients with a history of seizures, eating disorders, a CNS tumour or who are experiencing acute withdrawal from alcohol or benzodiazepines.
Varenicline tablets (Champix®▼) must be used in conjunction with a programme of counselling and cessation support. Uptake of varenicline has been high and research demonstrates it to be very successful. There have been recent safety concerns and prescribers should be aware that symptoms of depression, which may include suicidal ideation and suicide attempt, have been reported in patients taking varenicline.
Counselling and smoking cessation support is available through the NHS Grampian Smoking Advice Service (SAS). The SAS can be contacted, free of charge, on 0500 600 332. Our web address is http://www.nhsgrampian.org. Professionals wishing to find out more about the SAS may wish to log onto our section on Hi-net (http://www.hi-netgrampian.org/sas).
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A GP Decision Flow Chart and referral information is available at: http://cgi.grampian.scot.nhs.uk/
Other Support Available:Patients can access support by calling Smokeline (provided on behalf of HealthScotland) 0800 84 84 84. The Health Scotland “Can Stop Smoking” website (http://www.canstopsmoking.com/) offers advice and e-mail and text message support.
B3.6 Travel
It has become increasingly easy in recent years to travel all over the world offering exciting opportunities to many. For most patients diabetes mellitus should not be a bar to travel but certain factors have to be taken into consideration to ensure a healthy, hassle free trip.
General Advice
Those on tablets or insulin should pack extra snacks in case of delays in travel arrangements.
Additional supplies of medication should be taken in case of delay etc. Hot / cold climates may affect blood glucose control and additional
blood glucose monitoring may be appropriate. Diet may be very different in some countries – particularly in the type
and quantity of carbohydrate. It is not necessary to order special diabetic meals for flights. The
diabetic meals provided by the airlines do not contain enough carbohydrate.
The water in many countries is not safe to drink so food and water hygiene are very important as illnesses causing diarrhoea and vomiting may have a serious adverse effect on diabetes control and may precipitate the need for urgent medical review or even hospital admission.
It is important to protect the feet from sunburn. Footwear should be worn at all times including on the beach to avoid injury to the foot and the risk of infection.
It is useful to carry some kind of information stating that you have diabetes mellitus and are on medication, especially if travelling alone. Various items are available such as cards or bracelets.
Patients on long-haul flights should be given advice concerning minimising the risk of DVT.
Accidents and ill health can occur to any traveller and good travel insurance with repatriation cover if necessary should be taken out by all. The European Health Insurance card (EHIC) does not cover repatriation to the UK only medical costs incurred in countries in the EU. Diabetes UK can be helpful in this regard as can companies such as SAGA and Freespirit.
Specific advice for insulin-treated patients
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Hot climates can affect insulin absorption and activity levels and diet on holiday often differ from those at home so doses may have to be altered. Therefore it is advisable to test blood glucose more frequently on holiday to keep good control and avoid unexpected hypoglycaemia.
Any illness acquired while travelling could precipitate ketoacidosis. Ketostix should be taken on holiday so that urine can be tested for ketones if these illnesses arise.
Insulin adjustment may be required for long haul flights. For some the use of a short-acting insulin before meals while travelling may be added to the normal regimen.
Insulin should not be stored in the hold as it can freeze, thereby making it permanently less effective. It should be carried in hand luggage. For those travelling to very cold climates, special storage bags are available to insulate the insulin so that it does not freeze. These are available from companies such as Diabetes UK and Frio. High temperatures can also affect insulin and again storage bags can help to protect it but insulin will keep well at room temperature for periods of up to one month.
A letter from a doctor for those on insulin should be carried to avoid any problems with customs at airports both here and abroad. These are available from the diabetic clinic for those who attend Woolmanhill or from GPs. An example follows:
3.6.1 Travel Letter for Patients Using Insulin
To Whom It May Concern
Date
Dear Sir/Madam
Patients details
The above patient attends my Diabetic Clinic and is on insulin treatment.
Insulin, equipment for its administration including needles and equipment for blood glucose monitoring have to be carried at all times. Insulin should be kept in the flight cabin as it can be destroyed by the potentially low temperatures of an aeroplane hold. Lest there are any mishaps, it is also recommended that supplies are carried in more than one bag with some, where possible, being carried by a friend or partner.
Yours faithfully
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A useful check list for holiday packing can be found in the Diabetes UK booklet on travel.
Additional information can be found on the following websites:
Travax (for health professionals)Fit For Travel (for patients)
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B4.0 Information Technology
National and Regional Diabetes IT Overview
SCI-DC – Introduction
SCI-DC (Scottish Care Information – Diabetes Collaboration) is a national system that allows access to data regarding all people with diabetes in NHS Grampian. It aims to deliver an integrated diabetes record to diabetes health care providers in NHS Scotland. This was set up on the basis of the recommendations in the ‘Scottish Diabetes Framework’; which identified that well-managed, integrated diabetes care must be underpinned by effective information technology systems. The principal aim of SCI-DC is to deliver a shared electronic record for use by all involved in the provision of diabetes care.
SCI-DC brings support information and clinical data together from a variety of sources including general practice, hospital clinics and retinal screening. The SCI-DC project comprises two key products, namely SCI-DC Clinical and SCI-DC Network. The SCI-DC products are complementary, each with a different focus. SCI-DC Clinical is designed to provide hospital clinic-based support, delivering such features as the automatic generation of GP letters. An interface has been developed to take the clinical data captured by SCI-DC Clinical for automatic update of the patient record held on SCI-DC Network.
SCI-DC Network allows for the identification of all people with recorded diagnoses of diabetes in the General Practice computer systems, and provides full support for the Scottish Diabetes Survey. Its regionally customisable web pages allow access to standardised treatment guidelines for decision support, and provide access to patient leaflets.
The SCI-DC Network website is available to all General Practices regardless of what GP system an individual practice uses and SCI-DC holds a diabetes register of patients for all practices. SCI-DC Network allows for automated practice audit in support of clinical governance, and contains such features as graphical representation of laboratory results over time, allowing for longitudinal risk to be gauged and providing a focus for discussion with patients. In Grampian all practices have access to the system.
In Grampian the Diabetes Centre used PROTOS until Feb 2011 as its IT system, afterwhich the conversion to SCI-DC Clinical commenced.
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Figure 1 – Diagram of SCI-DC linkages with other systems
Accessing SCI-DC Network
The address for accessing SCI-DC is: https://diabetes.mhs.scot.nhs.uk/Grampian/scidc/
Access to SCI-DC is available to registered users from within NHS computer networks.
You can access SCI-DC Network through the GP Portal (see figure 2) from the Grampian Intranet pages.
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Figure 2 – Accessing SCI-DC Network through the GP Portal
In order to gain access to the information contained within SCI-DC Network you must enter your SCI-DC Network username and password from the login page (see figure 3).
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Figure 3 – SCI-DC Network Login Page
Once you have successfully logged into SCI-DC, the screens and options you will be presented with will vary slightly depending on whether you are working in primary or secondary care (see figures 4+5).
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PRACTICE NAME
Dr J ames, GP
Figure 4 – SCI-DC Primary Care Page
SCI-DC Network – Overview (Primary Care)
From this screen you can access a range of further screens that allow you to both enter and view information on individual patients at your practice from the practice overview screens such as biochemistry, cardiovascular and lifestyle data (HbA1c, cholesterol, blood pressure, height, weight and BMI for instance).
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Figure 5 – SCI-DC Secondary Care Page
SCI-DC Network – Overview (Secondary Care)
From this screen you can access a range of further screens that allow you to both enter and view information on individual patients at your clinic from the clinic overview screens such as biochemistry, cardiovascular and lifestyle data (HbA1c, cholesterol, blood pressure, height, weight and BMI for instance). Any patient who attends the clinic, and is registered with a GP Practice in NHS Grampian, can be viewed as appropriate.
Leaflets
You can also access and print off relevant leaflets irrespective of whether you work in primary or secondary care, such as foot screening leaflets for example (see figure 6). Shown below is a snapshot of the foot screening form that can be accessed from an individual patient summary screen and where you can access the foot screening leaflets.
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Click on the appropriate form and print as required
Figure 6 – Foot Screening Leaflet Screen
In SCI-DC Network you can also enter and view foot screening data and view results and images obtained from Diabetes Retinal Screening from the patient summary screen for individual patients (see figure 7).
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Figure 7 – Patient Summary Screen
If you work in the primary care sector you can gain information on the retinal screening status of all patients at your practice as well as their next appointment details (see figure 8). Additionally, you can also request suspensions for patients if required from retinal screening.
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Click here to access Diabetes Retinal Screening pages
PRACTICE NAME
Dr J ames, GP
Figure 8 – Accessing Diabetes Retinal Screening Results
Furthermore, if you work in primary care, you are also able to perform practice audits in a range of areas that allow you view patients with certain readings, patients with deteriorating readings or patients who have not had certain tests carried out or results recorded (see figure 9).
In addition you are also able to view summary information in a range of areas for your own practice and compare this with regional figures for NHS Grampian as a whole.
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Figure 9 – Performing a General Audit Using SCI-DC
SCI-DC Network – Back Population of GMS Contract Indicators
The functionality now exists for GMS Contract Indicators information to be back-populated into primary care systems (see appendix 1 for full list of items that can be back-populated).
Currently, this functionality is in place for practices with EMIS primary care system and work is in progress to include practices with Vision primary care system in 2011.
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SCI-DC – Help / Contacts
Should you require a user name and password for SCI-DC Network, forget your username or password, require additional training or have any other query please use the numbers or email below as a contact. There is a SCI-network user guide that can be e-mailed to assist you.
Contact Names
Robert O’DonnellMCN Support Officer Diabetes CentreWoolmanhill Hospital
t: 01224 555393 e: [email protected]
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Appendix 1 – SCI-DC Back-Population: Diabetes-Related GMS Contract Indicators
Data Item Relevant Indicator
s
Recommended/Agreed READ Code(s)
Diabetes Diagnosis
All Type 1 Diabetes (C10E. – Type 1 diabetes mellitus)Type 2 Diabetes (C10F. – Type 2 diabetes mellitus)
Date of Birth All 9155. – Patient date of birthBody Mass
IndexDM 2 22K.. – Body Mass Index
HbA1c DM 5, DM 20, DM 7
42W.. – Hb. A1C - diabetic control
Retinal Screening
DM 21 No Retinopathy – Left Eye (2BBK. – O/E - no L diabet retinopathy)
No Retinopathy – Right Eye (2BBJ. – O/E - no R diabet retinopathy)
Background Diabetic Retinopathy (BDR) Mild – Left Eye (2BBQ. – O/E - left eye back diab ret)
Background Diabetic Retinopathy (BDR) Mild – Right Eye (2BBP. – O/E - right eye back diab ret)
Previously Background Diabetic Retinopathy (BDR) Mild: (F4200)
BDR Moderate – Left Eye (2BBS. – O/E - L eye preprolif diab ret)
BDR Moderate – Right Eye (2BBR. – O/E - R eye preprolif diab ret)
BDR Severe – Left Eye (2BBS. – O/E - L eye preprolif diab ret)
BDR Severe – Right Eye (2BBR. – O/E - R eye preprolif diab ret)
Previously BDR Moderate / Severe: (F4202)
Proliferative Retinopathy – Left Eye (2BBV. – O/E - L eye prolif diab ret)
Proliferative Retinopathy – Right Eye (2BBT. – O/E - R eye prolif diab ret)
Previously Proliferative Retinopathy (F4201)
(2BBX. – O/E - L eye diab maculopathy)(2BBW. – O/E - R eye diab maculopathy)
Previously Diabetic Maculopathy (F4204) and Advanced Diabetic Maculopathy (F4203)
Not Adequately Visualised – Left (2BBC. – O/E - Left retina not seen)
Not Adequately Visualised – Right (2BBB. – O/E - Right retina not seen)
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Peripheral Pulses
DM 9 Pulse Present – Left (24FB. – O/E - left foot pulses present)
Pulses Absent – Left (24FA. – O/E - Absent left foot pulses)
Pulse Present – Right (24EB. – O/E - right foot pulse present)
Pulses Absent – Right (24EA. – O/E - Absent right foot pulses)
Neuropathy Testing
DM 10 Foot Sensation to Monofilaments Normal – Left (29BC. – 10g monofil sens L foot normal)
Foot Sensation to Monofilaments Normal – Right (29BB. – 10g monofil sens R foot normal)
Previously Foot Sensation to Monofilaments Normal (29B7.)
Foot Sensation to Monofilaments Impaired – Left (29BA. – 10g monofil sens L foot abnorm)
Foot Sensation to Monofilaments Impaired – Right (29B9. – 10g monofil sens R foot abnorm)
Previously Foot Sensation to Monofilaments Impaired (29B8.)
Foot Vibration Sensation Normal – Left (29H7. – O/E-Vibr sens Lt foot normal)
Foot Vibration Sensation Abnormal – Left (29H6. – O/E-Vibr sens Lt foot abnorm)
Foot Vibration Sensation Normal – Right (29H5. – O/E-Vibr sens Rt foot normal)
Foot Vibration Sensation Abnormal – Right (29H4. – O/E-Vibr sens Rt foot abnorm)
Foot Risk – Low Risk of Foot Ulceration – Left (2G5I. – O/E - L diab foot at low risk)
Low Risk of Foot Ulceration – Right (2G5E. – O/E - R diab foot at low risk)
Moderate Risk of Foot Ulceration – Left (2G5J. – O/E - L diab foot at mod risk)
Moderate Risk of Foot Ulceration – Right (2G5F. – O/E - R diab foot at mod risk)
High Risk of Foot Ulceration – Left (2G5K. – O/E - L diab foot at high risk)
High Risk of Foot Ulceration – Right (2G5G. – O/E - R diab foot at high risk)
Active Foot Ulceration – Left (2G5L. – O/E - L diab foot - ulcerated)
Active Foot Ulceration – Right (2G5H. – O/E - R diab foot - ulcerated)
Attending Podiatry
– Under care of podiatrist (9NN0.)
Blood Pressure DM 11, DM 12
Systolic (2469. – O/E – Systolic BP reading)Diastolic (246A. – O/E – Diastolic BP reading)
Microalbuminuria Testing
DM 13, DM 15
MA Value – mg/l (46N4. – Urine albumin)MA Value – mg/mmol (46TC. – Urine albumin:creatinine
ratio)MA Value – mg/24hrs (46N6. – 24 hour urine albumin
output)Serum
CreatinineDM 22 44J3. – Serum creatinine
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Estimated Glomerular
Filtration Rate (eGFR)
DM 22 451F. – Glomerular filtration rate
Total Cholesterol
DM 16, DM 17
44PH. – Serum cholesterol
Smoking Status Smoking 1, Smoking 2
Current Smoker (137R. – Current smoker)Ex Smoker (137S. – Ex smoker)
Never Smoked (1371. – Never smoked tobacco)Smoking Cessation
Advice
Smoking 2 8CAL. – Smoking cessation advice
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The following data items to be reviewed and included at a later date…
Data Item Relevant Indicator
s
Recommended/Agreed READ Code(s)
Proteinuria DM 13, DM 15
Urine Protein Test Not Done (4671.)Urine Protein Test Negative (4672.)Urine Protein Test = Trace (4673.)
Urine Protein Test = + (4674.)Urine Protein Test = ++ (4675.)
Urine Protein Test = +++ (4676.)ACE Inhibitor
TreatmentDM 15 Prescribed (8B6B.)
Contraindicated (8I28.)Declined (8I3D.)
Adverse Reaction (U60C4)AIII Antagonist
TreatmentDM 15 Prescribed (8B6E.)
Contraindicated (8I2H.)Declined (8I3P.)
Adverse Reaction (U60CB)Influenza
ImmunisationDM 18 Given (65E..)
Contraindicated (8I2F.)Declined (9OX5.)
General Depressed Wellbeing
Depression 1
3884.
Diabetes Depressed Wellbeing
Depression 1
3882.
Information supplied by SCI-DC Support Team on 10/08/2010
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Useful Links
The following websites provide a mixture of local and national information and are suitable for all with an interest in diabetes and diabetes care.
Grampian Diabetes Centre – this website provides a range of information about services in NHS Grampian and contains lots of useful information for both patients and those involved in patient care.http://www.diabetes.nhsgrampian.org
My Diabetes My Way – this website is designed to help support people who have diabetes as well as their family and friends and provides a host of resources with regards to all aspects of diabetes.http://www.mydiabetesmyway.scot.nhs.uk
Diabetes UK – this website provides information guides for people with diabetes as well as extensive information about research into diabetes and fundraising activities. The website also provides local and national information and information about professional conferences and diabetes campaigns.http://diabetes.org.uk
Active Scotland – this website allows you to enter your postcode and see what activities are available in your local area, from the easy to the extreme, to help people lead a more active lifestyle.http://www.activescotland.org.uk
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B5.0 Contraception, Pregnancy and the Management of Gestational Diabetes Mellitus
B5.0.1 Patient information
The national website mydiabetesmyway allows access to a range of information for people with diabetes who are pregnant or who are planning pregnancy. The “My Body” section has a link to general pregnancy leaflets and a DVD. Hard copies of the leaflets and DVD are available form combined clinics in Aberdeen and Elgin. Other locally produced leaflets are reproduced here on:Type 1 and Type 2 Diabetes and Pregnancy (detailed information) - information for womenGestational Diabetes – information for womenPre-Pregnancy and Antenatal care for women with diabetes mellitusThese are also available on the Diabetes MCN website..
5.0.2 Introduction
Type1 diabetes is one of the most common medical conditions during pregnancy and increasing numbers of women with Type 2 diabetes are having pregnancies. Thus discussion of contraception and pre-pregnancy care is important for all women with diabetes during their childbearing years.
Successful outcome of pregnancy can usually be anticipated in women with pre-existing diabetes. However, diabetic pregnancy is statistically a high-risk pregnancy with regard to foetal morbidity and mortality. In order to achieve an optimal foetal outcome major efforts and attention to detail are required on the part of the patient and her carers. Meticulous blood glucose control before and during pregnancy is the cornerstone of management. In addition to metabolic supervision, mothers require close clinical surveillance since there are increased risks with regard to progression of diabetic retinopathy and nephropathy, pregnancy-induced hypertension and intrapartum complications.
The congenital abnormality rate in diabetic pregnancy is at least double that of the background population. There is convincing evidence that good glycaemic control prior to and after conception during the period of organogenesis reduces the increased risk of congenital abnormality that is associated with poor control.
For these reasons diabetic pregnancy should always be planned and reliable contraception is therefore important.
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B5.1 ContraceptionThe importance of avoiding unplanned pregnancy should be an essential component of diabetes education for young women with pre-existing diabetes from adolescence. The failure rate of the condom is relatively high, however many of the other methods of contraception are safe for use by the majority of people who have diabetes.
For all those recently diagnosed as having diabetes mellitus all methods are suitable provided there are no other medical reasons why a particular method is unsuitable.
For those who have vascular complications such as diabetic eye disease or kidney problems the combined oral contraceptive pill may be contraindicated and most other methods would be suitable. Advice has to be tailored to each individual depending on the presence of complications and other medical problems. Expert advice is available at the diabetic clinic or at Sexual and Reproductive Health Service at Denburn Health Centre.
Contraceptives available are:
Contraceptive Failure RateCombined contraceptive pill (COC) – 0.3%Depo Provera Injection 0.3%Implanon subcutaneous implant almost 0%Progesterone only pill (POP) 1 to 2%Intrauterine system or Mirena <1%Intrauterine device (IUD) <1%Sterilisation 1 in 200 and gets worse over timeVasectomy 1 in 2000Condom 2 to 15%Persona 6% at bestDiaphragm or Cap 2 to 12%Natural family planning methods Can be around 25% if not followed
every day and requires a high degree of motivation
Long acting methods such as the IUD, IUS, and Implanon are best as they require no further thought once fitted until they need replaced.
Emergency contraception - failure rate of around 5% mid-cycle, 2% over the whole cycle. Need to obtain it within 72hrs of risk episode and the sooner it is taken the more effective it is. The copper IUD can be inserted as an emergency contraceptive up to 5 days after a risk episode and is nearly 100% effective but due to other considerations such as the risk of infection is not first choice. Other tablet methods are used on a trial basis under license from the Scottish Office and are available up to 5 days after the risk episode from The Sexual and Reproductive Health Department at Denburn Health Centre.
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B5.2 Planning pregnancy
Prior to conception Refer to a hospital or combined obstetric diabetic clinic for pre pregnancy assessment, where the following steps are taken:
Review treatment regimen. For intensive blood glucose control most women with Type 1 diabetes are best treated with a multiple injection regimen.
Provide blood glucose meter and test blood glucose four to six times daily Blood glucose targets should be individualised and will depend on factors such as hypoglycaemia unawareness or the residual maternal beta cell function. General targets are fasting and pre meal 4.0-6.0 mmol/l, one hour post-prandial <8 mmol/l, two hour post prandial <7.0 mmol/l and over 6 mmol/l before bed for women with Type 1 Diabetes.
Achieve optimal glycaemic control aiming for an HbA1c result within or as near to the non-diabetic range as is possible without inducing disabling hypoglycaemia A general target for HbA1C of <7% is advised for women with Type 1 diabetes although the ideal target quoted in NICE is < 6.1%. This lower value may be feasible in patients with Type 2 diabetes but cannot be achieved in many women with Type 1 diabetes because of the risk of severe hypoglycaemia.
Patients with Type 2 diabetes should be considered for insulin therapy with treatment targets as above. Women with pre existing diabetes may use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy when the likely benefits from improved glycaemic control outweigh the potential for harm. All other oral hypoglycaemics should be discontinued before pregnancy and insulin substituted.
Discuss lifestyle issues which may affect glycaemic control, e.g. o Difficulty with shift worko Encourage appropriate exercise
Review all medications and other potential teratogens. Statins, ACE inhibitors and ARBs should be discontinued before pregnancy or as soon as pregnancy is confirmed. Alternative antihypertensive agents suitable for use during pregnancy, eg methyl dopa, should be substituted.
Arrange dietetic review and reinforce antismoking advice Commence folic acid 5mg daily. (High dose recommended in view of
high risk of neural tube defects) Ensure complication screening is complete and take action as
appropriate – See 10.2 -Content of Annual checks Check rubella status Assess general health, fitness for pregnancy, and screen for factors
which could disturb glycaemic control, e.g. urinary infection and thyroid status
Review menstrual and gynaecological factors which could impair fertility
An intensive education update to self management should be offered. If available, a place on a structured education programme prior to
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pregnancy provides this level of education. Continuous glucose monitoring (CGMS) may be considered in women
with Type 1 and Type 2 diabetes before and during pregnancy to optimise control.
B5.3 Confirmed pregnancy
All diabetic women in whom pregnancy has been confirmed should be referred immediately by telephone or fax to a hospital combined obstetric / diabetic clinic for intensive education and multidisciplinary supervision. Clinics are held weekly in Aberdeen and Elgin, where women will be seen at one to four weekly intervals depending on metabolic control and obstetric progress. Admission is not routine but may be recommended for stabilisation of blood glucose control, management of diabetic complications or associated obstetric problems. There is a low threshold for admission in these relatively high-risk pregnancies.
