Diabetes (Type 2)

Diabetes (Type 2)

Screening for diabetes

There is good evidence that screening is worthwhile in high-risk populations NICE 2012:

< 40 years – People aged >25 who have Chinese, Afro Caribbean or S Asian ethnicity should have a DM risk assessment, as should patients with PCOS (e.g. from In patients, who are found to be at high risk, provide appropriate interventions and screen annually with a fasting blood sugar or HbA1c. Those found to have low to moderate risk should be screened every five years.
> 40 years of age all patients should have DM risk assessment (e.g. from and in patients who are found to be at high risk, provide appropriate interventions and screen annually with a fasting blood sugar or HbA1c. Those found to have low to moderate risk should be screened every five years.(Note the NHS healthcheck (40 - 74 years) will screen some people for diabetes)
Consider screening in other conditions which increase risk that are not included in this algorythm e.g. patients on drugs such aslong term or frequent steroid use, antiretrovirals and some antipsychotics.

But note the UK Primary Care'ADDITION TRIAL' - this showed no benefit of screening for diabetes to all cause mortality at 10 years

Annual blood tests.

Gestational diabetics need a fasting BS at 6 weeks post delivery and annual HbA1c there after.
Hypertensives – should have a diabetes risk assessment and those found to be at low to moderate risk only need screening fasting blood sugar or HbA1c every five years. Those at high risk need annual screening.
Patients withCKD or CVD: ischaemic heart disease, peripheral vascular disease and stroke – HbA1c forms part of their annual review or minimum annual data set.

Gestational Diabetes

Read code and promote to a major problem
Task Michelle so that she is aware regards annual recall
Fasting BS at 6 weeks check
Thereafter annual HbA1c for life.

WHO 2011 (Diagnosis of diabetes using HbA1c)

The WHO in January 2011 added HbA1c as a diagnostic test for Type 2 diabetes in adults who are not pregnant and do not have haemoglobinopathy or haemolytic anaemia if the HbA1c level is(48 mmol/mol) or above. The WHO state that diagnosis should be confirmed with a repeat HbA1c test, unless clinical symptoms and plasma glucose levels >11.1mmol/l are present in which case further testing is not required.

Note: Does not apply to children, pregnant women, patients with haemoglobinopathy, patients with acute onset osmotic symptoms (Hx < 2 months) or suspected Type 1 DM.

The usual diagnostic pathway for borderline results

Fasting BS 6.1 – 6.9 x 2 = Impaired Glucose Regulation = pre diabetes – Arrange HbA1c and non fasting lipid profile for CVD risk assessment. They will need annual HbA1c and CVD risk assessment

HbA1c 42 to 47 mmol/l x 2 = Impaired Glucose Regulation = pre diabetes – repeatHbA1c andnon fasting lipid profile for CVD risk assessment. They will need annual HbA1c and CVD risk assessment

A diagnosis of diabetes has important legal and medical implications for the patient and it is therefore essential to be secure in the diagnosis.

See our Impaired Glucose regulation (IFG & IGT) management protocols

The changing of HbA1c reporting from 2011

From April 2011 the DCCT aligned measurement of HbA1c will be phased out and replaced with the new IFCC method which has completely different units! Instead of being reported as a percentage it will be expressed in mmol/l.

HbA1c (DCCT) %HbA1c (IFCC) mmol/l

6.0%42

6.5%48

7.0 %53

7.5%59

8.0%64

9.0%75

For a full table of HbA1c conversions open the hyperlink
Other methods and criteria for diagnosing diabetes mellitus

WHO 2006 (Using blood glucose)

1. Diabetes symptoms (ie polyuria, polydipsia and unexplained weight loss) plus

a random venous plasma glucose concentration › 11.1 mmol/l or
or a fasting plasma glucose concentration › 7.0 mmol/l
or
two hour plasma glucose concentration › 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

2. With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test (or HbA1c) result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load. If the fasting values are borderline then the two-hour value should be used.

The New Patient with diabetes

Make sure the diagnosis is correct!
Provide information e.g. the practice information and/or theType 2 diabetes PILeaflet from and signpost them to the Diabetes UK website
Arrange base line review bloods.

(FBC to exclude haemoglobinopathy, HbA1c, TSH, Electrolytes & Creatinine, non fasting lipid profile, microproteinuria (urine ACR), BMI & BP and smoking status/cessation advice).

GP to add the Read code ‘Diabetes Type1 or Type 2’from the Read code formulary to the Problem Page..
Task Vanessa to set the diabetes recall (6 month default for first attendance) and arrange the DESMOND Education sessions and retinal screening referral who will ensure the appropriate QOF Read code QOF Read code 8Hj4 is used for Desmond referral.
If overweight consider referring to the Upbeat service (exercise on prescription), the Healthy Weight Clinic or other obesity treatments.

