- NICE CG15 IDDM
- NICE CG66 NIDDM
- NICE CG87 NIDDM newer agents
- QRG Adults
- QRG Paeds
- SIGN 116 Diabetes QRG
- Diabetes Inpatient Costs NHS Diabetes Nov 2011
- DM Rural Health West
Chronic metabolic disorder characterized by elevated blood glucose levels due to deficiency in insulin production or insulin resistance.
|Type 1 and type 2 diabetes|
|These terms describe aetiology of the condition but the preferred terms are IDDM and NIDDM which classify the condition in terms of treatment needed|
|Type 1 diabetes|
|acute beta cell failure leading to insulin deficiencyWhen 90% of the beta cells have been destroyed, the patient presents with:
often a faint smell of acetone on the patient’s breath
|Type 2 diabetes|
|chronic beta-cell failure with insulin resistance
There may be no symptoms or fatigue, visual disturbance, recurrent skin infections
|First or later presentations of T1DM may be a medical emergency with dehydration, ketoacidosis, and hyperglycaemic coma.
|Macrovascular disease accelerated atheroma|
|Coronary arteries, with a greatly increased risk of early coronary heart disease (CHD), IHD and MI
Cerebral arteries, with an increased risk of CVA
all of the other large arteries, with an increased risk of blockage by thrombosis
|Microvascular disease affecting the small peripheral arteries|
diabetic retinopathy and blindness
peripheral ischaemia – skin, nerves and other tissues of the lower limbs(some diabetic neuropathies are due to nerve ischaemia caused by small artery blockage; other diabetic neuropathy is due to lesions of the sensory and motor nerves themselves)
|Random or 2hr glucose > 11.1|
|Fasting >7.0 mmol/l|
|HbA1c > 6.5% 48mmol/mol|
|On one occassion with symptoms
(polyuria, polydipsia, unexplained weight loss)or on two separate occasions without symptoms
|Diagnosis, classification, and treatment of DM BMJ Sep 2011
HbA1c in the diagnosis of T2 DM – Diabetes UK
|NIDDM Diabetes Diagnosis using HbA1c|
|with symptoms = DM|
but confirmed on repeat = DM
= non-diabetic hyperglycaemia
2hr gluc 7.8-11 mmol/l = IGT
2hr gluc > 11 mmol/l = DM
|<6% /42mmol||non diabetic|
HbA1c testing is not recommended for diagnosis of type 1 diabetes, and should not be used to diagnose type 2 diabetes in children, or patients with end-stage kidney disease, haemoglobinopathies or anaemia.
A value less than 6.5% does not exclude diabetes diagnosed using glucose tests.
|HbA1c (%)||IFCC (mmol/mol)|
|Impaired glucose tolerance and raised fasting glucose|
|Impaired Glucose Tolerance
fasting glucose < 7
2hr OGTT >7.8 but less than 11.1
Read code R10D
|Impaired Fasting Glucose
fasting glucose between 6.1-7 and OGTT <7.8 @ 2hrs
Read code R10E
|Reduction in insulin secretion and the development of insulin resistance with increasing hyperglycaemia probably occur gradually over several years before type 2 diabetes is diagnosed. Patients are with IGT/IFG are already already carrying the risks of diabetes, which can be reduced before waiting for diabetes proper to develop|
|Glucose Tolerance Tests Patient UK|
|may be worthwhile in patients in higher risk population – over 40 with one/two or more of the belowrecent UK guidance calls for much wider annual screening in “high risk” individuals|
|1st degree relatives with diabetes or heart disease|
|BMI > 30 (>27.5 South Asian or Chinese)|
|Organ damage known to be associated with diabetes – retinopathy, CKD, neuropathy|
|CVD, hypertension or dyslipidaemia|
|Conditons asoc with diabetes – PDOS severe mental health disorder|
|current meds assoc with increased risk of diabetes eg corticosteroids newer antipsychotics|
|Diabetes – initial assesment and management|
|Exclude secondary causes such as pancreatic disease, hormone-induced diabetes, steroids or thiazides neuroleptics|
|Check smoking, diet, and exercise habits.|
|Measure BP, weight, height BMI|
|Examine for any existing complications|
|Initial investigations: HBA1c, FBC, RFTs, fasting lipids, and microalbuminuria|
|Give initial dietary advice
healthy balanced diet, with restriction of refined sugars.Most patients should have a three month trial of dietary treatment before starting on oral hypoglycaemic agents.
