HYWEL DDA HEALTH BOARD DIABETES CARE PATHWAY
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HYWEL DDA HEALTH BOARD DIABETES CARE PATHWAY
Contributors
Dr Jonathan Williams GP Church Surgery, Aberystwyth
Dr Christine Kotonya Consultant Physician & Diabetologist, Bronglais Hospital
Dr Nia Llewelyn GP Llyn Y Fran, Llandysul
Carol Evans Senior Diabetes Specialist Nurse, Bronglais Hospital
Dr Gethin Roberts Consultant Biochemist, Bronglais Hospital
Jenny Pugh-Jones Pharmacist Hywel Dda Health Board
Dr Karen Poyser Principal Biochemist, Bronglais Hospital
Glenys Jones Diabetes Specialist Dietician, Bronglais Hospital
Rhiannon Roberts Podiatrist, Bronglais Hospital
Liz Newbury-Davies Senior Health Promotion Specialist, Public Health Wales
This document has been approved by the following Hywel Dda wide bodies:
Hywel Dda DPDG
Hywel Dda Diabetes Clinical Network
Hywel Dda Community and Chronic Conditions Management Board
Special acknowledgement to NHS Enfield NSF Diabetes Team for permitting us to adapt their diabetes treatment
care pathway which is based on
NICE CG66 Type 2 diabetes guidelines for Diabetes 2008 and NICE CG 87 Type 2 diabetes: partial update 2009
The Preventing Type 2 Diabetes section of the care pathway is based on NICE (2011) Preventing type 2 diabetes: population and community level interventions
in high risk groups and the general population. NICE public health guidance 35.
This document has been revised and modified in September 2012. Review date will be September 2013
PREVENTING TYPE 2 DIABETES
For most people, type 2 diabetes can be prevented or delayed by maintaining a healthy weight, improving dietary intake, being physically active, not smoking and drinking alcohol within the
recommended units. Lifestyle interventions for example aimed at changing an individual’s diet and increasing physical activity levels can halve the number of people with impaired glucose
tolerance who develop type 2 diabetes (Gillies et al., 2007). The greatest impact on the prevalence of type 2 diabetes and associated costs is however likely to be achieved by addressing these
behavioural risk factors in whole communities and populations (NICE, 2011). Type 2 diabetes shares these common risk factors with other non-communicable diseases including cardiovascular
disease and some cancers. In addition to these individual risk factors, people from certain communities and population groups are particularly at risk, including people of South Asian, African-
Caribbean, black African and Chinese descent and those from lower socioeconomic groups. Action to address the wider determinants of health, health inequalities and inequities however
fundamentally underpins improving the health of our population.
Prevention of type 2 diabetes and non-communicable diseases and early intervention should therefore be considered as part of an integrated package of local measures aimed at empowering
individuals and communities and to promote and improve the health of the population.
Needs assessment and planning to prevent type 2 diabetes
• identify local communities at high risk of developing type 2 diabetes, assess their knowledge, awareness, attitudes and beliefs about the risk factors and assess their specific cultural,
language and literacy needs.
Through development of Hywel Dda Obesity Pathway
• Identify successful local interventions and gaps in service provision
• Identify local resources and existing community groups that could help promote healthy eating, physical activity and weight management, particularly within local
communities at high risk of developing type 2 diabetes.
Developing local strategies and action plans
Through development of the Obesity Pathway consider actions at level 1 and 2 to address increasing people’s physical activity levels and improve people's diet and weight management in order
to contribute to preventing type 2 diabetes and related non-communicable diseases (including cardiovascular disease).
Ensure that actions to address increasing people’s physical activity levels and improve people's diet and weight management, creating supportive environments and the wider determinants of
health and health inequalities are addressed in local areas Health, Social Care and Wellbeing Strategies/Integrated Strategy; Children and Young People’s Plans; Local physical activity action
plans
Implement the Hywel Dda Self Care Strategy which aims to support individuals
Training to promote a healthy lifestyle Developing the public health and health promoting competences and skills of the NHS workforce is a priority action identified through the Public Health Strategic Framework. More fundamental is the support and management needed for the change in the basic culture of health services and to ensure that promoting health is part of everyone’s role Conveying healthy lifestyle messages to the local population – in particular, to groups at risk of type 2 diabetes Ensure key public health messages are current, evidence based, consistent, clear and culturally appropriate. Work with local practitioners, role models and peers and through mechanisms such as Siarad Iechyd/Talking Health and 10 pledges to tailor national messages for the local community about preventing type 2 diabetes and other non-communicable diseases (such as cardiovascular disease and some cancers). Ensure messages and information are disseminated locally to groups at higher risk of type 2 diabetes than the general population, including black and minority ethnic and lower socioeconomic groups. .
DIABETES CARE PATHWAY TYPE 2 DIABETES
MILESTONE 1 MILESTONE 2 MILESTONE 3 MILESTONE 4 MILESTONE 5
Diagnostic phase Treatment management Complication / risk Maintenance phase
Educative phase
phase management
a. Lifestyle changes* a. Check and recheck a. - Offer dietary advice a. Hypertension a. Regular review if unstable
understanding - Trial of lifestyle 2 – 3 monthly
interventions including
b. Lifestyle issues*
increased activity
b. Patients given Inc Smoking and physical
information booklet s activity b. Lipid Management b. 6 monthly review once
c. Medication b. Treat all co – existent stabilized
c. Patient given hand held pathology e.g. BP, lipids
record c. Anti-platelet therapy
d. Complications Arrange screening for c. Annual review
complications (see Appendix 2)
d.Referral to Dietitian (see
appendix for referral criteria) e. Importance of regular See Milestone 4 d. Microalbuminuria
review
e.Referral to group education d. Ongoing review of
f. Driving c. See medication algorithm
sessions via Diabetes Referral educational needs
e. Management of CKD
& Triage
g. Importance of good BP
f.Regular review control d. Continued education & support e. Review of dietary needs
f. Management of painful
see maintenance phase h. Importance of good neuropathy f. People with existing diabetes
glycaemic control HbA1c
(mmol/mol ) e. 3 – 4 monthly HbA1c should have mental and
g. Assessment of emotional
mmol / mol emotional health monitored and
wellbeing i. Eye examinations with dilated g. Retinopathy /
be monitored for depression
pupils & retinal camera Foot care
h. People with severe
j. Foot health f. Continue to follow medication
mental health diagnosis g. Information about monitoring
algorithm
should be checked h. Erectile Dysfunction and glucose meters where
annually for diabetes k. Sexual health
appropriate
g. Once stabilised, regular review
l. Travel See Maintenance phase
i. Obesity
m. Diabetes UK / support
groups
j. Peripheral arterial disease
n. Offer structured education
programme
MILESTONE 1: DIAGNOSIS OF DIABETES MELLITUS
PRESENTING SYMPTOMS
1. Patient presents with signs and symptoms suggestive of Type 2 diabetes
Excessive thirst
Polyuria especially at night
Lethargy
Weight loss
Blurred vision
Infections e.g. pruritis, balanitis
None of the above
2. At routine /ad hoc health review patient has glycosuria
3. Increased suspicion due to risk factors
Ethnicity
Family history
≥ 40 years of age
Previous gestational diabetes
Polycystic ovarian syndrome
Existing severe mental illness such as schizophrenia
WHO DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS
NB: In the absence of osmotic symptoms 2 consecutive venous samples are required to diagnose Diabetes Mellitus
PLASMA DIABETES CONFIRMED IMPAIRED GLUCOSE IMPAIRED FASTING GLYCAEMIA
TOLERANCE
FBG ≥ 7.0 mmol/L < 7.0 mmol/L ≥ 6.1 mmol/L
< 7.0 mmol/L
OGTT ≥ 11.1 mmol/L ≥ 7.8 mmol/L Do OGTT to exclude diabetes
2 hour value
Early Detection of Type 2 Diabetes and Management of Pre- Diabetes
Presentation with symptoms and raised Identification of more than 1 risk factor
plasma glucose≥11.1mmol/L • IGT/IFG
• Age >45yrs (≥35 yrs in high risk ethnic groups) with BMI
>30 and hypertension
• Cardiovascular disease
• Polycystic ovarian syndrome
• Previous gestational diabetes
• Family history with BMI >30
• Metabolic syndrome
•
No
Symptoms Risk assessment questionnaire Annual risk questionnaire
above threshold?