Follow up by appropriate GP BUT remember new onset Type 1 often requires urgent DSN referral or admission if ketotic.
Only start oral Rx if the BMs are in the high teens and they are symptomatic OR IF HbA1c > 10%i.e. 86 mmol/l(Metformin 500mg bd taken with or after food) – if not then try diet for 12 weeks with HbA1c at that time – if not at target (see page 5) then start Rx with Metformin. Please remember Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction. Metformin has to be stopped if eGFR fall below 30! Metformin MR can be used if they run into problems with GI side effects.

Don’t forget that on starting hypoglycaemics to complete the prescription exemption form for those patients under 60 years of age. If using sulphonyl ureas counsel the patient about the symptoms of hypos, hypo management, hypos and driving and remind them about informing their car and travel insurer AND document this in their records. If they hold HGV or PSV licenses then check with the 6 monthly updated DVLA guidance with respect to them having to inform the DVLA.
See our guidance on further potential therapeutic interventions. If unsure please discuss management with the diabetes lead(s) within the practice.

Review schedules

Annual RV Invx = Cr&Es, eGFR, HbA1cand non fasting cholesterol.

Urinary ACR.

BP & smoking status/cessation advice, exercise status and alcohol intake.

BMI

Podiatry and retinal review.

? hypo unawareness, ? hypos requiring external intervention (see DVLA guidelines).

HGV/Bus driver (Group 2)? If so should be checking HBGM twice daily and at times relevant to driving

Advice re HBGM - How often? What are they doing with the results?

Provide diabetes and driving leaflet.

Targets at a glance

QOF= BP<140/<80 (aspiration <130/80 if end organ damage)

Non smoker (Don’t forget CCG services & in-house clinic)

Cholesterol

AspirationalCholesterol < 4.0mmol/l

QOFCholesterol <5.0mmol/l

HbA1c

Diet alone < 6.5% i.e. 48mmol/l

Diet and Metformin < 6.5% i.e. 48mmol/l

Diet, Metformin & 1 hypoglycaemic therapy7.0% - <7.5% i.e. 53 to 58mmol/l (Beware in frail elderly patients!)

New American Diabetes Association guidance

Elderly with little co-morbidity HbA1c < 58.5mmol/l (<7.5%)

Elderly with multiple co-morbidity or memory impairment HbA1c < 64mmol/l (<8%)

Elderly with end stage chronic disease or significant memory impairment HbA1c target < 69 mmol/l (<8.5%)

Home Blood Glucose Monitoring Diary

BMI >25(Don’t forget Upbeat & The Healthy Weight Clinic)

Medication re-authorisation

Check the annual minimum data set are all in date; BP, Cr&Es, HbA1c, cholesteroland urinary ACR.
If you have time check to see if the podiatry or retinal reviews are overdue.
Reset repeat re-authorisation for 1 year BUT shorten the review period if there are QOF targets yet to be achieved.

If at the time of issuing repeats the minimum data set or annual reviews are incomplete and their annual diabetic review is overdue just issue one supply and task Vanessa to arrange DM clinic review.

BP – Active management is essential!

Over half of all diabetics are hypertensive. Both the UKPDS and DCCT trials have shown that excellent BP control reduces retinopathy, nephropathy, strokes, heart failure and MI. BP control is as important as glycaemic control! Note recent trials have shown driving systolic BP <130 does not decrease CVD events and that if you drive systolic BP <110 it is associated with increased CVD risk.

If BP> the QOF standard you must act! Most antihypertensive treatments will have their full effect after 2 to 4 weeks, so uptitrate within that time frame.

ACE inhibitors are usually the first line drug - see the hypertension guidelines.

Ramipril starting regime derived from the HOPE study regime and BNF guidelines

If U&Es pre treatment reveal a creatinine < 150 micromol/l and a sodium >130 mmol/l then 2.5mg Ramipril daily (1.25mg if on lower dose concomitant diuretics) for one week with check U&Es and an increase to 5.0mg Ramipril for a further three weeks. Re-check U&Es and if indicated increase to 10mg Ramipril and repeat U&Es on an annual basis. If eGFR falls > 25% or creatinine rises by > 30% stop or back titrate treatment – see NICE guidelines. Don’t forget BNFcautions and contra indications.

Microproteinuria

ACR (Albumin Creatinine Ratio) is a screening test for diabetic microalbuminuria performed on a random sample of urine. The ACR for men should be less than 2.5 and for women less than 3.5. Rememberfalse +ve results may occur after strenuous exercise, UTIs or glomerulonephritis.

