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Diabetes Type 2 Management – Glos Care Pathway Overview

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Presentation

Signs and Symptoms

Red Flags

Hyperosmolar Hyperglycaemic State (HHS)

Commonly presents with symptoms of:

  • polydipsia, polyuria, nausea, vomiting, weakness, and lethargy
  • dehydration, Kussmaul's respirations (deep respirations), fruity odour on breath, and mental status changes
Admit directly to GHFT via A&E / SPCA
Differential Diagnosis
  • Type 1 Diabetes
  • Type 3c Diabetes
  • Drug induced hyperglycaemia
  • Endocrine related hyperglycaemia
  • Gestational diabetes mellitus
Initial Primary Care Assessment

Diagnosis of Diabetes using HbA1c 

Local Guidance: Diagnosis of diabetes (requires either HbA1c or fasting blood glucose)

  • HbA1c has been added to the diagnostic testing for patients who are at risk of diabetes. (WHO 2011).  This test can be used instead of fasting glucose or (OGTT – this is just used in pregnancy for diagnosis of GDM)
  • It is not appropriate for every patient.
  • Patients do not need to fast for HbA1c; the test can be taken at any time
  • Therefore people with diabetes can be identified opportunistically

  • All children and young people < 16 years
  • Women who are pregnant or have been pregnant in the past two months
  • Suspected Type 1 diabetes, regardless of age
  • Sudden onset of symptoms of diabetes
  • Patients at high risk of diabetes who are acutely ill
  • Patients taking drugs that may cause a rapid rise in glucose i.e. corticosteroids or antipsychotic drugs (≤2 months). HbA1c can be used in patients taking these drugs longer term (>2 months) who are not clinically unwell
  • Patients with acute pancreatic damage or following pancreatic surgery
  • Patients with CKD4 or 5
  • Patients with HIV infection
  • Patients who have anaemia
  • Patients who have haemoglobinopathies

Random glucose ≥11.1mmol/L
Fasting glucose TWO required if NO symptoms ≥ 7.0mmol/L
ONE required if symptoms ≥ 7.0mmol/L

Oral Glucose Tolerance Test

≥ 7.0mmol/L at zero hours or ≥ 11.1mmol/L at 2 hours

OR
Random HbA1c TWO required if NO symptoms
ONE result required if symptoms ≥ 48mmol/

Practice Point

If HbA1c or fasting blood glucose level is raised but no symptoms of hyperglycaemia are present the test should be repeated within 2 weeks. If the level is still raised a diagnosis of diabetes is confirmed.

If the result is <42mmol/mol give lifestyle advice then repeat test in 12 months if the patient is asymptomatic, or before if patient develops symptoms. Refer to National Diabetes Prevention Programme / Weight Management Pathway as appropriate if HbA1c 42-47mmol/mol.

Once a diagnosis is confirmed HbA1c can be used for monitoring 3 -12 monthly depending on clinical requirement.

  • HbA1c 42-47mmol/mol – refer to National Diabetes Prevention Programme.
  • If fasting plasma glucose is between 6.0-6.9mmol/L,proceed to HbA1c test.
  • These patients are at increased risk of diabetes and increased risk of cardiovascular disease. Review and re-check in 12 months.
  • Intensive lifestyle and risk management advice is a priority. HbA1c should be repeated annually.

An accurate pathological diagnosis is essential to ensure the correct treatment pathway can be followed.

If there is a discrepancy between the HbA1c and the plasma glucose result with a high clinical suspicion of diabetes, fasting plasma glucose should be the preferred test of choice. The HbA1c test can be repeated at 3 months provided the patient is suitable for the criteria.

Practice Point

GHFT laboratories are unable to perform an HbA1c in a glucose specimen tube. This damages laboratory equipment. Use Greiner Vacuette EDTA tube.

Initial Primary Care Management – Diagnostic Consultation Period

Please consider using this checklist to structure the delivery of information to your patients at diagnosis. This checklist does not have to be covered in one appointment, or in a particular order but please consider using it throughout the initial diagnostic period to ensure all key areas are covered.

Encouraging patients to attend structured education will provide them with all key information and current advice.

Diabetes and You

This is a three-hour session led by a diabetes educator. It is intended for anyone with Type 2 Diabetes or carers, regardless of length of diagnosis. During the session patients will have the opportunity to meet with other people who have Type 2 Diabetes and ask questions.

Diabetes Food and You

This is a two and a half hour session led by a Registered Nutritionist or Dietitian. It is intended for anyone with Type 2 Diabetes or carers, regardless of length of diagnosis.