Yes
Check fasting plasma glucose or
Oral glucose tolerance test if previous IGT/IFG high risk
FBG ≥7mmol/L FBG 6.0-6.9 mmol/L
MILESTONE 2: EDUCATION IN TYPE 2 DIABETES
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 STEP 7
Assess Review Discuss Discuss Facilitate Understanding Review
learning needs understanding Lifestyle issues Complications Dietetic referral the annual understanding
review
Determine first What is diabetes? Eyes Give “stop gap” Height, weight, Importance of
language Diet dietary advice BMI, waist regular diabetes
circumference checks
CVD
Physical
Is the patient Importance of Has patient been BP Review
activity
literate in referred to concordance with
Welsh/English? regular diabetes Kidney dietitian? medication
checks Routine blood
Smoking
tests / urine tests
Review
YES • HbA1c
concordance with
Is the patient What to expect at Erectile mmol/mol
Alcohol Recheck healthy eating
literate in own an Annual Review Dysfunction • U&E
understanding • TFT regimen
language?
• LFT
Importance of • Lipid profile
medication Neuropathy NO • eGFR Assess gaps in
Diabetes UK / knowledge and
Cymru e.g. Refer to • ACR
dietitian provide
www.diabetes.org.uk/cy
Arrange mru education as
Social
appointments as PVD Foot assessment appropriate
adjustments
necessary with • Pedal pulses
• Neuropathy
interpreter
mental and status
Foot
emotional
Offer patient
structured well being
Retinopathy
diabetes status
education Enrolment onto
Driving
programme regulations DRRSW
Programme
MILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2
DIABETES (Hywel Dda Health Board Prescribing Formulary)
= Usual approach = Alternative approach
IN THE FIRST INSTANCE, UNLESS THERE IS A CONTRA – INDICATION AIM FOR
HbA1c 48 mmol/mol (6.5%)
This will need to be reviewed on an annual basis, as diabetes progresses, HbA1c treatment target for intervention can be increased to 59 mmol/mol (7.5%)
INITIATE HEALTHY EATING PLAN AND INCREASED ACTIVITY FOR AT LEAST 12 – 16 WEEKS UNLESS SYMPTOMATIC
AGREE LEVEL OF HbA1C (mmol/mol) FOR INTERVENTION
Consider first
METFORMIN SULPHONYLUREAS
METFORMIN SHOULD NOT TO BE INITIATED IF SERUM CREATININE If not overweight , or Metformin not tolerated,
LEVEL IS > 150 µmol/L OR eGFR < 30 or a rapid therapeutic response is required because of hyperglycaemia
Review response to medication using the step guidelines, within 28 days in the first Consider a rapid-acting secretagogue for people with erratic lifestyles
instance, then 3 – 4 monthly using HbA1c mmol/mol GLICLAZIDE GLIMEPIRIDE
Commence 500mgs BD / TDS Further increase as tolerated 80 mgs OD/ 40 mgs 1 mg OD
1 gm BD/TDS. BD
If unable to tolerate Metformin, or compliance issues, consider reducing current dose 80 mgs BD 2 mgs OD
or change to slow release Metformin up to 2 gm OD 160 mgs AM / 4 mgsOD
Review Metformin dose if serum Creatinine 130 µmol/L or eGFR 45 80 mgs PM
SEE CKD PATHWAY FOR LONG TERM MONITORING 160 mgs BD max 6mgs max
nd
Consider second when HbA1c 48 mmol/mol or 6.5% if sulphonylurea is not appropriate 2 line or risk of hypoglycaemia
THIAZOLIDINEDIONES (TZD) DPP-4 INHIBITORS
Can be added to Metformin or sulphonylurea If significant risk of hypoglycaemia
Licensed for monotherapy use in patients who cannot tolerate Metformin If sulphonylurea or Metformin is not tolerated or contraindicated
Can be used with a sulphonylurea if control sub-optimal and cannot tolerate Metformin Not Can be used combination with Metformin when Metformin plus diet and
recommended in patients with evidence of heart failure*or a higher risk of fractures. Check LFT exercise, does not provide adequate glycaemic control.
prior to starting treatment, 2 months after & annually thereafter It can also be used in combination with either a sulphonylurea or a
glitazone**.
