Diabetes Mellitus

Diabetes Mellitus
Integrated Care Pathway
5th Edition 2012
Bristol
North Somerset
South Gloucestershire
NHS Diabetes Booklet.indd 1
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Integrated Care Pathway for adults with

diabetes mellitus
This Integrated Care Pathway is intended to inform team members and

patients of the process of care for adult patients with diabetes and the
resources available locally. It aims to provide guidance for health care
professionals new to the field or who have recently moved into the
area, as well as being a reference document for those already
involved in diabetes services both in primary and secondary care. It
includes basic guidelines for clinical management but it is not intended
to provide a comprehensive guide to the care of people with
diabetes. National standards have been included where these are
available. The appendices provide more detailed suggestions for the
management of specific aspects of diabetes care. It is intended that
the document will be regularly reviewed and updated; particularly in
light of the National Service Framework for diabetes and guidelines
arising from NICE and other bodies.
The ICP has been endorsed by the Bristol, North Somerset and South
Gloucestershire Drugs and Therapeutics Committee; the BNSSG
Stakeholder diabetes pathway group; Bristol, North Somerset and South
Gloucestershire Clinical Commissioning Groups; NHS North Somerset
Diabetes Network; North Somerset Community Partnership, and Bristol
Community Health. Formal equality impact assessment has not been
carried out.
Comments on the pathway should be sent to:
judith.wood3@nhs.net or polly.bingley@bristol.ac.uk
BNSSG Diabetes ICP November 2012
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Index
1) Diagnosis of diabetes ........................................................................................................... 1
2) Initial assessment and classification
1) in adults....................................................................................................................... 5
2) in children and adolescents .................................................................................... 6
3) Initial management of type 1 diabetes in adults ............................................................. 8
4) Initial management of type 2 diabetes ............................................................................. 9
1) Assessment or risk factors and complications ..................................................... 10
i.
Nephropathy screening ...............................................................11
ii.
Foot Assessment ............................................................................12
2) Dietary advice ......................................................................................................... 13
3) Lifestyle and exercise advice ................................................................................ 14
4) Structured education for people with diabetes................................................. 14
5) Continuing care of type 1 and type 2 diabetes............................................................. 16
1) Oral Hypoglycaemic agents and insulin.............................................................. 17
2) Glycaemic control and monitoring...................................................................... 18
a) Targets........................................................................................................ 18
b) Drug treatment ......................................................................................... 18
c) Monitoring ................................................................................................. 22
3) Management of intercurrent illness...................................................................... 23
4) Lifestyle Management and Education.................................................................24
a) Advice on blood glucose control and exercise .................................. 24
b) Structured Education............................................................................... 24
5) CVD risk factor control and targets ...................................................................... 25
6) Management of hypertension .............................................................................. 26
7) Alternative treatment pathway if ACE inhibitor and angiotensin II receptor blocker
contraindicated ...................................................................................................... 27
8) Management of dyslipidaemia ............................................................................ 29
9) Anti-platelet agents ................................................................................................ 31
6) Suggested specialist referrals ............................................................................................ 32
7) Appendices..............................................................................................................................
1) Management of complications
a) Hypoglycaemia........................................................................................ 33
b) Diabetes Foot Pathway........................................................................... 38
c) Painful diabetes neuropathy .................................................................. 40
d) Persistent albuminuria or microalbuminuria ......................................... 42
e) Erectile dysfunction ................................................................................. 44
2) Special situations
a) Diabetes in women
i.
From adolescence & throughout potential child-bearing
Years.................................................................................................. 46
ii.
Pre-pregnancy in women with type 1 or type 2 diabetes ........ 47
iii.
Confirmed pregnancy in women with type 1 or 2 diabetes ... 49
iv.
Pregnancy in women at risk of gestational diabetes ................ 50
v.
Post natal care ................................................................................ 51
b) Diabetes in children & young people ................................................... 52
c) Diabetes in the elderly & housebound ................................................. 53
d) Managing diabetes at the end of life................................................... 55
e) Diabetes and steroid treatment............................................................. 58
3) Treatment
a) Starting insulin in type 2 diabetes........................................................... 60
b) Weight management pathway............................................................. 63
c) Weight loss surgery in type 2 diabetes .................................................. 64
8) The Diabetes Teams and other contacts ........................................................................ 65
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Diagnosis of diabetes
Periodic testing in CVD,

previous IGT/IFG or
gestational diabetes,
or screening
high risk groups1
Symptoms
or signs
Routine testing
at new patient visit,
OPD, hospital admission
insurance medical, etc
Diagnosis by WHO criteria 2
Triage
acutely ill
or
severely symptomatic
or
urinary ketones
not acutely ill

and
no urinary ketones
immediate referral to
on-take team
Treatment of DKA or
hyperosmolar hyperglycaemic
state according to
N Bristol/ UH Bristol / Weston
protocols for adults or children
Initial assessment
and
classification
Initial assessment
and
classification in
adults
Initial assessment and

classification in
children and
adolescents below
16 years of age
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1. Screening:
Targeted screening with annual fasting glucose measurement or HbA1c is
appropriate in high-risk groups such as:
Family history of diabetes, obese, hypertensive, CVD, high waist
circumference, ethnic minority groups, previous gestational diabetes, history
of mental health problems or impaired glucose tolerance
2. Diagnosis:
Diabetes can be diagnosed using either glucose or glycated haemoglobin
(HbA1c). Diagnosis on the basis of blood glucose is possible in most cases
and is more cost effective.
Diagnosis of diabetes must be based on either glucose or HbA1c
but not a combination of the two
The WHO criteria for diagnosis of diabetes are:
a) Symptoms with
b) No symptoms but
random plasma glucose 11.1 mmol/l
random plasma glucose 11.1 mmol/l
or
or
fasting plasma glucose 7.0 mmol/l
fasting plasma glucose 7.0 mmol/l
on two tests taken on separate days
See also Appendix 2c, diabetes in the elderly and housebound.
Formal diagnosis of diabetes must be based on a laboratory glucose
measurement. The results of capillary blood glucose measurements must be
confirmed in a venous sample. The diagnosis of diabetes has major
consequences for the patient and the full criteria must be used e.g.
repeating the tests if the patient has no symptoms
N.B. Fasting glucose 6.1- 6.9 mmol/l is impaired fasting glucose, which (like
impaired glucose tolerance) is associated with increased cardiovascular
disease risk.
CVD risk factors should therefore be aggressively addressed in patients

in this group.
lifestyle changes (moderate weight loss and increased, regular

exercise) markedly reduce the rate of progression to overt diabetes in
patients in this category. Patients should be advised accordingly.
consider performing an OGTT in this group to clarify glucose tolerance

status, but this is unlikely to change patient management.
6-12 monthly testing of fasting glucose, re-assessment of CVD risk

factors and lifestyle review is recommended.
HbA1c may also be used in the diagnosis of diabetes in some patient groups
if there are no genetic, haematological or illness-related factors that
influence HbA1c formation or its measurement.
Do not use in pregnancy.
HbA1c may not be raised if blood glucose levels have risen rapidly
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(e.g. symptomatic children and young people, symptoms suggesting

type 1 diabetes, symptoms for less than 3 months, acutely ill patients,
medication that may cause a rapid rise in glucose e.g. steroids, anti
psychotic medication or acute pancreatic damage or pancreatic
surgery.)
HbA1c is not suitable for use in patients with abnormal haemoglobins,
anaemia and altered red blood cell lifespan (e.g. Iron and vitamin B12
deficiency, haemolytic anaemias, administration of iron, vitamin B12 or
erythropoietin, chronic liver disease, chronic kidney disease (CKD 4 and
5), alcoholism, rheumatoid arthritis, splenomagaly or splenectomy,
haemoglobinopathies and drugs that may affect erythrocyte lifespan
including antiretrovirals, ribavarin, dapsone)
HbA1c 48 mmol/mol (6.5%) = diabetes

HbA1c 42-47 mmol/mol (6.0-6.4%) = high risk of diabetes and cardiovascular
disease
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1. Algorithm for glucose-based diagnosis of diabetes

(n.b. this algorithm does not apply to diabetes in pregnancy)
< 5.5
mmol/l
Random
glucose
st
(! line if symptoms)
11.1
mmol/l
5.6 11.0 mmol/l

< 6.1
mmol/l
Diabetes
excluded
Fasting
glucose
st
(! line for screening)
7.0
mmol/l
Diabetes
(must be at least two diagnostic
glucose results if classical
symptoms are absent)
6.1- 6.9 mmol/l

Impaired Fasting
Glucose
2 hr glucose
< 7.8 mmol/l
Oral Glucose
Tolerance Test
2 hr glucose
11.1 mmol/l
2 hr glucose
7.8 11.0 mmol/l
Impaired
Glucose
Tolerance
2. Algorithm for HbA1c based diagnosis of diabetes (see notes for

exclusions)
Diabetes
unlikely
less than 42
mmol/mol
HbA1c
measurement
48 mmol/mol
Probable
diabetes
42-47 mmol/mol
Reassess
in 3 years
if
high-risk group
Increased risk
of diabetes
and CVD
Symptoms of
diabetes?
Reassess
in 1 year*
High risk
of diabetes
and
CVD
No
less than
48 mmol/mol
Reassess
in 6 months*
Yes
Repeat
HbA1c
within 2 weeks
48
mmol/mol
Diabetes
confirmed
* Reassess earlier if patient develops symptoms
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Initial assessment and classification in adults

Type 1 or Type 2 diabetes?
The following features suggest type 1 diabetes and
need for early insulin treatment
(ignore age and glucose level)
non-fasting ketonuria (test everyone)
short history and/or severe symptoms
marked weight loss (> 10% within 3 mth. from any weight )
family history of type 1 diabetes
family history of autoimmune disease
Type 1 diabetes
Not acutely ill
Type 2 diabetes
Acutely ill
or
Vomiting
or
Blood glucose >30 mmol/l
and/or severely symptomatic
Not acutely ill

BG < 30 mmol/l
Contact diabetes team within 24 hours

(DSNs Mon-Fri 9-5)
If out of normal working hours, or DSNs unavailable,
contact on-call medical team via switchboard
DO NOT LEAVE A MESSAGE
Insulin will be started as an outpatient
if appropriate and admission avoided
Initial management of
type 1 diabetes
Admission
Treatment of DKA or
hyperglycaemic hyperosmolar state
according to N Bristol/
UH Bristol/Weston protocol
type 2 diabetes
For Practical Classification Guidelines, please visit:

http://www.diabetes.nhs.uk/our_publications/reports_and_guidance/diabet
es_information_and_data/
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Initial assessment and classification in children and adolescents

below 16 years of age
Diagnosis of diabetes
Type 2 diabetes1
(very uncommon)
Type 1 diabetes
Refer to paediatric diabetes team
Child unwell,
signs of
diabetic ketoacidosis
(urine ketones +++ or blood
Ketones 3mmol/l)
Contact paediatric diabetes team

immediately
for urgent admission
(on-call paediatric team if outside
normal working hours)
Management of DKA
according to
paediatric protocol
Well child,
no signs
of
diabetic ketoacidosis
Refer
immediately
(within maximum 24 hours)
for same day admission
(on-call paediatric
team if over the weekend)
type 1 diabetes
Strong clinical evidence

that child has type 2
diabetes1
& symptoms
minimal or absent
Refer on
same/next working day
(if unsure discuss with
paediatric diabetes team)
Initial management
of
type 2 diabetes 2
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Notes:
1. The overwhelming majority of children and adolescents presenting with
diabetes have type 1 diabetes. Consider type 2 diabetes if the child is
overweight, has no ketonuria, has little weight loss and/or has
acanthosis nigricans. If in any doubt refer urgently to the paediatric
diabetes team as for type 1 diabetes
2. Children and adolescents with type 2 diabetes should currently be
managed in the specialist diabetes service rather than in primary care
clinics. This allows expertise in the management of this small group of
patients to be developed and appropriately focused.
3. Following a child or adolescents referral to the Bristol Paediatric
Diabetes Team at Bristol Royal Hospital for Children, they will be seen
straight away, assessed and admitted for management and ongoing
education. The duration of their admission will be influenced by
presence of DKA. Stabilisation on insulin, education from paediatric
diabetes nurses and paediatric dietitians and medical staff
commences in hospital, but there is an emphasis on early discharge
with significant ongoing input once at home.
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Initial management of type 1 diabetes in adults
confirm diagnosis and classification

screen for risk factors
Diabetes Nurse Specialist to coordinate

support and education
starting insulin
blood glucose monitoring
referral to dietitian
and interim dietary advice
explanation/counselling
Dietitian
regular DSN review to provide

ongoing support and education
review insulin doses
address lifestyle and social issues,
including contraception and pregnancy
planning
Specialist clinic
follow-up appt.
Within first year

optimise metabolic control with the aim of
achieving normal HbA1c with 3 months to
help preserve cell function
address psychological and behavioural issues
achieve optimum autonomy
continue education 1:1 and refer for group education
agree targets and continuing care plan
Continuing care & review

of educational needs
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Initial management of type 2 diabetes
screen for risk factors and complications as at annual review

refer to Diabetic Eye Screening Programme
refer to dietitian as per local guidelines and provide interim general dietary advice
lifestyle and exercise advice
refer to structured education programme or ensure alternative provision
3 month trial of diet and exercise, shorter only if symptoms persist
6 week review
symptoms improved
or asymptomatic
persistent symptoms
Review diet and exercise

