Diabetes Care Pathway 2010

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DIABETES CARE PATHWAY

VERSION 5 May 2010REVIEW May 2011


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CONTRIBUTORS

Chris Baynes Consultant Physician Barnet & Chase Farm HospitalPaul Gouldstone Head of Medicines Management NHS EnfieldDebbie Hicks Nurse Consultant Diabetes NHS Enfield Community Services

Kit McAuley Diabetes Specialist Nurse NHS Enfield Community ServicesDr Hilary Tindall Consultant Physician North Middlesex University HospitalAs endorsed by NHS Enfield NSF Implementation Group and NHS Enfield Commissioning Executive

The printing of this document was supported by an unrestricted educational grant from the following companies:

Abbott Laboratories LtdBayerBristol Myers Squibb Pharmaceuticals LtdEli Lilly & Co LtdGSKLifeScan (Johnson & Johnson)

MSDNovo Nordisk LtdPfizer LtdSanofi Aventis LtdTakeda UK Ltd

The following guidelines have been based on: NICE CG 66 Type 2 diabetes guidelines for Diabetes 2008and NICE CG 87 Type 2 diabetes: partial update 2009

This document has been reviewed in its entirety in May 2010, however only some pages have required updating due to new evidence.These pages can be identified by the review date May 2010


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DIABETES CARE PATHWAY TYPE 2 DIABETES

*

Reviewed May 09

*See laminated version appendix 1 & 2

MILESTONE 1

Diagnostic phase

MILESTONE 2

Educative phase

MILESTONE 3

Treatment managementphase

MILESTONE 4

Complication / riskmanagement

MILESTONE 5

Maintenance phase

a. Lifestyle changes*

b. Patient given PCTinformation booklet

c. Patient given PCT handheld record

d.Referral to dietitian

e. Referral to groupeducation sessions viaDiabetes Referral & Triage

f. Regular reviewsee maintenance phase

a. Check and recheckunderstanding

b. Lifestyle issues*Inc Smoking and exercise

c. Medication

d. Complications

e. Importance of regularreview

m. Diabetes UK / supportgroups

j. Foot health

l. Travel

h. Importance of goodglycaemic control HbA1c /mmols/mol

i. Eye examinations withdilated pupils & retinal camera

k. Sexual health

a. - Offer dietary advice- Trial of lifestyleinterventions includingincreased activity

b. Treat all co existentpathology e.g. BP, lipids

Arrange screening forcomplications

See Milestone 4

c. See medication algorithm

d. Continued education & support

e. 3 4 monthly HbA1c /mmols / mol

f. Continue to follow medicationalgorithm

g. Once stabilised, regular reviewSee Maintenance phase

a. Hypertension

b. Lipid Management

c. Anti-platelet therapy

d. Microalbuminuria

g. Retinopathy /Footcare

a. Regular review if unstable2 3 monthly

b. 6 monthly review oncestabilized

c. Annual review(see Appendix 2)

d. Ongoing review of

educational needs

g. Importance of good BPcontrol

e. Review of dietary needs

n. Offer structured educationprogramme

h. People with severemental health diagnosisshould be checkedannually for diabetes

f. People with existing diabetesshould be monitoredfordepression

e. Management of CKD

f. Management of painfulneuropathy

h. Erectile Dysfunction

g. Information about monitoringand glucose meters whereappropriate

g. Assessment of emtionalwellbeing

f. Driving

i. Obesity

j. Peripheral arterial disease


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MILESTONE 1: DIAGNOSIS OF DIABETES MELLITUS

PRESENTING SYMPTOMS

1. Patient presents with signs and symptoms suggestive of Type 2 diabetes Excessive thirst Increased urination 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 glycosuria3. Increased suspicion due to risk factors e.g.