NICE guidelines for microproteinuria

Measure serum Creatinine and urinary Albumin:Creatinine Ratio (ACR) concentration at least annually (unless consistently ACR > 6 in which case request urinary PCI).

If new onset microalbuminuria or proteinuria is present (ACR > 2.5 men and > 3.5 women) exclude UTI and repeat twice more (within 3 to 4 months) as it may become an irreversible nephropathy within 6 to12 months. Read Code microalbuminuria in their Problem Page & Summary.

If microproteinuria is still present check their records (or examine their eyes) to check for retinopathy. If retinopathy is not present, if they have resistant HT or if they have microscopic haematuria then look for a non-diabetes cause of renal disease/consider renal referral.

Ensure good glycaemic control (HbA1c target <7.5%i.e. 59 mmol/l)
Measure, assess and manage cardiovascular risk factors aggressively.
Initiate ACE inhibitor therapy for cardiovascular/renal protection.
Target blood pressure = QOF <140/80 aspirational 130/80 mmHg.
ACE inhibitors are the drug of first choice. To achieve target blood pressure then use combination therapy if ACE inhibition alone is not fully effective.
Measure ACR at each visit.
See CKD section re referral guidelines to nephrology.

Glycaemic control and HbA1c – HBA1c should just be checked at least annually if at target (but every three months if treatment is being uptitrated to achieve target).

If HbA1c is not at target, consider potential life style changes, compliance issues and/or increase treatment assuming this has not been done in the last 4 weeks – consider discussion with the diabetes lead clinician. Please note that HbA1c < 6.5%i.e. 42 mmol/l in diabetics on oral hypoglycaemics is associated with increased morbidity and mortality. Furthermore, there is now debate over the value of reducing HbA1c below 7.0% i.e. 53 mmol/l (BMJ April 2009) – watch this space.

Type 2 summary for improving glycaemic control

If they have mild or no symptoms of diabetes try dietary control over 3 months and then add Metformin (unless CI).
If they have intrusive symptoms or an HbA1c > 10% i.e. 86mmol/l at presentationconsider starting Metformin (unless CI).

Initiating Rx – Mono therapy

1st line Metformin

If they have mild or no symptoms of diabetes try dietary control over 3 months and then add Metformin (unless CI).
If they have intrusive symptoms or an HbA1c > 10% i.e. 86mmol/l at presentation

If metformin CI or not tolerated

2nd line Repaglinide (see advantages and disadvantages below)

If Metformin and Repaglinide CI or not tolerated

3rd line Pioglitazone (beware > 50, smoker, worker in dye/rubber industry, HF, IHD etc)

When monotherapy fails

Dual therapy

1st line = Metformin & Pio

2nd line = Metformin & SU

3rd line = Metformin and DPP-4

4th line = Metformin and Flozin

If hypo risk or wt gain an issue opt for 3rd or 4th line

If Metformin not tolerate or CI

1st line = Pio & SU (beware wt gain!)

2nd line = Pio & DPP4

3rd line = SU and DPP4

4th line = SU and Flozin

Triple therapy

Pio + Metformin + SU

Metformin + SU + DPP4 or Flozin or Insulin or GLP agonist (Gliptin)

Brigroyd preferred drugs SU = Gliclazide, DPP-4 = Linagliptin, Flozin = Canagliflozin

Metformin

There has been a shift to early Metformin use, as detailed above, due to it reducing CVD mortality. Start with 500mg with main meal and uptitrate each week over three weeks to a tds dose with breakfast, lunch and tea. Max dose is usually 2g a day.

Take it with or just after food

Metallic taste and diarrhoea are common initially but often settle. If not consider the once daily MR version with the main meal of the day.

Review need for continued Metformin if eGFR < 45

Withdraw Metformin if eGFR < 30

It also needs to be stopped 48 hours prior to contrast radiological studies and not re-started until check U&Es confirm it is safe to do so, no early than 72 hours post procedure.

Also stop it during intercurrent disease associated with dehydration.

Advantages: Cheap, reduces CVD risk and is weight neutral

Disadvantages: SE and multiple dosing if not using MR form

Repaglinide (A mitiglinide)

Very similar to sulphonyl ureas, rapid acting and short duration, so used pre-prandially (30 mins prior to meals, skip if skipping meals) usually 0.5 to 4mg tds. Hypos a risk but less than classical SUs. Licenced as monotherapy or in combination with Metformin, has to be stopped if other agents added. Caution in CKD and in the elderly.

