DIABETES SURGICAL
BOLT-ON
Presented by:
Phil Mannall
Inpatient DSN
DIABETES SURGICAL
BOLT-ON
AGENDA
SUBJECTS TO DISCUSS:
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T1 & T2 DM
DIABETES & NUTRICIAN
THERAPEUTIC BL. GL. LEVELS
HbA1c
HYPOGLYCAEMIA
DIABETES ORAL MEDS &
INSULIN
SAFE ADMINISTRATION OF
INSULIN
SLIDING SCALES
What Is Diabetes?
• Diabetes mellitus is a disorder in which the blood
sugar level is persistently raised above the
normal range.
• Normal blood glucose range:
» 4 – 7 mmol/l
• The abnormality is caused by an absolute or
relative lack of insulin, secreted from the
pancreatic β-cells.
Diabetes mellitus = ‘flowing over with sweet urine’
• Diabetes (Greek) means ‘siphon’ or ‘fountain’
• Mellitus (Latin) means ‘sweet like honey’
• The most obvious sign of diabetes is passing a
lot of urine. Early physicians in Egypt and India
tasted the urine and noted it was very sweet
(1500 BC and 400 BC).
• In many languages, like Finnish and German,
the condition is actually called ‘sugar disease’
How Is Diabetes Diagnosed?
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The person may experience some or none of the
following symptoms:
Frequent urination, even at night (polyuria)
Excessive thirst (polydipsia)
Tiredness and weakness (fatigue)
Constant hunger (polyphagia)
Blurred vision
Weight loss
Dry, itchy skin (pruritis), boils
Genital irritation/thrush/urinary infections
DIABETES SURGICAL
BOLT-ON
Diagnostic Criteria for Diabetes
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Patient showing symptoms of diabetes:
Random venous plasma glucose ≥ 11.1 mmol/l OR
Fasting venous plasma glucose
≥ 7.0 mmol/l
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Asymptomatic patient:
Two samples, either random or fasting, taken on different days, are
needed to confirm diagnosis
These blood values refer to blood taken from a vein and tested in the
laboratory. Capillary blood values by a finger prick test on the ward are
about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose
diabetes.
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(WHO Diagnosis and Classification of Diabetes Mellitus 1999)
Diagnostic Criteria for Diabetes
Patient showing symptoms of diabetes:
Random venous plasma glucose ≥ 11.1 mmol/l OR
Fasting venous plasma glucose
≥ 7.0 mmol/l
Asymptomatic patient:
Two samples, either random or fasting, taken on different days, are needed
to confirm diagnosis
These blood values refer to blood taken from a vein and tested in the
laboratory. Capillary blood values by a finger prick test on the ward are
about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose
diabetes.
(WHO Diagnosis and Classification of Diabetes Mellitus 1999)
What Is Type 1 Diabetes?
• Type 1 Diabetes happens when the β-cells in the
pancreas are destroyed by the body’s own
immune system. They stop making insulin and
blood glucose levels rise.
• Type 1 Diabetes usually comes on suddenly,
within a few months or weeks. The person is
typically young (<30 years) and thin.
• The missing insulin must be given every day for
lifetime in order to survive.
DIABETES SURGICAL
BOLT-ON
What Is Type 2 Diabetes?
•Type 2 Diabetes happens when the pancreas is
not making enough insulin, or the body is not able
to use insulin properly (insulin resistance).
•Type 2 Diabetes appears most often in middleaged and older adults. Often not diagnosed until
10-15 years after the onset.
•These people should aim to lose weight, be more
active.
•They may require tablets, and because Diabetes
is a slow onset disorder may require insulin in the
future.
DIABETES SURGICAL
BOLT-ON
What Causes Diabetes?
TYPE 1:
Inherited genetic susceptibility: HLA genes which initiate the
immune attack against β-cells
Environmental factors: viruses, early use of cow’s milk in
infancy, toxins in smoked fish/potatoes, low exposure to sunlight and
low Vitamin D level
Autoimmune response: pancreatic cells destroyed by own
lymphocytes (circulating islet cell antibodies, insulin antibodies, and
GAD antibodies)
Highest incidence in Finland, rare in Africa
DIABETES SURGICAL
BOLT-ON
What Causes Diabetes?