Hypoglycaemia (see section C4.0)Strict blood glucose control increases the risk of hypoglycaemia and warning signs are often lost in early pregnancy. All women should be provided with glucogel and a glucagon emergency kit, and their partner should be instructed in their use. Ideally women should not sleep in a house alone in early pregnancy because of the risk of hypoglycaemia. Women who lose awareness of hypoglycaemia in pregnancy should be advised to stop driving until warning symptoms return to normal.
Ketosis The foetus tolerates maternal hypoglycaemia well, but is very sensitive to ketosis. Established ketoacidosis in pregnancy results in a very high incidence of foetal loss at all gestations, and is usually potentially avoidable. Pregnant women should all have facilities to check blood or urine for ketones. Elevation of blood glucose (> 10mmol/l) together with persistent non-fasting ketonuria is an indication for increased insulin doses and urgent further assessment usually involving hospital admission for intravenous insulin and dextrose.
Women must be advised to contact either their DSN, hospital team or GP in such circumstances without delay. The most common cause of ketosis in pregnancy is urinary tract infection, which should be treated on a presumptive basis.
Delivery Women should be delivered where there are facilities for intensive neonatal care. Ideally delivery should be vaginal and at term (but not beyond). An individual decision will be made for each patient, and in practice the caesarean section rate remains much higher than that of the non-diabetic population (around 67%).
All women on insulin receive an infusion of dextrose and insulin during labour
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to maintain normoglycaemia.
Post partum insulin requirements usually fall to between 30% and 50% of that immediately prior to delivery. Breast-feeding is encouraged.
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B5.4 Management of Gestational Diabetes
Background and definition Gestational diabetes mellitus (GDM) has been defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.
During pregnancy the normal range for fasting blood glucose is much lower than in non-pregnant women and glycosuria with normal blood glucose levels is common due to a lowering of the renal threshold for glucose.
The optimal methods to screen for, diagnose and treat GDM are under review. The National Screening Committee is considering screening for GDM. NICE guidelines recommend use of risk factors for screening and SIGN, considered the topic as part of the updated Guideline 116.
Women with a history of gestational diabetes, who have not progressed to diabetes in the interim, should have an OGTT around 16-18 weeks during subsequent pregnancies.
o Risk factors for gestational diabetes326 (SIGN 116) BMI more than 30 kg/m² Previous macrosomic baby weighing 4.5 kg or more Previous gestational diabetes Family history of diabetes (first degree relative with diabetes) Family origin with a high prevalence of diabetes: ƒ. South Asian (specifically women whose country of family origin is
India, Pakistan or Bangladesh) ƒ. Black Caribbean ƒ. Middle Eastern (specifically women whose country of family origin is
Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait,
Lebanon or Egypt).
Recommended population screening protocol for gestational diabetes mellitus
Recommendations from Grampian guidelines 2009 (current screening process)
Urine should be tested for glycosuria at every antenatal visit (preferably fasting)
Timed or random venous plasma glucose measurements should be made:
o Whenever glycosuria (2+ or more) is detectedo At 28 weeks gestation
A 75g oral glucose tolerance test (OGTT) should be carried out if the venous plasma glucose is:
o >5.5 mmol/l 2 hours or more after foodo >7.0 mmol/l within 2 hours of food
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Midwifery, obstetric and medical staff in Grampian are reviewing the recommendations of SIGN 116 on gestational diabetes to consider how they could be implemented across the region. The recommendations from SIGN are given in SIGN 116 (pages 63-65).
Management Women diagnosed as having gestational diabetes should be seen by a physician and obstetrician with a special interest in diabetes and should receive intensive management with diet and/or insulin if macrosomia is suspected or if blood glucose levels are in the range for established diabetes.
Post-natal follow up Up to 50% of women may go on to develop Type 2 diabetes later in life and this group presents an excellent opportunity for screening and intervention. Studies have shown that lifestyle intervention can reduce the incidence of diabetes in at risk patients by over 50%. A local patient leaflet explaining this risk and measures to reduce the risk of diabetes is available on the MCN website. All patients with gestational diabetes are invited for a glucose tolerance test at 6 months after delivery.
Women with a history of gestational diabetes who have developed IGT, IFG or DM should be referred to the pre-pregnancy clinic or to the Combined Obstetric Diabetic clinic when pregnancy is confirmed. Some women will need active management from early pregnancy.
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B5.4.1 Follow up of Patients with Previous Gestational Diabetes
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B6.0 Children’s ServicesThere are services available for children and adolescents across Grampian based at RACH, Dr Gray’s Hospital and Woolmanhill.
Any child up to the age of 14 with suspected diabetes should be referred the same day to the receiving Paediatric Medical team at either RACH or Dr Gray’s Hospital. Older children and adolescents should be referred to adult services.
Local guidelines for the management of children with diabetes can be accessed via the Grampian diabetes website at: http://nhsgrampian.org/grampianfoi/files/RACHDiabeticChildrenManagement.doc
Further information about the service and the children’s team can also be obtained from Grampian Children’s Diabetes Service (http://www.diabetes-scotland.org/grampian/home.html)
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Pre-pregnancy
and antenatal care
for women with diabetes mellitus
(General information)
Information for women
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Planning a pregnancy?Planning ahead for pregnancy is important for all, but for women with diabetes we recommend extra care and advice before conception and throughout pregnancy. This will help to ensure a safe and successful pregnancy.
Before you become pregnant If possible, blood glucose levels should be kept
between 4 to 6 mmol/l before meals and HbA1c should have been stable and as near target as possible for 3 months before you stop using contraception.If your blood glucose is not well controlled in early pregnancy, the risk of stillbirth and miscarriage is increased. It may also affect your baby’s early development.The target for most women for pre-pregnancy glycaemic control should be an HbA1c of 42 to 53mmol/l (around 6 to 7%) for 3 months before pregnancy.
Discuss your current medicines with your diabetes team – you may have to stop or change medicines in preparation for pregnancy (such as medicines for high blood pressure).
Make sure you are up to date with routine retinal screening.
Start taking folic acid 5mg each day (you need a prescription for this strength). This helps normal development in the very early weeks of pregnancy.
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Stop smoking. Your diabetes team or GP can refer you to a cessation specialist.
Eat a healthy and balanced diet. A dietitian is on hand for advice at the specialist clinic.
Arrange a specialist pre-pregnancy consultation.
Your specialist care teamAt your pre-pregnancy consultation you will see a specialist team comprising of:
Obstetrician Diabetologist (doctor who specialises in diabetes) Dietitian Specialist diabetes midwife Lab technician
What will happen at apre-pregnancy appointment?You can discuss any questions you have about diabetic pregnancy and receive advice.
We will test your blood for anaemia, immunity to rubella (German measles), thyroid and kidney function as well as an HbA1c test.
We will offer screening for any complications of your diabetes such as problems with your eyes, feet and kidney function (including microalbumin).
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Why should I keep my blood glucose normal?
Early pregnancyFrom the time of conception (usually about 2 weeks after the first day of your last menstrual period) until about 10 weeks, the developing baby is sensitive to very high blood glucose levels. During this time, the major organs are being formed.
Later in pregnancyIf blood glucosesugar is high, your baby can grow larger than normal. This can lead to more difficult birth and may be a reason for needing a caesarean section.
Haemoglobin A1c (HbA1c)This is a measure of the average blood glucose over the preceding two months or so. Ideally, it should be less than 53 mmol/l ( 7%) although this can be challenging to achieve.
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Contact telephone numbersIf you have any questions about your health or care, you can call us on:
Diabetic ClinicWoolmanhill Clinic
(01224) 555443
Antenatal ClinicAberdeen Maternity Hospital
(01224) 552743
Useful websiteswww.mydiabetesmyway.scot.nhs.ukProvides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medicalProvides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable for the quality of the information, resources or maintenance of external websites. Any advice on external websites is not intended to replace a consultation with an appropriately qualified medical practitioner.
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This leaflet is also available in large print and on computer disk. Other formats and languages can be supplied on request. Please call Quality Development on (01224) 554149 for a copy. Ask for leaflet 0535.
Feedback from the public helped us to develop this leaflet. If you have any comments or suggestions about how we can improve this leaflet, please let us know.
Department of Diabetes revised November 2010Aberdeen Royal Infirmary ©NHS GrampianLeaflet supplied by: Quality Development, Foresterhill
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Type 1 and Type 2
diabetes and
pregnancy
(Detailed information)
Information for women
Department of DiabetesAberdeen Royal Infirmary
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As a woman with Type 1 or Type 2 diabetes, what do I need to know aboutbefore considering pregnancy? Over 95% of babies born to diabetic mothers are healthy and well. During pregnancy women are encouraged to take as much responsibility for their diabetic care as possible.Both mums and infants need very intensive input before, during and after pregnancy. Good glucose control is especially important before and throughout your pregnancy. Ideally your HbA1c should have been stable and as near target as possible (42 to 53mmol/l, 6.0 to 7.0%) for 3 months before considering pregnancy.We will offersee you an appointment for pre pregnancy councelling regularly at our specialist Combined Diabetic Antenatal Clinic (CDANC) and once pregnant you will be most women are advised to attend for early review. early in pregnancy. At the clinic, you may see an obstetrician, diabetologist, diabetic specialist nurse, midwife, dietitian and lab technicians.As a rough guide, you will be seen every 2 to 4 weeks until you are 28 weeks pregnant, fortnightly until 36 weeks and then weekly until you have your baby. You can fax your home blood glucose monitoring charts to the clinic and discuss them over the phone.Please be advised that these clinic visits can take 1 to 2 hours as there is a lot to discuss. We will give you a copy of the care plan for your pregnancy at your first our diabetes protocol at your booking visit. We arrange your scans in line with the recommendations in this protocol.
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During your pregnancy retinal screening, your eyes will be checked more often. Retinal screening will be arranged for you on three occasions. times during your pregnancy. This is because occasionally there can be changes in your eye during pregnancy which may need to be investigated further. Your kidney and thyroid function will also be monitored. by blood tests.
What about glucose control? It is important to keep your blood glucose levels within the normal range (fasting around 4 to 6mmol/l and 2 hours after a meal less than 7.0mmol/l) for as much of the day as possible. You should do this both before you become pregnant and throughout your pregnancy. Please be aware that this involves very regular blood testing (often over 4 times a day), keeping to dietary recommendations and having regular insulin (usually 4 times a day). If you have Type 2 diabetes you may need a change to your medication and may be advised to start insulin treatment before you become pregnant. if required This should help to improve your blood glucose control. Most women with Type 2 diabetes will need to be on insulin during their pregnancy. Some may manage excellent control with diet and tablets.
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What about hypos in pregnancy? For women with Type 1 diabetes, hypoglycaemia (blood glucose less than 4mmol/l) is common in pregnancy. It can happen more often and be more severe than it was before you were pregnant. You should warn family members of this and let them know how to treat hypoglycaemia. Symptoms of hypoglycaemia include: Sweating
Anxiety
Palpitations
Poor concentration
Turning pale
Feeling hungry
Dizziness
Odd behaviour
Tingling of the lips or fingers
Headache.
During pregnancy, women may find that their warning symptoms of hypoglycaemia become more difficult to recognise. This may mean you cannot drive temporarily. Please discuss this regularly with your diabetes team.
How to avoid hyposEat regularlyMissed or late meals are the most common cause of hypos.
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Testing your blood glucoseTest at least 4 times a day and adjust your food intake or insulin levels as advised by your care team.
Avoid spending long periods aloneMake sure you are in regular contact with people during the day and that you are not alone overnight if possible.
Carry your dextrose energy tablets, Lucozade® or fruit juiceCarry one of these at all times and tell family and friends how to help you. You will also be given a glucagon kit with instructions for your partner or family member on when and how this should be used.
Take care when drivingCheck your blood glucose before you drive, carry extra glucose with you and try not to drive before a meal.
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What if my tests are high? If your glucose levels are raised (over 10mmol/l) it is important to monitor your urinary ketones. Ketones can increase quickly during pregnancy. They can harm your baby as well as making you ill. Contact Ashgrove Ward for advice if you develop ketones. See “How to contact us” at the end of this leaflet for more details. Please do not hesitate to contact your GP or the ward if you are unwell.
Will my delivery be normal? In Scotland one third of diabetic women have a vaginal delivery and two thirds have caesarean sections. No matter what type of delivery you have, we will monitor and maintain your blood glucose closely throughout labour. We will discuss delivery with you in the later stages of your pregnancy. You should have your baby in hospital and most will be delivered between 38 and 39 weeks (full term is 40 weeks). We may need to induce labour at this point if it shows no sign of beginning itself.Once labour is established, you will need an insulin and glucose drip to keep your blood glucose normal during labour.We will monitor your baby continuously during labour. This is usually done by a machine called a cardiotocograph (CTG). You will have two straps round your abdomen which are connected to the CTG machine which picks up the baby’s heartbeat.
All women with diabetes have their babies in hospital with access to a neonatal unit. This is because your baby needs
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to have regular blood glucose measurements to make sure these are not in the low range. We will discuss delivery with you in the later stages of your pregnancy. You should have your baby in hospital and most will be delivered between 38 and 39 weeks (full term is 40 weeks). We may need to induce labour at this point if it shows no sign of beginning itself.Once labour is established, you will need an insulin and glucose drip to keep your blood glucose normal during labour.We will monitor your baby continuously during labour. This is usually done by a machine called a cardiotocograph (CTG). You will have two straps round your abdomen which are connected to the CTG machine which picks up the baby’s heartbeat.
Will the health of my baby be affected? Most pregnancies in women with diabetes have a very good outcome. Compared with the population as a whole however, there is a very slightly increased risk of stillbirth neonatal death and malformations in the infant. By making sure that your blood glucose is controlled as well as possible before and throughout your pregnancy, you can reduce these risks near to the levels for non-diabetic women. Babies of mothers with diabetes tend to be bigger than other babies. This is sometimes called macrosomia. The blood glucose level of the mother is one of the major factors affecting this growth. This is another reason why it’s important to keep your blood glucose as near the normal range as possible.
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Will my baby have diabetes?Compared to non-diabetic women, there is only a very slightly increased risk of your child developing diabetes in later life.
No, not at birth. In fact, babies of mothers with diabetes tend to have low blood glucose. For this reason your baby’s glucose levels will be monitored around the time of delivery.
What happens after my baby’s born?
Generally your experience will be the same as other mothers. You will be able to hold your baby and begin breastfeeding, if you choose to, as soon after delivery as possible.Babies go with their mums to the postnatal ward following birth and are only admitted to the neonatal unit if blood glucosesugar levels become difficult to maintain.After delivery of your placenta, your insulin requirements drop dramatically. In Type 2 diabetes, if insulin was used temporarily in
pregnancy this may be discontinued after delivery.
With Type 1 diabetes, you will be kept on a reduced insulin infusion for a few hours after delivery and once eating, your insulin requirements normally return to pre preganacy levels.dose will be adjusted as needed.
Your blood sugars will be checked regularly until your levels stabilise. When you resume your normal diet, you should also be able to return to approximately your
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pre-pregnancy dose of insulin (a care plan will be written in your notes before you have your baby).
Is breastfeeding possible if I’ve got diabetes? Yes. Just like for all other women, breastfeeding is recommended for women with diabetes. It provides the best nutrition for your baby and gives extra protection against infection through your antibodies. Please be aware that breastfeeding can reduce your blood glucose level and that you may need to adjust your diet or insulin to prevent hypoglycaemia. Try keeping a snack nearby in case your blood glucose levels drop during the feed. Following delivery, early breastfeeding is recommended as this helps to prevent low blood glucose levels in the baby.
What happens after I’ve had my baby?A postnatal check up is arrangeddone 6 weeks after your delivery. This check up is done at the antenatal clinic by the specialist team you saw during pregnancy. Please bring your blood glucose charts with you to discuss your insulin requirements. At this check up, you can also discuss contraception and any issues about your delivery.
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How to contact usIf you have any questions about your health or care, you can talk to one of our staff on the numbers listed below:
Antenatal ClinicAberdeen Maternity Hospital
(01224) 552743
Ashgrove WardAberdeen Maternity Hospital
(01224) 554939
Diabetic ClinicWoolmanhill Hospital (01224) 555443
Useful websiteswww.mydiabetesmyway.scot.nhs.ukProvides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medicalProvides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable for the quality of the information, resources or maintenance of external websites. Any advice on external websites is not intended to replace a consultation with an appropriately qualified medical practitioner.
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This leaflet is also available in large print and on computer disk. Other formats and languages can be supplied on request. Please call Quality Development on (01224) 554149 for a copy. Ask for leaflet 0536.
Feedback from the public helped us to develop this leaflet. If you have any comments or suggestions about how we can improve this leaflet, please let us know.
Department of Diabetes revised November 2010Aberdeen Royal Infirmary ©NHS GrampianLeaflet supplied by: Quality Development, Foresterhill
25 May 2011
Gestational diabetes
Information for women
Department of DiabetesAberdeen Royal Infirmary
25 May 2011
25 May 2011
What is gestational diabetes.Some women develop diabetes during pregnancy. This is called gestational diabetes. Gestational diabetes usually starts in the later stages of pregnancy. It happens when the body can’t control its own blood glucose level (this can also be called the blood sugar level). The hormone insulin is responsible for controlling blood glucose levels. The hormones produced during pregnancy block the action of insulin in the body. In women who develop gestational diabetes, there is not enough extra insulin produced to overcome the blocking effect. Gestational diabetes can usually be controlled by changes to your diet but some women may need to take tablets or insulin therapy as well.
Why do I need to keep my blood glucose down?It is important to control the level of glucose in your blood during pregnancy and keep it within the normal range. Normal ranges in pregnancy are: Fasting - less than 5.5mmol/l 2 hours after food - less than 7.0mmol/l (up to 35
weeks) 2 hours after food - less than 8.0mmol/l (over 35
weeks).
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If there’s too much glucose in your blood, your baby’s body may start to make extra insulin to try to cope with it. This extra insulin can make the baby grow larger, making delivery more difficult and so could cause injury to you and your baby.Also a baby who is making extra insulin may have low blood glucose after they are born, which can affect them in the first few hours of life.
How do I check my blood glucose?At the Combined Diabetic Ante Natal Clinic (CDANC) we’ll give you the equipment you need to do this and show you how and when to do it. Your GP willcan provide repeat prescriptions.
How can I control my blood glucose levels?Healthy eating is very important to help you control your blood glucose levels and help your baby get the nutrients they need. A dietitian at CDANC will offer you personal dietary advice.Regular exercise such as 30 minutes walking a day, if you are able, is also very beneficial.
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Aim to: Eat regular meals and have a variety of foods. Include
carbohydrate foods (such as bread, pasta, rice, potatoes and cereal) at each meal but be careful to avoid large portion sizes of these foods.
Higher fibre choices are best such as wholemeal bread and pasta.
Eat 3 pieces of fruit and 2 portions of vegetables each day.
Avoid sweet foods, biscuits and sugary drinks.
Include milk in your diet as part of your carbohydrate allowance. Other good sources of calcium include cheese and diet yoghurts (not low fat yoghurts as these are high in sugar).Include some oily fish 2 to 3 times a week (such as mackerel, sardines, herring, pilchards or salmon).Include foods rich in iron every day (such as lean red meat, chicken, turkey, eggs, peas, beans, lentils and green leafy vegetables). Avoid liver.
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Your specialist diabetic teamA specialist team is a group of healthcare professionals with experience of supporting people with diabetes. In the team there is: Obstetrician
Diabetologist (doctor who specialises in diabetes)
Dietitian
Specialist diabetes midwife
Lab technician
This team will provide you with routine care (such as regular urine tests for protein and blood pressure checks) during your pregnancy. You may also be offered a late scan to check the size of your baby.
Will I need to take medication?If you follow the advice of your specialist diabetes team but your blood glucose levels are still too high, you may need to start taking tablets or insulin. Your specialist diabetes team will explain how to take the insulin and what its effects will be.
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What happens during labour?During labour, your blood glucose levels will be monitored closely by an experienced team. If your diabetes is controlled just by your diet, your labour will be managed as normal., but Iif you need insulin during your pregnancy you will have an insulin infusion during labour to ensure your blood glucose remains normal. This is where a continuous amount of insulin, balanced with glucose, is fed into your blood through a drip.Women with gestational diabetes sometimes have larger than average babies. If this is the case, you may need to be induced before your due date or have a caesarean delivery. We will discuss this with you in the final weeks of your pregnancy.
What happens after my baby is born?Your baby is at risk of a low blood glucose after birth which can be serious. Because of this, they will have a heel prick test to check their blood glucose level. Your team will want to monitor your baby’s blood glucose levels closely for the first 24 hours. This may mean that your baby is taken to the special care baby unit. Your baby isn’t being tested for diabetes during this time, but is being monitored to see if extra feeds are needed to stabilise their blood glucose levels.You probably won’t have diabetes after you’ve given birth but we may ask you to monitor your blood glucose. If you’ve been taking insulin, you should be able to stop after your baby’s birth.
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You should be offered an oral glucose tolerance test (OGTT) 6 months after birth to check that your blood glucose levels have gone back to normal.
Can I breastfeed?Breastfeeding is generally thought to be the best start for babies and there’s no reason why you shouldn’t breastfeed your baby if you have had gestational diabetes. It provides the best nutrition for your baby and gives extra protection against infection through your antibodies.
What happens if I get pregnant again?If you’ve had gestational diabetes, it is more likely that you’ll develop it again in future pregnancies. You will be offered early screening by an oral glucose tolerance test in future pregnancies. You also have a higher chance of developing type 2 diabetes in later life if you’ve had gestational diabetes. To help reduce your risk, eat healthily, aim to keep your weight down and include some physical activity in your day.
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Who is at particular risk of developing gestational diabetes?GDM?The factors below increase the risk of developing gestational diabetes:
Being overweight (body mass index more than 30).
Having a previous large baby weighing 4.5kg or more.
Gestational diabetesGDM in a previous pregnancy.
Family history of diabetes (in first degree relatives such as your parents, brother, sister).
Family origin with a high prevalence of diabetes (South Asia, Black Caribbean, Middle Eastern).
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How to contact usIf you have any questions about your health or care, you can talk to one of our staff on the numbers listed below:
Antenatal ClinicAberdeen Maternity Hospital
(01224) 552743
Ashgrove WardAberdeen Maternity Hospital
(01224) 554939
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Useful websites
www.mydiabetesmyway.scot.nhs.ukProvides information on all aspects of diabetes.
www.dft.gov.uk/dvla/medicalProvides information on medical conditions and driving.
Please note that NHS Grampian is not responsible or liable for the quality of the information, resources or maintenance of external websites. Any advice on external websites is not intended to replace a consultation with an appropriately qualified medical practitioner.
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This leaflet is also available in large print and on computer disk. Other formats and languages can be supplied on request. Please call Quality Development on (01224) 554149 for a copy. Ask for leaflet 1250.
