21 April 2009
Grampian Guidelines for the
Management of Diabetes Mellitus
2009
21 April 2009
Table of Contents
Section A: Classification, Diagnosis Initial Management,
Prevention and Screening ...................................... 5
Section B: Supporting Self-Management ................................ 36
Section C: Glycaemic Control .................................................. 79
Section D: Complications ....................................................... 127
21 April 2009
Introduction
These guidelines are designed to assist everyone involved in the care of
people with diabetes in planning and implementing their own local care plans,
and in dealing with specific common problems. They have been written by
local healthcare professionals in primary and secondary care with the aim of
supporting local practice within Grampian.
They will facilitate the development of a common standard of care for all
people with diabetes in the region, and provide guidance on access to the
various support services that are available.
The purpose of diabetes care is to empower patients to make informed
decisions about their lifestyle, self-management and health choices. Holistic
patient care requires that patients are involved in setting their own realistic
targets.
A selective update of the electronic guideline will follow the publication of the
SIGN diabetes guideline (expected to be available in 2010).
Useful Websites:
Throughout the Guideline chapters there will be important links to additional
information. A comprehensive list of these websites is available at the end of
the document. Some important websites are included below:
Grampian Diabetes Website
http://www.diabetes.grampian.org
The live version of these Guidelines is available through the Diabetes MCN
website at http://www.diabetes.nhsgrampian and this is a useful website for
diabetes in Grampian in general.
Scotland’s Health on the Web (SHOW)
http://www.show.scot.nhs.uk/
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/
NICE Guidelines – Home Page
http://www.nice.org.uk
My Diabetes My Way
http://www.mydiabetesmyway.scot.nhs.uk
Diabetes in Scotland
http://www.diabetesinscotland.org.uk/
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SCI-DC – home page
https://ctc6.tayside.scot.nhs.uk/scidc/
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Section A: Classification,
Diagnosis Initial Management,
Prevention and Screening
A1.0 Types of Diabetes .............................................................................. 6
A2.0 Confirming the Diagnosis and Initial Management ............................... 8
A2.1 Confirming the diagnosis ............................................................. 8
A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l) .................... 8
A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO
2000) ............................................................................... 8
A2.2 Determine the risk of ketoacidosis and likely need for immediate
insulin therapy ............................................................................ 9
A2.2.1 Indications for immediate insulin therapy ........................ 9
A2.2.2 Patients not requiring immediate insulin ........................ 10
A2.3 Check list for recently diagnosed diabetes ................................ 10
A2.3.1 Checklist ....................................................................... 10
A2.4 Impaired glucose tolerance & impaired fasting glucose ............ 12
A2.5 Glycaemic control - management of the newly diagnosed patient:
................................................................................................. 13
A2.6 Performing a 75g Oral Glucose Tolerance Test ........................ 15
A3.0 Prevention of Diabetes .................................................................... 16
A3.1 Background ............................................................................... 17
A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle .. 19
A3.1.2 Key Facts – What is a healthy weight? ......................... 21
A3.1.3 Key Facts – Eating a Healthy Diet................................. 21
A3.1.4 Key Facts - Physical Activity ......................................... 23
A3.1.5 Key Facts: Healthy Lifestyle & Alcohol .......................... 26
A3.1.6 Key Facts: Medicines & Surgery as part of the
management of obesity ................................................. 28
A3.1.7 Sources of advice about how to achieve and maintain a
healthy weight & lifestyle ............................................... 30
A4.0 Screening for diabetes .................................................................... 32
A4.1 UK National Screening Committee (UK NSC) ........................... 32
A4.1.1 Summary of evidence regarding screening for diabetes32
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A1.0 Types of Diabetes
 Type 1 Diabetes: These patients usually present as children or young
adults, but it is important to be aware that they may present at any age. Their
hallmark is insulin deficiency due to autoimmune pancreatic β cell destruction,
resulting in weight loss and the presence of ketones in the urine. Such
patients are prone to ketoacidosis, and once diagnosed should be referred to
the Diabetes Service by telephone for treatment with insulin as a matter of
urgency, although emergency hospital admission is often unnecessary.
 Type 2 Diabetes: Although most present in middle and old age, an
increasing number present at younger ages. Many are obese. Peripheral
insulin resistance combined with relative insulin deficiency accounts for the
pathogenesis. Ketonuria is absent in the non-fasting state. Such patients are
not normally prone to ketoacidosis.
Those at Increased Risk of Diabetes:
 Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance
(IGT). IFG (fasting venous glucose >6.1<7.0mmol/l) and IGT (fasting venous
glucose <7.0mmol/l and 2 hours after OGTT venous glucose >7.8 <11.1
mmol/l) are associated with an increased risk of macrovascular disease and
require aggressive management of cardiovascular risk factors, dietary and
lifestyle advice. A fasting or random glucose level should be measured on an
annual basis to screen for development of diabetes.
 Syndromes Associated With Diabetes
Diabetes Mellitus: can be secondary to other conditions which cause
pancreatic destruction (haemochromatosis, cystic fibrosis, pancreatitis) or
associated with other syndromes which are characterised by insulin
resistance (acromegaly, polycystic ovarian syndrome, Cushing’s syndrome)
and drug therapy, particularly glucocorticoids. The table below illustrates
some of the conditions. It is important to remember that many of these
conditions are rare but a high index of suspicion may be needed to make such
a diagnosis.
Condition
Cushing’s syndrome
When to suspect
Centripetal obesity,
hypertension, hirsutism
Acromegaly
Coarse features,
prognathism, change in
ring / shoe size,
hypertension, sweating
Haemochromatosis
Pigmentation (“bronzed
diabetes”), abnormal
LFTs,
How to screen
First voided morning
urine sample for free
cortisol /creatinine ratio
Consider referral to
Endocrine clinic
Serum ferritin
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Polycystic Ovarian
Syndrome
Chronic pancreatic
destruction
hepatosplenomegaly
Irregular menstruation.
Features of the
metabolic syndrome.
History of alcohol
excess, recurrent
abdominal pain, cystic
fibrosis
Clinical history and
abdominal
ultrasound.
Abdominal ultrasound,
amylase, consider
referral to GI specialist
Recognised Genetic Syndromes: including MODY (maturity onset diabetes
of youth), which is characterised by early onset diabetes and often no
requirement for insulin (non-ketotic). Patients are often of normal weight. The
condition is inherited in an autosomal dominant fashion and there is almost
always a family history. Family history is therefore important in people with
diabetes. Website: http://www.diabetesgenes.org
Gestational Diabetes (see Section B 5.4.1) is defined as glucose
intolerance of variable severity with first onset or recognition during
pregnancy. The criteria for diagnosis of gestational diabetes are a fasting
venous plasma glucose of >5.5mmol/l or two hours after OGTT >9mmol/l. If
blood glucose levels are in the range for gestational diabetes specialist
management is needed. In most women the abnormality is reversible post
partum, but up to 50% develop Type 2 diabetes later in life. A small
proportion has coincidental Type 1 diabetes.
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A2.0 Confirming the Diagnosis and Initial
Management
A2.1 Confirming the diagnosis
In the symptomatic individual with dehydration or heavy ketonuria, a
presumptive diagnosis of diabetes may be made on the basis of urinalysis
and/or blood strip testing and urgent referral is likely to be appropriate.
Otherwise it is essential that a diagnosis of diabetes is confirmed before the
patient is advised that he/she has diabetes and before treatment with diet or
any other agent is commenced.
Symptoms of thirst and polyuria or the finding of glycosuria should prompt
blood glucose measurement using a laboratory method. The diagnosis of
diabetes should not be made on the basis of portable blood glucose meter
results alone. The diagnosis can be made on the basis of symptoms (thirst
and polyuria) and one diagnostic blood glucose measurement. The values of
blood glucose indicative of diabetes are as follows;



Random venous plasma glucose ≥ 11.1 mmol/l; or
Fasting plasma glucose ≥ 7 mmol/l; or
Venous plasma glucose ≥ 11.1 mmol/l at 2 hours after a 75g oral
glucose load (the oral glucose tolerance test
In the absence of symptoms the diagnosis is based on two diagnostic blood
glucose measurements on two separate days. On rare occasions therefore a
second oral glucose tolerance test may be needed before a diagnosis of
diabetes can be confirmed.
In the UK the 2000 WHO criteria were adopted from June 2000.
A2.1.1 Interpretation of Plasma Glucose Levels (mmol/l)
Fasting
Venous
≥7.0
Capillary
≥ 7.0
Random
Venous
Capillary
≥ 11.1
≥ 12.2
Diabetic range
5.5 to 11.1
6.5 to 12.2
≤ 5.5
≤ 6.5
Check fasting glucose
Impaired Fasting Glucose
(IFG) - 75g OGTT
required
Borderline - 75g OGTT
required
Diabetes unlikely
≥6.1 to 7.0 ≥6.1 to 7.0
5.5 to 6.0
5.5 to 6.0
≤ 5.5
≤ 5.5
A2.1.2 Interpretation of 75g Oral Glucose Tolerance Test (WHO 2000)
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Venous Plasma Glucose (mmol/l)
Fasting
2 Hour
Diabetes Mellitus
≥ 7.0
and/or
≥ 11.1
Impaired glucose
tolerance
<7.0
and/or
≥ 7.8, < 11.1
Capillary Plasma Glucose (mmol/l)
Fasting
2 Hour
Diabetes Mellitus
≥ 7.0
and/or
≥ 12.2
Impaired glucose
tolerance
<7.0
and/or
≥ 8.9, < 12.2
Capillary Whole Blood
Fasting
2 Hour
Diabetes Mellitus
≥6.0
and/or
≥ 11.1
Impaired glucose
tolerance
<6.0
and/or
≥ 7.8, < 11.1
A2.2 Determine the risk of ketoacidosis and likely need for
immediate insulin therapy
The most important decision once the diagnosis has been made is to decide
whether the patient is at risk of ketoacidosis and likely to require immediate
insulin therapy.
A2.2.1 Indications for immediate insulin therapy
 Persistent non-fasting ketonuria/ketonaemia
 Marked weight loss in the normal or underweight patient
 Vomiting and dehydration (will require immediate hospital admission for
intravenous therapy).
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
The initial blood glucose level or presence of primary symptoms of
thirst and polyuria are not good guides as to the need for insulin.
Hospital admission may be avoided in patients who clearly require
insulin, but are not dehydrated or in ketoacidosis, depending on the
logistics of arranging to start insulin at home on an urgent basis. Such
patients should be discussed by telephone with a member of the
diabetes specialist team with a view to starting insulin within 24
hours. These patients should receive immediate care from the hospital
diabetes team and may be admitted to hospital depending on the
practicalities of starting insulin at home. Patients with signs of
etoacidosis or dehydration should be admitted to hospital under the
emergency admissions system. Children under the age of fourteen
should be discussed urgently on the telephone with a paediatrician,
and will normally be admitted to hospital.
A2.2.2 Patients not requiring immediate insulin
The majority of newly diagnosed patients have Type 2 diabetes, and the
management approach can be more relaxed in timescale. The initial blood
glucose level or presence of primary symptoms of thirst and polyuria are not a
good guide as to the long term need for hypoglycaemic drug therapy. Patients
do not normally require oral hypoglycaemic agents until they have completed
at least two or three months on diet alone.
Group education facilities are available at a variety of locations throughout the
region for the initial education of Type 2 patients. All such patients should
initially receive dietary advice aiming to optimise body weight (see diet
section). General advice and the provision of the Diabetes UK diet leaflet is
acceptable for initial management, but all patients should be referred to a
dietitian at an early stage for more detailed and personalised advice.
2
Obese patients (BMI > 30kg/m ) inadequately controlled after a trial of diet but
showing evidence of weight loss may be left on diet alone as glycaemic
control is likely to continue to improve. Overweight and obese patients (BMI
>25) not achieving weight loss may be most appropriately treated with
metformin (section 3) in a low starting dose to minimise gastrointestinal side
2
effects. Patients not overweight (BMI ≤ 25kg/m ) but inadequately controlled
may be commenced on a sulphonylurea (section 3.1). Employment and social
issues may also influence the choice of treatment.
A2.3 Check list for recently diagnosed diabetes
Once the immediate issue of glycaemic control has been addressed it is
important to consider further educational topics and to ensure an adequate
physical examination for detection of established complications, which are
often present at diagnosis in Type 2 patients. The following checklist is
suggested for completion over the first few clinical contacts.
A2.3.1 Checklist
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Comment/Recording
Date/Signed
INITIAL
Decide on initial blood glucose management
and need for immediate insulin or otherwise
Provide initial dietary advice and arrange for
referral to a dietitian
CLINICAL RECORDINGS
Record weight and BMI
Blood pressure
Urinalysis for protein and ketones and glucose
Consider causes of secondary diabetes, see
Section A1 - Types of Diabetes
PODIATRY
Examine feet for signs of neuropathy,
peripheral vascular disease or active lesions.
Risk calculation available on SCI-DC.
Provide foot care information
Decide on need for referral to a podiatrist
RETINAL SCREENING
Perform, arrange and/or discuss need for
adequate retinal examination
Record visual acuity (pinhole corrected if
worse than 6/9)
Register with DRS programme.
LAB TESTS
Arrange biochemical assessment; serum
creatinine, LFTs, lipid profile, thyroid function,
HbA1c
Early morning urine for albumin/creatinine ratio
(microalbumin screen)
RISK
Record smoking status and advise as
appropriate
Assess cardiovascular risk status (smoking,
BP, family history, lipids,
proteinuria/microalbuminuria, established
macrovascular disease)
Consider ECG to assess evidence of previous
MI or left ventricular hypertrophy
FURTHER EDUCATION/MANAGEMENT
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Decide on appropriate patient self monitoring
Determine individualised blood glucose
treatment targets
Discuss hypoglycaemia and its management
in all insulin and sulphonylurea treated patients
Provide support literature and web sites
Cover selected topics from the education
checklist with the patient and relevant
individuals
Discuss driving/DVLA/insurance
Consider referral to a Diabetes Specialist
Nurse or hospital diabetes clinic
Ensure patient is registered with practice and
regional diabetes register
A2.4 Impaired glucose tolerance & impaired fasting glucose





These patients, like those with established diabetes, have an increased
risk of macrovascular disease and require assessment and aggressive
management of cardiovascular risk factors, dietary and lifestyle advice
– See Section D2.0 and Section B3.5 Smoking and Diabetes.
Patients with impaired fasting glucose (IFG) (≥ 6.1mmol/l, <7.0mmol/l)
should have a 75g OGTT as some will fulfil the criteria for diabetes
mellitus on the two hour value.
Patients with IGT & IFG should be entered into the practice diabetes
register.
Five per cent per year may go on to develop Type 2 diabetes and will
then need appropriate diabetes care.
A fasting or random blood glucose level should therefore be measured
on an annual basis, or earlier in the event of symptoms in people with
IGT or IFG and the results interpreted according to Section A2.1.1.
Although not diagnostic an HbA1c level can give further information.
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A2.5 Glycaemic control - management of the newly diagnosed
patient:
Algorithm for management of the newly diagnosed patient
Newly diagnosed diabetics
Clinically unwell – vomiting,
dehydrated or suspected
acidosis
Yes
No
Heavy Ketonuria
Yes
Marked unintentional weight loss
No
No current indication for
insulin therapy
Lifestyle advice e.g. start on diet
Self-monitoring if appropriate
4 – 6 weeks later –
Adequate control
Yes
No
Continue diet
for 4 weeks
Yes
Improving
Control
No
Yes
Can dietary compliance be
improved?
No
Overweight
BMI >25
Yes
No
Diet &
Metformin
Diet &
Sulphonylurea
Diet
alone
Seek
experienced
advice re.
insulin therapy
within 24 hours
Emergency
admission
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A2.6 Performing a 75g Oral Glucose Tolerance Test
Indications for this test are discussed in Section 2. It can easily be performed
in primary care but a standardised protocol must be followed and laboratory
glucose analysis must be used. This test should not be performed during
intercurrent illness. On rare occasions two oral glucose tolerance tests may
need to be performed before a diagnosis of diabetes can be confirmed.
The patient should maintain an adequate carbohydrate intake (> 150g) for at
least three days prior to the test.
Fast overnight for a minimum of 10 hours (water only permitted).
75 g oral glucose dissolved in 250 to 300 ml water to be consumed in no more
than 5 minutes followed by a further 100 ml water.
Acceptable alternatives are;


Lucozade 394 ml (73kcal/100 ml formulation)
Maltodextrins in appropriate volume to provide 75g carbohydrate (e.g.
Calsip 150 ml)
Blood for glucose estimation to be taken before (zero minutes) and 120
minutes after consumption of the drink.
Urine may also be tested for glucose to estimate the renal threshold, but this
does not contribute to the diagnosis of diabetes, which is based on the fasting
and two-hour blood glucose results.
The method of blood sampling is important and must be specified: venous or
capillary, plasma or whole blood.
Venous plasma is most commonly used. (Aberdeen Diabetes Clinic uses
whole blood capillary glucose).
The patient should remain sedentary and not smoke, eat or drink for the
duration of the test.
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A3.0 Prevention of Diabetes
A Healthy Weight - Summary
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A3.1 Background
In Grampian, there are currently more than 21,000 individuals with diabetes.
800 new people with diabetes were notified to the register in the last six
months alone. Type 2 diabetes accounts for 85% of cases. While the cause
of Type 1 diabetes is unknown, Type 2 diabetes mellitus is closely associated
with being overweight or obese. 80% of people with diabetes in Scotland are
obese.1
Prevention
Helping people to maintaining or achieve a healthy weight is the key
opportunity for prevention of diabetes. Approximately two out of every three
people in Scotland are overweight or obese. One in five is obese. One in
three children (under the age of 15) is overweight or obese. A ‘typical’ NHS
general practice with a list size of 6000 will have approximately 1200 adults
who are obese (BMI ≥ 30 kg/m2), 50 adults who have severe obesity (BMI ≥
40 kg/m2).2
Obesity is not just a consequence of an unhealthy lifestyle but is a disease
and a risk factor for other diseases. In adults, obesity is associated with an
increased risk of Type 2 diabetes, coronary heart disease, hypertension,
many cancers and osteoarthritis (see table 1).
Table 1: Risk of other diseases in obese adults2
Disease
Type 2 diabetes
Hypertension
Heart attack
Colon cancer
Angina
Gall bladder disease
Ovarian cancer
Osteoarthritis
Stroke
Relative risk
Women
Men
12.7
5.2
4.2
2.6
3.2
1.5
2.7
3
1.8
1.8
1.8
1.8
1.7
1.4
1.9
1.3
1.3
If you are male and obese you are 5 times more likely to develop diabetes
than if you were at a healthy weight; if you are female and obese, your risk is
increased 13 times.
If you lose weight you can not only improve the control and management of
your diabetes, reducing the need for insulin injections but, 2/3rds of Type 2
diabetes mellitus can be prevented by lifestyle and diet modification.3 You will
also reduce your risk of heart disease.
1
National Overview Follow up Report: Diabetes-March 2008, Diabetes UK & NHSQIS
NICE Guideline 43: Obesity NICE 2007
3
The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management, UK NSC 2007
2
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Screening for diabetes
Type 1 diabetes has a sudden onset and people present early for care but
because Type 2 diabetes has a gradual onset and presents with vague
symptoms, it can go unnoticed for many years. At the moment, an estimated
90001 people in Grampian may have Type 2 diabetes but will not know yet,
and they will not be known to healthcare teams. Diabetes can be detected by
a blood test and may be identified as an incidental finding or as part of
general health reviews by GPs, practice nurses or, increasingly, by
pharmacists.
Structure
This section of the guidelines aims to provide a summary of advice regarding:
 the prevention of Type 2 diabetes through the achievement & maintenance
of a healthy weight & lifestyle
 Screening for Type 2 diabetes
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A3.1.1 Achieving & Maintaining a Healthy Weight & Lifestyle
NHSGrampian Healthy Weight Strategy
The NHSGrampian Healthy Weight Strategy is currently under development
to produce “A co-ordinated approach to the provision of services and
interventions for obesity prevention, treatment and weight maintenance that
will improve the long-term health of people in Grampian.” We will update this
section as the strategy progresses.
The NHSGrampian Healthy Weight Strategy includes the development of a
care pathway for people who are overweight or obese. The pathway will
recognise that referral may come from a range of practitioners. Consideration
of the individual’s motivation will be important in determining their ability to
gain benefit from different types of weight loss intervention.
Factors affecting a person’s ability to maintain a healthy weight or lose
weight
Preventing and managing overweight and obesity are complex problems, with
no easy answers. Many factors could be affecting a person’s ability to stay at
a healthy weight or succeed in losing weight.4
Motivation: people choose whether or not to change their lifestyle or agree to
treatment. An individual’s readiness to alter their lifestyle can be enhanced by
engaging in a collaborative conversation about behaviour change. The type of
questions that could be asked to encourage client engagement include:
In what ways would it be good for you to…..?
If you decide to… how would you do it?
What would be the good things about…..?
Why would you want to……?
If you don’t make any change what do you think will happen?
Where would you like to be in…..years?
Barriers to lifestyle change: should be explored.
 lack of knowledge about buying and cooking food, and how diet
and exercise affect health
 the cost and availability of healthy foods and opportunities for
exercise
 safety concerns, for example about cycling
 lack of time
 personal tastes
 the views of family and community members
 low levels of fitness, or disabilities
 low self-esteem and lack of assertiveness.
Tailored advice: Advice needs to be tailored for different groups. This is
particularly important for people from black and minority ethnic groups,
4
NICE Guideline 43: Obesity NICE 2007
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vulnerable groups (such as those on low incomes) and people at life stages
with increased risk for weight gain (such as during and after pregnancy, at the
menopause or when stopping smoking).
Children: treating children for overweight or obesity may stigmatise them and
put them at risk of bullying, which in turn can aggravate problem eating.
Confidentiality and building self-esteem are particularly important if help is
offered at school.
It is important to consider these factors when supporting people to maintain or
achieve a healthy weight.
A range of services exist within Grampian where people can seek
opportunities to lose weight, improve their understanding of nutrition and
participate in physical activity. Patients can be referred, or self refer, to
Healthpoint to obtain health improvement advice, support and sign posting
to local services and facilities. In the next section, there are a series of key
facts and links to resources.
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A3.1.2 Key Facts – What is a healthy weight?
Maintaining a healthy weight is important for many health conditions including
diabetes mellitus. A healthy weight is often defined by BMI (body mass index)
– this is a measure of weight taking into account a person’s height.
BMI
Underweight:
Healthy weight:
Overweight:
Obesity, class I
Obesity, class II
Obesity, class III
<18.5
18.5 -24.9
25.0-29.9
30.0-34.9
35.0-39.9
≥40
A BMI of 18.5 to 24.9 means that adults are a healthy weight for their height.
However, this is general advice for adults only. It does not apply to children,
pregnant women or women who are breastfeeding. Also, BMI may not be
accurate if the person:

does a lot of weight-training and is very muscular,

has a long-term health condition.
A3.1.3 Key Facts – Eating a Healthy Diet








Base your meals on starchy foods that include breads, rice, potatoes
and pasta
Eat lots of fruit and vegetables
Eat more fish
Cut down on saturated fat and sugar
Try to eat less salt – no more than 6g a day
Get active and try to be a healthy weight
Drink plenty of water
Don’t skip breakfast
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As an example, the following Healthy Eating leaflets are available at the
Healthpoints (in Aberdeen and Elgin) and through Health Information
Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
Your Guide To Healthy Eating
The Balance of Good Health
The following websites provide useful sources of information about diet and
healthy eating:
http://www.takelifeon.co.uk
http://www.eatwell.gov.uk provides lots of guidance about nutrition and
healthy eating as well as diet related health issues (obesity, diabetes).
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A3.1.4 Key Facts - Physical Activity
Being physically active is important for health and contributes to maintaining a
healthy weight.
What Are The Benefits of Physical Activity?
 Helps to maintain an energy balance by increasing energy expenditure
(burning calories) and can help use up stored fat
 Builds muscle which will speed up metabolic rate. This increases the
amount of calories burnt even when the person is not exercising
 Reducing the amount of stored fat will help reduce the risk of
developing high blood pressure, diabetes and having a heart attack or
stroke
 Reduces the risk of certain cancers, osteoporosis, falling, levels of
stress and improves the person’s overall feeling of well-being and
quality of life
 If the person has diabetes, physical activity will help to maintain good
blood glucose control
How Much Physical Activity Should You Take?
The minimum recommended levels of physical activity to maintain good
health:
Adults should build up to at least 30 minutes of moderate intensity
activity on 5 or more days of the week.
Children to build up at least one hour of moderate intensity activity on 5
or more days of the week.
Moderate intensity means breathing a bit deeper, feeling warmer,
perhaps sweating a bit, but still able to carry out a conversation.
Making It Happen - it is often perceived to be difficult fit activity into the day.
Here are some suggestions about how to do it (NICE guideline 43).
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In Adults
Set realistic goals – don’t worry if the odd day is missed but try to make sure
physical activity is part of everyday life
Encourage the person to select activities that they enjoy – such as walking,
cycling, swimming, aerobics and gardening
Minimise sedentary activities, such as sitting for long periods watching
television, at a computer or playing video games.
Build activity into the day – for example, get off the bus a stop earlier and
walk, take the stairs instead of the lift, take a walk at lunchtime.
In Children
Encourage active play – for example, dancing and skipping.
Try to be more active as a family – for example, walking and cycling to
school and shops, going to the park or swimming.
Gradually reduce sedentary activities – such as watching television or
playing video games – and consider active alternatives such as dance,
football or walking.
Encourage children to participate in sport or other active recreation, and
make the most of opportunities for exercise at school.
Safety First!
 Seek advice from GP or practice nurse before starting an exercise
programme
 Start exercising slowly and build up to the recommended levels
 Wear appropriate clothing and footwear
 Stop exercising if you feel dizzy or unwell
Contacts and Further Information
Details of physical activity opportunities and leisure facilities in your area can
be found on the local authority websites:
http:///www.AberdeenCity.gov.uk
http://www.Aberdeenshire.gov.uk
http://www.Moray.gov.uk
Click on heading ‘Sports and
Leisure’
Quick Links – ‘Sport and
Recreation’
click on heading ‘Leisure’
(contact details of local Active School Co-ordinators can also be found on
these sites)
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As an example, the following Physical Activity leaflets are available at the
Healthpoints (in Aberdeen and Elgin) and through Health Information
Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
Get Active!
Hassle Free Exercise
Physical Activity and Weight Loss
Physical Activity and Diabetes
(British Heart Foundation)
(Health Scotland)
(HealthEx)
(HealthEx)
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A3.1.5 Key Facts: Healthy Lifestyle & Alcohol
Excess alcohol has a number of negative consequences for your health.







