Type 1 Diabetes Mellitus Insulin Therapy. 18 The handbook is not a textbook of diabetes, and should not be regarded as such. Key areas of Diabetes Management …

The Fife Diabetes Handbook 2008

A practical guide for managing Diabetes Mellitus in Fife

Editor: Dr Andrew Jamieson, Consultant Physician
Contents
| | |Page |
|Introduction | |3 |
| | | |
|Diagnosis and Initial Education | | |
|Classification of Diabetes and Related Glycaemic | |5 |
|Disorders Diagnosis of Diabetes Mellitus | |7 |
|The Oral Glucose Tolerance Test | |9 |
|Initial Management of a patient with Diabetes Mellitus| |10 |
|Newly Diagnosed Diabetes Mellitus | |11 |
|Management of Type 1 Diabetes Mellitus | |12 |
|Management of Type 2 Diabetes Mellitus | |13 |
|Four Corners approach to Vascular Risk Modification | |14 |
|Blood Pressure
| |15 |
|Blood Glucose Management | |18 |
| |Type 1 Diabetes Mellitus Insulin Therapy |18 |
| |CSII - Insulin pump therapy including hospital |22 |
| |admissions | |
| |Blood Glucose Monitoring |25 |
| |Commonly Used Insulin Preparations |26 |
| |Type 2 Diabetes Mellitus |27 |
| |Dietetic Intervention |28 |
| |Metformin |29 |
| |Second line treatment in type 2 diabetes |30 |
| |mellitus | |
| |Thiazolidenediones |31 |
| |Sulphonylureas |32 |
| |Insulin |33 |
| |New
Drugs |34 |
|Lipid lowering therapy | |36 |
|Anti-platelet therapy | |38 |
| | | |
|Complication Screening and Referral| |39 |
| | |39 |
|Management of Diabetic Renal | | |
|Disease | | |
|Management of Intercurrent Illness | |42 |
|Hypoglycaemia | |44 |
|Diabetic Ketoacidosis | |48 |
|In-patient Insulin Use and Supply | |51 |
|Diabetic Retinopathy | |52 |
|Erectile Dysfunction | |54 |
|Podiatry Care of the Diabetic Foot | |56 |
|
|Acute Foot Problems |59 |
| |Charcot Arthropathy |64 |
| |Painful Neuropathy |65 |
| |Podiatry Rapid Referral |67 |
|Diabetes Dietetic resources | |68 |
| | | |
|Pregnancy | |69 |
| | |71 |
|Living with Diabetes | | |
|Diabetes UK contacts | | |
|Staff Contacts | |72 |
|Key Publications | |79 |
| | | |

Introduction

Diabetes mellitus is a common long term condition, and the patient with
diabetes mellitus is likely to encounter a great many medical
and
paramedical practitioners during the course of their life with diabetes
The aim of treatment in people with diabetes mellitus is to abolish, delay,
or limit or the burden of vascular disease which can both limit the life of
a patient with diabetes, but also lead to a significant impact in the
persons quality of life

The handbook is not a textbook of diabetes, and should not be regarded as
such The purpose of this handbook is to provide a source of locally agreed
information for practitioners dealing with patients with diabetes in Fife,
to guide care in the direction of best practice, and also to provide
information for practitioners to access resources for patients in other
units or specialties when needed

Dr Andrew Jamieson
Key areas of Diabetes Management
Management can be broadly divided into the following categories:
Diagnosis and Initial Education
Key to this are accurate diagnosis, patient education, dietetic
referral

Ongoing glycaemic control and risk factor management
Four corners approach to vascular risk management

Complication screening and referral
Diabetic Retinopathy Screening, Podiatric
Assessment, Microalbuminuria

Each of these areas is addressed in the handbook

Diagnosis and Initial Education

Classification of Diabetes Mellitus and related Glycaemic Disorders

In many cases the classification of the type of diabetes mellitus will be
straightforward or of no particular consequence to the individual However,
in some cases there may be a need for greater detail to allow accurate
prediction of risk of diabetes in offspring, or likelihood of requiring
insulin therapy in the short term
Type 1 Diabetes Mellitus

Auto-immune pancreatic beta cell destruction
Absolute insulin deficiency - require lifelong insulin therapy
Acute Presentation with Diabetic Ketoacidosis common
Typically children or young adults 35 years of age
Positive Anti-Islet Cell Ab or Anti-GAD Ab
11 of Type 2 Patients in UKPDS had positive Antibodies - so-called
Latent Type 1 Diabetics

Type 2 Diabetes Mellitus

Hyperglycaemia associated with insulin resistance
Typically occurs in obese adults
Positive family history common
May occur in young adults with obesity and those with a prior history
of Gestational Diabetes, or Polycystic Ovarian
Syndrome PCOS
A significant number require insulin therapy at some stage

Gestational Diabetes Mellitus

Carbohydrate intolerance of variable severity with onset or first
recognition during pregnancy
Often associated with a family history of Type 2 diabetes mellitus or
features of PCOS
Diagnosed by oral glucose tolerance test

Maturity Onset Diabetes in the Young MODY

Uncommon - 1 of diabetes in white adults
Displays Autosomal Dominant inheritance
Genetic tests are available for a number of these conditions

Other forms of diabetes mellitus

Pancreatic disease: surgery, chronic pancreatitis, cystic fibrosis
Drugs: Steroid therapy, Thiazide-like diuretics
Haemochromatosis, other endocrine disorders
Definition, Diagnosis and Classification of Diabetes Mellitus and its
Complications;
Report of a WHO consultation, Part 1: Diagnosis and Classification of
Diabetes Mellitus; World Health Organisation 1999
MODY assistance: Linda Robertson, Paediatric Diabetes Liaison Nurse
01592 643355 ext 8364

Impaired Glucose Tolerance IGT
IGT is a state of impaired glucose regulation, diagnosed by the Oral
Glucose Tolerance Test OGTT,
see page 6, which confers an increased risk
of future diabetes of 2-5 per year Patients with IGT tend to have higher
blood pressure and plasma triglycerides when compared to non-diabetic
individuals

Impaired Fasting Glycaemia IFG
The term IFG has been introduced to classify individuals with fasting
glucose values above the normal range but below those diagnostic of
diabetes ie FPG 60 mmol/L but 70mmol/l Diabetes UK recommends that
all such individuals should have an oral glucose tolerance test to exclude
a diagnosis of diabetes in the presence of other risk factors, eg central
obesity
Such individuals have an increased risk of developing diabetes and should
be offered lifestyle advice

The Oral Glucose Tolerance Test OGTT

An OGTT may be considered to establish a diagnosis of diabetes if fasting
blood glucose values fall into an equivocal range eg FPG between 6 and
69 mmol/L but clinical suspicion of diabetes remains, eg positive
family history, cardiovascular risk, symptoms
A single dose of 75g oral glucose in water is given in the following way:

Perform OGTT after at least 3 days of unrestricted diet 150g CHO
daily
Fast patient overnight 8-14 hours,
water allowed before the test and
rest during the test
Samples at times other than 0 and 2 hours are not necessary for
diagnosis
See page 9 for more information

Diagnosis of Diabetes Mellitus

The diagnosis of diabetes mellitus requires three key factors:

Clinical Suspicion - Relevant history or the presence of
cardiovascular risk factors or heavy glycosuria in pregnancy
Clinical Symptoms - Thirst, Polyuria, Polydipsia, Unplanned Weight Loss,
Fatigue
Biochemical Evidence of Hyperglycaemia

By assessing all three of the above parameters, a diagnosis and initial
classification can be obtained for the majority of newly diagnosed
patients

In the majority of cases, the fasting blood glucose measurements obtained
in a patient with an appropriate clinical history will be sufficient to
make the diagnosis In those with persisting symptoms and a non-diagnostic
fasting glucose measurement, or impaired fasting glucose in the presence of
obesity, hypertension or elevated cholesterol, an oral glucose tolerance
test should be performed to clarify the diagnosis
Diagnosis of Diabetes Mellitus

Biochemical Evidence of Hyperglycaemia

Laboratory blood glucose measurement
Capillary blood glucose measurements have
no role in the diagnosis of diabetes mellitus

Symptoms of hyperglycaemia

Excessive Thirst
Polyuria
Nocturia
Thrush - Vaginal, Balanitis
Blurred Vision

Blood Glucose Measurement Values

Fasting blood glucose 7mmol/l
Random or 2-hour OGTT blood glucose 111 mmol/l

Diagnostic Criteria not met?

May have Impaired Glucose Tolerance or Impaired Fasting Glucose
Annual fasting glucose measurement and assessment of 10year CHD risk
An OGTT may help define a number of patients with symptoms of diabetes
without a raised fasting glucose
Lifestyle advice aimed at attaining target BMI

The Oral Glucose Tolerance Test OGTT

An OGTT may be considered to establish a diagnosis of diabetes if fasting
blood glucose values fall into an equivocal range eg FPG between 6 and
69 mmol/L but clinical suspicion of diabetes remains A single dose of
75g oral glucose in water is given in the following way:
Perform OGTT after at least 3 days of unrestricted diet 150g CHO
daily
Fast patient overnight 8-14 hours, water allowed before the
test and
rest during the test
Samples at times other than 0 and 2 hours are not necessary for
diagnosis
Diagnostic interpretation of OGTT is different in pregnancy see
pregnancy section

Diabetes UK and the ADA recommend annual fasting blood glucose measurements
in those
with IFG/IGT along with life style advice

Initial Management of a patient with Diabetes Mellitus

Once a patient is diagnosed with diabetes mellitus, an initial triage based
on the red/amber/green principle will determine their subsequent journey
see below

All patients benefit from avoiding hospital admission unless absolutely
necessary, but in those patients who are vomiting, have systemic upset or
evidence of cardiovascular compromise will merit referral to the local
Acute Sector Medical On-Call team

Those patients with none of the above features, ie amber, but who have
ketonuria and an elevated blood glucose, are likely to have type 1 diabetes
mellitus and the referring practitioner should attempt to liaise with the
local Acute Sector Diabetes Liaison Nurse, or a Primary Care Diabetes Nurse
if present to initiate initial treatment and education If the diagnosis
is made out with normal office hours, then referral to the local Acute
Sector Medical On-Call team can be made
Remember, however, that the average on-call medical team consists of very
junior Foundation Doctors whose experience is likely to be limited, and
substantially less than specific diabetes
practitioners
Patients in the green category are likely to be dealt with in a Primary
Care setting from diagnosis until a specific clinical event triggers
contact with the Acute Sector team