Feedback from the public helped us to develop this leaflet. If you have any comments or suggestions about how we can improve this leaflet, please let us know.
Department of Diabetes November 2010Aberdeen Royal Infirmary ©NHS GrampianLeaflet supplied by: Quality Development, Foresterhill
25 May 2011
Section C: Glycaemic Control
C1.0 Targets for Glycaemic Control..........................................................3C1.1 Glycosylated haemoglobin..........................................................3C1.2 Conversion Table for HbA1c % to mmol/mol...............................5
C2.0 Monitoring...........................................................................................6C2.1 Patients with Type 2 Diabetes controlled by diet or oral
medication...................................................................................6C2.2 Patients with Insulin-treated Diabetes.........................................7C2.3 Adjustment of insulin dose...........................................................8C2.4 Ketone testing in insulin-treated patients.....................................8
C2.4.1 Management of results:...................................................9C2.5 BLOOD GLUCOSE METERS / LANCERS/ LANCETS.............10
. C3.0 Hypoglycaemic Drug Therapy.......................................................11C3.0 Hypoglycaemic Drug Therapy.........................................................12
C3.1 Oral hypoglycaemic drugs.........................................................12C3.1.1 Comparative Costs of Treatments for Type 2 Diabetes.22
C3.2 Insulin regimens.........................................................................23C3.3 Types of Insulin.........................................................................24C3.4 Summary of insulin classification...............................................26
C3.4.1 Insulin costs...................................................................28
C4.0 Hypoglyaemia...................................................................................29C4.1 Causes of hypoglycaemia.........................................................29C4.2 Symptoms of hypoglycaemia.....................................................29C4.3 Hypoglycaemia unawareness....................................................30C4.4 Treatment of hypoglycaemia.....................................................30C4.5 Hypoglycaemia and sulphonylureas..........................................31C4.6 Nocturnal hypoglycaemia..........................................................31C4.7 Rebound Hyperglycaemia.........................................................32C4.8 Avoidance of hypoglycaemia.....................................................32C4.9 Driving and hypoglycaemia.......................................................32C4.10 Exercise related hypoglycaemia..............................................33
C5.0 Management of Diabetic Emergencies in the Community...........34C6.0 Management of Diabetes in Hospital..............................................36
C6.1 Introduction................................................................................36C6.2 Diabetic emergencies...............................................................38
C6.2.1. Diabetic Keto Acidosis (DKA).......................................38C6.2.2 Hyperosmolar Hyperglycaemic Non Ketotic syndrome
(HHNS)..........................................................................39C6.2.3 Hypoglycaemia in hospital.............................................39
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C6.2.4 Prevention of Hypoglycaemia during Hospital Admission......................................................................................40
C6.2.6 Prevention of Hypoglycaemia during Hospital Admission......................................................................................42
C6.3 Management of Diabetes during intercurrent illness.................43C6.3.1 Type 1 diabetes.............................................................43C6.3.2 Type 2 diabetes.............................................................43C6.3.3 Variable rate intravenous insulin infusion......................446.3.4 PROTOCOL FOR VARIABLE RATE INTRAVENOUS
INSULIN INFUSIONS....................................................46C6.4 Guidelines for diabetes management during procedures
requiring fasting........................................................................49
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C1.0 Targets for Glycaemic Control
Epidemiological studies show that the risks of arterial disease and micro vascular complications in people with diabetes are related to the extent of hyperglycaemia.
The Diabetes Control and Complication Trial (DCCT) and UK Prospective Diabetes Study (UKPDS) have shown that optimal blood glucose control in the early years after diagnosis substantially reduces the risk of development and progression of complications in people with diabetes.
The overall goal should therefore be the optimisation of blood glucose without undue hypoglycaemia. The extent to which this is pursued by the individual patient will depend on motivation, practical aspects of diabetes management (e.g. insulin delivery and self-monitoring), risks related to hypoglycaemia and concomitant co-morbidity. Long term outcome studies are not available for some of the newer therapeutic agents and their long term benefits are uncertain.
C1.1 Glycosylated haemoglobin Overall glycaemic control is best measured by HbA1c, which provides an index of the average blood glucose concentration over the preceding two months. Reference ranges for HbA1c vary according to method of assay.
From June 2009 HbA1c assays were standardised and reported in mmol/mol as well as %. Dual reporting in both units will continue for around 2 years to allow the diabetes community and others to adapt to the new units. Educational leaflets for patients, lab staff and clinical staff are available at Diabetes in Scotland
The range for HbA1c in people who do not have diabetes is up to 42 mmol/mol (6%). The DCCT and UKPDS intensively treated groups achieved HbA1c levels of 53 mmol/mol (7%) but this may not be achievable without undue adverse effects. Any reduction of elevated glycosylated haemoglobin will produce a significant reduction in microvascular complication risk.
To achieve optimal HbA1c levels the following blood glucose targets are likely to be required:
• Fasting plasma glucose in Type 2 patients ≤ 5.9 mmol/l • Pre-prandial blood glucose 4-7 mmol/l • 2 hours postprandial blood glucose 7-9 mmol/l
A single target figure may be unhelpful as this may vary between individuals depending on the:
Quality of life that would have to be sacrificed to reach that target. Extent of side effects Resources available for management
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In order to set realistic targets that patients can relate to and are motivated to achieve people with diabetes should be:
Involved in decisions as to their individual HbA1c level, which may be above or below that set for the general population of people with diabetes
Offered therapy (lifestyle and medication) to assist in achieving and maintaining their HbA1c target
Informed that any reduction in HbA1c towards the agreed target is advantageous to future health
In conclusion patients with diabetes should be encouraged to maintain an HbA1c less than 53 mmol/mol (7%) unless the resulting side effects of their efforts in achieving this significantly impair their quality of life.
An HbA1c target of 53 mmol/mol (7.0%) among people with Type 2 diabetes is reasonable to reduce risk of microvascular and macrovascular disease. A target of 48 mmol/mol (6.5%) may be appropriate at diagnosis. Targets should be set for individuals in order to balance benefits with harm, in particular hypoglycaemia and weight gain. Recent evidence suggests that tight control may increase overall mortality:
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C1.2 Conversion Table for HbA1c % to mmol/mol
% mmol/mol4.0 205.0 316.0 426.5 487.0 537.5 598.0 649.0 7510.0 86
Information for patients and for healthcare professionals can be found via the following factsheets:
Change In HbA1c Reporting – Information for People with Diabetes Factsheet
Change In HbA1c Reporting – Information for Healthcare Professionals Factsheet
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C2.0 Monitoring
Self Monitoring of blood glucose (SMBG) has an important role in the management of some individuals with diabetes. It should certainly not be seen as essential for everyone with diabetes. The evidence of value in improving HbA1c patients is limited (SHTG Evidence Note 26). Indeed, when used inappropriately, it can lead to added stress to the patient with no benefit.
No matter what the type of diabetes or the treatment modality being utilised SMBG will only be of value if used by a motivated, well educated patient. It should only be initiated as part of a package of care that should include structured education.
In these circumstances SMBG is an integral part of effective patient education packages and enhances the effective use of many therapies and lifestyle interventions.
Home blood glucose monitoring may help an individual to take control of their condition and can inform patients of the effects of eating certain foods or exercise on blood glucose. Conversely it may have no impact on control and has been associated with negative psychological outcomes. It should only be utilised in conjunction with an appropriate educational package.
C2.1 Patients with Type 2 Diabetes controlled by diet or oral medication
For most patients regular home blood glucose testing is not be appropriate. Patient choice and clinical need should be taken into account. When glycaemic control is stable and HbA1c on target, regular testing may not be essential but may help some patients maintain optimal control.
SMBG needs to be initiated by the clinician and patient in conjunction with a structured education package and in the context of clear outcome benefits.
Home blood glucose monitoring may help an individual to take control of their condition and can inform patients of the effects of eating certain foods and exercise on blood glucose. Some individuals will monitor blood glucose to empower them to make changes to lifestyle and thus improve glycaemia.
How often and when should patients monitor blood glucose?
When HbA1c is rising or when treatment is changing, eg to insulin or when there is intentional lifestyle change, blood glucose monitoring 2-3
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times per week at different times of day (e.g. fasting, 2 hours after eating) may be helpful up to a maximum of 4 tests every fourth day or one test per day.
Patients should be encouraged to record and understand the results of their blood testing and take action as agreed with their diabetes team.
Situations which may require more intensive blood glucose monitoring:
Patients should be advised to test blood glucose at least daily and possibly up to 4 times per day in the following situations:
During significant illness or if ketonuria present During times of psychological / emotional stress (e.g. exams, driving
tests) If the patient is on sulphonylurea and is at increased risk from hypoglycaemia (e.g. taxi / lorry driver / operating heavy machinery)
During pregnancy or pre-pregnancy planning To assess changes in glucose control due to medications and lifestyle
changes Before / After moderate physical activity
QIS Evidence note on clinical and cost-effectiveness of self-monitoring of blood glucose (SMBG) for non-insulin treated Type 2 diabetes – see link below.
SHTG Evidence Note 26
Blood glucose targets – these vary between individuals – (See section C1.1)
Urine Ketone Testing
This is not usually required in patients with Type 2 diabetes but where there is concern that the patient may have evolving Type 1 diabetes or becoming "insulin-requiring" the diabetes team may recommend urine ketone monitoring.
C2.2 Patients with Insulin-treated Diabetes Patients with diabetes who utilise insulin need to practice SMBG so as to titrate insulin dose and avoid the extremes of glycaemia. By correctly interpreting SMBG and making adjustments to insulin dose and lifestyle control can be maximised and long term outcomes improved. For this to be affected then the individual with diabetes utilising insulin needs to be well educated and empowered to make changes.
Home blood glucose monitoring is strongly recommended for people with insulin-treated diabetes, as it enables the individual to take control of their condition and can help highlight situational changes requiring insulin adjustment.
How often should patients monitor blood glucose?
A blood glucose test should only be taken if it is to be used in decision
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making.
Monitoring should be encouraged at a frequency that is useful to the particular individual with diabetes remembering that:
Frequency of monitoring will vary between patients depending on lifestyle, motivation and need.
Patients should be encouraged to do at least one test per day at different times or 4 times a day every 3rd or 4th days.
At times some patients wishing to have greater control or flexibility may choose to test up to 4 times per day (also see below for situations where more testing may be required)
When should patients test blood glucose?
Recommended times of testing would be before meals (i.e. breakfast, lunch and tea), before bed and sometimes 2 hours after eating. Patients should be encouraged to keep a record of results including details such as time of day, activity and dietary intake.
Situations which may require more intensive blood glucose monitoring
Therapeutic change During illness or ketonuria Before /After physical activity Before driving (any distance not just long journeys) Psychological / emotional stress (e.g. exams, driving tests) Impaired hypoglycaemic awareness or recurrent hypoglycaemia. Changes in lifestyle – job / shift patterns Pregnancy or pre-pregnancy planning Using an insulin pump
C2.3 Adjustment of insulin dose Individuals with diabetes should be empowered by their team of professionals to interpret the results of SMBG and be able to make changes to their insulin regime.
C2.4 Ketone testing in insulin-treated patients
Patients on insulin should be advised to keep an “in date” supply of urine ketone-testing strips. They may have access to blood ketone testing strips for use in specialised circumstances.
If blood glucose 17 or above or during intercurrent illness (e.g. cold /flu/ UTI etc) urine should be tested for ketones.
Routine ketone monitoring is not required however it is advised to monitor during periods of sustained hyperglycaemia.
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C2.4.1 Management of results:
Urine Ketones:1. If TRACE or SMALL - observe.2. If MODERATE or LARGE – extra insulin is probably required.
If blood glucose still 17 or above after 3 hours – re-test for ketones. If ketones are still present (i.e. moderate or large), further extra insulin may be required and if any uncertainty with the best course of action specialist help should be sought.
If blood glucose and urine/blood ketones are persistently elevated the patient is at significant risk of developing diabetic ketoacidosis and specialist advice will be required
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C2.5 BLOOD GLUCOSE METERS / LANCERS/ LANCETSRecommendations DSN Group June 2010 (Review Date June 2011)
METER NAME AVIVA NANO
CONTOUR FREESTYLE FREEDOM LITE
ONE TOUCH ULTRAEASY
TRUE ONE Meter/strips all in one
A ADVANTAGES Will not accept wrong batch or out of date test strips
Multiclik lancet reduces risk of needlestick injury
Small in size
No coding required
Various colours
No coding required
Large window displaying results
Small in size
Various colours
Usually for short term use and not normally put on repeat prescription
Useful situations:Steroid therapyChemo therapyIllnessHolidays
POSSIBLE DISADVANTAGES
Unsuitable for patients on renal dialysis
Requires coding by chip
Requires manual coding
Care needed when placing strip in meter
Accessory kit with lancer device and carry case required
STRIP NAME Aviva Contour FreeStyle Lite One Touch Ultra
TRUEone
STRIP COST £14.49 / 50 £14.74 / 50 £14.62 / 50 £14.53 / 50 £14.36 / 50
LANCER Multiclik Microlet Freestyle One Touch Ultrasoft
TRUEone Accessory Kit - order via manufacturer
LANCETS MULTICLIK BOX = (204)
ASCENCIA MICROLET2 or BD Microfine
FREESTYLE LANCET or BD Microfine
ONE TOUCH ULTRASOFT or BD Microfine
BD Microfine
MANUFACTURER ROCHE BAYER ABBOTT LIFESCAN HOME DIAGNOSTICS
CARELINE 0800 701000 0845 006030 0500 467466 0800 121200 0800 0858808
Alternative meters could be considered for patients in these categories:
Meter Name Advantages Test Strips Cost Contact DetailsType 1Diabetes
Optium Xceed Checks blood glucose
Checks blood ketonesUseful in pregnancy
Optium Plus B.G. strips Optium Ketone test strips
£14.53 /50£19.55 / 10
Abbott 0500 467466
Visual Impairment
Cleverchek Gives verbal commands and results
Cleverchek £16.30 / 50
BBI Healthcare01792 229333
Poor Compact Plus Can be operated with Compact Plus £14.88 / Roche
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Dexterity one hand 51 0800 701000National procurement of blood glucose meters and test strips is currently being undertaken by NHS Scotland. The meters listed are recommended for home blood glucose monitoring in NHS Grampian.
It is recommended that patients use one type of meter only as results can vary from one meter to another.
When test strips are changed please ensure previous ones are discontinued and removed from the repeat prescription. Some meters will accept other test strips which will produce inaccurate results.
Please ensure patients are aware if their meter requires re-coding for each new batch of test strips.
Blood sample size and range of results differ with each meter. It is recommended that patients register their meter with the manufacturing company. This can be done by telephone or completing and posting the registration card. Most Company Carelines will support patients with simple queries regarding their blood glucose testing equipment. They also supply software to download test results, free replacement batteries and new meters in the event of product recall.
It is recommended that meters be quality controlled regularly. Quality control solution is available on request from the manufacturing company.
Health care workers / others involved with blood glucose monitoring
The Unistix 3 single use lancets are recommended for use by any care worker involved with blood glucose monitoring. They can be ordered as follows:
PECOS 052233 Blood lancet disposable Unistik3 (FZT069) or On stock order GP10a for practices or On GP10 for a named patient
The Multiclik lancer device supplied with the Accuchek Aviva Nano meter can be used by others involved with blood glucose monitoring e.g. family members. The lancets for this device are contained within a drum, therefore reducing the risk of needlestick injury.
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C3.0 Hypoglycaemic Drug Therapy
C3.1 Oral hypoglycaemic drugs
These drugs are suitable for people with Type 2 diabetes when blood glucose control through lifestyle measures alone proves inadequate. Even when taking hypoglycaemic drugs lifestyle issues remain of key importance.
Since in practice the majority of patients are overweight, metformin is usually the drug of first choice. Sulphonylureas would be the usual second choice due to cost and safety factors. Pioglitazone or DPP 4 inhibitors may be an alternative in obese patients. However, recent safety concerns re: the glitazones (heart failure and reduced bone density) and the limited clinical experience with DPP 4s (as well as cost factors) place these agents as third choice for possible use as triple combination therapy (in addition to metformin and sulphonylureas), in patients who are reluctant to go on to insulin.
Early sulphonylurea treatment may be appropriate in the thin symptomatic patient without ketonuria.
Patients should be educated about their drugs and should carry documentation of any risk of hypoglycaemia. The risk of hypoglycaemia is present when using sulphonylureas alone or with any combination of oral agents with sulphonylureas.
The new treatments for Type 2 diabetes on the market at the present time have limited long term outcome data to support them and should be used with a degree of caution.
Oral medication is often continued once insulin therapy has been commenced in the treatment of Type 2 diabetes. The SIGN algorithm is attached over and each of the drug classes will be considered in the following pages.
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Algorithm for Glucose-Lowering in People with Type 2 Diabetes
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Metformin
ActionMetformin works principally by reducing insulin resistance.
IndicationsPrimary drug treatment of overweight Type 2 diabetes. As an adjuvant to other hypoglycaemic therapy in Type 2 patients. Metformin may be continued in some obese patients with Type 2 diabetes who ultimately require insulin therapy, to maximise insulin sensitivity and minimise weight gain on insulin.
Side EffectsDiarrhoea, lethargy, anorexia, malabsorption of B12 and folate. Lactic acidosis is a very rare but often fatal side effect. It occurs almost exclusively in alcoholics, patients with renal or severe cardiac failure, liver disease, sepsis, shock or recent myocardial infarction.
CautionContraindicated in renal impairment (creatinine >150µmol/l or eGFR <30 ml/min/1.73 m2), severe liver disease and alcoholism. Discontinue temporarily during severe inter-current illness. Discontinue for 48-hours following the injection of x-ray contrast media.
DoseInitially 500mg daily with or after main meal, increasing gradually in 500mg increments to a maximum of 1g tds as required for good glycaemic control. The dose is often limited by diarrhoea.
Extended Release Metformin (Glucophage SR, dose 500mg to 2gram daily) is restricted for use to patients intolerant to immediate release metformin or for patients for whom a once daily preparation offers a clinically significant advantage over immediate release metformin. This new formulation appears to have similar short-term efficacy to immediate-release metformin. Evidence of improved gastrointestinal tolerability is not convincing and it is more expensive than the immediate-release formulation. However, it may be useful in those who are poor at remembering tablets as a once daily dose may aid compliance. Metformin is also available in combination tablets with pioglitazone (Competact). The use of these tablets is not recommended unless essential to aid compliance in certain patients
Metformin and intravenous contrast studies
Contrast studies such as peripheral or coronary angiography and CT head scan with iv contrast, are associated with a small risk of acute renal failure that could result in the development of lactic acidosis in patients on Metformin therapy. Therefore, Metformin should be discontinued after such contrast studies for 48 hours or until renal function returns to normal. It is essential that the Radiology Department is aware of Metformin therapy and current
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eGFR in advance. In patients with significant renal impairment, (eGFR <50) ensure adequate hydration (eg normal saline 100 ml/hr 4 hours before and 24 hours afterwards) and discontinue any potential nephrotoxic drugs such as ACE inhibitor for 24-48 hours after the procedure.
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Sulphonylureas
Sulphonylureas remain a very important drug in the treatment of Type 2 diabetes and should be considered at an early stage after Metformin.
Action Potentiates the pancreatic β cell insulin release in response to glucose.
Indications Primary drug treatment of non-obese patients with Type 2 diabetes. Primary drug treatment of overweight Type 2 patients unable to take usual first line agents. As adjuvant therapy with other agents.
Side Effects Hypoglycaemia, weight gain, Other side effects are rare.
Drugs The three most commonly used sulphonylureas in Grampian are Gliclazide, Glipizide and Glimepiride, the last having the advantage of a once daily single tablet dose. Gliclazide is also available in a once daily dosage version which may aid compliance in some patients. Chlorpropamide and Glibenclamide are particularly prone to cause hypoglycaemia and should not be initiated, and their continued use should be reviewed periodically.
Doses It is usually appropriate to start with a small dose before breakfast, increasing progressively according to blood glucose response. The drug should always be taken before meals, ideally 20 to 30 minutes before eating.
Glimepiride 1-6 mg as a single daily dose.
Gliclazide 40-320mg daily (doses > 160mg should be divided). Also available as a 30mg modified release tablet (equivalent to 80 mg of standard preparation) – to achieve maximum dose range (120mg), patient required to ingest up to 4 tablets before breakfast.
Glipizide 2.5-20 mg (doses >10 mg should be divided). Maximum daily dose 10mg twice daily.
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Thiazolidinediones
Action: Acts at the level of the PPAR-gamma receptor to promote insulin sensitivity. To be effective, patients require to have sufficient endogenous insulin production. The maximum therapeutic benefit may not be apparent until after eight weeks. Pioglitazone is used to treat adult patients who have Type 2 diabetes, particularly in those who are overweight. Pioglitazone, can also be used in combination with insulin. Contra-indicated in patients with left ventricular impairment, heart failure or high risk of fractures. Warn a person prescribed a thiazolidinedione about the possibility of significant oedema and consider alternatives if this develops. (Rosiglitazone has had its marketing authorization withdrawn in Europe)
Indications Thiazolidinediones can be used as monotherapy although Metformin is the drug of first choiceThiazolidinediones may be added to
the combination of metformin and a sulfonylurea where insulin would otherwise be considered but is likely to be unacceptable or of reduced effectiveness because of employment, social or recreational issues related to putative hypoglycaemia– barriers arising from injection therapy or other personal issues such as adverse experience of insulin in others– those likely to need higher insulin doses or with barriers to insulin arising from particular concerns over weight gain (namely those with obesity or abdominal adiposity)
a sulfonylurea if metformin is not tolerated metformin as an alternative to a sulfonylurea where the
person’s job or other issues make the risk of hypoglycaemia with sulfonylureas particularly significant.
Side-effects Significant weight gain and fluid retention; associated with loss of bone mass and are associated with significantly higher risk of distal fractures in women.
Caution Avoid in hepatic impairment – Do not initiate if AAT≥ 2.5 x upper normal limit and therefore worth checking LFT’s before initiating therapy and as BNF states “periodically” thereafter.Liver toxicity is however rare.If AAT is ≥ 3x upper normal limit, therapy should be discontinued.
Dose Pioglitazone (Actos) - 15-45mg once daily. Pioglitazone 15mg is available in combination with Metformin 850mg (Competact)
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and can be used as 1 tablet twice daily. Pioglitazone should be continued only if a HBA1c reduction of 5.5 mol/mol is achieved at 6 months.
Drugs that affect the incretin system
Incretin hormones [eg, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP)] regulate glucose homeostasis by increasing insulin synthesis and release from pancreatic beta cells and decreasing glucagon secretion from pancreatic alpha cells. Decreased glucagon secretion results in decreased hepatic glucose production. Under normal physiologic circumstances, incretin hormones are released by the intestine throughout the day and levels are increased in response to a meal; incretin hormones are rapidly inactivated by the Dipepidyl Peptidase 4 (DPP-4) enzyme.