Consider starting oral
hypoglycaemic agents
continue
12 week review
Review fasting glucose results
(HbA1c not appropriate for monitoring treatment effect at this stage)
FBG < 7 mmol/l
FBG 7-10 mmol/l
FBG > 10 mmol/l
continue
Review diet and exercise
Start OHA
BMI 25 kg/m2
and
no contraindications
Rx metformin
start with 500 mg od with/after food
for 7 days and increase stepwise
BMI < 25 kg/m2

or
renal/cardiac/hepatic failure
Rx gliclazide
(unless high risk of hypoglycaemia
eg frail elderly)
Continuing care plan and targets agreed
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1.
Assessment of risk factors and complications (initial assessment and annual

review)
a) Identification of risk factors for CVD and other complications
Smoking history
Blood pressure
Random lipids (Cholesterol, HDL and triglycerides)
Waist circumference
Erectile dysfunction
Calculation of 10 yr CVD risk if no vascular disease using the
QRISK2 risk engine (www.qrisk2.org ). This has been developed
and externally validated in UK populations including patients with
type 2 diabetes. QRISK2 (2010) applies to patients aged 30-84
years.
b) Surveillance for long term complications
i.
Eyes:
Corrected visual acuity
All patients should be referred to the BNSSG retinal screening
service for retinal photographs.
All patients should be referred to the Bristol and Weston Diabetic Retinopathy
Screening Programme for ongoing regular eye screening. This is part of the English
national screening programme for diabetic retinopathy.
http://www.briscomhealth.org.uk/our-services/item/293-diabetic-retinopathyscreening?sid=293
For appointments Tel: 0117 342 0888, or email bris-pct.drsappointments@nhs.net
For further information visit www.nscretinopathy.org.uk/
ii.
Kidneys:
Serum creatinine and estimate GFR
Urine albumin:creatinine ratio
For further investigation and management of proteinuria or persistent
microalbuminuria see Appendix 1d
iii.
Feet (see Appendix 1b):

Foot assessment must be performed by staff who have received
appropriate training in risk factors and foot examination
History of foot pain or previous ulcers
General observation
Vascular examination
Neurological examination
Footwear
Education on footcare
Feet must be defined as being in one for four risk categories: low risk (no risk
factors), moderate/increased risk (one risk factor), high risk (two or more risk factors
or history of ulceration or Charcot foot) or active problems. This must be
documented and acted on, and the patient informed and given appropriate
advice.
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Nephropathy Screening
Annual review
creatinine with calculation of estimated GFR
eGFR 60
ml/min/1.73m2
eGFR < 60
ml/min/1.73m2
Treat as CKD according to

local guideline
Urine ACR
for microalbuminuria
ACR
2.5M/3.5F
- 30 mg/mmol
ACR
<2.5M/<3.5F
mg/mmol
ACR
> 30 mg/mmol
Repeat ACR on EMU within 3/12

(ensure not collected during
- acute illness,
- intercurrent infection,
- menstruation)
Repeat ACR
<2.5M/<3.5F
mg/mmol
3rd ACR
<2.5M/<3.5F
mg/mmol
Laboratory
confirmed albuminuria
Repeat EMU for urine ACR
after 1-2 weeks
Repeat ACR
2.5M/ 3.5F
mg/mmol
3rd ACR
2.5M/3.5F
mg/mmol
2 of 3 ACR
2.5M/3.5F
mg/mmol
Management
of
persistent proteinuria
or
microalbuminuria
For further management of diabetic foot problems and painful neuropathy see
Appendices 1b and 1c
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Foot Assessment
Examine feet with socks/stockings removed
Palpate foot pulses and
check for signs and
symptoms of ischaemia
Ask about any previous

ulcers/ Charcot
foot/amputations
Inspect for any deformity
Inspect footwear and

hosiery
Check for active

ulceration on
feet/Charcot foot
Test sensation using 10g

monofilament and look
for signs of neuropathy
Ask about foot pain
Inspect for any callus or

other pathology
Ask about blood glucose

control
RISK FACTORS
loss of sensation
signs of peripheral vascular disease
significant callus
deformity
Active ulceration
Spreading infection
Acute Charcot foot
Unexplained hot, red swollen foot
Critical ischaemia
Gangrene
Painful peripheral neuropathy
ACTIVE
Previous ulceration
or
TWO OR MORE
RISK FACTORS present
HIGH RISK
ONE RISK FACTOR present
NO RISK FACTORS present
Management of
active
foot disease
and
increased risk
MODERATE
or
INCREASED RISK
LOW RISK
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2. Dietary Advice
All people with newly diagnosed diabetes should be referred to a

Registered Dietitian in accordance with the locally agreed practice
The dietitian will provide individualised advice
Refer people with type 2 diabetes to the Living with Diabetes structured
education programme
Prior to seeing the dietitian, the patient should receive advice and written
information from practice staff as below
Initial dietary advice

1.
Advise weight loss if overweight
2.
Eat three small meals a day
3.
Include starchy carbohydrate foods (e.g. rice,

pasta, potatoes, bread, cereals, yams) at each
meal
4.
Reduce added fat and salt
5.
Aim for 5 portions of fruit & vegetables a day
6.
Limit sugar and sugary foods
7.
Keep alcohol within safe limits
Written/Further Information
Healthy Eating with Diabetes available from your local dietitian, Health
Promotion, or www.avondiabetes.nhs.uk
Eating Well with Diabetes free from Diabetes UK
www.diabetes.org.uk guide to food and diabetes
www.bda.uk.com/foodfacts - guide to food and diabetes
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3. Lifestyle and exercise advice

a) Smoking cessation
All people with diabetes should be strongly advised to stop smoking and should
be referred to the local Stop Smoking Service or other available sources of help.
o http://smokefree.nhs.uk/
b) Diabetes and exercise
Who
Anyone can do low impact exercise, and health care professionals should
encourage this
Exercise does not worsen diabetic retinopathy, nephropathy or neuropathy
and is safe in pregnancy
Individuals who have
o BP drop on standing
o Loss of heart rate variation
o Severe neuropathy
o Very low fitness levels
are at most risk of cardiac events and should initially be supervised when
exercising
Patients should be advised not to take up strenuous activity suddenly
Advice about exercise

Being more active is the aim.
Any increase in activity is beneficial
Ask patients to pick an activity that suits them
Start slowly and build up gradually
For further advice please visit:
o www.diabetes.org.uk/Guide-todiabetes/Healthy_lifestyle/Keeping_active/
o www.runsweet.com/ - A site for people with diabetes, with a focus on
sport and insulin
Details of facilities for exercise available locally, eligibility criteria and how to
refer a patient are available on the Avon Diabetes Website
www.avondiabetes.nhs.uk
4. Structured education for people with diabetes

In accordance with NICE guidelines, all people with diabetes should:
receive ongoing structured education as part of their normal care and
routine clinical reviews with their primary care team.
be offered the opportunity to participate in tailored group education
sessions, based on an individual assessment of their learning needs.
At diagnosis, all those with newly diagnosed Type 2 diabetes should be
given a copy of the Diabetes Information Pack,
referred to the Living with Diabetes group education programme. The
referral form is provided in the information pack and is available on
People benefit most from starting the programme within 4-6 weeks from
diagnosis, but referrals are accepted for those who have been diagnosed
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for up to 12 months. Patients can also self-refer, and the referral form will be
sent to their doctor to complete.
This programme consists of two days (3-4 months apart) and is delivered by
trained educators at venues throughout the BNSSG area on a regular basis.
After referral, patients will be contacted by the Programme Administrator to
discuss the date and venue that would be most convenient for them to
attend. For people who are housebound contact the diabetes education
team to discuss available options.
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Continuing care of type 1 and type 2 diabetes
Annual review
Exploration of any concerns

Metabolic management
home blood glucose monitoring
HbA1c
dietary assessment
hypoglycaemia
injection sites
Identification of risk factors
for CVD and other complications2
smoking
obesity, physical inactivity
hypertension
dyslipidaemia
Surveillance for long term
complications1
eyes: retinal photograph or
check patient has attended
annual eye screening appointment,
visual acuity
kidneys: creatinine, eGFR,
proteinuria/microalbuminuria
feet: standard foot assessment,
including painful neuropathy
erectile dysfunction
Interim review
concerns
glycaemic control
control of risk factors
management options
Goal setting
and agree care plan
Consider need for referral for

specialist advice, treatment
and/or diabetes education
programme
Other issues:
1. psychological or coping problems:
depression
eating disorders etc.
2. pregnancy and contraception
pre-pregnancy counselling
3. lifestyle issues
work, leisure, travel
driving regulations
4. immunization
influenza
pneumococcus
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Oral hypoglycaemic agents and insulin

Targets not achieved in spite of diet and lifestyle changes
BMI < 25 kg/m2

or
renal/cardiac/hepatic failure
Rx metformin
start with 500 mg od
with/after food for 7 days
and increase stepwise
Rx glicazide
(unless high risk
of hypoglycaemia)
First line
BMI 25 kg/m2
and
no contraindications
metformin
intolerance
high risk of
hypoglycaemia
e.g. frail elderly
metformin
intolerance
or
contraindication
consider adding
DPP-4 inhibitor
(gliptin)
consider adding
DPP-4 inhibitor
(gliptin)
or
pioglitazone
add metformin
start with 500 mg od
with/after food for 7 days
and increase stepwise
insulin
relatively contraindicated
(e.g. employment reasons)
or
high risk of weight gain
injectable therapy
unacceptable
or inappropriate
Starting insulin
in type 2 diabetes
consider adding
GLP-1
mimetic
consider triple therapy

using
metformin and gliclazide
+ gliptin or pioglitazone
Third line
insulin
(continue metformin if
tolerated and
no contraindications)
Second line
add gliclazide
Review at 6 months and regularly thereafter.

Continue only if beneficial metabolic response
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2. Glycaemic control and monitoring

a)
Targets (NICE clinical guideline 66, 2008)

Plasma glucose
Fasting
Postprandial
HbA1c
7.0 mmol/l
8.5 mmol/l
48-58 mmol/mol (6.5 - 7.5 %)
A higher target should be adopted in patients with a limited prognosis or

higher risk of iatrogenic hypoglycaemia (e.g. the elderly; see Appendix 1a
and Appendix 2c) and lower targets may be appropriate in certain
circumstances e.g. pregnancy or early type 1 diabetes. It should be
emphasised that any improvement in glycaemic control is associated with
reduction in risk of microvascular disease, even if the targets are not
achieved.
b)
Drug treatment: oral hypoglycaemic agents and insulin

i. Metformin
1st line OHA if BMI 25
Side effects:
Gastrointestinal symptoms (anorexia, nausea, vomiting,
diarrhoea, abdominal pain, flatulence)
Lactic acidosis
Contraindications:
Renal impairment creatinine 150 mol/l or eGFR < 30ml/min.
Use metformin only with caution if eGFR 30-59 ml/min. Ensure
renal function is stable before starting treatment, monitor eGFR
regularly and discontinue metformin if the eGFR is falling or in the
event of any intercurrent illness likely to be associated with
dehydration.
Cardiac failure not controlled by minimal doses of loop diuretic
(furosemide 40 mg o.d or equivalent without digoxin) and/or
ACE inhibitor (ramipril 10mg od or equivalent without digoxin)
Significant chronic pulmonary disease with potential for hypoxia
(exercise tolerance less than one flight of stairs)
Liver disease with ALT 3 x upper limit of normal range (if pretreatment results raised but < 3 x upper limit, recheck LFT after 1-2
months of treatment and investigate according to local
guidelines if still abnormal)
Treatment schedule:
Start at low dose (500mg o.d. with or after food) increase by
500mg per day each week to highest tolerated dose up to usual
maximum 1g b.d.
Always advise patient to take tablets with or after food
If gastrointestinal side effects, reduce back to previously
tolerated dose
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ii.
Modified release metformin may be better tolerated than

immediate-release metformin formulations by some patients. If
patients have persistent GI side effects in spite of slow
introduction of the standard formulation, a trial of modified
release metformin should be given before using alternative
treatments
Gliclazide and other sulphonylurea drugs

