Diabetes Protocol for General Practice
It is recognised that the level of knowledge and skills to manage people who require complex
diabetes care varies from practice to practice. This protocol is aimed at supporting practices
to ensure that patients receive the most appropriate care by the most appropriate person. If
your practice has a high level of knowledge and skill in managing patients with more
complex needs such as co-morbidities, injectable or new therapies, the practice should
continue to utilise their expertise and manage their patients at GP practice level.
Diabetes Protocol for General Practice
Issue; 1
Fife Diabetes MCN
1
December 2012
Review; December 2014
Contents
1. Aims
3
2. Screening for Diabetes
3
3. Diagnosis of Diabetes Mellitus
4
4. Impaired Glucose Tolerance
5
5. Impaired Fasting Glycaemia
5
6. Newly Diagnosed Diabetes
6
7. Initial Consultation
7
8. Annual Review
7
9. Routine Review
8
10. Targets;

HbA1c
9

BP
9

Cholesterol
10

Aspirin
11
11. Complex Patient Referral Criteria
12
12. Useful Contacts
13
13. Appendices;

Appendix 1
Diagnosing Diabetes
14

Appendix 2
The Oral Glucose Tolerance Test
15

Appendix 3
Algorithm for glucose-lowering in Type 2 Diabetes
16

Appendix 4
Referral Form
for Community Diabetes Specialist Nurse Services
17
Appendix 5
18

Key components for Diabetes Services Pathway
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Review; December 2014
Diabetes Protocol for General Practice
Aim
The aim of this diabetes protocol is to support the care of people with diabetes in primary
care by:

Promoting the early detection of diabetes

Recognising patients as partners in their care and ensure they are empowered to self
manage their condition

Appropriately monitoring the health of patients with diabetes to reduce the risk of
complications

Supporting patients to make healthy lifestyle choices to help maximise their quality of
life

Providing patients with access to evidence-based clinical services
Screening for Diabetes
Blanket screening of large populations has not yielded the hoped-for good results. It is much
more cost and time effective to perform targeted screening of at risk groups as follows:
1. Patients should be offered a fasting blood glucose test as a screening test for
diabetes, when presenting with thirst, polyuria, unexplained weight loss, nocturia,
incontinence, recurrent infections including thrush, neuropathic symptoms, changes in
visual acuity or unexplained tiredness.
2. All patients with established hypertension, obesity (BMI >30), CHD, PVD, CVD,
Polycystic Ovary Syndrome (PCOS), or a family history of diabetes should have a
fasting blood glucose test at least once every 3 years. Patients of Asian and AfroCaribbean descent over 40 should be offered a 3 yearly test.
3. Patients with a personal history of Gestational Diabetes, Impaired Fasting Glycaemia
or Impaired Glucose Tolerance should have an annual fasting blood glucose test.
Diabetes Protocol for General Practice
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Diagnosis of Diabetes Mellitus
Diabetes is diagnosed on the basis of history (i.e. polyuria, polydipsia and unexplained
weight loss) PLUS