GLP-1-based therapies affect glucose control through several mechanisms, including slowed gastric emptying, regulation of postprandial glucagon, reduction of food intake, and enhancement of glucose-dependent insulin secretion. These agents do not cause hypoglycaemia, in the absence of therapies that otherwise cause hypoglycaemia
DPP-4 Inhibitors
Dipeptidyl peptidase 4 (DPP-4) Is a ubiquitous enzyme that deactivates a variety of other bioactive peptides, including GIP and GLP-1; therefore, its inhibition could potentially affect glucose regulation through multiple effects. Sitagliptin is the only agent licensed for use in the UK and approved by the Grampian Joint Formulary Committee. Vildagliptin (twice daily dosing and liver function test monitoring) and Saxagliptin (SMC approved only for 2nd line use with metformin; modest efficacy and marginal unit cost advantage) were both currently deemed unworthy of inclusion when considered by the Grampian Joint Formulary Committee.
Action: Inhibits dipeptidyl peptidase 4 (DPP-4) enzyme resulting in prolonged active incretin levels.
Indications:1 May be used in combination with metformin when diet and
exercise, plus metformin, do not provide adequate glycaemic control. It should be restricted to use in patients only when the addition of sulphonylureas is not appropriate (intolerance or significant risk of hypoglycaemia or its consequence – certain jobs like heavy machinery use, working at heights etc.
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2 In combination with thiazolidinediones or sulphonylurea when diet and exercise and maximum tolerated dose do not prove adequate and metformin contraindicated or not tolerated.
3 Sitagliptin only is licensed for triple therapy in combination with Metformin and sulphonylurea when dual therapy is inadequate to maintain glycaemia control (as an alternative to other agents such as thiazolidinediones)
4. Sitagliptin can be used as monotherapy in exceptional cases when metformin and sulphonylurea use is inappropriate due to contraindications or intolerance.
Efficacy: As assessed by measurement of HbA1c, is similar to sulphonylurea and thiazolidinedione drugs added at this stage in therapy. It appears to have minimal effects on body weight. Consider withdrawing DPP-4 inhibitor therapy if the person has not had a beneficial metabolic response (a reduction of at least 5.5 mmol/mol points in HbA1c at six months.
Side effects: Seems to be well tolerated with minor headaches and nausea in
<5%. Hypoglycaemia risk is minimal with Metformin but significant when used with sulphonylurea.
Cautions: Gliptins are not recommended in patients with moderate to severe renal failure (GFR <50ml/min). Not recommended in severe hepatic failure.
Additional cautions for Vildagliptin: Not recommended in hepatic impairment, including patients with ALT >3x upper limit of normal. It is recommended that LFTs are monitored three monthly in the first year and periodically thereafter. Not recommended in patients with moderate cardiac failure (NYHA class III-IV). Due to rare reports of skin lesions in animal studies, monitoring of skin disorders such as blistering or ulceration is recommended.
GLP-1 Analogues:Exenatide and LiraglutideAction: Exenatide and Liraglutide are analogues of the hormone incretin
(glucagon-like peptide 1 or GLP-1) which increases insulin secretion, slows gastric emptying, and may decrease food intake
Indications: Both agents may be used with metformin and/or sulphonylureas in patients who have not achieved adequate glycaemic control on maximally tolerated doses of these oral therapies. Liraglutide
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may also be used in combination with metformin and pioglitazone. These are considered as a third line hypoglycaemic agent e.g. where a history of significant cardiac problems, or a fear of adverse cardiac risks, mitigates against use of other agents. These are injectable agents and could be considered at the point where insulin therapy would be suitable in selected individuals who have a BMI >30 and there are specific psychological, biochemical or physical problems due to the high weight. Continue exenatide/liraglutide therapy only if a beneficial metabolic response (at least 5.5 mmol/mol points HbA1c reduction in 6 months and a weight loss of at least 5% at 1 year) occurs and is maintained.
“Careful clinical judgement must be applied in relation to people with long duration of Type 2 diabetes on established oral glucose-lowering drugs with poor glycaemic control (>10 years, these individuals being poorly represented in published studies) to ensure insulin therapy is not delayed inappropriately for the perceived benefits of GLP-1 agonists.”(SIGN 116 6.9.2.)
Side effects: Hypoglycemia (with concurrent sulfonylurea therapy 14% to 36%; frequency similar to placebo with metformin therapy). See advice on Driving - in Section B3.1.
Significant Nausea 40% - may be dose-related and may decrease in frequency/severity with gradual titration and continued use.
Contraindicated in severe renal failure (eGFR <30 ml/min/1.73 m2)
Dose:
Exanatide Initial: 5 mcg subcutaneous injections twice daily within 60 minutes before main meals at least 6 hour apart; after 1 month, may be increased to 10 mcg twice daily as a maximum.
Liraglutide A starting dose of liraglutide 0.6mg daily is recommended to improve gastro-intestinal tolerability. After at least one week, the dose should be increased to 1.2mg daily. Liraglutide is administered once daily at any time, independent of meals, and can be injected subcutaneously in the abdomen, in the thigh or in the upper arm.
The Grampian Formulary does not recommend Liraglutide 1.8mg daily for the treatment of people with Type 2 diabetes mellitus.
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Prandial glucose regulators
Action: These agents act as insulin secretagogues, potentiating the post-prandial secretion of insulin that is impaired in the Type 2 diabetes. May be considered rarely for people with non-routine daily lifestyle patterns (creating difficulty with sulphonylureas) to assist in attaining glucose control to their individual target.
Indications: Repaglinide – As monotherapy or in combination with metformin ` Nateglinide – In combination with metfomin
Side effects:Both agents can precipitate hypoglycaemia
Caution: Avoid in severe hepatic impairment
Dose Repaglinide (Novonorm) -initially 500mcg within 30 minutes before main meals (1mg if transferring from another oral hypoglycaemic), adjusted according to response at 1-2 week intervals. Up to 4 mg as single dose; max daily dose 16mg.
Nateglinide (Starlix) - initially 60 mg 3 times daily within 30 minutes before main meals; adjust according to response to maximum 180mg 3 times daily.
Acarbose
Action An alpha-glucosidase inhibitor which acts within the gut to slow digestion and absorption of carbohydrates.
Indications Primary drug treatment of patients with Type 2 diabetes (especially the obese) if other drugs are contraindicated. As an adjuvant to other oral agents or insulin.
Side effects Flatulence and GI disturbance. As mono therapy it does not cause hypoglycaemia.
Caution Insulin or sulphonylurea induced hypoglycaemia in patients taking acarbose must be treated with glucose (dextrose)
Dose 25-50mg daily increased very gradually to 50-100mg tds according to tolerance.
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C3.1.1 Comparative Costs of Treatments for Type 2 Diabetes
Comparative 28 Day Treatment Costs for Type 2 Diabetes
0 10 20 30 40 50 60 70 80
Liraglutide 1.2mg x 1
Exenatide 10mcg x 2
Sitagliptin 100mg x 1
Pioglitazone 15mg x 1
Levemir 20 units x 1
Lantus 20 units x 1
Insulatard 20 units x 1
Metformin MR 2g x 1
Humulin I 20 units x 1
Gliclazide MR 60mg x 1
Metformin 1g x 2
Glimepiride 2mg x 1
Gliclazide 80mg x 1
£
Figures are taken from MIMs March 2011 and Scottish Drug Tariff March 2011. They do not consider any costs of additional materials, education, monitoring, wastage etc. It should also be noted that ‘typical’ daily doses are only indicative and somewhat arbitrary, and drugs are frequently used in combinations rather than as straight alternatives.
The price of metformin 1g twice daily used in the above graph is the cost if a pack size of 84 is used to dispense from. The price would be greater (£4.24) if a pack size of 28 was used. The reality is that metformin is dispensed in both 84’s and 28’s and the actual cost to NHS Grampian was £3.76 for the period Oct – Dec 2010 (PRISMs).
Insulin costs are all based on the prices of 5 x 3ml cartridges.
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C3.2 Insulin regimens
Initiation of insulin Patients with Type I diabetes are normally commenced on human insulin or an insulin analogue, in either a twice daily or a multiple injection regimen. The choice of the initial regimen and subsequent modifications should be made in consultation with the patient, taking due regard of the patient’s occupation and lifestyle. The precise insulin formulation may be determined by the patient’s preferred insulin delivery device. Most patients prefer to use pen devices.
Insulin Treatment in Type 2 DiabetesPatients with Type 2 diabetes may need insulin when oral agents are insufficient to achieve satisfactory glycaemic control due to progressive beta cell failure. It is expected that almost 50% of patients with Type 2 diabetes will eventually require insulin and patients should be counselled about this early in their management.
Once daily injections Single daily injections do not usually result in good glycaemic control, and are relatively rarely used. Such a regimen may be appropriate for patients where the therapeutic goal is only to prevent ketosis or suppress symptomatic hyperglycaemia, and where there are practical problems with insulin delivery, or particular concern over the risks of nocturnal hypoglycaemia. Elderly patients living alone and patients requiring injections to be given by a community nurse may fall into this category.
Once daily bedtime NPH insulin is the basal insulin of choice when adding insulin to metformin and/or sulphonylurea therapy. Long acting basal analogue insulins (Insulin Glargine and Levemir) may be considered if there are concerns regarding hypoglycaemic risk.
Patients and carers should recognise that if good glycaemic control is needed most cases will eventually need to move onto a more frequent injection regime (either by adding prandial insulin or switching to a twice daily insulin regime as per patient choice).
Twice daily injections This is a commonly used regimen, and suitable for patients starting on insulin. A combination of short and intermediate acting insulins is taken before breakfast and before the evening meal.
Multiple injections This arrangement, involving up to 4 injections a day, has the main advantage of increased flexibility with regard to exercise, meal timing and meal size. It is most likely to work effectively in a well-motivated patient, prepared to do regular and frequent blood glucose testing
The majority uses an insulin analogue or soluble insulin before each meal, and an injection of an intermediate, or long acting insulin usually before tea or bedtime to provide background cover.
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Continuous subcutaneous insulin infusion (Insulin Pump Therapy): CSII therapy is available as a treatment option for patients with Type 1 diabetes mellitus provided that
Multiple daily injections (MDI) therapy (including, if appropriate, the use of long-acting insulin analogues) has failed to provide adequate control of diabetes mellitus as defined below, and
those receiving the treatment have the commitment and competence to use the therapy effectively
MDI therapy is considered to have failed when, despite a high level of care of their diabetes mellitus:
it has been impossible for the individual to maintain a haemoglobin A1c (HbA1c) level of less than 8.5%, or
the person is experiencing disabling hypoglycaemia, which, means the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life.
Patients may be referred to the insulin pump service for assessment if they fulfil the above criteria and are on the basal bolus insulin regimen and reliably monitor their blood sugars at least four times a day. They should be able to count the carbohydrate content of meals (and been for a course such as the DAFNE – Dose Adjustment for Normal Eating). Funding for pumps is limited and presently priority is given to those patients who have documented severe hypoglycaemia. Patients will be considered by the Insulin Pump Panel.
Insulin pump therapy is a complex therapy relying upon not just the hardware of the insulin pump but also the educational package associated with it.
C3.3 Types of Insulin
There are a large and confusing number of insulin preparations available. If patients are satisfied with their treatment and achieving satisfactory control in the absence of hypoglycaemia, no modification of their regimen is required. Most insulin currently in use is biosynthetically manufactured of human sequence or analogues with altered pharmacokinetic properties. Many patients prefer the ultra short-acting analogues/mixtures for convenience. Some patients prefer to use animal derived insulin in the belief that use of human sequence insulin may cause loss of awareness of hypoglycaemia. Although such a conviction is quite widespread among the users, carefully conducted scientific studies have consistently failed to provide evidence to support this hypothesis.
Some preparations are available in both human and porcine versions (e.g. human and porcine actrapid) which can result in confusion in prescribing and dispensing. It is important to realise that such preparations although similar in their characteristics are not interchangeable, and patients should not be inadvertently changed from one to the other. When patients are deliberately changed from animal to human/analogue insulin a dose reduction of 25% is advised.
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Please refer to the Diabetes and Emergencies sections for management of insulin therapies during illness.
Insulins are most conveniently classified by duration of action as shown in the following table.
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C3.4 Summary of insulin classification
Ultra short acting Immediate onset Duration
up to 4 hours Peak action
60 minutes
Short acting analogues Insulin Lispro (Humalog), Insulin Aspart (Novorapid),
Insulin Glulisine (Apidra)
Short acting Soluble insulin Onset 30 minutes (Human) Actrapid 10ml Vial only, Humulin S, Insuman
Rapid
Duration up to 5 hours Hypurin Bovine Neutral*, Hypurin Porcine Neutral*.
Peak action 3 hours
Intermediate acting a: Onset 90 minutes
Duration: 16-20 hours
Peak action: 4-12 hours
Isophane insulin (contains protamine) Human Insulatard,
Humulin I, Insuman Basal, Hypurin Bovine Isophane*,
Hypurin Porcine Isophane*.
Intermediate acting b: Insulin Zinc SuspensionOnset 120 minutes Hypurin Bovine Lente*
Duration: 24 hours
Peak action: 6-18 hours
Long acting (a) Protamine Zinc Insulin*Onset 4 hours Hypurin Bovine Protamine Zinc 10ml Vial
Duration up to or greater
than 24 hours
Long acting (b) Insulin Glargine (Lantus)
Duration up to or greater
than 24 hours
Insulin Detemir (Levemir)
Mixed preparations Fixed mixtures of soluble and isophane insulin
Biphasic onset and
duration of action
Humulin M3 [Humulin S / Humulin I in ratios of 30/70]
Insuman Comb 15, 25 or 50, [Insuman Rapid / Basal in
ratios of 15/85, 25/75, 50/50].
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Biphasic Insulin Lispro Humalog Mix 25 or 50 [Lispro/LisproProtamine in ratios of
25/75 or 50/50]
Biphasic Insulin Aspart Novomix 30 [Aspart/Aspart Protamine in a ratio of 30/70]
Biphasic Isophane Insulin Hypurin Porcine 30/70 Mix*
*: These insulins are rarely used and would not usually be part of a new insulin start.
Note Ultra short-acting insulins (e.g. Humalog, Novorapid, Apidra and mixtures ie Humalog Mix 25 or 50 and Novomix 30) should be injected immediately before eating or after food. Other insulins should be injected subcutaneously 30 minutes before eating. Long acting insulins are usually taken once daily at the same time, eg bb or bt or bbed.
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C3.4.1 Insulin costs
Prices taken from MIMs March 2011
The graph shows the cost of insulin provided in boxes of 5x3ml cartridges for use with insulin pens. The insulin pens used with the cartridges cost between £15.55 and £26.86.
Pre-filled insulin pens are also very popular, and cost only slightly more (£0 - £2.62 per box of 5 pre-filled pens) than the 5x3ml cartridges.
Figure 1 - Insulin Costs
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C4.0 Hypoglyaemia
This section deals with hypoglycaemia in general. Some additional notes pertaining particularly to hypoglycaemia occurring in in-patient situations appear in section C6.0.
Clinical hypoglycaemia refers to any episode of low blood glucose (usually <3.5 mmol/l) with or without symptoms and may occur in patients taking insulin, sulphonylureas or prandial glucose regulators. To reduce hypoglycaemic risk, such patients are normally advised to avoid blood glucose levels below 4.0 mmol/l. Mild hypoglycaemic episodes may not only be inconvenient for the patient, but may predispose to more severe episodes which are associated with significant morbidity as well as the development of fear of hypoglycaemia. While prompt recognition and treatment of hypoglycaemia obviates the risk of progression, even if untreated, most isolated episodes recover spontaneously and are not associated with permanent damage. It is reasonable to reassure patients accordingly. Fear of hypogycaemia is such that many patients avoid tightening blood glucose control to minimise risk of its occurrence.
ALL PATIENTS PRESCRIBED SULPHONYLUREAS OR INSULIN MUST BE ADVISED ON THE OCCURRENCE, AVOIDANCE, RECOGNITION AND MANAGEMENT OF HYPOGLYCAEMIA.
C4.1 Causes of hypoglycaemia Hypoglycaemia occurs when there is an imbalance between:
Carbohydrate intake Insulin or oral hypoglycaemic drug dose Exercise/activity.
Additional factors that may contribute to the risk of hypoglycaemia include lumpy injection sites (leading to erratic absorption of insulin), inappropriate injection site / technique (including intramuscular injection eg caused by using too long a needle or using arms as injection site), alcohol excess (particularly if combined with exercise and reduced carbohydrate intake), gastroparesis in patients with autonomic neuropathy and adrenal insufficiency (increased frequency in patients with Type 1 diabetes).
C4.2 Symptoms of hypoglycaemia The symptoms of hypoglycaemia vary between patients and the same patient may experience different symptoms in different circumstances. Symptoms are sometimes classified as:
autonomic, due to activation of the autonomic nervous system (sweating, tremor, anxiety, palpitations etc)
neuroglycopenic due to reduced glucose delivery to the brain (poor concentration, odd behaviour, dizziness)
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non-specific (headache, tingling lips etc) ←Symptoms of hypoglycaemia may be non-specific and vague (eg dizziness, feeling “wobbly”), especially in the elderly. Hypoglycaemia should always be considered as a possible cause of such symptoms, or collapse, in any patient taking sulphonylureas or insulin.
Symptoms generally develop when the blood glucose falls to around 3.5 mmol/l. In most patients the autonomic symptoms occur before the neuroglycopenic symptoms and provide a useful warning. Sometimes autonomic symptoms are a reflection of anxiety about possible hypoglycaemia rather than a reflection of a truly low blood glucose level; capillary glucose testing can be useful in differentiating. Patients with poor control and chronic hyperglycaemia may report symptoms of hypoglycaemia at higher blood glucose levels; this situation is an indication for negotiating a gradual step-wise approach if there is to be progress in achieving improvement in blood glucose control.
C4.3 Hypoglycaemia unawareness In some patients the autonomic warning features may not provide effective warning e.g. those with long-duration of diabetes, very tight glycaemic control or recurrent episodes of hypoglycaemia. This may result in hypoglycaemia unawareness when the patient is unable to recognise the onset of problems, with potentially serious physical and psychological consequences. Hypoglycaemia unawareness due to very tight control is generally reversible through meticulous avoidance of hypoglycaemia and relaxation of targets e.g. three months with a minimum blood glucose level of 6 mmol/l.
C4.4 Treatment of hypoglycaemia All patients treated with insulin or sulphonylureas (or prandial glucose regulators) should be advised to carry carbohydrate with them. As soon as symptoms are recognised or if a low blood glucose value is recorded (with or without symptoms), the patient should be advised to take one of the following:
5/6 Dextrose sweets (containing 3g CHO in each) or 4/5 Glucotabs (containing 4g CHO in each) or sugar lumps
Fruit juice – 1 glass (200 ml) Half of a small bottle (150ml) of sugary drink e.g cola, lemonade, or
similar – (not diet or lite varieties)
If the patient’s medication includes acarbose (Glucobay), then glucose e.g. Dextrosol must be used for treatment of hypoglycaemia (not a disaccharide such as sucrose (table sugar) or lactose (milk sugar)).
If symptoms and / or metered glucose are not improving after 10 minutes this should be repeated. If the patient is too drowsy to cooperate, “Glucogel” (formerly known as Hypostop) may be applied to the inside of the cheek and massaged from the outside. It may be advisable for patients to keep Glucogel at home/work and instruct family members/ friends/colleagues how to use it.
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If the patient is unresponsive, 1 mg of glucagon (“Glucogen”) should be given subcutaneously or intramuscularly (once only per episode). It may be also appropriate to instruct partners, close relatives, friends or colleagues of susceptible insulin-treated people in the use of glucagon and to ensure that they keep a kit available.
Alternatively 25g (50ml) of 50% dextrose can be given intravenously by professional help.
During the initial treatment of hypoglycaemia, high fat foods (eg chocolate) or long acting carbohydrates (bread, plain biscuits) are not the best choice as these will treat be slow to raise the blood glucose and may impair absorption of ingested fast acting carbohydrate.
After the initial treatment (once metered glucose is >4mmol/l), it is essential for the patient to take long acting carbohydrate such as biscuits and milk or a sandwich to prevent the hypoglycaemia from recurring.
C4.5 Hypoglycaemia and sulphonylureas Hypoglycaemia may occur in patients taking sulphonylureas and is often underreported in the elderly when the symptoms are non-specific and are confused with other conditions e.g. TIAs. Hypoglycaemia may recur following initial treatment and occasionally admission to hospital may be required. Newer long-acting sulphonylureas e.g. Glimepiride and modified release Gliclazide seem much less likely to cause hypoglycaemia than obsolescent long acting agents such as chlorpropamide.
In the frail or elderly, when patients are eating less due to intercurrent illness / hospitalisation, dose reduction or cessation of sulphonylurea may need to be considered to avoid hypoglycaemia. The dose can be increased again once normal eating patterns are restored. Progressive renal impairment also potentiates the risk of hypoglycaemia with sulphonylureas (and insulin).
C4.6 Nocturnal hypoglycaemia This is a common occurrence in insulin-treated patients. Patients may or may not wake up during the night with symptoms, or sometimes wake up the following morning feeling “hung-over”. In the great majority of circumstances moderate levels of hypoglycaemia will wake the patient; ready access to appropriate fast acting carbohydrate by the bedside will facilitate corrective action. Nocturnal hypoglycaemia may contribute to the development of hypoglycaemia unawareness. The risk of nocturnal hypoglycaemia can be minimised by ensuring a snack containing complex carbohydrate is taken at bedtime (irrespective of blood glucose reading), and allowing the blood glucose to be between, say, 7 and 9 at bedtime. Patients who take a twice-daily regimen of mixed insulin, or isophane insulin at night should be advised to have a bedtime snack. However this is may not be so important for patients on a basal-bolus regimen using the newer long-acting analogues as these have a flatter action profile.
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The following measures may also reduce the risk of nocturnal hypoglycaemia:
With twice-daily pre-mixed regimens those containing a short-acting analogue such as Humalog Mix 25 or Novomix 30 may be associated with less nocturnal hypoglycaemia than those containing human sequence soluble insulin eg Mixtard 30 or Humulin M3.
Splitting the evening insulin dose so that the quick acting insulin is taken before the evening meal and the intermediate acting insulin is taken at bedtime may also be helpful for those using premixed insulin.
Replacing human sequence soluble insulin at teatime with a shorter acting insulin analogue e.g. Lispro / Novorapid
With basal/bolus regimens long acting insulin analogues, i.e. insulin glargine (Lantus) or insulin detemir (Levemir) appear to be associated with a lower incidence of hypoglycaemia than long acting human sequence insulins.
C4.7 Rebound Hyperglycaemia After an episode of hypoglycaemia patients may experience marked hyperglycaemia, which can be prolonged (12-20 hours). This is only partly related to carbohydrate consumption to treat hypoglycaemia. A greater contribution is made by release of so-called counter-regulatory hormones that act by various means to raise glucose (and thus try to prevent early recurrence of hypoglycaemia); counter-regulatory hormones will raise glucose levels following hypoglycaemia whether or not the episode was detected at the time (e.g. during sleep). It must be remembered that hyperglycaemia may follow an earlier period of hypoglycaemia and that reducing the hypoglycaemic risk may be the action required to prevent recurrence of the rebound hyperglycaemia.