Blood pressure. Drinking to excess is linked with a rise in blood
pressure. Raised blood pressure increases the risk of heart disease
and stroke.
Cancer. Drinking alcohol is the second biggest risk factor for cancers
of the mouth and throat. Drinking too much also increases risk of
breast cancer.
Liver disease. Alcohol turns some liver cells into fat and damages
others. Repeated heavy drinking scars the liver (liver cirrhosis) and
causes permanent damage which can cause death.
Drinking alcohol above the sensible guidelines can have other
consequences:
Sleep problems. Even small amounts of alcohol can prevent the deep
sleep we require to feel alert and refreshed.
Alcohol dehydrates the body, and this is partly responsible for
‘hangover’ symptoms.
Alcohol contains a lot of sugar and is high in calories that will contribute
to weight gain.
The Guidelines for Sensible Drinking
Men: No more than 3-4 units per day (maximum 21 units per week)*
Women: No more than 2-3 units per day (maximum 14 units per
week)*
*With at least 2 days a week without alcohol
How many units in a drink?
A unit equals 10ml of pure alcohol. That’s how much the body can
safely get rid of in an hour.
1 Pint standard beer/lager = 2.3 units;
1 Pint medium strength beer/lager = 2.8 units;
1 bottle standard beer/lager (330ml) = 1.7 units;
1 bottle alcopop (275ml) = 1.5 units;
1 Pint strong cider = 3.4 units;
1 glass of standard wine (175ml) = 2.1 units;
35ml measure gin/rum/vodka/whisky = 1.4 units;
Units above are average levels – the strength of drinks varies by
brand. Many display their unit content on label to help you drink at a
sensible level.
For more detailed information see SIGN Guideline 74 “The management of
harmful drinking and alcohol dependence in primary care” (2003).
http://www.sign.ac.uk/guidelines/fulltext/74
26
21 April 2009
As an example, the following Alcohol advice leaflets are available at the
Healthpoints (in Aberdeen and Elgin) and through the Health Information
Resource Service at Summerfield House, Aberdeen (Tel: 01224 558504)
About Alcohol
Sensible Drinking
Alcohol & Healthy Living
27
21 April 2009
A3.1.6 Key Facts: Medicines & Surgery as part of the management of obesity
Pharmacological treatment should be considered only after dietary, exercise
and behavioural approaches have been started and evaluated.
Medicine Therapy
Medicine treatment should be considered for adults who have not reached
their target weight loss or have reached a plateau on dietary, activity and
behavioural changes alone and who have:


a BMI of 27.0 kg/m2 or more with associated risk factors
a BMI of 30.0 kg/m2 or more.
The decision to start medicine treatment, and the choice of medicine, should
be made after discussing with the patient the potential benefits and limitations.
Medicine treatment should be offered only as part of a package of care and
support.
Medicines include in NICE guidance as suitable treatments for consideration:
 Orlistat
 Sibutramine
Children
Medicine treatment is not generally recommended for children younger than
12 years. Treatment should be started in a specialist paediatric setting, by
multidisciplinary teams with experience of prescribing in this age group.
Surgical Therapy
Bariatric surgery is recommended as a treatment option for people with
obesity if all of the following criteria are fulfilled:





they have a BMI of 40 kg/m2 or more, or between 35 kg/m2
and 40 kg/m2 and other significant disease (for example,
Type 2 diabetes or high blood pressure) that could be
improved if they lost weight
all appropriate non-surgical measures have been tried but
have failed to achieve or maintain adequate, clinically
beneficial weight loss for at least 6 months
the person has been receiving or will receive intensive
management in a specialist obesity service
the person is generally fit for anaesthesia and surgery
the person commits to the need for long-term follow-up.
Children
Surgical intervention is not generally recommended in children or young
people. Bariatric surgery may be considered for young people only in
exceptional circumstances, and if they have achieved or nearly achieved
physiological maturity.
28
21 April 2009
Only a multidisciplinary team that can provide the necessary expertise and
support should undertake surgery for obesity.
For more detailed information: NICE Guideline 43: Obesity (2006) & SIGN 69:
Management of obesity in children and young people (2003)
29
21 April 2009
A3.1.7 Sources of advice about how to achieve and maintain a healthy weight &
lifestyle
Below are some useful sources of advice about achieving and maintaining a
healthy weight and lifestyle.
For Everyone
Sources of information within Grampian
Healthpoint offers free advice and information on:






practical ways to improve your health;
your health concerns;
support groups and organisations;
how to access NHS services;
jobs in the NHS;
access to free condoms
Healthline is a free, confidential, telephone line that provides healthpoint
information.
Available: Monday - Friday 9.00am - 5.00pm.
Phone the free Healthline number on 0500 20 20 30
http://www.nhsgrampian.org provides details of local sources of advice and
contacts for further information about healthy active living. Follow the links to
“About NHS Grampian” then “health improvement” and then select
“healthy living”.
Other sources of information
http://www.takelifeon.co.uk Provides a user friendly guide to healthy eating
and physical activity for all.
http://www.healthinfoplus.scot.nhs.uk for a one-stop shop to quality
assured health information for patients, carers and the public. Follow the links
to “Wellbeing”.
http://www.healthscotland.com Health Scotland provides information to
support health improvement in Scotland. It includes is information about food
and nutrition and physical activity.
http://nhs24.com provides comprehensive up-to-date health information and
self care advice for people in Scotland.
http://www.nice.org.uk/nicemedia/pdf/CG43publicinfo2.pdf NICE, the
National Institute for Health and Clinical Excellence, has issued new guidance
to the health service about how to prevent obesity. This is a summary of the
evidence presented for the public.
http://www.nice.org.uk/nicemedia/pdf/CG43publicinfo1.pdf NICE, the
National Institute for Health and Clinical Excellence, has issued new guidance
to the health service about how to treat and manage overweight & obesity.
This is a summary of the evidence presented for the public.
30
21 April 2009
For Healthcare Professionals
In addition to the resources above you can find more information here:
Sources of information in Grampian
Supporting the Professional: Several services provided by Public Health
work together under the ‘Supporting the Professional’ heading.
Health Information Resource Service can provide free information leaflets
Recommended leaflets:
Diet: Eating for Health; Hassle Free Food, Strive for 5
Alcohol: About Alcohol; Sensible Drinking, Alcohol & Healthy
Living
Physical Activity: The ‘Active Living’ series; Hassle Free
Exercise
and other resources for a range of topics – a few are recommended below.
The service can be accessed by telephone: 01224 558504 (ext. 58504), fax:
01224 558630 (ext. 58630), and email: grampian.resources@nhs.net
However, the main access point is via the website:
http://www.nhsghpcat.org as this is the service’s catalogue, as well as
allowing online orders.
Refer a patient to Healthpoint – for advice, support and direction to local
services. You can refer a patient by using the “Healthpoint referral pads”.
http://www.hi-netgrampian.org: The Grampian Health Improvement
Network (HI-Net) provides a web based resource full of health improvement
information. You can access:
Physical Activity Strategy and Action Plan
Focus is Grampian’s Nutrition Health Promotion Strategy
Grampian Healthy Weight Strategy
Other sources of information
http://www.sign.ac.uk/pdf/sign69.pdf: Management of obesity in children
and young people (published April 2003) Includes guidance on the prevention
and treatment of obesity in children and young adults.
(SIGN 8 covered obesity in adults but was published in 1996 and is out of
date particularly in relation to treatments for obesity)
HTTP://WWW.NICE.ORG.UK/cg43: For the full NICE guideline number 43:
Obesity. It includes guidance on prevention of obesity, lifestyle advice and
interventions for the treatment of overweight and obesity, and medical or
surgical interventions.
31
21 April 2009
A4.0 Screening for diabetes
A4.1 UK National Screening Committee (UK NSC)
The UK National Screening Committee is chaired by the Chief Medical Officer
for Scotland and advises Ministers and the NHS in all four UK countries about
all aspects of screening policy and supports implementation. Using research
evidence, pilot programmes and economic evaluation, it assesses the
evidence for programmes against a set of internationally recognised criteria.
Assessing programmes in this way is intended to ensure that they do more
good than harm at a reasonable cost. In 1996, the NHS was instructed not to
introduce any new screening programmes until the UK NSC had reviewed
their effectiveness.
More information about the UK NSC can be obtained here:
http://www.nsc.nhs.uk
More information about the criteria used by the NSC to judge whether to
introduce a screening programme can be found here:
http://www.nsc.nhs.uk/pdfs/criteria.pdf
A4.1.1 Summary of evidence regarding screening for diabetes
There have been no national screening programmes in place for:



Diabetes
Impaired Glucose Tolerance (IGT)
Obesity
This month (March 2008) saw the publication of the “Handbook for Vascular
Risk Assessment, Risk reduction and Risk Management” A report
prepared for the UK National Screening Committee to, as outlined in a Press
statement by Dr Anne Mackie, Director of the NSC, “help us identify what is
desirable, and realistic, to provide…and inform primary care and public heath
professionals who are already providing risk assessment and risk
management.”
It provides an interesting summary of the evidence and suggested ways
forward for incorporation of screening and intervention for the main vascular
risk factors including obesity and diabetes.
You can access the document here
http://www.screening.nhs.uk/vascular/VascularRiskAssessment.pdf
This section will be updated as further information becomes available.
32
21 April 2009
APPENDIX 1: HEALTHPOINT & HEALTH LINE
Healthpoint is a walk in service which offers free and confidential advice and
information from trained staff on a wide range of topics:
 practical ways to improve your health;
 your health concerns;
 support groups and organisations;
 how to access NHS services;
 jobs in the NHS; access to free condoms
Visit healthpoint at:
Aberdeen Indoor Market (In Shops)
8 - 10 Market Street
Aberdeen
Open Monday to Saturday 10.00am to 4.00pm
This healthpoint is manned by trained staff
Healthpoint information is also available at:
Aberdeen Royal Infirmary Concourse
David Anderson Building, Foresterhill Road
Torry Neighbourhood Centre
The Point, St Nicholas House
Dr Gray's Hospital, Elgin
Healthy Hoose, Middlefield
Lhanbryde Community House
Denburn Health centre, Aberdeen
ASDA Pharmacy, Portlethen
Baird's Pharmacy, Huntly
Tarland Pharmacy, Tarland
Summers Chemist, Fraserburgh
Marywell Healthcare centre, Aberdeen
Buchanhaven Pharmacy, Peterhead
& SCP Management Unit at Spynie, Elgin
Denburn Health Centre, Aberdeen
Please note that these healthpoints are
unmanned.
Alternatively, you can contact the healthpoint team for information by email:
healthpoint@nhs.net or call on the free Healthline on 0500 20 20 30
Healthline is a free local telephone line available Monday - Friday 9.00am - 5.00pm. Any
information requested is sent by post free of charge. All calls are confidential and are
answered by trained health advisers
You can access these services with or without referral from a healthcare professional.
33
21 April 2009
APPENDIX 2: Measuring overweight & obesity
Adults BMI (body mass index)
To take account of the expected differences in weights in adults of different
heights, an index of weight-for-height has been devised as the BMI. This is
calculated as:
BMI = Weight (Kg)/Height (m2)
Example: An adult of 70 kg with a height of 175 cm has a BMI of:
BMI = 70 (Kg)/1.75 x 1.75(m2) = 22.9
Interpreting BMI
Underweight:
Healthy weight:
Overweight:
Obesity, class I
Obesity, class II
Obesity, class III
<18.5
18.5 -24.9
25.0-29.9
30.0-34.9
35.0-39.9
≥40
Waist circumference
Excess abdominal fat carries particularly elevated health risks. Waist
circumference is the most practical marker of abdominal fat. (Many people
understand this concept as ‘apple’ versus ‘pear’ shaped.). If the BMI is <35
then waist circumference is a useful marker for additional health risks.
Interpreting the waist circumference:
Substantially increased
risk
Men >102 cm (~40 inches)
Women > 88 cm (~35
A waist circumference of less than 94cminches)
in a man, and less than 80 cm in a
Increased risk
Men > 94 cm (~37 inches)
Women > 80 cm (~32
inches)
woman, means that their abdominal fat accumulation is not excessive.
Children
Body mass index (BMI) (compared to a reference population of children of the
same age and sex) is recommended as a practical estimate of overweight and
obesity in children and young people, but needs to be interpreted with caution
because it is not a direct measure of fat tissue.
For clinical use, SIGN recommends that obesity should be defined as those
with a BMI >=98th centile of the UK 1990 reference chart for age and sex. For
overweight, a BMI >=91st centile should be used.
For more detailed information: SIGN guideline 69
http://www.sign.ac.uk/pdf/sign69.pdf
34
21 April 2009
APPENDIX
3: SUPPORTING THE PROFESSIONAL
www.nhsghpcat.org
35
Section B: Supporting SelfManagement
B1.0 Structured Review Schedules ........................................................ 37
B1.1 Regular Review Schedules ...................................................... 37
B1.2 Every structured diabetic review ............................................... 37
B1.3 Content of Annual Checks ........................................................ 38
B2.0 Education ......................................................................................... 39
B2.1 Newly Diagnosed Diabetes ...................................................... 40
B2.2 Ongoing Diabetes Management ............................................... 41
B2.3 Diabetes Courses & Resources ............................................... 42
B3.0 Lifestyle ........................................................................................... 43
B3.1 Driving ....................................................................................... 43
B3.2 Occupations .............................................................................. 48
B3.3 Physical Activity ........................................................................ 50
B3.4 Psychological Wellbeing ........................................................... 53
B3.4.1 Introduction ................................................................... 53
B3.4.2 Depression .................................................................... 53
B3.4.3 Anxiety .......................................................................... 53
B3.4.4 Screening for Anxiety and Depression .......................... 54
B3.4.5 Other Psychological Issues ........................................... 54
B3.4.6 Behaviour Change ........................................................ 56
B3.5 Smoking .................................................................................... 59
B3.5.1 Smoking cessation ........................................................ 59
B3.6 Travel ........................................................................................ 60
B4.0 Information Technology .................................................................. 62
B4.1 National and Regional Diabetes IT Overview ............................ 62
B4.1.1 SCI-DC – Introduction ................................................... 62
B4.1.2 Accessing SCI-DC Network .......................................... 63
B4.1.3 SCI-DC Network - Overview.......................................... 66
B4.1.4 SCI-DC – Help / Contacts ............................................. 69
B5.0 Contraception, Pregnancy and the Management of Gestational
Diabetes Mellitus ............................................................................. 71
B5.1 Contraception ............................................................................ 71
B5.2 Planning pregnancy .................................................................. 72
B5.3 Confirmed pregnancy ................................................................ 74
B5.4 Management of Gestational Diabetes ....................................... 75
B5.4.1 Follow up of Patients with Previous Gestational Diabetes
...................................................................................... 77
B6.0 Children’s Services ......................................................................... 78
36
B1.0 Structured Review Schedules
B1.1 Regular Review Schedules
Patient empowerment through education to encourage optimal selfmanagement should be central to each review. Regular review of individuals
with diabetes should address both metabolic control and diabetic complication
screening. Reviews will involve metabolic management, education, health
promotion, and detection and management of diabetic complications. This
care must be structured, locally agreed and documented and may involve a
variety of professionals in various locations carrying out different parts of this
programme.

Interim metabolic and troubleshooting checks at three to six month
intervals are usually appropriate.

Systematic screening for the early detection of the microvascular
and associated macrovascular complications of diabetes is also an
essential component of structured diabetes care.

Effective interventions are available at an early or latent stage of the
disease processes which can slow or prevent further progression,
and which would not be as effective if delayed until the problem had
become clinically obvious.

Complication screening is usually performed on an annual basis,
either as a formal annual review or on a rolling program basis,
unless problems have been previously identified.
B1.2 Every structured diabetic review
The patient should be assessed and advised regarding:
 The impact of diabetes on lifestyle and psychological well-being.
 Symptoms of hyperglycaemia
 Occurrence and warning symptoms of hypoglycaemia
 Results of home monitoring if available.
 Episodes requiring hospital admission (including DKA)
 Medication
The following parameters should usually be recorded and discussed with the
patient at each visit:
 Blood pressure (particularly if hypertensive or previous recording
elevated). HbA1c (not more often than every 3 months).
 Weight and BMI.
 Urinalysis for ketones, protein and glucose.
An individual care plan and goals should be reviewed, agreed with the patient
and updated as appropriate. Additional interim visits may be required to
address specific problems.
37
B1.3 Content of Annual Checks
The patient should be assessed and
advised regarding:
•
•
•
•
•
•
The impact of diabetes on
lifestyle and psychological wellbeing.
Symptoms of hyperglycaemia
Occurrence and warning
symptoms of hypoglycaemia
Results of home monitoring if
available.
Episodes requiring hospital
admission (including DKA)
Medication
The following parameters should
usually be recorded and discussed
with the patient at each visit:
• Blood pressure (particularly if
hypertensive or previous
recording elevated).
• HbA1c (not more often than
every 3 months).
• Weight and BMI.
• Urinalysis for ketones, protein
and glucose.
The following parameters should be measured or examined on a minimum of an
annual basis, and are selectively further expanded in the following sections.












Blood pressure (sitting after 5 minutes rest)
Visual acuity (corrected with pin hole if worse than 6/9) and retinal screening.
Within Grampian, the Retinal Screening Service invites people on the Diabetes
Register for retinal screening.
Inspection of feet for callus, active lesions, colour and foot pulses.
Foot sensation using 10g monofilament. Calculation of foot risk.
Injection sites (in insulin treated people)
Urine for protein
First morning urine for microalbumin screen if proteinuria negative. (Persistent
proteinuria, when confirmed on two consecutive occasions, should be quantified
using a protein/creatinine ratio)
Glycosylated haemoglobin (HbA1c)
Serum lipid profile
Serum creatinine and eGFR
Serum TSH (optional).
Consider screening for Coeliac Disease
The patient should be assessed and advised regarding the following:
 Smoking habits
 Symptoms or other evidence of cardiovascular disease
 Symptoms suggestive of peripheral vascular disease
 Alcohol consumption
 Contraception and pregnancy planning if appropriate (remember the
increasing number of women with Type 2 diabetes in this group)
 Symptoms of erectile dysfunction
 Symptoms of depression
 Immunisation
 Exercise and physical activity
 Diet. Access should be available to dietetic specialist advice as required.
38
B2.0 Education
Education of the person with diabetes about their condition and its
management is a key component in the promotion of successful self-care.
Healthcare professionals can make a major contribution by helping those with
diabetes to understand their disease and the potential for intervention to
improve outcomes. In particular, emphasis on the beneficial effects of lifestyle
management should never be neglected. Similarly, facilitation of appropriate
learning with respect to administration of medications and self-monitoring are
essential parts of effective medical management of diabetes.
Educational input at diagnosis of the condition will need to be substantial and
will usually need ongoing reinforcement. The ‘correct’ amount of information
to present at any encounter is problematic and should not greatly exceed the
patient’s current needs or capacity to take new knowledge on board. It is
important to be aware that people learn best when physically and emotionally
‘comfortable’ and important to remember how stressful many individuals find
interactions with healthcare professionals. In attempting to enlighten, it is
more important to check understanding regularly than to continue to impart
ever more information; in this context less is often more. Also note that
different issues will be most appropriately addressed at different stages of the
patient experience. In facing the challenge of selecting topics to be
addressed, the healthcare professional must always attempt to recognise and
acknowledge the patient’s current agenda.
Skilled educators will understand the need to combine factual knowledge and
skills training with appropriate empathy and reassurance and will be able to
improvise on the breadth and depth of material appropriate to a given
consultation or enquiry. They will be aware of the variety of methods that
different people prefer to learn by and will use relevant combinations of
spoken, written and demonstrated material as well as leaflets, video
recordings, websites etc., that most appropriately match the patient’s needs.
Ideally they will have had the opportunity of some training in various methods
of teaching, including individual and group work.
Many different media, texts and courses are available for diabetes education,
particularly in relation to commonly recurring situations. It is important to have
a broad range of resources and skills to respond to patients’ various needs
and preferred learning styles. It is also useful to seek opportunities to
customise or develop training materials in line with local demands and
patterns of service provision and support.
More specific information follows on :
i)
The educational approach to the newly diagnosed patient
ii)
Ongoing education
iii)
Introduction of insulin therapy
iv)
Diabetes Courses and Resources
39
B2.1 Newly Diagnosed Diabetes
Attention needs to be paid to the manner in which information about the
diagnosis and its implications are delivered to the patient. As diabetes is so
prevalent, most individuals already have some ideas about, and experience
relating to, diabetes that may well be incomplete or misleading and thus
cause undue distress upon diagnosis.
Diabetes UK (Grampian Voluntary Group) provides Education packs for those
newly diagnosed with Type 2 Diabetes that are currently distributed to
practices around the region; these cover a wide range of issues of potential
relevance. Group Education sessions with specialist nurse, dietetic and
podiatry input for newly diagnosed Type 2 patients (+/- partners) are available
at various localities throughout Grampian. Additional opportunities may be
required for one to one follow-up consultations with diabetes team members.
Information for those with Type 1 diabetes is also available from Diabetes UK,
but the need for early initiation of insulin therapy means there is an even
greater need for education time and timely education. Early, and perhaps
serial, follow-up to is particularly important in this situation.
It is essential that adequate instruction is given on the use of any equipment
supplied (e.g. injection devices, blood testing equipment). The effectiveness
of such tuition needs to be assessed sensitively, recognising differences in
engagement, aptitude and application among patients.
All material considered for presentation to newly diagnosed patients should be
considered again at subsequent follow-up in recognition of the common need
for reinforcement, and the evolution of the patients understanding and
immediate focus of engagement.
A checklist of some of the commoner items to be considered in the early
period following the diagnosis of diabetes is reproduced below. This list is
neither exhaustive nor is coverage of many items obligatory. Furthermore, it
should be used at a pace and to an extent commensurate with its achieving
the aims of equipping the patient to cope more effectively with diabetes and
its management, and not to simply to record coverage of a list.
DIAGNOSIS
What is diabetes?
How has the diagnosis been confirmed?
What are the implications of the diagnosis on health?
LIFESTYLE ISSUES
Diet: quality, quantity and distribution through the day
Activity and exercise
Alcohol intake and health
Smoking and resources to aid cessation
Conception, contraception and sexual health
40
Travel and holidays
MONITORING
What to expect (glucose, HbA1c, weight, blood pressure, eyes, feet, urine)
Meaning and implications of results
Self-monitoring: whether, why, how and when?
Effects of intercurrent illness
MEDICATION
As an adjunct to self-management/ lifestyle modification
Evolving disease and treatment plans
Range and nature of treatments
Use of non-hypoglycaemic, risk-modifying drugs
OTHER ISSUES
Driving
Employment
Footwear and foot care
ID cards/ bracelets etc
Free prescriptions and eye tests
B2.2 Ongoing Diabetes Management
Education in various aspects of diabetes management will be a continuing
component of good diabetes care which will make considerable demands on
the knowledge, skill, experience and professionalism of those involved in
diabetes health care. Several issues will often need to be revisited with
patients and topics for discussion will sometimes be introduced proactively
during review consultations, and sometimes be in reaction to a patient’s
current particular concerns. Once again a range of educational approaches
and resources will allow for the requirements of each patient to be best met.
Some situations will have a particular set of topic areas that require to be
covered. Prominent among these will be the introduction of insulin therapy
and a second indicative table of items to consider discussing with the patient
at this stage is produced below.
INTRODUCING INSULIN
What is insulin and what does it do?
Insulin types
Insulin injections
Doses and dose adjustment
Supplies and disposal
Hypoglycaemia: causes, recognition, management, avoidance
Sick day rules
Driving, DVLA and employment issues
41
B2.3 Diabetes Courses & Resources
The MCN has an Education Advisory Group (contactable via the MCN Office)
that meets quarterly and is available to advise the MCN, and individuals or
groups across the region involved in diabetes care, on matters concerning
educational strategy and delivery. There is also local representation on the
national Diabetes Education Advisory Group, a subgroup of the Scottish
Diabetes Group.
Many diabetes educational opportunities are available for both professionals
and their patients. Training needs and course provision naturally vary over
time and anyone looking for something specific, or more general, will always
do well to consult colleagues about current or recent experience of what is
available. There is a strong history of locally developed and delivered
educational initiatives within Grampian. Forthcoming courses and events are
advertised on the Grampian Diabetes website www.diabetes.nhsgrampian.org
Among the local events for health care professionals on offer recently are the
Lilly GP Diabetes Scholarship, Managing the Change to Insulin in Type 2
Diabetes and Diabetes: Helping Nurses to Help Patients to Help Themselves.
The Grampian Diabetes Managed Clinical Network also hosts an Annual
Professional Conference in early summer.
More substantial courses, some including distance learning, are provided by
various Higher Education Institutions across the UK. Advice on diabetes
education for professionals and patients also appears on the Diabetes in
Scotland website: www.diabetesinscotland.org.uk
Among the current organised educational activities for patients in Grampian
are New Patient Groups, Patient Exercise Classes and DAFNE (Dose
Adjustment for Normal Eating) with further information available via the
Grampian Diabetes website or through health care professionals.
A wide variety of leaflets and literature are available from a number of sources
and these are often being reviewed and updated. The internet is well
established as a potential source of information for all, although one must
always be aware of commercial influences that could direct contents or
emphasis. A substantial amount of good quality information has been
available for some time on the Diabetes UK website: www.diabetes.org.uk
In 2008, NHS Scotland launched ‘My Diabetes My Way’, an interactive
website designed to help anyone with an interest in diabetes. Its partner
website comprises the ‘Diabetes Information Plus’ e-Library of quality assured
information. The respective web addresses of these NHSS websites are:
www.mydiabetesmyway.scot.nhs.uk and www.diabetesinfoplus.co.uk .
Another potentially useful and interesting resource for patients and
professionals is the Diabetes Stories website (www.diabetes-stories.com), a
collection of 100 oral histories recording the personal experiences of patients,
relatives and health care workers spanning more than 70 years.
42
B3.0 Lifestyle
B3.1 Driving
Full guidance on medical rules is available on the DVLA website:
www.dvla.gov.uk

Patients with diabetes treated with insulin must inform the DVLA of their
diagnosis and type of treatment.

Patients with diabetes treated by diet or tablets no longer need to inform
the DVLA unless they develop other complications or have frequent
episodes of hypoglycaemia (see patient information sheet in “At a glance
guide”).

All patients are advised to inform their car insurance company at
diagnosis and if their type of treatment changes.
For the individual patient information sheets please look at the “At A Glance
guide” on the DVLA website and download and give to patients as
appropriate:
Diet and tablet treated diabetes
Insulin treated diabetes
C1 licensing and insulin
Types of driving licence:
Group 1 entitlement allows the driving of vehicles up to 3.5 tonnes or with up
to 8 passenger seats, including motorcycles and mopeds. For patients on diet
or oral hypoglycaemic agents a licence lasting until age 70 will be issued in
the absence of other complications. Drivers whose diabetes is treated with
insulin will be issued with a 1,2 or 3 year licence, provided they are able to
recognise warning symptoms of hypoglycaemia and have no other
complications which would affect driving including recurrent hypoglycaemia.
Group 2 entitlement allows the driving of vehicles over 3.5 tonnes or more or
with more than 8 seats. This includes medium sized lorries (3.5-7.5 tonnes,
C1), minibuses (D1), lorries (C), buses (D). Before January 1997 drivers who
obtained a normal car driving licence were automatically awarded C1 and D1
entitlement. These holders of C1/D1 entitlement retain it until their licence
43
becomes due for renewal, when they must meet the medical standards
prescribed for all lorry and bus drivers. Group 2 drivers treated with oral
hypoglycaemic agents must inform the DVLA and group 2 entitlement will
continue as long as they can meet all group 2 medical standards. New
applicants on insulin or existing drivers starting insulin are barred in law from
driving HGV or PCV vehicles (C and D) from 1/4/91. Drivers licensed before
1/4/91 on insulin are dealt with individually and licensed subject to satisfactory
annual Consultant assessment. Regulation changes in April 2001 allow
“exceptional case” drivers to apply for or renew their entitlement to C1/C1E to
drive small lorries with or without a trailer subject to meeting all “Qualifying
Conditions”. Regular review by a consultant Diabetologist is required.
Patients on insulin are not allowed to hold a D1 licence (minibus).
Taxi drivers
The licensing of taxi-drivers is undertaken by individual local authorities and
therefore different standards are applied in different parts of the country.
However the DVLA recommended that Group 2 regulations should be applied
although this does not currently take place in Grampian.
Emergency response vehicles
The DVLA recommends that Group 2 rules are applied.
How are driving licences renewed?
At the time of licence renewal or at initial declaration of insulin treatment
patients on insulin will be required to complete a self-declaration form about
their diabetes with particular reference to hypoglycaemia and glucose
monitoring. If no problems are identified it is usual for the licence to be
renewed without requesting a medical report. However in all cases where
specific issues are identified then a medical report will be required and will be
sent to the doctor identified by the patient. Information required includes
whether the patient knows about the driving advice, monitors appropriately,
any recent episodes of severe hypoglycaemia (in last 12 months) or has lost
awareness of hypoglycaemia.
Diabetes related complications and driving
All drivers are required by law to be able to read a standard size car number
plate in good light at 20.5 metres. The advantage of this test is that it is easily
self-administered. Problems which affect the field of vision must be notified to
the DVLA. Drivers who have had laser treatment to both eyes for retinopathy
or suffer other conditions affecting both eyes must inform the DVLA so that
the extent of the problem can be assessed.
Drivers who develop problems with either the nerves or the circulation in the
lower limbs, sufficient to prevent safe operation of the foot pedals, must inform
the DVLA. This is unlikely to prevent driving as problems may be overcome
by either restricting driving to certain types of vehicles e.g. those with
automatic transmission, or by appropriate adaptations such as hand operated
accelerator / brake.
Insulin Treated Diabetes and Driving
44
Drivers who have any form of diabetes treated with any insulin
preparation must inform DVLA.
At the time of starting insulin patients should be advised not to drive
until their blood glucose levels are stable.
Hypoglycaemia
The risk of hypoglycaemia (low blood sugar) is the main hazard to safe
driving. Many of the accidents caused by hypoglycaemia are because drivers
continue to drive even though they are experiencing warning signs of
hypoglycaemia.
A patient must inform DVLA :

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If he / she develops impaired awareness of hypoglycaemia
If he / she suffers disabling hypoglycaemia at the wheel
If he / she has frequent episodes of hypoglycaemia
However in some circumstances the patient will be allowed to drive by the
DVLA and it is up to individual health professional to advise if the patient if fit
to drive whilst awaiting to hear from the DVLA.
If a patient drives against medical advice then his / her insurance and
driving licence are deemed not valid and the patient is therefore driving
without insurance or a valid driving licence.
Precautions advised for Drivers with insulin treated diabetes:

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Do not drive if you feel hypoglycaemic or if your blood glucose is less
than 4.0 mmol/l.
If hypoglycaemia develops while driving stop the vehicle as soon as
possible in a safe location, switch off the engine, remove the keys from
the ignition and move from the drivers seat.
Do not resume driving until 45 minutes after blood glucose has
returned to normal. It takes up to 45 minutes for the brain to fully
recover.
Always keep an emergency supply of fast-acting carbohydrate such as
glucose tablets or sweets within easy reach in the vehicle.
Carry your glucose meter and blood glucose strips with you. Check
blood glucose before driving (even on short journeys) and test regularly
(every 2 hours) on long journeys. If blood glucose is 5.0mmol/l or less,
take a snack before driving.
Carry personal identification indicating that you have diabetes in case
of injury in a road traffic accident.
Particular care should be taken during changes of insulin regimens,
changes of lifestyle, exercise, travel and pregnancy.
Take regular meals, snacks and rest periods on long journeys. Always
avoid alcohol.
45
Hypoglycaemic seizures
If a patient has a seizure which is hypoglycaemia related they may be allowed
to drive after notification to the DVLA. However, before this occurs clear
evidence will be required by the DVLA that hypoglycaemia was the cause of
the seizure and that there is very low risk of recurrence. Pending an
investigation / report the patient should be advised not to drive and to inform
the DVLA immediately.
C1/C1E Entitlement
Any C1 or other Group 2 licence reports must be completed by a consultant in
diabetes and require annual review.
Qualifying Conditions:
 No hypoglycaemic attacks requiring assistance whilst driving within the
previous 12 months.
 Regular monitoring at least twice daily and at times relevant to driving.
The use of a memory chip meters for such monitoring is strongly
recommended.
 Examination every 12 months by a hospital consultant, who specialises
in diabetes. At the examination the consultant will require sight of blood
glucose records and preferably the meter for the last 3 months.
 No other condition, which would render you a danger when driving C1
vehicles.
 required to sign an undertaking to comply with the directions of
doctors(s) treating the diabetes and to report immediately to DVLA any
significant change in your condition.
Exenatide and gliptins and driving
Exenatide has recently been licensed as a treatment for use in Type 2
diabetes, in combination with metformin and/or with sulphonylureas. Trials
published to date show a small but significant increased risk of hypoglycaemia
when exenatide is used in conjunction with a sulphonylurea. It would appear
that when the gliptins (DPP4 inhibitors) are used with sulphonylureas, the
hypoglycaemia risk is similarly raised.
The increased risk of hypoglycaemia from exenatide or gliptins when used in
combination with sulphonylureas is such that these are felt to be a
potentially high risk treatment for drivers holding Group 2 (LGV or PCV)
licences and that individual assessment will be required. Therefore any
patient who holds a Group 2 licence and who is commenced on either a gliptin
or exenatide in combination with a sulphonylurea must report this to the DVLA
(combination with metformin alone does not require reporting). The use of
gliptins and exenatide carries no specific driving restrictions for Group 1 (car
or motorcycle) licences.
46
DVLA website:
www.dvla.gov.uk
47
B3.2 Occupations
An occupational history is essential at diagnosis in order to help patients
adjust their diabetes to fit with work their routine. Some occupations may be
considered hazardous for patients with diabetes. Patients at particular risk of
hypoglycaemia ie those on insulin or sulphonylureas should be given advice
about appropriate detection and management of hypoglycaemia to minimize
risks which may occur. They should also be advised to consider carefully the
risks they may be exposed to if working unsupervised and the effect that
unstable shift patterns may have on their diabetes control.
Hazardous occupations