1st line OHA if BMI < 25 kg/m2, unless high risk of hypoglycaemia
Cautions:
Warn patient of potential risk of hypoglycaemia if meals omitted
or activity increased
Do not use as 1st line OHA in patients at high risk of
hypoglycaemia e.g. frail older people. Substitute metformin if no
other contraindications
Drivers need to notify the DVLA on starting treatment,
For further advice: www.dft.gov.uk/dvla/ and
www.diabetes.org.uk/Documents/catalogue/Driving_and_diabe
tes.1211.pdf
Glibenclamide should be avoided and a short acting agent (e.g.
gliclazide or tolbutamide) used if
Renal function deteriorates (creatinine 150 mol/l)
Patient 60 years
Treatment schedule:
Start gliclazide 40 - 80 mg o.d. and adjust according to response.
Increase at fortnightly intervals if necessary
Maximum dose 160 mg b.d.
iii.
Metformin/gliclazide combinations
2nd line if single agent treatment fails to achieve target
iv.
Acarbose
Sometimes useful if metformin intolerance
Associated with GI side effects and should be taken with food at
the start of the meal
If tolerated can reduce HbA1c by ~ 5.5 mmol/mol (0.5%)
v.
Prandial glucose regulators

e.g. repaglinide and nateglinide
Short acting agents potentially used in place of sulphonylureas
Their role currently lacks a clear evidence base and their use is not
therefore recommended.
vi.
Thiazolidinediones/glitazones
Pioglitazone can be used as alternative 2nd line OHA if one of the
standard agents is not tolerated
No proven advantage over metformin/gliclazide combinations
May be considered for use in conjunction with metformin and
sulphonylurea only in patients in whom insulin is relatively
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contraindicated because of occupation (e.g. HGV licence

holders) or other factors
vii.
Cautions:
Associated with weight gain ++
Associated with fluid retention. Avoid if current or previous heart
failure, ischaemic heart disease or high CVD risk and discontinue
if develops.
Associated with increased fracture risk
Should not be used in patients with a history of bladder cancer or
in patients with uninvestigated visible blood in the urine (MHRA
July 2011).
known risk factors for bladder cancer should be assessed before
starting treatment: age; current or past history of smoking;
exposure to occupational or chemotherapy agents (e.g.
cyclophosphamide); or previous pelvic radiotherapy
In view of the age-related risks (especially bladder cancer,
fractures and heart failure), the balance of benefits and risks
should be considered carefully before initiating pioglitazone in
the elderly.
Pioglitazone should be discontinued if HbA1c has not fallen by at
least 5.5 mmol/mol (0.5%) at 6 months or weight gain and other
adverse effects are unacceptable.
GLP-1 mimetics (exenatide & liraglutide)
Exenatide (including prolonged release) or liraglutide (given by s.c.
injection) may be considered for use in patients whose diabetes is
not controlled on maximum tolerated OHA (metformin and
sulphonylurea) in whom insulin conversion is being considered but
insulin is relatively contraindicated for employment reasons (e.g.

HGV licence holders) or other factors
there is a particularly high risk of weight gain identified by a)

previous weight loss (from maximum remembered weight), b)
HbA1c > 69 mmol/mol(8.5%), c) inability to increase activity
levels due to comorbidity etc.
BMI 35 kg/m2 with specific psychological or medical problems

associated with high body weight
Contraindications :
type 1 diabetes, severe renal impairment (eGFR <30 ml/min),

history of pancreatitis, severe gastrointestinal disease including
gastroparesis, child-bearing potential without adequate
contraception.
Cautions:
Severe pancreatitis (sometimes fatal), including haemorrhagic or
necrotising pancreatitis, has been reported rarely.
patients or their carers should be told how to recognise signs and
symptoms of pancreatitis and advised to seek prompt medical
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attention if symptoms such as abdominal pain, nausea, and

vomiting develop;
discontinue permanently if pancreatitis is diagnosed.
use with caution in patients with risk factors for pancreatitis such
as hyperlipidaemia and gallstones.
GLP-1 mimetic therapy should only be initiated by staff who have

received appropriate training
GLP-1 mimetics may be used in combination with insulin but this use is
amber light. Patients in whom it is being considered should therefore
be referred for consultant review.
Exenatide and liraglutide should be discontinued if HbA1c has not
fallen by at least 11mmol/mol (1.0%) within 6 months and there is not at
least 3% weight loss at 6 months or if improvement is not sustained
thereafter.
viii.
DPP-4 inhibitors (gliptins)

DPP-4 inhibitors may be suitable second-line therapy instead of
sulphonylurea if a patient is considered to be at significant risk of
iatrogenic hypoglycaemia e.g. frail older people living alone.
Combination therapy with DPP-4 and sulphonylurea may be a
suitable second-line treatment strategy in patients unable to
tolerate metformin, but caution is needed when adding a gliptin in
this situation because of risk of hypoglycaemia.
Gliptins should be discontinued if HbA1c has not fallen by at least
5.5 mmol/mol (0.5%) at 6 months.
Their role otherwise currently lacks a clear evidence base and their
long term safety is not known. As they are novel agents with
potential effects upon multiple tissues and have not yet been widely
used, their use in other situations is not recommended.
ix.
anti-obesity drugs and obesity surgery

Orlistat may be considered as part of a weight-loss strategy for
people with type 2 diabetes and BMI 28 kg/m2 accordance
with NICE guidance. Treatment should generally be discontinued
after 12 weeks if patients have been unable to lose at least 5 % of
the body weight as measured at the start of drug therapy,
though less strict goals may be appropriate in people with type 2
diabetes.
Patients with type 2 diabetes with body mass index 35 kg/m2
may be suitable for gastric banding or other bariatric surgery in
accordance with NICE guidance. Referrals to the service are
accepted only from secondary care and patients who are
potentially suitable should therefore be referred to the diabetes
specialist team in the first instance (see Appendix 3c)
x.
Insulin
Use if treatment with combined oral hypoglycaemic agents fails to
achieve targets. If metformin has previously been tolerated, it
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should generally be continued in patients with type 2 when starting

insulin. See Appendix 3a for guidelines.
References:
NICE clinical guideline 66: Management of type 2 diabetes (update)
(2008) (www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf)
NICE clinical guideline 43: Obesity (2006)
(www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdf )
c)
Monitoring
i.
Home blood glucose monitoring
Type 1 diabetes
Type 2 diabetes:
Multiple insulin
injections
Type 2 diabetes:
1 or 2 insulin
injections a day
Insulin users who

drive or operate
machinery
Type 2 diabetes:
diet alone
Type 2 diabetes:
On tablets which
carry risk of inducing
hypoglycaemia e.g.
sulphonylureas and
glinides
May be advised to test 4 times a day or more often

during illness and special situations (see below) and at
times relevant to driving
As above
If glucose levels are stable then 2-3 tests a week may be
sufficient, varying the times before meals or bed time and
at times relevant to driving. If glucose levels unstable it
may be necessary to test at least once a day before
meals or bed time and at times relevant to driving
Advisable for anyone using insulin to check blood
glucose levels before driving and at regular intervals
during a journey or when operating machinery
No need to test routinely unless there is an agreed goal or
purpose to testing such as special situations below
It may be appropriate to monitor blood glucose regularly
and at times relevant to driving or operating machinery
to enable the detection of hypoglycaemia
People with group 2 license: LGV/PGV need to monitor

blood glucose at least twice daily and at times relevant
to driving
Special situations :
Illness or stress
Most people with
Changes in insulin or diabetic tablets
diabetes advised to
Treatment with steroids e.g. rheumatoid arthritis,
test more often or
chemotherapy & COPD
start testing in these
Pregnancy or planning a pregnancy
Other situations as advised by nurse or doctor
situations
ii.
Glycated haemoglobin (HbA1c)

HbA1c should be monitored 3-6 monthly. As the results reflect
glycaemic control over a period of 6-8 weeks, tests performed at
intervals of less than 3 months are uninformative and should be
avoided. The frequency of testing depends on the target for
glycaemic control, stability of blood glucose control and changes in
therapy.
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iii.
Fructosamine
Use for monitoring glycaemic control in haemoglobinopathies that
interfere with the measurement of HbA1c. It may be possible to
measure HbA1c in some haemoglobinopathies and discussion with
the local clinical biochemistry laboratory is advised. In this situation, it
is generally recommended that HbA1c should be used to monitor
glycaemic control in preference to fructosamine, although the results
should be interpreted with caution as HbA1c is less accurate with
increased red cell turnover.
iv.
Ketone testing
Testing for ketones is relevant for people with type 1 diabetes and can
assist with insulin adjustment during illness or sustained hyperglycaemia
to prevent or detect diabetic ketoacidosis (DKA). It is not however
recommended as a routine measurement. DKA is preventable in most
cases and is more common in young people and those with poor
concordance. At risk groups include people with mental health
problems, eating disorders, poor understanding of their diabetes,
social problems or a history of recurrent DKA.
Urine ketone sticks are most commonly used for testing. Blood ketone
testing can be useful in some groups including some children, people
at particular risk of DKA, insulin pump users and in some patients in the
groups described above, but should not be used routinely.
3) Management of intercurrent illness

Patients must be provided with written advice on what to do if they
have an illness, infection or feel unwell, and given contact details for
obtaining help and advice in this situation
Key advice should include:
never stop insulin, even if not eating. Extra insulin may be needed
try to keep to normal meal pattern, but if unable to, replace
some or all of meals with snacks and/or drinks that contain
carbohydrate e.g. yoghurt, milk and other milky drinks, fruit juice
or sugary drinks
test blood glucose at least 4 times a day while unwell
check urine or blood ketones if able to do so
drink plenty of sugar-free fluids. Aim to drink at least three litres
(five pints) a day
patients should be encouraged to seek medical help if
o unsure what to do
o blood glucose above 17 mmol/l for more than 24 hours
o vomiting and unable to keep fluids down
o moderate to large amounts of ketones in urine or blood
o feeling increasingly unwell with high blood glucose levels
Patient information leaflets are available on www.avondiabetes.nhs.uk
23
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4) Lifestyle Management and Education

a)
Advice on blood glucose control and exercise

Type 1 diabetes
People with type 1 diabetes may find it helpful to discuss management
of diabetes and exercise with the diabetes nurse specialist
General principles:
Physical activity reduces blood glucose levels. There may be an
immediate effect and with bouts of heavy or prolonged activity,
there may also be a delayed effect up to 12 hours
Learning about these will help patients to anticipate the fall in
glucose and act before they become hypoglycaemic rather than
afterwards
Exercise should be avoided if unwell or blood glucose high with
ketones in blood or urine
Extra carbohydrate may be needed before, during and after
prolonged exercise
If exercise is done in the evening long acting/ evening insulin may
have to be reduced to prevent hypos
Type 2 diabetes
These individuals rarely have problems with blood sugar when
exercising
Extra carbohydrate is rarely needed
If exercise-induced hypoglycaemia is a persistent problem consider
reducing OHAs rather than compensating with extra food
Exercise should be avoided if unwell
Follow up
Aim to see people regularly to review how they are doing as this
provides encouragement
Best results are seen with supervised classes
Details of facilities for exercise available locally, eligibility criteria
and how to refer a patient are available on the Avon Diabetes
Website www.avondiabetes.nhs.uk and advice to target weight
management in Appendix 3b
Further advice:
www.runsweet.com/ - A site for people with diabetes, with a
focus on sport and insulin
www.diabetes.org.uk/Guide-todiabetes/Healthy_lifestyle/Keeping_active/
b)
Structured Education
The BNSSG diabetes structured education programme includes courses
for people with established type 1 (e.g. Skills for life with type 1
diabetes) and type 2 insulin users (e.g. Can I eat bananas?). The
programme is continually evolving. Further information is available on
the education link on www.avondiabetes.nhs.uk
24
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5. CVD risk factor control and targets

Targets (NICE clinical guideline 66, 2008)
Total cholesterol
< 5.0 mmol/l

(<4.0 mmol/l if vascular disease
or CVD risk > 20%)
Blood pressure
140/80 mmHg
( 130/80 mmHg if microalbuminuria
or proteinuria, retinopathy or
cerebrovascular disease)
Smoking
Non-Smoker
It should be emphasised that any improvement in the level of control of BP

and cholesterol is associated with reduction in risk of macrovascular disease,
even if the targets are not achieved.
References:
NICE guideline 66: Management of type 2 diabetes (update) (2008)
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Management of hypertension
Steps (1)-(6) indicate sequential additional treatment given if targets
not achieved
Urine ACR 2.5M/3.5F mg/mmol

Target <130/80
Urine ACR <2.5M/3.5F mg/mmol

Target <140/80
(1) LIFESTYLE CHANGES
Reduce salt
Lose weight and activity
(2) ACE INHIBITOR

hypertension alone
titrate over 2-3 wk to
achieve target BP
or maximum
licensed dose
microalbuminuria/proteinuria
titrate to maximum dose
over 2-3 wk
unless
symptomatic hypotension
Check creatinine & electrolytes

before and
1-2 weeks after starting
ACE inhibitor
or increasing dose2
ANGIOTENSIN II
RECEPTOR BLOCKER
if ACEI induced cough
STOP ACEI or ARB if:

K+ 6.0 mmol/l (at lower levels
ameliorate with addition of diuretic)
eGFR falls >25%
ACE inhibitor and AIIR blocker
CONTRAINDICATED
See next figure
(3) DIURETIC6
(3) CALCIUM CHANNEL BLOCKER 7
(4) DIURETIC and CALCIUM CHANNEL BLOCKER

combined
(5a) add
BLOCKER 8
(5b) add
BLOCKER 9
(5c) add
K+ SPARING DIURETIC10
(6) REVIEW TREATMENT