C4.8 Avoidance of hypoglycaemia The risk and recognition of hypoglycaemia can be reduced by self-monitoring of blood glucose, review of insulin / drug regimen, quantity and timing of carbohydrate intake and injection sites. Patients should be advised to “Make 4 the floor” with respect to their targets for glucose control i.e. try to avoid glucose values below 4. The targets for glycaemic control may need to be relaxed in patients who do not have awareness of low glucose levels and for those who have had problems with severe hypoglycaemia.
C4.9 Driving and hypoglycaemia Patients should be advised to check their blood glucose before and during long car journeys (at least every 2 hours) and should always carry carbohydrate in the car. If they have hypoglycaemic symptoms while driving they should stop the car as soon as safely possible, remove the keys from the ignition, leave the driver’s seat and take oral carbohydrate. Driving should not be resumed for at least 45 minutes. Patients who have lost their warning symptoms of hypoglycaemia or those experiencing recurrent hypoglycaemia
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should be advised not to drive until the problem has been resolved. It should be documented in clinical records when such advice has been given.
C4.10 Exercise related hypoglycaemia
Exercise is to be encouraged in those with diabetes and due care must be taken to give advice on observance of appropriate precautions for avoidance of problems. Hypoglycaemia related to exercise may occur at the time of exercise or up to 24 hours afterwards while the body’s glycogen (carbohydrate) stores are being replenished. The risk of hypoglycaemia is related to the intensity and duration of exercise. Where possible individuals should be advised not to exercise alone. Those less accustomed to regular exercise need to exercise particular caution. Patients should be advised to consider reducing insulin doses before and after exercise (including the day afterwards) and/or increase dietary carbohydrate and alter injection sites, e.g. avoiding legs if running/ cycling or arms if rowing/kayaking as such exercise will increase absorption of insulin. It is advisable for patients to have easy access to rapid-acting carbohydrate (eg orange juice / glucose tablets) when exercising. Exercise within 24 hours following an episode of hypoglycaemia carries a high risk of further hypoglycaemia.
Additional nutritional advice, particularly for those engaging in more vigorous physical activity is available on the following website: Runsweet.com
←
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C5.0 Management of Diabetic Emergencies in the Community
Acute illness in insulin-treated patients
Encourage blood glucose checks 2-4 hourly. Ensure monitoring equipment and technique satisfactory.
Never stop insulin. Increase dose according to blood glucose. Give e.g. 4 units of quick acting insulin every 2 hours until blood glucose less than 10
Check for ketones. Ketostix in urine (or Medisense Optium meter in blood). If moderate to high levels are detected, an increase in insulin may be necessary with subsequent check for ketones later same day.
Ensure continued fluid intake.100-200ml / hour (approx 1 glass) or an egg cupful /10 minutes. If vomiting prevents fluid intake, consider buccal or parenteral anti-emetic. Admission may be required.
Carbohydrate intake must be maintained by fluids if unable to eat. See 10g CHO Guidance below.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE.
Acute illness in Non-Insulin-treated patients
Provided not severely dehydrated or showing features of Hyperosmolar Coma ( drowsiness) then high blood glucose levels can be tolerated for a short illness
Markedly dehydrated hyperglycaemic patients should be admitted for IV fluids.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE
Consider admission if:
Inability to swallow or keep fluids down Persistent vomiting Persistent diarrhoea Persistently raised blood glucose greater than 28 despite increased
insulin Strongly positive ketones No improvement 24-48 hours When ketoacidosis clinically obvious (dehydration, thirst, polyuria,
abdominal pain, intractable vomiting, rapid or laboured breathing)
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10g CHO Guidance
Milk 1 cup (200ml)Fruit juice unsweetened 1 small glass (100ml)Lucozade 50mlCoca Cola (not diet) 150mlLemonade (fizzy/sweetened) 150mlIce cream 1 scoopJelly (ordinary) 2 table spoonsYoghurt (fruit) ½ small carton (60g)Yoghurt (plain) 1 small carton (120g)
If admission definitely necessary contact the relevant medical admitting team at ARI or Dr Gray’s as appropriate.
If advice or discussion appropriate first then contact (for ARI) the Diabetes Specialty Registrar who is available 9am – 9pm; 7 days (0845 456 6000 and ask for Bleep 2543) or, outwith these hours, the on-call Consultant for Diabetes can be contacted via Wards 27/28 ARI (01224 552004/552104).
For Dr Gray’s, during office hours contact the NHS Grampian switchboard 0845 456 6000 or 67998 and ask to speak to Dr Strachan or Dr Park. Alternatively ask to speak to the DSN covering Dr Gray’s.
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C6.0 Management of Diabetes in Hospital
C6.1 IntroductionIn first considering this subject, it is important to differentiate between people in hospital with acute metabolic decompensation, those with established diabetes that is an incidental or contributory issue in their hospitalisation, and those newly found to have a high glucose. The last group need to receive all the due consideration of any new patient with diabetes (see Section A2) – with additional attention paid to modifications occasioned by the nature of the hospital admission and input from the inpatient diabetes team as required.
For those with prior diabetes, the patient’s level of engagement and experience in self-management must always be borne in mind. Every encouragement should be given to preserve patient autonomy, but it should be remembered that the lack of familiarity with a particular clinical circumstance may compromise the patient’s coping strategies.
Glycaemic control may deteriorate in the hospital setting due to stress of intercurrent illness, changes in dietary intake and decrease in physical activity. Interruptions to accustomed dietary intake or enforcement of medication and dietary concordance may also considerably alter the patient’s circumstances. The circumstance of clinical decision making in hospital can also limit the skilled patient’s opportunity to apply appropriate flexibility in self-management. As a consequence, both hyperglycaemia and hypoglycaemia are common in the hospital setting. It is often therefore appropriate to alter interim glucose targets to a broader (and safer) range than would apply in the chronic out-patient situation (e.g. 6-14mmol/l) to prevent problems with hypoglycaemia and hyperglycaemia. However, persistent and significant hyperglycaemia (>17mmol/l) should be prevented/treated to avoid dehydration, caloric loss, infection and ketoacidosis.
Both hypoglycaemia and hyperglycaemia are common in the hospital setting. Factors that contribute to this include the stress of intercurrent illness, changes in dietary intake, enforcement of medication and decrease in physical activity.
The circumstance of clinical decision making in hospital can also limit the skilled patient’s opportunity to apply appropriate flexibility in self-management. It is often therefore appropriate to alter interim glucose targets to a broader (and safer) range than would apply in the chronic out-patient situation (e.g. 6-14mmol/l) to prevent problems with hypoglycaemia and hyperglycaemia. However, persistent and significant hyperglycaemia (>17mmol/l) should be prevented/treated to avoid dehydration, caloric loss, infection and ketoacidosis.
Hospitalised patients may benefit from opportunistic specialist review and appropriate education. Timely liaison with the specialist diabetes team can
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reduce the risk of glucose management problems during admission and can facilitate early discharge.
Hospitalised patients may benefit from opportunistic specialist review and appropriate education. This is of importance in those whose hospital admission is the only time some patients make contact with healthcare professionals. Timely liaison with the specialist diabetes team can reduce the risk of glucose management problems during admission, help to optimise patient’s long term diabetic care and can facilitate early discharge.
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C6.2 Diabetic emergenciesIf admission definitely necessary contact the relevant medical admitting team at ARI or Dr Gray’s as appropriate.
If advice or discussion appropriate first then contact:
1 (for ARI) the Diabetes Specialty Registrar who is available 9am – 9pm; 7 days (0845 456 6000 and ask for Bleep 2543) or, outwith these hours, the on-call Consultant for Diabetes can be contacted via Wards 27/28 ARI (01224 552004/552104).
2 For Dr Gray’s contact the switchboard 0845 456 50000 or 67998 and ask to speak to Dr Strachan, Dr Park or the DSN covering Dr Gray’s.
C6.2.1. Diabetic Keto Acidosis (DKA)DKA is a potentially life threatening complication of diabetes that while often preventable, must be dealt with as a matter of urgency once established. Diagnosis of DKA is only appropriate in the presence of diabetes AND ketosis AND acidosis .
A national protocol for management of confirmed DKA in adults only is being rolled out in spring 2011; it can also be down loaded from the intranet link below. A separate paediatric protocol is available for children under the age of 16 years. The paediatric protocol may also be appropriate in adults of low body weight (BMI < 16kg/m2), as it reduces the risk of fluid overload.
The Diabetes specialist team should be contacted as appropriate for advice regarding management of DKA
Consideration must be given to the cause of DKA for example, infection, myocardial infarction or insulin administration difficulties and the underlying cause appropriately treated.
The Diabetes specialist team should be contacted as appropriate for advice regarding management of DKA and, once the patient is stable, for education to try to prevent recurrence.
Adult DKA Care Pathway
Paediatric DKA Protocol
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C6.2.2 Hyperosmolar Hyperglycaemic Non Ketotic syndrome (HHNS)Hyperosmolar Hyperglycaemic Non Ketotic syndrome formally known as HONK is a life threatening condition, which mainly occurs in older people with Type 2 diabetes. HHNS is characterized by dehydration, very high blood glucose and high serum osmolality (>320mosm/l) but without ketoacidosis or heavy ketonuria; modest ketonuria and lactic acidosis may sometimes occur. Mortality is very high (up to 50%). Early diabetic specialist review is recommended. Management is similar to DKA but the fluid replacement should be less rapid. Some advocate rehydration with 0.45% saline claiming it reduces the risk of hypernatraemia. Blood glucose should be reduced gradually to avoid precipitating cerebral oedema. Patients with HHNS should also be considered for subcutaneous heparin prophylaxis due to increased risk of thrombo-embolism. Once treated, most patients can be managed on diet with or without oral hypoglycaemic agents.
Investigation into the underlying cause should also be given and treated as appropriate.
C6.2.3 Hypoglycaemia in hospital This section focuses on the treatment and prevention of hypoglycaemia in hospitalised patients. Further details regarding hypoglycaemia can be found in Section C4.
Hypoglycaemia is a lower than normal level of blood glucose. Patients with diabetes experience more frequent hypoglycaemia in the hospital setting than the community. Hypoglycaemia is the commonest side effect of insulin and sulphonylurea therapy (e.g. gliclazide, glipizide or glimepiride) and results from an imbalance between glucose supply, glucose utilisation and current insulin levels.
Hypoglycaemia should be excluded in any person with diabetes who is acutely unwell, drowsy, unconscious, unable to co-operate, presenting with aggressive behaviour or seizures. Any blood glucose of less than 4.0 mmol/L in people with diabetes on sulphonylurea or insulin therapy should be treated, whether symptomatic or not.
People experiencing hypoglycaemia require quick acting carbohydrate (15-20g) to return their blood glucose levels to the normal range. The quick acting carbohydrate should be followed up by giving long acting carbohydrate either as a snack or as part of a planned meal. All patients experiencing hypoglycaemia should be treated without delay. Where it is safe to do so, a blood glucose measurement should be taken to confirm hypoglycaemia. If measurement is difficult (e.g. in a patient undergoing a seizure) then treatment should not be delayed.
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The majority of patients will be able to ingest oral glucose. Patients unable to take things by mouth will require parenteral administration of glucose. Intravenous glucose in 10% or 20% concentrations is now preferred than the previous commonplace use of 50% glucose which is hyperosmolar and may increase the risk of extravasation injury.
All adults with a blood glucose level less than 4.0mmol/L with or without symptoms of hypoglycaemia should be treated as outlined below. Each ward should have a ‘hypo box’ which contains treatment for hypoglycaemia.
C6.2.4 Prevention of Hypoglycaemia during Hospital Admission
C.6.2.4 Treatment of hypoglycaemia:
Treatment of hypoglycaemia in adults who are conscious, orientated and able to swallow:
1) Give 15-20g of quick acting carbohydrate:a. 150-200 ml pure fruit juice (e.g. orange)b. 90-120ml of original Lucozade® (preferable in renal patients)c. 5-7 Dextrosol® tablets (or 4-5 Glucotabs®)d. 3-4 heaped teaspoons of sugar dissolved in water
2. Repeat capillary blood glucose measurement 10-15 minutes later. If it is still less than 4.0mmol/L, repeat step 1 up to 3 times
3. If blood glucose remains less than 4.0mmol/L after 45 minutes or 3 cycles, contact a doctor. Consider 1mg of glucagon IM (may be less effective in patients prescribed sulphonylurea therapy) or IV glucose (10 or 20%)
4. Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores Some examples are:
a. Two biscuitsb. One slice of bread/toastc. 200-300ml glass of milk (not soya)d. Normal meal if due (must contain carbohydrate)
5. DO NOT omit insulin injection if due (However, dose review may be required)
6. Document event in patient’s notes. Ensure regular capillary blood glucose monitoring is continued and ask the patient to continue this at
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home if they are to be discharged. Refer to the diabetes specialist nurse (DSN)
If the patient is too drowsy to co-operate, Glucogel® (2 tubes) should be applied to the inner cheeks and then massaged from the outside. This treatment can also be given to the fasting patient without compromising their fasting status.
If the patient is unresponsive - 125 mls of 20% Glucose or 250 mls of 10% glucose should be given intravenously as a bolus over a few minutes. This can be repeated if the patient remains unresponsive. More concentrated glucose preparation such as 50% Glucose should be avoided where possible due to the risk of extravasation injury. If there is no alternative then a generous saline flush both before and after the 50% glucose should be given, ideally through a large bore cannula.
If unable to obtain venous access – 1mg of Glucagon (Glucagen®) can be given intramuscularly or subcutaneously (once only per episode); patients frequently experience nausea and vomiting after this treatment so it should not be used unless essential.
C.6.2.5: When hypoglycaemia has been successfully treated
Take measures to avoid hypoglycaemia in the future, the Diabetes Specialist Nurses or on-call Diabetes Registrar can be contacted to discuss this.
Consider completing an incident (DATIX®) form if appropriate. If “hypo boxes” were used then replenish as appropriate. Identify the risk factor or cause resulting in hypoglycaemia. Unless the cause is easily identifiable and both the nursing staff and
patient are confident that steps can be taken to avoid future events then a review by the diabetes team should be considered. If the episode of hypoglycaemia was severe or recurrent, or if the patient voices concerns, then a review is indicated.
Please DO NOT omit the next insulin injection or start variable rate intravenous insulin infusion to ‘stabilise’ blood glucose. If unsure of subsequent diabetes treatment, discuss with the diabetes team.
Medical team responsible for the patient may consider reducing the dose of insulin prior to the time of previous hypoglycaemia events. This is to prevent further episodes of hypoglycaemia occurring.
Please DO NOT treat isolated spikes of hyperglycaemia with ‘stat’ doses of short/rapid acting insulin. Instead maintain regular capillary blood glucose monitoring and adjust normal insulin regimen if a particular pattern emerges.
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C6.2.6 Prevention of Hypoglycaemia during Hospital Admission
Avoid giving unopposed insulin infusion (i.e. without iv glucose – unless during early iv management phase of hyperglycaemia)
Avoid disconnecting or stopping intravenous fluids while on an intravenous insulin pump
If any concern, e.g. blood glucose levels suddenly dropping, temporarily reduce interval between capillary glucose checks to 30 or 15 minutes
Ensure patients treated with s/c insulin have carbohydrate-containing snacks available, especially for bedtime
Be aware that after episodes of hypoglycaemia patients typically have REBOUND hyperglycaemia perhaps lasting several hours. These high levels of blood glucose should be allowed to return to normal without intervention (unless developing significant ketonuria). Resisting the temptation to give extra insulin may avoid recurrence of the primary hypoglycaemic event!
For further information please see the national guidelines entitled “The Hospital Management of Hypoglycaemia in Adults”, published March 2010, available from NHS Diabetes (look under “publications and resources”)
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C6.3 Management of Diabetes during intercurrent illness
C6.3.1 Type 1 diabetes Patients with Type 1 diabetes are regarded as being continuously
dependent on external insulin for their survival. Whenever possible, patients should be involved in decision making concerning management of their glycaemia. If there is reasonable likelihood of patients being able to eat and drink, then the ‘sick day’ rules should be followed (chapter C5). If blood glucose levels are high, it may be appropriate to use increased insulin doses for patients on basal-bolus insulin therapy, and additional supplementary doses of quick acting insulin (before lunch and before bed) for patients on twice daily pre-mixed insulin.
A Variable Rate Insulin Infusion Protocol (C6.3.3) is available for use when oral intake is compromised.
C6.3.2 Type 2 diabetes Patients, who are on diet alone, may need no specific therapy during
intercurrent illness apart from monitoring, to ensure blood glucose is reasonably stable. Patients on oral hypoglycaemic agents may need increased oral therapy or may need insulin temporarily (especially, for example, with steroid therapy). If blood glucose levels are high (> 17 mmol/l before meal times), consider adding subcutaneous soluble insulin (e.g. Actrapid, Humulin S 4 units). Management of insulin treated Type 2 diabetic patients is usually similar to that of Type 1 diabetes. It is important to consider discontinuation of increased hypoglycaemic treatment on recovery.
Intercurrent or new chronic illness may alter safety of some OHAs and there
is potential for adverse interaction with newly introduced medications; this should be borne in mind when managing in-patients. Certain oral hypoglycaemic agents may be contraindicated in the acutely ill patient, e.g. Metformin should be discontinued in impaired renal function (eGFR < 30) severe sepsis and acute left ventricular failure. Similarly, glitazones are contraindicated in patients with unstable ischaemic heart disease and cardiac failure. Deteriorating renal function reduces insulin clearance and so may increase the hypoglycaemic potential of given doses of insulin or sulphonylureas.
Deteriorating renal function reduces insulin clearance and so may increase the hypoglycaemic potential of given doses of insulin, GLP1 analogues, DPPIV inhibitors or sulphonylureas.
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C6.3.3 Variable rate intravenous insulin infusion
This protocol is used in several circumstances: 1. For controlling glucose levels when patients are not able to take their usual
insulin and diet e.g. peri-operative fasting; 2. Intercurrent illness where blood glucose levels are insufficiently controlled
on usual diabetic medication; 3. For 48 hrs after diagnosis of acute myocardial infarction, if admission
glucose is over 11mmol/l.
The protocol aims at maintaining blood glucose levels in a safe range (8-14mmol/l) avoiding risks of significant hypo/hyperglycaemia. Circumstances necessitating the use of this protocol should be regularly reviewed and patients should be switched back to their usual diabetic medications as soon as possible.
Protocol for Variable Rate Intravenous Insulin Infusions
W hen to use this protocol:
Peri-operative management of patients with insulin-treated diabetes / patients on near maximum dose oral hypoglycaemic agents undergoing major surgery. This includes patients who are clinically well but who have a high glucose requiring stabilisation peri-operatively
Management of insulin-treated patients who are unable to take a normal diet (eg fasting for investigations / nausea and vomiting etc)
On rare occasions for the continuing management of patients who remain unable to take a full diet following initial treatment for diabetic ketoacidosis and hyperosmolar coma (ie bicarbonate has normalised and blood glucose less than 14 mmol/l)
When not to use this protocol:
For patients with DKA ie elevated glucose / ketonuria and acidosis (use DKA protocol)
For patients who are clinically well, not peri-operative and presenting with high glucose (ie > 14 mmol/l) with or without ketonuria. Please consider if insulin infusion is really required or whether subcutaneous insulin would be more appropriate
Control of blood glucose in patients who are eating and drinking, whether
or not they require IV fluids for other reasons (such patients should be treated with their normal oral hypoglycaemic agents or sc insulin)
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Pregnancy – please contact the maternity hospital for diabetes in pregnancy protocol.
High dependency/ intensive care situations – specific wards may have their own protocols to aim at tighter control
Patients on nasogastric feed. Although, Variable Intravenous insulin infusion can be used temporarily, subcutaneous insulin therapy is more appropriate in these circumstances (e.g. Isophane insulin twice daily). Please liaise with the diabetes team.
Patients on TPN – TPN team will usually advise.
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6.3.4 PROTOCOL FOR VARIABLE RATE INTRAVENOUS INSULIN INFUSIONS
GRAMPIAN UNIVERSITY HOSPITAL NHS TRUST SYRINGE PUMP PRESCRIPTION SHEET
HOSPITALSURNAME [ ]
…………………………………………………………. UNIT NO
FIRST NAMES …………………………………………………………………
ADDRESS …………………………………………………………………
………………………………………………………………… SEX
……………………………………………………………….. MARITAL STATUS
POST CODE ………………………………………………………………. DATE OF BIRTH
BAR CODE [ PLACE LABEL WITHIN BRACKETS ]
WARD/DEPARTMENT
CONSULTANT
DATE: CODE LETTER FROM MAIN PRESCRIPTION SHEET:MEDICINE: Human Actrapid 50 Units CONCENTRATION: 1unit in 1ml DILUENT: 0.9 % Sodium Chloride
TOTAL VOLUME: 50ml INTRAVENOUS FLUIDS (GLUCOSE MUST ALWAYS RUN CONCURRENTLY WITH INSULIN)4 % Glucose + 0.18 % Sodium chloride + 0.15 % Potassium chloride at 100ml/hour OR 5 % Glucose + 0.15 % Potassium chloride at 100 ml / hour In patients who are at risk of fluid overload (e.g cardiac failure) use 10% glucose +0.15% potassium chloride and run at 50 ml / hour If K>4.5mmol/L give above fluids without added K
Dialysis dependent patients: use 10 % glucose (with no added potassium) and run at 50 ml/hour Fluids to be prescribed separately on fluid prescription sheet.
INSTRUCTIONS FOR VARIABLE RATE INFUSIONSPlease note-Capillary Glucose to be checked prior to starting insulin infusion and then hourlyINITIAL SETTINGS:If capillary glucose between 8-14mmols/l start at 2ml/hourIf capillary glucose greater than 14mmol/l start at 4 ml/hour and check glucose again in 30 minutesIf capillary glucose less than 8mmol/l start infusion at 1ml/hourIf capillary glucose less than 4mmol/l discuss with medical staff or diabetes team
DATE: ROUTE: IV RATE(ml/hr): INSTRUCTIONS FOR CHANGING RATE: IF CAPILLARY GLUCOSE:- Between 8-14mol/l leave at present rateIF CAPILLARY GLUCOSE:-Greater than 14 mmol/l: increase infusion rate by 2 units/hour (if infusion rate at 6ml/hour and capillary glucose remains >14mmol/l inform medical staff). If within 2 hours of a meal do not increase dose.Greater than 17 mmol/l: increase infusion as above and check for ketones and inform medical staff if positive.Between 6 and 8 mmols/l halve rate of insulin infusion, (Round down to nearest 0.1 decimal place). Continue to monitor glucose hourly and if glucose still between 6 and 8 mmols/l continue to halve rate of insulin infusion (do not reduce rate below 0.5ml/hour). Between 3.5 and 6mmols/l : If patient normally on diet +/- oral hypoglycaemics, stop insulin infusion, and continue to monitor glucose hourly. If
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blood glucose rises to greater than 14 mmol/l restart infusion at 0.5ml/hour and follow protocol as above. If patient normally on insulin, provided patient is fully conscious, reduce insulin infusion to 0.5 ml/hour, recheck
glucose in 30 minutes and continue protocol. If patient not fully conscious stop insulin infusion and contact doctor immediately. (Consider changing to 10% glucose if insulin rate already 0.5 ml/hour (see over)).
