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Type 2 Diabetes Mellitus in Adults
A GUIDE FOR BROMLEY GENERAL PRACTICE
1. Lifestyle measures : reduce weight, increase exercise, reduce alcohol, healthy diet, stop smoking
2. Blood pressure : target BP ≤140/80mmHg (adjust for age and comorbidities)
3. Cholesterol : statin if QRISK2/ 3 ≥ 10% or history of CVD
4. Optimise HbA1c (adjust depending on hypoglycaemic risk and frailty)
5. Maximise dose of metformin to 1g BD if possible
November 2021 , review date June 2022
Risk factors
Symptoms and signs
Diagnostic results Red flags
HbA1c management
Hypertension
Cholesterol
Diabetic Kidney Disease
(urine ACR & eGFR)
Diabetic Foot Disease
Smoking
BMI
Retinal Screening
T2DM Review Planning
Diagnosing T2DM and non-diabetic Nine Care Processes
hyperglycaemia (prediabetes)
Dietary advice
Advice for Patients
Personalised Care
Goal setting
Hypoglycaemia
Sick Day Rules
Bromley T2DM Network Click on a box to go to the relevant section
Professional resources
Professional resources
Patient Resources
New diagnosis of
non-diabetic
hyperglycaemia, NDH
(prediabetes)
New diagnosis of
T2DM
Community Diabetes Centre
COVID- 19
Blood result
interpretation
CCB, thiazide-like
diuretic,
spironolactone,
alpha and beta
blockers, statin
Biguanide,
sulfonylurea, ACEI,
ARB
Preferred Medication
Pregnancy &
Preconception
Advanced Primary
Care Practice
- 1 Bromley Guide for Type 2 Diabetes Mellitus in Adults
- 1.1 Why is type 2 diabetes mellitus (T2DM) important in Bromley?
- 1.2 Diagnosing T2DM and non-diabetic hyperglycaemia (prediabetes)
- 1.2.1 Risk factors for T2DM.....................................................................................................................................................................................................
- 1.2.2 Symptoms and signs of T2DM
- 1.2.3 Diagnostic results for HbA1c and glucose measurements
- 1.2.4 Blood Result Interpretation
- 1.2.5 Red flags at diagnosis (atypical presentations)
- 1.3 Actions following diagnosis of non-diabetic hyperglycaemia and T2DM
- 1.3.1 New diagnosis of non-diabetic hyperglycaemia, NDH (prediabetes)
- 1.3.2 New diagnosis of T2DM
- 1.3.3 Patient Resource: Diabetes UK
- 1.4 Routine Care in T2DM: Nine Care Processes
- 1.5 Why is glycaemic control important?
- 1.5.1 Macrovascular complications
- 1.5.2 Microvascular complications
- 1.5.3 Foot disease
- 1.5.4 Metabolic
- 1.5.5 Erectile dysfunction
- 1.5.6 Psychosocial
- 1.6 HbA1c management
- 1.7 Diagnosing Hypertension
- 1.7.1 Measuring blood pressure
- 1.7.2 BP thresholds for initiating antihypertensives in patients with T2DM
- 1.8 Hypertension Management
- 1.8.1 Antihypertensive medications – stepwise
- 1.8.2 Blood pressure targets for hypertension management in diabetes
- 1.9 Lipid Management
- 1.9.1 Cardiovascular risk assessment
- 1.9.2 Cardiovascular risk management
- 1.9.3 Primary prevention of cardiovascular disease.............................................................................................................................................................
- 1.9.4 Secondary prevention of cardiovascular disease
- 1.9.5 Referral to Lipid Clinic
- 10 Diagnosing and Managing Diabetic Kidney Disease: eGFR and Urine Albumin/Creatinine Ratio
- 1.10.1 What is diabetic kidney disease and why is it important?
- 1.10.2 Diagnosing chronic kidney disease (CKD)
- 1.10.3 Managing diabetic kidney disease
- 1.10.4 Referral to Renal Clinic (SEL Nephrology Service)
- 1.11 Diabetic Foot Disease: Risk Stratification and Management
- 1.11.1 Why is diabetic foot disease important?