Ethnicity Family history

40 years of age Previous gestational diabetes Existing severe mental illness such as schizophrenia

WHO DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS

IF RBG 6.0 11.0 mmols/ l FBG IF RBG 11.1 mmols / l Diabetes diagnosed ( OGTT NOT required)If FBG < 6 mmols / l, diabetes is unlikely If FBG is 6.1 7.0 mmols / l perform OGTT

NB: In the absence of osmotic symptoms 2 consecutive venous samples are required to diagnose Diabetes Mellitus

PLASMA DIABETES CONFIRMED IMPAIRED GLUCOSETOLERANCE

IMPAIRED FASTING GLYCAEMIA

FBG 7.0 < 7.0 6.1< 7.0

OGTT2 hour value

11.1 7.8


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MILESTONE 2:EDUCATION IN TYPE 2 DIABETES

Reviewed May 09

STEP 1Assess

learning needs

STEP 2Review

understanding

STEP 3Discuss

Lifestyle issues

STEP 4Discuss

Complications

STEP 5Facilitate

Dietetic referral

STEP 7Review

understanding

STEP 6Understanding

the annualreview

Is English the firstlanguage?

What is diabetes? Diet

Is the patientliterate in English?

Is the patientliterate in ownlanguage?

Arrangeappointments asnecessary withinter reter

Importance ofregular diabeteschecks

What to expect atan Annual Review

Diabetes UK /Enfield supportgroup

Exercise

Smoking

Alcohol

Importance of

medication

Eyes

Kidney

Neuropathy

PVD

Foot

CVD

Has patient beenreferred todietitian?

YES

Recheck

understanding

Give stop gapdietary advice

NO

Refer todietitian

Height, weight,BMI, waistcircumference

BP

Foot assessment

Pedal pulses Neuropathy

status

Routine bloodtests / urine tests

HbA1c/mmols/mol

U&E

TFT LFT

Lipid profile

eGFR ACR

Retinopathystatus

Enrolment ontoNMUH Retinal

ScreeningProgramme

Importance ofregular diabeteschecks

Reviewconcordance withmedication

Reviewconcordance withhealthy eating

regimen

Assess gaps inknowledge andprovideeducateion asappropriate

Socialadjustments

Psychological well

being

Offer patient

EPCT structureddiabeteseducationprogramme

Drivingregulations

ErectileDysfunction


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT

HYPERTENSION

Information would be appreciated asap

IF BP REMAINS ABOVE TARGETOff

Reviewed & updated May 10

1. Aim for Blood Pressure

measurement of: If NO renal

complications arepresent aim for 140 / 80 mmHg

If eye complications arepresent aim for


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTD

LIPIDSRAISED 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)NB Intolerance is typically muscle or liver related: myalgia and/or rhabdomyolysis, CK > 10x or LFTs (AST/ALT) >3x normal

Step 2. Atorvastatin 40mgonce daily

Step 3. Atorvastatin 80 mg once daily

Step 4. If target not reached, either add in Ezetimibe 10mg or switch to Rosuvastatin 10mg. Start at 5mg in Asian population (Increase

Rosuvastatin slowly bi-monthly)

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, (Fenofibrate) on a case by case basis and consider referral to specialist services.

Reviewed & u dated Ma 10


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTD


ANTI PLATELET THERAPY:

Indications for low dose aspirin treatment in diabetes in the updated Joint British Societies (JBS 2) guidelines,British Cardiac Society et al, 2005.

People with established macrovascular disease:

IHD

TIA / CVA

PVD

OR considered very high risk with 2 or more of the following: Raised BP

Smoker

Dyslipidaemia

1st line:

Soluble aspirin 75 mg daily. This is to be given unless there is an absolute contraindication

2n

line:

For patients who cannot tolerate soluble aspirin, or have a history of ulceration, add in either Lansoprazole Capsules 15mg OD orOmeprazole Capsules 20mg OD and continue with soluble aspirin

3r

line:

If aspirin is still poorly tolerated, contra-indicated, has had a previous cardiovascular event, or compliance issues favour monotherapy,

Clopidogrel 75mg daily


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENTOBESITY

ASSESSMENT

All patients with diabetes should have their BMI recorded annually Classification of BMI*:

CLASSIFICATION BMI RISK OF CO-MORBIDITIES

Underweight 30.0

Class i 30.0 34.9 Moderate

Class ii 35.0 39.9 HighClass 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, learningdisabilities, 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 28


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENTOBESITY CONTD

MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT

TREATMENT OF OBESITYAim of treatment is to:

Reduce calorie intake 7.5% or 59 mmols/mol and BMI >35Refer to Diabetes Nursing Team using Referral and Triage form

IF BMI IS > 40, CONSIDER BARIATRIC SURGERY



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MILESTONE 4:COMPLICATIONS / RISK MANAGEMENT CONTD

RENAL COMPLICATIONS / MICROALBUMINURIA SCREENING

Reviewed May 09

DIPSTICK URINE FOR PROTEIN USING MULTISTIX / ALBUSTIX

IF POSITIVE

If 1st

specimen is abnormal exclude UTI (collect MSU)

If 2nd

specimen is abnormal quantify proteinuria by albumin /creatinine ratio (A:CR).

Treat to target1. BP (Aim < 125 / 75)2. Glycaemic control HbA1c 6.5% or 48 mmols/mol.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 tolocal CKD guidelines

SEE eGFR GUIDELINES

IF NEGATIVE

Refer to local laboratory guidelines for EMU collection protocol

Collect EMU for Albumin / Creatinine ratio

Normal A : C Ratio Males < 2.5 mg / mmol

Females < 3.5 mg / mmol

If specimen is within normal range retest annually

** PLEASE NOTE THAT THESE TESTSARE IN ADDITION TO THE eGFR **

NICE Clinical Guideline 66 Management of Type 2 diabetes mellitus, May 2008


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MILESTONE 4: COMPLICATIONS AND RISK MANAGEMENTREFERRAL FOR CKD USING eGFR IN DIABETES MELLITUS

Chronic 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 renalfunction is severely reduced.

Serum creatinine has traditionally been the mainstay for the initial identification of renal disease. Serum creatinine on itsown 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 andmonitoring of CKD patients being mls / minute / 1.73 m

2.

Both NMUH and CFH laboratory will calculate the eGFR using the following variables: creatinine, age, sex.

Ethnicity should be factored in by multiplying the result by 1.212 in patients of African Caribbean origin. This should bedone by a clinician.

eGFR is not applicable in people < 18 years, acute renal failure, pregnancy, amputees, extremes of body weight, 1 kidney.

Stage eGFR result Severity of CKD Frequency oftesting

Referral to renal team Type of referral

1 > 90 Normal Annually Only if specificallyindicated

See table 1

See below

2 60 - 89 Mild impairment60 90 % renal function

Annually As for stage 1See table 1

See below

3A 45 - 59 Moderate impairment45 - 59% renal function

3 - 6 monthly NO ONLY ifdeteriorating function

See table 2

Routine referral -See below

3B 30 - 44 Moderate impairment30 44% renal function

3 6 monthly Yes See table 3

Referral or discussion

4 15 - 29 Severe impairment15 30 % renal function

3 monthly YesSee table 4

Urgent referral ordiscussion

5 < 15 Established CKD 3 monthly YesSee table 4

Immediate referral ordiscussion


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YOU HAVE FOUND THAT YOUR PATIENT HAS A HIGH CREATININE (LOW eGFR)

In all cases initial assessment of high creatinine / low eGFR should include:

Is the patient well? Is there a history of significant disease? History of significant associated disease: Referral may need to be considered if indicators present e.g. urinary abnormalities Review previous results: Assess whether stable or deteriorating. If patient appears well repeat within 2 weeks, sooner if there

is any doubt. NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings

Clinical assessment: Look for signs of sepsis, heart failure, hypovolaemia, bladder enlargement Medication review: Look for recent additions e.g. ACE inhibitors, ARBs, NSAIDS, Antibiotics, diuretics, Mesalazine, PPIs Blood tests: HbA1c, Ca2+, PO4, FBC, CRP. Hypercalcaemia may cause acute renal impairment or deterioration