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Many occupations involve an element of hazard or risk. This could
involve anything from working near heavy machinery to being an active
fire fighter.
Regular monitoring of blood glucose needs is advised and disabling
hypoglycaemia and loss of warning signs of impending hypoglycaemia
should be discussed at each clinic review.
Patients undertaking physically active work should also be aware of
their carbohydrate requirements and insulin adjustment to prevent
hypoglycaemia.
The presence of other diabetes related complications may pose
additional risk eg advanced retinopathy, nephropathy or severe
neuropathy or coronary heart disease.
The role of the health professional and the employer
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Patients should be encouraged to declare their diabetes when applying
for employment.
The Disability Discrimination Act (updated 2005) provides legal
grounds for people with diabetes to address the issue of discrimination.
Within organisations that are not exempt from the Act, an employer is
no longer able to dismiss a person because they have developed
diabetes. Employment cannot be refused on the grounds of having
diabetes – indeed employers need to prove why they could not employ
an individual with diabetes.
Employer’s knowledge of diabetes may be minimal and health
professionals should be willing to liaise with employers to try and dispel
the myths that are commonly associated with diabetes.
People with diabetes should be encouraged to tell their work
colleagues and the first-aider about their diabetes so they know how to
recognise and treat hypoglycaemia.
Health professionals should ensure that people requiring insulin are on
the most appropriate insulin regimen to fit in with the patients work
schedule e.g. multiple injection regimen for shift workers.
Patients wishing to work overseas should be advised to ascertain the
availability of appropriate medical support if required.
48
Blanket bans do exist in relation to certain employment especially if a person’s
diabetes is treated with insulin. These bans tend to be where a job is
considered hazardous.
As the law stands, some occupations that have their own medical standards
can also legally refuse to employ people with diabetes.
Occupations with a blanket ban on recruiting people with insulin treated
diabetes:Armed forces
Airline pilot or airline cabin crew
Air traffic control
Jobs requiring a Large Goods Vehicle (LGV), Passenger Carrying Vehicle
(PCV) licence or a minibus (D1) licence. If a person drives a C1 class vehicle
for a living, and develops Type 1 diabetes or starts insulin treatment, they will
have to be medically assessed on their fitness to drive.
Train driver
There was a blanket ban on employing fire fighters with Type 1 diabetes.
However, several individuals challenged the ruling and were allowed to
continue active service, if they were already employed as fire fighters.
Prison service
Working offshore eg on oilrigs
Regulations concerning are being relaxed as of May 2008.
Patients requiring insulin may be given restricted certification of fitness to
work offshore if the following requirements are met:

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
There is a report from the individual treating physician
The patient has been assessed and not considered to be at excess risk
of hypoglycaemia
The patient must be fit to respond to any emergency situation on the
platform
There has been good control of their diabetes for a minimum period of
6 months
The patient can self-manage their insulin requirements
The patient does not have impaired awareness of hypoglycaemia
The operator’s medical advisor must be consulted regarding the
individual case and must agree with the proposal to allow the individual
offshore
There must be a supply of glucagon and iv dextrose on the platform
Certification is restricted to a named platform and restricted to a
maximum of 1 year.
Individuals require annual review
Patients on diet or oral agents will be assessed for their risk of hypoglycaemia
and presence of complications which may affect mobility and ability to
respond to emergency situations.
49
Seafarers
On a UK registered ship the following regulations apply:
For patients with diabetes not on insulin:
 Deemed unfit for distant waters (ie > 150 miles from safe haven in UK
waters) and for watchkeeping until stabilized but then may be fit for all
areas.
For patients with diabetes requiring insulin:
 Deemed unfit for all duties until stable and then permanently unfit for
distant waters and watchkeeping and emergency duties.
B3.3 Physical Activity
All people with diabetes should be asked about physical activity and most
should be encouraged to increase activity. Suitable educational material is
available on the NHS Scotland website www.mydiabetes.myway.org
Improving health
 All people (including health professionals) should be advised to
maintain at least moderate levels of activity, e.g. walking.

A gradual introduction and initial low intensity of physical activity should
be recommended for sedentary people with diabetes.

Exercise and physical activity is best undertaken regularly i.e.
preferably daily or on alternate days. Once a week is of limited benefit.
As a rough guide the first stage would be to encourage an
accumulation of 30 minutes of moderate activity (e.g. walking) on most
days of the week. The second stage is to encourage those who are
motivated. These individuals could be encouraged to engage in more
vigorous activity at least three days per week.

Exercise programmes are more likely to be successful and be
maintained if they are home-based and accompanied by on-going
support – so rushing out and joining a gym may not necessarily be the
answer.

Patients with complications should seek medical advice before
embarking on exercise programmes.

If patients have problems with mobility there are easy exercise
programmes which they could do, e.g. chair exercises

Above all encourage patients to choose an activity which they will
50
enjoy.

Health professionals should discuss barriers to increasing physical
activity and likely causes for relapse with patients.

Patients should be encouraged to set realistic targets for increasing
physical activity.

Appropriate footwear and socks should be encouraged and patients
with neuropathy may need to discuss their needs with a podiatrist.
Exercise and blood glucose control
(also see section C4.0 hypoglycaemia)

For patients who routinely monitor blood glucose and/or are insulin
treated, it is advisable to monitor blood glucose before and after
exercise.

It is usually unnecessary to reduce oral hypoglycaemic agents although
regular activity resulting in weight loss and improved glycaemic control
may require adjustments in medication.

People taking part in high intensity sporting activities may require
specialist advice and changes in insulin regimen.

Hypoglycaemia related to exercise may occur at the time of exercise or
up to 24 hours after when glycogen stores are being replenished.

The risk of hypoglycaemia is related to the intensity and duration of
exercise and also how used to exercising the patient is (those with little
experience may be more likely to go hypo compared with those
exercising regularly).

Patients should be advised to consider reducing insulin doses before
and after exercise (including the day afterwards), increase dietary
carbohydrate and alter injection sites, e.g. avoiding legs if running or
arms if kayaking as this will increase absorption of insulin.

It is advisable for patients to have easy access to rapid-acting
carbohydrate (e.g. orange juice / jelly beans) when exercising.

Additional nutritional advice, particularly for those engaging in more
vigorous physical activity is available on the following website:
www.runsweet.com.
51
Other ways of helping motivate patients to increase physical activity
It is helpful for each diabetes clinic (in primary or secondary care) to be able
to provide information to patients on local facilities. Each locality will have
various opportunities for exercise. Local councils can provide details of
classes running in the area and also details of opening times of swimming
pools etc. Details of walking routes are also available from Health Point.
Pedometers
 These have been shown to help people increase physical activity
levels.
 The reliability of pedometers varies greatly and people wishing to use
one should be advised to purchase it from a reliable outlet rather than
the back of a cereal packet!
 Pedometers should be attached to the hip belt for best accuracy.
 Pedometers are most effective when a “step goal” is agreed with the
patient. When first using a pedometer it is recommended that people
wear it for a week and document the average number of steps per day.
If they wish to increase physical activity an appropriate goal may be to
consider trying to increase the number of steps by 1000 - 1500 on 3
days of the week. After 2-4 weeks the target could be increased to an
additional 3000 steps on 3 days of the week.
 For many patients the frequently cited target of 10000 steps per day is
unrealistic.
Exercise Classes
Some patients enjoy the social interaction and motivation of exercise classes.
Diabetes exercise and information classes have been running in Grampian for
2 years.
At the present there are six classes (including an evening class and aquaaerobics class) which run for 1.5 hours with about 1 hour of exercise followed
by 30 minutes of group discussion. Further details including information
sheets and referral forms can be found on the MCN website
www.diabetes.nhsgrampian.org
Although many patients attend other exercise classes at various venues
throughout Grampian, patients new to exercise classes may find some
classes too strenuous. This can be de-motivating for patients.
Some patients may be suitable for referral to Grampian Cardiac Rehabilitation
Classes although, again some patients may find this too strenuous if they
have not been through the earlier stages of the Cardiac Rehab programme
(http://www.gcra.org.uk/).
52
B3.4 Psychological Wellbeing
B3.4.1 Introduction

Self-care relates to the way that people choose to lead their lives and
to their psychological wellbeing.

Psychological wellbeing is important to those working in diabetes
services because it has a profound effect on the efforts of people
with diabetes to self-care.

It is important to ascertain when significant psychological issues are
present because this will influence management decisions (for
example, whether or not we encourage lifestyle change), and can help
when to advise patients to get additional help if necessary (eg visit their
GP for management of depression)

The most common issues are clinical depression and anxiety. It is
best to think of peoples’ experience of depression and anxiety as
occurring along a continuum (ie you can have a little or lots of it) rather
than it simply being present or absent.
B3.4.2 Depression

Significant levels of depression, for example, are present in about 20%
of people with diabetes, and are associated with poorer glucose control
and more severe illness course (de Groot et al, 2001). That is not
surprising in view of the fact that key characteristics of depression
include: lack of motivation & energy; disrupted eating patterns, and
negative thinking styles particularly about being a failure and about
being unable to make positive changes.

Because of beliefs about being a failure and general reduced levels of
resourcefulness, great care needs to be taken if setting goals with
people who have significant levels of depression. Almost always, it is
wiser to postpone efforts to implement efforts to change
behaviour until the depression has been successfully treated.
B3.4.3 Anxiety

Clinical anxiety too is more prevalent among people with diabetes than
in the general population with a point prevalence of about 17%. There
is a biological component to anxiety, namely the release of stress
hormones such as cortisol and adrenaline. These hormones in turn
cause other biological responses including the release of glucose into
53
the bloodstream, and other somatic symptoms which overlap with
symptoms experienced during hypoglycaemia.

Because of the release of glucose into the blood and because
commonly people with diabetes misinterpret symptoms of anxiety as
indications of low blood glucose (so they take unneeded action to raise
blood glucose), clinical anxiety is also associated with poorer control
(Anderson et al, 2002).

Anxiety is associated with thoughts about future disasters occurring (in
minutes, days, months or years) and these recurring worries could be
about health-related or non-health-related events. Thus, health
professionals should be careful when providing information to
anxious people because they have a strong tendency to
superimpose a future “disaster-type” message, which will further
fuel worry and disturb blood glucose control.
B3.4.4 Screening for Anxiety and Depression

Identifying depression and anxiety in people with diabetes is
notoriously difficult (CMO Psychology Advisory Committee, 2003). This
is especially true in the case of those with significant but mild to
moderate levels because they can easily mask their difficulties over the
course of consultations. These are the very people who can be helped
most easily by self-help; psychological therapy, or medications. They
are also the very people that are unwittingly asked by health
professionals to make changes that are most probably not possible
until their psychological difficulties are resolved.

If it is deemed appropriate to investigate whether someone might have
significant levels of depression or anxiety, the use of a screening
questionnaire may be helpful. The Scottish Diabetes Group
recommends the Hospital Anxiety & Depression Scale (HADS)1
which takes patients about five minutes to complete and us about two
minutes to score. If other common inventories are used such as the
PHQ-9; Beck’s Anxiety Scale, or Beck’s Depression Inventory it is
important to bear in mind that more false positives will be identified
than if the HADS is used.
B3.4.5 Other Psychological Issues
Cognitive problems
Dementia (including the early stages of) is more common as people age
(prevalence among over 65s: 5-8%; over 75s: 15-20%; over 85s: 25-50%).
Non-dementia related cognitive changes can also occur particularly in the
presence of cardiovascular risk factors. Key factors to bear in mind include
54
possible difficulties with memory and learning; planning, and organising all
of which can impair significantly self-care.
Eating disorders
These are more common among people with diabetes than the general
population and like the other issues above typically impair self-care, for
example, because they can involve manipulation of insulin. Anorexia and
bulimia nervosa are both characterised by preoccupations with food and
body image (dread of weight gain and beliefs about being overweight and
so on). Those with anorexia engage in deliberate weight loss strategies
and have a BMI < 17.5. Bulimics have an irresistible craving for food which
is consumed in large amounts over short periods: this is typically followed
by vomiting. There is an Eating Disorder Clinic in Aberdeen which
specialises in the treatment of people experiencing these types of
problems.
55
B3.4.6 Behaviour Change
The guidance below provides brief, general information and some advice
about helping patients to change behaviours, which staff will need to adapt to
suit their specific model of working.
Those who attend adult diabetes services in primary and secondary care have
lifestyle habits that have been present for many years. Unsurprisingly then,
key areas of concern to professionals working with people who have diabetes
have been repeatedly highlighted as notoriously difficult to influence over
extended periods of time, and this is especially true of behaviours targeted at
prevention of future health problems.
Key ways to approach changing lifestyle behaviour that make success more
probable.

Good general clinical skills are imperative ie the ability to establish and
maintain a good working relationship with patients and to encourage
them to make changes in a warm, sensitive and considered manner.
There is about 40 years of research that indicates that how health
professionals get on with patients plays a much more important
role in helping people to make changes than technical skill &
knowledge.

Education and information alone are rarely sufficient to change
long-standing lifestyle behaviours. They generally do however play
an important part in behavioural changes programmes. So, the best
way to think about information provision is as necessary but not
sufficient.

The job of helping people to make changes to the way they live their
lives is really about encouraging, building confidence, and
motivating.

Existing behaviours tend to serve a function (purpose). In general,
people are trying to be happy and their efforts are often focused on the
shorter-term. So what might seem like odd behaviours or ideas are
often idiosyncratic efforts to either increase happiness or decrease
unhappiness. One example might be a person with Type 1 diabetes
who is extremely fearful of nocturnal hypoglycaemic episodes so loads
up on biscuits and toast before bed. She is trying (successfully) to
avoid immediate, very uncomfortable thoughts (about dying) and
feelings (fear, anxiety). The pattern is similar for people who frequently
comfort eat when distressed.

The same behaviour serves a different function in different
people. For example, one person might avoid testing blood glucose
levels because he cannot face the uncomfortable thoughts and feelings
(eg about being a failure or future health complications) that occur if
56
readings are higher than he would like, whereas another might do so
because she doesn’t want others to know she has diabetes.

The function or purpose of existing behaviours are the
maintaining factors, i.e., it explains why the current situation
continues. So, for example, loading-up on biscuits before bed in people
with significant fear of hypoglycaemia continues because it serves a
purpose (successful avoidance of negative thoughts and feelings).
Similarly, many people who (like most of us) have tried and failed to
lose weight or maintain weight loss are seemingly disinterested in
trying again. The purpose of this apparent inactivity is often to avoid the
typical feelings of frustration, disappointment and so on which are
typically associated with not losing the amount of weight desired /
putting weight back on. In both cases, to these people the outcome
is positive, in the shorter-term at least.

Helping change behaviour means patients are moved toward what they
find difficult and means focusing on the pay off between shorter and
longer-term outcomes. So in helping people overcome hypoglycaemic
fear they may be advised to eat and drink gradually less before bed,
thereby exposing them to their uncomfortable thoughts and feelings,
whilst helping them become mindful of the longer-term gains of
addressing this problem.

It is worth bearing in mind that often health alone is not a great
motivator for people to make significant changes to the way they lead
their lives. All of us could spend every hour of every day in efforts to
maximise health but few would choose to do so, even those with
serious medical conditions.

Generally, change is more likely if health gains can be linked to
what people feel is important compared to if change is only linked
to health outcomes. People do tend to be motivated by their values,
that is, those things in life which are important to them. Commonly,
values include intimate relationships; children and grandchildren;
extended family; friendships; enjoyable hobbies, pastimes and sports,
and work.
Goal Setting
This is an important aspect of helping patients to improve self-care. Although
seemingly simple, it is inevitably harder in practice.
o Think SMART: goals should be Specific; Measurable; Achievable;
Relevant, and Timely.
o Be active in negotiating goals because typically people will have
unrealistic expectations of themselves ie try to ensure goals are
achievable.
o Nothing de-motivates like failure so early successes are especially
imperative.
o Write down goals and methods for achieving them – a copy for
patients to take away and for clinical records is often helpful.
57
o
o
o
o
Diary keeping can help track progress for people with diabetes and
their clinicians.
Link diaries of behaviour or outcomes to the fact that change is rarely
linear rather we tend to do well perhaps one week and not so well the
next (they can look back to baseline for example and note overall
progress).
It’s normal to have setbacks.
You can strengthen the likelihood of new behaviours becoming
established by helping patients link behaviours to existing parts of
their daily routines. So, examples might include walks after the TV
news; blood glucose tests after showering, and so on.
It is generally best to have more regular contact initially with people trying to make
changes (this includes emails, telephone calls etc). This is because the early success
is generally imperative. It is also during this period that people make common
mistakes which can lead to them discontinuing their efforts like: remembering
incorrectly agreed goals and plan of action; becoming very disheartened by small or
infrequent failures; boosted by early success set themselves large goals which they
fail to achieve.
Remember, people often try on a number of occasions to change lifestyle
behaviours before they succeed (sometimes they never will), and often the fact
that things remain the same is an achievement (weight for example).
1
We have copies of the HADS in the Diabetes Service. Please contact Andy Keen
(email: Andrew.Keen@arh.grampian.scot.nhs.uk; telephone: 55507), consultant
health psychologist, if you would like to know how to use the HADS.
58
B3.5 Smoking

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All people with diabetes should be strongly counselled against smoking.
Smoking is a significant reversible risk factor for cardiovascular disease
(macrovascular and microvascular).
Patients with diabetes are already at increased risk of cardiovascular
disease.
Smoking increases the risk of development and progression of most
complications, e.g. retinopathy, microalbuminuria.
Smoking potentiates the risks during pregnancy in women with diabetes.
Smoking increases the risk of developing diabetes.
B3.5.1 Smoking cessation
Patients who wish to stop smoking should have access to motivational
support as this will increase the chances of quitting. Nicotine replacement
therapy, bupropion and varenicline are effective aids to smoking cessation for
patients smoking more than 5-10 cigarettes per day and who are nicotine
dependent.
Nicotine replacement therapy (NRT) (sublingual, chewing gum, patches,
nasal spray, inhaler). The form of nicotine replacement therapy chosen should
take into account clinical conditions, (e.g. pregnancy, skin disorders)
individual preference and tolerance of side-effects. NRT is available from
most community pharmacies conforming to a NHS pharmacy service
specification, where staff have undergone training in counselling and smoking
cessation support. Patients who are exempt from prescription costs receive
treatment free of charge, and patients who pay prescription charges will be
charged the equivalent of the prescription charge for each month of treatment.
Bupropion Tablets (Zyban®) must be used in conjunction with a programme
of counselling and cessation support. It should not be used in patients with a
history of seizures, eating disorders, a CNS tumour or who are experiencing
acute withdrawal from alcohol or benzodiazepines.
Varenicline tablets (Champix®▼) must be used in conjunction with a
programme of counselling and cessation support. Uptake of varenicline has
been high and research demonstrates it to be very successful. There have
been recent safety concerns and prescribers should be aware that symptoms
of depression, which may include suicidal ideation and suicide attempt, have
been reported in patients taking varenicline.
Counselling and smoking cessation support is available through the NHS
Grampian Smoking Advice Service (SAS). The SAS can be contacted, free of
charge, on 0500 600 332. Our web address is http://www.nhsgrampian.org.
Professionals wishing to find out more about the SAS may wish to log onto
our section on Hi-net at http://www.hi-netgrampian.org
59
A GP Decision Flow Chart and referral information is available at:
http://cgi.grampian.scot.nhs.uk/
Other Support Available:
Patients can access support by calling Smokeline (provided on behalf of
HealthScotland) 0800 84 84 84. The Health Scotland “Can Stop Smoking”
website offers advice and e-mail and text message support. It can be
accessed at http://www.canstopsmoking.com/home.htm
B3.6 Travel
It has become increasingly easy in recent years to travel all over the world
offering exciting opportunities to many. For most patients diabetes mellitus
should not be a bar to travel but certain factors have to be taken into
consideration to ensure a healthy, hassle free trip.
General Advice
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Those on tablets or insulin should pack extra snacks in case of delays
in travel arrangements.
Additional supplies of medication should be taken in case of delay etc.
Hot / cold climates may affect blood glucose control and additional
blood glucose monitoring may be appropriate.
Diet may be very different in some countries – particularly in the type
and quantity of carbohydrate.
It is not necessary to order special diabetic meals for flights. The
diabetic meals provided by the airlines do not contain enough
carbohydrate.
The water in many countries is not safe to drink so food and water
hygiene are very important as illnesses causing diarrhoea and vomiting
may have a serious adverse effect on diabetes control and may
precipitate the need for urgent medical review or even hospital
admission.
It is important to protect the feet from sunburn. Footwear should be
worn at all times including on the beach to avoid injury to the foot and
the risk of infection.
It is useful to carry some kind of information stating that you have
diabetes mellitus and are on medication, especially if travelling alone.
Various items are available such as cards or bracelets.
Patients on long-haul flights should be given advice concerning
minimising the risk of DVT.
Accidents and ill health can occur to any traveller and good travel
insurance with repatriation cover if necessary should be taken out by
all. The European Health Insurance card (EHIC) does not cover
repatriation to the UK only medical costs incurred in countries in the
EU. Diabetes UK can be helpful in this regard as can companies such
as SAGA and Freespirit.
60
Specific advice for insulin-treated patients
 Hot climates can affect insulin absorption and activity levels and diet on
holiday often differ from that at home so doses may have to be altered.
Therefore it is advisable to test blood glucose more frequently on
holiday to keep good control and avoid unexpected hypoglycaemia
(please check link.
 Any illness acquired while travelling could precipitate ketoacidosis.
Ketostix should be taken on holiday so that urine can be tested for
ketones if these illnesses arise.
 Insulin adjustment may be required for long haul flights. For some the
use of a short acting insulin before meals while travelling may be
added to the normal regimen.
 Insulin should not be stored in the hold as it can freeze, thereby making
it less effective. It should be carried in hand luggage. For those
travelling to very cold climates, special storage bags are available to
insulate the insulin so that it does not freeze. These are available from
companies such as Diabetes UK and Frio. High temperatures can also
affect insulin and again storage bags can help to protect it but insulin
will keep well at room temperature for periods of up to one month.
 A letter from a doctor for those on insulin should be carried to avoid
any problems with customs at airports both here and abroad. These
are available from the diabetic clinic for those who attend Woolmanhill
or from GPs.
A useful check list for holiday packing can be found in the Diabetes UK
booklet on travel.
Additional information can be found on the following websites:
http://www.travax.scot.nhs.uk (for health professionals)
http://fitfortravel.scot.nhs.uk (for patients)
61
B4.0 Information Technology
B4.1 National and Regional Diabetes IT Overview
B4.1.1 SCI-DC – Introduction
SCI-DC (Scottish Care Information – Diabetes Collaboration) is a national
system that allows access to data regarding all people with diabetes in NHS
Grampian. It aims to deliver an integrated diabetes record to diabetes health
care providers in NHS Scotland. This was set up in the basis of the
recommendations in the ‘Scottish Diabetes Framework’; which identified that
well-managed, integrated diabetes care must be underpinned by effective
information technology systems. The principal aim of SCI-DC is to deliver a
shared electronic record for use by all involved in the provision of diabetes
care.
SCI-DC brings support information and clinical data together from a variety of
sources including general practice, hospital clinics and retinal screening. The
SCI-DC project comprises of two key products, namely SCI-DC Clinical and
SCI-DC Network. The SCI-DC products are complimentary, each with a
different focus. SCI-DC Clinical is designed to provide hospital clinic-based
support, delivering such features as the automatic generation of GP letters.
An interface has been developed to take the clinical data captured by SCI-DC
Clinical for automatic update of the patient record held on SCI-DC Network.
SCI-DC Network allows for the identification of all people with recorded
diagnoses of diabetes in the General Practice computer systems, and
provides full support for the Scottish Diabetes Survey. Its regionally
customisable web pages allow access to standardised treatment guidelines
for decision support, and provide access to patient leaflets.
The SCI-DC Network website is available to all General Practices regardless
of what GP system an individual practice uses and SCI-DC holds a diabetes
register of patients for all practices. SCI-DC Network allows for automated
practice audit in support of clinical governance, and contains such features
as graphical representation of laboratory results over time, allowing for
longitudinal risk to be gauged and providing a focus for discussion with
patients. In Grampian all practices have access to the system.
In Grampian the Diabetes Centre uses PROTOS at present as the IT system.
62
Primary Care
SCI-Store
Secondary care
GP systems
HbA1c, Renal Function,
Lipid profile, etc.
SCI-DC Clinical*
(GPASS,VISION, EMIS etc)
Foot Screening
Weight
Height
Medication
Smoking Status
Vascular co-morbidity
Patients coded
as having Diabetes in
GP register
Added to
diabetes register
Identifies patients
for Retinal Screening
SCI-DC Data store
SCI-DC Network
Sorian
National Retinal
Screening system
Direct
data entry
DSN
Retinal Screening Results
Podiatry
•In Grampian the Diabetes Centre uses PROTOS at
present as the IT system, which does not interface
with SCI-DC, but there are plans to upgrade to SCIClinical.
Clinical
Review
Figure 1 – Diagram of SCI-DC linkages with other systems
B4.1.2 Accessing SCI-DC Network
The address for accessing SCI-DC is: https://ctc6.tayside.scot.nhs.uk/scidc/
Access to SCI-DC is available to registered users from within NHS computer
networks.
You can access SCI-DC Network through the GP Portal (see figure 2) from
the Grampian Intranet pages.
63
Click here
Figure 2 – Accessing SCI-DC Network through the GP Portal
In order to gain access to the information contained within SCI-DC Network
you must enter your username and password from the login page (see figure
3).
64
Figure 3 – SCI-DC Network Login Page
Once you have successfully logged into SCI-DC, the screens you will be
presented with will vary slightly depending on whether you are working in
primary or secondary care (see figure 4).
65
PRACTICE NAME
Dr James, GP
Figure 4 – SCI-DC Primary Care Page
B4.1.3 SCI-DC Network - Overview
From this screen you can access a range of further screens that allow you to
both enter and view information on individual patients from the practice
overview screens such as biochemistry, cardiovascular and lifestyle data
(HbA1c, cholesterol, blood pressure, height, weight and BMI for instance).
You can also access and print off relevant leaflets, such as foot screening
leaflets, from the individual patient summary screen (see figure 5). Shown
below is snapshot of the foot screening form that can be accessed through
the patient summary form.
66
Click on the appropriate form and
print as required
Figure 5 – Foot Screening Leaflet Screen
In SCI-DC Network you can also enter and view foot screening data and view
results and images obtained from Diabetes Retinal Screening (see figure 6).
67
PRACTICE NAME
Dr James, GP
Click here
to access
Diabetes
Retinal
Screening
pages
Figure 6 – Accessing Diabetes Retinal Screening Results
Furthermore, if you work in primary care, you are also able to perform practice
audits in a range of areas that allow you view patients with certain readings,
patients with deteriorating readings or patients who have not had certain tests
carried out or results recorded (see figure 7).
In addition you are also able to view summary information in a range of areas
for your own practice and compare this with regional figures for NHS
Grampian as a whole.
68
Figure 7 – Performing a General Audit Using SCI-DC
B4.1.4 SCI-DC – Help / Contacts
Should you require a user name and password for SCI-DC Network, forget
your username or password, require additional training or have any other
query please use the numbers or email below as a contact. There is a SCInetwork user guide that can be e-mailed to assist you.
Contact Names
Robert O’Donnell
Diabetes MCN Support Officer
Diabetes Centre
Woolmanhill Hospital
Frances Philip
MCN Administrator
Diabetes Centre
Woolmanhill Hospital
t: 01224 555379
e: rodonnell@nhs.net
t: 01224 555379
e: frances.philip@nhs.net
69
Useful Links
The following websites provide a mixture of local and national information and
are suitable for all with an interest in diabetes and diabetes care.
Grampian Diabetes Centre – this website provides a range of information
about services in NHS Grampian and contains lots of useful information for
both patients and those involved in patient care.
http://www.diabetes.nhsgrampian.org
My Diabetes My Way – this website is designed to help support people who
have diabetes as well as their family and friends and provides a host of
resources with regards to all aspects of diabetes.
http://www.mydiabetesmyway.org.uk/
Diabetes UK – this website provides information guides for people with
diabetes as well as extensive information about research into diabetes and
fundraising activities. The website also provides local and national
information and information about professional conferences and diabetes
campaigns.
http://diabetes.org.uk
Active Scotland – this website allows you to enter your postcode and see
what activities are available in your local area, from the easy to the extreme,
to help people lead a more active lifestyle.
http://www.activescotland.org.uk/
70
B5.0 Contraception, Pregnancy and the Management
of Gestational Diabetes Mellitus
Patient information websites
The national website http://www.mydiabetesmyway.scot.nhs.uk allows access
to a range of information for people with diabetes who are pregnant or who
are planning pregnancy.
The “My Body” section has a link to general pregnancy leaflets and a DVD.
Hard copies of the leaflets and DVD are available form combined clinics in
Aberdeen and Elgin. Other locally produced leaflets on are available on the
following MCN website:
http://www.diabetes.nhsgrampian.org/

Type 1 Diabetes is one of the most common medical conditions during
pregnancy and increasing numbers of women with Type 2 diabetes are
having pregnancies. Thus discussion o contraception and pre
pregnancy care is important for all women with diabetes during their
childbearing years.