May need to add centrally acting agent
(eg monoxidine or methyl dopa)
Consider secondary care referral
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Alternative treatment pathway if ACE inhibitor and angiotensin II

receptor blocker contraindicated
(1) CALCIUM CHANNEL BLOCKER

(Non-dihydropyridone CCB or
long acting dihydropyridone CCB)7
(2) DIURETIC6
(3) BLOCKER7
Caution should be used if co-prescribing
diltiazem and blockers
(4) BLOCKER9
(5) REVIEW TREATMENT
May need to add centrally acting agent
(eg monoxidine or methyl dopa)
Consider secondary care referral
n.b. patients whose eGFR falls >25% on starting ACE inhibitors or angiotensin II
receptor blockers should be referred to the nephrologists
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Notes:
1.
Salt intake should be reduced in all patients (patient advice is

available on the websites of NHS direct and the Food Standards
Agency: www.nhs.uk/Livewell/Goodfood/Pages/salt.aspx
2.
Patients with ACR 2.5M/ 3.5F mg/mmol should be started on an

ACEI irrespective of blood pressure in line with guidelines for the
management of proteinuria or persistent microalbuminuria
3.
Check eGFR and potassium before and 1-2 weeks after commencing
ACEI or ARB and after any dose increase
Stop ACEI/ARB if potassium > 6.0 mmol/l with no modifiable cause
Stop ACEI/ARB if eGFR falls >25% unless modifiable cause
If eGFR falls >5% but less than 25%, recheck eGFR in 1-2 weeks
Refer to nephrologists if eGFR falls >25%
4.
Consider stopping ACEI or ARB 1 week prior to elective surgery or

during intercurrent illness (especially if fluid depleted) to reduce risk of
acute kidney injury
5.
Antihypertensive medication should be reviewed in all women

planning pregnancy. If clinically acceptable ACEI and ARB should be
stopped in all women planning pregnancy and replaced with
alternative antihypertensive medication eg methyl dopa or nifedipine
6.
Diuretics: bendroflumethiazide 2.5 mg od (maximum effect after 4-6

wk). Use furosemide 40 mg bd if the patient has oedema or GFR <60
ml/min/1.73m2
7.
Calcium channel blockers: long acting dihydropyridone CCB (e.g.

amlodipine, nifedipine, felodipine) or non-dihydropyridone CCB (e.g.
diltiazem modified release preparation or verapamil). Long acting
dihydropyridone CCB and blockers may be combined. There is
some evidence of specific benefit from use of non-dihydropyridone
CCB in diabetic nephropathy. Caution should be used if prescribing
diltiazem and blockers. Verapamil should not be prescribed with
blockers
8.
blockers: e.g. doxazosin 1 mg od for one wk 2 mg od for one wk

4 mg od for one wk. Increase dose further if target not achieved
(max 16 mg od)
9.
blockers: Atenolol 50 mg od (avoid in critical limb ischaemia)
10. Potassium-sparing diuretics: potassium-sparing diuretics and

aldosterone antagonists (e.g. amiloride and spironolactone) should
be used with caution if the patient is already taking an ACEI or ARB.
11. This diabetes hypertension guideline differs to standard hypertension
guidance in that ACE is the first choice for all patients including afrocaribbean and those over age 55. For choice of agent see BNSSG
formulary www.bnssgformulary.nhs.uk/
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Management of dyslipidaemia
Type 1 or type 2 diabetes
age >40 yr
age 18-39 yr with additional risk factor1
Full lipid profile
Yes
Total cholesterol > 8 mmol/l
No
possible familial
hypercholesterolaemia
Cholesterol <4
Nommol/l
AND LDL <2 mmol/l
Yes
Reinforce lifestyle advice,

& reassess after 12/12
No
Simvastatin 40 mg
or
Atorvastatin 20 mg
Reassess lipid profile after 8 wk
CVD risk >20% in 10 yr
(using QRISK2)2
or
clinical evidence
of vascular disease
No
Reinforce lifestyle advice,

continue statin
at previous dose
& reassess after 12/12
Yes
Atorvastatin
40 mg
Consider Atorvastatin 80 mg
if target not achieved
Seek advice from secondary care
(lipid clinic)
if target not achieved
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Notes:
1. Additional risk factor:
One or more of the following:
Evidence of microvascular complications (retinopathy and/or

microalbuminuria)
hypertension on treatment,
family history of premature cardiovascular disease,
metabolic syndrome
HbA1c 75 mmol/mol (9.0%)
total cholesterol 6.0 mmol/l
2. In people with diabetes, use QRISK2 to estimate risk (www.qrisk2.org). This

has been developed and externally validated in UK populations including
patients with type 2 diabetes.
3. If fasting triglycerides > 10 mmol/L seek advice from secondary care (lipid
clinic)
4. If fasting triglycerides 2.3-10 mmol/L then this is a marker of high vascular
risk. Consider intensive statin treatment
5. Women who are considering pregnancy should stop statins prior to
conception as there is a suggestion that statins may affect CNS and limb
formation if taken during 1st trimester.
References:
NICE clinical guideline 66. The management of type 2 diabetes (update)
(May 2008)
NICE clinical guideline 67. Cardiovascular risk assessment and the
modification of blood lipids for the primary and secondary prevention of
cardiovascular disease (May 2008).
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Anti-platelet agents
National guidance on the use of antiplatelet agents for primary prevention of
cardiovascular disease in people with diabetes is currently under review. The
most recent NICE recommendations are to treat any person with type 1 or
type 2 diabetes who meets any of the following criteria:
Age 50
or
Age < 50 and significant other cardiovascular risk factors

o hypertension on treatment,
o family history of premature cardiovascular disease,
o metabolic syndrome
o smoking
o microalbuminuria
o existing cardiovascular disease (MI or angina, stroke or TIA, or PVD)
Start treatment after systolic blood pressure has been reduced to 145
mmHg.
Blood pressure should be kept at 145 mmHg or lower while aspirin is being
taken as anti-platelet therapy.
Prescribe dispersible aspirin 75 mg od unless contraindicated (see below)
Consider life-long clopidigrel in patients who have experienced a vascular
event whilst on aspirin.
Contraindications to anti-platelet agents
Aspirin allergy defined by anaphylaxis - rash or wheeze directly
attributable to aspirin ingestion. Consider use of clopidogrel for
secondary prevention
Previous cerebral haemorrhage (ever)
Active peptic ulceration. In previous peptic ulcer disease, aspirin can be

started in conjunction with a proton pump inhibitor
Bleeding tendency
Active hepatic disease
Concomitant therapy with warfarin or other oral anticoagulants, unless

indicated and carefully monitored
Uncontrolled hypertension (systolic BP 145 mmHg)
References:
NICE clinical guideline 66: Management of type 2 diabetes (update) (2008)
NICE clinical guideline 37: Type 1 diabetes (July 2004)
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Suggested specialist referrals

Urgent action
Hospital admission
patient unwell, unexplained or
protracted vomiting, marked ketonuria,
other severe illness
foot ulcers with systemic infection
Urgent advice from specialist team

newly diagnosed type 1 diabetes (telephone)
children and adolescents with newly diagnosed
diabetes (paediatric team)
infected foot ulcer in at risk foot/patient
pregnancy in a patient with diabetes
severe symptoms, BG 25 mmol/l
(especially with ketonuria)
severe hypoglycaemia or loss of warning
symptoms
Seek advice/consider referral
Diabetes nurse specialists

or medical team*
newly diagnosed diabetes type 1
uncertain classification of diabetes
initiation of insulin or GLP-1 mimetic
if local expertise not available
not achieving glycaemic targets
erratic blood glucose levels
recurrent/unexplained hypoglycaemia
loss of hypoglycaemic warning
recurrent diabetes-related admissions
CHD risk factors not controlled
planning pregnancy
intensification of treatment, inc. pumps
consideration of novel therapies
consideration of use of therapies
beyond licensed indications
consideration of bariatric surgery
unusual or troublesome complications
eating disorders (inc. insulin omission)
psychological or coping problems
all children
poor control in insulin treated patients
lifestyle/educational needs
end of life
steroid treatment
learning difficulties and insulin
dementia and insulin
State registered dietitian
newly diagnosed patients (see local guidelines)

patients presenting with gestational diabetes,
or patients with renal impairment will be seen
by a SRD at the appropriate secondary care
specialist clinics
patients with BMI 28 kg/m2
(overweight/obese) and poor glycaemic
control, HbA1c 58 mmol/mol (7.5%)
Podiatry team
acute foot infection
swollen neuropathic foot? Charcots
all patients with one or more risk factor
(neuropathy, ischaemia, deformity, callus or
swelling) should be referred to the podiatry
service
(see Appendix 1b)
*referrals can be made for full review

in clinic, or direct to the diabetes nurse
specialists if appropriate. The DSNs
can see urgent referrals.
Contact by telephone or fax.
The criteria for referral to the nephrologists are given in Appendix 1d
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Appendix 1a: Hypoglycaemia

Immediate treatment of a hypoglycaemic episode in the community
Hypoglycaemia
Mild hypoglycaemia
Severe hypoglycaemia
Person can self-treat
Person cannot self-treat

Can
swallow
Treatment options:
100 ml
mLof
ofLucozade
Lucozade
150 ml
mL(a
(a small
small can)
can)
non-diet fizzy drink
200 ml
mL (a
(a small
small carton)
carton)
smooth orange juice
5 or 6 dextrose tablets
4 large jelly babies
7 large jelly beans
Treatment options:
offer one
of the treatments
listed for mild
hypoglycaemia
stay with person

until they have
recovered.
Treatment options:
put into recovery

position.
glucose treatments
should not be put
in the month.
inject glucagon
if available and
trained to use it.
OR
Dial 999 for an
ambulance.
2 tubes of glucose gel
If person does
not feel better
or
blood glucose
isisstill
still<< 44 mmol/L
mmol/l
after 5 to 10
minutes,
repeat treatment
Cannot
swallow
When person
starts to feel better
and
blood glucose
> 4 mmol/l
make sure they eat
some starchy food
(e.g. sandwich,
banana or
meal if due)
stay with person

until they start to feel
better.
All patients who experience hypoglycaemia on sulphonylureas require emergency

admission because of the very high risk that hypoglycaemia will recur
Diabetes management should be reviewed to prevent further episodes of hypoglycaemia.

Contact the diabetes care provider.
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Management of problematic hypoglycaemia

Problematic hypoglycaemia
Explore possible reasons

food
activity
alcohol
medication
Patient on
insulin
Exclude underlying causes

weight loss
renal function
endocrine causes
(thyroid, adrenal etc)
coeliac disease
Patient on
sulphonylurea
Rx glucagon and
Glucogel
Hypos requiring
assistance from
a third party
Consider
stopping or reducing dose
starting CBGM by patient or carer
Advise
q.d.s.
self BG monitoring
Reduced warning
(results <3.5 mmol/l
without symptoms)
If medication
required
Review
injection sites
insulin doses
(inc. patients own
adjustments)
hypo treatment
driving safety
Consider urgent
referral to
SpecialistTeam
e.g DRAC
Move sites
and/or
adjust insulin dose
as appropriate
Day time hypos
Advise
regular low GI
bedtime snack
Consider change to
basal bolus
insulin regimen
Consider change to
short acting insulin analogue
(esp. if hypos 1.00 3.00 am)
long acting insulin analogue
If T1DM, refer to
dietitian for training
in carbohydrate
counting
Continued problem
Refer to secondary care
specialist team
Patient on
glibenclamide
consider low dose

tolbutamide
or a gliptin
substitute
gliclazide
or tolbutamide
Continued problem
Refer to secondary care
specialist team
Night hypos
Patient frail or
elderly
Review
carbohydrate counting
dose adjustment etc
Consider
CSII
in T1DM patients
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Targets for glycaemic control

The target HbA1c should be determined on an individual basis and a lower target
should be adopted in patients with a limited prognosis or higher risk of iatrogenic
hypoglycaemia (e.g. the elderly). It should be emphasised that any improvement
in glycaemic control is associated with reduction in risk of microvascular disease,
even if the targets are not achieved.
High risk of hypoglycaemia:

e.g.
previous hypoglycaemia or
treatment includes insulin,
sulphonylurea or glinide
None true
Target HbA1c
< 48 mmol/l
(< 6.5%)
High risk from hypoglycaemia:

e.g.
elderly or recent CV event
or arrhythmias or risk of falls
or risk of fractures
1-2 true
Target HbA1c
48 - 58 mmol/l
(6.5% - 7.5%)
Little proven benefit

from tight glycaemic control:
e.g.
elderly or long duration of disease
or established complications
or limited prognosis
2-3 true
Target HbA1c
53 64 mmol/l
(7.5 8.0%)
(the optimal individual goal
may be higher in
some circumstances)
Notes:
Blood glucose levels of < 4 mmol/L should be treated as hypos whether or not
accompanied by symptoms.
1. Possible reasons to be considered
Changes in food intake reduced carbohydrate, delayed or missed meals or
snacks. Varying carbohydrate intake at meals may also cause hypos.
Physical activity this can include activity such as housework, ironing, shopping
and gardening as well as exercise. Hypos may be delayed following intensive
exercise
Medication/ insulin incorrect or too much. Oral hypoglycaemic agents (eg
gliclazide, glibenclamide) can cause hypos
Alcohol - the effects can often be delayed until the following day, particularly if
large amounts of alcohol are consumed. Advise bedtime snack and blood
glucose monitoring following day
2. People at particular risk
People who frequently experience hypoglycaemia, even if they are able to
treat themselves
People with poor hypoglycaemia symptom awareness
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People who fast (e.g. during Ramadan)