PIOGLITAZONE Continue only if > 0.5% (5-6 mmol/mol) reduction in HbA1c at 6
*Can be used with insulin months which is maintained
NOT recommended in patients with
microscopic haematuria or history of bladder SITAGLIPTIN SAXAGLIPTIN
cancer **has triple licence Can be used as add on to insulin
Can be used as add-on to 5 mg OD
15 - 30 mg OD
Maximum 45 mgs OD insulin If on sulphonylurea dose may
100MG OD need to be reduced
CAUTION WHEN USED WITH SULPHONYLUREAS, RESPONSE MAY NOT BE
APPARENT FOR 6 – 12 WEEKS In mod-severe renal failure a dose of
If on sulphonylurea dose may 2.5mg OD
need to be reducedMILESTONE 3: TREATMENT MANAGEMENT IN TYPE 2 DIABETES
Consider third when HbA1c 59 mmol/mol (or > 7.5% ) or higher than individually agreed target
TZD DPP-4 GLP-1 NPH INSULIN OTHER INSULIN ALPHA
INHIBITOR If BMI ≥ 35 kg/m2 and other Ensure training course in GLUCOSIDASE
psychological/medical problem associated with Ensure insulin initiation done INHIBITOR
See overleaf See above and raised BMI training course
and If insulin is not If BMI ≥ 35kg/ m2 for whom insulin is in insulin ACARBOSE
If insulin is acceptable or unacceptable because of occupational implications initiation 50 mg OD
not inappropriate or where weight loss would benefit other co- Can be considered if Increase to 50 mg TDS
acceptable or Only Sitagliptin morbidities. patient requires assistance after 6 weeks 100mg
inappropriate can be used in Continue GLP-1 only if beneficial response seen At bedtime or TDS
combination and maintained (>1.0% reduction in HbA1C at 6 twice daily 200 mg TDS
with Metformin months and weight loss of at least according to
and a 3% at 6 months) need. from a carer/HCP to
Sulphonylurea Check SPC for contraindications administer
If lifestyle is restricted by
EXENATIDE LIRAGLUTIDE
recurrent hypoglycaemia
Prolonged Release Once Once daily dose 1.2mg If would otherwise need
WEEKLY max BD insulin and oral OHAs
or Not meal related If cannot manage injection
1.8mg dose is not device for NPH
Twice daily recommended by NICE
Meal related
The initiation of insulin or GLP-1 to people with diabetes should only be carried out by:
Practices that have attended an appropriate training course on insulin initiation and management and regularly maintain education update and
use GLP-1 in accordance with NICE guidelines or discussed with secondary care
Consider fourth if HbA1c remains 59 mmol/mol or 7.5%
NPH INSULIN OTHER INSULIN Consider Pioglitazone or
Ensure training course in insulin Sitagliptin with insulin if:
• Ensure initiation
training 1. Long acting insulin analogue Pioglitazone or Sitagliptin has
course in See above and switch if: previously had a marked
insulin Target HbA1c not reached due to significant glucose lowering effect or
initiation hypoglycaemia
Blood glucose is inadequate
has been Cannot manage device for insulin
done without high dose insulin
Requires assistance from carer/ HCP to
administer
2. Premix insulinMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT
1. Aim for Blood Pressure HYPERTENSION
measurement of: Step 1
If NO microvascular Offer ACE inhibitor
complications are Ramipril caps 2.5 – 10mg OD or Lisinopril 2.5-80mg OD.
present (Offer contraception advice to women of childbearing age)
≤ 140 / 80 mmHg For people of African – Caribbean descent, offer ACE inhibitor plus Diuretic
If eye or renal complications Bendroflumethiazide no more than 2.5mg OD as maximum dosage (check U&Es prior commencing and monitor
are present aim forREFER TO SPECIALIST SERVICE IN CASES OF UNRESOLVED HYPERTENSION
MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D…
LIPIDS
RAISED LIPID PROFILE:
1. Statin should be offered to all those aged 40 or above with either Type 1 or Type 2 diabetes (If 6.0 mmol /L
• Features of metabolic syndrome
• Family history of premature cardiovascular disease in a first degree relative
Step 1. Simvastatin 40mg nocte (if patient on Warfarin or is intolerant of Simvastatin, try Pravastatin up to 40mg nocte) Patients on amlodopine or diltiazem should not
exceed 20mg dose of simvastatin.
NB Intolerance is typically muscle or liver related: myalgia and/or rhabdomyolysis, CK > 10x or LFTs (AST/ALT) >3x normal
Increase to 80mg simvastatin (unless poor response and/or side-effects to 40mg dose)
Step 2. Atorvastatin 40mg once daily (may wish to consider initiating 20mg due to individual patient response)
Step 3. Atorvastatin 80 mg once daily
Step 4. Consider Ezetimibe 10mg as monotherapy if statin contraindicated or not tolerated
Step 5. In patients who have not reached target, cannot tolerate statins, or who have high CV risk and TG = 2.3 – 4.5 mmol/L despite statin, consider addition of a
fibrate (e.g.Fenofibrate) on case by case basis and consider referral to specialist services.
Omega-3 is not recommended for the routine treatment of raised TGs in diabetic patients.MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D…
ANTI PLATELET THERAPY:
Primary prevention: Anti platelet therapy should only be prescribed following an assessment of patient’s individual CV risk and a
review of the risks: benefits for that patient.
Secondary Prevention: Anti platelet therapy should be prescribed
st
1 line:
Soluble aspirin 75 mg daily. This is to be given unless there is an absolute contraindication
nd
2 line:
For patients who cannot tolerate soluble aspirin, or have a history of ulceration, add in either Lansoprazole Capsules 15mg OD or
Omeprazole Capsules 20mg OD and continue with soluble aspirin
rd
3 line: If aspirin is still poorly tolerated, contra-indicated, has had a previous cardiovascular event, or compliance issues favour monotherapy
Clopidogrel 75mg dailyMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT
OBESITY
ASSESSMENT
All patients with diabetes should have their BMI recorded annually
Classification of BMI*:
CLASSIFICATION BMI RISK OF CO-MORBIDITIES
Underweight 30.0 Increased
Class i 30.0 – 34.9 Moderate
Class ii 35.0 – 39.9 High
Class iii >40 V High
*DoH
Waist circumference:
SEX METRIC IMPERIAL
Male >102 cm ≥ 40 inches
Asian male ≥ 90cm ≥ 35
Female ≥88 cm ≥ 35
Asian female ≥80 cm ≥ 31
Medical history e.g. Current glycaemic control, hypothyroidism, hypertension, hyperlipidaemia, CHD, PCOS, sleep apnoea, osteoarthritis, learning disabilities,
mental health issues
Family history
Social history e.g. Alcohol, smoking status
Drug history e.g. sulphonylureas, anti-psychotics, steroids
Dietary history
Physical activity status
Readiness to change: Explore how person feels. Inform about solutions. Provide insight into risks
Active treatment of the obese person with diabetes should commence when BMI is greater than 28MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT
OBESITY CONT’D
TREATMENT OF OBESITY
Aim of treatment is to:
Reduce calorie intake – 59 mmol/mol or 7.5% and BMI >35
Or Refer to secondary care
IF BMI IS > 40, CONSIDER BARIATRIC SURGERY and refer to secondary careMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D MANAGEMENT OF PERIPHERAL ARTERIAL DISEASE