- 1.11.2 Diabetic foot checks
- 1.11.3 When to refer...............................................................................................................................................................................................................
- 1.11.4 Patient resources
- 1.11.5 Professional resources
- 1.12 Diabetic Foot Disease: Risk Stratification and Management – Traffic Light System
- 1.13 BMI - Weight Management
- 1.13.1 Advice on physical activity
- 1.13.2 Weight management options
- 1.14 Smoking cessation
- 1.14.1 “Very Brief Advice” for smoking cessation
- 1.14.2 Practice cessation services...........................................................................................................................................................................................
- 1.14.3 Stop Smoking London
- 1.15 Diabetic Eye Screening (Retinal Screening)
- 1.15.1 Referral to retinal screening
- 1.15.2 Results of screening visit
- 1.15.3 Patients who do not attend
- 1.16 T2DM Review Planning and Tasks
- 1.17 Diabetes Review: Advice for Patients
- 1.17.1 Dietary advice
- 1.17.2 Goal setting
- 1.17.3 Personalised Care.........................................................................................................................................................................................................
- 1.17.4 Hypoglycaemia
- 1.18 Diabetes Review: Advice for Patients - Sick Day Rules
- 1.19 Diabetes, Preconception & Pregnancy - 1.19.1 Preconception planning and care for patients with diabetes - 1.19.2 Pregnant and diabetic - 1.19.3 Gestational diabetes
- 1.20 T2DM: Preferred Medication (biguanide, sulfonylurea, ACEI, ARB)
- 1.21 T2DM: Preferred Medication (CCB, thiazide, spironolactone, alpha and beta blockers, statin)
- 2 Educational Resources
- 2.1 Professional resources
- 2.2 Patient resources
- 3 Bromley Clinical Support
- 3.1 Community Diabetes Centre........................................................................................................................................................
- 4 T2DM and COVID-
- 5 Advanced Primary Care Practice
- 5.1 Advanced Primary Care Practices (APCPs) in Bromley
- 5.1.1 What is an Advanced Primary Care Practice (APCP)?
- 5.1.2 What courses are needed for APCP healthcare professionals?
- 5.1.3 Key Performance Indicators (KPIs)...............................................................................................................................................................................
- 5.1.4 Practice and Patient Benefits
- 6 Abbreviations...................................................................................................................................................
- 7 References
- 8 Acknowledgements
1 Bromley Guide for Type 2 Diabetes Mellitus in Adults 1.1 Why is type 2 diabetes mellitus (T2DM) important in Bromley? T2DM is common There are over 17,000 adults living with diabetes in Bromley. T2DM is underdiagnosed QOF prevalence data shows that T2DM in Bromley was underdiagnosed in 2019- 2020. This is likely to be a greater issue following COVID-19 (60,000 missed or delayed diagnoses of T2DM across the UK between March and December 2020).^1 ,^2 T2DM is a risk factor for mortality with COVID- 19 23,698 people with COVID-19 died in hospital in England up to 11th May 2020 and 31% of these people had T2DM. 3 T2DM is preventable and treatable Management of non-diabetic hyperglycaemia and risk factors can reduce the risk of developing T2DM. Primary care intervention with weight management, glycaemic control, lipid lowering, blood pressure control and smoking cessation reduces complications, morbidity and mortality for patients with T2DM.^4 ,^5 ,^6 ,^7 ,^8 There is scope to enhance patient care in Bromley Bromley can improve care by better addressing all Care Processes as measured by the National Diabetes Audit. Urine albumin:creatinine ratio measurement and foot checks offer the greatest scope for improvement.
- 2019/ 2020 51 % T2DM patients had all 8 Care Processes checked 9
- 2020/ 2021 23 % T2DM patients had all 8 Care Processes checked 10
Diagnosing T2DM and non-diabetic hyperglycaemia (prediabetes) continued
1.2.4 Blood Result Interpretation
- If initial result is within the diagnostic range, repeat the same test, as soon as possible - do not delay (it is good practice to repeat the test even if symptomatic).