Newly Diagnosed Diabetes Mellitus

The majority of new cases of diabetes will be Type 2 Diabetes Mellitus,
particularly in adults
Many patients will be dealt with entirely by primary care at the time of
diagnosis and for some considerable time thereafter
Hospital referral/admission may be required for a small number with
associated metabolic derangement at the time of diagnosis
|Red Criteria |Amber Criteria |Green Criteria |
|Urgent Referral |Refer within 24 hours |Routine Referral |

Any young person 20 years of age should be referred to hospital within
24 hours for evaluation if a new diagnosis of diabetes is made

Contact Paediatric Diabetes Liaison Nurse
During normal working hours, contact local Diabetes Nurse Contact
Out with normal working hours, contact on-call Medical Receiving Team
Local arrangements will determine the initial pathway of care
Some late presentations of Type 1 DM do occur
and may require referral
to hospital
Initial management will depend on clinical factors and patient choice

Linda Robertson, Paediatric Diabetes Liaison Nurse 01592 643355 ext
8364
Queen Margaret Hospital: 01383 623623 ext 3728/5610
Victoria Hospital: 01592 643355 ext 8001
Management of Type 1 Diabetes Mellitus

The vast majority of patients with type 1 diabetes mellitus will require
insulin therapy from diagnosis onwards throughout their life

A small number will present with hyperglycaemia without ketonuria, and may
respond initially to oral agents, but often develop rapid treatment failure
requiring insulin initiation within 2-6 months of initial presentation

Historically insulin initiation has been the province of the Hospital
Diabetes team However, with the increase in local skills, there are a
number of Primary Care based Diabetes Nurses who may be able to initiate
insulin therapy for both type 1 and type 2 diabetic patients

It would be recommended that in the majority of cases falling into the
Red/Amber categories, direct contact with the hospital team would be
appropriate unless a clear local arrangement is in place for initiation
and
initial monitoring of insulin therapy within the patients Primary Care
contact setting

Once established on insulin therapy, a number of the other ongoing care
arrangements can be commenced and delivered via primary care, eg
podiatric screening, or Diabetic Retinopathy Screening
Many practices now deal with patients with Type 1 diabetes except in the
context of pregnancy or specific complications The Hospital teams are
happy to liaise on all aspects of care of the diabetic patient
Management of Type 2 Diabetes Mellitus

Increasingly type 2 diabetes will be managed within the primary care
setting The management of the patient with type 2 diabetes mellitus
requires co-ordination between the patients primary care physician/nurse,
complication screening activities and other professionals, especially
dieticians to ensure that the best possible package of care is provided

However, there are areas of diabetes management that are similar in both
type 1 and type 2 diabetes

Cardiovascular complications are frequent in patients with type 1 and 2
diabetes and as such multiple drug therapies are likely to be the norm for
the patient with diabetes mellitus Many of the targets for
modifiable risk
factors are central to the Primary Care GMS contract and this will help
drive the reduction in an individual and the populations 10 year
cardiovascular disease risk

Education

All patients with diabetes require educational input at the time of
diagnosis and throughout their life with diabetes The type of education
will vary depending on individual circumstance and needs at any one time

Central to this process however, are diabetes nurses, in both primary and
secondary care, practice nurses, dieticians and podiatrists All of these
individuals play a vital role in delivering the holistic care required, and
their details are listed in the handbook

Four Corners Approach to Vascular Risk Modification

Regardless of the vascular territory being treated, there are four areas
where lifestyle and pharmacological intervention are likely to result in
individual benefit The interventions are easily summarised using a Four
Corners approach based on the evidence available from published studies
and guidance published by professional bodies

Pharmacological therapy is based on an individual prescribers discretion,
local and national guidance and the ability of
the patient to tolerate the
therapy

Central to this is the recognition that not all patients will wish to or be
able to attain some or all Targets and this must be recognised when
dealing with an individual patient

Blood Pressure Management
A number of key studies have demonstrated the benefit of lowering blood
pressure in patients with diabetes, both in reducing the risk of
development and progression of retinopathy and nephropathy, but also in the
reduction in stroke and new cases of heart failure

Choice of Antihypertensive Agents
It is felt that all patients with diabetes are likely to require anti-
hypertensive therapy at some stage in their life The age of commencement
of therapy and the level at which therapy is started may vary from group to
group, but the initial strategy for hypertension management is similar for
all patients

Current national guidance suggests the use of a modified ABCD style of drug
therapy prescription, based on the British Hypertension Society and
subsequent NICE documents

These recommendations stress the use of ACE inhibitors or Angiotensin II
receptor blockers ARBs as first line therapies unless contraindications
to these agents exist

In
addition, they suggest beta blockers have a peripheral role in the
initial management of hypertension However, this does not mean that
patients with ischaemic heart disease, left ventricular dysfunction or
previous myocardial infarction should have them with held
Indeed, it is likely that for a number of patients, beta blocker therapy
will be a component of the Other group

Some of these combinations have little in the way of published evidence to
support them, but studies of anti-hypertensive therapy in patients with
diabetes reveal that at least 1/3 of all patients require 3 or more
different agents to achieve adequate blood pressure control Thus multiple
trial and error approaches are likely to be common practice to find a
tolerated and efficacious regimen for the individual
Stepped Therapy

Use of ACEI/ARB combination is best in those with persistent protein
excretion despite a maximal does of one agent When used in combination,
regular monitoring of eGFR and serum K are recommended
Blood Glucose Management
There are no hard and fast rules regarding the ideal management of
glycaemic control in diabetes
Drug therapy is only one aspect - dietetic intervention and exercise are
essential

Insulin Therapy - Type 1 Diabetes Mellitus
Initial therapy with insulin may be with intravenous therapy if
significant metabolic upset dictates hospital admission However, initial
subcutaneous therapy should be the aim for the majority of patients
The initial choice of insulin and format of administration is similarly ad
hoc although an individuals lifestyle and personal choice will be central
to the
choice

Insulin Treatment

Aim of insulin treatment

Prevent ketoacidosis
Relieve symptoms of uncontrolled diabetes
Maintenance of ideal body weight
Maintain blood glucose profiles as close to normal as possible to
prevent or minimise long term microvascular and macrovascular
complications

Principles of Treatment

Insulin given by subcutaneous injection is given to replace endogenous
insulin in patients with absolute or relative deficiencies in insulin
secretion
A balance must be maintained between carbohydrate intake, insulin dose
and exercise The aim is always to maintain near normoglycaemia
Self-monitoring of capillary blood glucose and HbA1c measurements are
advised to ensure treatment is effective and an individuals targets are
met
Regular review of insulin dosage and regimen are important to reflect
the needs of a patients and their changing circumstances

General Comments

Prescriptions are free for all patients on oral hypoglycaemic drugs and
insulin therapy
Depending on the type of insulin used, insulin should be injected
subcutaneously between 5-30 minutes before meals
Rapid acting Insulin
analogues eg Humalog or Novorapid are rapid
acting and can be injected at the time of eating
Insulin vials should be stored in the fridge, but not in the freezer
compartment
The pen/vial in current use should be kept out of the fridge
Diet should be reviewed for all patients starting insulin, with the
emphasis on regular and consistent carbohydrate Refer to State
Registered Dietitian
Appropriate education on hypoglycaemia and diabetic ketoacidosis DKA
is essential to allow effective self-management
Treatment needs to be individualised and must take account of things
such as shift work, patients lifestyle, holidays and exercise

In general, patients with type 1 diabetes treated with insulin SHOULD NEVER
STOP insulin therapy without prior consultation with a consultant
diabetologist

There are many potential problems in the management of patients receiving
insulin therapy They can generally be divided into two broad categories:

Over Insulinisation

The following symptoms are suggestive of over insulinisation too much
insulin:

Recurrent Hypoglycaemic episodes
Wildly swinging glucose values
Weight gain
Subtle features of chronic hypo
- headache, wakening at night, night
sweats
Hunger
Personality change in elderly / falls / confusion

Under Insulinisation

The following symptoms are suggestive of too little insulin:

Chronic hyperglycaemia/osmotic symptoms
Weight loss
Generally unwell
Nocturnal osmotic symptoms thirst, nocturia
Recurrent infections, especially candidiasis

Patients in these categories require review with a diabetes practitioner
who is able to identify the source of the problem and advise on appropriate
remedial action

Insulin Injection Sites and Injection Technique

Injection Sites

The use of a variety of injection areas is recommended to prevent
lipohypertrophy or lipoatrophy Both of these problems may lead to
erratic absorption of insulin and risk of hypoglycaemia or DKA
Insulin can be absorbed more quickly from the abdomen than from the
thighs or arms, this should be taken into account when assessing an
individuals control This depends on physical activity ie cycling,
skiing could increase absorption from thighs
Injection sites should be rotated regularly

Injection Technique
Insulin administration is best taught by a nurse with
specialist skills
in diabetes
Check insulin dose
Pinch up fold of skin not when using 5mm needles, unless small child
or emaciated
Avoid lumpy and atrophic areas
Inject needle at 900 into this fold
Dispose of syringe and/or needle appropriately
There is no need to swab the skin before or after injection

Disposal of Sharps

Syringes
Needles should be clipped off using the BD Safe Clip which is
available on prescription This device shears off and secures up to
1500 needles, which can then be disposed of safely with the household
refuse
The syringe minus the needle can then be dropped into an old ring pull
can or lidded container When it is full the lid should be secured or
the opening taped over, put into a plastic bag and disposed with the
refuse

Lancets
Lancets should be treated with the same respect making sure the lancet is
pushed firmly into the lancet cover before putting into containers or cans
Continuous Subcutaneous Infusion of Insulin CSII - Pump Therapy

The use of a CSII Pump may be recommended in certain circumstances Such
patients are likely to be identified by hospital practitioners in either
Paediatric or Adult
Diabetes clinics, and will require review by referral
by a Consultant Physician or Paediatrician to initiate pump therapy

What is CSII therapy?