Those with variable eating or exercise patterns
Older people, such as those in the early stages of dementia.
Those with poor mental health.
People with a learning disability.
Those with alcohol-related health problems
People with poor injection technique.
People using antidiabetes drug therapies incorrectly (e.g. dose or
timing)
Women who are pregnant or breastfeeding.
Groups for whom hypoglycaemia has potentially severe consequences e.g.
those who drive, work at heights, or live alone
3.
Potential underlying causes

Renal impairment
Weight loss
Endocrine disorders (eg hypothyroidism, Addisons disease)
Coeliac disease
Pregnancy
Injection sites (especially if the patient has moved sites)
Cessation/reduction of steroids without reduction in diabetes medication
4. Symptoms
Usual symptoms include sweating, trembling, weakness/fatigue, hunger,
palpitations, speech problems
Recurrent hypos will cause a change/reduction in hypo symptoms.
5. Immediate advice
Advise patients to test BG levels if possible in event of further hypos, and to
ingest 20g of quick acting carbohydrate eg Lucozade, glucose tablets. Once
blood glucose levels are above 4mmol/l to have a snack containing approx 1520g of longer acting carbohydrate.
Further information/patient information sheet is available at
6. Assessment and management
Identify the BG level at which the patients warning symptoms occur if
significant reduction in warning or symptoms occur only when BG less than
3.5mmol/l, refer to the diabetes specialist team: the Diabetes Rapid Access
Clinic (DRAC) at NBT, the DSNs at UHBristol or the diabetes team at Weston
General Hospital
Encourage patient to test BG levels pre-meals, bed and around the time that
hypos most commonly occur
Explore timing of medication and food. Ensure insulin or sulphonylurea is being
taken at recommended times in relation to meals
Identify patterns in hypos, advise adjustment in insulin/medication accordingly
Review injection sites lipohypertrophy can cause erratic absorption of insulin.
If patient advised to move sites reduce insulin by 10-20% initially.
Recheck HbA1c. HbA1c < 6.5% in insulin treated patients or HbA1c <6% on
sulphonylureas is suggestive of significant hypoglycaemia.
36
03/01/2013 10:44
7. Hypo unawareness
If the patient experiences no symptoms until blood glucose is <3.5mmol/l,
he/she is considered to have hypo unawareness
Unawareness is potentially dangerous, especially if driving or operating
machinery
Often the patient has no adrenergic symptoms, and therefore presents with
confusion or other neurological problems
Patients with hypo unawareness should be referred for specialist team review
complete avoidance of low BG levels for around 3 months can help restore
warning symptoms. This requires intensive multiprofessional input
8.
Indications for referral to secondary care

Hypo unawareness
Any unconscious episodes of hypoglycaemia
More than 3 hypos per week
Consider referral of any patient having hypos requiring assistance from a third
party
9. Driving and hypoglycaemia

Patients with hypoglycaemia unawareness should be advised not to drive until
warnings return. Must not have had more than one episode of hypoglycaemia
requiring assistance of another person in preceding 12 months.
Always check blood glucose levels before driving, and every 2 hours during the
journey
There must be appropriate blood glucose monitoring
Patients must not drive if feeling hypoglycaemic or if blood glucose less than 4
mmol/l
Patients must 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.
If blood glucose 5mmol/l, take snack before driving
Ensure the patient knows they must have a blood glucose meter and fast
acting carbohydrate in the car
Drivers holding a Class 2 (HGV) licence who require insulin must remain under
follow-up in a consultant clinic
Ref:
http://www.dft.gov.uk/dvla/medical.aspx
https://www.diabetes.org.uk/Documents/catalogue/Driving_and_diabetes.1211.p
df
37
03/01/2013 10:44
foot
hy
t
ACTIVE
HIGH RISK
MODERATE
or
INCREASED
RISK
LOW RISK
Community podiatry
review 3-6 monthly
(as required)
vascular assessment
footwear evaluation
education
12
annual review
within GP practice
education7
Local multidisciplinary
team4
or
Vascular surgeons
Management of painful
diabetic neuropathy
annual review
within GP practice
education7
LOW RISK
team4
NO RISK FACTORS1 present
Refer within 24 hours
present
Critical ischaemia
Gangrene
Chronic wounds,
tendon/bone involvement
or spreading infection
to local multidisciplinary
team4
Community podiatry
review 3-6 monthly
(as required)
vascular assessment
footwear evaluation
education
ONE RISK
MODERATE
or
INCREASED
RISK
Charcot foot
(red, warm , swollen
neuropathic)
Community podiatry
review 1-3 monthly
(as required)
vascular assessment
specialist footwear
and insoles
skin and nail care
special arrangements
for immobile or disabled
education
Painful peripheral
neuropathy
Critical ischaemia
Gangrene
Charcot foot
(red, warm , swollen
neuropathic)
New ulceration
Spreading infection
FACTOR 1
Painful peripheral
neuropathy
HIGH RISK
Inform GP
Assess CRP,
CV risk,
HbA1c
Start appropriate
antibiotics
if infection
clinically
suspected 2
Inform GP
Assess CRP,
CV risk,
HbA1c
Start appropriate
antibiotics
if infection
clinically
suspected 2
Previous ulceration
or
TWO OR MORE
RISK FACTORS1 present
ACTIVE
Community podiatry
review 1-3 monthly
(as required)
vascular assessment
specialist footwear
and insoles
skin and nail care
special arrangements
for immobile or disabled
education
Active ulceration
Spreading infection
Acute Charcot foot
Unexplained hot, red swollen foot
Critical ischaemia
Gangrene
Painful peripheral neuropathy
New ulceration
Spreading infection
38
Management of painful
diabetic neuropathy
team4
or
Vascular surgeons
team4
Chronic wounds,
tendon/bone involvement
or spreading infection
to local multidisciplinary
team4
Superficial wounds
to community podiatry3
Appendix 1b: Diabetes Foot Pathway: Management of active foot disease and increased risk
Diabetes Foot Pathway: Management of active foot disease and increased risk
Superficial wounds
to community podiatry3
38
03/01/2013 10:44
Notes:
1. Risk factors:
a. loss of sensation
b. signs of peripheral vascular disease
c. significant callus
d. Deformity
e. Previous ulceration/Charcot/amputation
2. Extra vigilance:
a. Problems with vision and/or mobility
b. Male gender
c. Co-morbidities associated with diabetes
d. Poor glycaemic control
e. Smoking
f. Social isolation and social deprivation should also be considered
3. If clinical suspicion of infection in foot, start appropropriate antibiotic (e.g.
flucloxacillin 500 mg qds) while waiting for appointment with community
podiatrist or multidisclipinary team
4. Community Podiatry Teams:
Bristol: 0117 919 0275 / fax: 0117 972 3644
South Gloucestershire: 0117 923 6322 / fax: 0117 969 8166
North Somerset: 01275 342285 / fax: 01275 546994
5. Multidisciplinary Teams:
Bristol Royal Infirmary: 0117 342 2175 / fax: 0117 342 3946
Southmead Hospital: 0117 3238697 / fax: 0117 323 6379
Weston General Hospital: 01934 647015 / fax: 01934 647297
6. Education:
a. Patient education/information on foot care needs to be tailored to meet
each individuals needs. Some individuals, because of their personal
circumstances or attitudes to their condition, may need increased levels
of education, care and support.
b. Patient information leaflets specific for each risk category can be
downloaded from
c. Further information is available from
NICE clinical guideline 10: Type 2 diabetes: prevention and
management of foot problems (2004)
(www.nice.org.uk/nicemedia/live/10934/29241/29241.pdf)
www.diabetes.org.uk/Get_involved/Campaigning/Putting-feet-first/
39
03/01/2013 10:44
Appendix 1c: Management of painful diabetic neuropathy

Neuropathic symptoms?
Burning, pain, hyperaesthesia, numbness, difficulty walking
Assess pain using Likert scale

(0 no pain 10 worst possible pain)
or PainDETECT questionnaire
Foot examination and

assessment of risk
Consider other
possible causes
Discuss cause
and prognosis
Drug treatment
Optimise
glycaemic control
Amitriptyline
contraindicated
or not tolerated
Amitriptyline
(max 75mg)
30% pain relief
<30% pain relief
<30% pain relief with

duloxetine alone
Add
Pregabalin
(max 300 mg/day)
Alternative pathway
if persistent pain
on TCA
and pregabalin
Substitute
Duloxetine
(max 60 mg)
consider
Tramadol
(50-100 mg qds)
Refer to
pain clinic or
regional DPN specialist service
40
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Notes:
1. Review patient regularly and increase dose of drugs 1-2 weekly depending
on the response
Use Likert scale or painDETECT questionnaire to guide for dose adjustment
(daily scoring by patient and the weekly mean of pain score)
If 30 % or more improvement but on maximal dose of a drug, add next

drug.
If < 30 % improvement on maximum dose, stop drug.

Starting dose
Suggested increment
interval
Maximum dose
10 mg nocte
10 mg
2 weeks
75 mg nocte
Duloxetine
60 mg o.d.
60 mg o.d.
Pregabalin
75 mg b.d.
75 mg
1 week
150 mg b.d.
Amitriptyline
Trials
show higher doses of duloxitene and pregabalin are generally associated with no
additional benefit but increased risk of side effects (see note 6)
The neuropathy symptom score record and information sheets for patient
prescribed duloxetine, pregabalin or amitriptyline/nortriptyline are available
to be downloaded from www.avondiabetes.nhs.uk
2. Titrate down the dose of drugs over 1-2 weeks when stopping them.
3. Warn patient about sedative effects of drugs especially while driving or
operating hazardous machinery.
4. When combining drugs.
Consider the sedative effects
If combining duloxetine and pregabalin, lower the doses.
The following should not be combined
amitriptyline and duloxetine
pregabalin and gabapentin
tramadol and amitriptyline or duloxetine.

5. In renal impairment doses may need to be adjusted depending on eGFR
6. Pregabalin should be used with caution in patients with pre-existing oedema.
The usual dose is up to 300 mg/day. A dose of 600 mg /day may give some
additional pain relief but is associated with increased side effects. Consider a
trial of the higher dose in patients who have partial benefit from 300 mg/day
and tolerate this dose without problems.
7. Gabapentin can be used as an alternative to pregabalin but has a more
complex dose titration schedule. Trials have used doses titrated from 9003600 mg/day or maximum tolerated dose.
8. If amitriptyline as first-line treatment results in satisfactory pain reduction but
the person cannot tolerate the adverse effects, consider oral imipramine or
nortriptyline as an alternative.
9. Do not start treatment with opioids (such as morphine or oxycodone) other
than tramadol without an assessment by a specialist pain clinic or diabetes
painful neuropathy
41
03/01/2013 10:44
Appendix 1d: Management of persistent albuminuria or

microalbuminuria
Persistent laboratory confirmed albuminuria
urine ACR >30 mg/mmol in 2 samples
at least 1-2 weeks apart
in absence of UTI
Microalbuminuria
2 of 3 urine ACR
2.5M/3.5F 30 mg/mmol
Persistent albuminuria
or microalbuminuria
Check
creatinine/eGFR & visible/non-visible haematuria
Follow local CKD guideline2 appropriate to CKD stage
No haematuria
Any haematuria
CKD 3
eGFR 30-59 ml/min/1.73m2
with no other problems
See CKD guideline2
CKD 1 & 2
eGFR 60 ml/min/1.73m2
with no other problems
CKD 4 & 5
eGFR< 30 ml/min/1.73m2
CKD 3 and at least 1 of the following:

progressive fall in GFR 3
fall in eGFR of >15% after starting
ACEI or ARB
uncontrolled BP (>150/90) on 4 agents
urine ACR > 30 mg/mmol
anaemia (after excluding other causes)
persistent hyperkalaemia
CKD 1 & 2 and 1 of the following:

progressive fall in GFR3
fall in eGFR of >15% after starting
ACEI or ARB
uncontrolled BP (>150/90) on 4 agents
urine ACR >70 mg/mmol
strong suspicion of non-diabetic renal
disease e.g. urine ACR > 30mg/mmol
with no retinopathy in type 1 DM
Discuss with or refer

to Nephrologists
optimise glycaemic control

HbA1c 48-58 mmol/l (6.5%-7.5%)
ACE inhibitor4 (ARB) titrated to full
dose irrespective of initial BP
BP control (target 130/80)
address other CVD risk factors
review medications. Avoid NSAIDs
check kidney function during acute
illness and pre-operatively
Targets
not
achieved
Targets
achieved
6 monthly (CKD 3)
annually (CKD 1&2)
e GFR
urine ACR
Refer to
Diabetes team
(urgent referral if:

GFR <30 ml/min/1.73m2
nephrotic syndrome)
42
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Notes:
1. Chronic kidney disease (CKD) cannot be diagnosed from a single
eGFR. If eGFR is reduced acute renal failure must be excluded. An
eGFR result <60 ml/min/1.73m2 in a person not previously tested must
be confirmed by repeating the test within 2 weeks
2. The local guideline for management of CKD is available on
3. A progressive fall in eGFR is defined >5 ml/min/1.73m 2 in less than 1 year
or >10 ml/min/1.73m2 over 5 years
4. Check eGFR and potassium before and 1-2 weeks after commencing
ACEI or ARB.
Stop ACEI/ARB if potassium > 6.0 mmol/l with no modifiable cause.
Stop ACEI/ARB if eGFR falls >25% unless modifiable cause
If eGFR falls but less than 25%, recheck eGFR in 1-2 weeks
Refer to nephrologists if eGFR falls >15% in patients with CKD 3 or

CKD 1&2
5. Consider stopping ACEI or ARB 1 week prior to elective surgery or

during intercurrent illness (especially if fluid depleted) to reduce risk of
acute kidney injury
6. Check kidney function during acute illness and pre-operatively
References:
NICE clinical guideline 73. Chronic kidney disease: early identification

and management of chronic kidney disease in adults in primary and
secondary care (September 2008)
BNSSG Care Pathway for management of Chronic Kidney Disease

(2009)
Joint British Association of Urological Surgeons/Renal Association
consensus document on management of haematuria
43
03/01/2013 10:44
Appendix 1e: Management of erectile dysfunction
Urological cause1
refer urology andrology

clinic
Medications 2
consider stopping
beta-blockers
Loss of or low libido
exclude endocrine cause3
Evidence of significant relationship/

psychosexual & lifestyle problems
Consider referrral for

relationship/ psychosexual
counselling
No nitrate use & fit for sex

(can climb 2 flights of stairs without
SOB or chest pain)
Trial of oral phosphodiesterase

inhibitor
effective &
no adverse
effects
Patient tries sildenafil 50 mg

on 4 occasions
adverse
effects
not sufficient for intercourse

try sildenafil 50 mg
on further 4-8 occasions 4
try
sildenafil
25 mg

try sildenafil 100 mg
on 8 occasions
Continue
try another PDE5 inhibitor5
Fails to respond to proper trial of PDE5 inhibtors

or unacceptable side effects at effective doses
refer to urology andrology clinic
44
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Notes:
Erectile dysfunction is usually multifactorial
Organic cause likely if: gradual onset, present in all situations (inc
waking & self stimulation), lack of tumescence, normal ejaculation, risk
factors.
Psychogenic cause likely if: sudden onset, early collapse of erection,

normal spontaneous/ waking/ self stimulated erections, premature or
absent ejaculation.
Identify treatable causes if possible

1. Urological causes: e.g. curved penis (Peyronies disease), pelvic injury,
pelvic/prostatic surgery or radiation treatment.
2. Many drugs can theoretically cause ED but medication changes rarely
result in improvement apart from stopping blockers.
3. Check testosterone, SHBG, LH, FSH, prolactin and thyroid function. Refer
for endocrine opinion if appropriate.
4. Effective erections occur after a mean of 8-12 doses of oral
phosphodiesterase inhibitors. If any appears ineffective, patient should
try the drug on at least 8 occasions at the maximum or maximum
tolerated dose before abandoning.
5. Other PDE5 inhibitors: tadalafil (Cialis) 5-20 mg or vardenafil (Levitra) 520mg. Start at sildenafil 50 mg or vardenafil 10 mg and titrate to
response and adverse effects as above. If either appears ineffective,
try on at least 8 occasions before abandoning.
6. All patients with diabetes are entitled to NHS prescriptions for drug
treatment of erectile dysfunction under the SLS criteria
45
03/01/2013 10:44
Appendix 2a: Diabetes in women

1. From adolescence and throughout potential childbearing years (type 1 and type 2 diabetes)
The importance of avoiding unplanned pregnancy
should be an essential component of diabetes education
and must be discussed (and documented)
at every opportunity with all women
with type 1 and type 2 diabetes
from adolescence and while of child-bearing age
Not currently planning

pregnancy
Ensure most effective contraception

possible
Explain (and document) risks of
unplanned pregnancy and the need
to optimise glycaemic control before
stopping contraception
Explain (and document) the need to

plan pregnancy when the time is right
and arrange pre pregnancy counselling
appointment with specialist team well
before pregnancy considered.
In view of the risks to mother and baby associated with unplanned

pregnancy, women with diabetes should be encouraged to use the
most reliable method of contraception available to them.
The following methods of contraception are generally most suitable for
women with diabetes:
Mirena coil usually know as intra-uterine system (IUS) or the
intra-uterine contraceptive device (IUD)
Progesterone only pill eg Cerazette
Contraceptive Implant e.g. Nexplanon
Combined hormonal contraceptives

n.b. generally avoid combined hormonal contraceptive if BMI >35.0,
or over age 35 yr or if diabetic complications/vascular disease present
46
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2. Pre-pregnancy in women with type 1 or type 2 diabetes
The importance of avoiding unplanned pregnancy

should be an essential component of diabetes education
and must be discussed (and documented)
at every opportunity with all women
with type 1 and type 2 diabetes
from adolescence and while of child-bearing age
Not currently planning

pregnancy
Considering
pregnancy
Ensure most effective contraception

possible
Refer for pre-pregnancy counselling

in antenatal clinics at unit chosen
for delivery (St Michaels
or Southmead 1,2 )
Explain (and document) risks of

unplanned pregnancy and the need
to optimise glycaemic control before
stopping contraception
Explain (and document) the need to
plan pregnancy when the time is right
and to arrange pre pregnancy
counselling with specialist team
Prescribe 5mg folic acid od 3
Aim for HbA1c 43 mmol/mol (6.1%) 4

Ensure retinal screening and
urine ACR in the past 6 months 5
Medication review 6
Notes:
1. All women with type 1 or type 2 diabetes planning to become
pregnant must be referred for preconception counselling delivered
by a specialist antenatal medical clinic
2. Referrals should be sent to:
For Southmead Hospital fax to Dr Andrew Johnsons

secretary 0117 323 6379. Also can contact DSN/DSD on
07717422891
For St Michaels Hospital - fax to Diabetes Specialist Nurses

0117 3423945 and to the secretary to the obstetric team (Miss
Sellers/Miss Trinder/Miss Treloar) 0117 342 5250
For Weston General Hospital - fax to Dr Kurien Johns secretary

01934 647209 and to St Michaels 0117 342 5250
47
03/01/2013 10:44
3. There is an increased risk of neural tube defects in babies of women

with diabetes. All women planning pregnancy should be given folic
acid 5mg once daily (not 400 micrograms) prior to conception and
up to 12 weeks gestation.
4. Advise women to aim for an HbA1c below 43 mmols/mol (6.1%), if
safe.
Inform women that any reduction in HbA1c may reduce risks.
Advise women with HbA1c above 86 mmols/mol (10%) to avoid
pregnancy.
5. Advise women who need intensification of hypoglycaemic therapy
to increase the frequency of self-monitoring to include fasting and a
mixture of pre- and postprandial levels.
Offer ketone testing strips to women with type 1 diabetes and
advise on use if hyperglycaemic or unwell
6. Diabetic retinopathy can worsen in pregnancy, therefore all women
must have retinal assessment by digital imaging with mydriasis using
tropicamide within the 6 months prior to conceiving
7. Medication review:
Oral hypoglycaemic agents may need to be stopped and insulin

started if required. However, NICE guidance allows the use of
metformin (and exceptionally, with informed consent,
glibenclamide) in pregnancy under specialist antenatal care.
Angiotensin-converting enzyme inhibitors and angiotensin-II

receptor antagonists should be stopped and alternative
antihypertensives started (methyldopa)
Statins should be stopped
Reference:
NICE clinical guideline 63: Diabetes in Pregnancy (July 2008)
http://www.nice.org.uk/nicemedia/pdf/CG063NICEGuideline.pdf
48
03/01/2013 10:44
3. Confirmed pregnancy in women with type 1 or type 2 diabetes
Confirmed pregnancy
(planned or unplanned)
in a woman with type 1
or type 2 diabetes
In all pregnancies ensure

prescribe 5mg Folic acid od for 12 weeks 3
aim for HbA1c 43 mmol/mol (6.1%) 4
medication review 6
Southmead Hospital
Urgent referral (same day) faxed to

Dr Johnsons secretary 0117 323 6379
and
Phone referral to DSNs and give
women the contact number
07717422891
St Michaels Hospital
Urgent referral to Peggy Woodward

Diabetes Specialist Midwife
0117 342 5577 or fax 0117 342 5523
Phone referral to DSNs
BRI - 0117 342 2892 or
Weston General Hospital
01934 647213
1. Advise women to aim for an HbA1c 43 mmol/mol (6.1%) if safe.

Inform women that any reduction in HbA1c may reduce risks.
2. Prescribe folic acid 5mg for 12 weeks and review medication as
indicated in pre-pregnancy section
3. Women will be expected to monitor capillary blood glucose for a
minimum of 7 times per day and before driving
4. Offer ketone testing strips to women with type 1 diabetes and
advise on use if hyperglycaemic or unwell
Reference:
NICE clinical guideline 63: Diabetes in Pregnancy (July 2008)
49
03/01/2013 10:44
4.
Pregnancy in women at risk of gestational diabetes
Screen at booking
BMI > 30 kg/m2
Previous gestational diabetes
Previous macrosomic baby

(birth weight 4.5 kg)
1st degree relative with diabetes

Family origin with high
prevalence of diabetes
(South Asian, black Caribbean/
African, Middle Eastern)
Offer 75g oral glucose

tolerance test at 16-18 weeks
and
repeat at 28 weeks
if first test normal
or
offer early self-monitoring
of blood glucose
Offer 75g oral glucose

tolerance test at 24-28 weeks
See local guidelines for

referral to specialist
maternity services
Southmead Hospital
St Michaels Hospital
Refer to Antenatal Clinic

Tel: 0117 323 5310
Fax: 0117 323 5313
Refer to Peggy Woodward

Tel: 0117 342 5577
or Fax 0117 342 5523
Refer to DSNs
01934 647213
1. Women with GDM will be expected to monitor capillary blood

glucose for a minimum of 4 times per day and before driving.
50
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5. Post natal care

General:
Breastfeeding - continue to avoid drugs discontinued for safety

reasons
Advise on the importance of contraception and pre-conception

care when planning future pregnancies
Gestational diabetes:
Advise on
o weight control, diet / exercise
o
symptoms of hyperglycaemia
o Risks of gestational diabetes and need for screening when

planning pregnancy
FBG at the 6-week postnatal appointment, then annually
Insulin-treated pre-existing diabetes:
Encourage frequent monitoring as insulin requirements may change
Risk of hypoglycaemia, especially while breastfeeding
Food available before / during breastfeeding
Refer back to routine diabetes care
Type 2 diabetes:
Resume or continue metformin or insulin while breastfeeding. Other

oral hypoglycaemic agents to be avoided
Refer back to routine diabetes care
Ophthalmological follow-up:
Women with preproliferative diabetic retinopathy diagnosed in

pregnancy should be offered ophthalmological follow-up for at least
6 months post partum
51
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Appendix 2b: Diabetes in children and young people

At diagnosis of diabetes, children should always be referred on the same
day to the Bristol Royal Hospital for Children.
Ongoing management
The paediatric diabetes nurse specialists undertake home visits,

telephone contact and liaison with other professionals involved in a
child/adolescents care e.g. health visitors, GPs, nurseries, schools.
After diagnosis, children and adolescents continue to have their care

delivered through secondary care, in line with the Diabetes NSF. The
Bristol and Weston Paediatric Diabetes team provides multidisciplinary
input to the care of these patients and their families, with care
provided by paediatric diabetes nurse specialists, paediatric dietitians,
medical staff and specialist clinical psychologists. There is close liaison
with CAMHS and Social Services.
Patients are seen in outpatients every 3-4 months in whichever of the

three locations offered by the Bristol Paediatric Diabetes team that is
the most convenient for the family: Bristol Royal Hospital for Children,
Southmead Hospital, Weston General Hospital. The Annual Review is
undertaken within this clinic setting, with the exception of the retinal
screening which is undertaken by the Digital Retinal Screening
programme.
Transition to adult services
Transition to adult diabetes services is a planned process, occurring at

a time appropriate for the adolescents individual requirements e.g.
educational, developmental and social. This handover process involves
close liaison between paediatric and adult services.
Young adults with type 1 diabetes who have just transferred to the
adult diabetes service should remain under regular review in specialist
clinics in secondary care.
52
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Appendix 2c: Diabetes in the elderly and housebound
Special considerations in annual review in the elderly
Explorations of any concerns
Cognitive assessment & depression screen

