http://www.gpct.grampian.scot.nhs.uk/grampintranet/ggmp/diabetes.cfm Type 2 Diabetes Mellitus. See Appendix 3 - Secondary Diabetes …

NHS Grampian Guidelines for

Management of Diabetes Mellitus

Revised for use by NHS Shetland staff in September 2006

Authorship

The guidelines for diabetes care in Grampian have been written on behalf of
the Grampian Diabetes Managed Clinical Network

A wide variety of individuals involved in the care of people with diabetes,
including practice nurses, dietitians, podiatrists, diabetes specialist
nurses, GPs and diabetes specialist physicians have contributed to and
commented on the text Colleagues in related departments including
ophthalmology, renal medicine, clinical pharmacology and urology have
advised on relevant sections The assistance of all those concerned is
gratefully acknowledged

Editorial board

Dr Prakash Abraham Consultant Diabetologist

Dr Shirley Copland Associate Specialist

Dr Ann Gold Consultant Diabetologist

Dr Mark Houliston General Practitioner

Dr Ken McHardy Consultant Diabetologist

Dr Donald Pearson Consultant Diabetologist

Dr Fiona Strachan Consultant Diabetologist

Dr Janie Thomason General
Practitioner

Dr Graham Young General Practitioner

Grampian Diabetes Managed Clinical Network 2003

Version 12

The document may be reproduced only for the purposes of diabetes care, and
may not be copied or otherwise used for commercial purposes in whole or in
part without the written permission of the Grampian Diabetes Managed
Clinical Network

The document and accompanying summary quick reference guidelines are
available for viewing and downloading on the Grampian Primary Care Intranet
at:

http://wwwgpctgrampianscotnhsuk/grampintranet/ggmp/diabetescfm

They will also be available for public access on the Grampian Health Board
public website

The electronic version requires Adobe Acrobat Reader 30 or higher and
contains hyperlinks to relevant SIGN guidelines, which also require Adobe
Acrobat Reader for viewing

The initial guideline was published in June 2000 This version was
published in 2004, and will be updated in 2007 Minor interim revisions
will be made available through the electronic version as required

Permission has been granted to NHS Shetland to revise and localise these
guidelines for use by healthcare
staff in Shetland Guidelines, which have
been revised specifically to reflect Shetland practice, are highlighted in
red The Diabetes MCN for NHS Shetland would like to thank the NHS Grampian
Editorial Board for permission to adapt these guidelines Dr Pauline
Wilson, Clinical Lead for Diabetes services, NHS Shetland, September 2006

1 Introduction 1

2 Classification of Diabetes 2

3 Management of Newly Diagnosed Diabetes 3

31 Confirming the diagnosis 3

32 Determine the risk of ketoacidosis and likely need for immediate
insulin therapy 4
321 Indications for immediate insulin therapy 4

33 Patients not requiring immediate insulin 4

34 Check list for recently diagnosed diabetes 4

35 Impaired glucose tolerance impaired fasting glucose 5

36 Algorithm for management of the newly diagnosed patient 6

4 Education Topics For New Patients 7

41 Education checklist for new patients 7

5 Diet 8
511 Major dietary messages for all types of diabetes mellitus 8
512 Recommended dietetic literature 9
513 Role of the dietitian 9

6 Psychological Well-Being and Diabetes 10

7 Physical
Activity and Diabetes 11

71 Improving health 11

72 Coping with physical activity 11

8 Smoking and Diabetes 12

81 Smoking 12

82 Smoking cessation 12

9 Driving and Diabetes 13

10 Regular Review Schedules 14

101 Every structured diabetic review 14

102 Content of annual checks 15

11 Targets For Glycaemic Control 16

111 Glycosylated haemoglobin 16

12 Hypoglycaemic Drug Therapy 17

121 Insulin therapy 17

122 Summary of insulin classification 18

123 Insulin regimens 19
1231 Initiation of insulin 19
1232 Once daily injections 19
1233 Twice daily injections 19
1234 Multiple injections 19

124 Oral hypoglycaemic drugs 19
1241 Metformin 19
1242 Sulphonylureas 20
1243 Prandial glucose regulators 20
1244 Thiazolidinediones 21
1245 Acarbose 21

13 Hypoglycaemia 23

131 Causes of hypoglycaemia 23

132 Symptoms of hypoglycaemia 23

133 Hypoglycaemia unawareness 23

134 Treatment of hypoglycaemia 23

135 Hypoglycaemia and sulphonylureas 24

136 Nocturnal hypoglycaemia 24

137 Rebound hyperglycaemia 24

138 Driving and
hypoglycaemia - See Section 9 and Appendix 4 24

139 Avoidance of hypoglycaemia 24

14 Management of Diabetes Emergencies in the community 26

141 Acute illness in insulin -treated patients 26

142 Acute illness in non-insulin-treated patients 26

15 Eye Screening 27

151 Screening criteria 27

152 Mydriasis 27

153 Medical treatment 27

154 Laser treatment 28

155 Diabetic eye screening guidelines - classification and action 28
1551 Visual acuity 28
1552 Fundoscopy 28

16 Foot Care and Screening 29

161 Foot care education 29

162 At risk feet 29

163 Foot assessment 30

164 Foot ulceration 30

165 Foot deformity 30

166 Charcot arthropathy 30

167 Painful peripheral neuropathy 30

17 Autonomic Neuropathy 31

18 Blood Pressure 32

181 Measuring blood pressure 32

182 Thresholds for treatment 32

183 Target blood pressure levels 32

184 Choice of antihypertensive drug 32

185 Notes on specific antihypertensive drugs 33
1851 ACE inhibitors 33
1852 Angiotensin II antagonists 33
1853 Diuretics 33
1854 Beta blockers 33
1855 Calcium
channel blockers 34
1856 Alpha blockers 34
1857 Centrally acting drugs 34

19 Renal Disease and Diabetes 35

191 Screening for diabetic renal disease 35

192 Definitions 35
1921 Assessment of dipstick positive patients 36
1922 Assessment of dipstick negative patients 36

193 Management of diabetic renal disease 36

194 Referral for specialist renal advice 37

20 Lipids and Diabetes 38

201 Screening for lipid abnormalities 38

202 Drugs for treatment of hyperlipidaemia 38
2021 HMG-CoA reductase inhibitors statins 38
2022 Fibrates 38

21 Cardiovascular Disease and Diabetes 39

211 Management of very high risk patients 39

212 Therapeutic interventions for very high risk patients 39

213 Primary prevention of coronary heart disease in type 2 diabetes
39

214 Primary prevention of coronary heart disease in type 1 diabetes
40

215 Screening criteria for coronary heart disease in diabetes 40

216 Calculating coronary heart disease risk 40

217 Aspirin 41

22 Diabetes and Pregnancy 42

221 Prior to conception 42

222 Confirmed pregnancy 42

223 Hypoglycaemia
43

224 Ketosis 43

225 Delivery 43

23 Management of Gestational Diabetes Mellitus 44

231 Background and definition 44

232 Recommended screening protocol for gestational diabetes mellitus
44

233 Diagnosis 44

234 Management of gestational diabetes mellitus 44

235 Post-natal follow up 44

24 Appendix 1 - 75g Oral Glucose Tolerance Test 45

25 Appendix 2 - Education Checklist 46

26 Appendix 3 - Secondary Diabetes 47

27 Appendix 4 - Driving Advice for patients with diabetes requiring
insulin-treatment 48

28 Appendix 5 - Scottish Diabetic Retinopathy Grading System 49

29 Appendix 6 - Diabetic 1st Line Foot Screening Form 51

30 Appendix 7 - 75th Centiles for Blood Pressure in Caucasian Adults
below the age of 45 53

31 Appendix 8 - Algorithm for microalbuminuria screening in the
community 54

32 Appendix 9 - Patient Information Sheet - Urine Testing And
Microalbuminuria 55

33 Appendix 10 - Instructions for timed overnight urine collections for
albumin excretion rate 56

34 Appendix 11 - Follow-up of patients with previous gestational
diabetes 57

35 Appendix 12 - Grampian recommendations
for Home Blood Glucose
Monitoring 58

36 Bibliography 60
Introduction

These guidelines are designed to assist everyone involved in the care of
people with diabetes in planning and implementing their own local care
plans, and in dealing with specific common problems They have been written
by local healthcare professionals in primary and secondary care with the
aim of supporting local practice within Grampian and Shetland

They will facilitate the development of a common standard of care for all
people with diabetes in the region, and provide guidance on access to the
various support services that are available

The purpose of diabetes care is to empower patients to make informed
decisions about their lifestyle, self-management and health choices
Holistic patient care requires that patients are involved in setting their
own realistic targets

Classification of diabetes

Type 1 Diabetes Mellitus These patients usually present as children
or young adults, but it is important to be aware that they may present
at any age Their hallmark is insulin deficiency due to autoimmune
pancreatic ? cell
destruction, resulting in weight loss and the
presence of ketones in the urine Such patients are prone to
ketoacidosis, and once diagnosed should be treated with insulin as a
matter of urgency, although emergency hospital admission is often
unnecessary

Type 2 Diabetes Mellitus Although most present in middle and old age,
an increasing number present at younger ages Many are obese
Peripheral insulin resistance combined with relative insulin
deficiency accounts for the pathogenesis Ketonuria is absent in the
non-fasting state Such patients are not normally prone to
ketoacidosis

Other Types:

Secondary Diabetes Mellitus: can be secondary to other conditions
which cause pancreatic destruction, haemochromatosis, cystic
fibrosis, pancreatitis or associated with other syndromes which
are characterised by insulin resistance acromegaly, polycystic
ovarian syndrome, Cushings syndrome and drug therapy,
particularly glucocorticoids See Appendix 3 - Secondary Diabetes

Recognised Genetic
Syndromes: including MODY maturity onset
diabetes of youth, which is characterised by early onset diabetes
and no requirement for insulin non-ketotic Patients are often
of normal weight The condition is inherited in an autosomal
dominant fashion and there is almost always a family history

Gestational Diabetes Mellitus is defined as glucose intolerance of
variable severity with first onset or recognition during pregnancy
In most women the abnormality is reversible post partum, but up to 50
develop Type 2 diabetes later in life A small proportion have
coincidental Type 1 diabetes presenting in pregnancy

Management of Newly Diagnosed Diabetes

1 Confirming the diagnosis

In the presence of dehydration or heavy ketonuria, a presumptive diagnosis
of diabetes may be made on the basis of urinalysis and/or blood strip
testing and urgent referral is likely to be appropriate

Otherwise it is essential that a diagnosis of diabetes is confirmed before
the patient is advised that he/she has diabetes and before treatment with
diet or any other agent is commenced

Symptoms of thirst
and polyuria or the finding of glycosuria should prompt
blood glucose measurement using a laboratory method The diagnosis of
diabetes should not be made on the basis of portable blood glucose meter
results alone The diagnosis can be made on the basis of symptoms thirst
and polyuria and one diagnostic blood glucose measurement The values of
blood glucose indicative of diabetes are as follows;

Random venous plasma glucose ? 111 mmol/l; or

Fasting plasma glucose ? 7 mmol/l; or

Venous plasma glucose ? 111 mmol/l at 2 hours after a 75g oral glucose
load the oral glucose tolerance test; See Appendix 1