- If repeat test is normal, monitor regularly for development of diabetes (use clinical judgement to decide on frequency of monitoring).
- Transient severe hyperglycaemia can occur with acute infection, trauma, circulatory or other stress and is not diagnostic of T2DM in these scenarios.
- HbA1c should be used with caution in conditions with abnormal red blood cell turnover/abnormal haemoglobin type (including haemoglobinopathy, severe anaemia, altered red cell life-span e.g. post-splenectomy, recent blood transfusion, chronic kidney disease).
- HbA1c may underestimate hyperglycaemia in the following conditions and other tests should be considered for diagnosis: pregnancy, symptoms <2months, <18 years, end-stage renal disease, HIV infection and acute pancreatic damage.
1.2.5 Red flags at diagnosis (atypical presentations)
New diabetes and unexplained weight loss or HbA1c >85mmol/mol Consider type 1 diabetes, ketosis-prone T2DM, latent autoimmune diabetes in adults (LADA) or other diabetes types. Seek specialist advice. New diabetes and unexplained weight loss and >60 years Consider 2 week wait referral to Upper GI for suspected cancer of pancreas. 16
1.3 Actions following diagnosis of non-diabetic hyperglycaemia and T2DM
1.3.1 New diagnosis of non-diabetic hyperglycaemia, NDH (prediabetes)
Offer structured education, covering nutritional and physical activity support, with strategies and tools to help make change. Offer annual review to include: HbA1c + the Vital 5 : BP, BMI, smoking status, mental health and alcohol intake.
1.3.2 New diagnosis of T2DM
Support patients to reach an understanding of the diagnosis, implications and what they can do to care for themselves. Emphasise to patients and carers that structured education is integral to their care. Offer referral to a Structured Education Programme (QOF: within 9 months of diagnosis). Monitor annually and manage as per all 9 Care Processes : ➢ HbA1C, BP, cholesterol, urine ACR, foot check, smoking status, BMI, eGFR (serum creatinine), retinopathy screen. Emphasise the importance of managing the 9 Care Processes and how this can reduce the risk of diabetes complications. ➢ Use Diabetes UK Information Prescriptions to support personal care (can be downloaded into EMIS). Agree a clear review date.
1.3.3 Patient Resource: Diabetes UK
Diabetes UK www.diabetes.org.uk is a national charity which provides information, support, and advocacy for people with diabetes and their families. Has a confidential helpline. Hosts an online community for peer support. Has a wide range of education and information patient resources. Code as ‘non-diabetic hyperglycaemia’ REFER ROP - Diabetic Medicine / Referrals DESMOND Patients can self-refer to DESMOND or other structured education but self-referral does not count towards QOF: diabetesbooking.co.uk T2DM courses Code as ‘type 2 diabetes mellitus’
REFER
ROP - Diabetic Medicine / Referrals Walking Away from Diabetes 2 sessions over 1 month: online and telephone National Diabetes Prevention Programme 13 sessions over 12+ months: online and telephone
1.5 Why is glycaemic control important? 24 Persistent hyperglycaemia leads to several serious complications and reduced life expectancy. Risk is reduced with good glucose control and this should be emphasised to patients.
1.5.1 Macrovascular complications
Atherosclerotic cardiovascular disease Myocardial infarction Stroke Peripheral arterial disease Heart failure
1.5.2 Microvascular complications
Diabetic kidney disease Retinopathy Autonomic neuropathy Peripheral neuropathy
1.5.3 Foot disease
Ulcers Charcot arthropathy Osteomyelitis Deep tissue infection Lower limb ischaemia and amputation Sepsis
1.5.4 Metabolic
Diabetic ketoacidosis Hyperosmolar hyperglycaemic state Dyslipidaemia
1.5.5 Erectile dysfunction
Proactively ask about this and explore with patient.
1.5.6 Psychosocial
Anxiety Depression Decreased QoL
1.6 HbA1c management See SEL Type 2 Diabetes Blood Glucose Control Pathway https://selondonccg.nhs.uk/download/11604/ for detailed guidance. 25 See Section 1.201.20 - Preferred Medication (biguanide, sulfonylurea, ACEI, ARB).