• TYPE 2:
Genetic factors: possibly several genes, leading to
inherited apple-shape body with abdominal (visceral)
fat layer; genes in certain ethnic groups (South-East
Asians, Afro-Caribbeans, American Indians,
Mexicans)
Environmental factors: small birth weight, rapid
weight gain in babyhood, sedentary lifestyle, large
calorie intake, obesity
Highest incidence in India, Hispanic people in USA, and
Black Americans
How Is Diabetes Treated?
• Type 1: need insulin for life; some doctors also
prescribe Metformin tablets, especially to people who
have raised fasting glucose levels, or who need large
amounts of insulin.
• Type 2: all patients benefit from dietary advice and
increase in physical activity; need to start on oral tablet
(OHA) or a combination of two/three, if glucose levels
still high; most Type 2 patients need insulin, if they live
long enough.
Eating, Drinking and Diabetes(1)
• There are no ‘forbidden’ foods for diabetics
• There is no ‘diabetic diet’! No ‘diabetic yoghurts, icecream, marmalade, or jam’!
• People with diabetes follow same healthy eating
principles as everyone should do:
 Avoid sugary puddings, cakes, biscuits
 Reduce saturated/animal fats – trim off fat, use low-fat
alternatives, avoid pastries and pies
 Avoid sweetened drinks and fruit juices – use ‘No added
sugar’ drinks or diet drinks
 Do not add salt in cooking, use herbs and spices
 Do not buy ‘diabetic foods’ – sorbitol is high in calories – they
are expensive, cause diarrhoea, taste foul
Eating, Drinking and Diabetes (2)
• Brown bread or wholemeal bread is no better than
white bread – whole-grain bread is preferable
• Eat at least 5 portions of fresh fruit and vegetables a
day (frozen or tinned are OK)
• Cut down your portion sizes – keep a diary of what
you eat for a week or two!
• Eat foods with low GI index – such as , pulses, lentils,
brown pasta, and nuts
• Drink plenty of fresh water – 2-3 litres a day
• In Type 2 diabetes, eat 3 small meals a day – to
avoid large increases in post-meal blood glucose
Eating, Drinking and Diabetes (3)
• Avoid ready meals and take-aways
• Use olive oil in cooking, have at least two meals of oily fish
(salmon, herring, mackerel, sardines) per week
• Alcohol (any wine or beer) in moderation is protective to your
blood vessels. Do not go for ‘low-alcohol’ beers – they are high
in sugar. Do not choose ‘low-sugar’ beers – they are high in
alcohol. Use the ordinary varieties
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1-2 units a day for women
2-3 units a day for men
REMEMBER: alcohol can lead to weight gain!
REMEMBER: if you take insulin or tablets, alcohol causes hypos
within 6-12 hours – always have food with alcohol
Tablets In Type 2 Diabetes
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Also called oral hypoglycaemic agents (OHAs) or antihyperglycaemic agents
1. Insulin secretagogues increase insulin
secretion from β-cells
2. Insulin sensitizers decrease insulin
resistance
3. Inhibitors of glucose absorption slow down
glucose absorption from the gut
ORAL HYPOGLYCAEMIC AGENTS
Class of drug
Name
Action
Side effects
Contraindications
Biguanide
Metformin
Metformin SR
Lowers liver glucose
output, increases
glucose use in muscles
and fat
Nausea,
vomiting and
diarrhoea
Renal failure (serum
creatinine>150)
Liver or heart failure
Sulphonylurea
Gliclazide /also MR
Glimepiride
Glipizide
Stimulates pancreas to
secrete more insulin
(second-phase
release)
Weight gain and
hypos
Renal impairment,
except Gliclazide and
Tolbutamide
Pioglitazone
Lowers insulin
resistance, helps to
preserve β-cells,
lowers BP and lipids
Fluid retention
Weight gain
Heart failure
Hepatic or renal
impairment
Thiazolidinedione
OHAs In Type 2 Diabetes (1)
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INSULIN SECRETAGOGUES:
1.