In the absence of symptoms the diagnosis is based on two diagnostic blood
glucose measurements on two separate days On rare occasions therefore a
second oral glucose tolerance test may need to be performed before a
diagnosis of diabetes can be confirmed

In the UK the 2000 WHO criteria were adopted from June 2000

Interpretation of Plasma Glucose Levels mmol/l

|Fasting| |Random | | |
| Venous|Capillar|Venous |Capilla| |
| |y | |ry |
|
|? 70 |? 70 |? 111 |? 122 |Diabetic range |
| | |55 |65 |Check fasting glucose |
| | |111 |122 | |
|61 |61 | | |Impaired Fasting Glucose IFG - 75g|
|70 |70 | | |OGTT required |
|55 |55 | | |75g OGTT required |
|69 |69 | | | |
|? 55 |? 55 |? 55 |? 65 |Diabetes unlikely |

Interpretation of 75g Oral Glucose Tolerance Test WHO 2000

| |Glucose mmol/l|Fasting | |2 Hour |
|Diabetes Mellitus | | | | |
|Venous |Plasma | | |? 111 |
|Capillary |Plasma | | |? 122 |
|Impaired glucose | | | | |
|tolerance | | | | |
|Venous |Plasma |70 |and |? 78, |
| | | |
|111 |
|Capillary |Plasma |70 |and |? 89, |
| | | | |122 |

2 Determine the risk of ketoacidosis and likely need for immediate insulin
therapy

The most important decision once the diagnosis has been made is to decide
whether the patient is at risk of ketoacidosis and likely to require
immediate insulin therapy

1 Indications for immediate insulin therapy

Persistent non-fasting ketonuria
Marked weight loss in the normal or underweight patient
Vomiting and dehydration will require immediate hospital admission for
intravenous therapy
The initial blood glucose level or presence of primary symptoms of thirst
and polyuria are not good guides as to the need for insulin
Hospital admission may be avoided in patients who clearly require insulin,
but are not dehydrated or in ketoacidosis, depending on the logistics of
arranging to start insulin at home on an urgent basis Such patients should
be discussed by telephone with a member of the diabetes specialist team
with a view to starting insulin within 24 hours These patients should
receive immediate care
from the hospital diabetes team and may be admitted
to hospital depending on the practicalities of starting insulin at home

Patients with signs of ketoacidosis or dehydration should be admitted to
hospital as an emergency See local DKA protocol for adults:
http://92001506/internal/healthcare/shetlandwide/ward3/Protocols/document
s/CopyofDKAadultspdf

Children under the age of sixteen should be discussed urgently on the
telephone with either Dr Wilson or the Consultant Physician on call, and
will normally be admitted to hospital See local DKA protocol for children
http://92001506/internal/healthcare/shetlandwide/ward3/Paediatrics/Paedia
tricsasp

3 Patients not requiring immediate insulin

The majority of newly diagnosed patients have Type 2 diabetes, and the
management approach can be more relaxed in timescale The initial blood
glucose level or presence of primary symptoms of thirst and polyuria is not
a good guide as to the long term need for hypoglycaemic drug therapy
Patients do not normally require oral hypoglycaemic agents until they have
completed at least two or three months on diet alone

All such patients should initially
receive dietary advice aiming to
optimise body weight see diet section General advice and the provision
of the Diabetes UK diet leaflet is acceptable for initial management, but
all patients should be referred to a dietitian at an early stage for more
detailed and personalised advice

Obese patients BMI 30kg/m2 inadequately controlled after a trial of
diet but showing evidence of weight loss may be left on diet alone as
glycaemic control is likely to continue to improve Overweight and obese
patients BMI 25 not achieving weight loss may be most appropriately
treated with metformin section 1241 in a low starting dose to minimise
gastrointestinal side effects Patients not overweight BMI 25kg/m2 but
inadequately controlled may be commenced on a sulphonylurea section
1242 Employment and social issues may also influence the choice of
treatment

4 Check list for recently diagnosed diabetes

Once the immediate issue of glycaemic control has been addressed it is
important to consider further educational topics and to ensure an adequate
physical examination for detection of established complications, which are
often present at
diagnosis in Type 2 patients The following checklist is
suggested for completion over the first few clinical contacts

Decide on initial blood glucose management and need for immediate insulin
or otherwise

Provide initial dietary advice and arrange for referral to a dietitian

Record weight kg and height m and calculate body mass index BMI kg/m2
: ie Weight in kg height in metres squared

Record blood pressure

Record urinalysis for protein and ketones and glucose

Examine feet for signs of neuropathy, peripheral vascular disease or active
lesions

Provide foot care information

Decide on need for referral to a podiatrist

Perform or arrange for adequate retinal examination

Record visual acuity pinhole corrected if worse than 6/9

Arrange biochemical assessment; serum creatinine, LFTs, lipid profile,
thyroid function, HbA1C

Early morning urine for albumin/creatinine ratio microalbumin screen

Record smoking status and advise as appropriate

Assess cardiovascular risk status smoking, BP, family history, lipids,
proteinuria/microalbuminuria, established macrovascular disease

Consider ECG to assess evidence of previous MI or left ventricular
hypertrophy

Decide on
appropriate patient self monitoring

Discuss hypoglycaemia and its management in all insulin and sulphonylurea
treated patients

Determine individualised blood glucose treatment targets

Provide support literature

Cover selected topics from the education checklist with the patient and
relevant individuals

24 Discuss driving/DVLA/insurance

25 Consider referral to a diabetes specialist nurse or hospital diabetic
clinic

Consider causes of secondary diabetes, see Appendix 3 - Secondary Diabetes

Ensure patient is registered with practice and regional diabetes register

5 Impaired glucose tolerance impaired fasting glucose

These patients, like those with established diabetes, have an increased
risk of macrovascular disease and require assessment and aggressive
management of cardiovascular risk factors, dietary and lifestyle advice -
See Section 5 - Diet and Section 7 - Smoking and Diabetes

Patients with impaired fasting glucose IFG 61mmol/l 70mmol/l
should have a 75g OGTT as some will fulfil the criteria for diabetes
mellitus on the two hour value

Patients with IGT IFG should be entered into the practice diabetes

register if available

Five per cent per year may go on to develop Type 2 diabetes and will then
need appropriate diabetes care

A fasting or random blood glucose level should therefore be measured on
an annual basis, or earlier in the event of symptoms in people with
IGT or IFG and the results interpreted according to Section 31

6 Algorithm for management of the newly diagnosed patient

Education Topics For New Patients

Discussion of each of the following topics should be considered with each
patient, but they will not all be relevant to all patients Further
information and advice on any of these subjects is available through the
diabetes resource nurse Sheila Smale or other appropriate health care
professionals

The relevant education syllabus for any one individual will alter with the
passage of time It is important to remember to revisit topics at regular
intervals, and to introduce new topics as and when they become relevant

1 Education checklist for new patients

See Appendix 2 - Education Checklist

Diet

The eating habits of people with diabetes play a major role in controlling
their condition The principles of the dietary recommendations for the
treatment of diabetes mellitus are as follows

When giving dietary advice to patients, assessment of willingness to change
should be considered

A suitable energy intake is required to meet energy demands and to achieve
a reasonable weight for height and age

All adults with diabetes should aim to optimise body weight Ideal body
mass index BMI is 20-25kg/m2

Carbohydrate should make up 45-60 of dietary energy intake, the majority
of
this coming from complex sources, preferably foods naturally high in
dietary fibre, eg wholegrain bread, wholegrain breakfast cereals, brown
rice, whole-wheat pasta, jacket potato, pulses, vegetables and fruit
Carbohydrates like sugar, sweets, chocolate, jam, honey, syrup, sugary
drinks, sweet puddings, biscuits, cakes and pastries should be minimised in
the overweight and advice given about when this can be consumed

The fat intake should be reduced to less than 35 of energy intake with no
more than 10 from saturated fat and trans fatty acids mainly from animal
sources eg dairy produce, fatty meats and meat products and bakery goods
and the rest from mono and polyunsaturated fatty acids mainly from plant
sources eg olive, soya, corn and sunflower oils and also from oily fish
such as sardines and mackerel

People should be encouraged to eat at least 5 portions of vegetables or
fruit per day to ensure a plentiful intake of vitamins and anti-oxidants

Protein intake should be no greater than 1g/kg ideal body weight and will
provide the remaining 10-15 of energy Ideally from fish, lean meats,
beans, pulses poultry

It is recommended that
salt should be limited to 6g per day

Up to 10 energy from added sugar over the course of a day is acceptable,
provided it is eaten in the context of a healthy diet ie part of a low
fat and high fibre diet

1 Major dietary messages for all types of diabetes mellitus

Aim for a healthy diet that everyone including people without diabetes
should be eating

Eat regular meals

Include starchy carbohydrate foods at each meal eg cereals, bread,
potato, pasta, rice

Encourage carbohydrate foods, which are naturally high in fibre

Include at least five portions of fruit or vegetables per day Spread
fruit intake out throughout the day

Encourage intake of oily fish, aim for 1-2 portions per week Fish oil
supplements are not recommended

Keep sugar to a minimum especially in the overweight

Dietary fat should be limited Where used, monounsaturated fat should be
encouraged

Try to achieve ideal body weight ie BMI 20-25, or a realistic and
achievable intermediate goal

Limit added salt to meals and food in preparation; keep highly processed
foods to a minimum

Special diabetic foods are unnecessary and are not recommended

Alcohol is acceptable
in moderation Avoid drinking on an empty stomach
Alcohol should be limited to 3-4 units per day for males and 2-3 units per
day for females with 1-2 alcohol free days per week The weeks allocation
should not be consumed at once

Patients on sulphonylurea or insulin should be advised that 3 units in one
session can have a significant effect on blood glucose especially if
combined with exercise

2 Recommended dietetic literature

Diabetes UK

Eating well with Diabetes - for initial stop gap dietary advice

Literature is available from the dietetic department

Diabetes UK recommends that all people with diabetes should see a dietitian
within four weeks of diagnosis to enable the individual to adopt an
appropriate eating plan This may be done on a one to one basis or a group
education session

There should also be access to up-to-date dietary advice on at least an
annual basis

Psychological Well-Being and Diabetes

At the time of diagnosis many patients will experience an emotional
reaction which should be acknowledged and appropriate support given

Anxiety, depression and phobias are more common in people with
diabetes
than the general population

At any one time it is estimated that one in five patients with diabetes
is clinically depressed and 40 of patients will experience an anxiety
disorder at some time

Depression is associated with poor glycaemic control and remission of
depression is associated with improved control Patients with
complications of diabetes have a higher prevalence of depression Health
professionals should identify these patients and offer appropriate
therapy, which may include SSRIs or psychological therapy such as
cognitive behavioural therapy

Physical Activity and Diabetes

All people with diabetes should be asked about physical activity and most
should be encouraged to increase activity; suitable educational material is
available on the Diabetes UK website wwwdiabetesorguk

1 Improving health

All people should be advised to maintain at least moderate levels of
activity, eg walking

A gradual introduction and initial low intensity of physical activity
should be recommended for sedentary people with diabetes