A battery driven pump providing a continuous infusion of rapid or short
acting insulin via an infusion set which is usually inserted into the
abdomen The rate at which the insulin is infused is pre-programmed in an
attempt to mimic the normal pancreatic secretion of insulin
A bolus dose of insulin may be given by pressing a button whenever food is
consumed

Criteria for eligibility for Insulin Pumps
1 Patient has Type 1 diabetes
2 Patient has tried a multiple daily injection MDI regimen for a 6-
month period
3 As part of the MDI regimen, patients must show commitment to adopting
an intensified regimen:
a one hour session with a Diabetes Specialist Nurse and/or
Diabetologist
two one hour sessions with dietician
Clinic attendance at 3-monthly intervals when intensification of
insulin for Type 1 diabetes will be discussed, OR a formal
educational programme for people with Type 1 diabetes with
focused sessions relating to the principles of normal
insulin
response to food, carbohydrate metabolism and how to adjust
their own treatment to their dietary preferences and lifestyle
4 In addition, patients must show a commitment to perform home blood
glucose monitoring at least 3 times a day
5 If after a six-month period of MDI, patients still have disabling
hypoglycaemia requiring external assistance, or have failed to achieve
optimal control with HbA1c 75 they may be considered for
intensification of diabetes control therapy that may involve pump
therapy
6 It will be made clear to patients at the outset:
That insulin pump therapy will be initiated for a trial of six
months in the first instance
The commitment to self-control, as outlined above for MDI
treatment, is also essential for continued pump use
Goals will be set at initiation and that the trial of pump
therapy may be discontinued after six months if the goals are
not met in terms of concordance with therapy, glycaemic control
or hypoglycaemia
7 Experience shows that, in some patients, pump therapy is found to be

inappropriate soon after starting treatment Pump therapy will
therefore be reviewed regularly within the first six months and can be
discontinued at any time during this period
8 There should be no significant concurrent history of alcohol or drug
abuse

Management of patients on CSII therapy during hospital admission

patients using insulin pump therapy have been trained to manage their
diabetes
patients using insulin pump therapy have a continuous supply of
insulin and therefore do not have to eat at set times
fasting is not a problem for pump users
patients treat hypoglycaemia with 10-15 grams of glucose which may be
repeated every 15 minutes until this resolves no snack or meal
required following this
if a patient who is admitted is unconscious DO NOT CUT TUBING Remove
catheter from insertion site and place pump in a safe place - PATIENT
WILL REQUIRE INSULIN REPLACEMENT IMMEDIATELY
if a surgical procedure is planned please liaise with a Diabetes
Specialist Nurse at pre-assessment
an insulin pump must be taken off during an MRI scan
patients on pump therapy can be
disconnected from it for up to an hour
for patients attending for x-ray or CT scan please discuss with a
radiographer

Patients admitted to hospital should continue to manage their diabetes
using their pump except in the following circumstances:

IF UNCONSCIOUS
ILLNESS PREVENTS SELF-MANAGEMENT
DIABETIC KETOACIDOSIS
MAJOR SURGERY

For any more information contact Diabetes Specialist Nurses

Guidance on Blood Glucose Monitoring

Who should blood glucose monitor and how frequently?

A wide variety of meters are available but test strips are not
interchangeable for use between the various brands Contact any of the
Diabetes Specialist Nurses for further details and advice
Local guidance on which meters are recommended for use within NHS Fife is
in development

Urine testing for glycosuria is useful in those diet and metformin
controlled patients who seek reassurance regarding the effects of diet on
their daily glycaemic control

Commonly Used Insulin Preparations

All patients commenced on insulin therapy will commence on either human or
analogue insulin in both primary and secondary care
A small number of patients either remain on animal derived insulin or are
commenced on animal insulin after a period of human insulin These
individuals are generally monitored via secondary care

This table is representative, not exhaustive - see the BNF for full
details
Type 2 Diabetes Mellitus

As in type 1 diabetes, diet and exercise are the cornerstone of management
However, to attain glycaemic targets associated with reductions in vascular
complication rates, a number of studies have demonstrated the need for oral
hypoglycaemic agents and or insulin therapy to achieve and maintain these
targets

It is felt that insulin resistance and centripetal obesity are key factors
in the origin of type 2 diabetes, although progressive failure of
pancreatic insulin secretion is also a key factor Thus, current
recommendations focus on using drugs which improve insulin resistance as
first line therapies in
patients with type 2 diabetes

Beyond the initial recommendation, there are still no clear outcome data
which support one therapeutic strategy over another It is clear however,
that combinations of oral hypoglycaemic agents are required to maintain
glycaemic targets within 2-3 years of initial diagnosis and commencement of
oral therapy

A strategy based on aggressive early use of combination therapy with oral
agents and insulin when felt clinically relevant is likely to be the best
means of maintaining adequate glycaemic control in the long term

Initial intervention should be aimed at lifestyle modification and an
attempt to reduce weight towards the individuals agreed target weight Data
from the Finnish Diabetes prevention study suggest a 5kg weight loss
maintained for 5 years will reduce the risk of diabetes by about 50
Please see page 68 for dietetic resources

Metformin
If lifestyle intervention is not successful at attaining an appropriate
target, then metformin therapy should be commenced
Commencing at a dose of 500mg bd with meals, the therapy should be
titrated based on HbA1c response and clinical effects If tolerated, the
dose could be increased after 6-8 weeks if required to meet a target HbA1c

The ideal dose of metformin is 2000-2500mg daily in divided doses

The use of generic metformin is often limited by gastrointestinal side-
effects, in particular diarrhoea and flatulence If a definite clinical
response has occurred but GI-upset makes dose escalation or continuation
impossible, a trial of modified release metformin is merited

Metformin 500-2500mg daily
Metformin modified Release Glucophage SR 500-2000mg
daily

Cautions
Metformin associated lactic acidosis is rare and generally occurs in
individuals with an intercurrent illness, eg acute gastrointestinal
upset, pneumonia, myocardial infarction, pulmonary oedema, exacerbation of
COPD, who continue to take metformin when it should be withheld
Patients should temporarily discontinue metformin in circumstances
where dehydration or hypoxia may occur
Metformin can be reinstituted once a return to baseline clinical state
has occurred
Renal impairment will modify the use of metformin see p 42

The Scottish Medicines Consortium SMC has advised that metformin SR
Glucophage SR is not recommended for use within NHS Scotland for the
treatment of type 2 diabetes in adults, particularly in overweight
patients, when dietary management and exercise alone do not result in
adequate glycaemic control The committee noted that metformin SR did not
demonstrate any benefits in efficacy or side effects over the immediate
release metformin and is considerably more expensive

Second line treatment in type 2 diabetes mellitus

If treatment with metformin is not sufficient to provide adequate glycaemic
control or cannot be
tolerated or is contra-indicated, then at this stage
an additional agent should be considered At this stage there are currently
3 possible licensed treatment options:
Thiazolidinediones Glitazones
Sulphonylureas
Insulin

Thiazolidinediones Glitazones
There are two agents licensed for use in the UK and both are approved by
the SMC:
Pioglitazone - 15-45mg od Actos
Rosiglitazone - 4-8mg od Avandia
Both agents target insulin resistance as a key mode of action, although by
mechanisms separate to that of metformin
Both agents may be used as monotherapy if a patient is intolerant of
metformin, although it is recommended they be used as second line agents
either in combination with metformin preferred or with a sulphonylurea
In addition, triple therapy of metformin, glitazone and sulphonylurea is
licensed and approved in the UK, and such a combination may be suitable for
those patients who do not wish insulin therapy

The risk of hypoglycaemia with glitazones is low, and the risk in
combination with metformin is also low Thus it is recommended that for the
majority of patients self blood glucose monitoring is not indicated for
patients receiving these
drugs

Cautions
Glitazones cause fluid retention and weight gain Fluid retention can lead
to heart failure and dilutional anaemia Caution should be exercised when
considering the use of these agents in patients with established cardiac
failure, renal disease and liver disease Annual review should address
these issues

Competact: Pioglitazone 15mg plus Metformin 850mg: 1-2 tablets daily
Avandamet: Rosiglitazone 2mg or 4mg plus Metformin 1000mg: 1-2 tablets
daily

Recent published data have highlighted a possible cardiovascular safety
concern with rosiglitazone At present there are no firm data that show a
clear excess of cardiovascular mortality associated with this agent,
however its use should be carefully considered in conjunction with the
License information of the SPC
A 12 lead ECG is a simple tool for excluding the majority at risk of having
LV disease, and consideration of echocardiography in appropriate
circumstances
Sulphonylureas

These drugs act by stimulating insulin secretion from pancreatic beta
cells As such they require surviving insulin secretion to be effective and
are thus of limited value in patients with pancreatic disease, eg
secondary to alcohol
excess

Sulphonylureas can be administered once or twice daily and a number of
agents are available for use:
Gliclazide - 40-320mg daily, eg 40mg od to 160mg bd
Glipizide - 25-20mg daily, eg 25mg od to 10mg bd
Glimepiride - 1-6mg od
Diamicron MR - 30-120mg od

Previously sulphonylureas were either used first line in lean patients with
Type 2 diabetes, or as initial second line treatment for obese patients
Currently, their use as second line agents has diminished due to the
recognition of insulin resistance as a key feature in the early stages of
Type 2 diabetes, although their side-effect profile lends them to being
useful agents in a number of circumstances where glitazones and metformin
may not be appropriate, eg renal impairment, cardiac failure

Cautions
The major concern with sulphonylureas is their risk of hypoglycaemia - up
to 40 of patients treated with long acting sulphonylureas Patients
prescribed sulphonylureas do experience hypoglycaemia with increased
frequency, and the elderly are at particular risk, especially if there is
evidence of co-existent renal impairment which may be exacerbated by
intercurrent illness
As a result,
self blood glucose measurement is recommended for all patients
taking sulphonylureas, the frequency and duration dependent upon individual
circumstances see Table p 26

Sulphonylureas are commonly used with metformin and in triple therapy with
glitazones and metformin They may be used with insulin although this trend
is becoming infrequent given the limited evidence of benefit over insulin
alone