Less than 3.5 mmol/L: Stop insulin infusion and give 100mls of 10% glucose IV over 5 – 10 minutes. (If patient’s conscious level reduced call medical staff). Repeat blood glucose after 10 minutes and if glucose still less than 3.5mmol/l give another 100 mls of 10% glucose and call medical staff for advice. Once glucose > 3.5 mmol/l follow instructions as above for “between 3.5 and 6 mmol/l”.
Prescriber’s signature: ……………………………………….(for 100mls 10%glucose)Administration of 100 mls Glucose 10 % Date/Time: : : : : : : Administered by: : : : : : :
PRESCRIBER’S NAME (PRINT)SIGNATURE:
GRADE BLEEP NO:
DATE DISCONTINUED: TIME (24 hour clock) INITIALS:
KNOWN DRUG / MEDICINE SENSITIVITY
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Protocol for Variable Rate Intravenous Insulin InfusionsWhen to use this protocol: Peri-operative management of patients with insulin-treated diabetes / patients on near maximum
dose oral hypoglycaemic agents undergoing major surgery. This includes patients who are clinically well but who have a high glucose requiring stabilisation peri-operatively
Management of insulin-treated patients who are unable to take a normal diet (eg fasting for investigations / nausea and vomiting)
On rare occasions for the continuing management of patients who remain unable to take a full diet following initial treatment for diabetic ketoacidosis and hyperosmolar coma (ie bicarbonate has normalised and blood glucose less than 14 mmol/l)
When not to use this protocol:
For patients with DKA / HONK ie elevated glucose / ketonuria and acidosis (use DKA protocol)
For patients who are clinically well, not peri-operative and presenting with high glucose (ie > 14 mmol/l) with or without ketonuria. Please consider if insulin infusion is really required or whether subcutaneous insulin would be more appropriate
Control of blood glucose in patients who are eating and drinking, whether or not they require IV
fluids for other reasons (such patients should be treated with their normal oral hypoglycaemic agents or sc insulin)
If patient on TPN (contact nutrition team )
If patient on naso-gastric feeds (contact diabetes team )
IF YOU ARE NOT SURE WHICH PROTOCOL YOU SHOULD USE PLEASE CONTACT THE DIABETES TEAM FOR ADVICE (ALL BASED AT ARI)
Diabetes specialist nurse: Bleep 3334 (Monday-Friday, 9-5)Diabetes registrar: Bleep 2543 (Monday-Sunday 9-9)Renal registrar: Bleep 2451Or contact ward 27/28 ARI and where senior nursing staff may be able to help you or give you the contact number for the ward registrar / SHO or diabetes consultant on-call.
IMPORTANT INFORMATION Insulin infusion (50 units Human Actrapid in 50ml 0.9% Sodium Chloride, ie 1 unit/ml) by
syringe pump according to the scale overleaf. Aim to keep blood glucose between 8 and 14 mmol/l, check capillary glucose hourly using ward
meter. If the blood glucose is persistently below target and insulin infusion rate has been reduced to
0.5ml/hour, a change to 10% glucose may be required at a rate of 100ml/hour Patients who are insulin-treated should not be left off iv insulin for more than 30 minutes as there
may be a risk of developing ketosis. Check U & E daily whist patient on infusion The presence of this additonal prescription sheet must be highlighted (by placing a tick in the
special prescription sheets box on the main prescription sheet) to indicate that a fluid prescription sheet and variable rate iv insulin sheet is in use.
Patients at risk of fluid overload or cardiac failure ( eg post MI) or dialysis dependent patientsTo avoid volume overload start the intravenous infusion at a rate of 50ml/hr as follows: 10% Glucose + 0.15% Potassium Chloride Omit potassium if dialysis dependent patient or K 4.5 or greater Insulin infusion as above (50 units Actrapid in 50ml 0.9% saline, ie 1 unit /ml).
Changing back to normal insulin / oral hypoglycaemic regimen
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For patients on human or pork soluble insulin, when the patient is able to eat, the usual dose of subcutaneous insulin should be given 30 minutes prior to eating and the insulin infusion discontinued 30 minutes after the subcutaneous injection.
For patients on Humalog, Humalog Mix, Novorapid, Novomix, when the patient is able to eat, the usual dose of subcutaneous insulin should be given 5 minutes prior to eating and the insulin infusion can be discontinued immediately after the subcutaneous injection.
Patients who take oral hypoglycaemic agents should have their drugs recommenced at this stage.
Once usual treatment has recommenced capillary blood glucose testing is required at a maximum of 4 times per day with additional 2am blood tests for those on insulin considered at risk of hypoglycaemia
NOTE: Separate sheets are available for: PCA PumpsFluid (Additive Medicines)Pumps calibrated in mm
APRIL 2004
IF YOU ARE NOT SURE WHICH PROTOCOL YOU SHOULD USE PLEASE CONTACT THE DIABETES TEAM FOR ADVICE: Diabetes specialist nurse: Bleep 3334 (Monday-Friday 9-5)Diabetes registrar: Bleep 2543 (Monday-Sunday 9-9) Or contact Ward 27/28 and where senior nursing staff may be able to help you or give you the contact number for the ward registrar / SHO or diabetes consultant on-call.
C6.4 Guidelines for diabetes management during procedures requiring fasting These guidelines help both health care professionals and diabetic patients manage diabetes safely without significant hypoglycaemia or hyperglycaemia during various procedures that require fasting. While it is difficult to include every possible scenario in detail, guidelines have been developed keeping colonoscopy as a general example (with as many variations as possible) and these guidelines can also be used in similar circumstances. Those on diet alone need no specific intervention but patients on insulin therapy and on OHAs need some adjustments in their medications. In general, patients on basal-bolus therapy need 50% reduction in their basal insulin on the previous day and should omit quick acting insulin while fasting. Patients on twice daily pre-mixed insulin should omit their morning insulin on the day of the procedure. Once able to eat and drink, normal insulin doses should be resumed at the earliest opportunity (e.g. if on twice daily insulin, after the procedure take half the usual morning insulin dose at lunch time). Frequent capillary glucose monitoring is essential to avoid
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hypo/hyperglycaemia which may often go unnoticed especially after administration of sedation. Occasionally, some patients (with particularly unstable diabetes or limited capability for safe self-management) may need to be admitted for intravenous insulin infusion during these procedures and the use of variable rate intravenous insulin infusion protocol (see section C6.3.3) is recommended.
The following specific patient information leaflets are available for certain hospital procedures:
i) Guidelines for people with insulin treated diabetes undergoing outpatient colonoscopy / flexible sigmoidoscopy (morning and afternoon)
ii) Guidelines for people with tablet treated diabetes undergoing outpatient colonoscopy / flexible sigmoidoscopy
iii) Guidelines for people with diabetes undergoing outpatient upper GI endoscopy
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Section D: Complications
Section D: Complications............................................................1D2.0 Cardiovascular disease and diabetes..............................................5
D2.1 Screening....................................................................................5
D3.0 Eye Care, Screening and Treatment.................................................7D3.1 Eye screening..............................................................................8D3.2 Mydriasis.....................................................................................9D3.3 Medical treatment........................................................................9D3.4 Laser treatment.........................................................................10D3.5 Diabetic eye screening guidelines - classification and action....10
D3.5.1 Visual acuity..................................................................10D3.6 Fundoscopy...............................................................................10D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1.......11D3.8 Obtaining individual patient results............................................14
D4.0 Foot Care, Screening and Treatment.............................................16D4.1 Foot Screening..........................................................................16
D4.1.1 SCI-DC Foot Screening Tool.........................................17D4.1.2 Annual Diabetic Foot Screening....................................18
D4.2 Management guidelines for Charcot neuroarthropathy in people with diabetes.............................................................................20
D4.3 Diabetic Foot Ulceration and Wound Management...................21D4.3.1Care Pathway for Active Diabetic Foot Ulceration..........21D4.3.2 Referral Pathway for Pressure Relief............................23
D4.4 Good practice guidance for the use of antibiotics in patients with diabetes foot ulcers...................................................................26
D4.5 Diabetic Foot Care Patient Education.......................................37
D5.0 Neuropathy - Autonomic.................................................................38D6.0 Renal Disease...................................................................................40
D6.1 Screening for diabetic renal disease.........................................406.2 Definitions....................................................................................40D6.2.1 Assessment of dipstick positive patients................................41D6.2.2 Assessment of dipstick negative patients...............................41
D6.2.3 Algorithm for microalbuminuria screening in the community.....................................................................43
D6.3 A simple guide to eGFR interpretation and nephrology referral guidelines..................................................................................44
D6.4 Management of Diabetic Renal Disease...................................47D6.5 Referral for specialist renal advice............................................47
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D1.0 Blood PressureBlood pressure control is extremely important. It is as important, if not more so, than blood sugar control. Tight blood pressure control in patients with hypertension and Type 2 diabetes achieves a clinically important reduction in the risk of deaths related to diabetes, complications related to diabetes, progression of diabetic retinopathy, and deterioration in visual acuity. (Conclusion of UKPDS 38 1998)
Reducing blood pressure needs to have high priority in caring for patients with diabetes. The target BP in diabetes is ≤ 130/80.In patients with diabetes and kidney disease blood pressure should be reduced to the lowest achievable level to slow the rate of decline of glomerular filtration and reduce proteinuria.
The ‘standard’ guidance of blood pressure management as described by the British Hypertension Society applies to all patients (http://www.bhsoc.org/Latest_BHS_management_Guidelines.stm).
Management specific to diabetes is contained in:
NICE clinical guideline 66 - Management of Type 2 diabetes (Section 1.8)
SIGN 116 – Management of diabetes 2010 (sections 8.3.2 and 9.5.3)
D1.1 SIGN 116 Antihypertensive therapyBlood pressure (BP) lowering in people with diabetes reduces the risk of macrovascular and microvascular disease. Hypertension in people with diabetes should be treated aggressively with lifestyle modification and drug therapy.The lowering of blood pressure to 80 mm Hg diastolic is of benefit in people with diabetes. In the Hypertension Optimal Treatment (HOT) study, the lowest incidence of major cardiovascular events in all patients occurred at a mean achieved diastolic blood pressure of 82.6 mm Hg and further reduction below this blood pressure was safe in patients with diabetes. There was a 51% reduction in major cardiovascular events in the BP target group ≤80 mm Hg compared with the target group ≤90 mm Hg (p=0.005).Target diastolic blood pressure in people with diabetes is ≤80 mm Hg.In the HOT study, although diastolic BP was accurately measured, systolic BP was consistently underestimated. The reported achieved systolic BP of 139.7 mm Hg in patients with a diastolic target of ≤80 mm Hg is likely to have been closer to 146 mm Hg. In the UKPDS, the achieved systolic BP of 144 mm Hg in patients allocated to ‘tight control’ was observed when aiming for a systolic BP of <150 mm Hg. The long term follow up of these patients emphasised the need for maintenance of good blood pressure control. In an epidemiological analysis, lowest risk was observed in those with a systolic BP <120 mm Hg.SIGN 97 recommends that the target systolic blood pressure for patients with diabetes should be <130 mm Hg.Target systolic blood pressure in people with diabetes is <130 mm Hg.
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When starting antihypertensive treatment, calcium channel blockers, diuretics and ACE inhibitors are equally effective. There was no significant difference in outcome among the three treatment groups in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). A subgroup analysis of ALLHAT found an increase in heart failure in the patient group treated with alpha blocker as first line compared to a diuretic although this may simply reflect an increase in ankle swelling prevalence (RR of heart failure in patients with diabetes 1.85, 95% CI 1.05 to 2.55).The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) found that amlodipine (a calcium channel blocker) based treatment (with an ACE inhibitor as an add-on treatment) reduced the incidence of total cardiovascular events and procedures compared with an atenolol (beta blocker) regimen (with a thiazide diuretic as an add-on treatment) (HR 0.86, CI 0.76 to 0.98, p=0.026).This study is also included in a meta-analysis of eight trials comparing beta blockers and other antihypertensive agents on cardiovascular outcomes which showed increased CV mortality in those treated with beta blockers in comparison with those treated with renin-angiotensin blockade agents. There is evidence from two studies for the use of a combination of ACE inhibitor and diuretic. Compared to placebo, ACE inhibitor and diuretic in one study reduced blood pressure (5.6/2.2 mm Hg) and the relative risks of all deaths, cardiovascular deaths and major vascular events by 14% (p=0.025), 18% (p=0.027) and 9% (p=0.041) respectively, no matter the initial BP level.A second study found that ACE inhibitor and diuretic reduced BP by 9.5/4.6 mm Hg compared to placebo. The reduction in risk of further stroke for those with diabetes was 38% (95% CI 8 to 58%) equivalent to one stroke avoided for every 16 patients treated for five years.Angiotensin-II receptor blockers (ARBs) are equally effective alternative antihypertensive agents in patients with ACE inhibitor-induced cough or rash. They also have similar renal benefits in patients with microalbuminuria.The British Hypertension Society A/CD algorithm has been accepted as the best method of defining combination drug therapy. It specifies the use of ACE inhibitors (or ARBs if intolerant), calcium channel blockers and thiazide-type diuretics. The A/CD algorithm can be found in SIGN 97: Risk estimation and the prevention of cardiovascular disease.Patients with diabetes requiring antihypertensive treatment should be commenced on:
o an ACE inhibitor (ARB if ACE inhibitor intolerant), oro a calcium channel blocker, oro a thiazide diuretic.
Beta blockers and alpha blockers should not normally be used in the initial management of blood pressure in patients with diabetes.
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D2.0 Cardiovascular disease and diabetes
Atherosclerotic macro-vascular disease is the major cause of morbidity and mortality in people with diabetes mellitus. The increased risk of angina, myocardial infarction, transient ischaemic attacks (TIAs), stroke disease and peripheral arterial disease is related to relative hyperglycaemia over a prolonged period of time.
For example diabetes is associated with a two to three-fold increased risk of coronary heart disease in men and in pre-menopausal women with longstanding diabetes the risk is increased four to five-fold.
Any additional risk factor further magnifies the risk i.e. smoking, hypertension, hyperlipidaemia, microalbuminuria/ proteinuria, obesity, ethnicity or family history of premature vascular disease.
D2.1 ScreeningAll people with diabetes aged over 18 should have their risk factors for cardiovascular disease assessed as part of the annual screening process:
History and examination as appropriate.
Smoking habit – SectionB3.5
Blood pressure –Section D1
Lipid levels – Section D2.3 page 135
Urinary microalbumin / proteinuria screen – Section D6
Diet/ Weight /BMI or waist circumference – Section A4.1
Physical activity level – Section B3.3
Glycaemic control – Section C
Intervention for these modifiable risk factors should be discussed with all patients and implemented as appropriate – see relevant sections.
D2.2 Specific cardio-protective therapyGeneral guidance on cardiovascular risk reduction is covered in depth in:
JBS 2: Joint British Societies’ Guidelines On Prevention Of Cardiovascular Disease In Clinical Practice (Prepared by: British Cardiac Society, Diabetes UK, British Hypertension Society, HEART UK, Primary Care Cardiovascular Society, The Stroke Association) http://www.bcs.com/download/651/JBS2final.pdf
SIGN 97 – Risk reduction and the prevention of cardiovascular disease 2007
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Management specific to diabetes is contained in:
SIGN 116 – Management of diabetes 2010
NICE Clinical Guideline 66 - Management of Type 2 diabetes (Section 1.9)
As well as addressing lifestyle risk factors , specific therapies to reduce the cardiovascular risk should be offered to the following individuals, after informed discussion between the individual and responsible clinician, unless contraindicated:
D2.3 Lipids
JOINT STATEMENT ON THE USE OF LIPID REGULATING DRUGS IN GRAMPIAN - November 2010
GENERIC SIMVASTATIN 40mg IS THE PREFERED INITIAL AGENTTHE OPTIMUM DOSE IS REGARDED AS 40MG AT NIGHT
Why has guidance otherwise changed?
Whilst simvastatin remains the preferred agent Atorvastatin can be used after initial treatment failure or unacceptable side effects with simvastatin. Rosuvastatin should be reserved for third line use. The risks and benefits of treatment should be discussed with the patient including the risk of side effects that can be increased by some drugs (see BNF) and medical conditions (e.g. renal failure). In such cases closer monitoring may be required. FOR PATIENTS WITH ESTABLISHED VASCULAR DISEASE:
An initial dose of simvastatin 40mg at night is recommended for most patients. Simvastatin 80mg is routinely not recommended in view of significant adverse effects.
If patients are complying with therapy and targets cannot be achieved on 40mg simvastatin, then a switch to atorvastatin 20 mgis recommended. .
Fibrates can be used when a patient is intolerant of any statin. Ezetimibe is not on the Grampian formulary but can be used as
monotherapy where patients cannot tolerate either statin or fibrate. It is not licensed for addition to fibrates.
If triglycerides (or initial total cholesterol) are >10mmol/litre then expert advice should be obtained.
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IN PRIMARY PREVENTION Diabetic patients over the age of 40 should be treated following the
'established disease' recommendations in the previous section; younger diabetic patients should be considered for primary prevention.
Drug therapy should now be routinely used for individuals with a risk >20% over 10 years. This assessment should be based on risk tables and not on cholesterol levels alone. Simvastatin 40mg at night is the recommended therapy.
There is no evidence for further dose titration and it is not a requirement of QoF.
Focused attention to improving general lifestyle measures is always an essential component of primary prevention.
There is currently no robust outcome data for the use of either fibrates or ezetimibe although pragmatically they could be used with discretion.
If cholesterol or triglycerides are >10mmol/l then expert advice should be obtained.
Lipid Management specific to diabetes is contained in:
SIGN 116 – Management of diabetes 2010 (Section 8.3.2 and 8.4.7)
NICE clinical guideline 66 – Management of Type 2 diabetes (Section 1.10)
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D3.0 Eye Care, Screening and Treatment
D3.1 Eye screening The Grampian Diabetes Retinal Screening Programme undertakes screening for diabetic retinopathy within Grampian Region. Any patient registered with diabetes on a GP software system in NHS Grampian will be automatically called for eye screening. Any person with diabetes can be excluded from eye screening through SCI-DC. All patients with diabetes are offered appointments at the discretion of their General Practitioner. Patients unable to co-operate with examination or who have no perception of light in either eye should not be offered screening. However it may be appropriate that these patients are referred directly to the ophthalmology department for review. All other patients should be invited to attend, including those registered blind as, despite the terminology, many still have useful remaining vision. In particular the commonest causes of blindness in people with diabetes are age-related macular degeneration and diabetic macular oedema. Screening is still essential to look for new-vessel formation that could affect their remaining peripheral vision.
Patients who attend Ophthalmology Clinics for reasons other than monitoring or management of their diabetic eye disease should still be encouraged to attend for retinal screening.
Screening criteria
Who People with diabetes aged 12 years or over When Refer at diagnosis. Screen at least annually*. Where Will vary according to local arrangements.
By Whom Routine screening by Diabetes Retinal Screening Programme. How Digital retinal imaging
*Ophthalmologists or the Retinal Screening Programme may undertake repeat examination more frequently in certain high-risk groups. In pregnancy retinal examination should be undertaken in each trimester.
Defaulters Screen opportunistically by whoever sees them - diabetologist, optometrist, general practitioner.
Should have visual acuity (with glasses or pinhole) recorded and either non-mydriatic retinal photography or direct ophthalmoscopy with mydriasis (1% tropicamide).
Documentation Methodology and findings should be reported according to the Scottish Diabetic Retinopathy Grading System – details in Appendix 5.
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Frequency of screening Patients will be recalled at least on an annual basis for screening for diabetic retinopathy. Those with referable retinopathy or referable maculopathy will be referred on to the ophthalmology service.Those patients will moderate retinopathy or observable maculopathy will be rescreened at a 6 month interval.
Obtaining individual patient results
Patients diabetic retinal screening outcomes and retinal images may be accessed and shown to your patients via the SCI-DC Network system – see section on Information Technology (B 4.0, Figure 8; D 3.8).
D3.2 Mydriasis Patients who are attending the Grampian Diabetes Retinal Screening Programme will not routinely have their pupils dilated unless it is not possible to get a gradeable image with digital photography. If dilation is required, 1% Tropicamide should be used. This may cause blurring of vision and affect the ability to drive or operate machinery for up to four hours, and patients should be appropriately warned.
Glaucoma, whatever form, is not a contraindication to mydriasis.
Contact lenses do not need to be removed.
D3.3 Medical treatment Tight blood pressure control has a dramatic effect on the progression of eye disease and the prevention of visual impairment. It is always strongly advised. Tight glycaemic control also has a beneficial effect on the progression of eye disease and the prevention of visual impairment. In some patients however if control is tightened up too quickly this can lead to progression of retinopathy. In patients with no retinopathy or only mild background changes this usually manifests itself as the development of cotton wool spots. These are of no consequence and will often disappear. In patients with severe background or worse retinopathy rapid tightening of glycaemic control can lead to rapid progression to high-risk proliferative retinopathy.
If the patient’s retinopathy status is unknown and they are poorly controlled then they should be referred to the Grampian Diabetes Retinal Screening Programme for assessment, if possible, prior to tightening up of glycaemic control.
As it takes years for the complications of diabetes to occur, it would seem prudent for glycaemic control to be improved gradually over 6-12 months in such at risk patients.
Opportunistic retinal examination for chronic defaulters from Retinal Screening/Ophthalmology review, should be undertaken prior to discharge from hospital.
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D3.4 Laser treatment Laser treatment is very effective at treating proliferative (new vessels) retinopathy and will prevent the majority of people developing significant visual impairment.
Laser treatment is less effective at treating patients with maculopathy (changes affect the centre of vision) but attention to blood pressure and glucose control can make a significant impact in preventing deterioration.
D3.5 Diabetic eye screening guidelines - classification and action
D3.5.1 Visual acuity
Normal corrected visual acuity Action Review visual acuity annually
Visual acuity worse than 6/9 in the worst eye
Stable or previously explained
Action Review visual acuity annually
Deteriorating (by 2 or more lines) or previously unexplained
Action Ask patient to attend their own Optometrist for refraction and if vision cannot be improved then consider reason unrelated to diabetic retinopathy (e.g., cataract, chronic amblyopia, senile macular degeneration). Refer to ophthalmologist as appropriate
Diabetic retinopathy. Macular oedema may present with no specific fundoscopic change.