Successful outcome of pregnancy can usually be anticipated in women
with pre-existing diabetes. However, diabetic pregnancy is statistically a
high-risk pregnancy with regard to fetal morbidity and mortality. In order
to achieve an optimal fetal outcome major efforts and attention to detail
are required on the part of the patient and her carers. Meticulous blood
glucose control before and during pregnancy is the cornerstone of
management. In addition to metabolic supervision, mothers require
close clinical surveillance since there are increased risks with regard to
progression of diabetic retinopathy and nephropathy, pregnancy
induced hypertension and intrapartum complications.

The congenital abnormality rate in diabetic pregnancy is at least double
that of the background population, and there is convincing evidence
that this relates to glycaemic control at or shortly after conception
during the period of organogenesis. This stage is often complete before
the mother realises that she is pregnant.
For these reasons diabetic pregnancy should always be planned and reliable
contraception is therefore important.
B5.1 Contraception
The importance of avoiding unplanned pregnancy should be an essential
component of diabetes education for young women with pre existing diabetes
from adolescence. The failure rate of the condom is relatively high, however
71
many of the other methods of contraception are safe for use by the majority of
people who have diabetes.
For all those recently diagnosed as having diabetes mellitus all methods are
suitable provided there are no other medical reasons why a particular method
is unsuitable.
For those who have vascular complications such as diabetic eye disease or
kidney problems the combined oral contraceptive pill may be contraindicated
and most other methods would be suitable. Advice has to be tailored to each
individual depending on the presence of complications and other medical
problems. Expert advice is available at the diabetic clinic or at Square 13,
Centre for Family planning and Reproductive health Care, 13, Golden Square,
Aberdeen.
Contraceptives available are:
Contraceptive
Combined contraceptive pill (COC) –
Depo Provera Injection
Implanon subcutaneous implant
Progesterone only pill (POP)
Intrauterine system or Mirena
Intrauterine device (IUD)
Sterilisation
Vasectomy
Condom
Persona
Diaphragm or Cap
Natural family planning methods
Failure Rate
0.3%
0.3%
almost 0%
1 to 2%
<1%
<1%
1 in 200 and gets worse over time
1 in 2000
2 to 15%
6% at best
2 to 12%
Can be around 25% if not followed
every day and requires a high degree
of motivation
Long acting methods such as the IUD, IUS, and Implanon are best as they
require no further thought once fitted until they need replaced.
Emergency contraception - failure rate of around 5% mid-cycle, 2% over the
whole cycle. Need to obtain it within 72hrs of risk episode and the sooner it is
taken the more effective it is. The copper IUD can be inserted as an
emergency contraceptive up to 5 days after a risk episode and is nearly 100%
effective but due to other considerations such as the risk of infection is not
first choice. Other tablet methods are used on a trial basis under license from
the Scottish Office and are available up to 5 days after the risk episode from
Square Thirteen in Golden Square.
B5.2 Planning pregnancy
Prior to conception
Refer to a hospital or combined obstetric diabetic clinic for pre pregnancy
assessment, where the following steps are taken:
72
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Review insulin regimen. For intensive blood glucose control most
women are best treated with a multiple injection regimen.
Provide blood glucose meter and test blood glucose four to six times
daily Blood glucose targets should be individualised and will depend on
factors such as hypoglycaemia unawareness or the residual maternal
beta cell function. General targets are fasting and pre meal 4.0-5.5
mmol/l, two hour post prandial <7.0 mmol/l for women with Type 1
Diabetes. NICE recommends 3.5-5.9 mmol/l fasting, one hour post
prandial below 7.8mmol/l during pregnancy and these levels may be
possible in eg Type 2 Diabetes treated by diet and and a small dose of
metformin.
Achieve optimal glycaemic control aiming for an HbA1c result within or
as near to the non-diabetic range as is possible without inducing
disabling hypoglycaemia A general target for HbA1c of <7% is
advised for women with Type 1 diabetes although the ideal target is
quoted in NICE is < 6.1%. This lower value may be feasible in patients
with Type 2 diabetes but cannot be achieved in many women with
Type 1 diabetes because of the risk of severe hypoglycaemia.
Patients with Type 2 diabetes should be considered for insulin therapy
with treatment targets as above. Women with pre existing diabetes
may use metformin as an adjunct or alternative to insulin in the
preconception period and during pregnancy when the likely benefits
from improved glycaemic control outweigh the potential for harm. All
other oral hypoglycaemics should be discontinued before pregnancy
and insulin substituted.
Discuss lifestyle issues which may affect glycaemic control, e.g.
o Difficulty with shift work
o Encourage appropriate exercise
Review all medications and other potential teratogens. ACE inhibitors
and ARBs should be discontinued before pregnancy or as soon as
pregnancy is confirmed . alternative antihypertensive agents suitable
for use during pregnancy, eg methyl dopa, should be substituted.
Arrange dietetic review and reinforce antismoking advice
Commence folic acid 5mg daily. (High dose recommended in view of
high risk of neural tube defects)
Ensure complication screening is complete and take action as
appropriate – See 10.2 -Content of Annual checks
Check rubella status
Assess general health, fitness for pregnancy, and screen for
factorswhich could disturb glycaemic control, e.g. urinary infection and
thyroid status
Review menstrual and gynaecological factors which could impair
fertility
An intensive education update to self management should be offered. If
available,a place on a structured education programme prior to
pregnancy provides this level of education.
73
B5.3 Confirmed pregnancy
All diabetic women in whom pregnancy has been confirmed should be
referred immediately by telephone or fax to a hospital combined obstetric /
diabetic clinic for intensive education and multidisciplinary supervision.
Clinics are held weekly in Aberdeen and Elgin, where women will be seen at
one to four weekly intervals depending on metabolic control and obstetric
progress. Admission is not routine but may be recommended for
stabilisation of blood glucose control, management of diabetic complications
or associated obstetric problems. There is a low threshold for admission in
these high-risk pregnancies.
Hypoglycaemia (see section C4.0)
Strict blood glucose control increases the risk of hypoglycaemia and warning
signs are often lost in early pregnancy. All women should be provided with
Glucogel and a glucagon emergency kit, and their partner should be
instructed in their use. Ideally women should not sleep in a house alone in
early pregnancy because of the risk of hypoglycaemia. Women who lose
awareness of hypoglycaemia in pregnancy should be advised to stop driving
until warning symptoms return to normal.
Ketosis
The fetus tolerates hypoglycaemia well, but is very sensitive to ketosis.
Established ketoacidosis in pregnancy results in a very high incidence of fetal
loss at all gestations, and is usually potentially avoidable. Pregnant women
should all have facilities to check blood or urine for ketones. Elevation of
blood glucose (> 10mmol/l) together with persistent non fasting ketonuria is an
indication for increased insulin doses and urgent further assessment usually
involving hospital admission for intravenous insulin and dextrose.
Women must be advised to contact either their DSN, hospital team or GP in
such circumstances without delay. The most common cause of ketosis in
pregnancy is urinary tract infection, which should be treated on a
presumptive basis.
Delivery
Women should be delivered where there are facilities for intensive neo-natal
care. Ideally should be vaginal and at term (but not beyond). An individual
decision will be made for each patient, and in practice the caesarean section
rate remains much higher than that of the non-diabetic population (around
67%).
All women on insulin receive an infusion of dextrose and insulin during labour
to maintain normoglycaemia.
Post partum insulin requirements usually fall to between 30% and 50% of
that immediately prior to delivery. Breast-feeding is encouraged. Link to
leaflet on Breast feeding and diabetes
74
B5.4 Management of Gestational Diabetes
Background and definition
Gestational diabetes mellitus (GDM) has been defined as carbohydrate
intolerance of variable severity with onset or first recognition during
pregnancy.
During pregnancy the normal range for fasting blood glucose is much lower
than in non-pregnant women and glycosuria with normal blood glucose levels
is common due to a lowering of the renal threshold for glucose.


The optimal methods to screen for, diagnose and treat GDM are under
review. The National Screening Committee is considering screening for
GDM. NICE guidelines recommend use of risk factors for screening
and SIGN, which currently recommend the process below (SIGN 55),
are to consider the topic as part of an updated guideline. Important
trials are also due for publication and, in the meantime, Grampian
guidelines for screening, diagnosis and treatment are unchanged until
the Scottish national guideline is updated.
Women with a history of gestational diabetes, who have not
progressed to diabetes in the interim, should have an OGTT around
16-18 weeks during subsequent pregnancies.
Recommended population screening protocol for gestational diabetes
mellitus
Diagnosis
The criteria for the diagnosis of gestational diabetes are recommended as
Venous plasma glucose on 75g OGTT
Fasting > 5.5 mmol/l
OR
2 hour value > 9.0 mmol/l
75
Management
Women diagnosed as having gestational diabetes should be seen by a
physician and obstetrician with a special interest in diabetes and should
receive intensive management with diet and/or insulin if macrosomia is
suspected or if blood glucose levels are in the range for established diabetes.
Post-natal follow up
Up to 50% of women may go on to develop Type 2 diabetes later in life and
this group presents an excellent opportunity for screening and intervention.
Studies have shown that lifestyle intervention can reduce the incidence of
diabetes in at risk patients by over 50%. A local patient leaflet explaining
this risk and measures to reduce the risk of diabetes is available on the
MCN website. Link to leaflet on advice to reduce DM in women with GDM.
All patients with gestational diabetes are invited for a glucose tolerance test
at 6 months after delivery.
Women with a history of gestational diabetes who have developed IGT, IFG
or DM should be referred to the pre-pregnancy clinic or to the Combined
Obstetric Diabetic clinic when pregnancy is confirmed. Some women will
need active management from early pregnancy.
76
B5.4.1 Follow up of Patients with Previous Gestational Diabetes
77
B6.0 Children’s Services
There are services available for children and adolescents across Grampian
based at RACH, Dr Gray’s Hospital and Woolmanhill.
Any child up to the age of 14 with suspected diabetes should be referred the
same day to the receiving Paediatric Medical team at either RACH or
Dr Gray’s Hospital. Older children and adolescents should be referred to adult
services.
Local guidelines for the management of children with diabetes can be
accessed via the Grampian diabetes website at:
..\..\..\..\Website\MANGEMENT OF DIABETIC CHILDREN IN
RACHvmar06_final[1].doc
Further information about the service and the children’s team can also be
obtained from:
http://www.diabetes-scotland.org/grampian/home.html
78
Section C: Glycaemic Control
C1.0 Targets for Glycaemic Control ....................................................... 81
C1.1 Glycosylated haemoglobin ........................................................ 81
C1.2 Conversion Table for HbA1c % to mmol/mol ............................ 82
C2.0 Monitoring ........................................................................................ 83
C2.1 Patients with Type 2 Diabetes controlled by diet or oral
medication ................................................................................ 83
C2.2 Patients with Insulin-treated Diabetes ....................................... 84
C2.3 Adjustment of insulin dose ........................................................ 85
C2.4 Ketone testing in insulin-treated patients .................................. 85
C2.4.1 Management of results: ................................................ 85
C2.5 NHS Grampian recommended blood glucose
meters/lancers/lancets.............................................................. 87
C3.0 Hypoglycaemic Drug Therapy ........................................................ 89
C3.1 Oral hypoglycaemic drugs ........................................................ 90
C3.1.1 28 day OHA treatment costs ....................................... 101
C3.2 NICE guidance on treatment of Type 2 diabetes .................... 102
C3.3 Insulin regimens....................................................................... 103
C3.4 Types of Insulin ....................................................................... 104
C3.4.1 Insulin costs ................................................................ 107
C4.0 Hypoglyaemia ................................................................................ 108
C4.1 Causes of hypoglycaemia ....................................................... 108
C4.2 Symptoms of hypoglycaemia .................................................. 108
C4.3 Hypoglycaemia unawareness ................................................. 109
C4.4 Treatment of hypoglycaemia ................................................... 109
C4.5 Hypoglycaemia and sulphonylureas ....................................... 110
C4.6 Nocturnal hypoglycaemia ........................................................ 110
C4.7 Rebound Hyperglycaemia ....................................................... 111
C4.8 Avoidance of hypoglycaemia .................................................. 111
C4.9 Driving and hypoglycaemia ..................................................... 111
C4.10 Exercise related hypoglycaemia ........................................... 112
C5.0 Management of Diabetic Emergencies in the Community ......... 113
C6.0 Management of Diabetes in Hospital ........................................... 115
C6.1 Introduction ............................................................................. 115
C6.2 Diabetic emergencies ............................................................ 117
C6.2.1. Diabetic Keto Acidosis (DKA)..................................... 117
C6.2.2 Hyperosmolar Non Ketotic Hyperglycaemia (HONK) .. 118
C6.2.3 Hypoglycaemia in hospital .......................................... 118
C6.2.4 Prevention of Hypoglycaemia during Hospital Admission
.................................................................................... 120
79
C6.3 Management of Diabetes during intercurrent illness ............... 121
C6.3.1 Type 1 diabetes .......................................................... 121
C6.3.2 Type 2 diabetes .......................................................... 121
C6.3.3 Variable rate intravenous insulin infusion .................... 121
C6.4 Guidelines for diabetes management during procedures
requiring fasting ...................................................................... 125
80
C1.0 Targets for Glycaemic Control
Epidemiological studies show that the risks of arterial disease and micro
vascular complications in people with diabetes are related to the extent of
hyperglycaemia.
The Diabetes Control and Complication Trial (DCCT) and UK Prospective
Diabetes Study (UKPDS) have shown that optimal blood glucose control in
the early years after diagnosis substantially reduces the risk of development
and progression of complications in people with diabetes.
The overall goal should therefore be the optimisation of blood glucose without
undue hypoglycaemia. The extent to which this is pursued by the individual
patient will depend on motivation, practical aspects of diabetes management
(e.g. insulin delivery and self-monitoring), risks related to hypoglycaemia and
concomitant co-morbidity. Long term outcome studies are not available for
some of the newer therapeutic agents and their long term benefits are
uncertain.
C1.1 Glycosylated haemoglobin
Overall glycaemic control is best measured by HbA1c, which provides an
index of the average blood glucose concentration over the preceding two
months. Reference ranges for HbA1c vary according to method of assay.
From June 2009 HbA1c assays will be standardised and reported in
mmol/mol as well as %. Dual reporting in both units will continue for around 2
years to allow the diabetes community and others to adapt to the new units.
Educational leaflets for patients, lab staff and clinical staff are available at
www.Diabetesinscotland.org.uk.
The range for HbA1c in people who do not have diabetes is up to 6% (42
mmol/mol). The DCCT and UKPDS intensively treated groups achieved
HbA1c levels of 7% (53 mmol/mol) but this may not be achievable without
undue adverse effects. Any reduction of elevated glycosylated haemoglobin
will produce a significant reduction in microvascular complication risk.
To achieve optimal HbA1c levels the following blood glucose targets are likely
to be required:
• Fasting plasma glucose in Type 2 patients ≤ 5.9 mmol/l
• Preprandial blood glucose 4-7 mmol/l
• 2 hours postprandial blood glucose 7-9 mmol/l
A single target figure may be unhelpful as this may vary between individuals
depending on the:
 Quality of life that would have to be sacrificed to reach that target.
 Extent of side effects
 Resources available for management
81
In order to set realistic targets that patients can relate to and are motivated to
achieve people with diabetes should be:
 Involved in decisions as to their individual HbA1c level, which may be
above or below that set for the general population of people with
diabetes
 Offered therapy (lifestyle and medication) to assist in achieving and
maintaining their HbA1c target
 Informed that any reduction in HbA1c towards the agreed target is
advantageous to future health
In conclusion patients with diabetes should be encouraged to maintain an
HbA1c less than 7% (53 mmol/mol) unless the resulting side effects of
their efforts in achieving this significantly impair their quality of life.
Some recent publications indicate a lack of benefit from very tight glucose
control especially in older patients with longer duration of diabetes.
Further guidance on this topic and the value of newer agents should be
available from the selective SIGN update due for publication in 2010.
C1.2 Conversion Table for HbA1c % to mmol/mol
%
4.0
5.0
6.0
6.5
7.0
7.5
8.0
9.0
10.0
mmol/mol
20
31
42
48
53
59
64
75
86
Information for patients and for healthcare professionals can be found on the
following webpages:
Information for patients
http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/53130%20H
bA1c%20PWD%20leaflet.pdf
Information for healthcare professionals
http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/53130%20H
bA1c%20HCP%20leaflet.pdf
82
C2.0 Monitoring
Self Monitoring of blood glucose (SMBG) has an important role in the
management of some individuals with diabetes. It should certainly not be seen
as essential for everyone with diabetes. The evidence of value in improving
HbA1c patients is limited http://nhshealthquality.org/evidencenote . When
used inappropriately it can lead to added stress to the patient with no benefit.
No matter what the type of diabetes or the treatment modality being utilised
SMBG will only be of value if used by a motivated, well educated patient. It
should only be initiated as part of a package of care that should include
structured education.
In these circumstances SMBG is an integral part of effective patient education
packages and enhances the effective use of many therapies and lifestyle
interventions.
C2.1 Patients with Type 2 Diabetes controlled by diet or oral
medication

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
For most patients regular home blood glucose testing may not be
appropriate. Patient choice and clinical need should be taken into
account. When glycaemic control is stable and HbA1c on target,
regular testing may not be essential but may help some patients
maintain optimal control.
SMBG needs to be initiated by the clinician and patient in conjunction
with a structured education package and in the context of clear
outcome benefits.
Home blood glucose monitoring may help an individual to take control
of their condition and can inform patients of the effects of eating certain
foods and exercise on blood glucose. Some individuals will monitor
blood glucose to empower them to make changes to lifestyle and thus
improve glycaemia.
How often and when should patients monitor blood glucose?


When HbA1c is rising or when treatment is changing, e to insulin or
when there is intentional lifestyle change, blood glucose monitoring 2-3
times per week at different times of day (e.g. fasting, 2 hours after
eating) may be helpful up to a maximum of 4 tests every fourth day or
one test per day.
Patients should be encouraged to record and understand the results of
their blood testing and take action as agreed with their diabetes team.
Situations which may require more intensive blood glucose monitoring:
83
Patients should be advised to test blood glucose at least daily and possibly up
to 4 times per day in the following situations:
 During significant illness or if ketonuria∗ present
 During times of psychological / emotional stress (e.g. exams, driving
tests)
 If the patient is on sulphonylurea and is at increased risk from
hypoglycaemia (e.g. taxi / lorry driver / operating heavy machinery)
 During pregnancy or pre-pregnancy planning
 To assess changes in glucose control due to medications and lifestyle
changes
 Before / After moderate physical activity
QIS Evidence note on clinical and cost-effectiveness of self-monitoring of
blood glucose (SMBG) for non-sinulin treated Type 2 diabetes – see link
below.
ClinicalGovernance_EN26ClinicalAndCostEffectivenessOfSMBG_JAN09.pdf
Blood glucose targets – these vary between individuals – (See section
C1.1)
∗ Urine Ketone Testing
This is not usually required in patients with Type 2 diabetes but where there is
concern that the patient may have evolving Type 1 diabetes or becoming
"insulin-requiring" the diabetes team may recommend urine ketone
monitoring.
C2.2 Patients with Insulin-treated Diabetes
Patients with diabetes who utilise insulin need to practice SMBG so as to
titrate insulin dose and avoid the extremes of glycaemia. By correctly
interpreting SMBG and making adjustments to insulin dose and lifestyle
control can be maximised and long term outcomes improved. For this to be
affected then the individual with diabetes utilising insulin needs to be well
educated and empowered to make changes.
Home blood glucose monitoring is strongly recommended for people with
insulin-treated diabetes, as it enables the individual to take control of their
condition and can help highlight situational changes requiring insulin
adjustment.
How often should patients monitor blood glucose?
A blood glucose test should only be taken if it is to be used in decision
making.
Monitoring should be encouraged at a frequency that is useful to the particular
individual with diabetes remembering that:

Frequency of monitoring will vary between patients depending on
84


lifestyle, motivation and need.
Patients should be encouraged to do at least one test per day at
different times or 4 times a day every 3rd or 4th days.
At times some patients wishing to have greater control or flexibility may
choose to test up to 4 times per day (also see below for situations
where more testing may be required)
When should patients test blood glucose?
Recommended times of testing would be before meals (i.e. breakfast, lunch
and tea), before bed and sometimes 2 hours after eating. Patients should be
encouraged to keep a record of results including details such as time of day,
activity and dietary intake.
Situations which may require more intensive blood glucose monitoring









Therapeutic change
During illness or ketonuria
Before /After physical activity
Before driving (any distance not just long journeys)
Psychological / emotional stress (e.g. exams, driving tests)
Impaired hypoglycaemic awareness or recurrent hypoglycaemia.
Changes in lifestyle – job / shift patterns
Pregnancy or pre-pregnancy planning
Using an insulin pump
C2.3 Adjustment of insulin dose
Individuals with diabetes should be empowered by their team of professionals
to interpret the results of SMBG and be able to make changes to their insulin
regime.
C2.4 Ketone testing in insulin-treated patients
Patients on insulin should be advised to keep an “in date” supply of ketonetesting strips. They may have access to blood ketone testing strips.

If blood glucose 17 or above or during intercurrent illness (e.g. cold /flu/
UTI etc) urine should be tested for ketones.
C2.4.1 Management of results:
Urine Ketones:
1. If TRACE or SMALL - observe.
2. If MODERATE or LARGE – extra insulin is probably required.

If blood glucose still 17 or above after 3 hours – re-test for ketones. If
ketones are still present (i.e. moderate or large), further extra insulin
may be required and if any uncertainty with the best course of action
specialist help should be sought.
85