Insulin

Insulin therapy is commonly used in patients with type 2 diabetes The
decision to use insulin will depend upon the balance between the need to
improve glycaemic control versus the risk of hypoglycaemia In addition,
the use of insulin may also affect an individuals employment status, eg
bus driver

In type 2 diabetes mellitus, most patients will be progressing from a
combination of oral agents including either metformin or a glitazone or
both, onto insulin These individuals will continue to be insulin
resistant, and as such an insulin modifying agent should be maintained in
addition to insulin

Insulin therapy should be commenced by those familiar with both the initial
initiation of therapy, but also the aspects relevant to follow up including
dose adjustment, advice on the
management of hypoglycaemia, injection site
care, sick day rules, driving etc

Choice of Insulin

In the initial management of type 2 diabetes, there is little to choose
between the available twice daily mixtures

A slow progressive escalation in doses accompanied by careful supervision
will usually suffice initially
Patients should be referred for dietetic review at this stage along with
being given written advice on the recognition and management of
hypoglycaemia

The introduction of more complicated regimens, eg basal bolus, depends on
local resources but is likely to require liaison with secondary care
diabetes nurse specialists

Addition of pioglitazone to insulin is a licensed indication, but
initially commencement of a glitazone in combination with insulin
should initially be reserved for patients in consultation with
secondary care clinics

New Drugs

At the time of publication, a number of other drugs are in the early stages
of pre-market release or initial marketing without SMC appraisal Further
information may become available regarding these agents in the future

Exenatide
Exenatide Byetta is a chemical analogue of the naturally occurring
peptide
GLP-1 It has recently been approved by the SMC for use in treating
type 2 diabetes in Scotland Its use is initially restricted those unable
to reach glycaemic targets on metformin plus SU in maximum tolerated doses
Its use is associated with approximately 4-5kg weight loss and a 1
reduction in HbA1c maintained over 3 years continuous use

Sitagliptin
An orally available inhibitor of DPP-4, the enzyme which inactivates
naturally occurring GLP-1
Its use is associated with a reduction in HbA1c of approximately 1, and no
weight gain The risk of hypoglycaemia is significantly less than
sulphonylureas
It has recently been approved by the SMC for use in treating type 2
diabetes in Scotland It is recommended for use in patients failing to
achieve glycaemic targets on metformin or a glitazone, in whom
sulphonylureas are not tolerated or contraindicated

Vildagliptin
Another DPP-4 inhibitor approved by the SMC for use in the NHS in Scotland
It has similar efficacy and indications to Sitagliptin

Lipid Lowering Therapy
As with all forms of vascular disease, levels of serum cholesterol and
triglycerides predict levels of increasing cardiovascular risk in the
diabetic
population
Two forms of evidence support the use of lipid lowering therapy:
Epidemiological - observation of increased risk of cardiovascular
events in patients with diabetes compared to non-diabetic individual
Pharmacological - the demonstration of reduction in death and
cardiovascular morbidity with drugs targeted at lowering cholesterol
or triglycerides
In a similar way, there are two approaches to lipid lowering therapy
and cholesterol targets:
Agent based - taking a particular agent is demonstrated to reduce key
events versus placebo, regardless of the absolute reduction or
attained level of serum cholesterol
Cholesterol based - the notion that reducing cholesterol, both total
and LDL as low as possible relates to increasing reductions in
cardiovascular events
The current advice from SIGN suggests the use of a single statin at a fixed
starting dose initially SIGN 97 does not lay down didactic targets for
Total or LDL- Cholesterol, however, other national bodies suggest the
latter approach as the preferred strategy dependent on an individuals
risk, eg JBS2 or GMS

Choice of Therapy

Current recommendations form
international groups suggest a target treated
cholesterol of 40mmol/l in patients with diabetes, and 35mmol/l in
those with established cardiovascular disease

Recent studies have shown no extra benefit from the combination of
Simvastatin and Exenatide or Rosuvastatin in some outcome studies, eg
Rosuvastatin in ischaemic heart failure
Antiplatelet Therapy

The role of antiplatelet therapy in the secondary prevention of vascular
disease is well established A number of studies have determined the
beneficial effect of aspirin in reducing vascular events following
myocardial infarction, unstable angina, stroke, TIA and peripheral vascular
disease

Primary therapy with aspirin is also thought to be beneficial in reducing
vascular events in patients with diabetes without overt macrovascular
disease, when the perceived 10 year CVD risk of 20

Additional anti-platelet therapy, ie clopidogrel in Acute Coronary
Syndrome, dipyridamole SR for TIA whilst on Aspirin, should only be used in
circumstances where clinically appropriate

Aspirin therapy should be commenced when treated blood pressure is
150/90mmHg to minimise the small but definite risk of
intracranial
haemorrhage

Complication Screening and Referral
Management of Diabetic Renal Disease

Diabetic Nephropathy develops in around 30 of all diabetics

Progression: 0-5 years: increased GFR
5-10 years: micro-albuminuria
10 years: overt proteinuria
End stage renal function 15-20 years

Renal function begins to decline once proteinuria commences
Diabetics frequently have other renal disease, particularly Renal Artery
Stenosis
Diabetic patients may develop complications and symptoms of renal disease
earlier than patients with other causes of renal failure

Frequency of creatinine measurement: CKD 3: 6 monthly 12 monthly if
stable
CKD 4: 3 monthly 6 monthly if stable

Diabetic nephropathy is slowly progressive loss of GFR c 1ml/min/month:
More rapid deterioration suggests other renal disease

What should be in the referral letter?

Medical history including other diabetic
complications particularly eye
disease
Blood pressure history and medications including those recently
discontinued
Serum creatinine and prior results to allow rate of change to be judged
Recent HbA1C
Urinary albumin to creatinine ratio ACR on a spot urine sample and any
prior results
A renal ultrasound should be booked though referral should precede scan

Targets

|Blood Pressure|Type 1 Diabetes |Type 2 Diabetes |
| |No | |No | |
| |Nephropathy |Nephropathy |Nephropathy |Nephropathy |
|Intervention | 140/90 | 140/90 | 140/90 | 140/90 |
|Target | 130/80 | 120/75 |130/80 |130/80 |

ACE inhibitors/angiotensin receptor blockers should be first line therapy
All patients should have a repeat UE 10-14 days after commencement to
check for rise in potassium or creatinine

Proteinuria
ACE inhibitors should be increased as tolerated to maximum in the presence
of proteinuria ARBs can be used in addition seek guidance if necessary

Microalbuminuria
Microalbuminuria represents abnormally high urinary albumen excretion below
the level detectable by urinalysis
30-300mg/day Microalbuminuria is best
detected by sending a spot urine sample for albumin to creatinine ratio
An ACR 25 in men or 30 in women is abnormal and requires assessment and
treatment
The rate of progression of diabetic nephropathy is typically halved by
control of proteinuria and blood pressure with an ACE inhibitor
Intervention at this early stage may slow the decline renal function in all
and in older patients reduce the chance of developing end stage renal
disease

Glycaemic control

Good control reduces both the likelihood of developing diabetic nephropathy
and the rate of progression in established disease

Metformin

Patients with an eGFR 25 or creatinine 200mol/L should have this
medication stopped unless there is a compelling reason to continue
Metformin should also be withheld at times of intercurrent illness - either
in-patient or out-patient, eg vomiting and diarrhoea, and re-started when
symptoms pass

CKD/eGFR

Serum creatinine is a crude marker of renal function eGFR is designed to
give a more user friendly indication of renal function
Patients are divided into chronic kidney disease stages 1-5 CKD 1-5

|Stage |Description |eGFR ml/min
/173m2 |Prevalence |
|1 |Kidney disease but normal | 90 |33 |
| |function | | |
|2 |Mild CKD |60-89 |30 |
|3 |Moderate CKD |30-59 |43 |
|4 |Severe CKD |15-29 |02 |
|5 |Established renal failure |15 or |02 |
| | |dialysis/transplant | |

CKD 3-4 represents a strong independent risk factor for cardiac death A
major purpose of the CKD classification is to identify these patients to
allow targeting for vascular risk factor modification
Most patients with CKD 3-4 will not progress to end stage renal failure

Management of Intercurrent Illness in Diabetes Mellitus

THE GOLDEN RULE: INSULIN SHOULD NEVER BE OMITTED

Maintain an adequate fluid intake sugar free of 100-200mL
approximately 1 glass every hour
Maintain a regular intake of carbohydrate, regardless of blood glucose
At mealtimes, if unable to eat, but tolerating fluids, take
carbohydrate in the form of 200ml of
the following;
Blackcurrant / Orange and water Not a sugar free variety
Fruit juice
Milk with Drinking Chocolate or Ovaltine
Flat Coca Cola or Lemonade sugary
Increase blood glucose monitoring to at least 4 hourly if the patient
has Type 1 Diabetes or is on insulin therapy and test for urine or
blood ketones at least four hourly
Do not be afraid to increase insulin; in general, 4 units of soluble
insulin every 2 hours until blood glucose is below 10 mmol/l is
advisable
Ensure that glucose monitoring technique and equipment are accurate and
arrange to review patient
If vomiting, an anti-emetic injection may help
Ketonuria is an early sign of decompensation and if acted upon
promptly, it will often prove possible to avert hospital admission

Patients on oral hypoglycaemics

Metformin and Glitazones
Patients taking metformin should consider withholding this medication
during an intercurrent illness, particularly if there is a risk of
dehydration, eg diarrhoea and vomiting If symptoms persist they should
seek medical advice Metformin can be re-started once they are improved

Similar advice is recommended for patients taking
glitazones, either with
metformin or as a single agent therapy
Sulphonylureas
Patients taking sulphonylureas are advised to continue to monitor blood
glucose regularly If readings rise above 20mmol/l for 12 hours or more,
they may require an increase in dose or the short term administration of
insulin

Patients who have co-existent renal impairment or who become dehydrated are
at risk of developing hypoglycaemia
In this circumstance, regular self blood glucose testing is recommended and
if readings of 4mmol/l are detected, regular oral glucose plus short-term
discontinuation of the sulphonylurea are recommended

If hypoglycaemia persists or is associated with neurological impairment
escalation of therapy may be required, including seeking hospital referral