Exercise and physical activity should be undertaken regularly ie

preferably daily or alternate days Once a week is of limited benefit
As a rough guide the first stage would be to encourage an accumulation of
30 minutes of moderate activity eg walking on most days of the week
The second stage is to encourage those who are motivated to engage in
more vigorous activity at least three days per week

Exercise programmes are more likely to be successful and be maintained if
they are home-based and accompanied by on-going support - so rushing out
and joining a gym may not necessarily be the answer

Patients with complications should seek medical advice before embarking
on exercise programmes

If patients have problems with mobility there are easy exercise
programmes which they could do, eg chair exercises

Above all encourage patients to choose an activity, which they
will enjoy

2 Coping with physical activity

For patients who routinely monitor blood glucose and/or are insulin
treated, it is advisable to monitor blood glucose before and after
exercise

Blood glucose levels may fall a number of hours after exercise, eg
overnight or even the next
day, due to depletion of glycogen reserves

It is usually unnecessary to reduce oral hypoglycaemic agents

Additional carbohydrate or a reduction in insulin up to 25 may be
required both before and after exercise in insulin treated people

People taking part in high intensity sporting activities may require
specialist advice

Smoking and Diabetes

1 Smoking

All people with diabetes should be strongly counselled against
smoking

Smoking is a significant reversible risk factor for cardiovascular
disease

Patients with diabetes are already at increased risk of
cardiovascular disease

Diabetes and smoking are multiplicative risk factors

Smoking increases the risk of development and progression of most
complications, eg retinopathy

Smoking potentiates the risks during pregnancy in women with diabetes

2 Smoking cessation

Nicotine replacement therapy and Bupropion therapy alone or in
combination are effective in those trying to quit smoking

Nicotine replacement therapy should be provided in smokers who smoke
more than 15 cigarettes a day and who are trying to quit
Therapy in
a form acceptable to the patient should be offered for up to 8 weeks

Bupropion therapy increases the rate of smoking cessation and can be
used alone or with nicotine replacement in the absence of
contraindications A lower dose of Bupropion 150 mg should be
used in patients on oral hypoglycaemic agents or insulin

Health Promotions are involved in the provision of smoking cessation
programmes

Driving and Diabetes

Patients with diabetes treated by oral hypoglycaemic agents or insulin must
inform the DVLA of their diagnosis and type of treatment Patients with
diabetes treated by diet alone do not need to inform the DVLA All
patients are advised to inform their car insurance company at diagnosis and
if their type of treatment changes

Group 1 entitlement allows the driving of vehicles up to 35 tonnes or with
up to 8 passenger seats, including motorcycles and mopeds For patients on
oral hypoglycaemic agents a licence lasting until age 70 will be issued in
the absence of other complications Drivers whose diabetes is treated with
insulin will be issued with a 1,2 or 3 year licence,
provided they are able
to recognise warning symptoms of hypoglycaemia and have no other
complications which would affect driving

Group 2 entitlement allows the driving of vehicles over 35 tonnes or more
or with more than 8 seats This includes medium sized lorries 35-75
tonnes, C1, minibuses D1, lorries C, buses D Before January 1997
drivers who obtained a normal car driving licence were automatically
awarded C1 and D1 entitlement These holders of C1/D1 entitlement retain
it until their licence becomes due for renewal, when they must meet the
medical standards prescribed for all lorry and bus drivers Group 2 drivers
treated with oral hypoglycaemic agents must inform the DVLA and group 2
entitlement will continue as long as they can meet all group 2 medical
standards For patients on insulin treatment there is a bar in law to
Group 2 driving unless the case is designated as exceptional under the EC
second directive These patients should be referred to Dr Pauline Wilson
for review

All drivers are required by law to be able to read a standard size car
number plate in good light at 205 metres The advantage of
this test is
that it is easily self-administered Problems, which affect the field of
vision, must be notified to the DVLA Drivers who have had laser treatment
to both eyes for retinopathy or suffer other conditions affecting both eyes
must inform the DVLA so that the extent of the problem can be assessed

Drivers who develop problems with either the nerves or the circulation in
the lower limbs, sufficient to prevent safe operation of the foot pedals,
must inform the DVLA This is unlikely to prevent driving as problems may
be overcome by either restricting driving to certain types of vehicles eg
those with automatic transmission, or by appropriate adaptations such as
hand operated accelerator / brake

Other advice may be obtained from the following websites / addresses :

Diabetes UK DVLA

10 Parkway Longview Road

London Swansea

NW1 7AA SA99 1TU

Tel: 020 7424 1030 Tel: 01792 761119

web: wwwdiabetesorguk web: wwwdvlagovuk

See Appendix 4 for
patient information sheet

Regular Review Schedules

Patient empowerment through education to encourage optimal self-management
should be central to each review Regular review of individuals with
diabetes should address both metabolic control and diabetic complication
screening Reviews will involve metabolic management, education, health
promotion, and detection and management of diabetic complications This
care must be structured, locally agreed and documented and may involve a
variety of professionals in various locations carrying out different parts
of this programme

Interim metabolic and troubleshooting checks at three to four month
intervals are usually appropriate

Systematic screening for the early detection of the microvascular and
associated macrovascular complications of diabetes is also an essential
component of structured diabetes care

Effective interventions are available at an early or latent stage of the
disease processes which can slow or prevent further progression, and which
would not be as effective if delayed until the problem had become
clinically obvious

Complication screening is
usually performed on an annual basis, either as a
formal annual review or on a rolling program basis, unless problems have
been previously identified

1 Every structured diabetic review

The patient should be assessed and advised regarding:

The impact of diabetes on lifestyle and psychological well-being

Symptoms of hyperglycaemia

Occurrence and warning symptoms of hypoglycaemia

Results of home monitoring if available

Episodes requiring hospital admission including DKA

Medication

The following parameters should usually be recorded and discussed with the
patient at each visit:

Blood pressure particularly if hypertensive or previous recording
elevated

HbA1c not more often than every 3 months

Weight and BMI

Urinalysis for ketones, protein and glucose

An individual care plan and goals should be reviewed, agreed with the
patient and updated as appropriate Additional interim visits may be
required to address specific problems

2 Content of annual checks

The following parameters should be measured or examined on a minimum of an
annual basis, and are selectively further expanded in the following
sections

Blood pressure
sitting after 5 minutes rest

Visual acuity corrected with pin hole if worse than 6/9 and retinal
screening

Inspection of feet for callus, active lesions, colour and foot pulses

Foot sensation using 10g monofilaments and C128 tuning fork

Injection sites in insulin treated people

Urine for protein

First morning urine for microalbumin screen if proteinuria negative

Glycosylated haemoglobin HbA1c

Serum lipid profile

Serum creatinine

Serum TSH optional

The patient should be assessed and advised regarding the following:

Smoking habits

Symptoms or other evidence of cardiovascular disease

Symptoms suggestive of peripheral vascular disease

Alcohol consumption

Contraception and pregnancy planning if appropriate

Targets For Glycaemic Control

In all patients the minimum therapeutic goal should be to lower blood
glucose to levels sufficient to abolish the primary symptoms of thirst and
polyuria

The Diabetes Control and Complication Trial DCCT and UK Prospective
Diabetes Study UKPDS have clearly shown that tight blood glucose control
substantially reduces the risk of development and progression of
complications in all people with
diabetes

The overall goal should therefore be the optimisation of blood glucose
without undue hypoglycaemia The extent to which this is pursued by the
individual patient will depend on motivation, practical aspects of diabetes
management eg insulin delivery and self-monitoring, risks related to
hypoglycaemia and overall life expectancy

1 Glycosylated haemoglobin

Overall glycaemic control is best measured by HbA1c, which provides an
index of the average blood glucose concentration over the preceding two
months Reference ranges for HbA1c vary according to method

The range for HbA1c in people who do not have diabetes is up to 6 The
DCCT and UKPDS intensively treated groups achieved HbA1c levels of 7 but
in many patients this may not be achievable without undue adverse effects
Any reduction of elevated glycosylated haemoglobin will produce a
significant reduction in complication risk Each 1 reduction in HbA1c is
associated with a 21 reduction in the risk of diabetes-related death and
specifically a 14 reduction for myocardial infarction over 10 years

To achieve optimal HbA1c levels the following blood glucose targets
are
likely to be required:

Fasting plasma glucose in type 2 patients ? 59 mmol/l

Preprandial blood glucose 4-7 mmol/l

Bedtime blood glucose 7-9 mmol/l insulin treated people

Hypoglycaemic Drug Therapy

1 Insulin therapy

There are a large and confusing number of insulin preparations available
If patients are satisfied with their treatment and achieving satisfactory
control in the absence of hypoglycaemia, no modification of their regimen
is required

Most insulin currently in use is biosynthetically manufactured of human
sequence or analogues with altered pharmacokinetic properties Many
patients prefer the ultra short-acting analogues/mixtures for convenience

Some patients prefer to use animal derived insulin in the belief that use
of human sequence insulin may cause loss of awareness of hypoglycaemia
Although such a conviction is quite widespread among the users, carefully
conducted scientific studies have consistently failed to provide evidence
to support this hypothesis

Some preparations are available in both human and porcine versions eg
human and porcine actrapid, which can result in confusion in prescribing
and
dispensing It is important to realise that such preparations although
similar in their characteristics are not interchangeable, and patients
should not be inadvertently changed from one to the other When patients
are deliberately changed from animal to human/analogue insulin a dose
reduction of 25 is advised

Insulins are most conveniently classified by duration of action as shown
in the following table

2 Summary of insulin classification

Note Ultra short-acting insulins eg Humalog, Novorapid and mixtures
ie Humalog Mix 25 or 50 and Novomix 30 should be injected
immediately before eating or after food Other insulins should be
injected subcutaneously 30
minutes before eating

3 Insulin regimens

1 Initiation of insulin

Patients are normally commenced on human insulin or an insulin analogue, in
either a twice daily or a multiple injection regimen The choice of the
initial regimen and subsequent modifications should be made in consultation
with the patient, taking due regard of the patients occupation and
lifestyle The precise insulin formulation may be determined by the
patients preferred insulin delivery device Most patients prefer to use
pen devices

2 Once daily injections

Single daily injections do not usually result in good glycaemic control,
and are relatively rarely used Such a regimen may be appropriate for
patients where the therapeutic goal is only to prevent ketosis or suppress
symptomatic hyperglycaemia, and where there are practical problems with
insulin delivery, or particular concern over the risks of nocturnal
hypoglycaemia Elderly patients living alone and patients requiring
injections to be given by a district nurse may fall into this category

An intermediate acting lente or isophane insulin is usually most suitable
in this context The
long acting basal analogue insulins are under
clinical evaluation

3 Twice daily injections

This is a commonly used regimen, and suitable for patients starting on
insulin A combination of short and intermediate acting insulins is taken
before breakfast and before the evening meal

4 Multiple injections

This arrangement, involving up to 4 injections a day, has the main
advantage of increased flexibility with regard to exercise, meal timing and
meal size It is most likely to work effectively in a well-motivated
patient, prepared to do regular and frequent blood glucose testing

The majority use an insulin analogue or soluble insulin before each meal,
and an injection of an intermediate or long acting insulin usually before
bedtime to provide background cover