|provide written information and instructions.Initial education may involve just a simple explanation of the nature of diabetes and clear advice on action to be taken if the condition deteriorates|
|Organizational tasks – Read coding , Diabetes Registers CVS Risk profiling|
|Referral for assessment of eye complications; and referral to dietician, chiropodist or podiatrist, and community diabetes educator, if available|
|immediate referral if patient unwell, has ketonuria, or blood glucose > 20 mmol/l.
Recent weight loss is an indication of severity of disease
1. Avoid sugary drinks i.e. pop and squash
2. Do not add sugar to foods or drinks e.g.cereals, tea, coffee, etc.
3. Reduce your intake of sugary foods by avoiding Jams, marmalade, honey, syrup, cakes, sweet biscuits and pastries, sweets, chocolate, puddings, sugar coated breakfast cereals.
5. Eat regular meals Try to have something to eat at breakfast, lunch, tea and supper
6. Eat plenty fruit and vegetables
7. Do not buy diabetic foods These foods are not necessary and are best avoided.
high in soluble fibre,
low in saturated fats, contain plenty of poultry, fish and veal
carbohydrate from whole grain products (for slow release of glucose)
and supply no more than the estimated daily calorie requirement.
– avoid low cal drinks
– dont obtain calories from drinks
Diabetes prevention lifestyle targets: weight reduction >5% if obese, fat intake <30% of energy intake, saturated fat
<10% of energy intake, fibre >15g per 1000 calories, exercise 4 hours/week. Normal dietary NaCl.
Smoking cessation, physical activity, weight control (5-10% loss per year if overweight).
Structured education: especially self-management, beliefs, knowledge, skills involve carers.
Regular follow-up with complete annual review.
|Initial||0.6 x body weight (kg) in divided doses
rest divided between meals
|0.6||exercisers – first phase of menstrual cycle|
|0.7||late menstrual cycle
pregnancy viral illness
newly diagnosed child
severe viral infection
|1.0||pregnancy – term
severe bacterial infection
peak of punescence
|Honeymoon period||final surge in endogenous insulin secretion when starting insulin
requirements may drop
eg 0.2-0.6 u/kg/day
| DM pocketflyer Borm
diabetes.nhs.uk safe use of insulin
NHS Diabetes insulin
NPSA Insulin Passport
|mixtures||varying proportions of short and intermediate acting
eg humulin M1
(10% short:90% intermediate)
|mixtures||ultrashort analogue + intermediate|
|Animal (bovine and pork) now rarely used|
Short acting insulin mixed with intermediate acting insulin bd before meals
eg Novomix 30 Humulin M3 Humalog mix 25
Biphasic insulin aspart 30/70 bd
Short acting insulin mixed with intermediate acting insulin before breakfast
plus short acting insulin: before evening meal
plus intermediate acting insulin: at bedtime.
|basal bolus regime
intermediate / long acting acting insulin at bedtime (basal)
plus short acting insulin tds (breakfast, lunch and evening meal) (bolus)
eg insulin aspart and insulin glargine or insulin etemir
|once daily regime
may suffice for some patients with T2DM needing insulin
Intermediate acting insulin with or without short acting insulin
either before breakfast or at bedtime
otherwise use above regimes
Insulin is injected subcutaneously varying the site of injection from the abdomen to the thighs, upper arms and buttocks.