Patients on ACE-Inhibitors/Angiotensin Receptor Blockers

Increasingly, many elderly patients are being appropriately prescribed ACE-
Inhibitors or Angiotensin Receptor Blockers Patients on these drugs are
particularly high risk of an acute deterioration in renal function during
intercurrent illness This is particularly do in those co-prescribed
diuretics, NSAIDs, and metformin

Withhold ACEI/ARB during acute
illness, especially those associated
with dehydration
Re-start ACEI/ARB once baseline state is recovered and eGFR back to
baseline

Hypoglycaemia

Hypoglycaemia is a potentially fatal consequence of the treatment of
diabetes mellitus The symptoms of hypoglycaemia can be different between
individuals but two major types of symptoms occur:

Autonomic features: Adrenaline like symptoms
Tremor, Sweating,
Tachycardia, Anxiety, Hunger

Neuroglycopenic symptoms: Brain sugar deficiency

Confusion, altered behaviour
Visual upset, dysphasia
Seizures, hemiparesis

All documented blood glucose values of 40 mmol/L can be considered a
hypoglycaemic event and should not be tolerated in any patient on a regular
basis

Hypoglycaemia is less common in patients treated with sulphonylurea
compared with those taking insulin; however sulphonylurea-induced
hypoglycaemia may be more prolonged and more severe, particularly when
associated with alcohol excess or in the presence of renal impairment

Delayed recovery from a
hypoglycaemic episode may occur if:

Hypoglycaemia was prolonged or severe
A seizure occurred
An alternative diagnosis responsible for reduced consciousness exists,
eg stroke

The treatment of symptomatic hypoglycaemia requires recognition of the
possibility of the diagnosis, adequate carbohydrate therapy and
consideration of the factors which provoked the episode

Treatment

Risk factors for Severe Hypoglycaemia

Intensive insulin therapy
Low HbA1c
Long duration of diabetes
Impaired hypoglycaemic awareness
Previous severe hypoglycaemic attack
Alcohol excess
Long acting sulphonylureas
Impaired renal function
Increasing age
Nocturnal Hypoglycaemia and Hypoglycaemic Awareness

Hypoglycaemia occurring at night may be relatively asymptomatic and of
prolonged duration The detection of nocturnal hypoglycaemia can be
difficult and may require self blood glucose measurement at 2 am to be
sure

There are a few symptoms that may give rise to clinical suspicion of
nocturnal hypoglycaemia:

Insomnia, night sweats and/or morning headache may be a symptom of
nocturnal hypoglycaemia
Hypoglycaemia may present as
confusion in the elderly, or cause
patients to be off food or forgetful and not eating
Restless legs at night
New onset seizures or unexplained falls

Prolonged or frequent hypoglycaemia may result in a reduction in the blood
glucose level at which autonomic symptoms of hypoglycaemia are triggered,
such that patients may not experience their normal warning before
neuroglycopenia occurs

So-called hypoglycaemic unawareness can be troublesome and occasionally
life threatening

The inability to appreciate hypoglycaemia may impair an individuals
ability to undertake work or other activities, especially driving

Once identified, a careful assessment of potential contributing factors is
required:

Lipohypertrophy
Alcohol excess
Duration of diabetes
Intensive control
Inappropriate insulin or oral agent regimen

If there are clear reversible factors these should be addressed, eg
rotation of injection sites away from hypertrophied areas

In some cases a supervised period of less tight glycaemic control
accompanied by regular self blood glucose monitoring can allow a patient to
regain either total or partial hypoglycaemic awareness, and thus
any
attempt at subsequent intensification of control be associated with a
resumption of normal hypoglycaemic awareness

However, there are some patients, especially those with a long history of
diabetes, poor glycaemic control and or autonomic neuropathy who are unable
to regain hypoglycaemic awareness
In these circumstances specialist involvement to gauge the need for CSII
therapy, monitoring devices and other therapies is necessary

Management of Diabetic Ketoacidosis

Diabetic Ketoacidosis DKA is a serious medical emergency with significant
morbidity and mortality

When in doubt - please phone the Diabetes Specialist Nurse, Diabetes
Consultant or on-call medical team

It arises in patients with diabetes due to insulin deficiency and is
characterised by the following:

Hyperglycaemia: Blood glucose 12mmol/l
Acidosis: Serum bicarbonate 15 mmol/l
Ketosis: Presence of ketones or greater in urine

Patients typically have Type 1 diabetes and are either newly diagnosed or
have developed DKA in relation to an intercurrent illness

Treatment of DKA

DKA is a medical emergency with significant risk of mortality The Scottish
Diabetes Group algorithm is suggested as an adequate regimen for treatment
in NHS Fife

Scottish Diabetes Group Algorithm for Management of DKA

Euglycaemic ketoacidosis: plasma glucose 17 mmol/L 300 mg/dl, HCO-3
10 mmol/L
Typical DKA: plasma glucose 26 mmol/L 650 mg/dl, HCO-3
15 mmol/L
HHNKC: plasma glucose 36 mmol/L 650 mg/dl, HCO-3 18
mmol/L

The treatment of HHNKC HONK is similar in principal to that of DKA
Intravenous insulin coupled with judicious fluid replacement including
potassium supplementation is essential

Initial blood glucose response is often slower than in DKA but many
patients often leave hospital on oral agents rather than insulin

All patients admitted with metabolic decompensation require to be assessed
by the diabetes team prior to discharge

In-patient Insulin Use and Supply

Patients admitted as emergencies to in-patient sites may not have their
prescribed insulin on their person The majority of patients
are treated
using a small number of insulin preparations To facilitate safe insulin
use, the following advice is provided:
Patients bringing their own supply, and who are able to administer
their own insulin, should do so
Patients who do not bring their own insulin, or who cannot administer
their own insulin, should receive ward stock as follows:

The appropriate ward stock insulin can be prescribed and substituted on a
unit-for-unit basis with the patients usual insulin, until this can be
supplied by pharmacy or the patient can self administer their own insulin
For patients who are on non-human insulin preparations, it is acceptable
to get a dose of the human equivalent prescribed with close monitoring

If a patient requires a supply of their own insulin from the hospital
pharmacy, it will be dispensed on the next working day on a named patient
basis for individual patient use This should be sent home with the
patient on discharge

Points to remember

All insulin vials should be marked with the date of first use
Within the hospital, all vials expire 4 weeks after their first use
Under no circumstances should pen devices be administered by nursing
staff
Under no circumstances should insulin cartridges be used for drawing
up insulin into a
syringe
Diabetic Retinopathy

Overview of the Diabetic Retinopathy Service DRS
Introduction

The risk of developing diabetic retinopathy is increased with duration of
diabetes, poor glycaemic control and hypertension Diabetic retinopathy may
be present in up to a third of newly diagnosed Type 2 patients Early
diagnosis of diabetic retinopathy via regular screening is vital to prevent
visual loss

Screening System

The national screening programme for diabetic retinopathy screening DRS
was initiated in Fife in June 2006 The NHS Fife scheme was one of the
first in Scotland to begin as part of the national service It uses digital
cameras based at the Queen Margaret Hospital, Dunfermline and the Victoria
Hospital, Kirkcaldy People with diabetes from these localities attend
here For those people living in the rural North East of Fife, or the West
Fife villages a mobile service visits community hospitals, health centres
and GP surgeries on a regular basis to perform screening clinics

Screening

The new system meets the robust national standards for retinal screening,
set by NHS Quality Improvement Scotland NHS QIS This calls for all
people with diabetes to be offered screening by
digital photography
annually There are rigorous quality assurance systems in place to ensure a
high level of service For example, all referrals to secondary care are
authorised by an Associate Specialist in Ophthalmology The system used for
DRS is the national SOARIAN product, provided by Siemens

The screening is completed by a Retinal Screener / Grader They also
provide a primary grading of the images Any images with evidence of eye
disease are sent to secondary grading, to be completed by an optometrist
Any tertiary grading is provided by an ophthalmologist

If an image is unfit for grading this will be classified as a technical
failure and the patient concerned will be invited for an indirect
opthalmoscopy, to be completed by an optometrist Patients and the GP
receive the results within 20 working days All patients requiring an
ophthalmology appointment will be referred to a consultant led diabetic eye
clinic

All patients over 12 years of age should have their eyes examined, at least
annually for detection of diabetic retinopathy

Treatment

Prevention of Visual Loss

Development or progression of retinopathy can be prevented by good
glycaemic control, management of
hypertension and hyperlipidaemia using the
4 - corner approach of the handbook

Laser treatment

Laser treatment is indicated for severe non-proliferative, proliferative
retinopathy and sight threatening macula oedema It is most effective when
applied early before the patient is symptomatic Early diagnosis via
screening is therefore vital

Laser treatment aims to prevent further visual loss and cannot improve
vision
Laser treatment for proliferative diabetic retinopathy can prevent
severe visual loss in 95 of patients
Laser treatment for macula oedema can prevent visual loss in 70 of
patients It is less effective in patients with uncontrolled blood
pressure, poor glycaemic control and nephropathy Management of these
risk factors can improve the chance of laser being effective

Eye Surgery
If laser is not effective for proliferative diabetic retinopathy or the
retinopathy is too severe for laser, patients are referred to Ninewells
Hospital, Dundee

Erectile Dysfunction

Erectile dysfunction ED is a common feature of diabetes in men
Approximately 50 of men over 50 years of age with diabetes will have
evidence of
erectile dysfunction
The aetiology of ED is multifactorial, and patients with ED need careful
evaluation to assess the combination of factors likely to be contributing
the genesis of the problem

Clinical factors in the aetiology of ED
ED is common and often associated with loss
of libido There may be a
spectrum of clinical effects from inability to sustain or maintain an
erection, through premature ejaculation to failure of ejaculation Pain due
to Peyronies disease, balanitis or phimosis may also be present

In addition to being a distinct clinical problem, ED is also a marker of
underlying cardiovascular disease
A diagnosis of ED should prompt a review of the patients current
cardiovascular risk profile including diabetes control, blood pressure,
cholesterol, and symptoms of angina and peripheral arterial disease If
appropriate, further referral and investigation should be instigated
along
with consideration of therapy for ED