STEP 1: Person-centred lifestyle changes
Review after 3 months, if HbA1c ≥ 48mmol/mol (6. 5 %)*, go to Step 2. See Section 1.17 Advice for Patients.
STEP 2: Metformin standard release to maximum achievable dose
Start metformin 500mg OD with/after food & increase by 500mg every 2 weeks until 1g BD if achievable (modified release if GI side-effects). Review 3 months from dose change, if HbA1c ≥ 58mmol/mol (7.5%) go to step 3. Criteria On maximum achievable dose of metformin On medication with risk of hypoglycaemia, e.g. sulfonylurea Moderate or severe frailty HbA1c target* ≤ 48mmol/mol (6.5%) ≤ 53mmol/mol (7%) ≤75 mmol/mol (9%)
STEP 3: Gliclazide as 2 nd-line (1st^ intensification) – guidance under review
Gliclazide dose 40mg-80mg OD to BD with meals. Titrate on pre-meal blood glucose target 4 - 6mmol/l or individualised BM target or HbA1c. Avoid in severe liver dysfunction and only prescribe under specialist advice if eGFR<30ml/min. Use with care if eGFR 30 – 60ml/min. Consider alternative to gliclazide, especially if BMI>35, frail elderly or concern regarding hypoglycaemia e.g. Group 2 driver.^26 Alternatives may include: gliptins, SGLT-2 and pioglitazone – check for contraindications. Review after 3 months - if HbA1c ≥ 58mmol/mol (7.5%)* go to step 4.
STEP 4: Third agent needed, considering insulin or contra-indications to metformin or gliclazide? (2nd^ intensification)
See SEL T2DM Blood Glucose Control Pathway https://selondonccg.nhs.uk/download/11604/ for guidance. Specialist advice can be obtained by referring to the Community Diabetes Centre.
Additional considerations
*Individualise targets and goals. The QOF target for patients with moderate or severe frailty is ≤75 mmol/mol (9%). Rescue therapy: if blood glucose is very high and/or symptomatically hyperglycaemic, seek specialist advice to consider a regime for rapid reduction of blood glucose. Specialist advice is available from the Bromley Community Diabetes Centre (see Section 3.1 - Community Diabetes Centre). If a patient is not achieving their HbA1c target with the steps above:
- Reinforce lifestyle advice, including diet.
- Check adherence with antidiabetic drug treatment. If patient achieves a lower HbA1c than their target without hypoglycaemic effects:
- Encourage them to maintain it.
- Consider alternative reasons for low HbA1c, including deteriorating renal function and sudden weight loss.
- Review medication. REFER (Community Diabetes Centre) ROP - Diabetic Medicine/Referrals/BHC Diabetes Service Referral Form Community Diabetes Referral Form (Bromley Healthcare Diabetes Service)
1.8 Hypertension Management^19
1.8.1 Antihypertensive medications – stepwise
See SEL Hypertension Guidance for Primary Care: https://selondonccg.nhs.uk/download/11532/ BP review recommended at least annually, or more frequently when clinically indicated. Drugs to avoid at conception/in pregnancy include ACEI/ARB/thiazide or thiazide like diuretic (increased risk of congenital abnormalities). NICE advises: Stop ACEI/ARBs and change medication (preferably within 2 working days of notification of pregnancy). Offer alternatives: labetalol (if no CI e.g. asthma), nifedipine or methyldopa. Can remain on amlodipine if already prescribed. Target BP ≤ 135/85 mmHg. Offer aspirin 75 - 150mg OD from week 12 of pregnancy. 27 All patients with diabetes who are pregnant or contemplating pregnancy should be referred for specialist care: see Section 1.19 Diabetes, Preconception & Pregnancy. For black African/Caribbean family origin use ARB instead of ACEI (as increased risk of angioedema with ACEI in this patient group). ACEI or ARB ramipril/lisinopril or losartan ACEI or ARB + CCB or thiazide-type diuretic* ramipril/lisinopril or losartan + amlodipine or indapamide ramipril/lisinopril or losartan + amlodipine + indapamide Uncontrolled on optimal doses - regard as resistant hypertension. Repeat ABPM/HBPM, assess for postural hypotension, discuss adherence. If good renal function and potassium ≤4.5mmol/L, consider adding low dose spironolactone. If potassium > 4.5mmol/L +/- reduced renal function, consider alpha blocker (doxazosin) or beta-blocker (atenolol/bisoprolol) +/- seeking specialist advice.