Sulphonylureas (Gliclazide, Glimepiride, Glipizide) increase
‘second-phase’ insulin release (10-120 minutes) after a
meal. They are taken with a meal. Can cause
hypoglycaemia, which can be severe.
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OHAs In Type 2 Diabetes (2)
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INSULIN SENSITIZERS:
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Metformin reduces hepatic glucose production, increases
glucose uptake by muscles, and reduces appetite. Helps to
lose weight, no hypos.
1.
Thiazolidinediones/ Glitazones ( Pioglitazone) increase
insulin sensitivity especially in fat tissue; improve lipid
problems; lower blood pressure; redistribute abdominal fat
to peripheral subcutaneous fat layers. Can cause weight
gain and oedema. Take 4-6 months to show full effect.
Which OHA(s) to choose?
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SULPHONYLUREAS:
METFORMIN/ METFORMIN SR
up to 1G bd
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 Glipizide up to 20mg od
 Glimepiride up to 6mg od
  2nd phase insulin secretion
 hypos, weight gain, NOT in renal
failure
 Gliclazide up to 160mg bd
 Gliclazide MR 30mg –up to
120mg od
First-line in all Type 2 diabetes
patients; hepatic glucose out-put;
fasting and post-prandial BG;
glucotoxicity; FFAs; insulin
requirement; appetite; weight gain;
allows β-cell recovery; endothelial
function; no hypos on its own
 Abdominal discomfort, diarrhoea; slow
release formula better tolerated
NOT in renal impairment (if creatinine
> 130), NOT in cardiac or respiratory
failure; NOT 48 hours before or after
IV contrast medium for radiological
investigations
Combination Therapy With Insulin And OHAs
• Until recently, insulin was introduced in Type 2 Diabetes
as a last resort after serious deterioration in glucose
levels
• Insulin is now discussed with the patient on diagnosis,
and the progressive loss of β-cells and hence insulin
secretion is explained
• NICE guidelines now recommend HbA1c target of ≤ 7%,
except in the elderly and very frail
• Insulin is now introduced when HbA1c is around 8% and
there is still some residual insulin secretion
Insulin Therapy With Tablets In Type 2 Diabetes
• Start with OD basal insulin, e.g. glargine, detemir, or
insulatard, together with metformin; this will suppress glucose
production from the liver at night-time and control fasting BG
level; metformin will keep the required insulin dose lower and
help control weight and improve blood cholesterol. Continue
sulphonylurea also to keep insulin dose low
• When post-meal glucose ‘spikes’ start to appear, BD pre-mix
insulin, e.g. NovoMix 30, or Humalog Mix 25, can be
introduced, together with Metformin
• Later basal bolus regimen with three rapid-acting pre-meal
injections and OD glargine/detemir is preferred for younger
patients with less predictable daily routines
• To keep insulin dosages lower, some diabetologists now add
thiazolidinedione, such as pioglitazone, which sensitizes tissue
cells to insulin. It enhances the utilisation of both endogenous
and exogenous insulin. (Not yet licensed in the UK.)
INSULINS
• Human insulin is manufactured using genetic
DNA methods in E.Coli bacteria or yeast
• Animal insulins are extracted from the
pancreas of pigs (porcine) or cows (bovine)
and purified. Some people still prefer to use
them, as they feel human insulins made them
lose their hypo-awareness
• Analogue insulins are made using DNA
recombinant technology in bacteria to make a
few changes in the human insulin structure
National Patient Safety Agency
Rapid Response Report
Safer Adminstration of Insulin
For IMMEDIATE ACTION by all organisations in the NHS and independent sector.
– 1. All regular and single insulin (bolus) doses are measured and administered using
an insulin syringe or commercial insulin pen device. Intravenous syringes must never
be used for insulin administration.
– 2. The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never
used.
– 3. All clinical areas and community staff treating patients with insulin have adequate
supplies of insulin syringes with subcutaneous needles, which staff can obtain at all
times.
– 4. An insulin syringe must always be used to measure and prepare insulin for an
intravenous infusion. Insulin infusions are administered in 50ml intravenous syringes
– 5. A training programme should be put in place for all healthcare staff (including
medical staff) expected to prescribe, prepare and administer insulin. An e-learning
programme is available from: www.diabetes.nhs.uk/safe_use_of_insulin
– 6. Policies and procedures for the preparation and administration of insulin and
insulin infusions in clinical areas are reviewed to ensure compliance with the above.