(repeat during year if sudden deterioration in BG control)
consider hypoglycaemia if new or increased confusion,
communication difficulties can lead to unrecognised
diabetes care needs
Metabolic management
If patient highly dependent & frail/ resident
in nursing home/ cognitively impaired:
aim for symptom control;
avoid hypoglycaemia & intrusive monitoring
Surveillance for long term complications

eyes: retinal screening & visual acuity or
domiciliary optometry service for housebound
feet: standard foot assessment & care advice
(increased risk of foot ulceration)
kidneys: creatinine, proteinuria microalbuminuria
Assess for diabetes related problems (see notes)

diet - poor nutrition & weight loss
hypoglycaemia
neuropathy
falls
incontinence - due to hyperglycaemia or urine infection
Assess suitability for self care or carer assistance

Check safety with insulin administration, medications
& CBG monitoring
Assess social situation
Discuss driving regulations
Review care plan for care staff if necessary
53
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Notes:
Diabetes is very common in the elderly; often undiagnosed; up to 25% of care home residents
have diabetes.
Diagnosing and classifying diabetes
Type 1 diabetes can have an insidious onset in the elderly.
Secondary diabetes can be caused by
other medication such as steroids
chronic pancreatitis and malignancy
Due to physiological changes the elderly may not present with classical symptoms. When
screening remember the fasting glucose may be normal in undiagnosed diabetes in the elderly.
Targets for glycaemic control should be adjusted to take into account the particular risks and
limited proven benefits of tight glycaemic control in this population (see Appendix 1a)
Diet
Ensure diet is adequate; weight loss may indicate deficient nutrition
Beware of mobile meals only being delivered on week days.
Insulin is used in type 2 diabetes to avoid osmotic symptoms, metabolic decompensation,
improve cognition and well being.
Use an insulin regimen that fits with the individuals lifestyle or is suitable for the carer to
manage discuss with the community DSN.
Assess suitability for self care and ensure the individual is safe administering insulin.
HbA1c measurement is unreliable in people with anaemia and HbA1c may be reported as
higher than it really is. Targets will need to be lowered accordingly
Hypoglycaemia may present as
Off legs or mobility problems, the elderly have poor hypoglycaemia awareness
Confusion - acute or chronic
Hemiparesis resembling a stroke or TIA, and fitting
Confusion
2-3 fold increased risk of dementia in the elderly with diabetes; consider the following possible
causes for confusion:
Hypoglycaemia, particularly nocturnal
B12 deficiency, hypothyroidism, hypercalcaemia, cerebrovascular disease
Management consists of social support for meals and medication, avoid agents with risk of
hypoglycaemia if possible and review targets.
Neuropathy
Check B12 & TFT as often abnormal in the elderly and can cause neuropathy
Treat neuropathic pain (see appendix 2c)
Falls
70% increased risk of fractures in the elderly with diabetes due to falls, assess:
Cognition, vision, neuropathy, postural hypotension, hypoglycaemia, vitamin D deficiency
Care home diabetes
Diabetes increases the risk of needing residential care. Hypoglycaemia is a risk, particularly on
admission, since medication is enforced and dietary intake may be lower. Ensure adequate diet
and then treat the plasma glucose. Weight is likely to decline with time as will BP so monitor and
adjust medication.
References: British Geriatrics Society Compendium Diabetes Guidelines; www.bgs.org.uk, DUK
residential care guidelines
www.diabetes.org.uk/Documents/Get%20involved/WDD/2010/Care_homes_report2010.pdf ; RCN
good practice in caring for people with diabetes in residential care
www.rcn.org.uk/development/practice/diabetes/good_practice/residential_care
54
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Appendix 2d: Managing diabetes at the end of life

i. Type 1 diabetes
Type 1 diabetes
will still need

some insulin until end of life
last weeks of life
eating usual
intake
continue usual insulin at

reduced dose
final days of life
eating minimal
amount
discontinue usual insulin

regimen and commence
insulin glargine
mane
dscontinue insulin and BG monitoring when patient unconscious

or clinical team and carers agree consequences of
uncontrolled hyperglycaemia are less burdensome
for patient than process of monitoring and injections.
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ii. Type 2 diabetes
Type 2 diabetes
insulin treated
tablet treated
discontinue usual insulin regimen

and monitor capillary BG b.d. for 2 days
discontinue OHA
and monitor capillary BG o.d. for 2 days
last weeks
of life
final days
of life
BG 20 mmol/l
or
BG 15 mmol/l
and symptoms
of hyperglycaemia
BG < 20 mmol/l
or
no symptoms
BG 20 mmol/l
and
symptoms
needs insulin
Rx insulin
glargine o.d.
no insulin
or
monitoring
required
consider
insulin
glargine o.d.
final days
of life
or
BG < 20
mmol/l
or
no symptoms
no OHA
or
monitoring
required
last weeks
of life
BG 20 mmol/l
or
BG 15 mmol/l
and symptoms
of hyperglycaemia
consider
restarting OHA
at reduced dose
discontinue insulin and BG monitoring when patient unconscious

or clinical team and carers agree consequences of
uncontrolled hyperglycaemia are less burdensome
for patient than process of monitoring and injections.
56
03/01/2013 10:44
Notes:
1. Objectives of care
To prevent symptomatic hyperglycaemia
To prevent diabetic ketoacidosis (DKA) or hyperosmolar

hyperglycaemic state (HHS); formerly known as hyperosmolar nonketotic state (HONK)
To prevent iatrogenic hypoglycaemia
To prevent unnecessarily invasive interventions in the last weeks to days

of life
To recognise that strict glycaemic control and dietary restrictions are

not desirable and aim for blood glucose range 5 20 mmol/l.
2. Clinical teams should recognise and communicate with the patient,
carers and staff that the patient with diabetes is entering the final weeks or
days of their life, so that care and medical management can be planned
3. The consensus clinical guideline to manage diabetes at the end of life is
available on www.avondiabetes.nhs.uk
4. The appropriate clinical guidance should be selected on the patients
expected prognosis and diabetes type.
Further information and detailed algorithms for the management of patients with
diabetes who are at the end of life are available at
www.diabetes.org.uk/About_us/Our_Views/Position_statements/End-of-Life-Care-/
57
03/01/2013 10:44
Appendix 2e: Diabetes and steroid treatment
Known diabetes
tablet/insulin treated
Diet controlled diabetes/not known

diabetes with symptoms that may be
related to hyperglycaemia
Monitor BG for 2 days
Monitor BG for 2 days
BG < 15 mmol/l
Continue
current
treatment
BG 15 mmol/l
Tablet
treated
Insulin
treated
BG < 15 mmol/l
BG 15 mmol/l
Stop
monitoring,
no Rx required
Start gliclazide
80mg
BG
<5
mmol/l
Continue
monitoring
for 2 days
Increase
OHAs
BG < 15
mmol/l
Continue
current dose
stop
monitoring
unless
symptomatic
BG 15
mmol/l
Start morning
isophane
insulin
& continue
OHAs
Reduce
gliclazide to
40 mg od
or
stop if
hypoglycaemia
BG
<15 mmol/l
with no
symptoms
stop
monitoring
BG 15
mmol/l or
symptoms
start morning
isophane
insulin &
continue
OHAs
Increase insulin and continue monitoring if BG

11 mmol/l
If on b.d. insulin regimen, consider adding
short acting insulin with lunch or switching to
basal-bolus regimen
58
03/01/2013 10:44
Effect of steroids on blood glucose levels
Steroids induce a state of relative insulin resistance, most patients will

not have significantly different fasting blood glucose but postprandial
hyperglycaemia is exaggerated
BG levels can start to rise within a few days of commencing oral

steroids and subside within 48 hours of stopping the medication.
Injected steroids may cause BG levels to rise soon after administration
& last 3 - 10 days
Controlling BG levels will improve hyperglycaemic symptoms, reduce

the risk of infections and hyperglycaemic emergencies
Managing diabetes and steroid therapy
Start BG monitoring (BGM) or increase the frequency check fasting

and post-prandial levels for 2 days
Diet/tablet controlled if BG 15mmol/l add gliclazide for people

normally controlled on diet alone or with metformin
If BG remains 15mmol/l after increasing OHAs, add isophane insulin,

initially at breakfast time
Frail or elderly patients may benefit from other regimens suited to their
glucose profile and circumstances contact the community DSN or
specialist team for advice if in doubt in any of these situations
Insulin treated increase insulin if BG 11mmol/l consider a basal bolus

regimen or adding short acting insulin to a bd regimen and adjust as
per sick day guidance (www.avondiabetes.nhs.uk)
Not known to have diabetes but displaying symptoms that may be

related to hyperglycaemia, initiate BGM for 2 days and treat as for
diabetes if BG 15mmol/l
General advice
Patients on steroids often have additional causes for the increase in BG
level, such as decrease in activity, increased appetite & weight gain
Follow a healthy eating plan & see a dietitian if indicated
Refer to DSN for ongoing education and support if indicated
These guidelines are intended for use in patients on short term

steroid treatment or at the end of life. Lower BG targets may be
appropriate in patients needing longer term steroid therapy
Further information and detailed algorithms are available in the

supplementary documents at
www.diabetes.org.uk/About_us/Our_Views/Position_statements/End-of-LifeCare-/
59
03/01/2013 10:44
Appendix 3a: Starting insulin in type 2 diabetes
Who should initiate insulin in type 2 diabetes?
Insulin can be initiated in primary care by GP and practice nurse teams who
have undergone recognized training (locally or nationally), attend CPD in
diabetes care and when the practice nurse has a recognized diabetes
qualification (e.g. diabetes diploma).
If in doubt contact the secondary care team or primary care DSN
How is it done?
1. Ensure the patient understands the relationship between insulin and BG,
this helps when increasing the dose of insulin (those unable to monitor BG
levels will require support from community nursing team)
2. Become familiar with the use of a limited range of insulins. For example:
a) isophane insulin (Insulatard, Humulin I or Insuman Basal) for
overnight regimens,
b) 30/70 biphasic pre-mixed soluble/isophane insulins (e.g.
Humulin M3) or isophane insulin for twice daily regimens.
For most people with type 2 diabetes insulin analogues offer no significant
advantage over human NPH isophane and are much more expensive.
Assess lifestyle issues and refer
to dietitian
Decision to start insulin

Involve patient in choice of regimen
and device to suit lifestyle and ability
add bedtime insulin to oral therapy
twice daily insulin

(continue metformin if tolerated)
start isophane insulin

10 units od if previously on
metformin only or if sulphonylurea
or gliptin continued
20 units od if previously on
combined treatment and
SU is stopped. Use lower dose if
BMI < 20 kg/m2 or patient is
frail/elderly
start
biphasic 30/70 premixed
soluble/isophane insulin
or isophane insulin b.d.
10 units bd if BMI > 20 kg/m2.
Use lower dose if BMI < 20 kg/m2
or patient is frail/elderly
continue metformin if tolerated
stop all other oral agents
In general, addition of a single dose of bedtime insulin to oral therapy is only

likely to control BG if the patient is asymptomatic and HbA1c < 80 mmol/mol
(9.5%)
60
03/01/2013 10:44
Continue metformin in combination with the insulin if tolerated in order to

minimize weight gain. If unable to tolerate metformin, consider switch to
modified release or reduced dose.
3. Hypoglycaemia patients need to be clear on how to recognize
symptoms and what corrective action to take (see page 33).
Hypoglycaemia guidelines/patient information sheet available on
4. Implications for DVLA need to be discussed refer to the DVLA website
www.dft.gov.uk/dvla/
5. Telephone support and an emergency contact are needed with regular
follow up.
Adjusting the dose of insulin

Targets may need to be modified for patients who are frail and elderly or
have cognitive impairment (see p35 targets for glycaemic control)
Bedtime insulin
adjust dose every 3 days to achieve
fasting BG 4.0 5.5 mmol/l
unless symptoms of hypoglycaemia
occur
fasting BG
5.5 - 10.0 mmol/l
fasting BG
consistently
>10.0 mmol/l
increase dose
by 2 units
increase dose
by 4 units
Twice daily insulin

adjust dose every 3 days to achieve
fasting and pre-evening meal
BG 4.0 5.5 mmol/l
unless symptoms of hypoglycaemia
occur
determine whether fasting or

pre-evening meal test is highest and
adjust the appropriate insulin
to bring this down
BG
5.5 - 10.0 mmol/l
BG
consistently
>10.0 mmol/l
increase dose
by 2 units
increase dose
by 4 units
Once the target is achieved, avoid making changes too frequently.
If BG levels remain elevated check factors such as injection technique,

diet, lifestyle and the patients understanding of what he/she is doing.
61
03/01/2013 10:44
Educational topics to be covered when starting insulin
Hypoglycaemia
What to do if unwell
Driving regulations
Insulin storage
Injection sites & technique
Insulin adjustment
Sharps disposal
Lifestyle
Blood glucose monitoring
Diet and alcohol
References:
RCN Guidance for nurses: Starting insulin treatment in adults with type 2
diabetes
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf
MeReC Bulletin 22 No 5 (2012) Implementing key therapeutic topics: 3
Type 2 diabetes.
http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol22_no5.php#
LIA
62
03/01/2013 10:44
Appendix 3b: Weight management pathway