Advantages: Cheap, risk of hypos lower than SUs, flexible use re patients with erratic eating habits

Disadvantages: hypos, multiple dosing, limited licensing

Gliclazide (A sulphonyl urea ‘SU’)

Consider avoiding if there is a significant risk of and/or implication regards hypos (e.g. patients with impaired cognition, patients > 60 years, patients with CKD3B or worse or someone who drives ++).

If a driver consider HBGM and counsel re hypo symptoms, hypo management and DVLA guidance

Use the short acting BD version (hypos less likely)

Taken 10 to 15 mins prior to the meal

Start with 40mg bd and uptitrate two weekly according to HBGM response to a max of 160mg bd

It’s metabolised by the liver and so can be used in renal impairment.

Avoid in severe hepatic impairment.

There is a once daily MR form of gliclazide (30 to 120mg daily) but as with all long acting sulphonylureas hypos are more likely.

Advantages: It is very effective

Disadvantages: Risks of hypos and weight gain

Linagliptin (a DPP-4 inhibitor)

Don’t use if pmh of pancreatitis

Warn patient risk small but if gets severe abdo pain, stop rx and see doctor same day re ? pancreatitis

Once daily dose 5mg, no dose adjustment for renal impairment.

Stop if Hba1c does not improve after 3 months (> 6mmol/l)

Can be used with Metformin, SU and insulin but not Pioglitazone (can use Sitagliptin with Pio)

Note – Alogliptin is a bit cheaper than Linagliptin but dose adjustment needed in renal impairment

Advantages: Once daily and weight neutral

Disadvantages: ? small risk of pancreatitis

Pioglitazone (a ‘glitazone’)

Once daily, dose 15 to 45 mg, up titrate every two to three months and stop if Hba1c not improving (> 6mmol/l) on max Rx (after 9 months post initiation).

Can be used with Metformin, SUs and insulin

Avoid if hx of HF, IHD, bladder cancer or undiagnosed haematuria

Beware > 50 years, smoker, worker in dye/rubber industry, HF, IHD etc

Advantages = cheap and once daily

Disadvantages = weight gain, fluid retention, heart failure and small risk of bladder cancer and osteoporosis

Canagliflozin (a ‘Flozin’)

One daily, 100mg to 300mg if eGFR > 60 (Don’t start it if eGFR < 60), 100mg if e GFR falls to 45 to 60, stop if eGFR < 45.

In combination with SUs or insulin can cause hypos, so step down insulin or SU dose temporarily when initiating Rx.

Licenced for use with Metformin & SUs & Insulin

Advantages = weight loss and BP reduction

Disadvantages = hypotension & increased genital infection due to glycosuria

Liraglutide & other GLP agonists. If the patient won’t accept insulin, especially if their BMI is raised (BMI > 35) consider referring to the DSN for a trial of an injectable GLP agonist e.g. twice daily Exenatide or once daily Liraglutide on once weekly Bydureon. They are now also licensed to be used with insulin.

They cause reduced appetite and mild nausea (usually settles) and often result in mild weight loss.

Exenatide is injected within 1 hour before 2 main meals (at least 6 hours apart). Bydurion is a slower release variant of Exenatide and is injected weekly.

Liraglutide can be given at any time of day (but best given around the same time each day) & no requirement for relationship to meals.

The main side effects include nausea and vomiting, but most side effects settle within 8 weeks. Exenatide and Liraglutide can delay gastric emptying. Don’t use in gastric paresis.

They are contraindicated if there is PMH of pancreatitis or severe inflammatory bowel disease. Always counsel patients to see their GP promptly if they develop vomiting or severe abdo pain.

Also beware reduced eGFR

Liraglutide – avoid if eGFR < 60

Exenatide - use with caution if eGFR 30-50, avoid if eGFR < 30

Continue Exenatide or Liraglutide only if the person has a reduction in HbA1c of ≥ 11mmol/l and ≥ 3% of initial body weight in 6 months.

Lipids & CVD risk

Target adult cholesterol = minimum QOF standard < 5.0and an aspirational target of <4.0 and LDL <2.0.

‘All’ Type 2 diabetics with CVD should be considered for long term Atorvastain 80mg.

'All' Type 2 diabetics should have an annual 10 year CVD risk assessment and if risk > 10% commence Atorvastain 20mg long term.

Smoking – Read code cessation advice & refer to Practice Nurse smoking cessation service.

BMI >25 - Don’t forget Upbeat & The Healthy Weight Clinic

THE PATIENT PATHWAY

Patients, as a result of the diabetes recall system run by Vanessa will be sent a letter inviting them to attend for their annual non fasting bloods and urine ACR. If they are non attenders then their usual GP will be attaching a reminder on their prescription or seeing them face to face to ask them to book their annual review. The reception team will book a non fasting bloods & BP appointment with one of the HCAs.