Diabetes Insulin and You (Education for Diabetes and Insulin Therapy)

This is an exciting patient education group aimed at people who are new to insulin. The sessions are run in small groups using Conversation Maps. Conversation Maps are a new way to learn about diabetes and insulin through group activities facilitated by a skilled diabetes healthcare professional. Follow the link for more information.

All of these sessions are self-referral and if a patient would like to attend they need to fill in the referral form within the information leaflet here and return it to the community diabetes team. Practices are reminded to code offered, referred and attended structured education.

DVLA Group 1
Changes – January 2018 – see DVLA leaflet INF188/2:  Information for drivers with diabetes treated by non-insulin medication, diet or both.

DVLA requirements for car & motorcycle drivers (DVLA Group 1) diabetics managed by tablets which carry a risk of inducing hypoglycaemia (eg. sulphonylureas and glinides):

It may be appropriate to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia.

For Group 1 entitlement the person must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months.

For DVLA Group 1 drivers who are not on oral medication at risk of hypoglycaemia or on insulin the need for blood glucose monitoring and frequency should be decided on an individual patient basis.

 

DVLA Group 2
Changes – January 2018 – see DVLA leaflet INF188/5:  Information for lorry drivers and bus drivers with diabetes treated by diet alone.

Commercial lorry or bus drivers (DVLA Group 2) on insulin or sulfonylureas (eg. glipizide or glicazideor glinides (eg. nateglinide, repaglinide) should regularly monitor blood glucose at least twice daily and at times relevant to driving. This may be either by using Blood Glucose Meters or Flash Glucose Monitors.  

DVLA Group 2 drivers on insulin should use a meter with a memory function capable of storing 3 months of readings.

For further information please see the DVLA Website

A local solution to online structured education is currently being scoped.

Guidance on Patient Self-Monitoring of Blood Glucose and Prescribing of Blood Glucose Testing Strips

This guidance aims to support people with diabetes and healthcare professionals involved in their care, to achieve optimal glycaemic control through the effective use of self-monitoring of blood glucose and Hba1c testing.

  • ​Patients on insulin therapy or being considered for insulin therapy
  • Commercial lorry or bus drivers (DVLA Group 2 drivers)
  • Car and motorcycle drivers (DVLA Group 1 drivers) on medication which carries a risk of hypoglycaemia (e.g. sulphonylureas and glinides)
  • Women with diabetes who are either pregnant or considering pregnancy
  • Patients advised to test for other specific reasons by diabetes specialists

Blood glucose monitoring should also be considered temporarily where there may be periods of unstable glucose levels e.g. patients on weight loss programmes, especially those on sulphonylureas, during periods of illness or changes in therapy or during a course of steroid treatment.

In these cases patients should be informed at the outset that the monitoring is indicated for a limited period of time only. Testing strips should not be placed on repeat prescription for patients for whom blood glucose testing is only indicated on a temporary basis.

In all other groups there is limited evidence that either random or routine blood glucose monitoring is of clinical benefit.

Patients who wish to monitor their blood glucose more frequently than is clinically indicated will need to purchase their own strips.

Twice yearly HbA1c testing is recommended as a minimum by NICE.

 

Use of Blood Glucose Level Testing

The use of BGL testing is helpful for getting an instant guide of a person’s fasting glucose level. Since the advent of using HbA1c, the use of BGL has become less common but does have a role for certain situations. The majority of diabetics do not need BGL monitoring meters and are adequately maintained by use of HbA1c results. There are however certain circumstances in which it would be recommended that patients have access to BGL meters:

People using Insulin
This is the commonest requirement BGL monitoring, it gives the patient an immediate record of fasting glucose and hence an indication of the insulin dosage they should they should be giving themselves. The strips should be readily accessible for both T1DM/T2DM on insulin and any other insulin using patient.

People using Sulphonylureas
(SUs) who are car drivers: Since the DVLA have changed their recommendations regarding Class 2 licensing to recorded twice daily monitoring for the HGV driver population, it has been suggested that  Class 1 drivers should also have the ability to test (1). Although this is not a legal requirement it is recommended.  Therefore despite the evidence for the clinical benefit offered from this approach being limited, BGL meters should be provided to this cohort to give them the option to test before driving.

(SUs) who are not car drivers: As SUs can potentially cause hypoglycaemia, all patients on SUs should be considered for test strips with advice on appropriate frequency of use.

Changes in medication and the direct effect on BGL
This cohort of patients should be advised to use BGL for short times only, after changes in medication have occurred without waiting 2-3 months for an HbA1c. This empowers the patient and gives them confidence in the treatment plans.