|Diabetes illness rules|
|Infections stimulates release of insulin antagonists, causing a rise in daily insulin requirements.If the patient becomes ill they should measure BMs several times per day and to test the urine for ketones
(some BM metersdo this now)Insulin dependent diabetics should be admitted to hospital if:
there are ketones in the urine
there is persistent vomiting
there is abdominal pain
compliance is known to be poor
the patient is a child.Patients with T1DM who develop concomitant illness should:
continue with insulin
measure blood glucose at least four times a day
test for ketones once a day
aim to drink just under 3l unsweetened fluids per day
adjust the dose of insulin according to the measurement of blood glucose and presence, or not, of urinary ketones
|Less than 13mmol/l ketones||Increase the dose of each insulin injection by 2 u continue until ketone clear|
|Between 13 and 22mmol/L no ketones||Increase the dose of each insulin injection by 2 u continue until blood glucose controlled|
|Between 13 and 22mmol/l ketones||Increase the dose of each insulin injection by 4 u continue until ketones clear|
|Greater than 22mmol/l no ketones||Increase the dose of each insulin injection by 4 u continue until blood glucose controlled|
|Greater than 22mmol/l ketones||Increase the dose of each insulin injection by 6 u continue until ketones clear|
Adults with type 2 diabetes who develop concomitant illness should continue taking their normal dose of oral hypoglycaemic agent or insulin as prescribed by the diabetes team and keep testing their urine and blood glucose.
Patients with ketones who develop a low blood glucose (less than 8mmol/L) should supplement their diet with milk or fruit juice to raise their blood glucose.
HbAlc testing measure routinely at six monthly intervals in all people with diabetes.
Regular self monitoring of plasma glucose levels is essential in type 1 diabetes – SBGM four or more times a day is recommended to prevent hypoglycaemia and control hyperglycaemia.
More frequent SBGM may be indicated in MI,dialysis, pregnancy, terminal care and impaired awareness of hypoglycaemia.
For type 2 diabetics who are not taking insulin SBGM is not usually necessary.
SBGM may be needed if diabetes is destabilised e.g. concurrent severe illness, steroid therapy, pending treatment escalation etc.
If SBGM deployed should be taught by a health care professional using the following guidelines
Routine—Twice weekly random testing (to maintain testing competency)
Twice daily for two weeks prior to clinic review
I day —pre breakfast and ihr after breakfast nd
2 day— pre lunch and 1 hr after lunch rd
3 day— pre evening meal and I hr after evening meal th
4 day— pre supper if taken, and pre bed Then repeat as four days cycle until review
|Type 2 diabetes treatment steps|
|Step1||Diet weight loss and exercise
If mild or no symptoms try dietary control over 3 months
If symptoms or failure to achieve control
metformin first line choice
|Step3||Oral combination therapy
If side effects/intolerance/poor control
|Step4||Insulin + oral agent
If they still have failed to achieve glycaemic control
|Metformin first choice in type 2 diabetesreduces hepatic glycogenolysis, intestinal absorption and (mildly) insulin resistance.It is cheap, has few side effects, less tendency to hypoglycaemia, helps wt loss/avoiding wt gain, and can be used in heart failureMetformin is renally excreted and accumulation may precipitate lactic acidosis.Patients with deteriorating renal function should be monitored closely.
Review dose if creatinine >130micromol/l or egfr<45ml/min/1.73m2
Stop if creatinine>150 or egfr<30Metformin tablets 500mg, 850mgStart low go slow – increase dose over several weeks to minimise GI side effectsDose: initially 500mg with breakfast for at least 1 week then 500mg with breakfast and evening meal for at least 1 week then 1g with breakfast and 500mg with evening meal for 1 week, then 1g with breakfast and evening meal; max. 3g daily in divided doses (1g with breakfast, lunch and evening meal).Note – The maximum dose of metformin differs between the manufacturer’s Summary of Product Characteristics (3g daily as 3 divided doses) and the BNF (usual max. 2g daily in divided doses). Some patients tolerate up to 3g metformin daily in divided doses and may have additional glycaemic improvement.Metformin prolonged release tablets (Glucophage® SR) is restricted to use in patients who are intolerant of immediate release metformin (due to severe GI side-effects) and in whom the prolonged release tablet allows the use of a dose not previously tolerated.