a random venous plasma glucose concentration ≥ 11.1 mmol/l
OR a fasting plasma glucose concentration ≥ 7.0 mmol/l
OR 2 hour plasma glucose concentration ≥ 11.1 mmol/l 2 hours after 75g anhydrous
glucose in an oral glucose tolerance test (OGTT see appendix 2)
With no symptoms diagnosis should not be based on a single glucose determination
but requires confirmatory plasma venous determination.
 One additional glucose test result at least 4 weeks apart with a value in the diabetic
range is essential, either fasting, from a random sample or from the two hour post
glucose load (see appendix 1 and 2). If the fasting or random values are not
diagnostic the 2-hour value should be used.
It should be noted that people including children with Type 1 diabetes usually present
with severe symptoms and diagnosis should then be based on a single raised blood
glucose result, as above. Immediate referral to the Secondary Care Diabetes Team
should not be delayed.
A diagnosis should never be made on the basis of glycosuria or capillary finger prick blood
glucose alone, although such tests may be useful for screening purposes. HbA1c
measurement is also not currently recommended for the diagnosis of diabetes within NHS
Fife.
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Pre-diabetes Conditions – Impaired Fasting Glycaemia and Impaired Glucose
Tolerance
Impaired Glucose Tolerance (IGT)
IGT is a state of impaired glucose regulation, diagnosed by the Oral Glucose Tolerance Test,
which confers an increased risk of future diabetes of 2-5% per year. Patients with IGT tend
to have higher blood pressure and plasma triglycerides when compared to non-diabetic
individuals.
Impaired Fasting Glycaemia (IFG)
The term IFG has been introduced to classify individuals with fasting glucose values above
the normal range but below those diagnostic of diabetes. Diabetes UK recommends that all
such individuals should have an oral glucose tolerance test to exclude a diagnosis of
diabetes in the presence of other risk factors, e.g. central obesity.
Such individuals have an increased risk of developing diabetes and should be offered
lifestyle advice.
Fasting Blood Glucose between 6 – 6.9mmols
Proceed to Oral Glucose Tolerance Test (see appendix 2)
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Newly Diagnosed Diabetes
For guidance on the appropriate Diabetes Service Pathway for patients with Diabetes
please see appendix 5.
Any young person (<20years) and adults with suspected diabetes (acute presentation of
hyperglycaemia +/- presence of ketonuria) should be referred urgently to Secondary Care.
This includes any young person suspected of having type 2 diabetes.
Women with suspected Gestational diabetes and women who are wishing to become
pregnant should also be referred to secondary care.
A small group of patients may have ‘other types’ of diabetes e.g. acquired or secondary to
pancreatitis, drug induced etc. and may need referral to secondary care or the community
diabetes specialist nurse
The majority (85-95%) of people with Diabetes have Type 2 diabetes and can be managed
within primary care as follows and do not require referral to secondary care (see appendix
5).
Patients should be appropriately assigned a ‘read code’ with a HIGH priority with the correct
date of diagnosis. This will populate the patient within SCI-Diabetes where their diagnosis
will be checked by a Fife external Validator*. The patient will also be enrolled in the
Diabetes Retinopathy Programme. The patient should be assigned an appropriate practice
recall for 3-6months following diagnosis to ensure all appropriate care is completed for the
patient.
SCI-Diabetes READ Codes
READ_CODE
Description
C10E.
Type 1 diabetes mellitus
C10F.
Type 2 diabetes mellitus
C10N.
Secondary diabetes mellitus
L1809
Gestational diabetes mellitus
R10D0
[D]Impaired fasting glycaemia
R10E.
[D]Impaired glucose tolerance
(*It is helpful if as much information as possible is recorded on blood forms as all patients
diagnosed with diabetes are subject to external validation of their diagnosis. Additional
information e.g. whether the blood sample is fasting, symptomatic, thirst, previous raised
glucose etc. helps validators’ understand how a diagnosis is reached)
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Initial Consultation
This may need to be delivered over one or more appointments. Each patient will receive the
following at their initial consultation including all the elements of the annual review which are
listed below:







Initial counselling and information on their diabetes diagnosis taking into consideration
patients concerns, feelings, existing knowledge and health beliefs.
Provision of initial educational booklets e.g. from Diabetes UK
Referral for Patient Education Classes. This should be encouraged as an essential
part of their diabetes care (see appendix 4 referral form and appendix 5).
Referral to community podiatry.
Referral to practice dietitian via SCI-Gateway and appointment in practice if available.
Arrange pneumococcal vaccination and influenza vaccination
Annual review as per below
Annual Review
Each patient will receive

An annual holistic review encompassing all aspects of diabetes care with the Practice
Nurse or GP with a specialist interest in diabetes (preferably with additional training in
Diabetes e.g. Warwick or Bradford diploma in diabetes).