Types Of Insulins By Their Action
Category
Type
Examples
Rapid-acting
Shortacting
Intermediateacting
Longacting
Biphasic
Analogue
Regular
‘Soluble’
Isophane
Analogue
Pre-mix
insulins
Actrapid
Humulin S
Insulatard
Humulin I
Glargine
NovoMix 30
Humalog Mix 25,
Mix 50
Mixtard 30/40/50
Humulin M3/M5
NovoRapid
Humalog
Glulisine Soon to
(Apidra)
NPH (Neutral Protamine
Hagedorn)
(Lantus)
Detemir
come !
Onset
5–20 min
30 min
1-2 hrs
30 minutes but, in
repeated dosing,
the onset
disappears
30 min
Peak
0.5-2 hrs
1-3 hrs
4-8 hrs
No peak
2-8 hrs
Duration
3–5 hrs
4-8 hrs
12-18 hrs
Glargine 24 h
Detemir 16-20
hours
12-18 hrs
Where Should Insulin Be Injected?
• Insulin should be injected into subcutaneous fat
tissue, not in the muscle
• Suitable sites:
 Abdomen below navel and both sides of the navel
 Upper outer thighs below trochanter
 Lower outer aspect of upper arms below deltoid
 Buttocks
 Short- and rapid-acting insulins are best injected in
the abdomen, long-acting in the thighs or buttocks.
 Glargine can be injected in any of the sites
 The actual injection spot in each site must be rotated
for every injection to avoid lipos from forming
Insulin injection sites
Timing Of Insulin Injections
• Rapid-acting analogues – NovoRapid and
Humalog - can be given just at the start of
a meal, or if BG is very low, even after the
meal
• Short-acting Actrapid or older pre-mixes,
Mixtard 30 (Disc. Dec. 2010 and Humulin
M3, should be given 20-30 minutes before
eating
• Analogue mixes, NovoMix 30, Humalog Mix
25/50, can be given at the start of the meal
Where Should Insulin Be Kept?
• Do not keep live insulin pens in the fridge!
• Do not leave the pen near heat (radiator, cooker,
car glovebox) or in sunlight.
• Only spare cartridges need to be in the fridge.
Vials must be marked with date of starting –
discard in a month.
• Always remove pen needle after injecting, fit a
new needle on the pen just before the next
injection.
What Is Hypoglycaemia ?
What Is Hypoglycaemia ?
Hypoglycaemia means blood glucose <4.0mmol/l although in
many people with diabetes hypos can occur >4.0 mmol/l.
Please check with patient/carers
Hypo is caused by insulin or sulphonylureas
Poor renal function can lead to hypos in Type 2 diabetic
patients, as some SU tablets and insulin are not secreted by
the kidneys and build up
When BG falls below 3.5 mmol, glucagon, epinephrine and
nor-epinephrine – counterregulatory hormones – are released
to make the liver release glucose
This causes the ‘autonomic’ signs of a hypo: sweating,
trembling, pounding heart, and hunger
Hypoglycaemia And Hypoglycaemia
Unawareness(2)
• If BG continues to fall to 3.2 – 2.8 mml/l, cognitive brain function
starts to deteriorate. Symptoms of this ‘neuroglycopenia’
include: confusion, visual disturbances, drowsiness, odd or
aggressive behaviour, speech difficulty, tingling in the lips and
tongue.
• If BG falls still below 1.5 mmol, coma develops. Children and
elderly may have convulsions or transient hemiplegia.
• Unfortunately, people who have had diabetes for years or who
suffer from frequent hypos, lose their hypo awareness: the
autonomic symptoms do not develop until the brain dysfunction
has started, and the person can no longer take any action to
correct the low blood sugar.
• A training programme of avoiding hypoglycaemia with regular
blood glucose testing and regular snacks can often restore
hypoglycaemia warning symptoms.