Patient presents with
- Intermittent Claudication (IC): A cramp like pain in the legs when walking or exercising (can be found in calf or thigh muscles and buttocks)
- Known Arterial Disease (Coronary, Carotid or renal artery disease)
- Absent or diminished Dorsalis Pedis or Posterior Tibial pulses
- Rest pain or gangrene of leg / foot
- Poorly healing / non healing wounds on leg or foot
- People who have increased risk of arterial disease e.g smokers, dyslipidaemia, hypertension,
Ankle:Brachial Pressure Index to be calculated.If this facility is not available “in –house” please refer to Community diabetes/ District nurses for neurovascular assessment using Podiatry
referral form and stating level of urgency
A:BPI < 0.9 **Actively A:BPI > 0.9
treat risk factors**
BP Aim to be < 130/ 80 The A:BPI may be falsely elevated due to medial artery calcification. This will
Aim for good glycaemic control (see Milestone 3:Treatment management ) elevate the A:BPI to above 1.3
Commence antiplatelet therapy If IC symptoms present, patient will need to be referred for an exercise Doppler
If Cholesterol > 4 mmol/L commence statin (See Milestone 4: Complications / examination at via referral and triage form
Risk management) If drop in A:BPI post exercise occurs, PAD is diagnosed and patient to be treated
Smoking cessation as if A:BPI is < 0.9 See text box opposite
Weight loss If A:BPI shows no reduction other causes for painful symptoms may to be
Exercise therapy “ Keep walking” investigate
If lifestyle impairment
SEVERE MILD
IMPAIRMENT IMPAIRMENT
Refer to Vascular Team Exercise therapy
Glangwili hospital Review 3/12
Consider naftidrofuryl oxalate 100mg 1-2 tds if no
improvement on exercise therapy alone (stop
if ineffective after 3/12) (NICE TA 223)
Referral criteria to Specialist services
(6Ps) Rapid onset of symptoms: Pain, pulselessness, pallor, paraesthesia, paralysis, perishingly cold = Emergency referral
Deterioration in chronic symptoms: Ischaemic rest pain, gangrene, non healing wound or ulceration, infection = Urgent referral
References: SIGN, TASC II, CFH guideline for management of PAD Diabetic foot protocolMILESTONE 4 COMPLICATIONS/RISK MANAGEMENT: ALL WALES DIABETIC FOOT CARE PATHWAY
All people with diabetes should be offered routine annual foot assessment
ANNUAL REVIEW – CALL AND RECALL
To be undertaken by a person appropriately trained (National Minimum Skills Framework):
Primary care team, GP Practice Nurse District Nurse DSN, Link Nurse Health Care Worker, Podiatrist
RISK FACTORS – Glycaemic control, Hyperlipidaemia, hypertension, weight management, Retinopathy, Nephropathy, Smoking
Assessment of social & educational needs
FOOT ASSESSMENT - callus / corns, deformities, muscle strength, amputations, ulceration, scarring, condition of nails, footwear
VASCULAR ASSESMENT - pedal pulses / Doppler (8 MHz), signs/ symptoms
NEUROLOGICAL ASSESSMENT - 10 g monofilament and 128 Hz tuning fork (Rydel Seiffer tuning fork)
LOW RISK INCREASED RISK HIGH RISK VERY HIGH RISK
Normal sensation, palpable pulses, no foot Neuropathy or absent pulses or foot pathology or Neuropathy or absent pulses AND deformity Ulcerated foot, acute cellulitis, sepsis –
pathology other risk factor or skin changes or previous Urgent referral to MDT/Podiatry Tissue
Annual Review Community Podiatry ulceration/amputation Viability wound management team
Management by the primary care team Review 3-6months Specialist Podiatry Management Revascularisation
Basic Foot care Education/ Structured Proactive foot care education Review 0-3 months Infection control
education Contact numbers for foot emergencies Proactive specific foot care education Glycaemic Control/ medical management
Empowerment for self care Assess footwear and insoles requirements Radiological investigations
Contact numbers for foot emergencies Offloading/pressure relief
Community Podiatry
Routine Care Intermediate/ Specialist ULCER CLINIC
Treatment Plan High Risk Podiatry Clinics Wound Healing / Management
including education Advanced neurological and vascular Tissue Viability
Orthotics /Appropriate Footwear assessment
Specialist treatment plan
MULTIDISCIPLINARY DIABETIC FOOT CLINIC (where available)
Acute foot problems, cellulitus, new or chronic ulceration, trauma, acute onset of pain (charcot foot, infection. painful neuropathy
Diabetologist & Diabetic Hospital Team Orthotist Specialist Footwear / Insoles
Podiatrist Diabetes Specialist Nurse Review HBA1c & Control
Vascular Consultant & Vascular Team- (Dedicated pathway) Dietician (Dedicated Pathway)
Orthopaedic Referral (Dedicated Pathway) Pain Team (Dedicated Pathway)
Plaster Technician (Dedicated Pathway) Tissue Viability SpecialistMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D…
TREATMENT OF ERECTILE DYSFUNCTION (ED)
Identify and treat curable causes of ED where possible:
Endocrine cause: Poor control of DM, Hypogonadism, Hyperprolactinaemia, Hypo / Hyperthyroidism, Cushing’s syndrome (will need Endocrine referral)
Vascular cause: PVD, CKD
Urological: Previous injury, Pelvic / Prostatic surgery or radiation therapy (may need urology referral)
Neurological cause: MS, Alzheimers, Parkinson’s, spinal cord injury (may need neurology referral)
Medications: Beta-blockers, Alpha Adrenergic Antagonists, Diuretics, Sedatives, tranquilizers, anxiolytics, antidepressants, antipsychotics, Corticosteroids, digoxin,
NSAIDs, H2 Antagonists etc
Lifestyle / habit / addiction: Substance abuse, smoking, alcoholism, anabolic steroids, Heroin, Marijuana
Psychological
Lifestyle changes and risk factor Education for patients and partners Counselling for patients and partners
modification Describe treatments available Refer for psychosexual therapy
Send blood for hormone levels Assess current CV risk & medication history (e.g.nitrates)
PRESCRIBE PDE5 INHIBITORS TRIAL: ALTERNATIVE THERAPIES:
The prescribing physician should be aware of mode of action, cautions, contra- NB: PATIENT NEEDS TO BE REFERRED TO UROLOGIST / ED
indications, side effects as per BNF CLINIC TO BE TRAINED IN USE OF THESE PRODUCTS
Frequency of treatment needs to be considered on a case by case basis. One treatment
per week is usually appropriate (DoH) Intracavernosal injections:Caverject, Viridal Duo
DRUG DOSE MINIMUM INFORMATION FOR Intraurethral alprostadil: Muse
PATIENTS Vacuum devices
50 – 100 mg
Start at 50 mg and titrate Effective 30-60 mins in Penile implants
SILDENAFIL presence of sexual stimulation
Viagra according to response and Effect reduced by fatty meal
side effects Half life 4 hours
ASSESS THERAPEUTIC OUTCOMES
5 – 20 mg
Start at 10mg and titrate Effective after 25 – 60 mins in IT IS ESSENTIAL IN DIABETES TO ADVISE PATIENTS TO TAKE ORAL
presence of sexual stimulation
VARDENAFIL according to response and MEDICATION APPROXIMATELY 4 HOURS PRIOR TO SEXUAL
(can be as early as 10 mins)
Levitra side effects ACTIVITY AS IT HAS BEEN OBSERVED THAT ONSET OF ACTION MAY
Effect reduced by fatty meal
Half life 4.5 hours
BE DELAYED IN MEN WITH DIABETES.