1.8.2 Blood pressure targets for hypertension management in diabetes
QOF ≤140/80mmHg (excludes moderate or severe frailty) NICE: <80 years ≤140/90mmHg (clinic), ≤135/85mmHg (ABPM/HBPM) NICE: ≥ 80 years ≤150/90mmHg (clinic), ≤145/85mmHg (ABPM/HBPM) NICE: CKD 120 - 129 / 8 0mmHg
REFER
ROP - Cardiology/ Referrals/ Hypertension Outpatient review or Advice and Guidance Step 1 Step 3 Step 2 Step 4
1.9 Lipid Management^20
1.9.1 Cardiovascular risk assessment
Management of cardiovascular risk factors is essential to prevent and reduce macrovascular complications of diabetes.
- Perform baseline bloods (non-fasting lipid profile, LFT, TFT, HbA1c, renal function).
- Record weight, smoking status, BP.
- Calculate QRisk2/3 score except in CKD/albuminuria or familial hypercholesterolaemia.
1.9.2 Cardiovascular risk management
For all patients, consider education and lifestyle interventions to modify CVD risk and use shared-decision making to consider risk vs benefit of therapy. Initiate lipid lowering therapy according to the following two sections.
1.9.3 Primary prevention of cardiovascular disease
- If QRisk2/3 ≥10% or patient has CKD: start atorvastatin 20mg OD or rosuvastatin 10mg OD.
- Calculate baseline non-HDL level (total cholesterol minus HDL cholesterol) and again after 3 months. Refer to Lipid Management Pathway for South East London for more detailed guidance: https://selondonccg.nhs.uk/download/16002/ Non-HDL level Non-HDL decreased ≥40% from baseline Non-HDL not decreased ≥40% from baseline Action Review annually Check adherence to medication, dose timing, adverse effects/intolerance/hesitancy & diet/lifestyle interventions. Consider up-titration to maximum dose of statin (atorvastatin 80mg OD or rosuvastatin 20mg OD). If intolerant to higher dose, consider adding ezetimibe 10mg OD. If intolerant to any dose of statin, start ezetimibe 10mg OD and refer to Lipid Clinic. If still not achieving ≥40% reduction, refer to Lipid Clinic.
1.9.4 Secondary prevention of cardiovascular disease
- Offer daily, high dose, high intensity statin ( atorvastatin 40-80mg OD or rosuvastatin 20mg OD) if history of CVD (including MI, angina, stroke/TIA, peripheral vascular disease, abdominal aortic aneurysm).
- Calculate baseline non-HDL level (total cholesterol minus HDL cholesterol) and again after 3 months. Refer to Lipid Management Pathway for South East London for more detailed guidance: https://selondonccg.nhs.uk/download/16002/ Non-HDL level Decreased ≥40% from baseline Not decreased ≥40% from baseline Action Review annually Check adherence, dose timing, adverse effects/intolerance/hesitancy & diet/lifestyle interventions. Ensure on maximum tolerated dose of statin and consider adding ezetimibe 10mg OD and review in a further 3 months - if non-HDL has not decreased ≥40% from baseline, refer to Lipid Clinic. You can calculate QRisk2 using the EMIS QRisk2 Data Entry Template QRisk3 is an update of QRisk2 with new parameters and will be available on Emis in due course
1.10 Diagnosing and Managing Diabetic Kidney Disease: eGFR and Urine Albumin/Creatinine Ratio^28 ,^29
1.10.1 What is diabetic kidney disease and why is it important?
Diabetes is the commonest cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD).