Urine tests: Dipstick for blood and protein BP/Cardiovascular assessment (including peripheral circulation) : Malignant hypertension and Grade 4 retinopathy needs

immediate referral to on call medical team

Imaging: Required if function is deteriorating and of unknown origin. Urgency will be ascertained by speed of deterioration

REFER TO APPROPRIATE TABLE:

Stage 1 & 2 Table 1

Stage 3A Table 2

Stage 3B Table 3

Stage 4 & 5 Table 4


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Table 1Management of Stage 1 and 2 CKD in Diabetes Mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT Patient can be managed in Primary Care

setting

Patients have normal / near normaleGFR but have other evidence of renaldisease e.g polycystic or refluxnephropathy or microalbuminuria in

diabetes

Referral to joint diabetes / renal clinic is notrequired unless:

Nephrotic range proteinuria > 3g/ 24 hoursor PCR > 300 mg /ml.

See below

Initial assessment to include:

- Blood tests: , HbA1c, TFTs, Ca2+, PO4, FBC, CRP- Urinalysis: Dipstick for blood and protein- BP/Cardiovascular assessment (including peripheral circulation) : Ensure BP within target range (


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Table 2Management of Stage 3A CKD in Diabetes Mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT

Patient can be managed in Primary Care

setting or on a shared care basis

Patients have stable renal function (eGFR orcreatinine)

Referral to joint diabetes/renal clinic is not

required unless eGFR is 40 mls / min.

**A diabetes referral form will be required**

See below for general management

Initial assessment to include:

Review previous results: Assess whether stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2 days.NB: Slight changes in eGFR may move patients frequently from one stage to another. Look at average readings

Assess for the following:

- Is the patient well? Is there a history of significant associated disease which involves kidneys e.g. urinary abnormalities

- Clinical assessment for heart failure, sepsis, hypovolaemia, examination for bladder enlargement ( may need imaging if obstruction) and rectalexamination for prostate enlargement

- Medication review. Look for recent additions e.g. ACE inhibitors, ARBs, NSAIDS, Mesalazine, Antibiotics, Diuretics- Blood tests: HbA1c, Ca2+, Phosphate, Hb, Cholesterol, PTH- Urinalysis: Dipstick urine for blood and protein- Cardiovascular assessment: BP and peripheral vascular disease.

- Imaging. Exclusion of obstruction

Ongoing management:IF CREATININE IS > 150 MICROMOLS/L OR THE eGFR < 30 STOP METFORMIN* IF DISCREPANCY BETWEEN 2 VALUES USE eGFR:REFER TO PRIMARY CARE DIABETES TEAM VIA DIABETES REFERRAL AND TRIAGE FORM IF NECESSARY

Blood tests initially to be done 3 monthly then 6 12 monthly when stable for:- HbA1c/ mmol/mol- Creatinine and Potassium- Ca2+- Phosphate- Hb

- Cholesterol

Urine tests:- Protein estimation if proteinuria- IfMICROSCOPIC haematuria Urology referral if > 50 years old, if < 50 years old Nephrology referral. All MACROSCOPIC haematuria needs

urology referral

Blood pressure. Meticulous control of BP 125/ 75 (see Milestone 4: Diabetes Care Pathway)

Smoking, exercise and lifestyle advice (see Diabetes Care Pathway Appendix 1)

Aspirin (see anti platelet therapy Milestone 4: Diabetes Care Pathway)

Cholesterol lowering therapy (Milestone 4 Diabetes Care Pathway)

Immunisation for influenza and pneumococcus

Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Please exercise caution in bisphosphonates


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Table 4Management of Stage 3B, 4 and 5 CKD in Diabetes Mellitus