What Causes Hypoglycaemia ? (3)
What Causes Hypoglycaemia? (3)
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Too much insulin or sulphonylurea, especially if renal or liver
function is impaired and/or appetite poor
Too little food or a missed meal
Vigorous, prolonged exercise hours earlier
Inappropriate giving time of insulin, e.g. rapid-acting NovoRapid
given too early and meal delayed
Gastroparesis, which causes delayed digestion and absorption of
food
Inappropriate type of insulin, e.g. Insulatard given at bedtime,
reaching peak action around 3 am, when no food taken! Pre-mixed
Mixtard 30 given am, hypo likely if lunch delayed
Sudden increase in skin temperature after injection, e.g. hot bath,
sauna, sunbathing
Alcohol intake without food – alcohol will stop the liver from
releasing glucose for hours afterwards
Drugs, such as betablocker (propranolol and sotalol), can reduce
hypo awareness and delay recovery from hypo
HYPO GLYCAEMIA FLOWCHART
How To Treat A Hypo? (1)
– 3-4 Dextrosol (1 tablet = 3g glucose) tablets plus a drink of
water
– 100 ml Lucozade
– 100 ml Orange juice
– 1 tube Glucogel
– ALL THESE WILL RAISE BG ABOUT 2-3 mmol IN 1020 MINUTES. RETEST BLOOD SUGAR IN 10 MINUTES.
HAVE A SANDWICH, 2 BISCUITS, A BANANA OR
YOUR NEXT MEAL, IF IT IS DUE
– Do NOT overtreat a hypo. Use this guide as a
prescription! Otherwise, severe hyperglycaemia will
follow leading to a vicious cycle.
How To Treat A Moderate to Severe Hypo
(2)
• If not able to swallow safely or too confused, DO NOT PUT
ANYTHING IN THE MOUTH! RISK OF ASPIRATION INTO
LUNGS!
• Glucagon 1 mg IM or SC – will raise BG by 2-3 mmol in 10-15
min. Easy to give even to an agitated person; does not need IV
access; does not damage veins; does not overtreat
hypoglycaemia. After 30 min, give 2-3 biscuits, a sandwich, a
yoghurt, or a meal.
• IV Dextrose 20% 75-80ml - will raise BG by 8-10 mmol in 5 min.
Needs a cannula; difficult to manage in a patient who is restless
or fitting; overtreats the hypo
• DO NOT USE DEXTROSE 50% - VERY VISCOUS,
DIFFICULT TO PUSH INTO CANNULA; DAMAGES
PATIENT’S VEIN; CAUSES SEVERE NECROSIS IF
EXTRAVASATES!
What Is ‘Rebound Hyperglycaemia’ ?
What Is ‘Rebound Hyperglycaemia’ ?
Answer
• Rebound hyperglycaemia:
high blood sugar following a severe hypo
and with little insulin left in the body, esp. in
the morning. Glucagon and epinephrine
release glucose from the liver too effectively,
the person over treats the hypo, and even
lowers the next insulin dose! Result: rebound
hyperglycaemia.
Question.
Where would you find the guideline for Perio-operative
management of patients with Diabetes?
Where would you find the guideline for Perio-operative
management of patients with Diabetes?
• Answer
On the intranet.
Type in ‘Diabetes’ in the search window and
scroll down to find all the guidelines for
Diabetes in hospital management.
Sliding Scale Insulin And After
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NOTE: Intravenous sliding scale insulin is given to treat Diabetic
ketoacidosis (DKA) and Hyperosmolar non-ketotic state (HONK),
but also to give insulin replacement peri-operatively or during
serious intercurrent illness (MI, stroke, or pancreatitis). The insulin
sliding scale may be the same, but the IV fluid regimen will differ.
In DKA, after the initial fall in BG to 15 mmol/l, N.Saline should be
replaced with 5% Dextrose infusion to keep BG around 10-15
mmol/l. It is important to provide the body with insulin and glucose
for fuel, in order to clear the ketones.
Once ketones have cleared from the urine (trace or negative) and
the patient is able to eat and drink, transfer to sc insulin.