4 Oral hypoglycaemic drugs

These drugs are suitable for people with Type 2 diabetes when blood glucose
control through dietary measures alone proves inadequate At present five
types are available; biguanides metformin, sulphonylureas, prandial
glucose regulators, the thiazolidinediones and the ?-glucosidase inhibitor
acarbose

See Section 33 for guidance on the role of
these drugs in the context of
diet and other management strategies

Since in practice the majority of patients are overweight, metformin is
usually the drug of first choice

Early sulphonylurea treatment may be appropriate in the thin symptomatic
patient without ketonuria

Patients should be educated about their drugs and should carry
documentation of any risk of hypoglycaemia

1 Metformin

Action Metformin works principally by reducing insulin
resistance

Indications Primary drug treatment of overweight Type 2 diabetics
As an adjuvant to other hypoglycaemic therapy in Type 2
patients

Metformin may be continued in some obese patients with Type 2
diabetes who ultimately require insulin therapy, to maximise
insulin sensitivity and minimise weight gain on insulin

Side Effects Diarrhoea, lethargy, anorexia, malabsorption of B12 and
folate

Lactic acidosis is a very rare but often fatal side effect It
occurs almost exclusively in alcoholics, patients with renal or
severe cardiac failure, liver disease, and those who are

undergoing surgery or are shocked

Caution Contraindicated in renal failure creatinine 150mol/l, liver
disease and alcoholism
Discontinue temporarily during severe intercurrent illness
Discontinue for 48-hours following the injection of x-ray contrast
media

Dose Initially 500mg daily with main meal, increasing gradually in 500mg
increments to a maximum of 1g tds The dose is often limited by
diarrhoea

2 Sulphonylureas

Action Potentiates the pancreatic ? cell insulin release in
response to glucose

Indications Primary drug treatment of non-obese patients with Type 2
diabetes
Primary drug treatment of overweight Type 2 patients unable to take
usual first line agents
As adjuvant therapy with other agents

Side Effects Hypoglycaemia
Weight gain
Other side effects are rare

Drugs The three most commonly used sulphonylureas in Grampian and
Shetland are Gliclazide, Glipizide and Glimepiride, the last
having the advantage of a once daily single tablet dose

Chlorpropamide and Glibenclamide are particularly prone to cause
hypoglycaemia and should not be initiated, and their continued
use should be reviewed periodically

Doses It is usually appropriate to start with a small dose before
breakfast, increasing progressively according to blood glucose
response The drug should always be taken before meals

Gliclazide 40-320mg daily doses 80mg should be divided
Also available as a 30mg modified release tablet
equivalent to 80 mg of standard preparation - to
achieve maximum dose range, patient required to
ingest several tablets before breakfast

Glimepiride 1-6 mg as a single daily dose

Glipizide 25-20 mg doses 10 mg should be divided

3 Prandial glucose regulators

Action These agents act as insulin secretagogues, potentiating the
post-prandial secretion of insulin that is impaired in the Type
2 diabetes The postprandial hyperglycaemia associated with
increased cardiovascular
mortality in the DECODE Study can be
improved by using these agents, with dosage timed according to
meals However, the evidence of an improvement in the clinical
end-points of reduced cardiovascular events and mortality is not
yet available

Indications Repaglinide - As monotherapy or in combination with metformin

Nateglinide - In combination with metfomin

Side effects Both agents can precipitate hypoglycaemia

Caution Avoid in severe hepatic impairment

Dose Repaglinide Novonorm - initially 500mcg within 30 minutes before
main meals 1mg if transferring from another oral
hypoglycaemic, adjusted according to response at 1-2 week
intervals Up to 4 mg as single dose; max daily dose 16mg

Nateglinide Starlix - initially 60 mg 3 times daily within
30 minutes of main meals; adjust according to response to
maximum 180mg 3 times daily

4 Thiazolidinediones

Action A relatively new group of agents acting at the level of the
PPAR-gamma receptor to promote insulin sensitivity To be

effective, patients are required to have sufficient endogenous
insulin production The maximum therapeutic benefit may not be
apparent until after eight weeks

Indications Can be used as monotherapy although Metformin is the drug of
first choice

As an adjunct to Metformin in the overweight patient with Type 2
diabetes or with sulphonylurea therapy when Metformin cannot be
tolerated in an efficacious dose

Not licensed for use with insulin

Side-effects May promote weight gain and fluid retention

Caution Avoid in hepatic impairment - Do not initiate if AAT 25 x
upper normal limit

Use requires a commitment to LFT monitoring on a two-monthly
basis for the first year of therapy; thereafter, monitoring
periodically is recommended

If AAT is 3x upper normal limit, therapy should be
discontinued

Absolute Avoid use in patients with left ventricular impairment or heart
failure
Contraindication

Dose Pioglitazone Actos - 15-45mg once daily

Rosiglitazone
Avandia - 4mg daily in combination with
a sulphonylurea

- 4-8mg daily may be used in combination
with Metformin

6 Acarbose

Action An alpha-glucosidase inhibitor which acts within the gut to
slow digestion and absorption of carbohydrates

Indications Primary drug treatment of patients with Type 2 diabetes
especially the obese if other drugs are contraindicated
As an adjuvant to other oral agents or insulin

Side effects Flatulence and GI disturbance As mono therapy it does
not cause hypoglycaemia

Caution Insulin or sulphonylurea induced hypoglycaemia patients taking
acarbose must be treated with glucose dextrose

Dose 25-50mg daily increased very gradually to 50-100mg tds
according to tolerance

Hypoglycaemia

Hypoglycaemia refers to any episode of low blood glucose usually 35
mmol/l with or without symptoms and may occur in patients taking insulin,
sulphonylureas or prandial glucose regulators Mild episodes may not only
be inconvenient for the
patient, but may predispose to more severe episodes
which are associated with significant morbidity as well as the development
of fear of hypoglycaemia Even if untreated, most isolated episodes
recover spontaneously and are not associated with permanent damage It is
reasonable to reassure patients accordingly Many patients will avoid
strict blood glucose control in order to minimise their risk of
experiencing hypoglycaemia

Patients should be advised about how to avoid, recognise, and treat
hypoglycaemia

1 Causes of hypoglycaemia

Hypoglycaemia occurs when there is an imbalance between:

Carbohydrate intake

Insulin or oral hypoglycaemic drug dose

Exercise/activity

Additional factors which may contribute to the risk of hypoglycaemia
include lumpy injection sites leading to erratic absorption of insulin,
errors in insulin administration, alcohol excess particularly if combined
with reduced carbohydrate intake, gastroparesis in patients with autonomic
neuropathy and adrenal insufficiency particularly in patients with Type 1
diabetes

2 Symptoms of hypoglycaemia

The symptoms of hypoglycaemia vary between patients
and the same patient
may experience different symptoms in different circumstances Symptoms
are classified as:

autonomic, due to activation of the autonomic nervous system sweating,
tremor, anxiety, palpitations etc

neuroglycopenic due to reduced glucose delivery to the brain poor
concentration, odd behaviour, dizziness

non-specific headache, tingling lips etc

In most patients the autonomic symptoms occur before the neuroglycopenic
symptoms and provide a useful warning Patients with poor control and
chronic hyperglycaemia may experience symptoms of hypoglycaemia at higher
blood glucose levels This is an indication for more gradual step-wise
improvement in blood glucose control

3 Hypoglycaemia unawareness

In some patients the order of onset of symptoms may be reversed eg those
with long-duration of diabetes, very tight glycaemic control or recurrent
episodes of hypoglycaemia or during pregnancy This may result in
hypoglycaemia unawareness when the patient is unable to recognise the onset
of the hypo, which can have serious consequences In some people it may
be possible to regain the normal symptoms of
hypoglycaemia through
meticulous avoidance of hypoglycaemia and specialist advice may be
required A three or four months period of relaxation of glycaemic
control may be appropriate, ie minimum blood sugar of 6 mmol/l

4 Treatment of hypoglycaemia

All patients treated with insulin or sulphonylureas or prandial glucose
regulators should be advised to carry carbohydrate with them As soon as
symptoms are recognised or if a low blood glucose value is recorded with
or without symptoms, the patient should be advised to take one of the
following:

3 Dextrosol tablets or sugar lumps

Half of a small bottle 150ml of lucozade or equivalent sugary drink eg
cola - not diet or lite

Fruit juice - 1 glass

Chocolate eg Mini Mars bar

If the patient is taking acarbose glucose eg Dextrosol must be used for
treatment of hypoglycaemia not a disaccharide such as sucrose sugar or
lactose milk

If symptoms are not improving after 10 minutes this should be repeated If
the patient is too drowsy to co-operate, Hypostop, honey or jam may be
applied to the inside of the cheeks and massaged from the outside It may
be advisable for patients to keep
Hypostop at home and to instruct family
members and friends how to use it

If the patient is unresponsive, 1 mg of glucagon should be given
subcutaneously or intramuscularly once only per episode It may be
advisable to instruct partners, close relatives or friends of insulin-
treated people in the use of glucagon and to ensure that they keep a kit at
home

Alternatively 25g 50ml 50 of dextrose can be given intravenously by
professional help

After the initial treatment it is essential for the patient to take long
acting carbohydrate such as biscuits and milk, or a sandwich to prevent the
hypoglycaemia from recurring

5 Hypoglycaemia and sulphonylureas

Hypoglycaemia may occur in patients taking sulphonylureas and is often
underreported in the elderly when the symptoms are non-specific and are
confused with other conditions eg TIAs Hypoglycaemia may recur
following initial treatment and sometimes admission to hospital may be
required The earlier generation of long-acting sulphonylureas
chlorpropamide and glibenclamide should not be initiated and are probably
best avoided in those over 65 However
the newer type of long-acting
sulphonylurea, eg Glimepiride and modified release Gliclazide do not
appear to be associated with an increased risk of hypoglycaemia

6 Nocturnal hypoglycaemia

This is a common occurrence in insulin-treated patients Patients may or
may not wake up during the night with symptoms, or sometimes wake up the
following morning feeling hung-over Nocturnal hypoglycaemia may
contribute to the development of hypoglycaemia unawareness The risk can
be minimised by ensuring a snack containing complex carbohydrate is taken
at bedtime irrespective of blood glucose reading, and allowing the blood
glucose to be between 7 and 9 at bedtime The following measures may reduce
the risk of nocturnal hypoglycaemia:

Splitting the evening insulin dose so that the quick acting insulin is
taken before the evening meal and the intermediate acting insulin is taken
at bedtime

Replacing soluble insulin at teatime with a shorter acting insulin analogue
eg Lispro

Insulin glargine Lantus appears to be associated with a lower incidence
of hypoglycaemia in patients on a basal bolus regime

7 Rebound Hyperglycaemia

After an episode
of hypoglycaemia patients may experience marked
hyperglycaemia, which may be prolonged, as a result of the release of
conterregulatory hormones It must therefore be remembered that
hyperglycaemia may indicate an earlier period of hypoglycaemia This is
often pertinent after an unrecognised hypoglycaemic event, particularly at
night

8 Driving and hypoglycaemia - See Section 9 and Appendix 4

Patients should be advised to check their blood glucose before and during
long car journeys and should always carry carbohydrate in the car If
they have a hypo while driving they should stop the car, remove the keys
from the ignition, leave the drivers seat and take oral carbohydrate
Driving should not be resumed for at least 45 minutes Patients who have
lost their warning symptoms of hypoglycaemia should be advised not to drive
until the problem has been resolved This advice should be documented in
clinical records

