Initial management of type 2 diabetes NS MOM

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Scope:

• diabetes mellitus (DM) in adults, including:
  • diagnosis
  • management:
    • blood glucose control
    • structured education
    • self-monitoring
  • management of complications:
    • diabetic foot disease
    • renal disease
    • retinopathy
    • cardiovascular disease (CVD)
    • diabetic ketoacidosis
    • hypoglycaemia
  • gestational diabetes mellitus (GDM), ie new onset during pregnancy
  • management of pre-existing diabetes or impaired glucose tolerance during pregnancy, including pre-conception care
  • diabetes specific care of mother and baby before and after birth

Out of scope:

• diabetes in children and adolescents 
• maturity-onset diabetes of the young (MODY) and neonatal diabetes mellitus (NDM)
• population screening for asymptomatic diabetes

Definition:

• lack of insulin production and/or insulin resistance, which leads to impairment of carbohydrate, protein, and fat metabolism
• type 1 DM is due to the lack of insulin production by beta cells in the pancreas, which may result from viral infection, autoimmune reactions, and genetic factors
• type 2 DM results from reduced tissue sensitivity to insulin (insulin resistance) and/or reduced insulin production
• monogenic diabetes results from single gene defects giving rise to hyperglycaemia
• secondary diabetes results from reduced insulin production (associated with other pancreatic disease, injury, or surgery) or from excess insulin antagonists, eg in Cushing's syndrome, acromegaly
• diabetes in pregnancy may be a pre-existing condition identified before pregnancy, or may develop during pregnancy
• diabetic ketoacidosis is a medical emergency with a significant morbidity and mortality

Incidence and prevalence [39]:

• as at March 2013, the Quality and Outcomes Framework data reports the known diagnosed population with diabetes in the UK is approximately three million people

Associations:

• type 1 diabetes:
  • family history of diabetes
  • other autoimmune disorders, eg Graves' disease
  • viruses, eg rubella, Coxsackie B virus, cytomegalovirus
• type 2 diabetes is multifactorial − associations include:
  • increasing age (most commonly appears in people over age 40 years)
  • obesity (particularly central obesity)
  • family history of diabetes
  • low level of physical activity
  • history of gestational diabetes
  • high risk ethnic population (African or Asian origin)
  • hypertension
  • Dyslipidemia
  • polycystic ovary syndrome (PCOS)
  • history of impaired glucose tolerance or impaired fasting glycaemia
  • smoking
  • social deprivation

Prognosis:

• type 1 diabetes:
  • increasing blood glucose levels, if diabetes is untreated, can lead to ketoacidosis and non-ketotic hyperosmolar states that may result in coma and death
  • some people with type 1 diabetes may have residual insulin production for several years – insulin treatment is usually still needed to prevent ketoacidosis and non-ketotic hyperosmolar states
• type 2 diabetes:
  • increasing blood glucose levels, if diabetes is untreated, lead to non-ketotic hyperosmolar and ketoacidosis states that may result in coma and death
• the mortality rate in patients with diabetic ketoacidosis (DKA) is approximately 3-5% and 15% in patients with hyperosmolar hyperglycaemic state (HHS) [37]

Complications may arise from long-term presence of diabetes:

• macrovascular
  • cardiovascular and cerebrovascular disease
  • peripheral vascular disease
• microvascular
  • neuropathy
  • renal disease
  • retinopathy

• 'Diabetes & high Blood Pressure' (PDF) from Patient UK at http://www.patient.co.uk
• 'Diabetes, Foot Care & Foot Ulcers' (PDF) from Patient UK at http://www.patient.co.uk
• 'Pregnancy and Diabetes' (PDF) from Patient UK at http://www.patient.co.uk
• 'Diabetes UK' (URL) from Diabetes UK at http://www.diabetes.org.uk
• 'Diabetic Retinopathy' (PDF) from Patient UK at http://www.patient.co.uk
• 'Treatments for Type 2 Diabetes' (PDF) from Patient UK at http://www.patient.co.uk
• 'Type 1 diabetes' (PDF) from Patient UK at http://www.patient.co.uk
• 'Diabetes in Adults' local web portal from NSCP health

Local administrative information

 NSCCG Sign off form May 2016

NSCCG Sign off form Sept 2014 - Please see the attached sign off form for further information about the development of this care map.

Date of publication: 31-Jul-2013

The clinical content of this care map has been accredited by the Royal College of Physicians (RCP).