People who have frequent or unexpected hypoglycaemic events
It is imperative that this group are given access to BGL meter strips. Hypoglycaemia events are potentially an avoidable situation that has physical and psychological consequences for people. Monitoring may allow reduction in the frequency of events but also potentially avoidable use of paramedics or hospital admissions.

Sick day rules
All people who have diabetes, whatever the underlying pathophysiology will become systemically unwell at some point in their journey. Those that have tendency to do this frequently may need to monitor their BGL closely. There is standardised guidance with regard to sick day rules, but the base line assessments are using BGL meters to advise further treatment.

People who have been advised by a diabetes specialist to test
This cohort of people may have ongoing issues with their diabetic control that needs monitoring closely by their Diabetes Specialist, or a range of other specific conditions necessitating testing e.g. renal patients, pancreatic transplant patients.

In summary, the use of BGL meters is variable throughout the county. We recommend that meters should only be given if there is good reason to do so. The results of BGL should be seen as a snapshot of the control but not as the long term trends that we should be using to help plan treatment regimes.  At present there is no place for Libre meters to be prescribed on the NHS for people with Type 2 diabetes within Gloucestershire.

Dietary Advice for People with Type 2 Diabetes, Non-Diabetic Hyperglycaemia, and Metabolic Syndrome

The aim of this position statement is to provide evidence-based guidance for Health Care Professionals working in primary, secondary care and the community in Gloucestershire, regarding the nutrition management of adults with Diabetes, Non-Diabetic Hyperglycaemia, and Metabolic Syndrome.

After careful review of the available evidence, there is no-one size-fits-all prescriptive approach to making food choices, and it is equally important that food choices are acceptable and enjoyable while also helping to achieve treatment goals, and improve health and quality of life.

Please follow the resource link below to view.

Promote Self-care

Signpost/Refer to:

Please follow this link for the weight management pathway.

Gloucestershire Healthy Lifestyles Service (HLS Glos) can also support individuals to change behaviours such as smoking cessation, weight management and increased activity.  Further information about HLS can be found here.

Exercise on referral (EOR) supports people with medical conditions (who are not normally active) to access a supported exercise programme (normally for 12 weeks) with the help of a specialist adviser. The majority of these take place in local leisure centres and community venues.

Please follow this link for schemes and referral guidance.

Please signpost patients to local support groups and the Healthy Lifestyles Service.

Please follow this link for information on the Healthy Lifestyle Service, including referral and patient information leaflets.

Encourage attendance at Diabetes, Food and You or referral for 1-1 support as per referral criteria with diabetes specialist dietitian (see below).  Please also refer to the local dietary position statement.

Please see the Patient and Carer Information and Leaflets section on the Diabetes UK website.

Gloucestershire's Community Wellbeing (Social Prescribing) Hubs offer primary care health professionals a structured way of linking identified patients with support in their community. The aim is to encourage patients to access organisations and community groups, which can support patient’s wellbeing. These opportunities may include arts, creativity, physical activity, learning new skills, volunteering, mutual aid, befriending and self-help, as well as support with other matters such as employment, benefits, housing, debt, legal advice, or parenting problems. The co-ordinators use a strength based approach and offer one to one support as well as signposting.

Please follow this link for further information

Prescribing Guidelines for Type 2 Diabetes

Prescribe glucose lowering medications if there is inadequately improved hyperglycemia with lifestyle modifications.

  • Metformin is the first-line drug of choice for type 2 diabetes. Please ensure renal function has been checked and appropriate for dosing.
    • Initial dosing is 500 mg twice daily or 850 mg once daily.
    • Increase dose by 500 mg/day weekly or 850 mg/day every other week.
    • Maximum suggested dose is 1 g twice daily or 850 mg 3 times daily.  If not tolerated due to side effects try to prescribe Metformin MR same initiation 500mg daily for 2/52. 1g daily for 2/52 and 2g to continue.

Refer to Glos Formulary and/or NICE Guidance Algorithm.  NICE guidance 28 resources/algorithm for blood glucose lowering therapy in adults with type 2 diabetes.

Refer to Glos Formulary and/or NICE Guidance Algorithm.  NICE guidance (NG28) resources/algorithm for blood glucose lowering therapy in adults with type 2 diabetes.

Refer to NICE Guidance and/or Glos Joint Formulary drug information for diabetes including;

  • Oral anti-diabetic drugs
  • Insulins
  • Diabetic ketoacidosis
  • Treatment of hypoglycaemia
  • Treatment of diabetic nephropathy and neuropathy
  • Diagnostic and monitoring agents for diabetes mellitus

See NICE Guidance.