9 Avoidance of hypoglycaemia

The risk of severe hypoglycaemia can be minimised by self-monitoring of
blood glucose, review of insulin / drug regimen, quantity and timing of
carbohydrate intake and injection sites
Patients should be advised to
Keep 4 the floor with respect to their targets for glucose control
However in some patients who do not monitor or who have had problems with
severe hypoglycaemia the targets for glycaemic control may need to be
relaxed

Management of Diabetes Emergencies in the community

1 Acute illness in insulin -treated patients

encourage more frequent blood glucose checks 2-4 hourly

never stop insulin, increase dose according to blood glucose

check urine for ketones - if moderate or large an increase in insulin may
be necessary

ensure continued fluid intake 2-3 litres - if vomiting prevents fluid
intake, consider admission

carbohydrate intake must be maintained by fluids eg milk, soup, ice
cream, fruit juice, Lucozade if unable to tolerate food

consider discussion with a member of the diabetes specialist team

2 Acute illness in non-insulin-treated patients

provided not severely dehydrated or showing features of Hyperosmolar Coma
eg drowsiness then high blood glucose levels can be tolerated for a
short illness

markedly dehydrated hyperglycaemic patients should be admitted as an
emergency for IV
fluids

Eye screening

The Shetland Diabetes Retinal Screening Programme now does screening for
diabetic retinopathy in Shetland The success of the Retinal Screening
Programme depends on referral to the service from primary care of all
appropriate patients All patients are offered appointments at the
discretion of their General Practitioner Patients unable to co-operate
with laser treatment or who have no perception of light in either eye
should not be offered screening All other patients should be invited to
attend, including those who are registered blind as, despite the
terminology, many still have useful remaining vision In particular the
commonest causes of blindness in people with diabetes are age-related
macular degeneration and diabetic macular oedema Screening is still
essential to look for new-vessel formation that could affect remaining
peripheral vision

Patients who attend visiting Ophthalmology Clinics for reasons other than
diabetic retinopathy should also be encouraged to attend for retinal
screening

1 Screening criteria

Who People with diabetes aged 12
years or over

When Refer at diagnosis Screen at least annually

Where Will vary according to local arrangements

By Whom Routine screening by Diabetes Retinal Screening Programme

How Digital retinal imaging

Ophthalmologists or the Retinal Screening Programme may undertake repeat
examination more frequently in certain high-risk groups In pregnancy
retinal examination should be undertaken in each trimester

Defaulters Screen opportunistically by whoever sees them - consultant
physician, optometrist, general practitioner

Should have visual acuity with glasses or pinhole recorded
and either non-mydriatic retinal photography or direct
ophthalmoscopy with mydriasis 1 tropicamide

Documentation Methodology and findings should be reported according to
the Scottish Diabetic Retinopathy Grading System - details in
Appendix 5

2 Mydriasis

Patients who are attending the Shetland Diabetes Retinal Screening
Programme will not routinely have their pupils dilated unless it is not
possible to get a gradable image with digital
photography If dilation is
required, 1 Tropicamide should be used This may cause blurring of vision
and affect the ability to drive or operate machinery for up to four hours,
and patients should be appropriately warned

Glaucoma, whatever form, is not a contraindication to mydriasis

Contact lenses do not need to be removed

3 Medical treatment

Tight blood pressure control has a dramatic effect on the progression of
eye disease and the prevention of visual impairment It is always strongly
advised Tight glycaemic control also has a beneficial effect on the
progression of eye disease and the prevention of visual impairment In some
patients however if control is tightened up too quickly this can lead to
progression of retinopathy In patients with no retinopathy or only mild
background changes this usually manifests itself as the development of
cotton wool spots These are of no consequence and will often disappear
In patients with severe background or worse retinopathy rapid tightening of
glycaemic control can lead to rapid progression to high-risk proliferative
retinopathy

If the patients retinopathy status is unknown and they
are poorly
controlled then they should be referred to the Shetland Diabetes Retinal
Screening Programme for assessment prior to tightening up of glycaemic
control

As it takes years for the complications of diabetes to occur, it would
seem prudent for glycaemic control to be improved gradually over 6-12
months in such at risk patients

Patients with poorly controlled diabetes who are admitted to hospital
with diabetes or non diabetes-related illness should have their eyes
examined prior to discharge This is particularly important if the
patient is a chronic defaulter from the Diabetic or Eye Clinic

4 Laser treatment

Laser treatment is very effective at treating proliferative new vessels
retinopathy and will prevent the majority of people developing significant
visual impairment

Laser treatment is less effective at treating patients with maculopathy
changes affect the centre of vision but attention to blood pressure and
glucose control can make a significant impact in preventing deterioration

5 Diabetic eye screening guidelines - classification and action

1 Visual acuity

Normal corrected visual
acuity

Action Review visual acuity annually

Visual acuity worse than 6/9 in the worst eye

Stable or previously explained
Action Review visual acuity annually

Deteriorating by 2 or more lines or previously unexplained
Action Ask patient to attend their own Optometrist for refraction
and if vision cannot be improved then consider reason -

Unrelated to diabetic retinopathy eg, cataract, chronic
amblyopia, senile macular degeneration
Refer to ophthalmologist as appropriate

Diabetic retinopathy Macular oedema may present with no specific
fundoscopic change
Refer to ophthalmologist

2 Fundoscopy

See Appendix 5

Foot care and screening

Foot problems account for a high proportion of preventable diabetes-related
hospital admissions The long-term effects of amputations are restrictive
to quality of life and costly in terms of healthcare resources Early
diagnosis of at-risk feet and proactive monitoring has been demonstrated to
reduce numbers proceeding to amputation Ulceration and amputation are not
the inevitable consequences of peripheral neuropathy or
peripheral vascular
disease Prevention of ulceration is effective if early recognition of the
at-risk foot is achieved through routine clinical assessment Absence of
symptoms should not be taken as an indication of absence of risk All
diabetic patients must have regular foot screening and education

Who All people with diabetes

When At diagnosis and annually thereafter

By whom

Where Will depend on local arrangements

How By inspection and clinical examination using 1st line screening
diabetic foot risk assessment Patients should be offered
appropriate referral

Documentation Local guidelines to be inserted

1 Foot care education

All patients with diabetes should receive basic continuing education
concerning:

effects of diabetes upon feet

care of feet

protection of feet

2 At risk feet

The presence of any of the following features indicates feet at increased
risk:

Skin - thin, fragile, tissue paper skin may indicate peripheral
vascular disease Dry, cracked skin may indicate autonomic neuropathy

Areas of callus or evidence
of increase in pressure especially with
haemorrhages underneath callus

History of previous foot ulceration, amputation or re-vascularisation

Visual impairment

Absence of both pulses in either foot

Symptoms of peripheral arterial disease

Active ulceration

Peripheral neuropathy

Deformity

Charcot joint

Other significant active lesions including corns, ingrowing toenails,
gross nail abnormalities

Physical disability which prevents proper self foot care often present
in the elderly

3 Foot assessment

Local guidelines to be inserted

4 Foot ulceration

Local guidelines to be inserted

5 Foot deformity

Patients with any type of foot deformity are prone to abnormal pressures,
callus formation and hence ulceration Such patients should be under
regular podiatry review and will require referral for specialist footwear

6 Charcot arthropathy

The finding of hot, swollen, deformed foot or ankle needs immediate
specialist investigation and management It is difficult to differentiate
between Charcot arthropathy and soft tissue infection Local guidelines to
be inserted

7 Painful peripheral neuropathy

This is usually
manifested by a burning sensation, particularly at night
and diagnosis is made on the basis of the clinical history Effective
treatment is difficult Therapeutic approaches are largely empirical and
include:

Optimisation of blood glucose control may cause temporary aggravation
of symptoms

Simple analgesia

Amitriptyline 25-50 mg at night Increased as necessary every few weeks

Gabapentin

Carbamazepine

Capsaicin Cream applied sparingly to the affected area

Op-site - occasionally this can prove surprisingly effective

Autonomic neuropathy

Patients with long-standing diabetes may develop neuropathy affecting
autonomic function, which may produce a number of different clinical and
management problems Symptoms are often non-specific and other diagnoses
should be considered and excluded

Erectile dysfunction: the advent of selective inhibitors of
phosphodiesterase in erectile tissue has revolutionised the management of
this relatively common problem in diabetic men Treatment is successful
in more than 50 of patients Sildenafil is available on prescription for
patients with diabetes; its
use should be avoided in cases of severely
compromised cardiovascular function and when nitrates are being taken
Newer agents claiming longer action are becoming available Where oral
therapies are unsuccessful, referral can be made to a specialist ED
clinic through NHS Grampian for consideration of intracavernosal
injection of prostaglandin or vacuum devices

Intermittent diarrhoea: especially occurring nocturnally, this problem
may be a direct result of gastrointestinal neuropathy in which codeine
phosphate or other antidarrhoeal agents can be helpful Alternatively,
gut dysmotility can lead to atypical bacterial overgrowth and short
courses of antimicrobial agents such as tetracycline or metronidazole can
be rapidly effective [Remember also other possible causes of diarrhoea,
including Metformin therapy, the possibility of coeliac disease or
exocrine pancreatic dysfunction in cases of secondary diabetes]

Postural hypotension: avoid rising up too quickly, and over-enthusiastic
use of diuretics and hypotensive agents Fludrocortisone may be useful in
severe cases but may lead to oedema

Vomiting due to gastroparesis: metoclopramide or domperidone may help by
promoting gastric emptying Erythromycin may benefit some patients

Gustatory sweating: fortunately uncommon; best managed by avoidance of
foods found by the sufferer to exacerbate the problem The
anticholinergic agent propantheline may be beneficial but often has
marked anticholinergic adverse effects

Neuropathic oedema: damage to control of capillary blood flow can lead to
accumulation of fluid in dependent extremities in the presence of a
normal serum albumin and the absence of fluid overload Ephedrine, an
alpha-adrenergic agonist may be useful but care is required in the
presence of hypertension and angina

Bladder hypotonia: drug treatment with alpha blocking agents is difficult
due to the risk of precipitating symptomatic postural hypotension

Blood pressure

Hypertension is an independent risk factor for both microvascular and
macrovascular disease in people with diabetes The risk of CVD death
progressively increases with rising systolic blood pressure, while each
10mm Hg reduction in systolic blood
pressure with treatment is associated
with a 15 reduction in the risk of CVD death over 10 years

Non-pharmacological measures including weight reduction, restriction of
dietary salt and increased physical activity should be implemented Most
patients will require drug therapy, and many will require more than one
drug to reach target BP levels In the UKPDS 29 of patients required
three or more agents to reach target blood pressure levels

1 Measuring blood pressure

Blood pressure should be measured using a validated spygmomanometer
according to the BHS guidelines for BP measurement
http://wwwhypacuk/bhs/ Most of the evidence for treatment and target
blood pressure levels has been obtained using clinic blood pressure
readings

2 Thresholds for treatment

Treatment should be considered in all patients with a sustained, eg 3
readings over two months systolic or diastolic blood pressure greater than
140/85 mm Hg