5 – 20mg IF SILDENAFIL IS INEFFECTIVE CHANGE TO ANOTHER PDE5
Start at 10mg and titrate Effective after 30 mins in INHIBITOR VARDENAFIL CURRENTLY IS THE MOST COST
TADALAFIL presence of sexual stimulation EFFECTIVE ALTERNATIVE
according to response and Effect not reduced by food
Cialis
side effects and alcohol
Half life 17.5 hoursMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTD…
RENAL COMPLICATIONS / MICROALBUMINURIA SCREENING
** PLEASE NOTE THAT THESE TESTS
ARE IN ADDITION TO THE eGFR **
DIPSTICK URINE FOR PROTEIN USING MULTISTIX / ALBUSTIX
IF NEGATIVE IF POSITIVE
st
Refer to local laboratory guidelines for EMU collection protocol If 1 specimen is abnormal exclude UTI (collect MSU)
nd
Collect EMU for Albumin / Creatinine ratio If 2 specimen is abnormal quantify proteinuria by albumin /
creatinine ratio (ACR).
Normal A : C Ratio Males < 2.5 mg / mmol
Females < 3.5 mg / mmol Treat to target
1. BP (Aim < 130 / 80)
If specimen is within normal range retest annually 2. Glycaemic control HbA1c ≤ 48 mmol/mol (7.5%)
3. Commence ACE inhibitor or ARB if intolerant to ACEI
(Irbesartan has licence in microalbuminuria)
Repeat ACR after 6 months
If specimen is abnormal, refer to specialist care according to
local CKD guidelines
SEE eGFR GUIDELINES
NICE Clinical Guideline 66 Management of Type 2 diabetes mellitus, May 2008MILESTONE 4: RENAL COMPLICATIONS- Annual albumin screening
Annual urine microalbumin
screening
Raised Values Normal Values
≥ 2.5 mg/mmol, males < 2.5 mg/mmol, males
≥ 3.5 mg/mmol, females < 3.5 mg/mmol, females
NO
First high reading Established microalbuminuria or proteinuria
YES
Ensure urine sample obtained
under appropriate conditions
(exclude UTI)
Titrate to highest recommended dose of ACE-I/ A2RB to
Repeat early morning urine on 2 separate mornings to confirm target BP < 130/80
level of microalbuminuria* Optimise HbA1c to 48-59 mmol/mol (6.5-7.5%)
(Positive test - if 2 out of 3 samples elevated. Repeat samples positive
Commence statin and aspirin.
tested one week apart. Urge smoking cessation
In the event of negative tests – return to annual screening
If proteinuria persistent over 6-12 months
arrange USS kidneys and refer to secondary care
services
If proteinuria confirmed (alb/creat ≥ 30mg/mmol) in the absence of significant retinopathy investigate for non-diabetic causes
N.B. Refer to nephrologists if eGFR < 30 ml/minute/1.73m2 or if non diabetic aetiology suspected e.g. short duration of diabetes, the presence of the nephritic
syndrome, collagen vascular disease, haematuria with a structurally normal urinary tract, or rapid worsening of GFR or proteinuria.MILESTONE 4: RENAL COMPLICATIONS - Microalbuminuria
Lifestyle measures
• Brief intervention on smoking, signposting to cessation support service Stop Smoking Wales
• Restrict dietary salt. (Unrestricted salt intake can virtually eliminate the antiproteinuric effect of an ACE inhibitor.)
• All patients with chronic renal disease (stage 3: National Kidney Foundation) should undergo nutritional screening. Individuals identified as
having an inadequate dietary intake should have identifiable causes corrected, in addition to receiving appropriate advice from a registered
dietitian.
• Advice on weight reduction if obese (and has not received this as a part of diabetes care to date)
Pharmacotherapy
• Begin or titrate ACE or if intolerant A2RB to maximum tolerated dose irrespective of initial blood pressure. Check serum creatinine and
potassium 2 weeks after initial dose and after subsequent increases in dose. A stable rise in creatinine of up to 20% or a 15% fall in eGFR does
not require dose adjustment. If serum creatinine continues to rise then ACE/A2RB should be stopped and the possibility of renal artery stenosis
considered.
• Treat with Statin and attend to glycaemic control
• Aspirin 75 mg od (given due to increased cardiovascular risk)
Treatment Targets:
Blood pressure control
Target blood pressure to: ≤ 140/80 in all diabetic patients
≤ 130/80 in microalbuminuria/proteinuria
Glycaemic control: HbA1c 48-59 mmol/mol (6.5 - 7.5 %)
The risk of hypoglycaemia increases as renal disease progresses. This needs to be balanced against the benefit of tight control
Lipids
Commence lipid-lowering therapy unless contra-indicated in all patients with microalbuminuria or proteinuria.
Lipid Targets
Total cholesterol < 4 mmol/L
OR
LDL cholesterol < 2 mmol/L
HDL cholesterol ≥ 1.0 mmol/L
These guidelines are based on: CG73 NICE Guideline: Early Identification and management of Chronic Kidney Disease in adults in primary
and secondary care, September 2008Chronic Kidney Disease (CKD) and the estimated Glomerular Filtration Rate (eGFR)
• Chronic Kidney Disease (CKD) is common. It affects approx 10% of the population and is often asymptomatic until renal function is
severely reduced.
• Serum creatinine has traditionally been the mainstay for the initial identification of renal disease. Serum creatinine on its own does not
detect minor degrees of kidney impairment and is not directly related to the GFR.
• eGFR forms the basis for the classification and management of CKD.
• CKD is an important risk factor for cardiovascular problems. eGFR makes it easier to tell who should be offered treatment.
• DoH has recommended a formula-based eGFR calculation which is used for the identification and initial staging and monitoring of
CKD patients being ml/ minute / 1.73 m2.
• eGFR is not applicable in people < 18 years, acute renal failure, pregnancy, amputees, extremes of body weight, 1 kidney.
eGFR result Severity of CKD Frequency of
testing
1/2 60 - > 90 Normal/Mild Annually
6 months (12 months if
stable)
Refer to secondary care if not
3 30-59 Moderate renal impairment stable or rapid decline
3 months if stable
Refer to nephrology if not
4 15-29 Severe kidney disease stable or rapid declineMILESTONE 4: Management of Chronic Kidney Disease (CKD)
Annual estimated eGFR)
(MDRD*); serum creatinine
Dipstick urine for blood and protein (as
above)
Abnormal eGFR < 60 eGFR ≥ 60 ml/min/1.73m2 (MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D - PAINFUL NEUROPATHY
DIAGNOSIS
HISTORY
- Consider differential diagnosis (alcohol excess, B12 deficiency, malignancy)
- Sometimes acute, sometimes insidious onset and progressive
- Paraesthesia in toes, feet and shins
- Anaesthesia
- Hyperaesthesia
Symptoms often worse at night or at rest
PAIN
- A wide variety of descriptions of peripheral symptoms can be present.