The preferred basal insulin recommended by NICE is human NPH (Neutral Protamine Hagedorn) insulin. Long-acting insulin analogues are recommended by NICE only in specific patient circumstances (see below). However, for most people with type 2 diabetes, long-acting insulin analogues offer no significant clinical advantage over human NPH insulin and are much more expensive.

The following guidance has been produced as part of the national NHS QIPP programme to address the appropriate use of insulin in patients with type 2 diabetes.

Choose Human NPH insulin for type 2 diabetics requiring insulin

  • Initiation of insulin in these patients occurs after failure of appropriate oral or non-insulin injectable therapy.
  • The majority of patients will be obese with high blood glucose levels on waking which are similar throughout the day. If this is the case, patients should be started on night time (basal) human NPH insulin (Humulin I® or Insuman® Basal or Insulatard®)
  • If blood glucose levels rise throughout the day despite maximum oral therapy, or use of a basal insulin, then consider either:
    • Twice daily biphasic non-analogue insulin should be started (e.g. Humulin M3®, Insuman® Comb 25)
      OR
    • A basal bolus scheme (e.g. Insuman® Basal, Humulin I® or Insulatard® PLUS Insuman® Rapid or Humulin S® with meals) depending on patient’s preference.

Consider switching type 2 diabetics with poor control on analogue insulin to Human NPH insulin

For those patients already on analogue insulins whose control is poor (HbA1c persistently ≥ 74mmol/mol), switch to human insulins especially if on disposable regimes; see above for examples

Use analogue insulin in type 2 diabetic patients appropriately

Insulin analogues should only be considered in the following circumstances:

  • The patient is reliant on a professional to inject insulin, and use of a long-acting insulin analogue (abasaglar, insulin detemir, insulin glargine) would reduce the frequency of injections from twice to once daily
  • The person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic
  • Patients who cannot use the device needed to inject human NPH insulin

When an insulin analogue is indicated, Abasaglar should be considered as the first choice, with (detemir) an option for any patients not well controlled on glargine.

Initial Annual Review

Annual review - 8 Care Process

Every year all type 2 diabetic patients should have the following assessments:

Generally recommended targets in adults with type 2 diabetes are HbA1c <53mmol/mol in most non-pregnant adults and <42mmol/mol in pregnant women with pre-existing diabetes, though less stringent goals may also be appropriate for people with moderate or severe frailty.

In adults with type 2 diabetes, a blood pressure of <130/8-mm Hg or <140/90 mm Hg

In adults with type 2 diabetes targets are low-density lipoprotein (LDL) cholesterol <100mg/dL (2.6mmol/L)

An annual foot and leg check should take place. If any problems are identified please follow the diabetic footcare pathway.

Please see the Patient and Carer Information and Leaflets section for the Diabetes UK Footcare leaflet.

A random urine specimen can be collected to send for  Urine ACR (albumen creatinine ratio).  Any patient with a raised level should have two urine specimens collected as first urine specimens in the morning.  All patients with raised ACR should be initiated on ACE inhibitors or equivalent.

All patients should have at least an annual renal function assessment using eGFR to ensure appropriate dosaging of medications.  If there is a deterioration then consideration of referral to the renal team to evaluate this further should be made.

Consider onward referral to weight management service as appropriate. 

Consider education and onward referral to smoking cessation if appropriate.

Other info

This service is provided by NHS England Screening Board.

Diabetic Retinopathy affects sight by damaging the small blood vessels at the back of the eye. Diabetic Retinopathy progresses with time but may not cause symptoms until it is advanced.

Screening for diabetic retinopathy should occur soon after diagnosis ad then when invited by the Screening Programme to allow early detection and management of any problems.

Practices are aware that diabetic patients being referred and then screened in the diabetic eye clinic on an annual basis forms 1 of 9 care processes for people with diabetes, against which the practice is monitored as part of the National Diabetes Audit and forms part of the Community Enhanced Service.

For children over the age of 12 annual screening should be arranged by the GP. Screening for diabetic retinopathy should occur annually to allow early detection and management of any problems.

The GHT website page for Diabetic Screening can be accessed here.

Notifications:

Practice Diabetic Leads should:

  • Ensure that all new patients newly diagnosed with Diabetes Mellitus (DM) and patients with DM newly registered at the surgery are notified to Gloucestershire Diabetic Eye Screening Programme (GDESP) within 1 month of diagnosis of DM or registration at practice.
  • Ensure that changes to patient information (moved out of area, change of address etc) are notified to GDESP within 1 month.
  • Submit a full register of patients diagnosed with DM to GDES bi-annually.