GENERAL POINTS EXCEPTIONS MANAGEMENT

Patient will be cared for on a shared care

basis Referral in first instance to Dr H Tindall / Dr

D Jayaseena joint diabetes / renal clinic atNMUH

If severe renal impairment is part of another

terminal illness Those patients for whom further

investigation and management is clearlyinappropriate

There is a clear and understood pathway ofcare already in place

Referral to Dr H Tindall / Dr D Jayaseena

joint diabetes / renal clinic at NMUH

Assess for the following:- Clinical Assessment and Medication Review as per stage 3 CKD

- Assess whether values are stable or deteriorating. Repeat within 2 weeks if patient appears well. If patient is unwell repeat within 2 days.- Is the patient well? / Clinical assessment: Is there significant associated disease? If yes, consider urgent referral- Blood tests: HbA1c, Ca2+ Phosphate ,Hb, cholesterol, PTH- Urinalysis: Dipstick urine for blood and protein- BP/ Cardiovascular assessment- Dietary assessment

Ongoing management:

METFORMIN SHOULD BE STOPPED IN ALL PATIENTS WITH eGFR 30

Blood tests 3 monthly for:- HbA1c / mmols/mol- Creatinine, Potassium and bicarbonate- Ca2+- Phosphate- Hb, Ferritin, B12 and folate- Cholesterol- PTH

Urine tests:- Protein estimation if proteinuria- Haematuria as in Stage 3

Correction of acidosis. Oral bicarbonate after discussion with joint diabetes / renal team

Blood pressure. Meticulous control of BP120/ 70 (see Milestone 4: Diabetes Care Pathway)

Smoking, exercise and lifestyle advice (see Diabetes Care Pathway Appendix 1)

Aspirin (see anti platelet therapy Milestone 4: Diabetes Care Pathway)

Cholesterol lowering therapy (Milestone 4 Diabetes Care Pathway)

Immunisation for influenza and pneumococcus. In stage 4&5 CKD Hepatitis B is also added Medication review: Regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs). Please exercise caution in bisphosphonates


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MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTD - PAINFUL NEUROPATHY


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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 distribution

MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTD - PAINFUL NEUROPATHY


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Updated NICE Guidance May 2010


PERIPHERAL NEUROPATHY HAS BEEN DIAGNOSED

STEP 1 Improve glycaemic control. Liaise with diabetes nursing team / dietician if appropriate. Aim for normoglycaemia Prescribe 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 Duloxetine previously prescribed in Step 1 If pain is still present, add in:

- Amitryptyline 25 mg 75mg at night (unlicensed for this indication)

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

MILESTONE 4: COMPLICATIONS / RISK MANAGEMENT CONTINUED


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Reviewed May 09

RETINOPATHY:

1. Ensure that patient understands the importance of annual retinopathy screening

2. Ensure that patient is enrolled on the Enfield & Haringey Community Retinopathy Screening Programme for digitalphotography. Please contact NMUH Diabetes Centre Retinopathy team on 0208 887 2352 or fax 020 8887 4414.

3. At annual review, check that a result is present in the patient records dated within the last 12 months4. Results of retinal screening should be discussed with patient5. If retinopathy is present ensure appropriate referral is made re: NICE guidelines

FOOT CARE:

1. Ensure that feet are assessed including foot pulses, vibration, sensation by a competent practitioner annually (See alsoMilestone 4: Peripheral Arterial Disease [PAD])

2. Record results on diabetes template3. Ensure that principles of good foot care are reiterated at each review

4. Refer for podiatry treatment as appropriate5. ReferURGENTLYTO RAPID ACCESS CLINIC 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

This service is available Monday to Friday 9 4 only. Please telephone 020 8887 4257 and ask to speak to the VascularNurse Specialist or telephone 020 8887 2000 and ask for Bleep 324.

DO NOT SEND PATIENTS TO THIS SERVICE UNLESS CONTACT HAS BEEN MADE WITH THE DIABETES TEAM

6. Refer to Painful Neuropathy Care Pathway if symptoms of painful neuropathy are present or referral to EPCTNeurovascular assessment clinic via Diabetes Referral and Triage form.