A mutually agreed action plan for their diabetes care and a hand held patient held
record (either printed from SCI-Diabetes or practice’s own). Patients should be given
information on Diabetes UK and My Diabetes My Way where they can access their
own diabetes record on line.
At the annual review patients to have:












Height
Weight
BMI
BP
Smoking status discussed and advice given if smoking and where agreement referral
made to the smoking cessation service
Urinalysis / Albumin: creatinine ratio* (see advice below)
U&Es, LFTs, lipids, and HbA1c consider TFT and FBC on diagnosis and every two
years thereafter.
Discussion of exercise and diet, and alcohol intake; refer to dietitian up to date
tailored advice if required (see referral guideline – Appendix 6)
Medication concordance
Screening for depression
Checking of foot screening (refer to podiatrist if not screened in last 15 months)
Checking of eye screening and correct coding has been recorded
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




Targeted education about diabetes care and management
Consideration of whether blood glucose monitoring is appropriate for this patient and
enquire about hypoglycaemia if patient on a sulphonylurea or insulin. Also discuss
driving implications if relevant.
Enquire about symptoms of complications:
- angina, SOB, claudication, TIAs
- neuropathy, erectile dysfunction
Discussion of contraception or pre-conceptual counselling as appropriate.
Initiation or titration of medications if patient out with agreed targets or refer to GP as
appropriate
If the patient is on insulin they should also receive advice on:








Hypoglycaemia
Hyperglycaemia/sick day rules
Appropriate home blood glucose monitoring and meter care
Injection technique/rotation of sites (lipohypertrophy) /timing/re-suspension
Travel letter
Personal Identification
Driving/DVLA/insurance
Insulin dose adjusting or intensification where necessary (see the Insulin Guidance for
Type 2 Diabetes) or refer to Community Diabetes Specialist Nurse for advice (see
appendix 4 and 5).
Blood tests (U&Es, fasting lipids, LFTs and HbA1c) should all be taken at least a week prior
to the clinic for annual reviews wherever possible. NB if a patient is at increased risk of
hypoglycaemia e.g. on a sulphonylurea or insulin they must NOT fast for their blood tests.
Routine review
Patients should receive an ‘interim review’ every 3 to 6 months to review their diabetes
control and any other concern or failure to reach agreed targets. Patients who have had
medication changes should be reviewed at 3 months and if stable, an HbA1c should be done
every 6 months. This appointment will usually be shorter and include in most cases:







HBA1c (U&E, LFT and Lipids where appropriate)
BP
Weight
Repeat urine albumin/ACR (if previous raised*)
Lifestyle issues
Concerns, advice, revisit goals and self-management and update of patient held
record
Initiate medication changes or refer to GP as appropriate
* ACR should be measured in a first-pass morning urine specimen once a year. ACR may be measured on a
spot sample if a first-pass sample is not provided (but should be repeated on a first-pass specimen if
abnormal). Microalbuminuria is confirmed if, in the absence of infection or overt proteinuria, two out of three
specimens have an elevated ACR. (See treatment recommendations under BP Target)
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Targets
These will be individualised to the patient in order to balance benefits against side effects
and risk and are based on recent evidence base.
HbA1c

SIGN HbA1c target of 53 mmol/mol among people with type 2 diabetes is reasonable
to reduce risk of microvascular and macrovascular disease.

A target of 48 mmol/mol may be appropriate at diagnosis

QOF target <59mmol/mol

Targets should be set for individuals in order to balance benefits against side effects
and risk, in particular hypoglycaemia and weight gain. For some vulnerable groups
e.g. elderly a higher target may be appropriate.
 If patients HbA1c is above their individual target at their review appointment they
should have lifestyle issues addressed and medication initiated or titrated as
appropriate (see NHS Fife formulary; NHS Fife Diabetes Handbook; NHS Fife
adapted SIGN Glucose lowering algorithm in Type 2 diabetes – Appendix 3, Dietetic
Referral Guidelines – Appendix 6)
 If patients on maximum tolerated oral therapy and HBA1c above target consider
referral to the Community Diabetes Specialist Nurse (see appendix 4 and 5) for
initiation of injectables or insulin, unless practice staff trained in initiation of these
drugs. Please refer to the NHS Fife Insulin Strategy, Insulin Guidance for Type 2
Diabetes, Dietetic Referral Guidelines – Appendix 6, NHS Fife Exenatide and
Liraglutide primary care protocols and CDSN referral criteria below.
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BP

SIGN BP <130/80

QOF BP target <140/80

In people with diabetes and established kidney disease, blood pressure should be
reduced to the lowest achievable level to slow the glomerular filtration rate and reduce
proteinuria.