Eligibility for Screening:
GDESP will invite the following patients for screening:

  • Patients with a definite diagnosis of DM (Type 1 or Type 2)
  • Patients who are 'diabetes resolved' where there has been a previous definite diagnosis of DM
  • Patients with steroid-induced DM

GDESP will not invite the following patients for screening:

  • Patients with gestational diabetes
  • People with Pre-diabetes or Non diabetic Hyperglycaemia
  • Patients who have Impaired Glucose Tolerance (not in Diabetes range)
  • Patients who have never had diabetes and were coded in error

Invitation to Screening:

  • When notification of a new patient is recieved, GDESP will register the patient and invite them to attend for diabetic eye screening at an appropriate clinic.
  • If a phone call is received from a patient requesting an appointment before notification has been received of their diagnosis, GDESP will contact the patient's surgery to confirm diagnosis before an appointment is made.
  • Any patients requesting to be excluded from screening as medically unfit or not diabetic will require signed consent from a GP or the Clinical Lead at GDESP. Any such requests will only be actioned by GDESP if accompanied by a GP signature and GMC registration number.

Please follow this link to the NHS  website for further information on Diabetic eye screening.

Please see the Patient and Carer Information and Leaflets section for the NHS Website leaflet on diabetic eye screening.

Please see the Pregnancy and Diabetes section below for full details.

Please see the Patient Information Leaflet section for GHFT's Sick Day Rules leaflet.
Pregnancy and Diabetes

The majority of women with diabetes who become pregnant give birth to healthy babies, BUT, diabetes increases the risk of complications both for the baby and the mother especially if the HbA1c is elevated. The chance of miscarriage is higher and the chance of the baby having a birth defect is doubled.

Effective care before pregnancy improves pregnancy outcomes in women with diabetes The National Institute for Health and Clinical Excellence (NICE) lists preconception care as a ‘key priority’ to improving pregnancy outcomes in women with diabetes. Contraception should be considered for all diabetic females in order to decrease risk of accidental pregnancy. Please consider contraception and type of contraception with your patient and her partner.

Planning Pregnancy - First Steps

All diabetic patients considering pregnancy MUST be referred to the Specialist Diabetes Team at both Cheltenham General or Gloucestershire Royal Hospitals using this form.

Patients can self-refer by calling 03004224266 or emailing: ghn-tr.diabetespregnancy@nhs.net

The below guideline is for GPs to support their patients alongside secondary care, not instead of secondary care.

Blood Glucose should be checked at home, NICE recommends targets of less than 5.3mmol/L before food and 6.4mmol/L 2 hour post food and less than 7.8 1 hour post food.

Healthy Eating is essential for good growth. A Dietitian will be able to provide you with specific dietary advice to help maintain your blood glucose levels and this can be accessed via the specialist secondary care team.

If patients are overweight it is recommended that they try and reduce their weight prior to pregnancy to increase chances of becoming pregnant and having a healthy pregnancy.  Gloucestershire Healthy Lifestyles Service (HLS Glos) can also support individuals to change behaviours such as smoking cessation, weight management, increased activity.  Further information about the Healthy Lifestyles Service can be found here.

All patients should be advised to stop smoking before becoming pregnant. To get help with this patients can phone the free NHS smoking helpline 0300 123 1044, visit www.smokefree.nhs.uk or refer to the Healthy Lifestyle Service

Reduce Alcohol, although it is recommended that diabetic women trying to conceive should stop drinking before and during pregnancy. Consider referral/signpost patient to the Healthy Lifestyle Service.

Ensure your patient is up to date with Rubella vaccinations.

Start 5mg Folic Acid. This is only available on prescription. Ideally this needs to be taken 3 months before conception. This will help reduce the risk of Neural Tube Defects (NFD) such as Spina Bifida.

Planning Pregnancy - Nearly Ready

  • Continue with contraception.
  • Continue with Folic Acid 5mg
  • Review all diabetes medication. Some medications may need to be stopped or changed to an alternative. This should be done by the Specialist Diabetes Team, but if your patient is not engaging this may need your facilitation. The Specialist Diabetes Team are happy to liaise with you in this instance

  • Patients’ blood glucose should be ideally 4-5.3mmols/L pre meals and 4-7.8mmols/L one hour post food
  • HbA1c should be less than 48mmols/L (6.5%) Having an elevated HbA1c above 64mmols/L increases the risk of miscarriage, malformations of the heart, limbs, spine and other organs. 

  • Retinal (eye) screening and Kidney checks (blood and urine specimens) should be up to date due to risk of deterioration in pregnancy. They may need reviewing prior to conception and advised accordingly.