Baseline management of ED

Establish diagnosis
Determine likely contributing factors
Gynaecomastia, obesity, neuropathy
Blood tests: Glucose/HbA1c, Prolactin, Testosterone
Associated CVD risk markers: claudication, angina
Discuss available modalities and determine patients expectations
Consider referral to ED service

Treatment

There are 4 basic therapeutic options for the management of ED:

Oral phosphodiesterase 5 PDE5 inhibitors
Intraurethral alprostadil preparations
Intracavernosal alprostadil preparations
Vacuum Devices

If oral therapy is not successful or contraindicated, other therapies may
be initiated following referral to the Secondary Care ED service depending
on individual experience See Contacts Section for details of ED clinic

Podiatry Care of the Diabetic Foot

HPC registered Podiatrists play an important role in the education,
monitoring and treatment of patients presenting with lower limb
complications of diabetes
All people with diabetes should receive education in foot care and be
assessed annually for foot disease, to reduce the incidence of
ulceration,
gangrene and if possible amputation
HPC - Health Professions Council

Aims and Objectives of Diabetes Foot Care

Education of patients and/or carers on the importance of supported
self-management
Prevention of trauma and subsequent development of foot lesions
To aid healing of established lesions and prevention of recurrence
To maintain patient mobility and avoid hospital admission
Adherence to national guidelines, to reduce the morbidity associated
with diabetic foot disease

Objectives of Diabetic Foot Assessments
To provide all patients with diabetes with education on foot care
To ensure that all patients receive annual foot examination
To provide a service whereby patients are referred appropriately to
members of a specialist podiatry team, or others, according to level
of risk

Risk Categories in the assessment of the Diabetic Foot

Annual assessment of foot risk for each patient with diabetes is essential
This assessment includes both vascular and neuropathy assessment as well as
obtaining appropriate information about prior foot related episodes and
musculoskeletal issues

The
delivery of such care is aimed at both stratifying risk and ensuring
the appropriate patients see the correct practitioner, but also to reduce
the risk of non-traumatic lower limb amputations

Classification of Diabetes Foot Disease

Risk stratification requires three pieces of information:

Peripheral Pulses - Absent or Present, including Doppler assessment
Neuropathy - sensory impairment: 10g monofilament or
neurosthesiometer
Prior History - Ulceration, Surgery, Charcot Arthropathy

Basic Foot Care Advice for Patients

Acute Foot Problems

Patients with diabetes who develop any signs suggestive of infection or
inflammation in or around the foot:

Redness

Swelling

Blistering

Ulceration

Especially if associated with systemic upset

Should be prioritised for emergency podiatry assessment and treatment and
be reviewed by a specialist podiatrist within 3 working days wherever
possible

Treatment of Infection: Antibiotic Therapy

General Principles
The majority of patients are
likely to be treated as out-patients and
therefore require reliable clinical review
Superficial skin infection is often seen in the absence of clear
ulceration
Ulceration may occur with minimal signs of superficial infection
Antibiotic therapy may not be necessary in all cases of ulceration,
but a low threshold for their use seems appropriate in most instances
The majority of true infections result from SAureus or ?-haemolytic
streptococcus sp A growing number will include Pseudomonas sp,
coliforms or anaerobes

Swabs of infected wounds are preferable Results may allow early detection
of MRSA or unexpected organisms not sensitive to first line therapy
Treatment should not be delayed waiting for the results of bacteriology
swabs

The NHS Fife Antibiotic Guidance 2006 contains details on the management of
lower limb infection in patients with diabetes

Outpatient Management

Oral antibiotic therapy is acceptable in most cases if the infection is
limited and there are no signs of systemic illness

If the cellulitis is extensive, IV antibiotics either as an out-
patients OPIVAB or in-patient
If the systemic upset is significant, IV antibiotics either as an
out-patients OPIVAB or in-patient
If the systemic upset is significant, IV antibiotics either as an
out-patients OPIVAB or in-patient

Co - amoxiclav 625 mg tds if not penicillin allergic

Clarithromycin 500 mg bd plus Ciprofloxacin 500 mg bd if penicillin
allergic

If anaerobic
infection is possible eg offensive smell or deep
infection, add oral Metronidazole 400 mg tds
Oral Ciprofloxacin may be added to Co-amoxyclav if the wound is deep
or has excessive slough
If seen at a hospital clinic, initial therapy should be undertaken
with out-patient starter packs from the Diabetes Foot Clinic, with
prescription advice given to the patient and to his/her General
Practitioner
The duration of treatment will vary but should continue until there is
clear evidence of progressive wound healing and absence of signs of
active infection Initial treatment periods should be no less than 7
full days

In Patient Management

If there are signs of rapidly progressive cellulitis or systemic upset,
admission may be appropriate
Swabs of the affected area, blood cultures and CRP are appropriate initial
investigations
Other laboratory investigations will depend on clinical factors

Initial intravenous therapy should be as follows:

Co - amoxiclav 12g tds if not penicillin allergic

Clindamycin 450 mg qds plus Ciprofloxacin 500 mg bd if penicillin

allergic

If anaerobic infection is possible eg offensive smell or deep
infection, add intravenous Metronidazole 500 mg tds
Intravenous Ciprofloxacin may be added to Co-amoxyclav if the wound is
deep or has excessive slough
Do not wait for microbiology results before starting antibiotics If
in doubt discuss with the On-Call Microbiologist, particularly if
there is a likelihood of MRSA infection
Notify the Diabetes Team or diabetes specialist podiatrist of any
admission with a diabetic foot ulcer

Failure of Initial Treatment

A lack of clinical response to initial therapy may occur for a number of
reasons, eg

Antibiotic Resistance
Unusual organisms
Vascular Insufficiency
Anaerobic Infection
Incorrect diagnosis - Charcot Arthropathy, Gout

In these instances, careful clinical assessment, including radiology and
review of microbiology and by Vascular services is essential

Although not always helpful, a change of antibiotic regimen may help:

Intravenous Benzylpenicillin 12 g qds plus
Flucloxacillin 1g qds plus
Ciprofloxacin 750mg bd orally or 400 mgs
bd iv plus
Metronidazole 400 mg tds orally

Clindamycin 450 mg qds can be used if penicillin
allergic in place of Benzylpenicillin and flucloxacillin

Early consideration of vascular insufficiency or alternative diagnosis may
avoid unnecessarily prolonged antibiotic therapy

MRSA infection
This organism is becoming increasingly common both as an infective agent
and a wound contaminant If there are no clinical signs of infection there
is no need to treat, ie colonization

Outpatient management of MRSA infection should be guided by sensitivities
from swabs and these may vary between sites
Combinations of oral agents are often used, either empirically or ideally
following microbiological confirmation Common combinations include:

Trimethoprim 200 mg bd plus Fusidic Acid 500 mg tds

Doxycycline 100 mg od plus Fusidic Acid 500 mg tds

Oral Linezolid or Intravenous teicoplanin or daptomycin are alternative
outpatient drugs but should be reserved for use only after discussion with
microbiology
In-patient management of acute infection should be commenced as follows:

Intravenous Vancomycin - pharmacy for dose plus oral Fusidic acid
500mg
tds
Or
Intravenous Vancomycin plus oral Clindamycin 300 mgs qds

Osteomyelitis
Approximately 80 of ulcers which probe to bone will have osteomyelitis
Swabs may be helpful initially, eg identification of MRSA, although in
the presence of longstanding ulceration they are less helpful
Prolonged oral antibiotic therapy is likely to be necessary, ie 8 - 12
weeks, to ensure bone sterilization This may mean continuation of therapy
beyond ulcer healing by many weeks Initial therapy should be as follows:

Oral Flucloxacillin 1gm qds plus Fusidic Acid 500 mg tds
Or
Oral Clarithromycin 500 mg bd plus Fusidic Acid 500 mg tds If
penicillin allergic

Treat infection very vigorously but if patient does not respond seek
urgent Consultant review
In all cases review drugs and doses on an individual basis eg
presence of renal impairment, drug allergies etc
If in doubt discuss with Microbiologists, Consultant Diabetes
Physician or Pharmacy re doses
X-rays early on may not show osteomyelitis, but may show gas in
anaerobic infection
Non-surgical removal of bone may avoid the need for amputation

Specialist
Opinion

Any ulcer in a patient with diabetes - either neuropathic, ischaemic or
neuro-ischaemic - which has been present for more than four weeks and is
not showing signs of improvement, should be referred to the acute multi-
disciplinary team or if appropriate to the vascular team Such patients
may have potentially remediable underlying obstructive peripheral arterial
disease

If unable to travel to acute clinic patient should be referred to their
local Specialist Diabetes Podiatrist

Charcot Arthropathy

Charcot arthropathy is a multi stage progressive deterioration of the
weight bearing joints, usually of the foot or ankle in a patient with
sensory neuropathy About 1 in 10 patients with sensory neuropathy have
plain radiological evidence of prior degenerative changes consistent
with Charcot Arthropathy

Patients typically present with a red painful foot on the background of
longstanding diabetes and documented neuropathy

Clinical features

Pain

Redness - clear temperature difference between feet

Swelling

Few systemic features of infection

Neuropathy

Foot deformity

These features are not always easily appreciated, and any patient who
does
not respond to an initial course of antibiotic therapy for presumed
infection should be reviewed with a view to excluding Charcot Arthropathy

Distribution

70 Midtarsal
15 Forefoot or rearfoot
5 1st MTPJ
50 of patients with Charcot arthropathy have a history of foot
ulceration

Patients suspected of having an acute episode of Charcot arthropathy should
be referred to the Acute Sector podiatry team for further assessment

Management

Immobilisation - either in a total contact cast of Aircast boot
This may be required for 12 months or more - 6 months is the average
Bisphosphonate therapy - oral Alendronate 70mg once weekly for 6
months or intravenous Pamidronate 60mg weekly for 5 weeks
Regular Podiatric supervision and Orthotic input for footwear
provision

Painful Neuropathy

Painful neuropathy can be a devastating feature of diabetes The likelihood
of developing painful neuropathy is related to duration of diabetes, level
of control over time and age