If blood glucose and urine/blood ketones are persistently
elevated the patient is at significant risk of developing diabetic
ketoacidosis and specialist advice will be required.
86
C2.5 NHS Grampian recommended blood glucose
meters/lancers/lancets
January 2009. Review Date 2010 DSN Group
National procurement of blood glucose test strips is being
undertaken by NHS Scotland at present. The cost of certain
meters may be less by 2010.
In NHS Grampian the meters listed above in detail are
recommended for home blood glucose testing (HBG).
We recommend patients should not use more than one meter for
day to day testing as results can vary from meter to meter.
In the interests of good practice and safety, please ensure the
repeat prescription is for the correct test strip and discontinue the
previous meter strips.
Please ensure the patient re-codes the meter for each new batch
of test strips.
For specific patients there are other meters available.
Patient
Meter name
Advantages
Test strips
Cost
Contact
87
Type 1
Optium
Xceed
Checks for
blood Ketones
Visually
Impaired
SensoCard
Plus
Poor
Dexterity
Accuchek
Compact
plus
Gives verbal
commands and
results
Can be
operated with
one hand
Optium
Ketone test
strips
SensoCard
plus test
strips
Compact
Plus
£18.80
/ 10
£16.30
/ 50
£14.59
/ 51
details
Abbott
0500
467466
SensoCard
01792
229333
Roche
0800
701000
Some meters accept the wrong strip and wrong readings can be
given e.g. for blood glucose readings Optium Xceed.
Please be aware sample size and range of readings differ with
each meter.
We recommend patients register their meter with the company
who supplied the meter by phone or registration card.
This saves you time if there is any problem with the meter or the
patients technique, as the care lines will help the patients and
supply replacement batteries or new meters in the event of product
recall.
Meters should be tested regularly using the quality control (QC)
solution supplied by the company. This is available free on
request, along with replacement batteries and downloads software.
LANCERS
For single patient use, in practices or by nursing staff in the
patient’s home, the following is advised UNISTIK3 COMFORT
(OWEN MUMFORD) order code FZT 069 or on FP10 for a named
patient.
This is a device where lancer and lancet are in one and are
disposable after single use.
88
If carers’ change the patient’s personal lancet the Multiclik lancer
pen supplied with the Accuchek Aviva meter is recommended as
six lancets are contained in a barrel and there is reduced risk of
needle stick injury to the carer.
C3.0 Hypoglycaemic Drug Therapy
Index:
Oral
Metformin
Sulphonylureas
Thiazolidinediones
Incretin hormone therapies
DPP-IV inhibitors
GLP analogues
Prandial glucose regulators
Acarbose
Insulin – see table on p 82/83
Insulin Lispro (Humalog)
Insulin Aspart (Novorapid)
Insulin Glulisine (Apidra)
Human Actrapid
Humulin S
Insuman Rapid
Hypurin Bovine Neutral
Hypurin Porcine Neutral
Human Insulatard
Humulin I
Insuman Basal
Hypurin Bovine Isophane
Hypurin Porcine Isophane
Hypurin Bovine Lente
Hypurin Bovine Protamine Zinc 10ml Vial
Insulin Glargine (Lantus)
Insulin Detemir (Levemir)
Human Mixtard 30 / Actrapid / Insulatard in ratios of 30/70
Humulin, M3 Humulin S / Humulin I in ratios of 30/70
Insuman Comb 15, 25 or 50,
Insuman Rapid / Basal in ratios of 15/85 to 50/50
Humalog Mix 25 or 50 Lispro/LisproProtamine in ratios of 25/75 or 50/50
Novomix 30 Aspart/Aspart Protamine in a ratio of 30/70
Hypurin Porcine 30/70 Mix
89
C3.1 Oral hypoglycaemic drugs
These drugs are suitable for people with Type 2 diabetes when blood glucose
control through dietary measures alone proves inadequate.
Since in practice the majority of patients are overweight, metformin is usually
the drug of first choice. Sulphonylureas would be the usual second choice
due to cost and safety factors. Pioglitazone or DPP IV inhibitors may be an
alternative in obese patients. However, recent safety concerns re: the
glitazones (heart failure and reduced bone density) and the limited clinical
experience with DPP IVs (as well as cost factors) place these agents as third
choice for possible use as triple combination therapy (in addition to metformin
and sulphonylureas), in patients who are reluctant to go on to insulin.
Early sulphonylurea treatment may be appropriate in the thin symptomatic
patient without ketonuria.
Patients should be educated about their drugs and should carry
documentation of any risk of hypoglycaemia. The risk of hypoglycaemia is
present when using sulphonylureas alone or with any combination of oral
agents with sulphonylureas.
The new treatments for Type 2 diabetes on the market at the present time
have limited long term outcome data to support them and should be used with
a degree of caution.
90
Metformin
Action
Metformin works principally by reducing insulin resistance.
Indications
Primary drug treatment of overweight Type 2 diabetes. As an adjuvant to
other hypoglycaemic therapy in Type 2 patients. Metformin may be continued
in some obese patients with Type 2 diabetes who ultimately require insulin
therapy, to maximise insulin sensitivity and minimise weight gain on insulin.
Side Effects
Diarrhoea, lethargy, anorexia, malabsorption of B12 and folate Lactic acidosis
is a very rare but often fatal side effect. It occurs almost exclusively in
alcoholics, patients with renal or severe cardiac failure, liver disease, and
those who are undergoing surgery or are shocked.
Caution
Contraindicated in renal impairment (creatinine >150µmol/l or eGFR <30
ml/min/1.73 m2), severe liver disease and alcoholism. Discontinue temporarily
during severe inter-current illness. Discontinue for 48-hours following the
injection of x-ray contrast media.
Dose
Initially 500mg daily with or after main meal, increasing gradually in 500mg
increments to a maximum of 1g tds as required for good glycaemic control.
The dose is often limited by diarrhoea.
Extended Release Metformin (Glucophage SR) is not recommended for the
treatment of adults with type-2 diabetes. This new formulation appears to
have similar short-term efficacy to immediate-release metformin. Evidence of
improved gastrointestinal tolerability is not convincing and it is more
expensive than the immediate-release formulation. However, it may be useful
in those who are poor at remembering tablets as a once daily dose may aid
compliance.
Metformin is also available in combination tablets with rosiglitazone
(Avandamet) and pioglitazone (Competact). The use of these tablets is not
recommended unless essential to aid compliance in certain patients
Metformin and intravenous contrast studies
Contrast studies such as peripheral or coronary angiography and CT head
scan with iv contrast, are associated with a small risk of acute renal failure
that could result in the development of lactic acidosis in patients on Metformin
therapy. Therefore, Metformin should be discontinued after such contrast
studies for 48 hours or until renal function returns to normal. It is essential
that the Radiology Department is aware of Metformin therapy and current
91
eGFR in advance. In patients with significant renal impairment, (eGFR <50)
ensure adequate hydration (eg normal saline 100 ml/hr 4 hours before and 24
hours afterwards) and discontinue any potential nephrotoxic drugs such as
ACE inhibitor for 24-48 hours after the procedure.
92
Sulphonylureas
Action
Potentiates the pancreatic β cell insulin release in response to
glucose.
Indications Primary drug treatment of non-obese patients with Type 2
diabetes. Primary drug treatment of overweight Type 2 patients
unable to take usual first line agents. As adjuvant therapy with
other agents.
Side Effects Hypoglycaemia, weight gain, Other side effects are rare.
Drugs
The three most commonly used sulphonylureas in Grampian are
Gliclazide, Glipizide and Glimepiride, the last having the
advantage of a once daily single tablet dose. Gliclazide is also
available in a once daily dosage version which may aid
compliance in some patients. Chlorpropamide and
Glibenclamide are particularly prone to cause hypoglycaemia
and should not be initiated, and their continued use should be
reviewed periodically.
Doses
It is usually appropriate to start with a small dose before
breakfast, increasing progressively according to blood glucose
response. The drug should always be taken before meals,
ideally 20 to 30 minutes before eating.
Gliclazide
40-320mg daily (doses > 160mg should be
divided). Also available as a 30mg modified
release tablet (equivalent to 80 mg of standard
preparation) – to achieve maximum dose range
(120mg), patient required to ingest up to 4 tablets
before breakfast.
Glimepiride 1-6 mg as a single daily dose.
Glipizide
2.5-20 mg (doses >10 mg should be divided).
Maximum daily dose 10mg twice daily.
93
Thiazolidinediones
Action:
Group of agents acting at the level of the PPAR-gamma
receptor to promote insulin sensitivity. To be effective, patients
require to have sufficient endogenous insulin production. The
maximum therapeutic benefit may not be apparent until after
eight weeks. Rosiglitazone and pioglitazone are both used to
treat adult patients who have Type 2 diabetes, particularly in
those who are overweight. Pioglitazone, but not rosiglitazone
can also be used in combination with insulin. Contra-indicated in
patients with left ventricular impairment, heart failure or high risk
of fractures. Warn a person prescribed a thiazolidinedione about
the possibility of significant oedema and consider alternatives if
this develops. In addition Rosiglitazone is contra-indicatedin
patients with Ischaemic Heart Disease or Peripheral Vascular
disease.
Indications Thiazolidinediones can be used as monotherapy although
Metformin is the drug of first choice
Thiazolidinediones may be added to
 the combination of metformin and a sulfonylurea where
insulin would otherwise be considered but is likely to be
unacceptable or of reduced effectiveness because of
employment, social or recreational issues related to
putative hypoglycaemia
– barriers arising from injection therapy or other personal
issues such as adverse experience of insulin in others
– those likely to need higher insulin doses or with barriers
to insulin arising from particular concerns over weight
gain (namely those with obesity or abdominal adiposity)
 a sulfonylurea if metformin is not tolerated
 metformin as an alternative to a sulfonylurea where the
person’s job or other issues make the risk of
hypoglycaemia with sulfonylureas particularly significant.
Side-effects Significant weight gain and fluid retention. Both agents
associated with loss of bone mass and are associated with
significantly higher risk of distal fractures in women.
Caution
Avoid in hepatic impairment – Do not initiate if AAT≥ 2.5 x upper
normal limit and therefore worth checking LFT’s before initiating
therapy and as BNF states “periodically” thereafter.
Liver toxicity is however rare.
If AAT is ≥ 3x upper normal limit, therapy should be
discontinued.
94
Dose
Pioglitazone (Actos) - 15-45mg once daily. Pioglitazone 15mg is
available in combination with Metformin 850mg (Competact) and
can be used as 1 tablet twice daily.
All patients on Rosiglitazone should be reviewed and their
requirements for the drug be assessed.
In view of recent advice regarding avoidance of Rosiglitazone in patients
with ischaemic heart disease and peripheral vascular disease, clinicians
need to be confident of the absence of these before commencement and
review regularly the appropriateness of continual therapy in suspected
IHD or PVD. Pioglitazone would be an alternative agent or a DPP IV may
also be considered. It may also be appropriate to consider insulin
therapy at this stage.
95
Incretin hormone therapies
Incretin hormones [eg, glucagon-like peptide-1 (GLP-1) and glucosedependent insulinotropic polypeptide (GIP)] regulate glucose homeostasis by
increasing insulin synthesis and release from pancreatic beta cells and
decreasing glucagon secretion from pancreatic alpha cells. Decreased
glucagon secretion results in decreased hepatic glucose production. Under
normal physiologic circumstances, incretin hormones are released by the
intestine throughout the day and levels are increased in response to a meal;
incretin hormones are rapidly inactivated by the DPP-IV enzyme.
GLP-1-based therapies affect glucose control through several mechanisms,
including slowed gastric emptying, regulation of postprandial glucagon,
reduction of food intake, and enhancement of glucose-dependent insulin
secretion. These agents do not cause hypoglycaemia, in the absence of
therapies that otherwise cause hypoglycaemia
96
DPP-IV Inhibitors
Dipeptidyl peptidase IV (DPP-IV)
Is a ubiquitous enzyme that deactivates a variety of other bioactive peptides,
including GIP and GLP-1; therefore, its inhibition could potentially affect
glucose regulation through multiple effects. There are several agents being
studied. Sitagliptin and Vildagliptin are licensed for use in the UK and others
are in development. Sitagliptin is on the Grampian Formulary.
Action:
Inhibits dipeptidyl peptidase IV (DPP-IV) enzyme resulting in prolonged active
incretin levels.
Indications:
1. May be used in combination with metformin when diet and exercise,
plus metformin, do not provide adequate glycaemic control. It should
be restricted to use in patients only when the addition of
sulphonylureas is not appropriate.
2. In combination with thiazolidinediones or sulphonylurea when diet and
exercise and maximum tolerated dose do not prove adequate and
metformin contraindicated or not tolerated.
3. Sitagliptin only is licensed for triple therapy in combination with
Metformin and sulphonylurea when dual therapy is inadequate to
maintain glycaemia control (as an alternative to other agents such as
thiazolidinediones)
Efficacy:
As assessed by measurement of HbA1c, is similar to sulphonylurea and
thiazolidinedione drugs added at this stage in therapy. It appears to have
minimal effects on body weight.
Cautions:
Both agents are not recommended in patients with moderate to severe renal
failure (GFR <50ml/min). Not recommended in severe hepatic failure.
Additional cautions for Vildagliptin:
Not recommended in hepatic impairement, including patients with ALT >3x
upper limit of normal. It is recommended that LFTs are monitored three
monthly in the first year and periodically thereafter. Not recommended in
patients with moderate cardiac failure (NYHA class III-IV). Due to rare reports
of skin lesions in animal studies, monitoring of skin disorders such as
blistering or ulceration is recommended.
Side effects:
Seems to be well tolerated with minor headaches and nausea in <5%.
Hypoglycaemia risk is minimal with Metformin but significant when used with
sulphonylurea.
97
GLP-1 Analogues:
Exenatide
Action:
Exenatide is an analogue of the hormone incretin (glucagon-like peptide 1 or
GLP-1) which increases insulin secretion, increases B-cell growth/replication,
slows gastric emptying, and may decrease food intake
Indications:
In combination with metformin and/or sulphonylureas in patients who have not
achieved adequate glycaemic control on maximally tolerated doses of these
oral therapies. It is considered as a third hypoglycaemic agent e.g. where a
history of significant cardiac problems, or a fear of adverse cardiac risks,
mitigates against use of other agents. These are injectable agents and would
be considered at the point where insulin therapy would be suitable in selected
individuals who have a BMI >35 and there are specific psychological,
biochemical or physical problems due to the high weight. Continue exenatide
therapy only if a beneficial metabolic response (at least 1.0 % HbA1c
reduction in 6 months and a weight loss of at least 5% at 1 year) occurs and is
maintained.
Side effects:
Hypoglycemia (with concurrent sulfonylurea therapy 14% to 36%; frequency
similar to placebo with metformin therapy). Check Driving section for driving
guidelines.
Significant Nausea 40% - may be dose-related and may decrease in
frequency/severity with gradual titration and continued use.
2
Contraindicated in severe renal failure (eGFR <30 ml/min/1.73 m )
Dose:
Initial: 5 mcg subcutaneous injections twice daily within 60 minutes before
main meals at least 6 hour apart; after 1 month, may be increased to 10 mcg
twice daily as a maximum
98
Prandial glucose regulators
Action:
These agents act as insulin ecretagogues, potentiating the post-prandial
secretion of insulin that is impaired in the Type 2 diabetes. May be
considered rarely for people with non-routine daily lifestyle patterns (creating
difficulty with sulphonylureas) to assist in attaining glucose control to their
individual target.
Indications:
Repaglinide – As monotherapy or in combination with metformin `Nateglinide
– In combination with metfomin
Side effects
Both agents can precipitate hypoglycaemia
Caution
Avoid in severe hepatic impairment
Dose
Repaglinide (Novonorm) -initially 500mcg within 30 minutes before main
meals (1mg if transferring from another oral hypoglycaemic), adjusted
according to response at 1-2 week intervals. Up to 4 mg as single dose; max
daily dose 16mg.
Nateglinide (Starlix) - initially 60 mg 3 times daily within 30 minutes before
main meals; adjust according to response to maximum 180mg 3 times daily.
Acarbose
Action
An alpha-glucosidase inhibitor which acts within the gut to slow digestion and
absorption of carbohydrates.
Indications
Primary drug treatment of patients with Type 2 diabetes (especially the
obese) if other drugs are contraindicated. As an adjuvant to other oral agents
or insulin.
Side effects
Flatulence and GI disturbance. As mono therapy it does not cause
hypoglycaemia.
Caution
Insulin or sulphonylurea induced hypoglycaemia in patients taking acarbose
must be treated with glucose (dextrose)
99
Dose 25-50mg daily increased very gradually to 50-100mg tds according to
tolerance.
100
C3.1.1 28 day OHA treatment costs
28 Day Treatment Costs (MIMS January 2009, Scottish Drug Tariff April 2009)
40
35
30
20
15
10
5
od
g
10
0
tin
Si
ta
gl
ip
zo
R
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gl
it
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g
15
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ne
on
e
30
60
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e
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od
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101
C3.2 NICE guidance on treatment of Type 2 diabetes
http://www.nice.org.uk/CG66/NiceGuidance/pdf/English
A treatment protocol developed in Spring 2008 for management of Type
2 diabetes:
102
C3.3 Insulin regimens
Initiation of insulin
Patients with Type I diabetes are normally commenced on human insulin or
an insulin analogue, in either a twice daily or a multiple injection regimen. The
choice of the initial regimen and subsequent modifications should be made in
consultation with the patient, taking due regard of the patient’s occupation and
lifestyle. The precise insulin formulation may be determined by the patient’s
preferred insulin delivery device. Most patients prefer to use pen devices.
Patients with Type 2 diabetes may need insulin when oral agents are
insufficient to achieve satisfactory glycaemic control due to progressive beta
cell failure. It is expected that almost 50% of patients with Type 2 diabetes will
eventually require insulin and patients should be counselled about this early in
their management.
Once daily injections
Single daily injections do not usually result in good glycaemic control, and are
relatively rarely used. Such a regimen may be appropriate for patients where
the therapeutic goal is only to prevent ketosis or suppress symptomatic
hyperglycaemia, and where there are practical problems with insulin delivery,
or particular concern over the risks of nocturnal hypoglycaemia. Elderly
patients living alone and patients requiring injections to be given by a
community nurse may fall into this category.
Long acting basal analogue insulins (Insulin Glargine and Levemir)
These may be used in addition to oral hypoglycaemic agents in type II
diabetics when oral agents are inadequate to achieve satisfactory glycaemic
control. Patients and carers should recognise that if good glycaemic control is
needed most cases will eventually need to move onto a more frequent
injection regime.
Twice daily injections
This is a commonly used regimen, and suitable for patients starting on insulin.
A combination of short and intermediate acting insulins is taken before
breakfast and before the evening meal.
Multiple injections
This arrangement, involving up to 4 injections a day, has the main advantage
of increased flexibility with regard to exercise, meal timing and meal size. It is
most likely to work effectively in a well-motivated patient, prepared to do
regular and frequent blood glucose testing
The majority uses an insulin analogue or soluble insulin before each meal,
and an injection of an intermediate, or long acting insulin usually before tea or
bedtime to provide background cover.
103
Continuous subcutaneous insulin infusion (Insulin Pump Therapy):
CSII therapy is available as a treatment option for patients with Type 1
diabetes mellitus provided that
 Multiple daily injections (MDI) therapy (including, if appropriate, the
use of long-acting insulin analogues) has failed to provide adequate
control of diabetes mellitus as defined below, and
 those receiving the treatment have the commitment and competence
to use the therapy effectively
MDI therapy is considered to have failed when, despite a high level of care of
their diabetes mellitus:
 it has been impossible for the individual to maintain a haemoglobin A1c
(HbA1c) level of less than 8.5%, or
 the person is experiencing disabling hypoglycaemia, which, means the
repeated and unpredictable occurrence of hypoglycaemia that results
in persistent anxiety about recurrence and is associated with a
significant adverse effect on quality of life.
Patients may be referred to the insulin pump service for assessment if they
fulfil the above criteria and are on the basal bolus insulin regimen and reliably
monitor their blood sugars at least four times a day. They should be able to
count the carbohydrate content of meals (and ideally been for a course such
as the DAFNE – Dose Adjustment for Normal Eating).
C3.4 Types of Insulin
There are a large and confusing number of insulin preparations available. If
patients are satisfied with their treatment and achieving satisfactory control in
the absence of hypoglycaemia, no modification of their regimen is required.
Most insulin currently in use is biosynthetically manufactured of human
sequence or analogues with altered pharmacokinetic properties. Many
patients prefer the ultra short-acting analogues/mixtures for convenience.
Some patients prefer to use animal derived insulin in the belief that use of
human sequence insulin may cause loss of awareness of hypoglycaemia.
Although such a conviction is quite widespread among the users, carefully
conducted scientific studies have consistently failed to provide evidence to
support this hypothesis.
Some preparations are available in both human and porcine versions (e.g.
human and porcine actrapid) which can result in confusion in prescribing and
dispensing. It is important to realise that such preparations although similar in
their characteristics are not interchangeable, and patients should not be
inadvertently changed from one to the other. When patients are deliberately
changed from animal to human/analogue insulin a dose reduction of 25% is
advised.
Please refer to the Diabetes and Emergencies sections for management of
insulin therapies during illness.
104
Insulins are most conveniently classified by duration of action as shown in the
following table.
Summary of insulin classification
Ultra short acting
Short acting analogues
Immediate onset Duration
Insulin Lispro (Humalog), Insulin Aspart (Novorapid),
up to 4 hours Peak action
Insulin Glulisine (Apidra)
60 minutes
Short acting
Soluble insulin
Onset 30 minutes
(Human) Actrapid 10ml Vial only, Humulin S, Insuman
Rapid*
Duration up to 5 hours
Hypurin Bovine Neutral*, Hypurin Porcine Neutral*.
Peak action 3 hours
Intermediate acting a:
Isophane insulin (contains protamine) Human Insulatard,
Onset 90 minutes
Humulin I, Insuman Basal*, Hypurin Bovine Isophane*,
Duration: 16-20 hours
Hypurin Porcine Isophane*.
Peak action: 4-12 hours
Intermediate acting b:
Insulin Zinc Suspension
Onset 120 minutes
Hypurin Bovine Lente*
Duration: 24 hours
Peak action: 6-18 hours
Long acting (a)
Protamine Zinc Insulin*
Onset 4 hours
Hypurin Bovine Protamine Zinc 10ml Vial
Duration up to or greater
than 24 hours
Long acting (b)
Insulin Glargine (Lantus)
Duration up to or greater
Insulin Detemir (Levemir)
than 24 hours
Mixed preparations
Biphasic onset and
duration of action
Fixed mixtures of soluble and isophane insulin
(Human) Mixtard 30 / Actrapid / Insulatard in ratios of 30/70
Humulin, M3 Humulin S / Humulin I in ratios of 30/70
Insuman Comb* 15, 25 or 50,
Insuman Rapid / Basal* in ratios of 15/85 to 50/50
105
Biphasic Insulin Lispro
Humalog Mix 25 or 50 Lispro/LisproProtamine in ratios of
25/75 or 50/50
Biphasic Insulin Aspart
Novomix 30 Aspart/Aspart Protamine in a ratio of 30/70
Biphasic Isophane Insulin
Hypurin Porcine 30/70 Mix*
*: These insulins are rarely used and would not usually be part of a new
insulin start.
Note Ultra short-acting insulins (e.g. Humalog, Novorapid, Apidra and
mixtures i.e. Humalog Mix 25 or 50 and Novomix 30) should be injected
immediately before eating or after food. Other insulins should be
injected subcutaneously 30 minutes before eating. Long actiong
insulins are taken once daily at the same time, eg bb or bt or bbed.
106
C3.4.1 Insulin costs
5x3ml Cartridge Costs (MIMS January 2009)
45
40
35
30
25
20
15
10
5
0
Apidra
(Glulisin)
Humalog
(Lispro)
Novorapid
(Aspart)
Figure 1 - Insulin Costs
Humulin S
(soluble)
Lantus
(Glargine)
Levemir
(Detemir)
Humulin I
(isophane)
Insulatard Humalog 25 Humulin M3 Mixtard 30 Novomix 30
(isophane)
Mix
£
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Draft Guideline – 25 September 2008
C4.0 Hypoglyaemia
This section deals with hypoglycaemia in general. Some additional notes
pertaining particularly to hypoglycaemia occurring in in-patient situations
appear in section C6.0.
Hypoglycaemia refers to any episode of low blood glucose (usually <3.5
mmol/l) with or without symptoms and may occur in patients taking insulin,
sulphonylureas or prandial glucose regulators. Mild episodes may not only be
inconvenient for the patient, but may predispose to more severe episodes
which are associated with significant morbidity as well as the development of
fear of hypoglycaemia. While prompt recognition and treatment of
hypoglycaemia obviates the risk of progression, even if untreated, most
isolated episodes recover spontaneously and are not associated with
permanent damage. It is reasonable to reassure patients accordingly. Fear
of hypogycaemia is such that many patients avoid tightening blood glucose
control to minimise risk of its occurrence.
ALL PATIENTS PRESCRIBED SULPHONYLUREAS OR INSULIN MUST
BE ADVISED ON THE OCCURRENCE, AVOIDANCE, RECOGNITION AND
MANAGEMENT OF HYPOGLYCAEMIA.
C4.1 Causes of hypoglycaemia
Hypoglycaemia occurs when there is an imbalance between:



Carbohydrate intake
Insulin or oral hypoglycaemic drug dose
Exercise/activity.
Additional factors that may contribute to the risk of hypoglycaemia include
lumpy injection sites (leading to erratic absorption of insulin), inappropriate
injection site / technique (including intramuscular injection eg caused by using
too long a needle or using arms as injection site), alcohol excess (particularly
if combined with exercise and reduced carbohydrate intake) and
gastroparesis in patients with autonomic neuropathy and adrenal insufficiency
(increased frequency in patients with Type 1 diabetes).
C4.2 Symptoms of hypoglycaemia
The symptoms of hypoglycaemia vary between patients and the same patient
may experience different symptoms in different circumstances. Symptoms
are sometimes classified as:



autonomic, due to activation of the autonomic nervous system
(sweating, tremor, anxiety, palpitations etc)
neuroglycopenic due to reduced glucose delivery to the brain (poor
concentration, odd behaviour, dizziness)
non-specific (headache, tingling lips etc)
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.
Symptoms of hypoglycaemia may be non-specific and vague (eg dizziness,
feeling “wobbly”), especially in the elderly. Hypoglycaemia should always be
considered as a possible cause of such symptoms, or collapse, in any patient
taking sulphonylureas or insulin.
Symptoms generally develop when the blood glucose falls to around 3.5
mmol/l. In most patients the autonomic symptoms occur before the
neuroglycopenic symptoms and provide a useful warning. Sometimes
autonomic symptoms are a reflection of anxiety about possible hypoglycaemia
rather than a reflection of a truly low blood glucose level; capillary glucose
testing can be useful in differentiating. Patients with poor control and chronic
hyperglycaemia may report symptoms of hypoglycaemia at higher blood
glucose levels; this situation is an indication for negotiating a gradual stepwise approach if there is to be progress in achieving improvement in blood
glucose control.
C4.3 Hypoglycaemia unawareness
In some patients the autonomic warning features may not provide effective
warning e.g. those with long-duration of diabetes, very tight glycaemic control
or recurrent episodes of hypoglycaemia. This may result in hypoglycaemia
unawareness when the patient is unable to recognise the onset of problems,
with potentially serious physical and psychological consequences.
Hypoglycaemia unawareness due to very tight control is generally reversible
through meticulous avoidance of hypoglycaemia and relaxation of targets e.g.
three months with a minimum blood glucose level of 6 mmol/l.
C4.4 Treatment of hypoglycaemia
All patients treated with insulin or sulphonylureas (or prandial glucose
regulators) should be advised to carry carbohydrate with them. As soon as
symptoms are recognised or if a low blood glucose value is recorded (with or
without symptoms), the patient should be advised to take one of the following:



3 Dextrose tablets or sugar lumps
Half of a small bottle (150ml) of sugary drink e.g cola, lemonade, or
similar – (not diet or lite varieties)
Fruit juice – 1 glass (200 ml)
If the patient’s medication includes acarbose (Glucobay), then glucose e.g.
Dextrosol must be used for treatment of hypoglycaemia (not a disaccharide
such as sucrose (table sugar) or lactose (milk sugar)).
If symptoms and / or metered glucose are not improving after 10 minutes this
should be repeated. If the patient is too drowsy to cooperate, “Glucogel”
(formerly known as Hypostop) may be applied to the inside of the cheek and
massaged from the outside. It may be advisable for patients to keep Glucogel
at home/work and instruct family members/ friends/colleagues how to use it.
If the patient is unresponsive, 1 mg of glucagon (“Glucogen”) should be given
subcutaneously or intramuscularly (once only per episode). It may be also
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appropriate to instruct partners, close relatives, friends or colleagues of
susceptible insulin-treated people in the use of glucagon and to ensure that
they keep a kit available.
Alternatively 25g (50ml) of 50% dextrose can be given intravenously by
professional help.
During the initial treatment of hypoglycaemia, high fat foods (eg chocolate) or
long acting carbohydrates (bread, plain biscuits) are not the best choice as
these will treat be slow to raise the blood glucose and may impair absorption
of ingested fast acting carbohydrate.
After the initial treatment (once metered glucose is >4mmol/l), it is essential
for the patient to take long acting carbohydrate such as biscuits and milk or a
sandwich to prevent the hypoglycaemia from recurring.
C4.5 Hypoglycaemia and sulphonylureas
Hypoglycaemia may occur in patients taking sulphonylureas and is often
underreported in the elderly when the symptoms are non-specific and are
confused with other conditions e.g. TIAs. Hypoglycaemia may recur following
initial treatment and occasionally admission to hospital may be required.
Newer long-acting sulphonylureas e.g. Glimepiride and modified release
Gliclazide seem much less likely to cause hypoglycaemia than obsolescent
long acting agents such as chlorpropamide.
In the frail or elderly, when patients are eating less due to intercurrent illness /
hospitalisation, dose reduction or cessation of sulphonylurea may need to be
considered to avoid hypoglycaemia. The dose can be increased again once
normal eating patterns are restored. Progressive renal impairment also
potentiates the risk of hypoglycaemia with sulphonylureas (and insulin).
C4.6 Nocturnal hypoglycaemia
This is a common occurrence in insulin-treated patients. Patients may or may
not wake up during the night with symptoms, or sometimes wake up the
following morning feeling “hung-over”. In the great majority of circumstances
moderate levels of hypoglycaemia will wake the patient; ready access to
appropriate fast acting carbohydrate by the bedside will facilitate corrective
action. Nocturnal hypoglycaemia may contribute to the development of
hypoglycaemia unawareness. The risk of nocturnal hypoglycaemia can be
minimised by ensuring a snack containing complex carbohydrate is taken at
bedtime (irrespective of blood glucose reading), and allowing the blood
glucose to be between, say, 7 and 9 at bedtime. Patients who take a twicedaily regimen of mixed insulin, or isophane insulin at night should be advised
to have a bedtime snack. However this is may not be so important for patients
on a basal-bolus regimen using the newer long-acting analogues as these
have a flatter action profile.
The following measures may also reduce the risk of nocturnal hypoglycaemia:
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Draft Guideline – 25 September 2008




With basal/bolus regimens long acting insulin analogues, i.e. insulin
glargine (Lantus) or insulin detemir (Levemir) appear to be associated
with a lower incidence of hypoglycaemia than long acting human
sequence insulins.
With twice-daily pre-mixed regimens those containing a short-acting
analogue such as Humalog Mix 25 or Novomix 30 are associated with
less nocturnal hypoglycaemia than those containing human sequence
soluble insulin eg Mixtard 30 or Humulin M3.
Splitting the evening insulin dose so that the quick acting insulin is
taken before the evening meal and the intermediate acting insulin is
taken at bedtime may also be helpful for those using premixed insulin.
Replacing human sequence soluble insulin at teatime with a shorter
acting insulin analogue e.g. Lispro / Novorapid
C4.7 Rebound Hyperglycaemia
After an episode of hypoglycaemia patients may experience marked
hyperglycaemia, which can be prolonged (12-20 hours). This is only partly
related to carbohydrate consumption to treat hypoglycaemia. A greater
contribution is made by release of so-called counter-regulatory hormones that
act by various means to raise glucose (and thus try to prevent early
recurrence of hypoglycaemia); counter-regulatory hormones will raise glucose
levels following hypoglycaemia whether or not the episode was detected at
the time (e.g. during sleep). It must be remembered that hyperglycaemia may
follow an earlier period of hypoglycaemia and that reducing the
hypoglycaemic risk may be the action required to prevent recurrence of the
rebound hyperglycaemia.
C4.8 Avoidance of hypoglycaemia
The risk of severe hypoglycaemia can be minimised by self-monitoring of
blood glucose, review of insulin / drug regimen, quantity and timing of
carbohydrate intake and injection sites. Patients should be advised to “Make
4 the floor” with respect to their targets for glucose control i.e. try to avoid
glucose values below 4. However in patients who do not low glucose levels
will be unknown unless symptomatic and for those who have had problems
with severe hypoglycaemia the lower targets for glycaemic control may need
to be relaxed.
C4.9 Driving and hypoglycaemia
Patients should be advised to check their blood glucose before and during
long car journeys (at least every 2 hours) and should always carry
carbohydrate in the car. If they have hypoglycaemic symptoms while driving
they should stop the car as soon as safely possible, remove the keys from the
ignition, leave the driver’s seat and take oral carbohydrate. Driving should not
be resumed for at least 45 minutes. Patients who have lost their warning
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symptoms of hypoglycaemia or those experiencing recurrent hypoglycaemia
should be advised not to drive until the problem has been resolved. It should
be documented in clinical records when such advice has been given.
C4.10 Exercise related hypoglycaemia
Exercise is to be encouraged in those with diabetes and due care must be
taken to give advice on observance of appropriate precautions for avoidance
of problems. Hypoglycaemia related to exercise may occur at the time of
exercise or up to 24 hours afterwards while the body’s glycogen
(carbohydrate) stores are being replenished. The risk of hypoglycaemia is
related to the intensity and duration of exercise. Those less accustomed to
regular exercise need to exercise particular caution. Patients should be
advised to consider reducing insulin doses before and after exercise
(including the day afterwards) and/or increase dietary carbohydrate and alter
injection sites, e.g. avoiding legs if running/ cycling or arms if rowing/kayaking
as such exercise will increase absorption of insulin. It is advisable for patients
to have easy access to rapid-acting carbohydrate (eg orange juice / glucose
tablets) when exercising. Additional nutritional advice, particularly for those
engaging in more vigorous physical activity is available on the following
website: http://www.runsweet.com
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C5.0 Management of Diabetic Emergencies in the
Community
Acute illness in insulin-treated patients






Encourage blood glucose checks 2-4 hourly. Ensure monitoring
equipment and technique satisfactory.
Never stop insulin. Increase dose according to blood glucose. Give
4 units of quick acting insulin every 2 hours until blood glucose less
than 10
Check for ketones.Ketostix urine or Medisense Optium meter
blood. If moderate or large an increase in insulin may be necessary
with subsequent check for ketones later same day.
Ensure continued fluid intake.100-200ml / hour (approx 1 glass) or
an egg cupful /10 minutes. If vomiting prevents fluid intake,
consider buccal or parenteral anti-emetic. Admission may be
required.
Carbohydrate intake must be maintained by fluids if unable to eat.
See 10g CHO Guidance below.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE.
Acute illness in Non-Insulin-treated patients



Provided not severely dehydrated or showing features of
Hyperosmolar Coma ( drowsiness) then high blood glucose levels
can be tolerated for a short illness
Markedly dehydrated hyperglycaemic patients should be admitted
for IV fluids.
THE HOSPITAL DIABETES TEAM IS THERE TO ADVISE
Consider admission if:







Inability to swallow or keep fluids down
Persistent vomiting
Persistent diahorroea
Persistently raised blood glucose greater than 28 despite increased
insulin
Strongly positive ketones
No improvement 24-48 hours
When ketoacidosis clinically obvious (dehydration, thirst, polyuria,
abdominal pain, intractable vomiting, rapid or laboured breathing)
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10g CHO Guidance
Milk
1 cup (200ml)
Fruit juice unsweetened
1 small glass (100ml)
Lucozade
50ml
Coca Cola (not diet)
150ml
Lemonade (fizzy/sweetened) 150ml
Ice cream
1 scoop
Jelly (ordinary)
2 table spoons
Yoghurt (fruit)
½ small carton (60g)
Yoghurt (plain)
1 small carton (120g)
On Call Hospital Specialist Registrar at ARI
Number/Bleep: 2543
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Draft Guideline – 25 September 2008
C6.0 Management of Diabetes in Hospital
C6.1 Introduction
In first considering this subject, it is important to differentiate between people
in hospital with acute metabolic decompensation, those with established
diabetes that is an incidental or contributory issue in their hospitalisation, and
those newly found to have a high glucose. The last group need to receive all
the due consideration of any new patient with diabetes (see Section A2) –
with additional attention paid to modifications occasioned by the nature of the
hospital admission and input from the inpatient diabetes team as required.
For those with prior diabetes, the patient’s level of engagement and
experience in self-management must always be borne in mind. Every
encouragement should be given to preserve patient autonomy, but it should
be remembered that the lack of familiarity with a particular clinical
circumstance may compromise the patient’s coping strategies.
Glycaemic control may deteriorate in the hospital setting due to stress of
intercurrent illness, changes in dietary intake and decrease in physical
activity. Interruptions to accustomed dietary intake or enforcement of
medication and dietary concordance may also considerably alter the patient’s
circumstances. The circumstance of clinical decision making in hospital can
also limit the skilled patient’s opportunity to apply appropriate flexibility in selfmanagement. As a consequence, both hyperglycaemia and hypoglycaemia
are common in the hospital setting. It is often therefore appropriate to alter
interim glucose targets to a broader (and safer) range than would apply in the
chronic out-patient situation (e.g. 6-14mmol/l) to prevent problems with
hypoglycaemia and hyperglycaemia. However, persistent and significant
hyperglycaemia (>17mmol/l) should be prevented/treated to avoid
dehydration, caloric loss, infection and ketoacidosis.
Hospitalised patients may benefit from opportunistic specialist review and
appropriate education. Timely liaison with the specialist diabetes team can
reduce the risk of glucose management problems during admission and can
facilitate early discharge.
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Draft Guideline – 25 September 2008
Contact details for ARI inpatient diabetes team:
Diabetes Specialist Nurse: Telephone 01224 559364 (direct line), 59364
(internal) or Bleep 3334 for urgent matters
(Monday to Friday 9am to 5pm)
Diabetes Specialty Registrar: Bleep 2543
(Monday to Fridays 9am to 5pm, Weekends 9am to 12.30pm)
Out-with these hours please contact nursing station at Ward 28 on 01224
552004 (52004 internal) for medical staff contact details.
Elgin: Contact Switchboard: 01343 543131 (Internal 67998)
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Draft Guideline – 25 September 2008
C6.2 Diabetic emergencies
C6.2.1. Diabetic Keto Acidosis (DKA)
DKA is a potentially life threatening complication of diabetes that while
often preventable, must be dealt with as a matter of urgency once
established. Diagnosis of DKA is only appropriate in the presence of
diabetes AND ketosis AND acidosis.
A national protocol for management of confirmed DKA in adults only is
available on pre-printed forms in acute areas; it can also be down loaded
from the intranet link below. A separate paediatric protocol is available for
children under the age of 15 years. The paediatric protocol may also be
appropriate in adults of low body weight (BMI < 16kg/m 2), as it reduces the
risk of fluid overload.
The Diabetes specialist team should be contacted as appropriate for
advice regarding management of DKA
Adult DKA protocol
http://intranet/ccc_nhsg/6179.909.html?pMenuID=460&pElementID=909
Paediatric DKA protocol
http://www.bsped.org.uk
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Draft Guideline – 25 September 2008
C6.2.2 Hyperosmolar Non Ketotic Hyperglycaemia (HONK)
HONK is a life threatening condition, which mainly occurs in older people
with Type 2 diabetes. HONK is characterized by dehydration, very high
blood glucose and high serum osmolality (>320mosm/l) but without
ketoacidosis or heavy ketonuria; modest ketonuria and lactic acidosis may
sometimes occur. Mortality is very high (up to 50%). Early diabetic
specialist review is recommended. Management is similar to DKA but the
fluid replacement should be less rapid. Some advocate rehydration with
0.45% saline claiming it reduces the risk of hypernatraemia. Blood glucose
should be reduced gradually to avoid precipitating cerebral oedema.
Patients with HONK should also be considered for subcutaneous heparin
prophylaxis due to increased risk of thrombo-embolism. Once treated,
most patients can be managed on diet with or without oral hypoglycaemic
agents.
C6.2.3 Hypoglycaemia in hospital
Hypoglycaemia occurs more frequently in hospitalised patients with diabetes.
Common causes include interruptions to accustomed dietary intake, change
in their medications and fasting for various procedures. This section focuses
on the treatment and prevention of hypoglycaemia in hospitalised patients.
Further details regarding hypoglycaemia can be found in Section C4.
Hypoglycaemia refers to any episode of low blood glucose (< 3.5 mmol/l)
with or without symptoms and may occur in patients taking insulin or
sulphonylureas (e.g. Gliclazide, Glipizide, Glimepiride).
As soon as symptoms are recognised or if a low blood glucose value is
recorded (with or without symptoms) the patient should be advised to
take one of the following:
3 Dextrose Tablets
150 ml (half glass) of lucozade or cola or lemonade (not ‘diet’ varieties)
Fruit juice –200-300mls
Check blood glucose level after 10-15 minutes. If blood glucose level
still less than 4 mmol/l, repeat the treatment.
If the patient is too drowsy to co-operate, Glucogel (2 tubes) should be
applied to the inner cheeks and then massaged from the outside. This
treatment can also be given to the fasting patient without compromising their
fasting status.
If the patient is unresponsive - 20 mls of 50% Glucose should be given
intravenously using a large cannula as a bolus. This can be repeated if the
patient remains unresponsive.
If unable to obtain venous access – 1mg of Glucagon (Glucagen) can be
given intramuscularly or sub-cutaneously (once only per episode); patients
frequently experience nausea and vomiting after this treatment so it should
not be used unless essential.
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Draft Guideline – 25 September 2008
After the initial treatment, it is advisable when appropriate for the patient to
take complex carbohydrate such as milk and biscuits or a sandwich to try to
prevent further episodes of hypoglycaemia.
Following hypoglycaemia, consider the circumstances that led to it and the
potential need for adjustment of diabetes treatment to reduce the risk of
recurrence.
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Draft Guideline – 25 September 2008
C6.2.4 Prevention of Hypoglycaemia during Hospital Admission





Avoid giving unopposed insulin infusion (i.e. without iv glucose – unless
during early iv management phase of hyperglycaemia)
Avoid disconnecting or stopping I.V.fluids while on intravenous insulin
pump
If any concern, e.g. blood glucose levels suddenly dropping,
temporarily reduce interval between capillary glucose checks to 30 or
15 minutes
Ensure patients treated with s/c insulin have carbohydrate-containing
snacks available, especially for bedtime
Be aware that after episodes of hypoglycaemia patients typically have
REBOUND hyperglycaemia perhaps lasting several hours. These
high levels of blood glucose should be allowed to return to normal
without intervention (unless developing significant ketonuria).
Resisting the temptation to give extra insulin may avoid
recurrence of the primary hypoglycaemic event!
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Draft Guideline – 25 September 2008
C6.3 Management of Diabetes during intercurrent illness
C6.3.1 Type 1 diabetes
Patients with Type 1 diabetes are regarded as being continuously
dependent on external insulin for their survival. Whenever possible,
patients should be involved in decision making concerning management of
their glycaemia. If there is reasonable likelihood of patients being able to eat
and drink, then the ‘sick day’ rules should be followed (chapter C5). If blood
glucose levels are high, it may be appropriate to use increased insulin doses
for patients on basal-bolus insulin therapy, and additional supplementary
doses of quick acting insulin (before lunch and before bed) for patients on
twice daily pre-mixed insulin.
A Variable Rate Insulin Infusion Protocol (C6.3.3) is available for use when
oral intake is compromised.
C6.3.2 Type 2 diabetes
Patients, who are on diet alone, may need no specific therapy during
intercurrent illness apart from monitoring, to ensure blood glucose is
reasonably stable. Patients on oral hypoglycaemic agents may need
increased oral therapy or may need insulin temporarily (especially, for
example, with steroid therapy). If blood glucose levels are high (> 17 mmol/l
before meal times), consider adding subcutaneous soluble insulin (e.g.
Actrapid, Humulin S 4 units). Management of insulin treated Type 2 diabetic
patients is usually similar to that of Type 1 diabetes. It is important to consider
discontinuation of increased hypoglycaemic treatment on recovery.
Intercurrent or new chronic illness may alter safety of some OHAs and there
is potential for adverse interaction with newly introduced medications; this
should be borne in mind when managing in-patients. Certain oral
hypoglycaemic agents may be contraindicated in the acutely ill patient, e.g.
Metformin should be discontinued in impaired renal function (eGFR < 30)
severe sepsis and acute left ventricular failure. Similarly, glitazones are
contraindicated in patients with unstable ischaemic heart disease and cardiac
failure. Deteriorating renal function reduces insulin clearance and so may
increase the hypoglycaemic potential of given doses of insulin or
sulphonylureas.
C6.3.3 Variable rate intravenous insulin infusion
This protocol is used in several circumstances:
1. For controlling glucose levels when patients are not able to take their usual
insulin and diet e.g. peri-operative fasting;
 2. Intercurrent illness where blood glucose levels are insufficiently controlled
on usual diabetic medication;
 3. For 48 hrs after diagnosis of acute myocardial infarction, if admission
glucose is over 11mmol/l.

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Draft Guideline – 25 September 2008
The protocol aims at maintaining blood glucose levels in a safe range (814mmol/l) avoiding risks of significant hypo/hyperglycaemia. Circumstances
necessitating the use of this protocol should be regularly reviewed and
patients should be switched back to their usual diabetic medications as soon
as possible.
Adult DKA protocol
http://intranet/ccc_nhsg/6179.909.html?pMenuID=460&pElementID=909
Paediatric DKA protocol
http://www.bsped.org.uk
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Draft Guideline – 25 September 2008
Protocol for Variable Rate Intravenous Insulin Infusions
When to use this protocol:

Peri-operative management of patients with insulin-treated diabetes /
patients on near maximum dose oral hypoglycaemic agents undergoing
major surgery. This includes patients who are clinically well but who have
a high glucose requiring stabilisation
peri-operatively

Management of insulin-treated patients who are unable to take a normal
diet (eg fasting for investigations / nausea and vomiting etc)

On rare occasions for the continuing management of patients who remain
unable to take a full diet following initial treatment for diabetic ketoacidosis
and hyperosmolar coma (ie bicarbonate has normalised and blood glucose
less than 14 mmol/l)
When not to use this protocol:

For patients with DKA ie elevated glucose / ketonuria and acidosis (use
DKA protocol)

For patients who are clinically well, not peri-operative and presenting with
high glucose (ie > 14 mmol/l) with or without ketonuria. Please consider if
insulin infusion is really required or whether subcutaneous insulin would be
more appropriate

Control of blood glucose in patients who are eating and drinking, whether
or not they require IV fluids for other reasons (such patients should be
treated with their normal oral hypoglycaemic agents or sc insulin)
IF YOU ARE NOT SURE WHICH PROTOCOL YOU SHOULD USE PLEASE
CONTACT THE DIABETES TEAM FOR ADVICE:
Diabetes specialist nurse: Bleep 3334
Diabetes registrar:
Bleep 2543
Or contact ward 27/28 and where senior nursing staff may be able to help you
or give you the contact number for the ward registrar / SHO or diabetes
consultant on-call.
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Draft Guideline – 25 September 2008
Protocol for Variable Rate Intravenous Insulin Infusions
FLUIDS
Set up an iv infusion at a rate of 100ml/hr, containing:
 500ml 4% Glucose + 0.18% Sodium Chloride + 0.15% (10mmol)
Potassium Chloride
 OR 500ml 5% Glucose + 0.15% Potassium Chloride
 Omit potassium if plasma potassium level > 4.5mmol/l (nb care in patients
with renal impairment).
INSULIN
 Insulin infusion (50 units Human Actrapid in 50ml 0.9% Sodium Chloride,
ie 1 unit/ml) by syringe pump according to the scale below.
 Aim to keep blood glucose between 8 and 14 mmol/l, check capillary
glucose hourly using ward meter.
Insulin infusion scale
Start insulin infusion at 2 units / hour (2 ml/hour) and monitor at hourly
intervals:
 If capillary glucose between 8 and 14 mmol/l, leave at present infusion
rate.
 If capillary glucose > 14 mmol/l and patient is not eating increase infusion
rate by 2 units / hour, to a maximum of 8 units per hour , then inform Dr.
 If capillary glucose > 14 mmol/l within 2 hours of a meal, do not increase
dose.
 If capillary glucose < 8 mmol/l and conscious level is obtunded (eg perianaesthesia), stop the insulin infusion and consult a doctor immediately.
 If capillary glucose < 8 mmol/l and patient is fully conscious, halve rate of
insulin infusion. (Recheck glucose in 30 minutes). Do not reduce rate
below 0.5 units per hour – contact Dr.
 If capillary glucose still < 8 mmol/l at 0.5 units / hour, change to 10% Glucose +
0.15% Potassium Chloride (using a large peripheral vein eg antecubital).
 If capillary glucose < 3.5 mmol/l, reduce insulin infusion rate as above and
give 100mls of 10% Glucose over 5-10minutes.
 If capillary glucose > 17mmol/l, check urine for ketones.
Patients at risk of fluid overload or cardiac failure eg post MI
To avoid volume overload start the intravenous infusion at a rate of 50ml/hr as
follows:
 500 ml 10% Glucose + 0.15% Potassium Chloride (10mmol)
 Insulin infusion as above (50 units Actrapid in 50ml 0.9% saline, ie 1 unit
/ml).
 For patients on human or pork soluble insulin, when the
patient is able to eat, the usual dose of subcutaneous insulin
should be given 30 minutes prior to eating and the insulin
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Draft Guideline – 25 September 2008
infusion discontinued 30 minutes after the subcutaneous
injection.
 For patients on Humalog or other fast acting insulin
analogues, when the patient is able to eat, the usual dose of
subcutaneous insulin should be given 5 minutes prior to
eating and the insulin infusion can be discontinued
immediately after the subcutaneous injection.
 Patients who take oral hypoglycaemic agents should have
their drugs recommenced at this stage.
If you experience any problems, please contact the hospital Diabetes
Specialist Nurse (bleep 3334) or Diabetes Registrar (bleep 2543) during
working hours or Ward 27/28 after 5pm and at weekends.
Feb 2002
When not to use this protocol:
1) Patients with diabetes, who present with hyperglycaemia (e.g. >14mmol/l)
alone, who are otherwise well, eating and drinking normally. Please consider
whether insulin infusion is really necessary. Review their present diabetic
medications and if necessary, consider subcutaneous soluble insulin before
meals if capillary glucose is more than 17mmol/l (e.g. Actrapid, Humulin S 4
units).
2) Patients with DKA/ HONK- use appropriate protocol (see Section ).
3) Patients on nasogastric feed. Although, Variable Intravenous insulin
infusion can be used temporarily, subcutaneous insulin therapy is more
appropriate in these circumstances (e.g. Isophane insulin twice daily). Please
liaise with the diabetes team.
4) Patients on TPN – TPN team will usually advise.
C6.4 Guidelines for diabetes management during procedures
requiring fasting
These guidelines help both health care professionals and diabetic patients
manage diabetes safely without significant hypoglycaemia or hyperglycaemia
during various procedures that require fasting. While it is difficult to include
every possible scenario in detail, guidelines have been developed keeping
colonoscopy as a general example (with as many variations as possible) and
these guidelines can also be used in similar circumstances.
Those on diet alone need no specific intervention but patients on insulin
therapy and on OHAs need some adjustments in their medications. In
general, patients on basal-bolus therapy need 50% reduction in their basal
insulin on the previous day and should omit quick acting insulin while fasting.
Patients on twice daily pre-mixed insulin should omit their morning insulin on
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Draft Guideline – 25 September 2008
the day of the procedure. Once able to eat and drink, normal insulin doses
should be resumed at the earliest opportunity (e.g. if on twice daily insulin,
after the procedure take half the usual morning insulin dose at lunch time).
Frequent capillary glucose monitoring is essential to avoid
hypo/hyperglycaemia which may often go unnoticed especially after
administration of sedation.
Occasionally, some patients (with particularly unstable diabetes or limited
capability for safe self-management) may need to be admitted for intravenous
insulin infusion during these procedures and the use of variable rate
intravenous insulin infusion protocol (see section C6.3.3) is recommended.
The following specific patient information leaflets are available for certain
hospital procedures:
i) Guidelines for people with insulin treated diabetes undergoing
outpatient colonoscopy / flexible sigmoidoscopy (morning and
afternoon)
ii) Guidelines for people with tablet treated diabetes undergoing outpatient
colonoscopy / flexible sigmoidoscopy
iii) Guidelines for people with diabetes undergoing outpatient upper GI
endoscopy
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Draft Guideline – 25 September 2008
Section D: Complications
D1.0 Blood Pressure .............................................................................. 128
D1.1 NICE clinical guideline 66 – Type 2 diabetes – Blood Pressure
............................................................................................... 129
D2.0 Cardiovascular disease and diabetes .......................................... 130
D2.1 Screening ................................................................................ 130
D2.2 Specific cardio-protective therapy ........................................... 130
D2.3 Lipids ...................................................................................... 132
D3.0 Eye Care, Screening and Treatment ............................................ 134
D3.1 Eye screening ......................................................................... 134
D3.2 Mydriasis ................................................................................. 135
D3.3 Medical treatment ................................................................... 135
D3.4 Laser treatment ....................................................................... 136
D3.5 Diabetic eye screening guidelines - classification and action .. 136
D3.5.1 Visual acuity ................................................................ 136
D3.6 Fundoscopy ............................................................................ 136
D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1..... 137
D3.8 Obtaining individual patient results ......................................... 140
D4.0 Foot Care, Screening and Treatment ........................................... 142
D4.1 Foot Screening........................................................................ 142
D4.1.1 SCI-DC Foot Screening Tool ...................................... 143
D4.1.2 Annual Diabetic Foot Screening.................................. 144
D4.2 Management guidelines for Charcot neuroarthropathy in people
with diabetes .......................................................................... 146
D4.3 Diabetic Foot Ulceration and Wound Management................. 147
D4.3.1Care Pathway for Active Diabetic Foot Ulceration ....... 148
D4.3.2 Referral Pathway for Pressure Relief .......................... 149
D4.4 Good practice guidance for the use of antibiotics in patients with
diabetes foot ulcers ................................................................ 151
D5.0 Neuropathy - Autonomic ............................................................... 163
D6.0 Renal Disease ................................................................................ 165
D6.1 Screening for diabetic renal disease ....................................... 165
6.2 Definitions .................................................................................. 165
D6.2.1 Assessment of dipstick positive patients .............................. 166
D6.2.2 Assessment of dipstick negative patients ............................ 166
D6.2.3 Algorithm for microalbuminuria screening in the
community ................................................................... 168
D6.3 A simple guide to eGFR interpretation and nephrology referral
guidelines. .............................................................................. 169
D6.4 Management of Diabetic Renal Disease ................................. 171
D6.5 Referral for specialist renal advice .......................................... 171
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Draft Guideline – 25 September 2008
D1.0 Blood Pressure
Blood pressure control is extremely important. It is as important, if not more
so, than blood sugar control. Tight blood pressure control in patients with
hypertension and Type 2 diabetes achieves a clinically important reduction in
the risk of deaths related to diabetes, complications related to diabetes,
progression of diabetic retinopathy, and deterioration in visual acuity.
(Conclusion of UKPDS 38 1998)
Reducing blood pressure needs to have high priority in caring for
patients with Type 2 diabetes.
The ‘standard’ guidance of blood pressure management as described by the
British Hypertension Society applies to all patients.
http://www.bhsoc.org/Latest_BHS_management_Guidelines.stm
Management specific to diabetes is contained in NICE clinical guideline 66 The management of Type 2 diabetes Section 1.8
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
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Draft Guideline – 25 September 2008
D1.1 NICE clinical guideline 66 – Type 2 diabetes – Blood Pressure
Measure BP annually if not hypertensive or
renal disease
If >140/80 mmHg confirm consistently
raised
above target
Trial lifestyle measures alone unless >150/90
mmHg
above target
Maintain
lifestyle
measures
Start ACEI (and titrate dose)
(if African-Caribbean plus
diuretic or plus CCB)
above target
Targets
People with retinopathy or cerebrovascular
disease
or with microalbuminuria
Follow algorithm with target <130/80 mmHg
Others
Follow algorithm with target <140/80 mmHg
Women with possibility of pregnancy
Avoid use of ACEI or A2RB drugs
Begin with CCB
In people with continuing intolerance to an
ACE inhibitor (other than renal
deterioration or hyperkalaemia)
substitute the ACE inhibitor with an
A2RB drug.
People with microalbuminuria
Will already be on full dose ACEI or alternative
Then follow algorithm with target <130/80
mmHg
Add CCB or bendroflumethiazide
above target
Add bendroflumethiazide or CCB
above target
Add α-blocker, β-blocker,
or potassium-sparing diuretic
Scheme for the management of
blood pressure for people with
Type 2 diabetes
ACEI, ACE inhibitor;
A2RB, angiotensin 2 receptor blocker
(sartan);
CCB, calcium channel blocker
above target
Add α-blocker, β-blocker, or
potassium-sparing diuretic, or refer
to specialist
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D2.0 Cardiovascular disease and diabetes
Atherosclerotic macro-vascular disease is the major cause of morbidity and
mortality in people with diabetes mellitus. The increased risk of angina,
myocardial infarction, transient ischaemic attacks (TIAs), stroke disease and
peripheral arterial disease is related to relative hyperglycaemia over a prolonged
period of time.
For example diabetes is associated with a two to three-fold increased risk of
coronary heart disease in men and in pre-menopausal women with longstanding
diabetes the risk is increased four to five-fold.
Any additional risk factor further magnifies the risk i.e. smoking, hypertension,
hyperlipidaemia, microalbuminuria/ proteinuria, obesity, ethnicity or family
history of premature vascular disease.
D2.1 Screening
All people with diabetes aged over 18 should have their risk factors for
cardiovascular disease assessed as part of the annual screening process:
 History and examination as appropriate.

Smoking habit – SectionB3.5

Blood pressure –Section D1

Lipid levels – Section D2.3 page 135

Urinary microalbumin / proteinuria screen – Section D6

Diet/ Weight /BMI or waist circumference – SectionA4.1

Physical activity level – SectionB3.3

Glycaemic control – Section C
Intervention for these modifiable risk factors should be discussed with all
patients and implemented as appropriate – see relevant sections.
D2.2 Specific cardio-protective therapy
General guidance on cardiovascular risk reduction is covered in depth in JBS
2: Joint British Societies’ Guidelines On Prevention Of Cardiovascular
Disease In Clinical Practice (Prepared by: British Cardiac Society, Diabetes
UK, British Hypertension Society, HEART UK, Primary Care Cardiovascular
Society, The Stroke Association)
http://www.bcs.com/download/651/JBS2final.pdf
Management specific to diabetes is contained in NICE clinical guideline 66 The management of Type 2 diabetes Section 1.9
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
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In addition to the above interventions, specific therapies to reduce the
cardiovascular risk should be offered to the following individuals, after
informed discussion between the individual and responsible clinician, unless
contraindicated:
Known cardiovascular disease i.e. history
of angina, myocardial infarction, transient
ischaemic attack, stroke or symptomatic
peripheral arterial disease ?
Known diabetic nephropathy (proteinuria or
microalbuminuria) ?
Simvastatin 40mgs or
equivalent *
Low dose aspirin ^
Ace inhibitor or AT2
blocker #
Yes
No
No
No
Aged ≥ 40 years with Type 1 or
type 2 diabetes mellitus?
Yes
Simvastatin 40mgs or equivalent *
No
Younger adult with Type 1 or Type 2
diabetes and one or more of the following?
 Hypertension
Yes
 Severe retinopathy, treated proliferative
retinopathy or confirmed maculopathy?
 Total cholesterol ≥ 6 mmol/l
 Features of metabolic syndrome †
 FH of premature CVD (siblings or
parents)
 Poor glycaemic control (HbA1c >
9%)
No
Observe
* Statins are contraindicated in pregnancy and careful discussion regarding
contraception is required before use in women in child bearing years. Please
see Grampian formulary for most recent advice on lipid lowering therapy
www.nhsgrampian.org/grampianfoi/files/Statin_statement_October2007.
pdf The risks and benefits of Aspirin for primary prevention of cardiovascular
disease in people with diabetes are under investigation.
^ Clopidogrel 75 mg daily may be used as an alternative for patients intolerant
of Aspirin. Avoid antiplatelet therapy if there is active vitreous haemorrhage.
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Draft Guideline – 25 September 2008
† Central obesity and fasting triglyceride > 1.7 mmol/l (non fasting >2.0
mmol/l) and /or HDL < 1.0 mmol/l in men or < 1.2 mmol/l in women
# Renal function should be closely monitored after introduction and titration.
D2.3 Lipids
JOINT STATEMENT ON THE USE OF LIPID REGULATING DRUGS IN GRAMPIAN - March
2009
http://www.nhsgrampian.org/nhsgrampian/GJF_general.jsp?pContentID=4756
&p_applic=CCC&p_service=Content.show#m.nh
Advice on use of lipid lowering agents in Grampian first issued in February
2005 (second review February 2007), has been updated March 2009. This
review was undertaken by the Grampian Medicines Management Group
(GMMG) and the Managed Clinical Network for CHD.
GENERIC SIMVASTATIN 40mg IS THE PREFERED INITIAL AGENT
THE OPTIMUM DOSE IS REGARDED AS 40MG AT NIGHT
WHY HAS GUIDANCE OTHERWISE CHANGED?
Recently robust safety and efficacy data has become available for
rosuvastatin. This agent has a number of advantages over atorvastatin. It is
cheaper, more potent, less likely to cause drug interactions and at least in the
10mg dose associated with few side effects. Whilst rosuvastatin is the
preferred second-line statin there are still occasions where atorvastatin may
be specifically recommended.
The risks and benefits of treatment should be discussed with the patient
including the risk of
side effects that can be increased by some drugs (see BNF) and medical
conditions (e.g. renal
failure). In such cases closer monitoring may be required.
FOR PATIENTS WITH ESTABLISHED VASCULAR DISEASE:






An initial dose of simvastatin 40mg at night is recommended for
most patients. Simvastatin 80mg is not recommended in view of
significant adverse effects.
If patients are complying with therapy and targets cannot be
achieved on 40mg simvastatin, then a switch to rosuvastatin 10mg
is recommended. As a guide this should give approximately 25%
more efficacy.
Higher doses of rousuvastatin should not be used for initiation of
routine therapy.
Fibrates can be used when a patient is intolerant of any statin.
Ezetimibe can be used as monotherapy where patients cannot
tolerate either statin or fibrate or as additive therapy in patients who
fail to achieve target on 20mg of rousuvastatin. It is not licensed for
addition to fibrates.
If triglycerides (or initial total cholesterol) are >10mmol/litre then
expert advice should be obtained.
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Draft Guideline – 25 September 2008
IN PRIMARY PREVENTION






Drug therapy should now be routinely used for individuals with a
risk >20% over 10 years. This assessment should be based on risk
tables and not on cholesterol levels alone. Simvastatin 40mg at
night is the recommended therapy.
There is no evidence for further dose titration and it is not a
requirement of QoF.
Focused attention to improving general lifestyle measures is always
an essential component of primary prevention.
Diabetic patients over the age of 40 should be treated following the
'established disease' recommendations above; younger diabetic
patients should be considered for primary prevention.
There is currently no robust outcome data for the use of either
fibrates or ezetimibe although pragmatically they could be used with
discretion.
If cholesterol or triglycerides are >10mmol/l then expert advice
should be obtained.
Lipid Management specific to diabetes is contained in NICE clinical
guideline 66 - The management of Type 2 diabetes Section 1.10
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
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D3.0 Eye Care, Screening and Treatment
D3.1 Eye screening
The Grampian Diabetes Retinal Screening Programme undertakes screening
for diabetic retinopathy within Grampian Region. The success of the Retinal
Screening Programme depends on referral to the service from primary
care of all appropriate patients. All patients with diabetes are offered
appointments at the discretion of their General Practitioner. Patients unable to
co-operate with examination or who have no perception of light in either eye
should not be offered screening. However it may be appropriate that these
patients are referred directly to the ophthalmology department for review. All
other patients should be invited to attend, including those registered blind as,
despite the terminology, many still have useful remaining vision. In particular
the commonest causes of blindness in people with diabetes are age-related
macular degeneration and diabetic macular oedema. Screening is still
essential to look for new-vessel formation that could affect their remaining
peripheral vision.
Patients who attend Ophthalmology Clinics for reasons other than monitoring
or management of their diabetic eye disease should still be encouraged to
attend for retinal screening.
Screening criteria
Who
When
Where
By Whom
How
People with diabetes aged 12 years or over
Refer at diagnosis. Screen at least annually*.
Will vary according to local arrangements.
Routine screening by Diabetes Retinal Screening Programme.
Digital retinal imaging
*Ophthalmologists or the Retinal Screening Programme may undertake
repeat examination more frequently in certain high-risk groups. In pregnancy
retinal examination should be undertaken in each trimester.
Defaulters
Screen opportunistically by whoever sees them diabetologist, optometrist, general practitioner.
Should have visual acuity (with glasses or pinhole) recorded
and either non-mydriatic retinal photography or direct
ophthalmoscopy with mydriasis (1% tropicamide).
Documentation Methodology and findings should be reported according to
the Scottish Diabetic Retinopathy Grading System – details in
Appendix 5.
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Draft Guideline – 25 September 2008
Frequency of screening Patients will be recalled at least on an annual basis
for screening for diabetic retinopathy. Those with referable retinopathy or
referable maculopathy will be referred on to the ophthalmology service.
Those patients will moderate retinopathy or observable maculopathy will be
rescreened at a 6 month interval.
Obtaining individual patient results
Patients diabetic retinal screening outcomes and retinal images may be
accessed and shown to your patients via the SCI-DC Network system – see
section on Information Technology.
D3.2 Mydriasis
Patients who are attending the Grampian Diabetes Retinal Screening
Programme will not routinely have their pupils dilated unless it is not possible
to get a gradeable image with digital photography. If dilation is required, 1%
Tropicamide should be used. This may cause blurring of vision and affect the
ability to drive or operate machinery for up to four hours, and patients should
be appropriately warned.
Glaucoma, whatever form, is not a contraindication to mydriasis.
Contact lenses do not need to be removed.
D3.3 Medical treatment
Tight blood pressure control has a dramatic effect on the progression of eye
disease and the prevention of visual impairment. It is always strongly advised.
Tight glycaemic control also has a beneficial effect on the progression of eye
disease and the prevention of visual impairment. In some patients however if
control is tightened up too quickly this can lead to progression of retinopathy.
In patients with no retinopathy or only mild background changes this usually
manifests itself as the development of cotton wool spots. These are of no
consequence and will often disappear. In patients with severe background or
worse retinopathy rapid tightening of glycaemic control can lead to rapid
progression to high-risk proliferative retinopathy.