[Below the age of 45 initiation of treatment should be considered at lower
thresholds approximating to the 75th centile see Appendix 7, taking
account of retinopathy,
microalbuminuria and risk factors for
cardiovascular disease]

3 Target blood pressure levels

Target blood pressure in patients with diabetes should be less than 140/80
mm Hg

There is some evidence that in certain groups eg age under 45, those with
microalbuminuria or proteinuria, lower blood pressure targets may be
appropriate Refer to Section 193

4 Choice of antihypertensive drug

The most important issue is to obtain adequate blood pressure control, with
a minimum of adverse effects

Type 1 patients: ACE inhibitors should be considered as first line agents
For patients unable to tolerate ACE inhibitors, an angiotensin II
antagonist should be used A variety of other antihypertensive agents can
be used in addition if required

Type 2 patients: ACE inhibitors should be considered as first line therapy
in patients with microalbuminuria with AIIA for those intolerant of ACEI
Thiazides, beta-blockers, ACE inhibitors, calcium channel blockers and
angiotensin II antagonists AIIAs are all effective in lowering blood
pressure and reducing the risk of vascular events

5 Notes on specific antihypertensive drugs

1 ACE
inhibitors

Agent of first choice in Type 1 patients, and Type 2 patients

Serum creatinine and electrolytes should be measured before and one to
two weeks after initiation of therapy, and after each dosage increment

An increase of creatinine of 10 can be expected, but larger increases
would need reconsideration of the dose, further investigation and/or
specialist advice on further assessment

An elevated serum creatinine is not an absolute contraindication to the
use of ACE inhibitors These patients should have further investigation
and/or specialist advice prior to initiation of these agents

Potassium-sparing diuretics eg amiloride, co-amilofruse should
normally be discontinued when an ACE inhibitor is introduced

The risk of underlying renal artery stenosis should be considered,
particularly in patients with peripheral arterial disease and renal
impairment

ACE inhibitors are contraindicated in pregnancy Women of child-bearing
age should be advised of this prior to commencement of treatment, and
should practice effective contraception The drug should be withdrawn
prior to planned
conception, or immediately in the event of a confirmed
pregnancy

2 Angiotensin II antagonists

The points raised under ACE inhibitors also apply to these drugs

AIIAs should be reserved for patients unable to tolerate ACE inhibitors
mostly due to cough

AIIAs have been shown to be effective in preventing progression of renal
disease in patients with Type 2 diabetes They are as effective as beta-
blockers in the prevention of cardiovascular events, and may be more
effective at preventing cerebrovascular events

For patients who have difficulty reaching BP targets, and who have normal
renal function, the combination of ACE and AIIA may offer additional
benefits This should only be considered with close monitoring of renal
function and BP response

3 Diuretics

Best used in combination with ACEI and A2 receptor antagonists

4 Beta blockers

Diabetic patients with ischaemic heart disease will benefit from beta
blocker therapy

In the UKPDS atenolol was at least as effective as an ACE inhibitor
captopril in both blood pressure control and prevention of diabetic
complications, although less well
tolerated

Non-cardioselective beta-blockers should be avoided Cardioselective
beta-blockers do not affect awareness of, or recovery from,
hypoglycaemia

Caution is required in patients with peripheral vascular disease and
airways disease

5 Calcium channel blockers

Long acting, once daily, calcium channel blockers are safe and effective
in diabetes There is some concern over the safety of shorter acting
agents, which should not be used

6 Alpha blockers

Doxazosin is the recommended agent in this class as the risk of postural
hypotension is low

The ALLHAT study showed an increased incidence of hospitalisation due to
heart failure in patients taking doxazosin compared to those taking a
thiazide This drug should be avoided in patients with compromised left
ventricular function or those thought to be at high risk of developing
heart failure

7 Centrally acting drugs

Methyldopa is the antihypertensive of choice prior to and during
pregnancy

Moxonidine can be used as an add on therapy when other therapies have
not achieved target pressures

Renal disease and
diabetes

Renal impairment is important in patients with chronic diseases or on
multiple drug therapy and serum creatinine should be checked annually
Diabetic nephropathy is an important long-term complication of diabetes,
which is characterised by persistent proteinuria, hypertension and a
progressive decline in renal function The absence of retinopathy or the
presence of haematuria should prompt investigation for other possible forms
of renal disease A definitive diagnosis of diabetic nephropathy can be
made by renal biopsy, although this is unnecessary in most cases

Persistent proteinuria confers an eighty to one hundred fold increased
mortality due largely to cardiovascular disease and such patients often
succumb before the need for renal support arises Survivors with persistent
proteinuria eventually progress to end stage renal failure requiring
dialysis or transplantation

Microalbuminuria is an early marker of diabetic renal disease and predicts
the onset of overt nephropathy in both Type 1 and Type 2 diabetes
Microalbuminuria is also a significant independent risk factor for the
development and
progression of cardiovascular disease

Aggressive management of blood pressure can retard the progression of
diabetic renal disease at all stages

1 Screening for diabetic renal disease

Who People with diabetes aged 12 years or over

When At diagnosis and annually

How Dipstick for proteinuria Albustix or equivalent

Microalbumin estimation if dipstick negative

Outcome
Dipstick positive - see 1921 - Assessment of dipstick positive patients

Dipstick negative - see 1922 - Assessment of dipstick negative patients

2 Definitions

Spot urine samples for screening

Albustix Dipstick one plus or greater 200mg/l indicates proteinuria

Albumin/creatinine ratio ACR The ratio of urinary albumin to
creatinine concentration This is a screening
test for microalbuminuria

Normal values - female 35mg/mmol, male 25mg/mmol

Timed overnight urine collections for diagnosis - see Appendix 10

Normoalbuminuria Normal albumin excretion rate 20 g/min

Microalbuminuria Albumin excretion rate 20-200g/min

Proteinuria Albumin excretion rate 200g/min
Spot protein/creatinine ratio PCR
70mg/mmol
24hr urinary protein 500mg

1 Assessment of dipstick positive patients

Consider urinary infection or other non diabetic causes

Repeat test

Persistent proteinuria, when confirmed on two consecutive occasions,
should be quantified using a protein/ creatinine ratio measurement on a
spot sample

Review result of recent serum creatinine and blood pressure

Persistent dipstick positive proteinuria negates the need for
measurement of microalbuminuria

2 Assessment of dipstick negative patients

Screen for microalbuminuria

First voided urine sample after sleep, for albumin/creatinine ratio ACR

Reject samples with evidence of infection

Normal male 25, female 35 mg/mmol repeat in twelve months

Abnormal - Re-test

If repeat test abnormal proceed to timed overnight urine collection

AER 20ug/min - revert to annual screening

AER 20ug/min - microalbuminuria confirmed

ACR levels persistently in excess of 10 mg/mmol always indicate an
AER 20g/min, and in such circumstances a timed collection may be
omitted

In some clinics preliminary screening is performed to identify
normal
results using the Klinitek 50

Result from Klinitek 50 - both ACR 35 and urinary albumin
concentration 10 mg/l normal albuminuria Repeat in 12 months

Result from Klinitek 50 -ACR 35 and/or urinary albumin concentration
10 mg/l send first voided urine to Lab for further analysis

3 Management of Diabetic Renal Disease

Patients with diabetic renal disease require frequent and intensive
monitoring

Microalbuminuria and proteinuria confirm diabetic renal disease and
aggressive management of blood pressure and other risk factors is
essential to preserve renal function

These patients are also at high risk of retinopathy, autonomic neuropathy
and cardiovascular disease

All patients with microalbuminuria or proteinuria should be commenced on
ACE inhibitor therapy The dosage should be gradually increased to the
maximum tolerated dose Those intolerant of ACE inhibitors should be
given Angiotensin II antagonists Annual measurements of creatinine and
albumin/creatinine ratio protein/creatinine ratio if proteinuric should
be continued

Lowering blood pressure in relatively
hypertensive microalbuminuric
patients reduces albumin excretion and progression to nephropathy All
agents which lower blood pressure reduce albumin excretion, although ACE
inhibitors and AIIAs probably have a class specific effect independent of
their hypotensive effect and are the drugs of choice for initial therapy

Blood pressure should be maintained 140/80 mm Hg in all patients SIGN
55 In Type 1 patients with microalbuminuria or proteinuria the target
blood pressure should be lower The Shetland Renal Clinic currently
recommend 125/75

Insulin or sulphonylurea requirements usually decrease with advancing
renal impairment Metformin should be discontinued when serum creatinine
is 150 mol/l

Patients with Type 1 diabetes and proteinuria may benefit from advice
from a Dietitian

Patients with diabetic renal disease have a high risk of cardiovascular
co-morbidity and should be managed aggressively

See Appendix 8 - Algorithm for microalbuminuria screening

4 Referral for specialist renal advice

Consider referral to specialist renal services when creatinine 150
mol/l male, 130 mol/l female or
protein/creatinine ratio 300
mg/mol

Referral should also be considered for features suggestive of nephrotic
syndrome or if persistent proteinuria is not thought to be explained by
diabetes considering the duration of diabetes and absence of other
microvascular complications

The presence of both blood and protein may also be indicative of an
alternative renal pathology and in cases where this is persistent ie
detected on more than 2 occasions a referral should be considered
Isolated haematuria will require separate evaluation and is not a feature
of diabetic nephropathy

Specialist renal assessment will include assessment for non-diabetic
renal conditions if necessary, assessment of GFR and estimation of likely
progression of renal disease Patients with stable renal disease will be
discharged back to routine diabetes care primary or secondary care with
advice on a threshold for further referral

Lipids and Diabetes

Abnormal lipid profiles are frequently seen in patients with diabetes and
these have implications for macrovascular complications Lipid status is
an important component in calculating overall risk of
cardiovascular
morbidity

1 Screening for lipid abnormalities

Triglycerides, total, HDL and LDL cholesterol should be measured as soon
as acceptable blood glucose control has been achieved following
diagnosis, and annually thereafter

Lipid lowering therapy should not be commenced on the basis of a single
estimation

Non fasting samples are usually suitable for interpretation of the lipid
profile

Lipid levels should be reassessed on a fasting sample if there is marked
hypertriglyceridaemia 45 mmol/l

Untreated or under-treated hypothyroidism causes dyslipidaemia and TSH
must be checked and any underlying hypothyroidism treated before lipid
lowering therapy is prescribed

Excess alcohol consumption may result in hypertriglyceridaemia

Poor glycaemic control may result in hypertriglyceridaemia

There is some evidence to suggest that elevated triglycerides may confer
additional cardiovascular risk but data are insufficient to use in risk
prediction High triglycerides may however influence the choice of
hypolipidaemic therapy

2 Drugs for treatment of hyperlipidaemia

1 Statins HMG-CoA reductase
inhibitors

Statins are particularly effective in lowering LDL-cholesterol and are
regarded as first line agents in the primary and secondary prevention of
cardiovascular disease The effect on HDL-cholesterol is marginal These
drugs can be used safely in the presence of significant diabetic
nephropathy A reversible myositis may occur rarely, which can be confirmed
by measurement of serum creatine kinase Although these drugs may cause a
rise in serum transaminase see current BNF, mild abnormalities in liver
function tests are common in patients with diabetes and are not an absolute
contraindication to their use in this context