Patients with diabetes requiring antihypertensive treatment should be provided with
lifestyle advice and commenced on
 An ACE Inhibitor (ARB if ACE Inhibitor intolerant), or a calcium channel
blocker, or a thiazide diuretic.
 Beta blockers and alpha blockers should not normally be used in the initial
management of blood pressure in patients with diabetes.
 For specific hypertension management guidance see British Hypertension
Guidance and NHS Fife Formulary. The expectation should be that most
patients end up on more than one agent.
 People with type 2 diabetes and microalbuminuria should be treated with an
ACE inhibitor or an ARB and titrated to maximum tolerated dose irrespective of
blood pressure.
 ACE inhibitors and/or ARBs should be used as agents of choice in patients
with chronic kidney disease and proteinuria (≥0.5 g/day, approximately
equivalent to a protein/creatinine ratio of 50 mg/mmol) to reduce the rate of
progression of chronic kidney disease.
Cholesterol/ lipids

Total Cholesterol <4mmols/l (QOF <5mmols/l) for patients with diabetes

Triglyceride <1.7mmol/l

LDL <2mmol/l

HDL >1mmol/l (men) and >1.2mmol/l (women)
 Lipid-lowering drug therapy with simvastatin 40 mg is recommended for primary
prevention in patients with type 2 diabetes aged >40 years regardless of baseline
cholesterol.
 If Total Cholesterol remains >4mmols on Simvastatin 40mg change to Atorvastatin
40mgs and titrate up if necessary to 80mgs.
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 If target is not met by the above, there is little outcome evidence to suggest that the
addition of fibrates, bile acid sequestrants or nicotinic acid improve cardiovascular
morbidity or mortality.
 If patient <40years with a CVD risk score of >20% using ASSIGN risk calculator
initiate Simvastatin 40mg.
 Please refer to the NHS Fife Heart Disease MCN Management of Cholesterol
Guidelines for Stable Disease.
 If patients have co-morbidity of established vascular disease, targets and guidance
will differ. Please refer to the NHS Fife Heart Disease MCN Management of
Cholesterol Guidelines Intensive Treatment.
Aspirin

Low dose Aspirin is not recommended for the primary prevention on vascular
disease for patients with diabetes