- Microalbuminuria is usually the first sign of diabetic kidney disease.
- CKD is an independent risk factor for cardiovascular disease.
1.10.2 Diagnosing chronic kidney disease (CKD)
Annually:
- Request urine albumin: creatinine ratio (ACR) testing – early morning void wherever possible.
- If random urine ACR is raised, confirm result with early morning sample in case of a false positive result.
- Exclude UTI if ACR is raised.
- Measure serum creatinine to calculate eGFR (no meat for 12h before the test). Do not adjust eGFR for ethnicity as this is no longer recommended and may lead to underdiagnosis. Diagnose and treat chronic kidney disease if:
- Persistent* reduction in kidney function (eGFR<60 ml/min/1.73m^2 ) and/or
- Persistent* microalbuminuria (urine ACR ≥3mg/mmol). *For three months or more – repeat initial test after 3 month interval.
1.10.3 Managing diabetic kidney disease
- Aim for a systolic blood pressure of 120-129 mmHg and diastolic less than 80 mmHg.
- Start a low-cost ACEI/ARB even if normotensive (ramipril or losartan) or up-titrate existing dose to achieve the maximum tolerated dose, depending on contraindications, cautions, and drug interactions (see Section 1.20).
- Do not co-prescribe ACEI & ARB.
- Optimise blood glucose control.
- Advise on SICK DAY RULES (see Section 1.18).
- If not on a statin, offer atorvastatin 20mg once a day, irrespective of lipid profile.
- Provide patient education resources (see Diabetes UK: Diabetic nephropathy (kidney disease).
1.10.4 Referral to Renal Clinic (SEL Nephrology Service)
Referral criteria : eGFR<30ml/min, sustained decrease in eGFR of 15ml/min or 25% decrease, ACR≥30mg/ml with haematuria, ACR˃70mg/ml in spite of optimal diabetes management, poorly controlled hypertension with co-existing CKD 3-5, known or suspected rare/genetic cause of CKD, suspected renal artery stenosis.
REFER
ROP – Nephrology / Referrals For AKI: ROP – Acute / Referrals / Acute Referral Form Intervention can prevent/reduce progression of renal disease
1.11 Diabetic Foot Disease: Risk Stratification and Management
1.11.1 Why is diabetic foot disease important?
- Diabetic foot disease is a significant cause of disability and amputation.
- Early detection and intervention can prevent progression to severe disease.
1.11.2 Diabetic foot checks^30
Patient education and regular foot checks are the foundation of good diabetic foot care. Feet should be examined at least annually. Face to face examination should include testing using 10g monofilament to detect nephropathy. Diabetic foot pathology:
- Limb ischaemia
- Ulceration
- Callus
- • Infection and/or inflammation
- Deformity
- Neuropathy
- Charcot arthropathy (usually presents as hot swollen joint/foot)
- Gangrene
1.11.3 When to refer
The traffic light system on the next page provides a useful guide about when and where to refer. Time is tissue! Do not delay referral for diabetic foot problems. Refer immediately to be seen within 24 hours if you suspect foot infection.
1.11.4 Patient resources
The following patient information leaflet is available from the ROP (Diabetic Medicine/ Patient Resources / Diabetic Footcare Patient Information) or by clicking the hyperlink: Diabetes and Looking After Your Feet (Diabetes UK patient leaflet).
1.11.5 Professional resources
The SEL High Risk Foot EMIS Search is a risk stratification tool for identifying patients at greatest risk of foot disease. The search must be copied to a practice local search folder before it can be run. Find the folder within the Population Reporting module of EMIS Web: ‘Clinical Effectiveness Group (Shared Folder) / SEL CCG High Risk Foot Search’.
REFER
ROP - Diabetic Medicine / Referrals/ Podiatry Select appropriate foot condition and you will be guided to the optimum pathway Nail cutting services are not available on the NHS. Patients who require help with nail cutting can be signposted to the patient-funded Age UK “Clip It” service: https://www.ageuk.org.uk/bromleyandgreenwich/our-services/footcare/clip-it-clinics/