If the patient’s retinopathy status is unknown and they are poorly
controlled then they should be referred to the Grampian Diabetes
Retinal Screening Programme for assessment, if possible, prior to
tightening up of glycaemic control.
As it takes years for the complications of diabetes to occur, it would
seem prudent for glycaemic control to be improved gradually over 6-12
months in such at risk patients.
Patients with poorly controlled diabetes who are admitted to hospital
with diabetes or non diabetes-related illness should have their eyes
examined prior to discharge. This is particularly important if the patient
is a chronic defaulter from the Diabetic or Eye Clinic.
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Draft Guideline – 25 September 2008
D3.4 Laser treatment
Laser treatment is very effective at treating proliferative (new vessels)
retinopathy and will prevent the majority of people developing significant
visual impairment.
Laser treatment is less effective at treating patients with maculopathy
(changes affect the centre of vision) but attention to blood pressure and
glucose control can make a significant impact in preventing deterioration.
D3.5 Diabetic eye screening guidelines - classification and action
D3.5.1 Visual acuity


Normal corrected visual acuity
Action Review visual acuity annually

Visual acuity worse than 6/9 in the worst eye

Stable or previously explained

Action Review visual acuity annually

Deteriorating (by 2 or more lines) or previously unexplained

Action Ask patient to attend their own Optometrist for refraction and if
vision cannot be improved then consider reason unrelated to diabetic
retinopathy (e.g., cataract, chronic amblyopia, senile macular
degeneration). Refer to ophthalmologist as appropriate

Diabetic retinopathy. Macular oedema may present with no specific
fundoscopic change.

Action Refer to ophthalmologist
D3.6 Fundoscopy
Ophthalmoscopy is an alternative method to photography for examining the
retina. The Health Technology Board for Scotland recognises that indirect
ophthalmoscopy using a slit-lamp is sensitive and specific enough for retinal
screening but notes that it carries the disadvantage that there is no permanent
record of the image for quality assurance or for monitoring progressive
changes. However, this technique will be essential for screening failures of
digital photography. Direct ophthalmoscopy has high specificity but its
sensitivity is too low to form the basis of a national screening programme.
Direct ophthalmoscopy still has a role though in opportunistic screening for
those who persistently default from the systematic national programme.
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Draft Guideline – 25 September 2008
D3.7 Scottish Diabetic Retinopathy Grading Scheme 2007 v1.1
This system is used for screening by the Grampian Retinal Screening
Programme or opportunistically. The Grampian Retinal Screening Programme
will initiate appropriate onward referrals or review schedules.
Retinopathy
Description
Outcome
R0
(no visible
retinopathy)
No diabetic retinopathy anywhere
Rescreen 12
months
R1 (mild)
Background diabetic retinopathy BDR –
mild
The presence of at least one of any of the
following features anywhere
 dot haemorrhages
 microaneurysms
 hard exudates
 cotton wool spots
 blot haemorrhages
 superficial/ flame shaped
haemorrhages
Rescreen 12
months
R2
(observable
background)
Background diabetic retinopathy BDR observable
Four or more blot haemorrhages (ie _AH
standard
photograph 2a – see below) in one hemifield only (Inferior
and superior hemi-fields delineated by a
line passing
through the centre of the fovea and optic
disc)
Rescreen 6
months (or refer
to ophthalmology if
this is not feasible)
R3 (referable
background)
Background diabetic retinopathy BDR –
referable
Any of the following features:
 Four or more blot haemorrhages (ie
AH standard
 photograph 2a – see below) in both
inferior and superior
 hemi-fields
 Venous beading (AH standard
photograph 6a – see
 below)
 IRMA (AH standard photograph 8a –
see below)
Refer
ophthalmology
These patients
may
be kept under
surveillance and
will
not necessarily
receive immediate
laser treatment.
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Draft Guideline – 25 September 2008
R4
(proliferative)
Proliferative diabetic retinopathy PDR
Any of the following features:
Active new vessels
Vitreous haemorrhage
Refer
ophthalmology
These patients are
likely to receive
laser treatment or
another
intervention.
R5
(enucleated)
Enucleated eye
R6
(inadequate)
Not adequately visualised :
Retina not sufficiently visible for
assessment
Rescreen 12
months (other
eye)
Technical failure
Arrange alternative
screening
examination. This
will be automatic
within the
screening
programme.
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Draft Guideline – 25 September 2008
Photo 2a
Photo 6a
Photo 8a
All photographic images in relation to Diabetic Retinopathy grading outcomes
can be viewed at
http://eyephoto.ophth.wisc.edu/ResearchAreas/Diabetes/DiabStds.htm
Maculopathy
M1
(Observable)
Description
Lesions within a radius of > 1 but ≤ 2 disc
diameters of the centre of the fovea
 Any hard exudates
M2
(Referable)
Lesions within a radius of ≤ 1 disc diameter
of the centre of the fovea
 Any blot haemorrhages
 Any hard exudates
Coincidental
Description
findings
PhotoLaser photocoagulation scars present
coagulation
Other
Other non-diabetic lesion present
 Pigmented lesion (naevus)
 Age-related macular degeneration
 Drusen maculopathy
 Myelinated nerve fibres
 Asteroid hyalosis
 Retinal vein thrombosis
Outcome
Rescreen 6
months (or refer
to ophthalmology if
this is not feasible)
Refer
ophthalmology
These patients
may
be kept under
surveillance and
will
not necessarily
receive immediate
laser treatment.
Outcome
Grading note
This grading scheme is not intended to be done by levels. It is meant to be
done by features. The grader reports the presence or absence of each of the
following features for each hemisphere and then derives the level for the
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Draft Guideline – 25 September 2008
individual eye:
.
.
.
.
.
.
• Dot haemorrhages or microaneurysm
• 4 or more blot haemorrhages (i.e. ≥ standard photography 2a)
• Venous Beading (≥ AH standard photograph 6a)
• IRMA (≥ AH standard photograph 8a)
• New vessels
• Vitreous haemorrhage
D3.8 Obtaining individual patient results
Retinal screening results and images may be accessed using SCI-DC.
Click on ‘eye screening images to access retinal images
Click here to view patient’s retinal images
Grading outcomes at top of page, scroll down to see retinal image
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Draft Guideline – 25 September 2008
Please refer to IT section regarding call/recall process.
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Draft Guideline – 25 September 2008
D4.0 Foot Care, Screening and Treatment
D4.1 Foot Screening
The chief factors responsible for foot problems in the diabetic foot are
neuropathy and ischaemia, often a combination of the two, with infection as
both a provoking and complicating factor. The purpose of diabetic foot
screening is to detect patients who are showing signs of neuropathy and/or
ischaemia. It is important to enable appropriate management patients with
diabetes; absence of symptoms should not be taken as an indication of
absence of risk.

All people with diabetes will be foot screened at diagnosis and
annually thereafter using the SCI DC foot screening tool (see next
page) to determine their foot risk stratification.
 Foot screening will be provided by NHS Grampian Retina Screening
Service or at practice level.
 A suitably-trained healthcare professional will carried out foot
screening using the SCI DC foot screening tool. Training will be
provided by NHS Grampian podiatry department. Contact details from
NHS Grampian MCN website www.diabetes.nhsgrampian.org
 The use of a calibrated 10g Monofilament is essential.
 Ongoing management of the diabetic foot depends on risk stratification
of the patient which identifies those at risk of developing diabetic foot
complications. See appendix 1
Having identified the patients at increased risk of developing a diabetic foot
ulcer we can then minimise this risk by interventions such as education,
regular podiatry and therapeutic footwear and insoles.
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D4.1.1 SCI-DC Foot Screening Tool
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Draft Guideline – 25 September 2008
D4.1.2 Annual Diabetic Foot Screening
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Draft Guideline – 25 September 2008
D4.1.3 Diabetic Foot Risk Stratification and Triage “Traffic Lights”
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Draft Guideline – 25 September 2008
D4.2 Management guidelines for Charcot neuroarthropathy in
people with diabetes
Charcot foot is a neuroarthropathy process with osteoporosis, fracture, acute
inflammation and disorganisation of foot architecture, (SIGN 2001)
Clinical features
Diabetes patient presents with red, oedematous, hot and possibly painful foot.
Usually bounding pedal pulses with evidence of impaired neurological testing.
Differential Diagnosis
Differential diagnosis between Charcot Neuroarthropathy and infection should
always be considered.
Diagnosis / Investigations
“Diagnosis should be made by clinical examination”. (Frykberg et al 2000;
Jeffcoate et al 2000)








Usually a good blood supply to lower limb with degree of neuropathy
Observe foot for obvious signs of tissue trauma, cellulites or systemic
toxicity to rule out
Infection
History of trauma to limb may be present
Heat differentiation between limbs -affected limb often 2-8 degrees
higher than the contra lateral foot
Blood test- HbA1c, Hb, ESR and C-reactive protein
X-Ray for baseline and to exclude diabetic neurophathic fracture
If Charcot foot suspected consider MRI/Bone scan
Management





“Refer people with suspected Charcot’s foot immediately to the
Multidisciplinary Foot Clinic or Diabetes Podiatrist for immobilisation of
the affected joint(s) and for long term management to prevent
ulceration”. (NICE 2004)
Off loading urgently required ideally with either Total Contact Casting
or Aircast Boot. Pressure relieving
Off loading device usually worn until inflammation settles, heat
differentiation disappears and bone activity reduces. (SIGN 2001)
Patient education, Patients require comprehensive education on the
causes and management of Charcot foot and advice on prevention of
complications.
There is insufficient evidence to support the routine use of
Bisphosphonates in the acute Charcot Foot (SIGN 2001) however
there are a number of studies which indicate that the Bisphosphonates
may be useful in halting the acute phase of Charcot neuroarthropathy
in some patients. (Anderson et al 2004, Jude et al 2001). All
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Draft Guideline – 25 September 2008

suspected Charcot Foot cases to be reviewed by Consultant Physician
at Multidisciplinary Foot Clinic to consider options.
Discontinue therapy when foot temperature equal.
Long Term Management


Patients will require a referral to the Orthotist for a managed
program of pressure relief.
Classify patient as High Risk and review regularly for signs of longterm complications.
D4.3 Diabetic Foot Ulceration and Wound Management
5-7% of all people with diabetes will by affected by a foot ulcer at some point
during their lives. Diabetic foot ulcers are a major reason for hospitalisation
and account for more than two-thirds of non-traumatic lower limb amputations
performed. A unified approach to foot care management is essential. No one
health care professional should deal with this problem. It continues to be a
challenge to diabetic medicine and requires a multi-disciplinary approach.
(SIGN guideline 55, 2001, NICE guideline10, 2004))
Urgent referral to a Diabetes Podiatrist (by telephone or fax followed by a
written referral) is the most appropriate route for patients with a diabetic foot
ulcer and possible soft tissue infection.
(Please refer to NHS Grampian MCN website for contact details of Diabetes
Podiatrist. www.diabetes.nhsgrampian.org)
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Draft Guideline – 25 September 2008
D4.3.1Care Pathway for Active Diabetic Foot Ulceration
Ulcer present
( Def.- A break in skin with loss of surface tissue and disintegration of
epithelial tissue)
Determine cause of ulcer e.g. trauma, neuropathic, ischaemic or
neuroischaemic.
Determine current vascular and neurological status. Assess wound and
record all findings e.g. duration of wound, size, depth, appearance etc.
Is infection present?


Contact GP for
commencement of antibiotic
cover
Take a wound swab and
send to microbiology
Refer to Diabetes Podiatrists
for
(Contact details available from NHS
Grampian MCN website
www.diabetes.nhsgrampian.org )




Assessment of patient
Immediate pressure relief
Referral to members of the
multidisciplinary foot team
Referral to M.A.R.S. for a managed
program of pressure relief.
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D4.3.2 Referral Pathway for Pressure Relief
Diabetic Foot Ulcer
Refer to Diabetes Podiatrist for

Initial Pressure relieving device

Appropriate referral to Orthotist at Mobility
and Rehabilitation Service (MARS) for
Assessment of a managed program of
pressure relief
(Contact details for Diabetes Podiatrists are available
from NHS Grampian MCN website
www.diabetes.nhsgrampian.org)
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D4.3.3Painful Diabetic Neuropathy
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D4.4 Good practice guidance for the use of antibiotics in patients
with diabetes foot ulcers
This document has been endorsed by the Scottish Diabetes Group on behalf
of the Scottish Government, and is recommended for use as National
guidance.
1. INTRODUCTION
The following is guidance to help health-care professionals to make decisions
that will improve outcomes for their patients. This is a consensus document
based on limited available clinical trial evidence, review of international
guidelines and expert opinion. There may be circumstances where alternative
courses of action may be appropriate.
Guidance about antibiotic choice is primarily dependent on local
microbiological epidemiology and susceptibility patterns. However, the
consensus group felt that the pathogens causing infection in Scotland for the
various diabetic foot infection clinical syndromes are unlikely to vary
substantially within Scotland. Therefore there is some merit in providing
broad practical guidance about antibiotic choice but this should be subject to
local adaptation if necessary.
2. GENERAL APPROACH TO FOOT ULCERS
Team Approach
 All patients with diabetes and foot ulcers should be managed in a
multidisciplinary foot-care setting. Previous ulceration is the strongest
predictor for further ulceration. Thus, after healing, preventative
measures need to be addressed. Attention to aggressive treatment of
macrovascular risk factors in patients with foot ulcers has been shown
to prolong survival.
Specimens for Culture
 It is debated whether ulcers with clinical signs of infection should have
a specimen taken for culture at outset. If not then cultures should be
taken if there is clinical failure of empirical antibiotics. Aspiration of
purulent secretions, curettage of debrided wound base, punch biopsy
and exuded bone are the best specimens to obtain.
Loose Bone
 Loose bone exuded from an ulcer, or any bone debrided should be
sent for bone culture and microbiological assessment. The extrusion of
a bone fragment (sequestrum) is highly suggestive of underlying
osteomyelitis although the infection may have arrested coincident on
the passage of the sequestrum.
Investigation of Osteomyelitis
 If concerned about osteomyelitis, Plain X-ray is the usual initial
investigation of choice. However, the X-ray can be normal for 2 weeks
before any changes are seen, and thus serial X-rays may be required.
If there is ongoing concern then the secondary investigations of choice
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are (in order of preference): MRI > Isotope White cell Scan > Triple
phase Bone scan. The isotope bone scan is relatively sensitive at
diagnosing osteomyelitis, but is not specific, and can remain positive
for over one year. The white cell scan may be difficult to obtain in
some areas. Choice of test may be dictated by local availability.
“Probe to Bone”
 Inability to touch bone when probing a wound with a sterile metal
probe, makes osteomyelitis very unlikely, with a negative predictive
value of about 90%. The positive predictive value of a positive probe to
bone test is only around 50%, which means that ulcers that probe to
bone frequently do not have osteomyelitis.
“Sausage Digit”
 The presence of a red swollen “sausage” digit is suggestive, of
osteomyelitis, but can be consistent with other causes such as fracture.
Differentiating Osteomyelitis and Charcot
 This can be difficult, and is based on taking a good history and
examination with supplementary evidence from MRI and other
investigations. Osteomyelitis and Charcot foot can frequently occur
simultaneously.
Foot Ulcer Classification
 Various Ulcer classification schemes can be used (Wagner, Texas,
SINBAD, PEDIS). The SCI-DC electronic ulcer management
programme is based on the Texas scheme (figure 1)
Classification of Infection
 It is recommended that the presence and severity of infection can be
classified according to the Infectious Disease Society of America
(IDSA)/ International Working Group for the Diabetic Foot (IWGDF)
classification (table 1).
Table 1 (Lipsky et al, Clinical Infectious Diseases 2004: 39: 885-910: IDSA
guidelines)
SEVERITY OF INFECTION DESCRIPTION
1. NO INFECTION
2. MILD (GRADE 2)
Either:
a) 2 or more features of inflammation:
Pus; Erythema; Pain; Tender; Warmth; Induration
Or
b) Cellulitis < 2cm. Confined to skin or subcutaneous tissue.
No systemic illness.
3. MODERATE (GRADE 3). Above with
Either
a) lymphatic streaking, deep tissue infection (subcutaneous, fascia,
tendon, bone), abscess,
Or
b) Cellulitis >2cm
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(but with no systemic illness)
4. SEVERE (GRADE 4). Any infection with systemic toxicity (fever, shock,
vomiting, confusion, metabolic instability). Presence of critical
ischaemia may make the infection severe.
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3. GENERAL PRINCIPLES OF ANTIBIOTIC USE (see below for specifics)








Antibiotic choice is primarily dependent on local microbiological
susceptibility and epidemiology. However antibiotics often need to be
started before this information is available. As the pathogens in
diabetic foot infections do not vary significantly in Scotland, the
consensus group recommends broad practical guidance about
antibiotic use. These are however subject to changing local
epidemiology and prescribing policy.
Initial treatment is frequently empirical based on the presumed
pathogen; see table 2 and 3. This guidance is of value until
microbiological and clinical response shed further light.
The choice of antibiotic, agent and route of delivery, should reflect the
severity of infection as reflected by the IDSA/IWGDF definition– see
table 1.
The duration of antibiotic use should be adjusted according to the
severity of infection (table) and can be guided by monitoring clinical
improvement. In general duration of antibiotic therapy should be kept
short.
In light of international concerns over the risk of C.difficile associated
with broad spectrum antibiotics (especially clindamycin, co-amoxiclav,
cephalosporins and quinolones) and MRSA risk (associated with coamoxiclav, cephalosporins and quinolones and macrolides) narrow
spectrum therapy should be used wherever possible. C.difficile is a
particular risk for patients aged over 65years and in-patients.
Adjustment of therapy based on microbiology results, when available,
is important.
Allergies to antibiotics refer to skin rash or anaphylaxis. This does not
include minor side-effects such as nausea.
Enterococci, Pseudomonas and anaerobes are frequently grown as
colonising organisms, rather than infecting organisms. If however there
is a chronic persisting infection or they are the predominant organisms,
they may be more important, and need treatment.
This document provides general advice, but direct contact with local
specialists may be necessary in certain circumstances for advice with
regard to more specialised use of these or other antibiotics.
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Figure 1.
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4. SPECIFIC ANTIBIOTIC GUIDANCE (see Table 2 for summary)
For different clinical syndromes the likely microbiology and therefore initial
antibiotic can be predicted with some degree of confidence although there will
on occasions be unusual circumstances. We emphasize the importance of
getting good quality specimens (see above) for microbiology and of close
liaison with the local infection specialist. Main choice antibiotics in blue and
alternatives in green are provided. The advice given is for empirical choices of
antibiotics. If there is local guidance based on local sensitivities, then this
should take precedent.
4.1 Mild infection (IDSA) or (PEDIS 2) and the patient is antibiotic naïve.
Likely pathogens are S.aureus (coagulase-negative Staphylococcus) or
beta-haemolytic streptococci. If previously treated with antibiotics,
enterococci and gram negative rods (GNRs) are likely to be present.
Oral flucloxacillin 1g qds.
Oral Alternatives
Doxycyline 100mg bd
Clindamycin 300-450mg qds, if the patient is allergic to or intolerant of
flucloxacillin.
A second course of flucloxacillin is rarely effective if the first course has been
unsuccessful, assuming that the first course was given in high dose and for a
full 5-7 days. There is an increased prevalence of resistant organisms after
the first exposure to flucloxacillin.
Treat for 5-7 days and then decide about further antibiotics depending on
clinical response and microbiological culture. Ensure microbiological culture if
unusual organism suspected, or initial treatment fails.
4.2a Moderate (IDSA) or PEDIS 3 and the patient is antibiotic naïve. Good
quality microbiological culture is usually helpful in these circumstances. Likely
pathogens are S.aureus or beta-haemolytic streptococci. Those with limb
ischaemia, gangrene, necrosis or a foul odour from the wound often have
obligate anaerobic pathogens.
Oral flucloxacillin 1g qds
Oral Alternatives:
Co-trimoxazole 960mg bd
Co-amoxiclav 625mg tds
Clindamycin 300-450mg qds or co-trimoxazole, if the patient is allergic to
penicillins.
Add in oral metronidazole 400mg tds if anaerobes suspected
IV flucloxacillin 1g qds.
If IV route for clindamycin is needed then use 450-600mg qds.
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4.2b Moderate (IDSA) (or PEDIS 3) and the patient is NOT antibiotic
naïve.
Patients with chronic infections, especially if they have received antibiotics
previously often have polymicrobial infections, including aerobic gramnegative bacilli among the flora.
a) IV co-amoxiclav 1.2gtds – especially if anaerobes or coliforms suspected
Oral switch option is
oral co-amoxiclav 625 tds or
Co-trimoxazole 960mg bd
If the patient is allergic to penicillins consider:
b) IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds ± vancomycin (if
MRSA considered likely)
Or
IV gentamicin* and IV metronidazole ± vancomycin (if MRSA considered
likely)
The choice will depend on the relative risks of C.difficile versus those of renal
impairment.
* The dosing of gentamicin is high dose once daily and should be determined
by local practice and will require close monitoring of serum levels and renal
function. Gentamicin dosing for more than 48 hours should only be continued
with specific advice from the infection specialist.
Oral switch option is
oral ciprofloxacin 500- 750mgbd with oral metronidazole 400mg tds, or
oral ciprofloxacin 500- 750mg bd and clindamycin 300-450mg qds
 Treat for 7 days. Adjust therapy in light of clinical response and results
of culture and sensitivity results.
4.3a Severe infection (IDSA) (or PEDIS 4), antibiotic naïve. High quality
culture (see section 2) is usually helpful in these circumstances. The likely
pathogens are S.aureus or beta-haemolytic streptococci but may need to
cover also for anaerobes and enterobacteriacea and Pseudomonas
aeruginosa. Caution: Pseudomonas is usually a coloniser rather than being
an infecting organism. As grade 4 infection implies systemic toxicity, it is
generally advised that such patients should be admitted to hospital for the
initial phase of management.
IV co-amoxiclav 1.2gtds +/- gentamicin 5-7mg/kg once daily or as per local
practice. . Gentamicin dosing for more than 48 hours should only be
continued with specific advice from the infection specialist
If the patient is allergic to penicillins or there is concern about renal function
consider
IV ciprofloxacin 400mg bd and IV metronidazole 500mgtds. ± vancomycin (if
MRSA considered likely)
 Treat for a minimum of 10-14 days
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4.3b Severe infection (IDSA) (or PEDIS 4) and the patient is not antibiotic
naive and has risk factors for drug resistant infection
Previous antibiotics within last 90 days, recent hospitalisation/s for more than
2 days within last 90 days, previous colonisation or infection with resistant
organism e.g MRSA or Extended Spectrum Beta-Lactamase (ESBL)
producing E.coli or Klebsiella spp) or proven resistant infection
IV piperacillin/tazobactam (tazocin) 4.5g tds ± vancomycin if MRSA suspected
(consult pharmacy for dose but aim for a trough vancomycin level of 1520mg/l). If penicillin allergy IV ciprofloxacin 400mg bd and add IV
metronidazole 500mg tds.
Oral switch options in these patients are best guided by microbiology where
possible. Otherwise, try oral ciprofloxacin 500- 750mg bd and metronidazole
400mg tds.
 If extended spectrum beta-lactamase (ESBL) producing coliform is
proven then seek specialist infection advice.
 Treat for minimum of 10-14 days, then review need for antibiotic.
If continuing MRSA cover is required and the patient can be discharged from
hospital we suggest
either outpatient and home parenteral antimicrobial therapy (OHPAT) if
available (usually given iv teicoplanin)
or oral linezolid is an option but treatment beyond two weeks needs to be
monitored closely for bone marrow toxicity, particularly thrombocytopenia or
leucopenia, and lactic acidosis, which are usually reversible on
discontinuation of the drug
Rifampicin 300mg bd AND
oral doxycycline 100mg bd OR fusidic acid 500mg tds OR trimethoprim
200mg bd
The rifampicin may offer difficulties related to drug interaction [eg warfarin]. All
these agents can be used in penicillin allergic patients.
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5. OSTEOMYELITIS
Early local surgery to excise infected bone can help accelerate healing and
reduce the length of time antibiotics are required. For other cases, antibiotic
therapy will lead to resolution of infection in up to 60% to 80% of cases. The
exact role of local surgery remains controversial.
The evidence base for antibiotic choice for these infections is poor. However,
in general terms the group recommends that where there is evidence of
osteomyelitis the treatments outlined above should be continued for at least 46 weeks, and sometimes longer depending on clinical response. Sometimes
measurement of serial CRP’s and White cell count may help, but not more
than once per week. Various antibiotics require monitoring of liver function
tests, full blood count and/or serum drug levels. Rationalisation of therapy
should be discussed with an infection specialist.
For MRSA osteomyelitis there is some evidence that adding rifampicin 600mg
bd or Sodium Fusidate to other treatments can be beneficial
There is no evidence that IV therapy is superior to oral therapy, although in
certain infections like MRSA IV therapy delivered in the OHPAT setting is
attractive to enhance compliance and reduce hospitalisation.
In osteomyelitis tolerability of oral antibiotics is a significant issue and therapy
may need to be tailored accordingly. If considering the use of linezolid for
osteomyelitis the prescriber must be aware of its unlicensed status for this
indication and of the risks of bone marrow toxicity, peripheral or optic
neuropathy and lactic acidosis.
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Table 2. Summary of Good practice statement on Antibiotic choice for the
diabetic foot.
Choices should always be guided by deep culture results when available.
Treatment should be for 5-7 days (mild/moderate) to 10-14 days (severe) and
then review the need for longer treatment. If osteomyelitis present then treat
for at least 4-6 weeks and then review the need for longer treatment. IV
antibiotics may be switched to oral preparations after an appropriate interval
(see main text)
MILD
Either 2 or more features
of inflammation (pus,
erythema, pain, tender,
warmth, induration),
OR Cellulitis < 2cm.
Confined to skin or
subcutaneous tissue. No
systemic illness
ANTIBIOTIC NAIVE
Oral Flucloxacillin 1g
qds*
Alternatives:
Doxycycline 100mg bd
Clindamycin 300-450mg
qds
MODERATE
Either two or more
features lymphatic
streaking, deep tissue
infection (subcutaneous,
tendon, fascia, bone),
abscess, OR b) Cellulitis
>2cm
SEVERE
Systemic toxicity (fever,
shock, vomiting, confusion,
metabolic instability)
ANTIBIOTIC NAIVE
Oral Fluxcloxacillin 1g qds*
(for MSSA, ß-H Strep)
Alternatives:
Cotrimoxazole 960mg bd
Coamoxiclav 625mg tds
Clindamycin 450mg bd
+/-metronidazole 400mg
tds
ANTIBIOTIC NAIVE
(Oral therapy
inappropriate)
IV Co-amoxiclav 1.2g tds ±
Gentamicin* 5-7mg/kg
If allergic to penicillin: IV
Ciprofloxacin 400mg BD &
IV metronidazole 500mg
tds ± Vancomycin
If NOT antibiotic naïve:
See alternatives above
If NOT antibiotic naïve:
IV CoAmoxiclav 1.2g tds
Alternatives:
IV Ciprofloxacin 400mg tds
& IV Metronidazole 500mg
tds
±IV Vancomycin* (if
MRSA)
or
IV Gentamicin & IV
Metronidazole 500mg tds ±
IV Vancomycin* (if MRSA)
Oral switch: Ciprofloxacin
750mg bd & Metronidazole
400mg tds or
Ciprofloxacin 750mg bd &
Clindamycin 300-450mg
qds
If NOT antibiotic naïve:
IV Tazocin 4.5g tds + IV
Vancomycin if MRSA.
If allergic to penicillin see
alternatives opposite
MRSA
IV Vancomycin*
IV Teicoplanin* (Home IV
service)
Oral switch: Rifampicin*
with trimethoprim or
MRSA
IV Vancomycin*
IV teicoplanin* (Home IV
service)
Oral switch: Rifampicin*
with trimethoprim or
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Draft Guideline – 25 September 2008
doxycycline or fusidic acid* doxycycline or fusidic acid*
Linezolid 600mg bd#*
Linezolid 600mg bd#*
* Require monitoring. Add rifampicin 600mg bd or Sodium Fusidate if osteomyelitis
#
Note concerns about linezolid toxicity with protracted therapy
Table 3. Empirical guide as to which organisms are likely to be the infecting
organism and which antibiotics are likely to be effective.
INFECTING
ORGANISM
Staphylococcus
(aureus)
MRSA
-Haemolytic
Streptococcus
Enterococcus
Pseudomonas
(Gm negative bacillus)
Anaerobic
PRIMARY GROUP OF
ANTIBIOTICS
Penicillinase resistant
Penicillin
Eg Flucloxacillin
Vancomycin
Teicoplanin
(for other options
discuss with infection
specialist)
ALTERNATIVE
Doxycycline
Clindamycin
Amoxicillin
Rifampicin combined
with trimethoprim or
doxycycline or fusidic
acid,
Cotrimoxazole,
Linezolid
Clindamycin
Amoxicillin/co-amoxiclav
Quinolones eg high
dose Ciprofloxacin
Metronidazole
Vancomycin, Linezolid
Piperacillin-tazobactam
(tazocin), meropenem
Clindamycin
Bibliography
Lipsky BA, Berendt AR, Deery HG. IDSA guidelines: diagnosis and
treatment of diabetic foot infection. Clin Infect Dis 2004; 39: 885-910.
Lipsky BA. Empirical therapy for diabetic foot infections: are there clinical
clues to guide antibiotic selection. Clin Microbiol Infect. 2007: 13: 351-3
Lipsky BA. New developments in diagnosing and treating diabetic foot
infections. Diab Met Res Rev 2008; 28 (suppl 1) S66-71
Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing
osteomyelitis in diabetes. Clinl Inf Dis2004; 39 (Suppl 2): S115-22.
Game FL, Jeffcoate WJ. Primarily non-surgical management of osteomyelitis
of the foot in diabetes. Diabetologia 2008; 51: 962-7.
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ,
Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Specific guidelines
for treatment of diabetic foot osteomyelitis Diabetes Metab Res Rev. 2008; 24
Suppl 1:S190-1
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Draft Guideline – 25 September 2008
Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ,
Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Diabetic foot
osteomyelitis: a progress report on diagnosis and a systematic review of
treatment Diabetes Metab Res Rev. 2008; 24 Suppl 1:S145-61
162
Draft Guideline – 25 September 2008
D5.0 Neuropathy - Autonomic
Patients with long-standing diabetes may develop neuropathy affecting
autonomic function, which may produce a number of different difficult clinical
and management problems. Symptoms are often non-specific and other
diagnoses should be considered and excluded, if appropriate. As many of
these problems are fortunately uncommon it is appropriate to consider
seeking specialist advice. The following notes give some basic advice on
therapeutic approaches to a range of problems that can result from diabetic
autonomic neuropathy.