IV SOLUBLE INSULIN HAS A HALF- LIFE OF 4-6 MINUTES
ONLY – AFTER THAT THE PATIENT WILL HAVE VIRTUALLY NO
INSULIN AND BLOOD SUGAR WILL RISE DRAMATICALLY IF
S/C INSULIN HAS NOT BEEN GIVEN AT THE RIGHT TIME
BEFORE STOPPING THE IV SLIDING SCALE INSULIN!
How to stop Sliding Scale Insulin correctly?
• Stop IV sliding scale around a meal time
after giving sc insulin, depending on the
type of the sc insulin, as follows:
– NovoRapid,Humalog, Actrapid or Humulin S – stop Sliding
scale ½ hour later
– Insulatard or Humulin I – stop Sliding scale 1 hour later
– Glargine or Detemir – stop Sliding scale any time but check
with a doctor if a small dose of soluble insulin might be
needed if BG rises above 13 mmol/l in the first 24 hours
– If uncertain, contact Diabetes Specialist Nurse
What Is DKA? What Is HONK?
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Diabetic keto-acidosis (DKA) is an acute emergency in a person with
Type 1 diabetes, rarely in Type 2. Over a day or two, hyperglycaemia,
ketonaemia, acidosis, and dehydration develop, due to lack of sufficient
insulin and the release of counter-regulatory stress hormones
(glucagon, epinephrine, norepinephrine and cortisol). Typical symptoms
are thirst, polyuria, abdominal pain, nausea, vomiting, air hunger, and
drowsiness. Ketones appear in urine. Hypotension, tachycardia, and
hypothermia follow.
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Hyper-osmolar non-ketotic state (HONK) develops in Type 2
diabetes, often the elderly, and is similar to DKA, with gross
hyperglycaemia (BG ≥50 mmol/l), severe dehydration, confusion, and
even coma, but without significant ketosis. Ketones are not formed as
there is some insulin secretion left in the patient with Type 2 diabetes.
Infection is often present, history of feeling unwell for weeks, drinking
sugary fluids for thirst, and often taking diuretics for hypertension.
There is a serious risk of thrombosis, MI, or stroke. HONK is a
condition with high mortality.
What Are Ketones?
• Ketones are produced in the liver when the body has
to break down fat for energy. We all make ketones if
we have been without food for some time. A person
with diabetes makes ketones if they do have not have
enough insulin, even though glucose levels are high
in the blood stream. The body cells are starving as
there is not insulin to let glucose inside the cells.
Brain, heart, muscles and kidneys can use ketones
for energy, but increasing ketones make the blood
acidotic (<7.3, which is normal). Most enzymes stop
working when keto-acidosis develops, coma and
death will follow unless treated urgently.
What Is HbA1c?
• HbA1c means glycosylated or glycated haemoglobin and shows
the average blood glucose level over the past 2-3 months.
• Glucose binds to the protein, haemoglobin, in the blood, causing
it to become glycosylated. The higher the average blood glucose
is over the life cycle of red blood cells (appr.120 days), the
higher the percentage of them that become coated with glucose,
i.e., the higher the % of HbA1c.
• Normal range is 4.6-6.0%.
• The goal of diabetes treatment is to achieve HbA1c <7% to
reduce the risk of complications, but every patient needs a
personal target goal set for them, depending on their individual
circumstances (age, overall health, employment, social
circumstances). Generally, HbA1c consistently >8% means that
treatment action or change should be taken.
Useful websites on diabetes
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www.diabetes.org.uk
www.yorkshirediabetes.com
www.diabetesuffolk.com
www.diabetes-healthnet.ac.uk
www.nelh.nhs.uk/nsf/diabetes/default.htm
www.nice.org.uk
www.diabetesresource.com
http://care.diabetesjournals.org
www.idf.org
www.diabetesonestop.com
www.medscape.com
www.diabetescare.warwick.ac.uk
www.diabetesnow.co.uk
www.cgsupport.nhs.uk/disn/
References used in this handbook
The following websites have been accessed to obtain guidelines for diabetes
management in individual NHS Trust Hospitals and nationally:
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www.webdem.org/pubstaff.asp
www.nottinghamdiabetes.nhs.uk
www.yorkshirediabetes.com
www.nice.org.uk
www.idf.org/home
THANK YOU FOR LISTENING
QUESTIONS ?