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MILESTONE 5: MAINTENANCE

Reviewed May 09

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 on BOTH feet

Lifestyle issues- Driving- Activity levels- Smoking- Alcohol

- Sexual activity- Stress Assess for de ression

S C G S


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APPENDIX 1 LIFESTYLE CHANGES

HEALTHY EATING (STOP GAP INFORMATION)

ADVICE TO BE GIVEN EXAMPLES

Regular meals that include carbohydratesThis will help to control blood glucose levels*

High fibre low salt and low fat breakfast cereals 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 fruitintake 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 drinks

Reviewed May 09

APPENDIX 1 LIFESTYLE CHANGES CONTD


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APPENDIX 1 LIFESTYLE CHANGES CONTD

STOPPING SMOKING

ADVICE TO BE GIVEN WHAT TO DO

Assess smoking status Advise to stop*

Give information about smoking cessation service Give patient information card / leaflet Contact Quit Smoking Service on FREEPHONE 0800 085 6258 or

EMAIL www.quitsmoking.uk.com

ALCOHOL ADVICE

ADVICE TO BE GIVEN EXAMPLE

There is no harm in drinking in moderation* 1 unit of alcohol = half a pint of beer or lager, 1 small glass of wine or1 single measure

Men should drink no more than 3 units a day Women should drink no more than 2 units a day

*Diabetes UK Patient information www.diabetes.org.uk

Reviewed May 09

INCREASING ACTIVITY

ADVICE TO BE GIVEN EXAMPLES

Increase exercise levels gradually until exercising for at least 30 minutesa day 5 x week*

Walking daily Increase distance and speed Once exercising regularly, try cycling, swimming etc. If heart problems Heart Throbs Exercise class Housework / gardening if mobility is limited

If immobile teach armchair exercises

APPENDIX 2 PATIENT EDUCATION


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APPENDIX 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

Patient held record given

What is diabetes

Causes of diabetes

The Annual Review - what care to expect

HbA1c normal ranges

Lifestyle issues: Diet Exercise Smoking Alcohol

Medication relevant information about current medication

Hypoglycaemia

HyperglycaemiaDriving What / when to report to DVLA

Sick day rules

Possible complications associated with poor control:Retinopathy and importance of annual screeningRenal problemsArterial problemsNeuropathyFoot problems / foot care

Travel

Fasting / feasting

Blood glucose monitoring

Sexual Health - women

Sexual Health men (Erectile Dysfunction)

Diabetes UK info / Enfield support group

Psychological well-being

Reviewed May 09


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Appendix 3: Blood glucose monitoring in Primary Care contd


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Reviewed and updated May 10

PHARMACIES INVOLVED IN EQA PROJECT FOR BLOOD GLUCOSE METERS IN ENFIELD

Atkinson Chemist 20, The Grangeway N21 2HGAtkinson Chemist 750, Green Lanes N21 3RE

Co-op Pharmacy 255-257 Hertford Road EN3 5JL

Co-op Pharmacy 247 High Rd EN3 4DR

Co-op Pharmacy 417 Hertford Rd EN3 5PT

Co-op Pharmacy 66, Silver St EN1 3EP

Co-op Pharmacy 670, Hertford Rd EN3 6LZ

Forest Pharmacy 308a Hertford Road N9 7HDHayward Pharmacy 10, Queen Anne Place, EN1 2HB

Lloyds Pharmacy 261 Fore St N18 2TY

Lloyds Pharmacy Florey Sq N21 1UJ

Lloyds Pharmacy 44, Cannon Hill N14 6LH

Lloyds Pharmacy 98A South St EN3 4QA

Lloyds Pharmacy 304, Baker St EN1 3LD

Lloyds Pharmacy 614 616 Hertford Rd EN3 5TD

Sainsbury Pharmacy 681, Green Lanes N21 3RS

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

Documents

Diabetes Care Pathway 2010