This care map has been drafted using the Map of Medicine editorial methodology (URL) and represents best clinical practice according to the highest quality evidence available, including the following:

• [2] American Diabetes Association (ADA). Standards of medical care in diabetes. Diabetes Care 2011; 35 (Suppl 1): S11-S63.
• [7] American College of Physicians (ACP). Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians (2012). Annals of Internal Medicine 2012; 156: 218-31.
• [9] Institute for Clinical Systems Improvement (ICSI). Diagnosis and Management of Type 1 Diabetes Mellitus in Adults. Bloomington, MN: ICSI; 2012.
• [15] National Institute for Health and Clinical Excellence (NICE). QS06 Diabetes in adults quality standard. London: NICE; 2011.
• [16] Diabetes UK. Evidence-based nutrition guidelines for the prevention and management of diabetes. London: Diabetes UK; 2011.
• [18] American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD). Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Philadelphia, PA : ADA/EASD; 2012.
• [24] National Institute for Health and Clinical Excellence (NICE). TA248 Diabetes (type 2) − exenatide (prolonged release): guidance. London: NICE; 2012.
• [27] Driver and Vehicle Licensing Agency (DVLA). At a glance guide to the current medical standards of fitness to drive. London: DVLA; 2012.
• [28] International Diabetes Federation (IDF). Guideline for the Management of post meal glucose. Brussels: IDF; 2011
• [29] Joint British Diabetes Societies (JBDS). Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Bristol: JBDS; 2013.
• [31] The Royal College of Ophthalmologists (RCOpth). Diabetic Retinopathy Screening Preferred Practice Guidance. London: RCOpth; 2010.
• [35] National Institute for Health and Clinical Excellence (NICE). PH38 Preventing type 2 diabetes - risk identification and interventions for individuals at high risk: guidance. London: NICE; 2012.
• [36] Diabetes UK (DUK). The national minimum skills framework for commissioning of foot care services for people with diabetes. London: DUK; 2011.
• [37] NHS Diabetes, Joint British Diabetes Societies(JBDS). JBDS guidance on management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes. Newcastle Upon Tyne: NHS Diabetes/JBDS; 2012.
• [38] Roderick R, Roth M, Mindell J. Prevalence of chronic kidney disease in England: Findings from the 2009 Health Survey for England. J Epidemiol Community Health 2011; 65:A1-A40.
• [39] Contributors representing the Royal College of Physicians (RCP) and the Royal College of General Practitioners RCGP), London; 2013.
• [42] National Institute for Health and Clinical Excellence (NICE). Diabetic foot problems: inpatient management of diabetic foot problems. Clinical guideline 119. London: NICE; 2012.
• [46] PRODIGY. Insulin therapy in type 2 diabetes. Version 1.6. Newcastle Upon Tyne: PRODIGY; 2012.
• [53] Kidney Disease Outcome Quality Initiative. K/DOQI clinical practice guidelines for diabetes: 2012 update. Am J Kidney Dis 2012; 60: 850-86.
• [55] Royal College of Ophthalmologists (RCOPHTH). Diabetic Retinopathy Guidelines. London: RCOPHTH; 2012.
• [57] Royal College of Obstetricians and Gynaecologists (RCOG). Shoulder Dystocia, Green-top Guideline 42. London: RCOG; 2012.

 Local administrative information

 DVLA driving guidelines

 The initial management of type 2 diabetes must cover the following topics;

• Screening for risk factors and long term complications
• Dietary advice including a referral to a dietitian for a specified plan
• Lifestyle and exercise advice
  • Smoking cessation
  • Exercise
• Structured education programme
  • All people with diabetes should be offered an ongoing education in the form of group education or 1:1

All newly diagnosed type 2 diabetes patients must be handed a Diabetes Information Pack (known locally as the 'Purple Folder'), the purple folder acts as an information resource for the patient and can help them fully understand everything discussed with their GP in regards to diabetes and how it can affect them.

Local administrative information

 Consider immediate discussion with clinician experienced in diabetic management and immediate commencement of medication

 Risk factors and long term complications to be assessed upon initial appointment with the patient.

Risk factors to be identified for cardio vascular disease and other complications; 

• Smoking history
• Blood pressure
• Random lipids (cholesterol, high density lipoprotein and triglycerides)
• Waist circumference
• Erectile dysfunction
• Calculation of 10 yr cardio vascular disease risk if no vascular disease using the QRISK 2 engine (ww.qrisk2.org). This has been developed and externally validated in United Kingdom populations including patients with type 2 diabetes. QRISK 2 (2010) applies to patients aged 30-84 years.