Going for it! 

HbA1c less than 48mmols/L and hypo free

Blood glucose levels 4-6.4mmols/L and testing at least 4 x a day and relevant to driving.

Continue with Folic Acid 5mg

Patients should be under the Specialist Diabetes Team prior to conceiving where possible

Your patient is now in the best condition to conceive

Pregnant

As a matter of urgency, once you are aware a patient is pregnant, if you haven’t already done so please inform the Specialist Diabetes Team within secondary care. 

ghn-tr.diabetespregnancy@nhs.net

0300 422 4266 (answerphone)

Diet.diabetes@glos.nhs.uk

0300 422 4094 (answerphone)

Type 2 Diabetes in Younger Patients

Due to increasing levels of obesity and inactive lifestyles improved identification and diagnosis of hyperglycaemia, we are diagnosing people with diabetes at a younger age than historically. This diagnosis is of Type 2 diabetes as patients do not present with typical Type 1 diabetes.

There are multiple causes of hyperglycaemia and we must endeavour to define the specific cause of this process for individual patients. 

In young persons the predominant pathology is autoimmune Type 1 Diabetes Mellitus but we must also consider; Latent Autoimmune Diabetes of the Adult (LADA) a slower developing autoimmune disease and Maturity Onset Diabetes of the Young (MODY), the genetic condition.

Endocrine disorders such as Cushing Disease and Acromegaly must also be considered as well as drug Induced Hyperglycaemia. This can present during or after treatment with drugs e.g. high dose prednisone or dexamethasone. 

Pancreatic disease can be associated with hyperglycaemia, either as trauma, alcohol related, malignancy or infection. These should be considered should the individual not appear to be responding to conventional treatments 

People diagnosed at an early age with diabetes will have many years of living and managing their condition. Because of this they are likely to experience both physical problems, with high risk of micro and macrovascular complications and psychological problems as a result of dealing with the diagnosis throughout their lives.

Young women are likely to have their pregnancies whilst having the condition leading to potential complications for both them and their unborn child. We must be proactive with pre and perinatal care and have early referral to secondary care.

For women with diabetes who are pregnant please fax the referral (to ensure it is seen immediately) and also send an e-mail to: ghn-tr.DiabetesPregnancy@nhs.net

We must ensure the correct diagnosis is given in a timely fashion. Throughout all management and treatment we must ensure education with the opportunity for ongoing refresher education in an attempt to prevent deterioration over the many years that they carry the condition.

Children under the age of 16 should be referred as soon as possible to secondary care Diabetes Paediatrics Team. There is active discussion whether people diagnosed at an early age (but over 16) should be offered their treatment in the secondary care setting due to the increased risks carried by this group; it remains with General Practice to manage these people, however, aggressive management of their symptoms and awareness of complications is imperative.  A low threshold for referral should be considered.

Unless we actively support this cohort of people there will be longer term issues that we as a health population will struggle to deal with.

Complications associated with diabetes

Complications may include:

Further guidance on complications can be accessed on the Diabetes UK website.

Type 2 diabetes and frailty

There is increasing evidence regarding the relative risks and benefits of treatment of diabetes in frail people. This evidence is currently not reflected strongly in either NICE Guidance (CG87 - 2014), where frailty fails to receive a mention, or in the QOF targets. Frail people with diabetes are at marked increase in risk of adverse effects of treatments including hospital admission, and are less likely to benefit from the long-term benefits of good glycaemic control. There is therefore a need for local guidance on achieving a balance in controlling both blood pressure and glycaemia in this context.

Frailty is essentially the loss of reserve resulting in a greater vulnerability to insults. It is generally associated with multi-morbidity and often seen in terms of dependency. There is no simple test to define frailty, however frailty may be suspected wherever the person is ‘slowing up’ e.g. takes more than 5 seconds to walk 4 metres.

Frailty should also be considered likely in the following contexts:

  • Requiring daily help with activities of daily living
  • Living in a Care Home
  • Having recurrent accidental falls
  • Recurrent emergency presentations to hospital
  • Moderate degree of dementia

It is present in around 50% of all those aged over 85 years.

Use the Rockwood Scale (below) during assessment

Currently in Gloucestershire, the degree of frailty may be judged using the Rockwood Clinical Frailty Scale (See below). This assesses the amount of help required in activities of daily living (ADL) i.e. those with frailty score of 5 cannot leave the house alone; at 6 or above they require help in personal ADL; those with frailty of 8 or 9 require total care and are likely to be in the last year of life.