- Careful patient questioning is necessary as symptoms can be confusing
- Consider use of Pain Pictures or S-LANNS assessment questionnaire
Symptoms may include:
- Numbness
- Tingling
- Prickling
- Pins and Needles
- Aching
- Dull pain
- Burning
- Buzzing
- Cold
- Sharp
- Knife – like
- Electric shocks
The severity of individual patient symptoms will influence which step of the care pathway is appropriate for commencement of treatment
SIGNS
WEAKNESS
- Distal and/or proximal
- Loss of reflexes
NEUROPATHIC EXAMINATION
- 10 g Monofilament
- Vibration perception (tuning fork 128 Hz), calibrated tuning fork, Bio / Neurothesiometer)
- Proprioception
- Light touch
- Sensory loss glove and stocking distributionMILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONT’D - PAINFUL
NEUROPATHY
PERIPHERAL NEUROPATHY HAS BEEN DIAGNOSED
STEP 1
Improve glycaemic control. Liaise with diabetes nursing team / dietician if appropriate. Aim for normoglycaemia
Prescribe Amitriptylline 10-75mg at night or Duloxetine 60mg daily (child and adolescent under 18 years not
recommended)
If patient is experiencing night time cramps only, consider prescribing:
- Quinine sulphate 200 – 300 mg nocte (Inform patient that it may take up to 1 month to see an improvement)
- May benefit from low calorie Indian tonic water (not available on FP10)
Reassure. (Use of pain diary may be useful)
Review in 1 month
If patient is reluctant to take oral medication consider Capsaicin cream 45 g, noting that initially there may be an intense burning sensation.
STEP 2
Review symptoms, pain and glycaemic
control If pain still present, reassure
Check concordance with 1st line treatment and consider the alternative as
in Step 1
Review in 1 month
STEP 3
Review symptoms, pain and glycaemic control
If pain still present / no improvement in symptoms, refer for specialist input
Monitor therapy, and increase, up to maximum licensed dosage.
Consider prescribing in place of previous medication:
- Pregabalin 150 – 600 mg in divided doses
- Consider addition of Tramadol 50mg – 150 mg tds
STEP 4
Review symptoms, pain and glycaemic control
If pain is not controlled referral to specialist pain clinic
Updated NICE Guidance May 2010MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTINUED
FOOT CARE:
1. Ensure that feet are assessed including foot pulses, vibration, sensation by a competent practitioner annually (See also
Milestone 4: Peripheral Arterial Disease – [PAD])
2. Record results on diabetes template
3. Ensure that principles of good foot care are reiterated at each review
4. Refer for podiatry treatment as appropriate
5. Refer URGENTLY TO RAPID ACCESS FOOT CLINIC / DIABETES TEAM if any of the following problems occur:
Acute foot injury (including any penetrating foot injury) Foot
ulcer present
Signs of infection
Evidence of ischaemia noted
Suspicion of Charcot’s neuropathy
RETINOPATHY:
1. Ensure that patient understands the importance of annual retinopathy screening
2. Ensure that patient is enrolled on the Diabetes Retinal Screening Service for Wales for digital photography. Please contact DRSSW
Telephone 01443 844244
3. At annual review, check that a result is present in the patient records dated within the last 12 months
4. Results of retinal screening should be discussed with patientMILESTONE 5: MAINTENANCE
1. Regular review if unstable 2-3 monthly BP
Lipids
Glycaemic control (there is no benefit to repeating HbA1c reading more frequently than 3 monthly) Diet
Lifestyle
2. 6 monthly review
As above
3. Annual review
Weight / BMI
BP
Review of medication
Review of diet
Review of glycaemic control
Review of investigations
- HbA1c
- Lipids
- U&E including eGFR
- TFT
- LFT if taking Glitazone or Statin
- Albumin / Creatinine ratio (ACR)
Foot examination
- Shoes, socks, stockings MUST be removed
- Observation of colour, warmth, sensation, symptoms, general appearance of nails, skin, callus etc.
- Pedal pulses at Dorsalis Pedis and Posterior Tibial points
-10gm Monofilament and vibration perception on BOTH feet
Lifestyle issues
- Driving
- Physical Activity levels
- Smoking
- Alcohol
- Sexual health/ contraception
- Mental and emotional health(Assess Stress and depression)FOR HDHB BILINGUAL FIRST LINE ADVICE SHEET – ‘HEALTHY EATING WITH
APPENDIX 1 LIFESTYLE CHANGES DIABETES’ (SEE APPENDIX 8)
HEALTHY EATING (STOP GAP INFORMATION)
ADVICE TO BE GIVEN EXAMPLES
Regular meals that include carbohydrates High fibre low salt and low fat breakfast cereals
This will help to control blood glucose levels* Wholemeal / whole grain breads, including pitta, crackers,
crispbreads
Pasta and noodles
Potatoes
Rice
Foods that are high in fibre* Beans
Lentils
Bran
Wholemeal and wholegrain breads and cereals
Fruit and vegetables
Cut down / Eat less saturated fat* Less animal fats and fatty foods
Choose olive oil, rapeseed oil or other vegetable oils
Grill, steam ,bake food
Use less butter, margarine, cheese and fatty meats
Use low fat dairy foods like skimmed or semi skimmed milk, low fat
yoghurt
Reducing salt* Less processed food
Leave out salt in cooking
Buy reduced salt versions of food
Use herbs and spices instead of salt
Five a day* Try to eat five portions of fruit or vegetables a day, but limit fruit
intake to no more than 3 – 4 portions a day
A portion is a handful of fruit or vegetables
Cut down on sugar / sugary foods* This does NOT mean a sugar free diet
Sugar can be used as an ingredient in foods in small quantities
Use sugar free, diet or low sugar squashes and fizzy drinksAPPENDIX 1 LIFESTYLE CHANGES CONT’D
INCREASING PHYSICAL ACTIVITY
ADVICE TO BE GIVEN EXAMPLES
Aim to be active daily
ncrease physical activity levels gradually until over a week activity builds up to at least
150 minutes (2 ½ hours) of moderate intensity activity in bouts of 10 minutes or
more. One way to do this is 30 minutes of activity on at least 5 days of the week Brisk Walking daily
Moderate intensity activity means activity that makes you feel warm and slightly
breathless but you should still be able to talk Increase distance and speed
Once exercising regularly, try cycling, swimming etc.