If no benefit in GI side-effects is seen within 6 months, metformin prolonged release should be stopped and an alternative agent commencedMetformin or glibenclamide are both occ considered as initial pharmacological glucose lowering treatment in women with gestational diabetes depending on fasting and postprandial targets [both unlicensed use].
If however, blood glucose levels are in the range for established diabetes, intensive specialist management and initial therapy with insulin is required.
Sulphonylureas other than glibenclamide should not be used during pregnancy due to placental passage.
|Insulin secretagogues – increase beta cell insulin secretionwarn about risk of hypoglycaemia especialy if renal impairementuse if weight gain not a problem for rapid blood glucose reduction or metformin intolerant/CIGliclazide tablets 80mg
Initially, 40-80mg daily adjusted according to response; up to 160mg as a single dose, with breakfast;
higher doses divided; max 320mg daily.
Gliclazide is principally metabolised in the liver and is preferred in renal failure.Glipizide tablets 2.5mg, 5mg
Initially, 2.5-5mg daily shortly before breakfast or lunch, adjusted according to response; max. 20mg daily; up to 15mg may be given as a single dose; higher doses divided.Glibenclamide
long-acting sulphonylurea with a greater risk of hypoglycaemia
only used in special circumstances eg some women with mild gestational diabetes
both gliptins and incretins better for wt loss than sulphonylureas and pioglitazone
gliptins lower risk of hypoglycaemia than sulphonylureas
|DDP4 inhibitors aka gliptins – sitagliptin vildagliptin linagliptin|
Prandial glucose regulators
These are amino acid derivatives licensed for 2nd or 3rd line use with metformin in type 2 diabetes, where better control is needed, or where patients experience hypoglycaemia when treated with sulphonylureas.The drugs are glucose responsive: so induce insulin release when the patient eats, by acting on the pancreatic betacells to stimulate a rapid, shortlasting release of insulin to a level dependent on the glucose concentration, ie. where there is a postprandial rise in glucose.This is thought to be beneficial where the patient has an erratic lifestyle (e.g. junior doctors)prefer over TZDs if
previously poor response or intolerance
or further wt gain would cause significant problems
continue only if HbA1c reduction > 0.5% in 6mSitagliptin
monotherapy in patients for whom both metformin and sulphonylureas are inappropriate due to CI or intolerance
in combination with metformin when the addition of a sulphonylurea inappropriate;
or in combination with a sulphonylurea when metformin is not appropriate;
or in combination with both a sulphonylurea and metformin when dual therapy does not provide adequate control.Sitagliptin and metformin combined tablets (sitagliptin 50mg / metformin 1000mg Janumet®?) are available which may offer some patients a more convenient dosing regimen. Their use is restricted to patients for whom this combination is an appropriate choice of therapy either and only when the addition of sulphonylureas to metformin monotherapy is not appropriate or in combination with a sulphonylurea (triple combination therapy) in patients inadequately controlled on their maximal tolerated dose of metformin and sulphonylurea.Saxagliptin may be used as add-on combination therapy with metformin when metformin alone with diet and exercise does not provide adequate glycaemic control.
Use is restricted to patients where the addition of a sulphonylurea is not appropriate.Linagliptin 5mg od
|Meglitinides naglitinide and repaglinide|
|Second generation insulin secretagoguesless prone to cause wt gain and hypoglycaemia but expensive an less effective than the sulphonylureas|
delays intestinal CHO absorption
only consider if unable to use other oral glucose-lowering drugs
|Glitazones aka Thiazolidinediones
|Enhance the effects of insulin in adipose tissue and skeletal muscle (ie reducing insulin resistance).Second line or third line treatment options for management of glycaemic control in patients with type 2 diabetes.prefer over DDP4s if:
marked insulin insensitivity
previously poor response or intolerance
consider combining with insulin when
previous good glucose reduction with TZDs
Pt inadequately controlled on high dose insulinAvoid in HF or osteoporosis risk
continue only if HbA1c reduction > 0.5% in 6mmay be added to metformin and sulphonylurea therapy, or substituted for either in cases of intolerance.May also be used as monotherapy for patients in whom metformin and sulphonylureas are contraindicated or not tolerated.An increased incidence of cardiac failure has been seen with rosiglitazone when used with insulin.It has also been linked to an increase in fracture risk.