Low dose aspirin is recommended for patients with diabetes and established
vascular disease
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Community Diabetes Specialist Nurse (CDSN) Complex Patient
Referral Criteria (Option 1: Appendix 4)
Refer to Secondary Care_____________________________________________
1. ALL URGENT referrals should be referred to secondary care using the standard
secondary care referral form.
2. Symptomatic patients with a blood glucose of greater than 18 that the practice feels
should be seen within 2 weeks should be treated as an urgent referral as above.
3. Patients may be referred on to secondary care at the CDSN’s discretion
 Urgent referrals will be seen within 2 weeks, these patients may be triaged back to the
CDSNs for their management as appropriate.
Refer to Community Diabetes Specialist Nurse_____________________________
4. HbA1c >7.5% (59mmol/mol) on 2 occasions in the previous 6 months and on
maximum tolerated therapy
5. Any patient newly admitted to a care home, who is on insulin
6. Patient with diabetes, with hyperglycaemia and unexplained weight loss
7. Palliative patients on insulin (changing needs)
8. Any patient on insulin who needs reviewed (hypoglycaemic/hyperglycaemia)
9. Steroid induced hyperglycaemia
 The Community Diabetes Specialist Nurse Service will see all ROUTINE referrals
within 12 weeks however will endeavour to see within 8 weeks from receipt or referral.
 Patients will be discharged back to GP care once they are stabilised and have
achieved their individual glycaemic target.
 Patients will be provided with a management plan and the CDSN contact details for
future advice if necessary.
 GP surgeries can re-refer any patient if they have future concerns about a patient’s
glycaemic control.
 CDSNs may discharge a patient to secondary care when clinically appropriate
 For patient Diabetes Service Pathway see appendix 5
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USEFUL CONTACT NUMBERS
Community Diabetes Specialist Nurse
Dunfermline &West Fife CHP
01383 623623 x 35882/35127
Kirkcaldy &Levenmouth CHP
01592 892004 / 07774977393
Glenrothes &North East CHP
01337 832114 / 07766558868
Dietitians
Dunfermline &West Fife CHP
01383 565348
Kirkcaldy &Levenmouth CHP
01592 643355 ext 22055
Glenrothes &North East CHP
01592 643355 ext 22053
Podiatrists
Dunfermline & West Fife Area
01383 722911
Kirkcaldy & Levenmouth Area
01592 645218
Glenrothes & North East Fife Area
01334 465780
Urgent Podiatry:
01592 643366 ext. 28360 or 28882
Diabetic Retinopathy Screening Program
01592 226852
Hospital Diabetes Specialist Nurses
Queen Margaret Hospital
01383 623623 DSNs: extension 3728
Victoria Hospital Diabetes Centre
01592 648001
Ninewells Hospital Diabetes Centre
01382 632293
Perth Royal Infirmary
01738 473211
Falkirk Royal Infirmary
01324 624000
Other Additional Numbers
NHS Fife Stop Smoking Service;
0800 0253000
SCI-DC
01592 226844
My Diabetes My Way; www.mydiabetesmyway.scot.nhs.uk
Diabetes UK; www.diabetes.org.uk
Diabetes UK Local Support Group; www.diabetes-fife.org.uk
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Appendix 1: Diagnosing Diabetes
Random Blood Glucose ≥7.8mmol/l
Repeat as a fasting sample
Symptoms of hyperglycaemia
Present
Single measurement of blood glucose
Random glucose ≥ 11.1 mmol/l
Or
Absent
Perform on 2 separate occasions at
least 4 weeks apart
Fasting blood Glucose ≥7.0 mmol/l on
both occasions
Fasting Glucose ≥ 7.0 mmol/l
PATIENT HAS DIABETES MELLITUS
PATIENT HAS DIABETES MELLITUS
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Appendix 2: The Oral Glucose Tolerance Test (OGTT)
An OGTT may be considered to establish a diagnosis of diabetes if fasting blood glucose
values fall into an equivocal range (e.g. FPG between 6 and 6.9 mmol/L) but clinical
suspicion of diabetes remains. A single dose of 75g oral glucose in water is given in the
following way:

Perform OGTT after at least 3 days of unrestricted diet (> 150g CHO daily)

Fast patient overnight (8-14 hours, water allowed before the test) and rest during the
test.

Samples at times other than 0 and 2 hours are not necessary for diagnosis.