Housework / gardening if mobility is limited
If immobile teach armchair exercises
Refer to National Exercise Referral Scheme (NERS)
Recommend community based physical activity opportunities e.g. walking groups,
activity classes
If heart problems consider referral to cardiac rehab
STOPPING SMOKING
ADVICE TO BE GIVEN WHAT TO DO
Give information about Stop Smoking Wales smoking cessation support service
Assess smoking status
Refer client to Stop Smoking Wales as this offers the best chance of quitting
•Give client a Stop Smoking Wales referral card and encourage them to contact the
Brief intervention on smoking, harms of continuing, benefits of stopping service for an appointment
Accessing free Stop Smoking Service can support patients to stop smoking
NICE (2006) guidance on Brief intervention for Smoking Cessation recommends
that
•Everyone who smokes should be advised to quit. People who smoke should be
asked how interested they are in quitting
•Health professionals and those who work with clients should refer people who
smoke to an intensive support service such as Stop Smoking Wales Contact Stop Smoking WalesFREEPHONE 0800 085 2219 or
www.stopsmokingwales.comALCOHOL ADVICE
ADVICE TO BE GIVEN EXAMPLE
Consume alcohol in moderation and within the recommended guidelines for 1 unit of alcohol = half a pint of ordinary strength beer or lager at 3.5% abv
alcohol consumption 1 standardglass (125 ml)of wine at 8% abv
1 single standard measure (25ml) spirits at 40% abv
(abv = alcohol by volume)
Men should drink no more than 3 units a day/ 21 units per week
Women should drink no more than 2 units a day / 14 units per week
These rough alcohol units however are ineffective at calculating the actual amounts
of alcohol consumed and can be misleading. Therefore recommended to calculate
accurate alcohol units by the following formula:
ABV x Amount in mls= 1000 = Unit value
So a pint of Stella Artois would be:5.2 x 568 = 1000 = 2.9 units
Both men and women should have at least 2 days per week where no alcohol is
consumed and no binge drinking. (A binge is regarded as being half or more of the
recommended allowance beign consumed in one drinking session i.e. 10.5 units for
men and 7 units for women)
Prism Generic Alcohol Services for Adults tel 01267 231634
Free, open access service to people who have difficulties with their own or someone
elses use of alcohol, for adults over 18 in Pembrokeshire, Carmarthenshire and
Ceredigion
Alcoholics Anonymous NationalHelpline0845769555*Diabetes UK Patient information www.diabetes.org.uk
Mental and Emotional Health
ADVICE TO BE GIVEN EXAMPLES
How to cope with a diagnosis of diabetes Talking to your healthcare professional about how you feel and how you are
coping. Healthcare professional giving support and reassurance.
www.diabetes.org.uk has section on coping with diabetes.
10 positive steps – keeping active, eating well, drinking in moderation, talking about
your feelings, keeping in touch with friends and loved ones, asking for help, taking a
break, doing something you are good at, valuing yourself and others, caring for
others.(Mental Health Foundation – website below)
Maintain and protect and your mental and emotional health www.mentalhealth.org.ukAPPENDIX 2 PATIENT EDUCATION
After diagnosis it is essential that education is given at a level appropriate to individual needs.
EDUCATION CHECKLIST
INFORMATION TO BE GIVEN SIGN OFF WHEN GIVEN
Patient information booklet given (Specify)
Patient hand held record given
What is diabetes
Causes of diabetes
The Annual Review - what care to expect
HbA1c normal ranges
Lifestyle issues:
Diet
Physical activity
Smoking
Alcohol
Mental and emotional health
Medication – relevant information about current medication
Hypoglycaemia
Hyperglycaemia
Driving What / when to report to DVLA
Sick day rules
Possible complications associated with poor control:
Retinopathy and importance of annual screening
Renal problems
Arterial problems
Neuropathy
Foot problems / foot care
Travel
Fasting / feasting
Blood glucose monitoring
Sexual Health – women (see appendix)
Sexual Health – men (Erectile Dysfunction)
Diabetes UK info
Yearly Flu immunization recommendation and review pneumococcal
statusAppendix 3: Blood glucose monitoring in Primary Care
All patients monitoring blood glucose levels should be advised to check the accuracy (Quality Assurance) of the blood glucose meter on a monthly basis. Control solutions used to
carry out this procedure are, in most cases, available free of charge from the manufacturer.
FREQUENCY OF TESTING
Type 1 diabetes Type 2 diabetes
If on diet and physical activity
Blood glucose testing is essential for ALL people with type 1 diabetes If taking - Patients do not need to monitor blood glucose levels on a daily basis. Ensure HbA1c is
undertaken regularly.
basal bolus regimen this could be up to 6 times a day
If on diet, physical activity and Metformin (+/- Glitazone)
Frequency may be increased during intercurrent illness
- As above
Ketone testing equipment should be available for times of acute illness
If on sulphonylurea / Insulin secretagogue
Drivers should maintain a record (as per DVLA recommendations) and test - Increased risk of hypoglycaemia. Testing may be necessary to confirm or avoid this
prior to all journeys including those on sulphonylureas
Type 2 on conventional insulin therapy
Pre Pregnancy and pregnancy - may be necessary to test up to 6 times daily
- If stable, 2 – 3 times a week at different times
- If unstable, once daily testing at different times of the day until stability achieved
Approximate usage - See Type 1 diabetes for DVLA recommendations
Six tests per day = 48 boxes (50 strips each) per year Type 2 on intensive insulin therapy
= 4 boxes per month
- May be necessary up to 6 times daily
One test per day = 8 boxes per year - See Type 1 for DVLA recommendations
Pre Pregnancy and pregnancy
Three tests per week = 4 boxes per year
(This includes extra strips for testing when ill & accidental wastage) - May be necessary up to 6 times daily PTO…
An annual assessment of self-monitoring skills, quality and frequency of
testing, the use made of results, impact on quality of life and equipment used
is essential.Appendix 3: Blood glucose monitoring in Primary Care cont’d When considering suitability for blood glucose monitoring the following points should be considered: Visual acuity Manual dexterity Ability to use blood glucose meter Willingness of patient to perform tests When initiating blood glucose monitoring the following process should take place: Offer choice from standardised range of meters ONLY according to patient needs Demonstrate chosen meter and finger pricking device, identifying procedure for patient to follow Give information on the safe disposal of sharps Issue blood glucose monitoring diary indicating agreed individual target range and frequency of testing (See previous page) Give information to patient regarding what to do with self testing results Ensure patient has a contact number for access to HCP advice Arrange to review self testing results at a suitable interval