Erectile dysfunction: the advent of selective inhibitors of
phosphodiesterase-5 in erectile tissue has revolutionised the initial
management of this relatively common problem in diabetic men.
Treatment is said to be successful in more than 50% of patients.
Sildenafil, Vardenafil and Tadalafil are all available on prescription for
patients with diabetes; their use should be avoided in cases of severely
compromised cardiovascular function and when nitrates are being
taken. Where oral therapies are unsuccessful, referral can be made to
a specialist ED clinic (run in Aberdeen by the Urology Department and
Mr Gunn in Elgin) for consideration of intracavernosal injection of
prostaglandin or vacuum devices.

Intermittent diarrhoea: especially occurring nocturnally, this problem
may be a direct result of gastrointestinal neuropathy in which codeine
phosphate or other antidarrhoeal agents can be helpful. Alternatively,
gut dysmotility can lead to atypical bacterial overgrowth and short
courses of antimicrobial agents such as tetracycline or metronidazole
can be rapidly effective. [Remember also other possible causes of
diarrhoea, including Metformin therapy, the possibility of coeliac
disease or exocrine pancreatic dysfunction in cases of secondary
diabetes].

Postural hypotension: advice on rising/standing cautiously, and
avoidance of over-enthusiastic use of diuretics and hypotensive agents
may be most effective. Fludrocortisone can be useful in severe cases
but may lead to oedema.

Vomiting due to gastroparesis: metoclopramide or domperidone may
help by promoting gastric emptying. Alternatively, Erythromycin may
benefit some patients.

Gustatory sweating: fortunately uncommon; best managed by
avoidance of foods found by the sufferer to exacerbate the problem.
Agents, such as propantheline, may be beneficial but often have
marked anticholinergic adverse effects.
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

Neuropathic oedema: damage to control of capillary blood flow can
lead to accumulation of fluid in dependent extremities in the presence
of a normal serum albumin and the absence of fluid overload.
Ephedrine, an alpha-adrenergic agonist may be useful but care is
required in the presence of hypertension and angina.
Bladder hypotonia: drug treatment with alpha blocking agents is difficult
due to the risk of precipitating symptomatic postural hypotension.
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D6.0 Renal Disease
Renal impairment is important in patients with chronic diseases or on multiple
drug therapy and serum creatinine should be checked annually. Diabetic
nephropathy is an important long-term complication of diabetes, which is
characterised by persistent proteinuria, hypertension and a progressive
decline in renal function. The absence of retinopathy or the presence of
haematuria should prompt investigation for other possible forms of renal
disease. A definitive diagnosis of diabetic nephropathy can be made by renal
biopsy, although this is unnecessary in most cases.
Persistent proteinuria confers eighty to one hundred fold increased mortality
due largely to cardiovascular disease and such patients often succumb before
the need for renal support arises. Survivors with persistent proteinuria
eventually progress to end stage renal failure requiring dialysis or
transplantation.
Microalbuminuria is an early marker of diabetic renal disease and predicts the
onset of overt nephropathy in both Type 1 and Type 2 diabetes.
Microalbuminuria is also a significant independent risk factor for the
development and progression of cardiovascular disease.
Aggressive management of blood pressure can retard the progression of
diabetic renal disease at all stages.
SIGN 103 Diagnosis and Management of CKD
http://www.sign.ac.uk/pdf/sign103.pdf
covers updated guidance for all patients. The notes below are points
more specific to diabetes.
D6.1 Screening for diabetic renal disease
Who
People with diabetes aged 12 years or over
When
At diagnosis and annually
How
Dipstick for proteinuria (Albustix or equivalent)
Microalbumin estimation if dipstick negative
eGFR
Outcome
Ø Dipstick positive – see 6.2.1 – Assessment of dipstick positive patients
Ø Dipstick negative – see 6.2.2 – Assessment of dipstick negative patients
6.2 Definitions
Spot urine samples (for screening)
Albustix
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Dipstick one plus or greater (>200mg/l) indicates proteinuria.
Albumin/creatinine ratio (ACR)
The ratio of urinary albumin to creatinine concentration. This is a screening
test for microalbuminuria.
Normal values – female <3.5mg/mmol, male <2.5mg/mmol
Timed overnight urine collections (for diagnosis)
Normoalbuminuria
Normal albumin excretion rate <20 µg/min
Microalbuminuria
Albumin excretion rate 20- 200µg/min
Proteinuria
Albumin excretion rate > 200µg/min
Spot protein/creatinine ratio (PCR) > 70mg/mmol
24hr urinary protein > 500mg
Instructions for patients:
..\Linked documents\Instructions for timed overnight urine
collections for albumin excretion rate.doc
D6.2.1 Assessment of dipstick positive patients





Consider urinary infection or other non diabetic causes
Repeat test
Persistent proteinuria, when confirmed on two consecutive occasions,
should be quantified using a protein/ creatinine ratio measurement on a
spot sample.
Review result of recent serum creatinine and blood pressure
Persistent “dipstick positive” proteinuria negates the need for
measurement of microalbuminuria
D6.2.2 Assessment of dipstick negative patients






Screen for microalbuminuria
First voided urine sample after sleep, for albumin/creatinine ratio (ACR).
Reject samples with evidence of infection.
Normal (male < 2.5, female < 3.5 mg/mmol). Repeat in twelve months.
Abnormal – Re-test.
If repeat test abnormal proceed to timed overnight urine collection*
AER <20ug/min – revert to annual screening
AER >20ug/min – microalbuminuria confirmed
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
ACR levels persistently in excess of 10 mg/mmol always indicate an
AER > 20µg/min, and in such circumstances a timed collection may be
omitted.
In some clinics preliminary screening is performed to identify normal results
using the Klinitek 50.

Result from Klinitek 50 – both ACR <3.5 and urinary albumin
concentration <10 mg/l = normal albuminuria. Repeat in 12 months.

Result from Klinitek 50 –ACR >3.5 and/or urinary albumin concentration
>10 mg/l = send first voided urine to Lab for further analysis.
Patient information sheet – urine testing and microalbuminuria
..\Linked documents\Patient Information Sheet urine testing and
microalbuminuria.doc
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D6.2.3 Algorithm for microalbuminuria screening in the community
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D6.3 A simple guide to eGFR interpretation and nephrology referral
guidelines.
What Is eGFR?
Glomerular Filtration Rate is the most
useful measure to describe kidney
function in adults. Direct measurement
of GFR is involved and expensive.
However serum Creatinine can be used
together with age and gender to give a
calculated estimate which is reasonably
accurate, particularly in those with
impaired function. A correction factor of
1.212 should be applied to AfricanCaribbean individuals. The calculation is
not applicable in acute renal failure and
gives poor results in those at the
extremes of weight. The GFR is around
100ml/min/1.73m2 in health, so the
eGFR effectively describes % kidney
function.
The introduction of eGFR In Grampian
From June 2006, the Biochemistry
department will report an estimated
GFR (eGFR) alongside reports for
serum creatinine. The calculations
being used nationally depend on the
creatinine assay used, so GFR should
not be estimated outside the laboratory.
The eGFR will not be reported in
delayed samples (>24h), or in children.
All values above 60 will all be reported
as >60 ml/min/1.73m2. Patient
information required by the
Biochemistry department to determine
eGFR include date of birth and sex.
Chronic Kidney Disease Classification
GFR can be used to classify patients
with chronic kidney disease (CKD). The
system in current use was developed by
the National Kidney Foundation in the
USA.
Stage
Description
GFR
1
Kidney damage and normal GFR
>90
2
Kidney damage and mild decrease
60 to 89
in GFR
3
Moderate decrease in GFR
30 to 59
4
Severe decrease in GFR
15 to 29
5
Kidney failure (dialysis or kidney
< 15
transplant needed)
Kidney damage refers to the additional
finding of either direct evidence (eg
ultrasound showing polycystic kidneys)
or indirect evidence (eg persisting
proteinuria) of kidney disease.
For further Information and a guide to
the management of CKD see
www.renal.org/CKDguide/ckd.html.
An eGFR guide is also available at
http://www.renal.org/eGFR/.
How to Interpret the
eGFR result
eGFR > =60
ml/min/1.73m2
On its own an eGFR result of 2 60
ml/min/1.73m2 indicates normal kidney
function and requires no specific action.
Clearly there are however many other
indicators of kidney disease (eg nephrotic
syndrome, severe hyperkalaemia and
malignant hypertension) and a normal
eGFR should not prevent or delay
appropriate referral to a specialist.
eGFR 30—- 59 ml/min/1.73m2 ( Stage 3
CKD )
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Draft Guideline – 25 September 2008
If this is the first time an abnormal result
has been identified then it should be
repeated within the week to ensure this is
not acute renal failure which should be
urgently assessed and referred. The
majority of patients with this level of
kidney disease will have already been
recognised as having an associated risk
factor (most commonly diabetes,
hypertension or cardiovascular disease in
the older patient). The patient should be
reviewed with specific note of past
results, current medications, BP,
cardiovascular risk factors, family history
of renal disease and urinary symptoms.
Most patients will be asymptomatic and
have no specific complications of CKD
(Anaemia and Renal Bone Disease).
Management should include the
following:








Advice on smoking, weight, exercise,
salt and alcohol intake.

Cause of CKD not obvious

Progressive declining kidney function

Persisting abnormalities on urine
dipstick testing (Proteinuria and/or
Haematuria).

Suspected underlying systemic
disease (eg SLE or Vasculitis)

Anaemia, cause not identified on
standard investigation

Persisting abnormalities in Potassium,
Calcium or Phosphate.

Difficult or uncontrolled hypertension

Consider urological referral if
indicated by urinary symptoms,
ultrasound findings or haematuria.
eGFR < 30 ml/min/1.73m2 ( Stage 4+ 5
CKD )
This indicates advanced or severe
chronic kidney disease. The majority of
Check drug doses, avoid or stop
patients in this group will already be
nephrotoxic agents.
known to the renal service or are
Cardiovascular risk reduction with
receiving renal replacement therapy.
consideration of aspirin and statin
Patients who have not previously been
therapy
assessed by a nephrologist should be
Strict BP control target 130/80 in most urgently referred or discussed by
telephone. There will be some situations
and 125/75 in those with Proteinuria
where this is clearly inappropriate due to
ACEI or ARB is first line
the coexistence of other significant
antihypertensive therapy (check
pathology but again where there is doubt
bloods after introduction to ensure
telephone advice can be sought.
GFR does not fall > 15%)
Management is broadly similar to that
outlined in stage 3 CKD but there are
Request renal ultrasound in those
likely to be specific problems associated
with urinary symptoms
with Anaemia or Renal bone disease
Check Hb, Potassium, Calcium and
which warrant specialist advice.
Phosphate and monitor bloods 4 - 6
Discussing renal replacement therapy
monthly.
options (dialysis, transplantation or
conservative) should also be undertaken
Offer Influenza and Pneumococcal
at this time by the specialist renal
vaccination
multidisciplinary team
Stage 3 CKD Nephrology Referral
Guidelines
Around 5% of the population will have
stage 3 CKD and many will remain stable
and can be managed in primary care as
detailed above. Criteria for referral are
listed below:
Further referral advice available from
consultant staff
Nick.Fluck@arh.grampian.scot.nhs.uk
01224 553536
Izhar.Khan@arh.grampian.scot.nhs.uk 01224 552122
Carol.Brunton@nhs.net
01224 559502
C.G.Millar@arh.grampian.scot.nhs.uk
01224 559503
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Draft Guideline – 25 September 2008
D6.4 Management of Diabetic Renal Disease









Patients with diabetic renal disease require frequent and intensive
monitoring.
Microalbuminuria and proteinuria confirm diabetic renal disease and
aggressive management of blood pressure and other risk factors is
essential to preserve renal function.
These patients are also at high risk of retinopathy, autonomic
neuropathy and cardiovascular disease.
All patients with microalbuminuria or proteinuria should be commenced
on ACE inhibitor therapy. The dosage should be gradually increased
to the maximum tolerated dose. Those intolerant of ACE inhibitors
should be given Angiotensin II antagonists. Annual measurements of
creatinine and albumin/creatinine ratio (protein/creatinine ratio if
proteinuric) should be continued.
Lowering blood pressure in relatively hypertensive microalbuminuric
patients reduces albumin excretion and progression to nephropathy.
All agents which lower blood pressure reduce albumin excretion,
although ACE inhibitors and AIIAs probably have a class specific effect
independent of their hypotensive effect and are the drugs of choice for
initial therapy.
Blood pressure should be maintained <140/80 mm Hg in all patients
(SIGN 55). In Type 1 patients with microalbuminuria or proteinuria the
target blood pressure should be lower. The Aberdeen Renal Clinic
currently recommend <125/75.
Insulin or sulphonylurea requirements usually decrease with advancing
renal impairment. Metformin should be discontinued when serum
creatinine is > 150 µmol/l.
Patients with Type 1 diabetes and proteinuria may benefit from advice
from a Dietitian. A reduction of protein intake to 0.6-0.8 g/kg per day
may reduce progression of overt diabetic nephropathy.
Patients with diabetic renal disease have a high risk of cardiovascular
co-morbidity and should be managed aggressively.
D6.5 Referral for specialist renal advice




Consider referral to specialist renal services when creatinine >150
µmol/l (male), >130 µmol/l (female) or protein/creatinine ratio >300
mg/µmol , eGFR <30.
Referral should also be considered for features suggestive of nephrotic
syndrome or if persistent proteinuria is not thought to be explained by
diabetes (considering the duration of diabetes and absence of other
microvascular complications).
The presence of both blood and protein may also be indicative of an
alternative renal pathology and in cases where this is persistent i.e.
detected on more than 2 occasions a referral should be considered.
Isolated haematuria will require separate evaluation and is not a
feature of diabetic nephropathy.
Specialist renal assessment will include assessment for non- diabetic
renal conditions if necessary, assessment of GFR and estimation of
171
Draft Guideline – 25 September 2008
likely progression of renal disease. Patients with stable renal disease
will be discharged back to routine diabetes care (primary or secondary
care) with advice on a threshold for further referral.
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Draft Guideline – 25 September 2008
Web-sites listed in the Guidelines:
NHS Grampian
http://www.nhsgrampian.org
Main Grampian Diabetes Guidelines:
http://www.diabetes.nhsgrampian.org
Scotland’s Health on the Web (SHOW)
http://www.show.scot.nhs.uk/
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/
NHS Scotland information websites:
My Diabetes My Way
http://www.mydiabetesmyway.org.uk/
Diabetes Information +
www.diabetesinfoplus.co.uk
NICE Guidelines – Home Page
http://www.nice.org.uk
NICE guidance on treatment of Type 2 diabetes
http://www.nice.org.uk/Guidance/CG66
SCI-DC – home page
https://ctc6.tayside.scot.nhs.uk/scidc/
will only work from NHS computer or via intranet
DVLA website
www.dvla.gov.uk
Benefits advice:
www.direct.gov.uk
JobCentrePlus – help to gain or retain employment:
www.jobcentreplus.gov.uk
Alcohol:
“The management of harmful drinking and alcohol dependence in primary
care” (2003).
http://www.sign.ac.uk/guidelines/fulltext/74
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Draft Guideline – 25 September 2008
Obesity:
http://www.sign.ac.uk/guidelines/fulltext/69/index.html: SIGN 69:
Management of obesity in children and young people (2003)
http://www.nice.org.uk/cg043publicinfo2
NICE, the National Institute for Health and Clinical Excellence, has issued
new guidance to the health service about how to prevent obesity. This is a
summary of the evidence presented for the public.
http://www.nice.org.uk/cg043publicinfo
NICE, the National Institute for Health and Clinical Excellence, has issued
new guidance to the health service about how to treat and manage
overweight & obesity. This is a summary of the evidence presented for the
public.
Health Information Resource Service
***http://www.nhsghpcat.org for catalogue and orders
http://www.hi-netgrampian.org The Grampian Health Improvement
Network (HI-Net) provides a web based resource full of health improvement
information.
http://www.sign.ac.uk/guidelines/fulltext/69/index.html
http://www.nsc.nhs.uk
Criteria used by the NSC to judge whether to introduce a screening
programme
http://www.nsc.nhs.uk/pdfs/criteria.pdf
UK National Screening Committee: Summary of screening and intervention
for the main vascular risk factors including obesity and diabetes
http://www.screening.nhs.uk/vascular/VascularRiskAssessment.pdf
Healthpoint:
***http://www.healthpoint@nhs.net – email address
Genetic Types of Diabetes (including MODY)
http://www.diabetesgenes.org
Food Standards Agency
www.Food.gov.uk
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Draft Guideline – 25 September 2008
Nutrition and healthy eating advice:
http://www.takelifeon.co.uk
http://www.eatwell.gov.uk
www.runsweet.com – nutrition and physical activity
Physical activity opportunities and leisure facilities in your area:
http://www.AberdeenCity.gov.uk
http://www.Aberdeenshire.gov.uk
http://www.Moray.gov.uk
Click on heading ‘Sports and Leisure’
Quick Links – ‘Sport and Recreation’
Click on heading ‘Leisure’
Cardiac Rehab Programme
http://www.gcra.org.uk/
http://www.healthinfoplus.scot.nhs.uk for a one-stop shop to quality
assured health information for patients, carers and the public. Follow the links
to “Wellbeing”.
http://www.healthscotland.com/
Health Scotland provides information to support health improvement in
Scotland. It includes is information about food and nutrition and physical
activity.
http://nhs24.com provides comprehensive up-to-date health information and
self care advice for people in Scotland.
Diabetes UK
http://diabetes.org.uk
***Diabetes in Scotland
http://www.sign.ac.uk/guidelines/fulltext/69/index.html
leads to SIGN 69 – management of obesity in children & young people
Smoking Advice
A GP Decision Flow Chart and referral information:
http://cgi.grampian.scot.nhs.uk/
http://www.canstopsmoking.com/home.htm
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Draft Guideline – 25 September 2008
Travel
http://www.travax.scot.nhs.uk (for health professionals)
http://www.fitfortravel.scot.nhs.uk (for patients)
Evidence of value in improving HbA1c
Evidence Note – NHS Quality Improvement Scotland
http://www.nhshealthquality.org/nhsqis/files/ClinicalGovernance_EN26ClinicalAndCost
EffectivenessOfSMBG_JAN09.pdf
***Adult DKA protocol – takes to list and can choose DKA from this
http://intranet/ccc_nhsg/6179.909.html?pMenuID=460&pElementID=909
within intranet so wont get access from outside
Paediatric DKA protocol
http://www.bsped.org.uk
NICE guidance on treatment of Type 2 diabetes
http://www.nice.org.uk/Guidance/CG66
Blood Pressure:
British Hypertension Society
http://www.bhsoc.org/Latest_BHS_management_Guidelines.stm
Management specific to diabetes is contained in NICE clinical guideline 66 The management of Type 2 diabetes Section 1.8
http://www.nice.org.uk/Guidance/CG66
General guidance on cardiovascular risk reduction is covered in depth in JBS
2: Joint British Societies’ Guidelines On Prevention Of Cardiovascular
Disease In Clinical Practice
http://www.bcs.com/download/651/JBS2final.pdf
Management specific to diabetes is contained in NICE clinical guideline 66 The management of type 2 diabetes Section 1.9
http://www.nice.org.uk/Guidance/CG66
NHS Grampian statement on statins:
www.nhsgrampian.org/grampianfoi/files/Statin_statement_October2007.
pdf
176
Draft Guideline – 25 September 2008
Lipid Management specific to diabetes is contained in NICE clinical guideline
66 - The management of Type 2 diabetes Section 1.10
http://www.nice.org.uk/Guidance/CG66
Renal:
SIGN 103 Diagnosis and Management of CKD
http://www.sign.ac.uk/guidelines/fulltext/103/index.html
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Draft Guideline – 25 September 2008
List of Websites Within the Guidelines
Section A:
Genetic types of diabetes (including MODY):
http://www.diabetesgenes.org
The following websites provide useful sources of information about diet and
healthy eating:
http://www.eatwell.gov.uk provides lots of guidance about nutrition and
healthy eating as well as diet related health issues (obesity, diabetes).
For more detailed information on alcohol - see SIGN Guideline 74 “The
management of harmful drinking and alcohol dependence in primary care”
(2003).
http://www.sign.ac.uk/guidelines/fulltext/74
http://www.nhsgrampian.org provides details of local sources of advice and
contacts for further information about healthy active living. Follow the links to
“About NHS Grampian” then “health improvement” and then select
“healthy living”.
http://www.takelifeon.co.uk Provides a user friendly guide to healthy eating
and physical activity for all.
http://www.healthinfoplus.scot.nhs.uk for a one-stop shop to quality
assured health information for patients, carers and the public. Follow the links
to “Wellbeing”.
http://www.healthscotland.com Health Scotland provides information to
support health improvement in Scotland. It includes is information about food
and nutrition and physical activity.
http://nhs24.com provides comprehensive up-to-date health information and
self care advice for people in Scotland.
http://www.nice.org.uk/nicemedia/pdf/CG43publicinfo2.pdf NICE, the
National Institute for Health and Clinical Excellence, has issued new guidance
to the health service about how to prevent obesity. This is a summary of the
evidence presented for the public.
http://www.nice.org.uk/nicemedia/pdf/CG43publicinfo1.pdf NICE, the
National Institute for Health and Clinical Excellence, has issued new guidance
to the health service about how to treat and manage overweight & obesity.
This is a summary of the evidence presented for the public.
http://www.nice.org.uk/nicemedia/pdf/CG43publicinfo1.pdf NICE, the
National Institute for Health and Clinical Excellence, has issued new guidance
to the health service about how to treat and manage overweight & obesity.
178
Draft Guideline – 25 September 2008
This is a summary of the evidence presented for the public.
http://www.sign.ac.uk/pdf/sign69.pdf: Management of obesity in children
and young people (published April 2003) Includes guidance on the prevention
and treatment of obesity in children and young adults.
(SIGN 8 covered obesity in adults but was published in 1996 and is out of
date particularly in relation to treatments for obesity)
HTTP://WWW.NICE.ORG.UK/cg43: For the full NICE guideline number 43:
Obesity. It includes guidance on prevention of obesity, lifestyle advice and
interventions for the treatment of overweight and obesity, and medical or
surgical interventions.
Health Information Resource Service can provide free information leaflets
Catalogue available at: http://www.nhsghpcat.org
http://www.hi-negrampian.org: The Grampian Health Improvement
Network (HI-Net) provides a web based resource full of health improvement
information.
Details of physical activity opportunities and leisure facilities in your area can
be found on the local authority websites:
http:///www.AberdeenCity.gov.uk
http://www.Aberdeenshire.gov.uk
http://www.Moray.gov.uk
Click on heading ‘Sports and
Leisure’
Quick Links – ‘Sport and
Recreation’
click on heading ‘Leisure’
(contact details of local Active School Co-ordinators can also be found on
these sites)
http://www.nhsgrampian.org provides details of local sources of advice and
contacts for further information about healthy active living. Follow the links to
“About NHS Grampian” then “health improvement” and then select
“healthy living”.
More information about the UK National Screening Committee can be
obtained at: http://www.nsc.nhs.uk
More information about the criteria used by the National Screening Committee
to judge whether to introduce a screening programme can be found here:
http://www.nsc.nhs.uk/pdfs/criteria.pdf
“Handbook for Vascular Risk Assessment, Risk reduction and Risk
Management”
http://www.screening.nhs.uk/vascular/VascularRiskAssessment.pdf
SIGN guideline 69
179
Draft Guideline – 25 September 2008
http://www.sign.ac.uk/pdf/sign69.pdf
Section B
Forthcoming courses and events are advertised on the Grampian Diabetes
website www.diabetes.nhsgrampian.org
Advice on diabetes education for professionals and patients also appears on
the Diabetes in Scotland website: www.diabetesinscotland.org.uk
Diabetes UK website: www.diabetes.org.uk
NHS Scotland My Diabetes My Way
www.mydiabetesmyway.scot.nhs.uk
Quality Assured Information
www.diabetesinfoplus.co.uk
Diabetes Stories website (www.diabetes-stories.com)
DVLA website: www.dvla.gov.uk
Nutritional advice, particularly for those engaging in more vigorous physical
activity: www.runsweet.com
Exercise Classes
Information sheets and referral forms can be found on the MCN website
www.diabetes.nhsgrampian.org
Cardiac Rehab Programme:
http://www.gcra.org.uk/
Smoking Advice Service:
http://www.nhsgrampian.org
Professionals wishing to find out more about the SAS may wish to log onto
our section on Hi-net at http://www.hi-netgrampian.org
A GP Decision Flow Chart and referral information is available at:
http://cgi.grampian.scot.nhs.uk/
The Health Scotland “Can Stop Smoking” website offers advice and e-mail
and text message support. It can be accessed at
http://www.canstopsmoking.com/home.htm
Additional information can be found on the following websites:
http://www.travax.scot.nhs.uk (for health professionals)
http://fitfortravel.scot.nhs.uk (for patients)
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Draft Guideline – 25 September 2008
SCI-DC Network – Access to registered users within NHS computer networks
https://ctc6.tayside.scot.nhs.uk/scidc/
Grampian Diabetes Centre – this website provides a range of information
about services in NHS Grampian and contains lots of useful information for
both patients and those involved in patient care.
http://www.diabetes.nhsgrampian.org
My Diabetes My Way – this website is designed to help support people who
have diabetes as well as their family and friends and provides a host of
resources with regards to all aspects of diabetes.
http://www.mydiabetesmyway.org.uk/
Diabetes UK – this website provides information guides for people with
diabetes as well as extensive information about research into diabetes and
fundraising activities. The website also provides local and national
information and information about professional conferences and diabetes
campaigns.
http://diabetes.org.uk
Active Scotland – this website allows you to enter your postcode and see
what activities are available in your local area, from the easy to the extreme,
to help people lead a more active lifestyle.
http://www.activescotland.org.uk/
Patient information websites
The national website http://www.mydiabetesmyway.scot.nhs.uk
Other locally produced leaflets on are available on the MCN website
http://www.diabetes.nhsgrampian.org/
Local guidelines for the management of children with diabetes can be
accessed via the Grampian diabetes website at:
..\..\..\..\Website\MANGEMENT OF DIABETIC CHILDREN IN
RACHvmar06_final[1].doc
Further information about the service and the children’s team can also be
obtained from:
http://www.diabetes-scotland.org/grampian/home.html
Section C:
Educational leaflets for patients, lab staff and clinical staff are available at
www.Diabetesinscotland.org.uk.
181
Draft Guideline – 25 September 2008
Conversion of HbA1c % to mmol/mol
Information for patients
http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/53130%20H
bA1c%20PWD%20leaflet.pdf
Information for healthcare professionals
http://www.diabetes.org.uk/upload/Professionals/Key%20leaflets/53130%20H
bA1c%20HCP%20leaflet.pdf
The evidence of value in improving HbA1c patients is limited
http://nhshealthquality.org/evidencenote
NICE Treatment protocol for the management of Type 2 diabetes
http://www.nice.org.uk/CG66/NiceGuidance/pdf/English
Additional nutritional advice, particularly for those engaging in more vigorous
physical activity is available on the following website:
http://www.runsweet.com
Adult DKA protocol
http://intranet/ccc_nhsg/6179.909.html?pMenuID=460&pElementID=909
Paediatric DKA protocol
http://www.bsped.org.uk
Section D:
The ‘standard’ guidance of blood pressure management as described by the
British Hypertension Society applies to all patients.
http://www.bhsoc.org/Latest_BHS_management_Guidelines.stm
Management specific to diabetes is contained in NICE clinical guideline 66 The management of Type 2 diabetes Section 1.8
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
General guidance on cardiovascular risk reduction is covered in depth in JBS
2: Joint British Societies’ Guidelines On Prevention Of Cardiovascular
Disease In Clinical Practice (Prepared by: British Cardiac Society, Diabetes
UK, British Hypertension Society, HEART UK, Primary Care Cardiovascular
Society, The Stroke Association)
http://www.bcs.com/download/651/JBS2final.pdf
Management specific to diabetes is contained in NICE clinical guideline 66 The management of Type 2 diabetes Section 1.9
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
Grampian formulary for most recent advice on lipid lowering therapy
www.nhsgrampian.org/grampianfoi/files/Statin_statement_October2007.
pdf
182
Draft Guideline – 25 September 2008
Joint statement on the use of lipid regulating drugs in Grampian - March
2009
http://www.nhsgrampian.org/nhsgrampian/GJF_general.jsp?pContentID=4756
&p_applic=CCC&p_service=Content.show#m.nh
Lipid Management specific to diabetes is contained in NICE clinical
guideline 66 - The management of Type 2 diabetes Section 1.10
http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuidance.pdf
Contact details for Podiatry Department for foot screening training:
www.diabetes.nhsgrampian.org
SIGN 103 Diagnosis and Management of CKD
http://www.sign.ac.uk/pdf/sign103.pdf
For further Information and a guide to the management of CKD see
www.renal.org/CKDguide/ckd.html.
An eGFR guide is also available at http://www.renal.org/eGFR/.
183