2 Fibrates

Triglycerides persistently 10 mmol/l should be treated with fibrates
irrespective of cardiovascular risk

Fibrates may be a suitable alternative therapy where statin therapy is
not tolerated

Combination use increases the risk of myositis and they should be used
with caution in the presence of diabetic nephropathy

Cardiovascular disease and diabetes

Atherosclerotic vascular disease is the major cause of morbidity and
mortality in people with diabetes mellitus

Diabetes is associated with a two to three-fold increased risk of
coronary heart disease in men and a four to five-fold increase in pre-
menopausal women

The risk conferred by diabetes is independent of and additional to the
other major risk factors:

Smoking

Hypertension

Hyperlipidaemia

Microalbuminuria or proteinuria

Obesity

Adverse family history

1 Management of very high risk patients

This includes patients with:

Coronary heart disease

Peripheral arterial disease

Cerebrovascular disease

Diabetic nephropathy proteinuria

Those with calculated coronary heart disease risk 30 over 10 years

2 Therapeutic interventions for very high risk patients

Smoking cessation

Aspirin - 75 mg per day Clopidogrel 75 mg/day should be considered in
aspirin-intolerant patients and should be added in aspirin-treated
patients with a past history of coronary artery disease presenting with
acute coronary syndromes

Statin therapy - unless contraindicated The cholesterol targets are:

Total cholesterol 25 reduction from baseline or 5 mmol/l whichever
is lower

LDL cholesterol 3 mmol/l

Glycaemic control - See Section 11 - Targets for glycaemic control

Blood pressure control - See Section 18 - Blood pressure

Beta blockade - following myocardial infarction - SIGN guideline No 55

Weight reduction

ACE inhibition - unless contraindicated

3 Primary prevention of coronary heart disease in type 2 diabetes

Statin and Aspirin therapy should be considered for all patients with Type
2 diabetes Where the calculated coronary heart disease risk is 15 and
total cholesterol 5 or LDL 3, statin and Aspirin 75 mg per day therapy
should be offered in the absence of contraindications

Primary prevention relates to all patients with Type 2 diabetes not
included in Section 211

4 Primary prevention of coronary heart disease in type 1 diabetes

In the absence of contraindications, statin and Aspirin 75 mg per day
therapy should be considered for all patients with Type 1 diabetes of
greater than 10 years duration who are over 40 years of age, or in younger
patients if coronary heart disease risk exceeds 15 in 10 years

Primary prevention relates to all patients with Type 1 diabetes not
included in
section 211

5 Screening criteria for coronary heart disease in diabetes

Who All people with diabetes aged over 25

When Annually

By whom Any member of the diabetes care team

How The following should be addressed annually and the overall coronary
heart disease risk calculated

History and examination as appropriate Consider ECG

Smoking - see Section 8 - Smoking and Diabetes

Blood pressure - See Section 18 - Blood Pressure

Measurement of urinary albumin - see Section 191 - Screening
for diabetic renal disease

Lipid profile - see Section 200 - Lipids and Diabetes

Obesity and diet - see Section 511 - Major dietary messages
for all types of Diabetes Mellitus

Glycaemic control - see Section 11 - Targets for glycaemic
control

Outcome For primary prevention - See213 Primary prevention of coronary
heart disease in type 2 diabetes and 214 Primary prevention of
coronary heart disease in type 1diabetes

For secondary prevention - See 212 - Therapeutic
interventions
for very high risk patients

6 Calculating coronary heart disease risk

The coronary heart disease risk is determined on the basis of certain pre-
existing conditions or by the use of risk factor tables For the purposes
of this document the Joint British Societies Coronary Risk Prediction
Charts have been used See BNF or SIGN Guideline 40 - Lipids and the
Primary Prevention of Coronary Heart Disease22 and the SIGN 40 Quick
Reference Charts See also electronic risk calculator
wwwgpctgrampianscotnhsuk/grampintranet/ggmp/diabetes/riskxls

The risk calculated should be increased as shown for each of the following
additional risks:

7 Aspirin

All patients with Type 2 diabetes and a calculated 10 year coronary heart
disease risk 15 and Type 1 patients aged over 40 with greater than ten
years duration of diabetes, who have no contraindications, should take 75
mg Aspirin per day Clopidogrel 75 mg daily is an alternative for patients
intolerant of Aspirin

In primary prevention before starting Aspirin therapy aim to reduce
systolic blood pressure to 145 mmHg or below

Diabetes and Pregnancy

Successful outcome of pregnancy can usually be anticipated in women with
pre existing diabetes However, diabetic pregnancy is statistically a high
risk pregnancy with regard to fetal morbidity and mortality To achieve a
good fetal outcome major efforts and attention to detail are required on
the part of the patient and her carers Meticulous blood glucose control
before and during pregnancy is the cornerstone of management

In addition to metabolic supervision, mothers require close clinical
surveillance since there are increased risks with regard to progression of
diabetic retinopathy and nephropathy, pregnancy
induced hypertension and
intrapartum complications

The congenital abnormality rate in diabetic pregnancy is at least double
that of the background population, and there is convincing evidence that
this relates to glycaemic control at or shortly after conception during the
period of organogenesis This stage is often complete before the mother
realises that she is pregnant

For these reasons diabetic pregnancy should always be planned and reliable
contraception is therefore important

1 Prior to conception

Refer to a hospital or combined obstetric diabetic clinic for pre pregnancy
assessment, where the following steps are taken:

Achieve optimal glycaemic control aiming for an HbA1c result within or as
near to the non-diabetic range as is possible without inducing disabling
hypoglycaemia

Provide blood glucose meter and test blood glucose four to six times
daily

Blood glucose targets are fasting and pre meal 40-55 mmol/l, two hour
post prandial 70 mmol/l

Review insulin regimen For intensive blood glucose control most women
are best treated with a multiple injection regimen using a pen device

Patients with Type 2
diabetes should be considered for insulin therapy
with treatment targets as above

Discuss lifestyle issues which may affect glycaemic control, eg
difficulty with shift work and reinforce antismoking advice

Review all medications and other potential teratogens

Arrange dietetic review

Commence folic acid 5mg daily High dose recommended in view of high
risk of neural tube defects

Ensure complication screening is complete and take action as appropriate
- See 102 - Content of Annual checks

Check rubella status

Assess general health, fitness for pregnancy, and screen for factors
which could disturb glycaemic control, eg urinary infection and thyroid
status

Review menstrual and gynaecological factors which could impair fertility

2 Confirmed pregnancy

All diabetic women in whom pregnancy has been confirmed should be referred
immediately to a hospital combined obstetric / diabetic clinic for
multidisciplinary supervision through Dr Wilson Joint clinics are held in
Shetland where women will be seen at intervals depending on metabolic
control and obstetric progress Admission is not routine but may be
recommended for
stabilisation of blood glucose control, management of
diabetic complications or associated obstetric problems Planned delivery
will be arranged to take place in Aberdeen

3 Hypoglycaemia

Strict blood glucose control increases the risk of hypoglycaemia and
warning signs are often lost in early
pregnancy All women should be provided with Hypostop and a glucagon
emergency kit, and their partner
should be instructed in their use Ideally women should not sleep in a
house alone in early pregnancy because of the risk of hypoglycaemia Women
who lose awareness of hypoglycaemia in pregnancy should be advised to stop
driving until warning symptoms return to normal

4 Ketosis

The fetus tolerates hypoglycaemia well, but is very sensitive to ketosis
Established ketoacidosis in pregnancy results in a very high incidence of
fetal loss at all gestations, and is usually potentially avoidable
Pregnant women should all have facilities for urine testing for ketones
Elevation of blood glucose 10mmol/l together with persistent non
fasting ketonuria is an indication for increased insulin doses and urgent
further assessment usually involving hospital admission for intravenous
insulin and
dextrose

Women must be advised to contact either their the hospital team or GP in
such circumstances without delay The most common cause of ketosis in
pregnancy is urinary tract infection, which should be treated on a
presumptive basis

5 Delivery

Women should be delivered where there are facilities for intensive neo-
natal care Ideally should be vaginal and at term but not beyond An
individual decision will be made for each patient, and in practice the
caesarean section rate remains about double that of the non-diabetic
population

All women on insulin receive an infusion of dextrose and insulin during
labour to maintain normoglycaemia

Post partum insulin requirements usually fall to between 30 and 50 of
that immediately prior to delivery Breast-feeding is encouraged

Management of Gestational Diabetes Mellitus

1 Background and definition

Gestational diabetes mellitus GDM has been defined as carbohydrate
intolerance of variable severity with onset or first recognition during
pregnancy

During pregnancy the normal range for fasting blood glucose is much lower
than in non-pregnant women and glycosuria with normal blood glucose levels
is common due to a
lowering of the renal threshold for glucose

2 Recommended screening protocol for gestational diabetes mellitus

3 Diagnosis

The criteria for the diagnosis of gestational diabetes are recommended as

4 Management of gestational diabetes mellitus

Women diagnosed as having gestational diabetes should be seen by a
physician and obstetrician with a special interest in diabetes and should
receive intensive management with diet and/or insulin if macrosomia is
suspected or if blood glucose levels are in the range for established
diabetes

5 Post-natal follow up

Up to 50 of women may go on to develop Type 2 diabetes later in life and
this group presents an excellent opportunity for screening and
intervention Studies have shown that lifestyle intervention can reduce
the incidence of diabetes in at risk patients by over 50 see Appendix 11
for suggested follow-up protocol All patients with gestational diabetes
are invited for a glucose tolerance test at 6 months after delivery

Appendix 1 - 75g Oral Glucose Tolerance
Test

Indications for this test are discussed on page 3 It can easily be
performed in primary care but a standardised protocol must be followed and
laboratory glucose analysis must be used This test should not be
performed during intercurrent illness On rare occasions two oral glucose
tolerance tests may need to be performed before a diagnosis of diabetes can
be confirmed

The patient should maintain an adequate carbohydrate intake 150g for at
least three days prior to the test

Fast overnight for a minimum of 10 hours water only permitted

75 g oral glucose dissolved in 250 to 300ml water to be consumed in no more
than 5 minutes followed by a further 100mls water

Acceptable alternatives are;

Lucozade 394ml 73kcal/100ml formulation

Maltodextrins in appropriate volume to provide 75g carbohydrate eg
Calsip 150ml

Blood for glucose estimation to be taken before zero minutes and 120
minutes after consumption of the drink

Urine may also be tested for glucose to estimate the renal threshold, but
this does not contribute to the diagnosis of diabetes, which is based on
the fasting and two-hour blood glucose results

The method
of blood sampling is important and must be specified: venous or
capillary, plasma or whole blood Venous plasma is most commonly used

The patient should remain sedentary and not smoke, eat or drink for the
duration of the test

Interpretation of 75g Oral Glucose Tolerance Test WHO 2000

| |Glucose mmol/l|Fasting | |2 Hour |
|Diabetes Mellitus | | | | |
|Venous |Plasma | | |? 111 |
|Capillary |Plasma | | |? 122 |
|Impaired glucose | | | | |
|tolerance | | | | |
|Venous |Plasma |70 |and |? 78, |
| | | | |111 |
|Capillary |Plasma |70 |and |? 89, |
| | | | |122 |