Clinical Features

Pain may be intermittent or constant, in hands or feet or both, and may be
described as burning, electric shocks or tingling, and is often worse
at
night or when sheets touch the bare feet allodynia
In addition to the typical glove and stocking distribution, proximal limb
pain and muscle wasting may occur, often with significant systemic upset -
so-called Diabetic Amyotrophy

It is important to remember that pain may arise from other sources, eg
carpal tunnel syndrome, peripheral arterial disease or infection, and
careful evaluation is required to ensure accurate diagnosis

The presence of objective evidence of sensory impairment is helpful in
making the diagnosis, but pain may be present in the presence of normal
sensation

Treatment
Initial management is based on accurate diagnosis and the recognition of
the possibility of both the diagnosis and alternatives

Once a diagnosis of painful neuropathy is made, every attempt should be
made to optimise glycaemic control as this often limits the magnitude of
the response to other therapies if not achieved

Simple analgesia may be tried, although combinations paracetamol, mild
opiates and NSAIDs are often ineffective Once patients have tried these
agents, a trial of pain altering therapy is merited:

Amitriptylline: 10-150mg at night
Gabapentin: 300-2400mg
daily

Within the class of tricyclic antidepressants, other agents may be tried
if no response is seen with amitriptyliine or its use is limited by side-
effects, eg nortriptylline

If neither of these groups of agents is found useful, a trial of the
newer licensed agent Duloxetine 60mg od may be tried

At this stage, other agents may be used or a referral to the pain service
made:

Sodium Valproate, Carbamazepine, Phenytoin
SSRIs - Fluoxetine
Capsaicin Cream 0075

Key to ensuring an adequate response is the combination of improved
glycaemic control, adequate analgesia and appropriate use of pain
modulating drugs

Pain Service

A Fife wide Pain Management service is available through its base in Queen
Margaret Hospital Patients who do not respond to first or second line
agents may benefit from referral and assessment by this service See
Contact Section for more details

Podiatry Rapid Referral Process

Referral guidelines for Diabetes Specialist Clinics in Primary and
Secondary Care
Patients with the following symptoms/pathology should be referred directly
into appropriate clinic

Referral to Community Diabetes Clinics
These clinics are
designed for patients with diabetes who require regular
podiatry and surveillance outside the scope of routine clinics

Patients with PAD/PVD who have poor tissue viability
High and Moderate risk Patients who have significant pathology and
require intensive treatment
History of previous ulceration and difficulty travelling to acute for
treatment
Any patient with diabetes may be referred for a second opinion
regarding their treatment plan
Intensive education

Referral to Acute Diabetes Clinics
These clinics are for patients who require multidisciplinary care in an
acute setting and highly specialist podiatric intervention

Suspected osteomyelitis, spreading infection, cellulitis, necrosis
or acute Charcot Arthropathy to be referred immediately to the
acute clinic
Any ulcer that has been present for more than 4 weeks and has shown
no signs of improvement
Deteriorating ulcer size, depth, infection should be referred
immediately
X-ray suggests suspected Charcot Arthropathyor osteomyelitis
Pressure relief ie aircast boot
If in doubt of urgency of treatment required please refer
to acute
immediately

Diabetes Dietetic resources

Diet sheets and resources

Written diet information becomes out dated fairly quickly Dietitians
throughout Fife use agreed, evidence based, up to date resources

If practices wish to issue diet sheets to patients we recommend the
following:

Nutrition and Dietetic Information Pack for Primary Care and Community
Staff available in all practicesIncludes the following information :
Diabetes and a Healthy Heart
A Healthy Balance to Diabetes and Weight Loss
Impaired Glucose Tolerance, What Should you Do

Diabetes UK : wwwdiabetesorguk available for cost of postage
packing
Eating Well with Diabetes
Weight Creeping up on you

SNDRI Scottish National Dietetic Resource Initiative
wwwcaledonianacuk/sndri
These resources are not intended as stand alone information but to be
explained and tailored to an individual patient

Pregnancy

Pregnancy is an important consideration for women with diabetes, and is
also a time when a number of women encounter diabetes for the first time

Diabetes can have profound effects on both the mother with diabetes and the
developing
fetus, and it is essential that all women with diabetes or who
develop diabetes during pregnancy are managed in a specialist setting

In Fife, there are professional who deal with the following aspects of
diabetes in pregnancy:

Pre-pregnancy Counselling

Diabetes Ante-Natal care

High Risk Pregnancy Management

Post-Delivery Care and Follow up

As a result, pregnancy is treated with great respect and women with
diabetes are encouraged to plan pregnancy with secondary care diabetes
staff prior to embarking on conception

Glycaemic Control
Type 1 diabetic patients on insulin/type 2 patients requiring insulin
treatment
These females usually will have been through pre-pregnancy clinic training
They will be aware of how to adjust insulin appropriately according to the
blood sugar levels but they may get in touch with the named nurse contact
as detailed in their blood sugar book for any advice regarding the
adjusting of insulin

The type 2 diabetic patients treated with metformin insulin
The number of these is increasing At presentation they are usually in
their late 30s or even early 40s Some patients require metformin
alone;
others require insulin alone, occasionally a combination If the patient
requires advice on insulin, then this will be given in the usual way but if
they require advice regarding adjustment of metformin then refer below to
the management advice

Gestational diabetes treated with metformin
An increasing number of females with gestational diabetes especially in the
third trimester, are being treated with metformin rather than insulin
The patient may start on metformin 05 g daily or twice daily If the
glycaemic control is not satisfactory this can be increased by 05 g daily
for 2-3 days, then reviewed It can be increased by another 05 g daily
thereafter For instance, patients on 05 g twice daily would be asked to
go up to 05 g three times per day then after a few days up to 1 g twice
daily This is the optimal dose of metformin If the control is not
satisfactory then the patient would require to go for insulin therapy
either at Queen Margaret Hospital in Dunfermline, the Diabetes Centre at
Victoria Hospital or to be discussed at the next Wednesday morning joint
diabetic/obstetric clinic at Forth Park Hospital,
Kirkcaldy depending on
the circumstance

Those patients requiring non-urgent/selective advice regarding glycaemic
control will be instructed on how to contact their Diabetes Specialist
Nurse A doctor is usually available on Friday morning for advice

Contacting Services

If a woman with diabetes wishes to discuss pregnancy or thinks she may be
pregnant, contact with the pre-pregnancy clinic should be made as quickly
as possible

Living with Diabetes

There is a Scotland wide Diabetes Website available for patients:
http://wwwmydiabetesmywayorguk/

There is also a great deal of support available for people with diabetes in
Fife They can contact the numbers below to hear about local meetings and
conferences that support diabetes self care

VOLUNTARY PATIENT SUPPORT GROUPS

Diabetes UK WEST FIFE GROUP

Ross Kerr 07762 223438

Diabetes UK EAST FIFE GROUP

Ross Kerr 07762 223438

Diabetes UK NORTH EAST FIFE GROUP
Ross Kerr 07762 223438

Marjory Burnett 07929 777402

People with diabetes can also join Diabetes UK to receive Balance Magazine
regularly Call Diabetes UK Scotland for more details

Diabetes UK SCOTLAND
0141 332 2700

|Fife Diabetic Retinopathy Service |
| | | |
|Retinopathy Manager |01592 22ext | |
| |Ext 6850 | |
|Retinal Screener / Graders |Ext 7945 | |
|DRS Secretaries |Ext 6852 | |

Podiatric Contacts and Clinics in Fife
Dunfermline and West Fife:

Wendy McCormack WendyMcCormack@fife-pctscotnhsuk
Carnegie Clinic Office 01383 722911 Ext 2053

Clinics

Monday PM Abbeyview Clinic 01383 723259
Tuesday AM Carnegie Clinic
Wednesday AM Carnegie Clinic
Friday PM Carnegie Clinic
Janice Birrell janicebirrell@fifepctscotnhsuk

Clinics
Tuesday AM Inverkeithing 01383 413234
Tuesday PM Dalgety Bay 01383 821099
Wednesday PM Dalgety Bay
Contact Number 01592861962
Kerry Mavor
kerrymavor@nhsnet

Clinics
Tuesday AM Cowdenbeath
Friday PM Weeks 1 and 2
Dalgety Bay Week 3
Crossgates all day
Contact number 01383511111

Central Fife
Allison Reilly 07900161772
Fiona Graham 07810056710
Kirkcaldy Health Centre 01592 266271 ext 268

Clinics
Wednesday pm Whytemans Brae Hospital
Thursday pm Glenrothes Hospital
Friday am Randolph Wemyss Memorial Hospital

North East Fife
Allan Lang 07834435944
Ladybank Office 01337 830398
St Andrews Health Centre Tuesday am 01334477117
Wednesday pm

Domiciliary Care

Any housebound patient requiring specialist diabetes podiatry should be
referred directly to their local diabetes specialist podiatrist at the
above contact numbers / addresses

Hospital Podiatry Diabetes Specialist Clinics

At QMH Dunfermline: 01383 623623 ext 5928 or ext 3754

Gillian Meldrum gillianmeldrum@fahtscotnhsuk
Angela Green ANGELAGREEN2@fahtscotnhsuk

At VHK Kirkcaldy: 01592 643355 ext 8360

Les
Hogarth leshogarth@fahtscotnhsuk
Diane Snell dianesnell@fahtscotnhsuk
Fiona McMillan Fionamcmillan@nhsnet
| |

Pain Service Contact Details
A Fife wide Pain Management service is available through its base in Queen
Margaret Hospital Patients who do not respond to first or second line
agents may benefit from referral and assessment by this service

Pain Management Nurse Specialist Fran Proctor
Ext 3703
franproctor@fahtscotnhsuk
Secretarial Office Ext 4749
Specialist Physiotherapist Ext 5904
| |

Nurse Led Erectile Dysfunction Service Contact Details
Ruth Cameron, Clinical Nurse Specialist Urology
Urology Diagnostic Treatment Centre, Victoria Hospital, Kirkcaldy
01592 643355 ext: 1470
Clinics are held at varying times within the Urology Diagnostic and
Treatment Centre Review clinics and educational sessions regarding
specific treatment options are available
by appointment with the CNS
Urology
Dietetic Contacts and Clinics in Fife

For general or service enquiries contact:

Katie Duncan, Lead Specialist Dietitian, Pentland House, Lynebank Hospital
KatieDuncan@fife-pctscotnhsuk or Tel 01383 565353