Action Refer to ophthalmologist
D3.6 Fundoscopy Ophthalmoscopy is an alternative method to photography for examining the retina. The Health Technology Board for Scotland recognises that indirect ophthalmoscopy using a slit-lamp is sensitive and specific enough for retinal screening but notes that it carries the disadvantage that there is no permanent record of the image for quality assurance or for monitoring progressive changes. However, this technique will be essential for screening failures of digital photography. Direct ophthalmoscopy has high specificity but its sensitivity is too low to form the basis of a national screening programme. Direct ophthalmoscopy still has a role though in opportunistic screening for those who persistently default from the systematic national programme.
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D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1 This system is used for screening by the Grampian Retinal Screening Programme or opportunistically. The Grampian Retinal Screening Programme will initiate appropriate onward referrals or review schedules.
Retinopathy Description Outcome R0 (no visibleretinopathy)
No diabetic retinopathy anywhere Rescreen 12 months
R1 (mild) Background diabetic retinopathy BDR – mild The presence of at least one of any of the following features anywhere
dot haemorrhages microaneurysms hard exudates cotton wool spots blot haemorrhages superficial/ flame shaped
haemorrhages
Rescreen 12 months
R2 (observablebackground)
Background diabetic retinopathy BDR - observableFour or more blot haemorrhages (ie _AH standardphotograph 2a – see below) in one hemi-field only (Inferiorand superior hemi-fields delineated by a line passingthrough the centre of the fovea and optic disc)
Rescreen 6 months (or refer to ophthalmology if this is not feasible)
R3 (referablebackground)
Background diabetic retinopathy BDR – referableAny of the following features:
Four or more blot haemorrhages (ie AH standard
photograph 2a – see below) in both inferior and superior
hemi-fields Venous beading (AH standard
photograph 6a – see below) IRMA (AH standard photograph 8a –
see below)
Refer ophthalmology These patients maybe kept undersurveillance and willnot necessarilyreceive immediatelaser treatment.
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R4 (proliferative)
Proliferative diabetic retinopathy PDRAny of the following features:Active new vesselsVitreous haemorrhage
Refer ophthalmology These patients arelikely to receive laser treatment or anotherintervention.
R5 (enucleated)
Enucleated eye Rescreen 12 months (other eye)
R6(inadequate)
Not adequately visualised :Retina not sufficiently visible for assessment
Technical failureArrange alternativescreeningexamination. This will be automatic within the screeningprogramme.
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Photo 2a Photo 6a Photo 8a
All photographic images in relation to Diabetic Retinopathy grading outcomes can be viewed at http://eyephoto.ophth.wisc.edu/ResearchAreas/Diabetes/DiabStds.htm
Maculopathy Description Outcome M1 (Observable)
Lesions within a radius of > 1 but ≤ 2 disc diameters of the centre of the fovea
Any hard exudates
Rescreen 6 months (or refer to ophthalmology if this is not feasible)
M2(Referable)
Lesions within a radius of ≤ 1 disc diameter of the centre of the fovea
Any blot haemorrhages Any hard exudates
ReferophthalmologyThese patients maybe kept undersurveillance and willnot necessarilyreceive immediatelaser treatment.
Coincidental findings
Description Outcome
Photo-coagulation
Laser photocoagulation scars present
Other Other non-diabetic lesion present Pigmented lesion (naevus) Age-related macular degeneration Drusen maculopathy Myelinated nerve fibres Asteroid hyalosis Retinal vein thrombosis
Grading note This grading scheme is not intended to be done by levels. It is meant to be done by features. The grader reports the presence or absence of each of the following features for each hemisphere and then derives the level for the
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individual eye:
← • Dot haemorrhages or microaneurysm ← • 4 or more blot haemorrhages (i.e. ≥ standard photography 2a) ← • Venous Beading (≥ AH standard photograph 6a) ← • IRMA (≥ AH standard photograph 8a) ← • New vessels ← • Vitreous haemorrhage
D3.8 Obtaining individual patient results
Retinal screening results and images may be accessed using SCI-DC.
Grading outcomes at top of page, scroll down to see retinal image
Click here to view patient’s retinal images
Click on ‘eye screening images to access retinal images
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Please refer to IT section regarding call/recall process.
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D 4.0 Foot Care, Screening and Treatment
D 4.1 Foot ScreeningThe chief factors responsible for foot problems in the diabetic foot are
neuropathy and ischaemia, often a combination of the two, with infection as
both a provoking and complicating factor. Diabetic foot screening is beneficial
in identifying the level of risk of developing foot ulceration in patients with
diabetes. It is important to enable appropriate management patients with
diabetes; Absence of symptoms should not be taken as an indication of
absence of risk.
All patients with diabetes should be screened at diagnosis and
annually thereafter to assess their level of risk. (SIGN 116)
The result of foot screening examination should be entered onto SCI
DC foot screening tool. This will provide automatic risk stratification
and a recommended management plan. See appendix 1 (SIGN 116)
Foot screening in Grampian will be provided by NHS Grampian
Integrated Screening Service or at practice level.
Only suitably-trained healthcare professional will carried out foot
screening. Training will be provided by NHS Grampian podiatry
department using the SCI DC foot screening tool. Contact details from
NHS Grampian Diabetes MCN website. The use of a calibrated 10g Monofilament is essential.
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D4.1.1 SCI-DC Foot Screening Tool
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D4.1.2 Annual Diabetic Foot Screening
Annual Diabetic risk assessment at GP Practice
Education
Draft Guideline – 25 September 2008
D4.1.3 Diabetic Foot Risk Stratification and Triage “Traffic Lights”
Draft Guideline – 25 September 2008
D4.2 Management guidelines for Charcot neuroarthropathy in people with diabetes
Charcot neuroarthropathy of the foot is a neuroarthropathic process with osteoporosis, fracture, acute inflammation and disorganisation of foot architecture, During the acute phase it can be difficult to distinguish from infection (SIGN 116, 2010)
Clinical featuresDiabetes patient presents with red, oedematous, hot and possibly painful foot in the absence of infection.Usually bounding pedal pulses with evidence of impaired neurological testing.
Diagnosis / Investigations
Diagnosis should be made by clinical examination. (SIGN 116, 2010, Frykberg et al 2000; Jeffcoate et al 2000) Post-diagnosis thermography can be used to monitor the disease activity. (SIGN 116, 2010)
Usually a good blood supply to lower limb with degree of neuropathy Observe foot for obvious signs of tissue trauma, cellulites or systemic
toxicity to rule out infection History of trauma to limb may be present Heat differentiation between limbs -affected limb often 2-8 degrees
higher than the contra lateral foot Blood test- HbA1c, ESR and C-reactive protein X-Ray for baseline and to exclude diabetic neurophathic fracture MRI can be used to detect early changes of Charcot neuroarthropathy
which cannot be detected by x-ray
Management
Suspected Charcot neuroarthropathy is an emergency and should be referred immediately to the Multidisciplinary Foot Clinic. (SIGN 116, 2010, NICE 2004)
Total Contact Casting or a prefabricated walker rendered irremovable with a total contact insole and non weight bearing are effective treatment for patients with Charcot neuroarthropathy.
Off loading device usually worn until inflammation settles, heat differentiation disappears and bone activity reduces.
Patients require comprehensive education on the causes, management and prevention of complications associated with Charcot neuroarthropathy
There is insufficient evidence to support the routine use of Bisphosphonates in the acute Charcot neuroarthropathy (SIGN 116, 2010)
Draft Guideline – 25 September 2008
Contact details of the Multidisciplinary Foot Clinics are available on the NHS Grampian Diabetes MCN website. Alternatively referral can be made via local Diabetes Podiatrist.
PHIL 1 Charcot Foot Leaflet .PDF
D4.3 Diabetic Foot Ulceration and Wound Management
5-7% of all people with diabetes will by affected by a foot ulcer at some point during their lives. Diabetic foot ulcers are a major reason for hospitalisation and account for more than two-thirds of non-traumatic lower limb amputations performed. A unified approach to foot care management is essential. No one health care professional should deal with this problem. It continues to be a challenge to diabetic medicine and requires a multi-disciplinary approach. (SIGN guideline 116, 2010,Section 11)
Urgent referral to a Diabetes Podiatrist (by telephone or fax followed by a written referral) is the most appropriate route for patients with a diabetic foot ulcer and possible soft tissue infection. (Please refer to NHS Grampian Diabetes MCN website for contact details of Diabetes Podiatrist).
D4.3.1 Care Pathway for Active Diabetic Foot Ulceration
Patients with active diabetic foot disease should be referred to a multidisciplinary diabetic foot care service. (SIGN 116, 2010)
If the referral is urgent please contact by telephone or fax followed by a written referral to the multidisciplinary diabetic foot care service via the diabetes podiatry team. (Please refer to NHS Grampian Diabetes MCN website for contact details of Diabetes Podiatrist).
Draft Guideline – 25 September 2008
Care pathway for Active Diabetic Foot Disease
Refer to Diabetes Podiatristsfor
(Contact details available from NHS Grampian Diabetes MCN website www.diabetes.nhsgrampian.org ) Assessment of patient Immediate pressure relief Referral to members of the
multidisciplinary foot team Referral to M.A.R.S. for a managed
program of pressure relief.
Is infection present?
Contact GP for commencement of antibiotic cover
Take a wound swab and send to microbiology
Active foot disease - Def: Active foot disease may be either of recent onset or chronic but deteriorating. The term refers to anyone with diabetes who has:
o An ulcer, blister or break in the skin of the footo Inflammation or swelling of any part of the foot, or any sign of
infectiono Unexplained pain in the footo Fracture or dislocation in the foot with no preceding history of
significant trauma
Determine the cause e.g. trauma, neuropathic, ischaemic or neuroischaemic.
Determine current vascular and neurological status. Assess wound and record all findings e.g. duration of wound, size, depth, appearance etc.
Draft Guideline – 25 September 2008
D4.3.2 Referral Pathway for Pressure Relief
Active Diabetic Foot Disease
Refer to Diabetes Podiatrist for
Initial Pressure relieving device
Appropriate referral to Orthotist at Mobility and Rehabilitation Service (MARS) for
Assessment of a managed program of pressure relief
(Contact details for Diabetes Podiatrist’s are available from NHS Grampian Diabetes MCN website
www.diabetes.nhsgrampian.org)
Draft Guideline – 25 September 2008
ControlledControlled
Uncontrolled
Refer to Consultant Diabetologist
Uncontrolled
D4.3.3Painful Diabetic NeuropathySymptoms of neuropathy or neuropathic symptoms present at annual check (e.g. Pain (burning, shooting or electrical
quality), dysthesia and paraesthesia (e.g. crawling, itching, numbness, tingling), sensory loss or allodynia)
Investigations- Check Vitamin B12 , Immunoglobulin, Thyroid function, Creatinine,. Optimise HBA1c and blood pressure Encourage all patients with diabetes who smoke to stop.
Assess severity of symptoms. Severe symptoms can cause e.g. sleep disturbance, interference with normal activity etc
Consider trial of:- Simple analgesia - Capsaisin Cream 0.075% (under specialist supervision)- Opsite, bed cradle
Consider Medication (see following page)
Non-severe Severe
Continue annual checks.Monitor for worsening or
remission.
Consider referral to Diabetes Podiatrist
Draft Guideline – 25 September 2008
MEDICATION FOR PAINFUL DIABETIC NEUROPATHY
AMITRIPTYLINEUnlicensed for this indication, but adult dose initially of 10 mg at night, gradually increased if necessary to 75mg; higher doses under specialist supervision.1
GABAPENTINAdult dose: 300mg once daily on day 1, then 300mg twice daily on day 2, then 300mg three times daily of day 3 or initially 300mg three times daily on day 1, then increased according to response in steps of 300mg (in 3 divides doses) every 2-3 days up to max 3.6g daily. 1
TRAMADOLIn combination with gabapentin should be considered for the treatment of patients with painful diabetic neuropathy 1,3
Adult dose: 50-100mg not more than every 4 hours, total of more than 400mg daily not usually required. 1
DULOXETINE60mg once daily, increased to a max of 120mg in divided doses.1 May be initiated under specialist supervision as second or third line therapy.2
PREGABALINIt should be restricted to use in patients who have not achieved adequate pain relief from, or have not tolerated, conventional first- and second-line treatments for peripheral neuropathic pain. Treatment should be stopped if the patient has not shown sufficient benefit within 8 weeks of reaching the maximally tolerated therapeutic dose. Available for restricted use under specialist supervision.2
Dose for adult over 18 years of age: initially 150mg daily in 2-3 divided doses, increased if necessary after 3-7 days to 300mg daily in 2-3 divided doses, increased further if necessary after 7 days to max. 600mg daily in 2-3 divided doses . 1
References1. BNF 61, March 20112. Grampian Joint Formulary3. SIGN Guideline 116: Management of Diabetes
Draft Guideline – 25 September 2008
D 4.4 Good practice guidance for the use of antibiotics in patients with diabetes foot ulcers
This document has been endorsed by the Scottish Diabetes Group on behalf of the Scottish Government, and is recommended for use as National guidance.
D 4.4.1 INTRODUCTION
The following is guidance to help health-care professionals to make decisions that will improve outcomes for their patients. This is a consensus document based on limited available clinical trial evidence, review of international guidelines and expert opinion. There may be circumstances where alternative courses of action may be appropriate.
Guidance about antibiotic choice is primarily dependent on local microbiological epidemiology and susceptibility patterns. However, the consensus group felt that the pathogens causing infection in Scotland for the various diabetic foot infection clinical syndromes are unlikely to vary substantially within Scotland. Therefore there is some merit in providing broad practical guidance about antibiotic choice but this should be subject to local adaptation if necessary.
D 4.4.2 GENERAL APPROACH TO FOOT ULCERS
Team Approach All patients with diabetes and foot ulcers should be managed in a
multidisciplinary foot-care setting. Previous ulceration is the strongest predictor for further ulceration. Thus, after healing, preventative measures need to be addressed. Attention to aggressive treatment of macrovascular risk factors in patients with foot ulcers has been shown to prolong survival.
Specimens for Culture It is debated whether ulcers with clinical signs of infection should have
a specimen taken for culture at outset. If not then cultures should be taken if there is clinical failure of empirical antibiotics. Aspiration of purulent secretions, curettage of debrided wound base, punch biopsy and exuded bone are the best specimens to obtain. Keep in mind that in foot ulcers what maybe cultured as mixed growth, doubtful significance , unusual organisms maybe of great significance and warrant therapy to achieve healing.
Loose Bone Loose bone exuded from an ulcer, or any bone debrided should be
sent for bone culture and microbiological assessment. The extrusion of a bone fragment (sequestrum) is highly suggestive of underlying osteomyelitis although the infection may have arrested coincident on the passage of the sequestrum.
Draft Guideline – 25 September 2008
Investigation of Osteomyelitis If concerned about osteomyelitis, Plain X-ray is the usual initial
investigation of choice. However, the X-ray can be normal for 2 weeks before any changes are seen, and thus serial X-rays may be required. If there is ongoing concern then the secondary investigations of choice are (in order of preference): MRI > Isotope White cell Scan > Triple phase Bone scan. The isotope bone scan is relatively sensitive at diagnosing osteomyelitis, but is not specific, and can remain positive for over one year. The white cell scan may be difficult to obtain in some areas. Choice of test may be dictated by local availability.
“Probe to Bone” Inability to touch bone when probing a wound with a sterile metal
probe, makes osteomyelitis very unlikely, with a negative predictive value of about 90%. The positive predictive value of a positive probe to bone test is only around 50%, which means that ulcers that probe to bone frequently do not have osteomyelitis.
“Sausage Digit” The presence of a red swollen “sausage” digit is suggestive, of
osteomyelitis, but can be consistent with other causes such as fracture.Differentiating Osteomyelitis and Charcot
This can be difficult, and is based on taking a good history and examination with supplementary evidence from MRI and other investigations. Osteomyelitis and Charcot foot can frequently occur simultaneously.
Foot Ulcer Classification Various Ulcer classification schemes can be used (Wagner, Texas,
SINBAD, PEDIS). The SCI-DC electronic ulcer management programme is based on the Texas scheme (figure 1)
Classification of Infection It is recommended that the presence and severity of infection can be
classified according to the Infectious Disease Society of America (IDSA)/ International Working Group for the Diabetic Foot (IWGDF) classification (table 1).
Table 1 (Lipsky et al, Clinical Infectious Diseases 2004: 39: 885-910: IDSA guidelines)
SEVERITY OF INFECTION DESCRIPTION1. NO INFECTION
2. MILD (GRADE 2)Either:
a) 2 or more features of inflammation: Pus; Erythema; Pain; Tender; Warmth; Induration
Orb) Cellulitis < 2cm. Confined to skin or subcutaneous tissue.
No systemic illness.
3. MODERATE (GRADE 3). Above withEither
Draft Guideline – 25 September 2008
a) lymphatic streaking, deep tissue infection (subcutaneous, fascia, tendon, bone), abscess,Or b) Cellulitis >2cm
(but with no systemic illness)
4. SEVERE (GRADE 4). Any infection with systemic toxicity (fever, shock, vomiting, confusion, metabolic instability). Presence of critical ischaemia may make the infection severe.
Draft Guideline – 25 September 2008
D 4.4.3. GENERAL PRINCIPLES OF ANTIBIOTIC USE (see below for specifics)
Antibiotic choice is primarily dependent on local microbiological susceptibility and epidemiology. However antibiotics often need to be started before this information is available. As the pathogens in diabetic foot infections do not vary significantly in Scotland, the consensus group recommends broad practical guidance about antibiotic use. These are however subject to changing local epidemiology and prescribing policy.
Initial treatment is frequently empirical based on the presumed pathogen; see table 2 and 3.This guidance is of value until microbiological and clinical response shed further light.
The choice of antibiotic, agent and route of delivery, should reflect the severity of infection as reflected by the IDSA/IWGDF definition– see table 1.
The duration of antibiotic use should be adjusted according to the severity of infection (table) and can be guided by monitoring clinical improvement. In general duration of antibiotic therapy should be kept short, but the dose used should be high dose.
In light of international concerns over the risk of C.difficile associated with broad spectrum antibiotics (especially clindamycin, co-amoxiclav, cephalosporins and quinolones) and MRSA risk (associated with co-amoxiclav, cephalosporins and quinolones and macrolides) narrow spectrum therapy should be used wherever possible. C.difficile is a particular risk for patients aged over 65years and in-patients. Adjustment of therapy based on microbiology results, when available, is important. These agents should be used where indicated empirically I this specialist foot ulcer advice or by sensitivities to achieve foot ulcer healing, even if conflicting with general advice on antibiotic selection.
Allergies to antibiotics refer to skin rash or anaphylaxis. This does not include minor side-effects such as nausea.
Enterococci, Pseudomonas and anaerobes are frequently grown as colonising organisms, rather than infecting organisms. If however there is a chronic persisting infection or they are the predominant organisms, they may be more important, and need treatment.
This document provides general advice, but direct contact with local specialists may be necessary in certain circumstances for advice with regard to more specialised use of these or other antibiotics.
Draft Guideline – 25 September 2008
Figure 1.
Draft Guideline – 25 September 2008
D4.4 SPECIFIC ANTIBIOTIC GUIDANCE (see Table 2 for summary)
For different clinical syndromes the likely microbiology and therefore initial antibiotic can be predicted with some degree of confidence although there will on occasions be unusual circumstances. We emphasize the importance of getting good quality specimens (see above) for microbiology and of close liaison with the local infection specialist. Main choice antibiotics in blue and alternatives in green are provided. The advice given is for empirical choices of antibiotics. If there is local guidance based on local sensitivities, then this should take precedent.
4.4.1 Mild infection (IDSA) or (PEDIS 2) and the patient is antibiotic naïve.
Likely pathogens are S.aureus (coagulase-negative Staphylococcus) or beta-haemolytic streptococci. If previously treated with antibiotics, enterococci and gram negative rods (GNRs) are likely to be present.
Oral flucloxacillin 1g qds. Oral Alternatives Doxycyline 100mg bdClindamycin 300-450mg qds, if the patient is allergic to or intolerant of flucloxacillin.
A second course of flucloxacillin is rarely effective if the first course has been unsuccessful, assuming that the first course was given in high dose and for a full 5-7 days. There is an increased prevalence of resistant organisms after the first exposure to flucloxacillin.Treat for 5-7 days and then decide about further antibiotics depending on clinical response and microbiological culture. Ensure microbiological culture if unusual organism suspected, or initial treatment fails.
4.4.2a Moderate (IDSA) or PEDIS 3 and the patient is antibiotic naïve.
Good quality microbiological culture is usually helpful in these circumstances. Likely pathogens are S.aureus or beta-haemolytic streptococci. Those with limb ischaemia, gangrene, necrosis or a foul odour from the wound often have obligate anaerobic pathogens.
Oral flucloxacillin 1g qdsOral Alternatives:Co-trimoxazole 960mg bdCo-amoxiclav 625mg tdsClindamycin 300-450mg qds or co-trimoxazole, if the patient is allergic to penicillins. Add in oral metronidazole 400mg tds if anaerobes suspected
Draft Guideline – 25 September 2008
IV flucloxacillin 1g qds. If IV route for clindamycin is needed then use 450-600mg qds.
Draft Guideline – 25 September 2008
4.4.2b Moderate (IDSA) (or PEDIS 3) and the patient is NOT antibiotic naïve. Patients with chronic infections, especially if they have received antibiotics previously often have polymicrobial infections, including aerobic gram-negative bacilli among the flora. a) IV co-amoxiclav 1.2gtds – especially if anaerobes or coliforms suspected Oral switch option is oral co-amoxiclav 625 tds orCo-trimoxazole 960mg bd
If the patient is allergic to penicillins consider:b) IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds ± vancomycin (if MRSA considered likely)OrIV gentamicin* and IV metronidazole ± vancomycin (if MRSA considered likely)The choice will depend on the relative risks of C.difficile versus those of renal impairment.* The dosing of gentamicin is high dose once daily and should be determined by local practice and will require close monitoring of serum levels and renal function. Gentamicin dosing for more than 48 hours should only be continued with specific advice from the infection specialist.
Oral switch option is oral ciprofloxacin 500- 750mgbd with oral metronidazole 400mg tds, or oral ciprofloxacin 500- 750mg bd and clindamycin 300-450mg qds
Treat for 7 days. Adjust therapy in light of clinical response and results of culture and sensitivity results.
4.4.3a Severe infection (IDSA) (or PEDIS 4), antibiotic naïve. High quality culture (see section 2) is usually helpful in these circumstances. The likely pathogens are S.aureus or beta-haemolytic streptococci but may need to cover also for anaerobes and enterobacteriacea and Pseudomonas aeruginosa. Caution: Pseudomonas is usually a coloniser rather than being an infecting organism. As grade 4 infection implies systemic toxicity, it is generally advised that such patients should be admitted to hospital for the initial phase of management.