Appendix 4: Nutrition and Dietetic Services Hywel Dda Health Board
Draft of Referral Criteria for Diabetes 2011
Referral Criteria for Diabetes Referral Details / Notes Evidence Base First Line Advise / Signposting
Newly Diagnosed Type 1 Referred to structured group Consensus Guidelines for the www.diabetes.org.uk is a reliable
education programme (as Management of Adults with evidence based website for HCP and
appropriate) after 1:1 with Diabetes across Wales (2008) all patients with Diabetes
Urgent Dietitian
NICE Guidance: Type 1
Diagnosis & Management (2010)
Poorly controlled Type 1 Diabetes Referred to structured group Consensus Guidelines for the www.diabetes.org.uk is a reliable
education programme where Management of Adults with evidence based website for HCP and
available, otherwise please Diabetes across Wales (2008) all patients with Diabetes
Routine complete Dietetic referral
form with detail to enable NICE Guidance:Type 1 Diagnosis
effective/optimal problem & Management (2010)
solving
Carbohydrate Counting for Insulin Structured Group Education Consensus Guidelines for Wales www.diabetes.org.uk is a reliable
Dose Adjusting - Education Programme when possible. (2008) evidence based website for HCP and
all patients with Diabetes
Refer to Dietetic service if NICE Guidance: Type 1 (2010)
programme not available / if
Routine patient prefers individual NICE Guidance: Insulin Pump
consultation Therapy (2008)Appendix 4: Dietetic referral criteria
Diabetes in Pregnancy/Gestational Urgent 1:1 consultation Consensus Guidelines for Wales (2008) www.diabetes.org.uk is a reliable evidence
Dietetic Referral Criteria HDHB April 2011
required
Diabetes based website for HCP and all patients with
Refer to Dietetic service & NICE Guidance: Diabetes in Pregnancy Diabetes
Urgent contact service to enable (March 2008)
combined appointment when
possible
Type 2 Diabetes (new or poorly First choice: XPERT structured Consensus Guidelines for Wales (2008) First line advice from HCP
controlled) group education programme for
people with Type 2 diabetes. The Diabetes National Service The Health Board’s Dietetic Service ‘First Line
XPERT referral form need to be Framework NSF for Wales (2003) Advice’ booklet is available for use by HCP
completed & forwarded to local
Routine diabetes team. NICE Guidance: The Management of
Refer for 1:1 consultation with type 2 Diabetes (2008)
Dietitian if the patient is not
appropriate for group education The Implementation of Nutritional
Advice for People with Diabetes:
Diabetes UK (2003)
Type 2 Diabetes progressing onto First choice: XPERT structured Consensus Guidelines for Wales (2008) www.diabetes.org.uk is a reliable evidence
insulin therapy group education programme, based website for HCP and all patients with
Refer for 1:1 consultation with NICE Guidance (2008) Diabetes
Dietitian if the patient is not
appropriate for group education NSF (2003)
Routine
IGT/IFG Consensus Guidelines for Wales (2008) First line advice from HCP
Routine NICE Guidance:Type 2 (2008) The Health Board’s first line weight management
patient information leaflet can be used by HCP
Encouraged to increase physical exercise & consider
referral to Exercise for Life programme
www.food.gov.uk/healthiereating/eatwellplate/
Reliable information on healthy eating for HCP and
patientsAppendix 4: Dietetic referral criteria Referrals to the Dietetic Service should include the following information as a minimum: Full Name: D.O.B. Address: NHS number: Contact details: Reason for Referral: Medical History (& relevant family history), including height, weight, BMI and recent biochemistry results. Current Medication: Other Information:
Appendix 5: Pregnancy and Diabetes/IGT
Ask patient if she is planning pregnancy
No, not planning pregnancy Yes, thinking of pregnancy
Check HbA1c if Screen for Review all meds Offer / refer to
none within last 6 complications Commence folic acid 5mg pre-conception
Check she is taking effective
months Retinal/ Advice smoking cessation clinic
contraception
microalbuminuria
Advise to seek advice if she Check U/E, TFT,
wishes to be pregnant rubella
HbA1c >7% (53mmol/mol), HbA1cAppendix 6: HbA1c Conversion Chart. Older DCCT-aligned (%) and newer IFCC-standardised (mmol/mol) concentrations
DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC
(mmol/mol) (mmol/mol) (mmol/mol) (mmol/mol) (mmol/mol)
5.0 31 6.0 42 7.0§ 53 8.0 64 9.0 75
5.1 32 6.1 43 7.1 54 8.1 65 9.1 76
5.2 33 6.2 44 7.2 55 8.2 66 9.2 77
5.3 34 6.3 45 7.3 56 8.3 67 9.3 78
5.4 36 6.4 46 7.4 57 8.4 68 9.4 79
5.5 37 6.5†,‡ 48 7.5†,‡ 58 8.5 69 9.5 80
5.6 38 6.6 49 7.6 60 8.6 70 9.6 81
5.7 39 6.7 50 7.7 61 8.7 72 9.7 83
5.8 40 6.8 51 7.8 62 8.8 73 9.8 84
5.9 41 6.9 52 7.9 63 8.9 74 9.9 85
DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC DCCT (%) IFCC
(mmol/mol) (mmol/mol) (mmol/mol) (mmol/mol) (mmol/mol)
10.0 86 11.0 97 12.0 108 13.0 119 14.0 130
10.1 87 11.1 98 12.1 109 13.1 120 14.1 131
10.2 88 11.2 99 12.2 110 13.2 121 14.2 132
10.3 89 11.3 100 12.3 111 13.3 122 14.3 133
10.4 90 11.4 101 12.4 112 13.4 123 14.4 134
10.5 91 11.5 102 12.5 113 13.5 124 14.5 135
10.6 92 11.6 103 12.6 114 13.6 125 14.6 136
10.7 93 11.7 104 12.7 115 13.7 126 14.7 137
10.8 95 11.8 105 12.8 116 13.8 127 14.8 138
10.9 96 11.9 107 12.9 117 13.9 128 14.9 139Appendix 7: Useful Telephone Contacts
Locality Carmarthenshire Ceredigion Pembrokeshire
Diabetes Consultant 01267 227869 01970 635749 01437 774358
Diabetes Specialist nurses 01267 227746 01970 635750 01437 773329
Dietetics 01267 227067 01970 635730 01437 774356
Community nurse 07964109694
Podiatry 01267 227058 01970 635987 / 01239 615302
Vascular surgeon 01267 227951 01267 227951 01437 773399
Tissue viability nurse 01267 227761 07974962716
01437 773122
Stop Smoking Wales 0800 085 2219 0800 085 2219 0800 085 2219
Retinal screening 01443 844244 01443 844244 01443 844244
Ophthalmology 01267 227749
Consultant Biochemist 01267 227454 01970 635784/5836 01437 773232Exercise referral programme 01269 590234 01970 633610
Alcohol support service PRISM 01267 231634
West Wales Substance Misuse West Wales Substance Misuse West Wales Substance Misuse Service
Service 01267 244442 Service Tel: 01970 636340 Tel: 01646 690327
Mental and Emotional health Primary Care mental health team
support stress control programme 01269 Primary care mental health team
833368Appendix 8
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