  • ​Patients with life expectancy less than 5 years are unlikely to gain microvascular benefits from good glycaemic control or good blood pressure control (average life expectancy at 85 in Glos is 6 years, 25th centile 9 years, 75th centile 3 years). Frailty is a strong determinant of life expectancy. A use of the local CCG Frailty Guidelines is strongly recommended – see the Frailty section for further info.
  • Aims of treatment in the context of frailty should be:

             a. To avoid hypoglycaemia

             b. To control symptoms

             c. To reduce risk of infection

             d. To avoid hospital admission

             e. To introduce timely end-of-life care

  • Changes in medication and treatment should be discussed with the patient and their carer. The reasons for changes need to be understood in terms of increased risk of therapy and/or low likelihood of benefit.
  • It is important to respond to falling HbA1C or losing weight by reviewing and reducing diabetic treatments. Too often, primary care views these as desirable targets and no remedial action is taken until an admission with hypoglycaemia occurs.
  • The new diagnosis of Type 2 diabetes after the age of 80-85 years carries little if any impact on life expectancy. Again the emphasis will be entirely on avoidance of symptoms. There is no benefit in screening for diabetes beyond the age of 80.

Level of frailty Therapeutic target Suggested actions

Rockwood 1-5

Generally able
  • HbA1c 54-59
  • BP 150/90

Appropriate to use third line agents

Reassess if worsening frailty

Rockwood 5-6

Modest frailty
  • Control of symptoms
  • HbA1c 60–85
  • BP 150/90 and no postural drop

Caution with metformin

Do not use third line agents unless to control symptoms

Do not restrict diet if low weight or losing weight

Rockwood 7-9

Severe frailty
  • Symptom control
  • Avoid hypos
  • HbA1C only to identify risk of hypos (>65)
  • Usually no BP Rx

Reduce treatment

Symptomatic drugs only – stop other drugs e.g. statins, BP

Stop metformin if e-GFR worsening

Consider stopping sulphonlyurea or insulin

Watch for falling weight

There will be situations where short-term good glycaemic control is advantageous – during severe sepsis, a myocardial infarct, or post-operatively. The figures below show the range of pre-meal glucose to minimise the risk of symptoms related to high and low blood sugar.

There is a heightened risk of hypoglycaemia in the following situations:

  • Patients with dementia
  • Patients on insulin and/or sulphonylurea therapy
  • Long-standing Type 1 diabetes
  • Deteriorating renal function or heart failure
  • Dependency on carers for meals

Level of frailty Modest risk of hypoglycaemia High risk of hypoglycaemia
Rockwood 1-5 Range 4 - 11 mmol/l Range 8 – 15 mmol/l
Rockwood 5-6 Range 8 – 15 mmol/l Range 10 – 20 mmol/l
Rockwood 7-9 Range 8 – 20 mmol/l Range 10 – 20 mmol/l

Basal/bolus regimes are generally reserved for those seeking to achieve good glycaemic control to prevent long-term adverse outcomes. This would not be used when frailty is identified, unless a regime is very well established and tolerated.

Whenever there is concern about the patient’s ability to reliably administer their own insulin in the context of frailty e.g. dementia, an admission with hypoglycaemia or failing eyesight, use of a once daily regime with long-acting insulin should be preferred. This also is more manageable by a visiting healthcare professional.

Longstanding Type 1 or insulin-treated Type 2 may still require twice daily insulin to avoid symptoms.

Those with diabetes approaching end-of-life have a unique set of care needs relating to their diabetes. The goals of management will often shift and focus more on minimising adverse effects of both the diabetes but also the treatment, such as risk of inducing hypoglycaemia if medication continues where appetite reduces. It is important to regularly review goals of care, including patients and carers in discussion around the options for management and if appropriate encouraging a shift in focus towards comfort measures and relaxation of the tight protocols around diet, sugar monitoring/control etc.

                                             

Guideline Info - Review date: December 2016 

Authors
Dr Alison Evans: Clinical Lead Diabetologist – GHNHSFT
Dr Ian Donald: Consultant in General Older Age Medicine - GHNHSFT
Dr Rob Estelrich: GPSI in Diabetes – GCS Community Diabetes Team
Dr Caroline Bennett: GCCG GP & Chair of Diabetes & Endocrinology Clinical Programme Group

Please also see theClinician Education section to view a selection of podcasts by Dr Le Roux and Dr Donald on Diabetes and Frailty.

When to Refer / Services

Please follow this link to the referral form.

The community diabetes specialist service supports people with type 2 diabetes to manage their condition effectively and to the best of their ability.  The team consists of 5 x Diabetes Specialist Nurses,  2  x Diabetes Specialist Dietitians and 2 x Diabetes Educators

The team provide community clinics in various venues throughout Gloucestershire, home visits to the housebound or nursing home patients and they will see patients at their own surgeries when appropriate.