Appendix 2 - Education Checklist

Appendix 3 - Secondary Diabetes

Cushings Syndrome

When to suspect: Centripetal obesity thin arms, hypertension,
hirsutism

How to screen: First voided morning urine sample for free cortisol
/creatinine ratio 3 separate samples

Acromegaly

When to suspect: Coarse features, prognathism, change in ring / shoe
size, hypertension, sweating

How to screen: Consider referral to Endocrine clinic

Haemachromatosis

When to suspect: Pigmented bronzed diabetes, abnormal AAT,
hepatosplenomegaly

How to screen: Serum ferritin

Chronic Pancreatic Destruction

When to suspect: History of alcohol excess, recurrent abdominal
pain,
cystic fibrosis

How to screen: Plain x-ray, abdominal ultrasound, amylase, consider
referral to GI specialist

Appendix 4 - Driving Advice for patients with diabetes requiring insulin-
treatment

The main hazard to safe driving caused by insulin treatment is the risk of
hypoglycaemia at the wheel Hypoglycaemia whilst driving may not only
endanger your own life but also that of other road users There are a
number of notifications to the DVLA about accidents relating to
hypoglycaemia where the driver is aware of impending hypoglycaemia but
continues to drive

The following measures are recommended for all drivers with insulin-treated
diabetes:

Always keep an emergency supply of fast-acting carbohydrate such as
glucose tablets or sweets or a drink such as lucozade or coca-cola
within reach in the vehicle

Carry your blood glucose meter / strips with you

Check blood glucose before driving even on short journeys and test
regularly every 2 hours on long journeys If blood glucose is
50mmol/l or less, take a snack before driving

Take regular meals, snacks and rest periods
on long journeys

Avoid alcohol

DO NOT DRIVE if you feel hypoglycaemic or your blood glucose is less than
40 mmol/l

If hypoglycaemia develops while driving stop the vehicle immediately in a
suitable location, bearing safety in mind, switch off the engine and
remove the keys from the ignition and vacate the driving seat Do not
resume driving until 45 minutes after blood glucose has returned to
normal it takes this time for the brain to fully recover

Carry personal identification indicating that you have diabetes in case
of injury in a road traffic accident

If you have just changed your insulin regimen or started insulin for the
first time you should be particularly careful and not drive if your blood
glucose levels are unstable If you are trying to tighten blood glucose
control, have changed your physical activity or are pregnant you should
monitor your blood glucose very carefully and extra care should be taken
when driving

If you suffer as disabling attack of hypoglycaemia during waking hours
you must inform the DVLA

If you lose your warning symptoms of hypoglycaemia you should not drive
until
advised by your diabetes specialist If loss of warning symptoms
persist then you should inform the DVLA

All drivers are required by law to be able to read a standard size car
number plate in good light at 205 metres The advantage of this test is
that it is easily self-administered Problems which affect the field of
vision must be notified to the DVLA Drivers who have had laser treatment
to both eyes for retinopathy or suffer other conditions affecting both eyes
must inform the DVLA so that the extent of the problem can be assessed

Other advice may be obtained from the following websites / addresses:

Diabetes UK, DVLA

10 Parkway Longview Road

London
Swansea

NW1 7AA SA99 1TU

Tel: 020 7424 1030 Tel: 01792 761119

web: wwwdiabetesorguk web: wwwdvlagovuk

Appendix 5 Scottish Diabetic Retinopathy Grading System

This system is used for screening by the Shetland Retinal Screening
Programme or opportunistically The Shetland Retinal Screening Programme
will initiate appropriate onward referrals or review schedules

Grading note

This grading scheme is not intended to be done by levels It is meant to be
done by features The grader reports the presence or
absence of each of the
following features for each hemisphere and then derives the level for the
individual eye:

Dot haemorrhages or microaneurysm

4 or more blot haemorrhages ie standard photography 2a

Venous Beading AH standard photograph 6a

IRMA AH standard photograph 8a

New vessels

Vitreous haemorrhage

Airlie House standard photographs available at:

http://eyephotoophthwiscedu/ResearchAreas/Diabetes/DiabStdshtm

Foot screening form

Local guidelines to be inserted

Appendix 7 - 75th Centiles for blood pressure in Caucasian Adults below
the age of 45

|Age |Male |Female |
|35-44 |137/85 |130/83 |
|25-34 |133/83 |122/79 |
|18-24 |124/79 |110/75 |

Appendix 8 - Algorithm for microalbuminuria screening in the community

See Section 1922

Appendix 9 - Patient Information Sheet - Urine Testing And
Microalbuminuria

As part of your routine diabetic assessment your urine is tested for
protein Protein
in the urine may suggest the presence of a urine
infection or may indicate the effects of diabetes on the kidneys In
addition, a urine sample is screened routinely to the laboratory at least
once a year to identify very small amounts of the protein called albumin
microalbuminuria

What is microalbuminuria and why is it important?

A slightly elevated amount of albumin in the urine, is called
microalbuminuria Microalbuminuria is a sensitive indicator, which
signals that the kidneys may be beginning to be affected by diabetes It
is important to identify this in the very early stages so that treatment
can be added to try and prevent progression to more severe kidney damage in
later years Very good control of blood pressure combined with improving
glucose control as much as possible have been shown to be very beneficial

Does a positive test for microalbuminuria always mean that the kidneys are
affected by diabetes?

NO Sometimes other factors can make the urine show small amounts of
albumin in the laboratory test For example a urine infection or recent
vigorous exercise may also cause elevated levels
For this reason, if one
specimen of urine suggests that microalbumin is present, this should always
be confirmed by a repeat sample at a later date If the second sample is
also abnormal, it is usual to obtain an overnight urine collection to
diagnose microalbuminuria

Appendix 10 - Instructions for timed overnight urine collections for
albumin excretion rate

This test measures the rate of protein albumin excretion in the urine
Elevated levels may indicate early diabetic kidney damage, which is usually
amenable to treatment at this stage

General points to note

Please avoid strenuous physical activity prior to making a collection
You should refrain from sexual activity whilst making the collection
Ladies should not make a collection whilst menstruating and should wait for
at least 3 days after the period ends before making a collection
Avoid making collections on Friday or Saturday nights or before a local
holiday to prevent delay in the sample reaching the laboratory

Instructions

When you retire to bed empty your bladder and discard the urine
Note the clock time on the collection bottle as the start time
If you have occasion to pass urine
in the night, it should be collected and
decanted into the collection bottle
When you get up in the morning empty your bladder, collect the urine and
decant it into the collection bottle
Note the clock time on the collection bottle as the finish time
Deliver the collection bottle to your GP or hospital clinic together with
the request chit if you were given one

Appendix 11 - Follow-up Of Patients With Previous Gestational Diabetes

Appendix 12 - Grampian Shetland Recommendations for Home Blood Glucose
Monitoring

Patients with Type 2 Diabetes controlled by diet or oral medication

Why test blood glucose at home ?

Blood glucose monitoring should not be seen as a stand-alone intervention
but should only be taught if the need/purpose is clear and agreed with
the patient as part of an educational package

For some patients regular home blood glucose testing may not be
appropriate and patient choice should be taken into account

Home blood glucose monitoring may help an individual to take control of
their condition and can inform patients of the effects of eating certain
foods and exercise on blood
glucose

How often and when should patients monitor blood glucose ?

Frequency of monitoring will vary between patients depending on lifestyle
and motivation

When glycaemic control is stable and HbA1c on target, regular testing may
not be essential but may help some patients maintain optimal control

When HbA1c is rising or when treatment is changing or when there is
intentional lifestyle change, blood glucose monitoring 2-3 times per week
at different times of day eg fasting, 2 hours after eating may be
helpful up to a maximum of 4 tests every fourth day or one test per day

Patients should be encouraged to record and understand the results of
their blood testing and take action as agreed with their diabetes team

Situations, which may require more intensive blood glucose monitoring

Patients should be advised to test blood glucose at least daily and
possibly up to 4 times per day in the following situations:

During illness or if ketonuria present

Before / After moderate physical activity

During times of psychological / emotional stress eg exams, driving
tests

If the patient is at increased risk from
hypoglycaemia eg taxi / lorry
driver / operating heavy machinery

During pregnancy or pre-pregnancy planning

Blood glucose targets - these vary between individuals - See section 11

Urine glucose testing

For some patients regular blood glucose testing may not be possible or
appropriate and urine glucose testing may provide an alternative method of
monitoring glycaemic control

Urine Ketone Testing

This is not usually required in patients with Type 2 diabetes but where
there is concern that the patient may have Type 1 diabetes or becoming
insulin-requiring the diabetes team may recommend urine ketone
monitoring

Grampian Shetland Recommendations for Home Blood Glucose Monitoring

Patients with Insulin-treated Diabetes

Why test blood glucose at home?

Home blood glucose monitoring is strongly recommended for people with
insulin-treated diabetes, as it enables the individual to take control of
their condition and can help highlight situational changes requiring
insulin adjustment

How often should patients monitor blood glucose?

Frequency of monitoring will vary between patients depending on lifestyle

and motivation

Patients should be encouraged to do at least one test per day at
different times or 4 times a day every 3rd or 4th day

Some patients wishing to have greater control or flexibility may choose
to test up to 4 time per day also see below for situations where more
testing may be required

When should patients test blood glucose?

Recommended times of testing would be before meals ie breakfast, lunch
and tea, before bed and sometimes 2 hours after eating Patients should
be encouraged to keep a record of results including details such as time of
day, activity and dietary intake

Situations which may require more intensive blood glucose monitoring

During illness or ketonuria

Before / After physical activity

Before driving any distance not just long journeys

Carbohydrate counting programmes

After a change of insulin type / regimen

During times of psychological / emotional stress eg exams, driving
tests

If impaired hypoglycaemic awareness or recurrent hypoglycaemia are
present

During changes in lifestyle - job / shift patterns

During pregnancy or pre-pregnancy planning

Blood glucose
targets - these vary between individuals - See section 11

Adjustment of insulin dose

If patients are not aware of how to adjust their insulin doses help should
be sought from their diabetes team

Ketone testing in insulin-treated patients

Patients on insulin should be advised to keep an in date supply of
ketone-testing strips

If blood glucose 17 or above or during intercurrent illness eg cold
/flu / UTI etc urine should be tested for ketones If TRACE or SMALL
observe, if MODERATE or LARGE - extra insulin is probably required

If blood glucose still 17 or above after 3 hours - retest urine for
ketones If ketones are still present ie moderate or large further
extra insulin may be required

If blood glucose and urine ketones are persistently elevated the patient
is at significant risk of developing diabetic ketoacidosis and specialist
advice may be required

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———————–
Newly diagnosed diabetes

No current indication for insulin therapy

Yes

Urine should be tested for glycosuria at every antenatal visit
preferably fasting

Timed or random venous plasma glucose measurements should be made:

o Whenever glycosuria 2 or more is detected

o At 28 weeks gestation

A 75g oral glucose tolerance test OGTT should be carried out if the
venous plasma glucose is:

o 55 mmol/l 2 hours or more after food

o 70 mmol/l within 2 hours of food

Seek experienced advice Re insulin therapy within 24 hours

4-6 weeks later - Adequate control