Key Publications

American Diabetes Association Diagnosis and Classification of Diabetes
Mellitus Diabetes Care 2004;27 Suppl 1: S5-10

Alberti KG, Zimmet PZ Definition, diagnosis and classification of diabetes
mellitus and its complications Diagnosis and classification of diabetes
mellitus: provisional report of WHO consultation Diabet Med 1998:539-53

Nathan DM, Buse JB, Davidson MB, Heine RJ, Holman RR, Sherwin R, Zinman B
Management of Hyperglycaemia in Type 2 Diabetes: A Consensus Algorithm for
the Initiation and Adjustment of Therapy Diabetes Care 2006; 29:1963-1972
Marshall SM, Flyvbjerg A Prevention and early detection of vascular
complications of diabetes Br Med J 2006;333:475-80

UK Prospective Diabetes
Study UKPDS Group Intensive blood glucose
control with sulphonylureas or insulin compared with conventional treatment
and risk of complications in patients with type 2 diabetes UKPDS 33
Lancet 1998; 352:837-853

UK Prospective Diabetes Study UKPDS Group: Effect of intensive blood
glucose control with metformin on complications in overweight with type 2
diabetes UKPDS 34 Lancet 1998; 352:854-865

The Diabetes Control and Complications Trial Research Group The effect of
intensive treatment of diabetes on the development and progression of long-
term complications in insulin-dependent diabetes mellitus N Engl J Med
1993;329:977-86

Writing Team for the Diabetes Control and Complications Trial/ Epidemiology
of Diabetes Interventions and Complications Research Group Sustained
effect of intensive treatment of type 1 diabetes mellitus on development
and progression of diabetic nephropathy: the epidemiology of diabetes
interventions and complications EDIC study JAMA 2003;290:2159-67

UK Prospective Diabetes Study Group Tight blood pressure control and
risk of macrovascular and microvascular complications in type 2 diabetes
UKPDS 38 BMJ 1998;317:703-13

Dahlof B, Sever PS, Poulter NR,Wedel
H, Beevers DG, Caulfield M, et al,
ASCOT Investigators Prevention of cardiovascular events with an
antihypertensive regimen of amlodipine adding perindopril as required
versus atenolol adding bendroflumethazide as required, in the Anglo-
Scandinavian cardiac outcomes trial-blood pressure lowering arm ASCOT-
BPLA: a multicentre randomised controlled trial Lancet 2005;366:895-906

Heart Protection Study Collaborative Group MRC/BHF heart protection study
of cholesterol lowering with simvastatin in 20536 high risk individuals: a
randomised placebo-controlled trial Lancet 2002;360:7-22

Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone
SJ, et al, CARDS Investigators Primary prevention of cardiovascular
disease with atorvastatin in type 2 diabetes in the collaborative
atorvastatin diabetes study CARDS: multicentre randomised placebo
controlled trial Lancet 2004;364:685-96

Costa J, Borges M, David C, Vaz Carneiro A Efficacy of lipid lowering drug
treatment for diabetic and non-diabetic patients: meta-analysis of
randomised controlled trials BMJ 2006;332:1115-24

ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research
Group Major outcomes in
high-risk hypertensive patients randomized to
angiotensin-converting enzyme inhibitor or calcium channel blocker vs
diuretic: the antihypertensive and lipid-lowering treatment to prevent
heart attack trial ALLHAT JAMA 2002;288:2981-97

Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O
Multifactorial intervention and cardiovascular disease in patients with
type 2 diabetes N Engl J Med 2003;348:383-93

McIntosh A, Hutchinson A, Home PD, Brown F, Bruce A, Damerell A, Davis R,
Field R, Frost G, Marshall S, Roddick J, Tesfaye S, Withers H, Suckling R,
Smith S, Griffin S, Kaltenthaler E, Peters J, Feder G Clinical guidelines
and evidence review for Type 2 diabetes: management of blood glucose 2001
ScHARR, University of Sheffield, Sheffield
http://wwwshefacuk/guidelines/

Hutchinson A, McIntosh A, Griffiths CJ, Amiel S, Bilous R, Chaturvedi N,
Heller S, Holman R, Peters J, Kaltenthaler E, Home PD Clinical guidelines
and evidence review for Type 2 diabetes: Blood pressure management 2001
ScHARR, University of Sheffield, Sheffield

NHS Quality Improvement Scotland Diabetic Retinopathy Screening Clinical
Standard 2004 NHS Quality Improvement Scotland 2004 ISBN
1-84404-258-8

Singh S, Loke YK, Furberg CD Long-term risk of cardiovascular events with
rosiglitazone: a meta-analysis JAMA 2007; 298:1189-95

Singh S, Loke YK, Furberg CD Thiazolidenediones and Heart Failure: a teleo-
analysis Diabetes Care 2007;30:2148-53

Lincoff Am, Wolski K, Nicholls SJ, Nissen SE Pioglitazone and risk of
cardiovascular events in patients with type 2 diabetes mellitus: a meta-
analysis of randomized trials JAMA 2007;298:1180-88
———————–
Single Measurement of Blood Glucose

Random Glucose 111 mmol/l
or
Fasting Glucose 70 mmol/l

Patient has Diabetes Mellitus

Random Blood Glucose 78 mmol/l

Symptoms of Hyperglycaemia?

Present

Absent

Perform on 2 separate occasions at least 4 weeks apart

Fasting Blood Glucose 70 mmol/l
On both occasions

Patient has Diabetes Mellitus

Ketonuria detectable on dipstix

Heavy 3

Contact Local Hospital Paediatric Services

Age 15 years

Mild-Mod Trace - 2

15 Age 35 years

None

Age 35 years

Type 2 DM likely
Primary Care Management

Type 1 DM likely
Refer to local
Hospital Diabetes Service

Blood Pressure

Anti-platelet therapy

Lipids

Blood Glucose

Intervention threshold and treatment target for blood pressure in diabetes

Blood Pressure

120/75

130/80

Target

140/85

Intervention

Nephropathy

No nephropathy

Diabetes

Blood Pressure

ACD Algorithm suggested for
use in treatment escalation

Polypharmacy and appropriate Beta Blocker usage stressed

A - ACEI or ARB

D - Thiazide like diuretic

C - Calcium Channel Antagonist

O - Other

Approximately 35 of patients will require
this level of treatment to attain target blood pressure

Stepwise introduction of agents recommended
Combination preparations of ACEI/ARB plus diuretic may aid
compliance

Possible combinations may include both ACEI and ARB or ACEI/ARB plus
spironolactone

Such combinations require close monitoring of eGFR and serum K

Beta blockers should be used if indicated for secondary prevention of
established CHD or for LV dysfunction

The order of introduction is not mandatory, but a combination of ACD would
be expected to control the majority of cases

Treatment based on Diagnostic Classification

Lifestyle management remains the cornerstone of management

Titrated Regimens of Oral Agents

Insulin use in appropriate circumstance

Target HbA1c measurements will vary according to individual
circumstances

National guidelines may vary with time

Blood Glucose

Insulin therapy Metformin

Insulin plus
pioglitazone may be considered if metformin not tolerated and
features of insulin resistance predominate, eg using 1 unit/kg per day

Insulin

Sulphonylurea

Glitazone

Consider

Glitazone/
Metformin
Preparation to reduce tablets

Consider

Modified Release preparation if hypoglycaemia

Consider

Maintain metformin if tolerated no contraindication

Titrate dose to 1000mg bd if tolerated
Consider Glucophage SR if GI upset

Metformin

Triple Therapy with
Glitazone/Metformin/Sulphonylurea
May improve HbA1c without need for insulin, eg specific occupations

Other Agents: Exenatide, Gliptins, Glitinides, Acarbose

Use if indicated, eg intolerant of other agents

Insulin therapy may be added earlier if
clinically appropriate

Consider
Orlistat or Rimonabant if obesity a

Metformin Glitazone Sulphonylurea

Insulin Metformin

Continue metformin at pre-insulin dose and discontinue other oral agents
Titrate insulin dose to target HbA1c

Insulin only

Discontinue all oral agents and substitute insulin Titrate insulin dose to
target HbA1c

Insulin Pioglitazone

Introduce glitazone therapy Monitor HbA1c, SBGM and observe for fluid
overload Maximise dose of glitazone and minimize insulin dose

Commence insulin therapy

Intolerant of Metformin

Yes

Requiring escalating doses of insulin with obesity

Institution of Insulin therapy
in Type 2 Diabetes

Lipid lowering

Aspirin 75mg once daily

Established vascular disease: Macro or Microvascular

Diabetes Mellitus - Age 40
BP 140/90

Target Total Cholesterol 40mmol/l
Target LDL Cholesterol 19mmol/l

Triglycerides 17mmol/l
HDL Cholesterol 10 men, 12mmol/l women
Consider Fibrate therapy

1 Statin Based: Simvastatin 40mg od SIGN 97
Atorvastatin 20mg od
Rosuvastatin 10mg od

2 Targets not achieved: Titrate up dose of Statin add in second agent

Ezetimibe 10mg od

Fibrate - Fenofibrate
Bezafibrate

3 Elevated Triglycerides Fibrates - Fenofibrate
Low HDL- cholesterol Nicotinic Acid
Non-target TC/LDL-C Colestyramine

Anti-platelet therapy

Aspirin 75mg once daily
Established vascular disease
Diabetes Mellitus - Age 40
BP 140/85

Hypoglycaemia

Conscious

2-4 dextrose tablets
50-100ml Cola/Lemonade

Wait 5-10 minutes and repeat

[?]IJR[cdðèàèàÈÈ?zzziUChfLong acting carbohydrate
if next meal not imminent, eg
sandwich, fruit

50 Dextrose: 20ml1 iv push

Wait 5-10 minutes and repeat

10 Dextrose Infusion - start at 100ml/hour
Contact Senior Medical Staff if no response
Consider Dexamethasone 16mg iv bolus

Glucagen2 1mg sc or im

Unconscious and severe

1 Give via large vein to avoid extravasation injury
2 May be ineffective in sulphonylureas therapy,
alcohol excess or liver disease
May induce vomiting in some individuals

Source:doh.gov.za

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