Surveillance for long term complications;

• Eyes
  • Corrected visual acuity
  • All patients should be referred to the NS retinal screening service for retinal photographs.
• Kidneys
  • Serum creatinine and estimate glomerular filtration rate
  • Urine albumin: creatinine ratio
• Feet (Foot assessment must be performed by staff who have received appropriate training in risk factors and foot examination)

 Local administrative information

 The BNSSG referral form is available as an EMIS template

 Foot assessment must be performed by staff who have received appropriate training in risk factors and foot examination)

• History of foot pain or previous ulcers
• General observation
• Vascular examination
• Neurological examination
• Footwear
• Education on footwear

Feet must be defined as being in one of four risk categories: low risk (no risk factors), moderate/increased risk (one risk factor), high risk (two or more risk factors or history of ulceration or charcot foot) and active problems. This must be documented and acted on, and the patient informed and given appropriate advice.

Provide information and clear explanations to people with diabetes and/or their
family members or carers (as appropriate) when diabetes is diagnosed, during
assessments, and if problems arise. Information should be oral and written, and
include the following:
Basic foot care advice and the importance of foot care.
Foot emergencies and who to contact.
Footwear advice.
The person's current individual risk of developing a foot problem.
Information about diabetes and the importance of blood glucose control

See Diabetes footcare NS MOM

 All people with newly diagnosed diabetes should receive dietary advice from a Practice Nurse as below:

• Advise weight loss if overweight, set an initial weight loss target of 5-10%
• Eat three small meals a day
• Include starchy carbohydrate foods (e.g. rice, pasta, potatoes, bread, cereals, yams) at each meal
• Reduced added fat and salt
• Aim for 5 portions of fruit & vegetables a day
• Limit sugar and sugary foods
• Keep alcohol within safe limits

Refer people with type 2 diabetes to the 'Living with Diabetes' structured education programme

 If the patient requires enhanced dietary advice then refer to a registered dietitian

Local administrative information

 NSCP Dietitians referral is via Managed referrals
WAHT Dietitians referral form is available as an EMIS template

 Smoking cessation;

• All people with diabetes should be strongly advised to stop smoking and should be referred to the local Stop Smoking service or other available sources of help;
  • see the Smoking cessation NS MOM pathway

Diabetes and exercise;

PositiveStep offer a free weight management course

• Who?
  • Anyone can do low impact exercise, and health care professionals should encourage this
  • Exercise does not worsen diabetic retinopathy, nephropathy or neuropathy and is safe in pregnancy
  • Individuals who have the following symptoms are at most risk of cardiac events and should initially be supervised when exercising
    • blood pressure drop on standing
    • loss of heart rate variation
    • severe neuropathy
    • very low fitness levels
• Patients should be advised not to take up strenuous activity suddenly
• Advice about exercise
  • Being more active is the aim
  • Any increase in activity is beneficial
  • Ask patients to pick an activity that suits them
  • Start slowly and build up gradually
  • For further advice please visit:
    • http://www.diabetes.org.uk/Guide-to-diabetes/Healthy_lifestyle/Keeping_active/
    • http://www.runsweet.com/ - A site for people with diabetes, with a focus on sport and insulin

 See the Exercise NS MOM pathway for online referral process

 In accordance with NICE guidelines, all people with diabetes should:

• receive ongoing structured education as part of their normal care and routine clinical reviews with their primary care team
• be offered the opportunity to participate in tailored group education sessions, based on an individual assessment of their learning needs
• or undergo 1:1 education with their practice

At diagnosis, all those with newly diagnosed type 2 diabetes should be:

• given a copy of the Purple Diabetes Information Pack
• referred to the 'Living with Diabetes' group education programme.

Referrals are accepted for those who have been diagnosed for up to 12 months. Patients can also self-refer, and the referral form will be sent to their doctor to complete.

This programme is a one day course delivered by trained educators at venues throughout the North Somerset area on a regular basis. After referral, patients will recieve an invitation letter to ring the education office to discuss the date and venue that would be most convenient for them to attend. For people who are housebound, contact the diabetes education team to discuss available options.

Local administrative information

 Referral to NSCP Diabetes Education programmes is via Managed referrals

 Aim for a trial of diet and exercise alteration for 3 months.

If symptoms are still persistent at 6 week review then consider starting oral hypoglycaemics at this point.

 Polyuria and thirst

 Consider short term use of self-monitoring of blood glucose so that patient can see effects of diet but emphasis only likely to be for 3 months to manage patient expectation

 Review fasting glucose results (HbA1c not appropriate for monitoring treatment effect at this stage) 

It is acceptable to defer initiation of oral hypoglycaemic treatment in an asymptomatic patient if glucose control continues to improve with lifestyle change alone.  

If patient is struggling with their newly diagnosed diabetes, PositiveStep run a free coping with diabetes course