Diagnostic interpretation of OGTT is different in pregnancy (see pregnancy section)
OGTT RESULTS
Fasting plasma
glucose
< 6.0 mmol/l 6.1–6.9 mmol/l
and
2 hour plasma
glucose
Management
Normal
No follow
up
 7.0 or
and
7.8–11.0 mmol/l  11.1
< 7.8 mmol/l < 7.8 mmol/l
Diagnosis
< 7.0 mmol/l
IFG
IGT
Annual fasting plasma glucose
and CVD risk assessment
DIABETES
Diabetes
Management
Diabetes UK and the ADA recommend annual fasting blood glucose measurements in those
with IFG/IGT along with life style advice
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Appendix 3: Algorithm for glucose-lowering in Type 2 Diabetes (Adapted from SIGN 116)
1st LINE OPTIONS in addition to lifestyle measures; START ONE OF;
Biguanide (Metformin
if intolerant consider
MFMR)
The SHADED boxes show the preferred treatment
options; however clinical assessment should always
guide treatment choices taking into consideration the
implications of weight gain and risk of hypoglycaemia.
Sulphonylurea (SU);
 If intolerant of metformin or
 If weight loss/osmotic symptoms
If patient’s target HbA1c not achieved
2nd LINE OPTIONS in addition to lifestyle measures, adherence to medication and dose optimisation; ADD ONE OF
Thiazolidinedione (Glitizone)
 If hypos a concern (e.g. driving, occupation, at risk of falls) and
 If no congestive heart failure
 If patient overweight and likely to be insulin resistant, use of glitazone preferred
Sulphonylurea (SU)
 If weight
loss/osmotic
symptoms
DPP-IV inhibitor (Gliptin)
 If hypos a concern (e.g. driving,
occupational hazards, at risk of falls)
 If weight gain a concern
If patient’s target HbA1c not achieved
3rd LINE OPTIONS in addition to lifestyle measures, adherence to medication and dose optimisation; ADD OR SUBSTITUTE WITH ONE OF
Sulphonylurea
(SU);
 If weight
loss/osmotic
symptoms
ORAL (continue MF/SU if tolerated)
INJECTABLE (if willing to self inject; continue MF/SU if tolerated
Thiazolidinedione
(Glitizone)
 If no congestive
heart failure
 If hypos a concern
(e.g. driving,
occupation, at risk
of falls)
Insulin (inject before bed)
 If osmotic symptoms/rising HbA1c; add
intermediate acting (NPH) insulin initially
 If hypo risk a concern or patient under district
nurse care, consider using basal analogue
insulin as an alternative
 Add prandial insulin with time if required
 Pre-mixed insulins
DPP-IV inhibitor (Gliptin)


If hypos a concern
(e.g. driving,
occupational hazards,
at risk of falls)
If weight gain a
concern
GLP-1 agonists
 If BMI >
30kg/m²
 If a desire to
loose weight
 Usually < 10
years from
diagnosis
All medication changes should be reviewed after 6 months; if not effective, stop and consider alternative therapies.
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Appendix 4: Referral to Community Diabetes Specialist Nurse Service
Name:
Date of Birth/CHI:
Address:
GP:
Telephone:
Mobile:
Telephone:
Date of Diagnosis:
Type 1
Type 2
Height:
BMI:
HbA1c (date):
Weight:
Name of person making referral:
Type of Referral:
New:
BP:
Telephone:
Re-referral:
Urgent:
Routine:
Reason For Referral:
Option 1
(please tick)
Option 2
(please tick)
Option 3
(please tick)
Complex Patient / Glycaemic
Control Review
Group Education for Patients
Newly Diagnosed with Type 2
Diabetes (conversation maps)
Ongoing Group Education for
Type 2 Diabetes Patients
Can attend Locality Clinic:
Would like to attend:
Basic Education (option 2):
Housebound requires
Home visit:
Would attend if held in
The evening:
X-PERT Education:
Joint Clinic with GP Staff:
A Patient summary including all
Medications and PMH must be
attached for Patients referred for
Option 1.
Other Relevant Information:
Unable to attend:
Reason;
Insulin Group Education:
Please send referral form to the appropriate Diabetes Specialist Nurse:
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Appendix 5; Key components for Diabetes Services Pathway
All type 1 Diabetes,
except those;
 Housebound
 or in care homes
New type 2
Diabetes
Housebound or
in Care Homes
Primary Care
Management
Urgent referral
for Type 2
Complex
Gestational
or planning
pregnancy
Patient
Education:
Conversation
Maps
(Option 2)
CDSN
Intermediate
Specialist
Service
(Option 1)
If poor control and/or
complex needs.
Insulin/GLP Initiation
Ongoing Structured
Patient Education
(Option 3)
If further
complexities
Secondary Care
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Appendix 6 Dietetic Referrals for Adults
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