IV co-amoxiclav 1.2gtds +/- gentamicin 5-7mg/kg once daily or as per local practice. . Gentamicin dosing for more than 48 hours should only be continued with specific advice from the infection specialist If the patient is allergic to penicillins or there is concern about renal function consider IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds. ± vancomycin (if MRSA considered likely)
Treat for a minimum of 10-14 days
Draft Guideline – 25 September 2008
4.4.3b Severe infection (IDSA) (or PEDIS 4) and the patient is not antibiotic naïve and has risk factors for drug resistant infection
Previous antibiotics within last 90 days, recent hospitalisation/s for more than 2 days within last 90 days, previous colonisation or infection with resistant organism e.g MRSA or Extended Spectrum Beta-Lactamase (ESBL) producing E.coli or Klebsiella spp) or proven resistant infection
IV piperacillin/tazobactam (tazocin) 4.5g tds ± vancomycin if MRSA suspected (consult pharmacy for dose but aim for a trough vancomycin level of 15-20mg/l). If penicillin allergy IV ciprofloxacin 400mg bd and add IV metronidazole 500mg tds.
Oral switch options in these patients are best guided by microbiology where possible. Otherwise, try oral ciprofloxacin 500- 750mg bd and metronidazole 400mg tds.
If extended spectrum beta-lactamase (ESBL) producing coliform is proven then seek specialist infection advice.
Treat for minimum of 10-14 days, then review need for antibiotic.
If continuing MRSA cover is required and the patient can be discharged from hospital we suggesteither outpatient and home parenteral antimicrobial therapy (OHPAT) if available (usually given iv teicoplanin)or oral linezolid is an option but treatment beyond two weeks needs to be monitored closely for bone marrow toxicity, particularly thrombocytopenia or leucopenia, and lactic acidosis, which are usually reversible on discontinuation of the drugRifampicin 300mg bd ANDoral doxycycline 100mg bd OR fusidic acid 500mg tds OR trimethoprim 200mg bd
The rifampicin may offer difficulties related to drug interaction [eg warfarin]. All these agents can be used in penicillin allergic patients.
At all times advice can be sought from your local podiatry team:
Contact numbers on Grampian Diabetes MCN website
Draft Guideline – 25 September 2008
4.4.5. OSTEOMYELITIS
Early local surgery to excise infected bone can help accelerate healing and reduce the length of time antibiotics are required. For other cases, antibiotic therapy will lead to resolution of infection in up to 60% to 80% of cases. The exact role of local surgery remains controversial.
The evidence base for antibiotic choice for these infections is poor. However, in general terms the group recommends that where there is evidence of osteomyelitis the treatments outlined above should be continued for at least 4-6 weeks, and sometimes longer depending on clinical response. Sometimes measurement of serial CRP’s and White cell count may help, but not more than once per week. Various antibiotics require monitoring of liver function tests, full blood count and/or serum drug levels. Rationalisation of therapy should be discussed with an infection specialist.
For MRSA osteomyelitis there is some evidence that adding rifampicin 600mg bd or Sodium Fusidate to other treatments can be beneficial
There is no evidence that IV therapy is superior to oral therapy, although in certain infections like MRSA IV therapy delivered in the OHPAT setting is attractive to enhance compliance and reduce hospitalisation.
In osteomyelitis tolerability of oral antibiotics is a significant issue and therapy may need to be tailored accordingly. If considering the use of linezolid for osteomyelitis the prescriber must be aware of its unlicensed status for this indication and of the risks of bone marrow toxicity, peripheral or optic neuropathy and lactic acidosis.
Draft Guideline – 25 September 2008
Table 2. Summary of Good practice statement on Antibiotic choice for the diabetic foot.Choices should always be guided by deep culture results when available.Treatment should be for 5-7 days (mild/moderate) to 10-14 days (severe) and then review the need for longer treatment. If osteomyelitis present then treat for at least 4-6 weeks and then review the need for longer treatment. IV antibiotics may be switched to oral preparations after an appropriate interval (see main text)
MILD Either 2 or more features of inflammation (pus, erythema, pain, tender, warmth, induration), OR Cellulitis < 2cm. Confined to skin or subcutaneous tissue. No systemic illness
MODERATE Either two or more features lymphatic streaking, deep tissue infection (subcutaneous, tendon, fascia, bone), abscess, OR b) Cellulitis >2cm
SEVERE Systemic toxicity (fever, shock, vomiting, confusion, metabolic instability)
ANTIBIOTIC NAIVE ANTIBIOTIC NAIVE ANTIBIOTIC NAIVEOral Flucloxacillin 1g qds*
Oral Fluxcloxacillin 1g qds*(for MSSA, ß-H Strep)
(Oral therapy inappropriate)
Alternatives:Doxycycline 100mg bd Clindamycin 300-450mg qds
Alternatives:Cotrimoxazole 960mg bdCoamoxiclav 625mg tdsClindamycin 450mg bd +/-metronidazole 400mg tds
IV Co-amoxiclav 1.2g tds ±Gentamicin* 5-7mg/kgIf allergic to penicillin: IV Ciprofloxacin 400mg BD & IV metronidazole 500mg tds ± Vancomycin
If NOT antibiotic naïve: If NOT antibiotic naïve: If NOT antibiotic naïve:See alternatives above IV CoAmoxiclav 1.2g tds
Alternatives:IV Ciprofloxacin 400mg tds & IV Metronidazole 500mg tds ±IV Vancomycin* (if MRSA)orIV Gentamicin & IV Metronidazole 500mg tds ± IV Vancomycin* (if MRSA)
IV Tazocin 4.5g tds + IV Vancomycin if MRSA.If allergic to penicillin see alternatives opposite
Oral switch: Ciprofloxacin 750mg bd & Metronidazole 400mg tds or Ciprofloxacin 750mg bd &Clindamycin 300-450mg qds
MRSA MRSAIV Vancomycin* IV Vancomycin* IV Teicoplanin* (Home IV service)
IV teicoplanin* (Home IV service)
Oral switch: Rifampicin* with trimethoprim or
Oral switch: Rifampicin* with trimethoprim or
Draft Guideline – 25 September 2008
doxycycline or fusidic acid* doxycycline or fusidic acid*Linezolid 600mg bd#* Linezolid 600mg bd#*
* Require monitoring. Add rifampicin 600mg bd or Sodium Fusidate if osteomyelitis#Note concerns about linezolid toxicity with protracted therapyTable 3. Empirical guide as to which organisms are likely to be the infecting organism and which antibiotics are likely to be effective.
INFECTING ORGANISM
PRIMARY GROUP OF ANTIBIOTICS
ALTERNATIVE
Staphylococcus (aureus)
Penicillinase resistant PenicillinEg Flucloxacillin
DoxycyclineClindamycin
MRSA VancomycinTeicoplanin(for other options discuss with infection specialist)
Rifampicin combined with trimethoprim or doxycycline or fusidic acid, Cotrimoxazole,Linezolid
-Haemolytic Streptococcus
Amoxicillin Clindamycin
Enterococcus Amoxicillin/co-amoxiclav Vancomycin, LinezolidPseudomonas(Gm negative bacillus)
Quinolones eg high dose Ciprofloxacin
Piperacillin-tazobactam (tazocin), meropenem
Anaerobic Metronidazole Clindamycin
BibliographyLipsky BA, Berendt AR, Deery HG. IDSA guidelines: diagnosis and treatment of diabetic foot infection. Clin Infect Dis 2004; 39: 885-910.
Lipsky BA. Empirical therapy for diabetic foot infections: are there clinical clues to guide antibiotic selection. Clin Microbiol Infect. 2007: 13: 351-3
Lipsky BA. New developments in diagnosing and treating diabetic foot infections. Diab Met Res Rev 2008; 28 (suppl 1) S66-71
Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis in diabetes. Clinl Inf Dis2004; 39 (Suppl 2): S115-22.
Game FL, Jeffcoate WJ. Primarily non-surgical management of osteomyelitis of the foot in diabetes. Diabetologia 2008; 51: 962-7.
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Specific guidelines for treatment of diabetic foot osteomyelitis Diabetes Metab Res Rev. 2008; 24 Suppl 1:S190-1
Draft Guideline – 25 September 2008
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment Diabetes Metab Res Rev. 2008; 24 Suppl 1:S145-61
D4.5 Diabetic Foot Care Patient Education
Foot care education is an integral part of any treatment plan and is recommended as part of a multidisciplinary approach in all patients with diabetes. (SIGN 116, 2010). Education is an essential element in the empowerment of people with diabetes. Patient education/information should be tailored to meet each individuals needs and should be timely, appropriate and consistent. A patient with diabetes should be given the appropriate NHS Scotland foot leaflet (according to their foot risk stratification) at their foot screening appointment.
NHS Scotland foot care leaflets include
Low Risk Moderate risk High Risk Holiday Feet Looking after your diabetic foot ulcer Advice about your footwear
Draft Guideline – 25 September 2008
D5.0 Neuropathy - Autonomic
Patients with long-standing diabetes may develop neuropathy affecting autonomic function, which may produce a number of different difficult clinical and management problems. Symptoms are often non-specific and other diagnoses should be considered and excluded, if appropriate. As many of these problems are fortunately uncommon it is appropriate to consider seeking specialist advice. The following notes give some basic advice on therapeutic approaches to a range of problems that can result from diabetic autonomic neuropathy.
Erectile dysfunction: the advent of selective inhibitors of phosphodiesterase-5 in erectile tissue has revolutionised the initial management of this relatively common problem in diabetic men. Treatment is said to be successful in more than 50% of patients. Sildenafil, Vardenafil and Tadalafil are all available on prescription for patients with diabetes; their use should be avoided in cases of severely compromised cardiovascular function and when nitrates are being taken. Where oral therapies are unsuccessful, referral can be made to a specialist ED clinic (run in Aberdeen by the Urology Department and Mr Gunn in Elgin) for consideration of intracavernosal injection of prostaglandin or vacuum devices.
Intermittent diarrhoea: especially occurring nocturnally, this problem may be a direct result of gastrointestinal neuropathy in which codeine phosphate or other antidarrhoeal agents can be helpful. Alternatively, gut dysmotility can lead to atypical bacterial overgrowth and short courses of antimicrobial agents such as tetracycline or metronidazole can be rapidly effective. [Remember also other possible causes of diarrhoea, including Metformin therapy, the possibility of coeliac disease or exocrine pancreatic dysfunction in cases of secondary diabetes].
Postural hypotension: advice on rising/standing cautiously, and avoidance of over-enthusiastic use of diuretics and hypotensive agents may be most effective. Fludrocortisone can be useful in severe cases but may lead to oedema.
Vomiting due to gastroparesis: metoclopramide or domperidone may help by promoting gastric emptying. Alternatively, Erythromycin may benefit some patients.
Gustatory sweating: fortunately uncommon; best managed by avoidance of foods found by the sufferer to exacerbate the problem. Agents, such as propantheline, may be beneficial but often have marked anticholinergic adverse effects.
Draft Guideline – 25 September 2008
Neuropathic oedema: damage to control of capillary blood flow can lead to accumulation of fluid in dependent extremities in the presence of a normal serum albumin and the absence of fluid overload. Ephedrine, an alpha-adrenergic agonist may be useful but care is required in the presence of hypertension and angina.
Bladder hypotonia: drug treatment with alpha blocking agents is difficult due to the risk of precipitating symptomatic postural hypotension.
Draft Guideline – 25 September 2008
D6.0 Renal Disease
Renal impairment is important in patients with chronic diseases or on multiple drug therapy and serum creatinine should be checked annually. Diabetic nephropathy is an important long-term complication of diabetes, which is characterised by persistent proteinuria, hypertension and a progressive decline in renal function. The absence of retinopathy or the presence of haematuria should prompt investigation for other possible forms of renal disease. A definitive diagnosis of diabetic nephropathy can be made by renal biopsy, although this is unnecessary in most cases.
Persistent proteinuria confers eighty to one hundred fold increased mortality due largely to cardiovascular disease and such patients often succumb before the need for renal support arises. Survivors with persistent proteinuria eventually progress to end stage renal failure requiring dialysis or transplantation.
Microalbuminuria is an early marker of diabetic renal disease and predicts the onset of overt nephropathy in both Type 1 and Type 2 diabetes. Microalbuminuria is also a significant independent risk factor for the development and progression of cardiovascular disease.
Aggressive management of blood pressure can retard the progression of diabetic renal disease at all stages.
SIGN 103 – Diagnosis and Management of CKD covers updated guidance for all patients. SIGN 116 has a section on diabetic renal disease.
D6.1 Screening for diabetic renal disease Who People with diabetes aged 12 years or over
When At diagnosis and annually
How Dipstick for proteinuria (Albustix or equivalent)
Microalbumin estimation if dipstick negative
eGFROutcome
Dipstick positive – see 6.2.1 – Assessment of dipstick positive patients
Dipstick negative – see 6.2.2 – Assessment of dipstick negative patients
6.2 Definitions Spot urine samples (for screening)
Albustix
Dipstick one plus or greater (>200mg/l) indicates proteinuria.
Draft Guideline – 25 September 2008
Albumin/creatinine ratio (ACR)
The ratio of urinary albumin to creatinine concentration. This is a screening test for microalbuminuria.Normal values – female <3.5mg/mmol, male <2.5mg/mmol
Timed overnight urine collections Normoalbuminuria Normal albumin excretion rate <20 µg/min Microalbuminuria Albumin excretion rate 20- 200µg/min ProteinuriaAlbumin excretion rate > 200µg/min Spot protein/creatinine ratio (PCR) > 70mg/mmol24hr urinary protein > 500mg
Patient Information Sheet: Urine Testing And Microalbuminuria
Related topicsD6.0 Renal Disease
D6.2.1 Assessment of dipstick positive patients Consider urinary infection or other non diabetic causes Repeat test Persistent proteinuria, when confirmed on two consecutive occasions,
should be quantified using a protein / creatinine ratio measurement on a spot sample.
In individuals with significant proteinuria, a PCR on a first pass morning urine specimen is preferable to a timed collection.
Review result of recent serum creatinine and blood pressure Persistent “dipstick positive” proteinuria negates the need for
measurement of microalbuminuria
D6.2.2 Assessment of dipstick negative patients Screen for microalbuminuria First voided urine sample after sleep, for albumin/creatinine ratio (ACR). Reject samples with evidence of infection. Normal (male < 2.5, female < 3.5 mg/mmol). Repeat in twelve months. Abnormal – Re-test. Urinary albumin excretion may be temporarily increased by other factors
such as intercurrent illness and exercise. Therefore it is usual to request multiple positive tests, usually two out of three, over a period of months,
Draft Guideline – 25 September 2008
before microalbuminuria is confirmed.
ACR levels persistently in excess of 10 mg/mmol always indicate an AER > 20µg/min.
Result from Klinitek 50 – both ACR <3.5 and urinary albumin concentration <10 mg/l = normal albuminuria. Repeat in 12 months.
Result from Klinitek 50 –ACR >3.5 and/or urinary albumin concentration >10 mg/l = send first voided urine to Lab for further analysis.
Patient information sheet – urine testing and microalbuminuria
Draft Guideline – 25 September 2008
D6.2.3 Algorithm for microalbuminuria screening in the community
Official annual screening from diagnosis for patients
Albustix negative
Evidence of infection
Reject
Measure Albumin / Creatinine Ratio
(ACR)
ACR > 2.5 men or > 3.5
women
Normal – re-screen in one year
Re-test first voided urinary ACR
Repeat ACR on 3 occasions. ACR +ve on at least 2 out of 3.
Persistent microalbuminuria confirmedReassess cardiovascular risk
Contraindication for ACE inhibitor or
AIIA?
BP > 125 / 75 (Type 1) ?BP > 140 / 80 (Type 2) ?
Start ACE/AIIA inhibitor, irrespective of BPAim for BP < 125 / 75 (Type 1)Aim for BP < 140 / 80 (Type 2)
Start non-ACE antihypertensiveAim for BP < 125 / 75 (Type 1)Aim for BP < 140 / 80 (Type 2)
Monitor BP
ACR > 2.5 men or > 3.5
women
First voided urine sample after sleep
Yes
No
No
No
No
Yes
YesNo
No
Yes
Yes
Yes
YesYes
Draft Guideline – 25 September 2008
D6.3 A simple guide to eGFR interpretation and nephrology referral guidelines.What Is eGFR?
Glomerular Filtration Rate is the most useful measure to describe kidney function in adults. Direct measurement of GFR is involved and expensive. However serum Creatinine can be used together with age and gender to give a calculated estimate which is reasonably accurate, particularly in those with impaired function. A correction factor of 1.212 should be applied to African-Caribbean individuals. The calculation is not applicable in acute renal failure and gives poor results in those at the extremes of weight. The GFR is around 100ml/min/1.73m2 in health, so the eGFR effectively describes % kidney function.
The introduction of eGFR In Grampian
From June 2006, the Biochemistry department will report an estimated GFR (eGFR) alongside reports for serum creatinine. The calculations being used nationally depend on the creatinine assay used, so GFR should not be estimated outside the laboratory. The eGFR will not be reported in delayed samples (>24h), or in children. All values above 60 will all be reported as >60 ml/min/1.73m2. Patient information required by the Biochemistry department to determine eGFR include date of birth and sex.
Chronic Kidney Disease Classification
GFR can be used to classify patients with chronic kidney disease (CKD). The system in current use was developed by the National Kidney Foundation in the USA.
Kidney damage refers to the additional finding of either direct evidence (eg ultrasound showing polycystic kidneys) or indirect evidence (eg persisting proteinuria) of kidney disease.
For further Information and a guide to the management of CKD see www.renal.org/CKDguide/ckd.html.
An eGFR guide is also available at http://www.renal.org/eGFR/.
How to Interpret the
eGFR result
eGFR > =60
ml/min/1.73m2
On its own an eGFR result of 2 60 ml/min/1.73m2 indicates normal kidney function and requires no specific action. Clearly there are however many other indicators of kidney disease (eg nephrotic syndrome, severe hyperkalaemia and malignant hypertension) and a normal eGFR should not prevent or delay appropriate referral to a specialist.
eGFR 30—- 59 ml/min/1.73m2 ( Stage 3 CKD )
Stage Description GFR
1 Kidney damage and normal GFR >90
2 Kidney damage and mild decrease
in GFR
60 to 89
3 Moderate decrease in GFR 30 to 59
4 Severe decrease in GFR 15 to 29
5 Kidney failure (dialysis or kidney
transplant needed)
< 15
Draft Guideline – 25 September 2008
If this is the first time an abnormal result has been identified then it should be repeated within the week to ensure this is not acute renal failure which should be urgently assessed and referred. The majority of patients with this level of kidney disease will have already been recognised as having an associated risk factor (most commonly diabetes, hypertension or cardiovascular disease in the older patient). The patient should be reviewed with specific note of past results, current medications, BP, cardiovascular risk factors, family history of renal disease and urinary symptoms. Most patients will be asymptomatic and have no specific complications of CKD (Anaemia and Renal Bone Disease). Management should include the following:
Advice on smoking, weight, exercise, salt and alcohol intake.
Check drug doses, avoid or stop nephrotoxic agents.
Cardiovascular risk reduction with consideration of aspirin and statin therapy
Strict BP control target 130/80 in most and 125/75 in those with Proteinuria
ACEI or ARB is first line antihypertensive therapy (check bloods after introduction to ensure GFR does not fall > 15%)
Request renal ultrasound in those with urinary symptoms
Check Hb, Potassium, Calcium and Phosphate and monitor bloods 4 - 6 monthly.
Offer Influenza and Pneumococcal vaccination
Stage 3 CKD Nephrology Referral Guidelines
Around 5% of the population will have stage 3 CKD and many will remain stable and can be managed in primary care as detailed above. Criteria for referral are listed below:
Cause of CKD not obvious
Progressive declining kidney function
Persisting abnormalities on urine dipstick testing (Proteinuria and/or Haematuria).
Suspected underlying systemic disease (eg SLE or Vasculitis)
Anaemia, cause not identified on standard investigation
Persisting abnormalities in Potassium, Calcium or Phosphate.
Difficult or uncontrolled hypertension
Consider urological referral if indicated by urinary symptoms, ultrasound findings or haematuria.
eGFR < 30 ml/min/1.73m2 ( Stage 4+ 5 CKD )
This indicates advanced or severe chronic kidney disease. The majority of patients in this group will already be known to the renal service or are receiving renal replacement therapy. Patients who have not previously been assessed by a nephrologist should be urgently referred or discussed by telephone. There will be some situations where this is clearly inappropriate due to the coexistence of other significant pathology but again where there is doubt telephone advice can be sought. Management is broadly similar to that outlined in stage 3 CKD but there are likely to be specific problems associated with Anaemia or Renal bone disease which warrant specialist advice. Discussing renal replacement therapy options (dialysis, transplantation or conservative) should also be undertaken at this time by the specialist renal multidisciplinary team
Further referral advice available from consultant staff
Draft Guideline – 25 September 2008
D6.4 Management of Diabetic Renal Disease Patients with diabetic renal disease require frequent and intensive
monitoring. Microalbuminuria and proteinuria confirm diabetic renal disease and
aggressive management of blood pressure and other risk factors is essential to preserve renal function.
These patients are also at high risk of retinopathy, autonomic neuropathy and cardiovascular disease.
All patients with microalbuminuria or proteinuria should be commenced on ACE inhibitor therapy. The dosage should be gradually increased to the maximum tolerated dose. Those intolerant of ACE inhibitors should be given Angiotensin II antagonists. Annual measurements of creatinine and albumin/creatinine ratio (protein/creatinine ratio if proteinuric) should be continued.
Lowering blood pressure in relatively hypertensive microalbuminuric patients reduces albumin excretion and progression to nephropathy. All agents which lower blood pressure reduce albumin excretion, although ACE inhibitors and AIIAs probably have a class specific effect independent of their hypotensive effect and are the drugs of choice for initial therapy.
Blood pressure should be maintained to the lowest achievable level and certainly <130/80 mm Hg in all patients (SIGN 116). In Type 1 patients with microalbuminuria or proteinuria the target blood pressure should be lower. The Aberdeen Renal Clinic currently recommend <125/75.
Insulin or sulphonylurea requirements usually decrease with advancing renal impairment. Metformin should be discontinued when serum creatinine is > 150 µmol/l.
Reducing proteinuria should be a treatment target regardless of baseline urinary protein excretion. The greater the reduction from baseline urinary protein excretion, the greater effect on slowing the rate of loss of GFR.
Patients with diabetic renal disease have a high risk of cardiovascular co-morbidity and should be managed aggressively.
D6.5 Referral for specialist renal advice Consider referral to specialist renal services when creatinine >150
µmol/l (male), >130 µmol/l (female) or protein/creatinine ratio >300 mg/µmol , eGFR <30.
Referral should also be considered for features suggestive of nephrotic syndrome or if persistent proteinuria is not thought to be explained by diabetes (considering the duration of diabetes and absence of other microvascular complications).
The presence of both blood and protein may also be indicative of an alternative renal pathology and in cases where this is persistent i.e. detected on more than 2 occasions a referral should be considered. Isolated haematuria will require separate evaluation and is not a feature of diabetic nephropathy.
Specialist renal assessment will include assessment for non-diabetic renal conditions if necessary, assessment of GFR and estimation of likely progression of renal disease. Patients with stable renal disease will be discharged back to routine diabetes care (primary or secondary care) with advice on a threshold for further referral.