Essential criteria:
patient medically stable

Patient psychologically stable
Patient motivated to lose weight and attend appointments
determine degree of obesity : BMI and waist circumference

assess patients readiness to change
is weight loss their main concern?
Tier 1: Structured Weight Management Support

(most appropriate for BMI 28 kg/m2 )
physical activity options & slimming groups
practice nurse for 1:1 consultation
or practice-based weight management group
trial of anti-obesity medication
refer to dietitian as per local guidelines
BMI 30 kg/m2
OR
BMI 28 kg/m2 with co-morbidities, relevant ethnicity or pregnant
OR
Tier 1 objectives not achieved
Tier 2: Community Weight Management Service

(not available in all BNSSG areas)
Dietietic 1:1 counselling
Dietetic-led / community led groups
Adult Specialist Weight Management Service Referral form
available on www.avondiabetes.nhs.uk
(currently no Tier 3 service in BNSSG)

Tier 4: Morbid Obesity Service
Consider referral to specialist diabetes service
for consideration of weight loss surgery
if appropriate
Weight loss surgery in type 2 diabetes
Waist Circumference
Increased Risk
Men
Women
>94cm (37 inches)

>80cm (32 inches)
Substantially
increased Risk
>102cm (40 inches)
>88cm (35 inches)
Asian
Population
>90cm
>80cm
Useful resources are available on www.avondiabetes.nhs.uk

63
03/01/2013 10:44
Appendix 3c: Weight Loss Surgery in Type 2 Diabetes
Type 2 diabetes
+
BMI 35.0
No
Is the patient
interested in losing weight
at this time?
Surgery not
indicated/available
Review of situation in
6/12, to assess motivation
and query changes
Review: Slimming clubs

Exercise on prescription
Walking programmes
No
Yes
Refer to local secondary

care diabetes service
Yes
Reassessment:
clinical, psychological &
behavioural
Review: Including
lifestyle changes, diet,
physical activity
& medication
Have changes been

partially successful?
Yes
Consider drug
therapy
Drug
therapy
3 to 6
months
Has the patient

undergone a weight
management programme
Successful?
i.e. 10% target weight
loss achieved?
Inappropriate or
unwanted
at current time
Yes
Yes
No
Hold off surgery
for the moment
Referred for
consideration
for surgery
6/12 review.
If weight
increased
64
03/01/2013 10:44
Contact List
Consists of the specialist multiprofessional team, supported by primary care
teams and community nursing teams.
Specialist care team contact numbers:
1. UNIVERSITY HOSPITALS BRISTOL TRUST
Diabetes Nurse Specialists
Helen John, Lis Jones, Jane Godfrey
0117 342 2892
(voicemail, messages dealt with regularly)
Dietitian
Kim Vonk
0117 342 6334
Consultant secretaries
Dr N Thorogood
Dr K Bradley
Dr G Bayly
Dr B Ahmed
Dr S Croxson (elderly care)
Professor D Wynick (diabetic painful neuropathy)
0117 342 2768

0117 342 3082
0117 342 3245
0117 342 2271
0117 342 1316
0117 342 3553
Appointments
Department Fax/Secretaries
0117 342 0281
These contact numbers are available Mon-Fri office hours

Services are provided from Bristol Royal Infirmary outpatient dept. and
community podiatry clinics.
Specialist Podiatrist
(Tel)
(Fax)
0117 342 2175

0117 342 3946
Obstetric (referrals)
St Michaels Hospital - fax to BRI Diabetes Specialist Nurses
and to secretary (Miss Sellers/Miss Trinder/Miss Treloar)
0117 342 3945

0117 342 5523

Peggy Woodward
Adult Weight Management
Weight Management Referral Administrator
Email: laura.rowe@bristol.nhs.uk
Adult Specialist Weight Management Service
(Greenway Community Practice)
Dietitians
0117 342 5577

0782 689 4219
0117 900 2405
0117 959 8935/ 8921

65
03/01/2013 10:44
2. NORTH BRISTOL TRUST

Frenchay
Julie Emsley/Nikki Davies
0117 975 3701/3866
Southmead
Prue Richardson
Catherine Offer
Deborah Stern
0117 323 5390

0117 323 5391
0117 323 4111
Renal Diabetes Clinical Nurse Specialist

Southmead (Karen Marchant)
0117 323 6059
Dietitians
Frenchay (Cathy Grove)
Southmead (Lynn Sawyer)
0117 975 3839

0117 323 5428
Specialist Podiatrists
Nicola Percy, Nikki Drake
0117 323 5688

(Fax)0117 323 5671
Southmead fax to Dr Johnsons secretary
0117 323 6345
Frenchay (Dr Parfitt):
0117 918 6509
Southmead (Dr Johnson/Prof Bingley/Dr Chau):
0117 323 5283
Diabetes Rapid Access Clinic (referrals)
07500 027 385
These contact numbers are available Mon-Fri during office hours

Services are provided from Southmead and Frenchay outpatient depts. and
community podiatry fields
3. WESTON GENERAL HOSPITAL
Sian Erasmus, Jane Brazier
0193 464 7213
Dietitians
Sally Furniss, Gillian Cook
0193 464 7031
Fax to Dr Johns secretary
and to St Michaels Hospital
0193 464 7209

0117 342 5523
66
03/01/2013 10:44
Dr Singhal/Dr John
01934 636 363 (ext 3803)
4. NORTH SOMERSET COMMUNITY PARTNERSHIP

Primary care diabetes specialist nurses
(Based at Locking Castle, Medical Centre, Worle)
Judith Wood
Sarah Gane
01934 527 116

Mobile: 07920 138864
01934 527 117
Mobile: 07768 926549
Podiatry
For all enquiries & bookings related to Clinics at:
WGH, Winscombe, Yatton & Worle
Clevedon, Nailsea & Portishead
01275 547 085

01275 342 285
Secretary
Fax (Please phone prior to faxing referrals)
Hot foot clinic referrals
01275 546 810

01275 546 994
01934 647 297
5. PAEDIATRIC DIABETES TEAM

Diabetes specialist nurses
UHB (Noeleen Lovell, Alison Gunn, Clare Parsloe, Helen Cook & Helen
ODonnell)
0117 342 8559
0117 342 8572
North Somerset Community Partnership Nurses
Vivien Arthur
Carol Motteram
01934 521729
Mobile: 07775 778448
Mobile: 07768 933453
Dietitians
Bristol Royal Hospital for Children
Shelley Easter
Sally Furniss, Clare Ewan
01934 647 031
Dr Burren
Dr Crowne
Prof Shield
Dr Bragonier
Dr Barton
Dr Eggers
0117 342 0203

0117 342 0165
0117 342 8809
0117 342 8681
0117 342 0203
0193 488 1373
0117 342 8802
67
03/01/2013 10:44
6. BRISTOL COMMUNITY HEALTH (www.briscomhealth.org.uk)

6. BRISTOL COMMUNITY HEALTH (www.briscomhealth.org.uk)
Community Diabetes specialist nurses (Bristol)
Community
Diabetes
nurses
(Bristol)
(All
post to John
Miltonspecialist
Clinic, Crow
Lane,
Henbury BS 10 7DP)
(All post to
John Nicki
MiltonMeade
Clinic, Crow Lane, Henbury BS 100117
7DP)959 8970
Beverley
Britton,
Beverley Britton,
Nicki
Meade
0117 959
959 8970
8970
Associate
Diabetes
Nurse:
Helen Barrett
0117
Associate Diabetes Nurse: Helen Barrett
0117 959 8970
Nutrition and Dietetics (Bristol)
Nutrition
and
Dietetics
(All
post to
John
Milton(Bristol)
Clinic, Crow Lane, Henbury BS 10 7DP)
(All post Dinnall,
to John Jackie
Milton Clinic,
Crow
Lane, Henbury
BS 10
7DP)
Monica
Freeman,
Elizabeth
Joslin, Beth
Rougier
Monica
Dinnall, Jackie Freeman, Elizabeth Joslin, Beth Rougier
Email:
bchdietitians@nhs.net
0117 959 8970
Email: bchdietitians@nhs.net
0117 959 8970
Community Podiatry (Bristol)
Community
Podiatry
(Bristol)
(All
post to Knowle
Clinic,
Broadfield Road, Knowle BS4 2UH)
(All post office
to Knowle
Central
for allClinic,
BristolBroadfield
clinics andRoad,
staff Knowle BS4 2UH)
0117 919 0275
Central office for all Bristol clinics and staff
0117 919 0275
Diabetes Education - BNSSG
Diabetes
Education
- BNSSG
(All
post to
John Milton
Clinic, Crow Lane, Henbury BS 10 7DP)
(All post to John Milton Clinic,
Lane,
Henbury
BS 100117
7DP)959 8970
Booking/Administration:
Linda Crow
Faulkner,
Noreen
Sims
Booking/Administration:
Linda Faulkner, Noreen Sims
0117 959 8970
Email:
diabetes.education@bristol.nhs.uk
Email: diabetes.education@bristol.nhs.uk
Programme Manager: Kizzy Harris
0117 959 8970
Programme Manager: Kizzy Harris
0117 959 8970
Diabetic Retinal Screening BNSSG Eye screening service
Diabetic
Retinal Screening BNSSG Eye screening service
Appointments:
0117 342 0888
Appointments:
0117 342 0888
Email: bris-pct.drssappointments@nhs.net
Email: bris-pct.drssappointments@nhs.net
7. NHS SOUTH GLOUCESTERSHIRE
7. NHS SOUTH GLOUCESTERSHIRE
Primary Care Dietitians
Primaryat
Care
Dietitians
(Based
5 Fountain
Court New Leaze Bradley Stoke)
(Based atNorris,
5 Fountain
New
Leaze
Lorraine
JackieCourt
Wilson,
Fiona
Lile,Bradley Stoke)
Lorraine
Norris, Jackie Wilson, Fiona Lile,
Jenny
Forrester-Wood
01454 275 245
Jenny Forrester-Wood
01454 275 245
Podiatrists
Podiatrists
(Based at 5 Fountain Court New Leaze Bradley Stoke)
(Based
at 5 Fountain
Court
New Leaze Bradley Stoke)
Anne Wharram,
Nicola
Hudson
01454 275 253
Anne Wharram, Nicola Hudson
Fax: 01454
01454 275
270 253
840
Fax: 01454 270 840
Exercise on prescription
Exercise
prescription
(Based aton
The
Council Offices, Badminton Rd, Yate)
(Based
at The Council Offices, Badminton Rd, Yate)
Clare Fleming
01454 864384
Clare Fleming
Fax: 01454
01454 864384
868535
Fax: 01454
868535
Postal address: PO Box 2081, Council Offices, Castle St, Thornbury,
BS35
9BJ
Postal address: PO Box 2081, Council Offices, Castle St, Thornbury, BS35 9BJ
Email: healthylifestyles@southglox.gov.uk
http://www.southglos.gov.uk/Pages/Article%20Pages/Exercise-onhttp://www.southglos.gov.uk/Pages/Article%20Pages/Exercise-onprescription-Referrer-11182.aspx
prescription-Referrer-11182.aspx

68
68
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03/01/2013 10:44

Diabetes Mellitus - Integrated Care Pathway

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Integrated Care Pathway

5th Edition 2012

NHS Diabetes Booklet.indd 1

Integrated Care Pathway for adults with

This Integrated Care Pathway is intended to inform team members and

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 2

NHS Diabetes Booklet.indd 3

Periodic testing in CVD,

Diagnosis by WHO criteria 2

not acutely ill

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 4

Initial assessment and

CVD risk factors should therefore be aggressively addressed in patients

lifestyle changes (moderate weight loss and increased, regular

consider performing an OGTT in this group to clarify glucose tolerance

6-12 monthly testing of fasting glucose, re-assessment of CVD risk

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 5

(e.g. symptomatic children and young people, symptoms suggesting

HbA1c 48 mmol/mol (6.5%) = diabetes

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 6

1. Algorithm for glucose-based diagnosis of diabetes

5.6 11.0 mmol/l

6.1- 6.9 mmol/l

2. Algorithm for HbA1c based diagnosis of diabetes (see notes for

* Reassess earlier if patient develops symptoms

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 7

Initial assessment and classification in adults

Not acutely ill

Not acutely ill

Contact diabetes team within 24 hours

For Practical Classification Guidelines, please visit:

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 8

Initial assessment and classification in children and adolescents

Refer to paediatric diabetes team

Contact paediatric diabetes team

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 9

Strong clinical evidence

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 10

Initial management of type 1 diabetes in adults

confirm diagnosis and classification

Diabetes Nurse Specialist to coordinate

regular DSN review to provide

Within first year

Continuing care & review

BNSSG Diabetes ICP November 2012

NHS Diabetes Booklet.indd 11

Initial management of type 2 diabetes

screen for risk factors and complications as at annual review

Review diet and exercise

FBG < 7 mmol/l

FBG 7-10 mmol/l

FBG > 10 mmol/l

Review diet and exercise

BMI < 25 kg/m2