Diabetes Dietitians provide consultations Countywide in community clinics, GP surgeries and home visits for housebound patients only.

Exclusion Criteria:

  • Type 1 Diabetes
  • Significant/unstable renal disease
  • Patient under diabetes consultant care
  • Progressive retinal disease or maculopathy

Community Diabetes Dietitians Inclusion Criteria:

  • Type 2 Diabetes with HbA1c above 58mmol/mol and BMI above 25kg/m²(or over 23kg/m² if South Asian or African-Caribbean) if not suitable for group education)
  • Patients requesting dietary advice for raised lipid levels who have an HbA1C above 58mmol/mol
  • HbA1c above 58mmol/mol) with BMI below 19kg/m²
  • Patients who are starting / have started GLP-1 or Insulin therapy.
  • Any patients with Type 2 Diabetes considering Orlistat.
  • Patients who have an HbA1c over 58mmol/mol and wish to follow specific diets; e.g. Low Carbohydrate, 5:2, Atkins and would like more support. (please specify type of diet patient wishes to consider on referral)
  • Patients with Type 2 Diabetes and HbA1c above 58mmol/mol who are diagnosed with other conditions which are affected by diet (eg; IBS, Coeliac Disease, Cardiovascular Disease, Renal Disease) who require support and are not already receiving dietetic care.

Types of patients we will see:

  • Hyperglycaemia on maximally tolerated oral therapies
  • Medically complex patient with T2DM needing rationalisation of diabetes therapy, following discussion with CDS and GPwSI
  • Assessment for Insulin therapy
  • Assessment for GLP1 Agonist therapy
  • Insulin therapy review for patients with poor glycaemic control (hypo/hyper)
  • Structured education for newly diagnosed patients with Type 2 Diabetes to Diabetes & You.
  • For dietary support only refer to Diabetes, Food & You or for one to one support with the dietitian as per referral criteria below.
  • For patients recently started on insulin please refer to Diabetes, Insulin & You.
  • Self-referral is encouraged to all structured education by using the self-referral leaflet/form.
  • Unexplained / recurrent hypoglycaemia
  • Patients with enteral feeding with poor glycaemic control
  • Care/nursing home patients that meet any of the above criteria

Discharge from CDS to Primary Care Management

  • Inappropriate referral – does not meet any of the criteria above
  • Improvement in diabetes control with reduction of at least 7 mmol/mol, discharged from CDS back to GP with management plan
  • No improvement in control despite maximal intervention after six months
  • Patients who are clinically stable with suboptimal control where aggressive therapy is not indicated
  • Patients who do not engage / recurrent non attendees

The Community Diabetes Service also offer education sessions including 3 self-referral patient sessions; 'Diabetes and You', 'Diabetes, Food and You' and 'Diabetes, Insulin and You'. Please follow this link to the patient information / self-referral leaflet or alternatively this link to the education referral form.

Any patients who have a BMI over 40kg/m² and Diabetes who want to lose weight should be offered the opportunity to be referred to the Specialist Weight Management Service (SWMS) at Beacon House, Gloucester Royal Hospital by their GP. 

Please follow this link to the Community Diabetes Service Referral form.

If patients don’t meet the service criteria but need additional assistance please see the Obesity pathway and the Healthy Lifestyles Service information where patients can be referred to Slimming World or signposted for one to one support with HLS.

Please follow this link to the referral form

Referral Guidelines

Please refer to the guidance below prior to referring to GHFT's Specialist Diabetes service

Indications for Referral

  • Assessment/management of those on Insulin Pump Therapy
  • Specialist diabetic footcare

Exclusion Criteria:

  • Not registered with a Gloucestershire GP
  • Stable/non-complex T2
  • Type 1 diabetes for: 1)children (incl. transition) and 2) those with poor blood glucose control
  • Specialist nephropathy (incl. those on dialysis)
  • Specialist antenatal diabetes care (women with diabetes contemplating pregnancy)
  • Other reason for referral – e.g. significant or worsening complications requiring acute/specialist input (please provide information below)

Contact Details

GRH fax number: 0300 422 8604
GRH telephone number: 0300 422 8606

CGH fax number: 0300 422 2570
CGH telephone number: 0300 422 3680

Please follow this link for the Annual Diabetic Foot Assessment Pathway

Diabetes Enhanced Service 2019/2020 – CCG

Please follow the resource link below to the 2019/20 Diabetes Enhanced service spec.

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