The risk of fracture should be considered in the long term care of female patients treated with a thiazolidinedioneCheck LFTs prior to starting treatment and then at two monthly intervals for the first year.
stop if LFTs rise three times the normal level or if the patient becomes jaundiced.Pioglitazone may be combined with insulin under close specialist supervision (risk of heart failure) in patients with insufficient glycaemic control on insulin for whom metformin is inappropriate because of contraindications or intolerance.Pioglitazone tablets 15mg, 30mg, 45mg
initially, 15-30mg od increased to 45mg od according to response.Pioglitazone is available as a combination product with metformin (pioglitazone 15mg / metformin 850mg Competact®?) which may offer some patients a more convenient, though less flexible, dosing regimen than the separate individual constituents. Use is restricted to patients who cannot be treated with a sulphonylurea in combination with metformin.
It may take up to 8 weeks to achieve maximum effect with the thiazolidinediones (glitazones).The glitazones cause fluid retention and double the risk of heart failure. They are contraindicated in any heart failure (NYHA I-IV). They can rarely cause liver dysfunction; monitor liver function before treatment and periodically thereafter based on clinical judgement. Following new evidence showing increased cardiovascular risk with rosiglitazone compared to pioglitazone highlighted in a recent MHRA safety alert (26th July 2010), rosiglitazone is not recommended for use within NHS Tayside. Further information can be found on the MHRA websiteCases of heart failure have been reported when pioglitazone has been used in combination with insulin, especially in patients with risk factors for the development of heart failure. If the combination is used, all patients should be monitored for signs and symptoms of heart failure, weight gain and oedema, and pioglitazone should be discontinued if any deterioration in cardiac status occurs.
|GLP agonists – Exenatide Liraglutide NICE Exenetide|
|Bind to and activate the GLP-1 (glucagon-like peptide-1) receptor to increase insulin secretion, suppress glucagon secretion, and slow gastric emptying.Third line therapies initiated in secondary care.
Given by subcut injection.
In Tayside liraglutide is preferred over exenatide (in patients with eGFR>60mL/min) due to greater efficacy, lower rates of nausea, and a once daily administration.Liraglutide
may be considered in type 2 diabetic patients with eGFR >60mL/min in combination with metformin and/or a sulphonylurea or metformin and a thiazolidinedione in patients with insufficient glycaemic control despite maximal tolerated doses of monotherapy with metformin or sulphonylurea or despite dual therapy with metformin and a sulphonylurea or metformin and a thiazolidinedione.Exenatiderestricted to type 2 diabetic patients with eGFR 30-60mL/min in combination with metformin and/or sulphonylureas or metformin and a thiazolidinedione in patients who have failed to achieve glycaemic control on maximally tolerated doses of these oral therapies
or in patients for whom glitazones are unsuitable (e.g. due to heart failure, hepatic impairment or where rapid glycaemic control is required) and who would otherwise move to insulin therapy.Exenatide: Consider if BMI >35 kg/m2 or weight-gain specific important issue, HbAlc >7.5% (>58 mmollmol), instead of insulin or TZD.Only continue if >1% reduction of HbA1c and >3% wt loss at 6m
NHS Tayside Guidelines for oral antidiabetic drugs
|T2 DM Drugs||Names|
|Sulphonylureas||GliclazideGlipizide MonodiabGlipenclamideGlimepiride Amyryl|
|Meglitinides||naglitinide Starlixrepaglinide Prandin|
|DDP4 inhibitors aka gliptins||sitagliptin Januvia
vildagliptin Galvuslinagliptin Trajenta
|GLP agonists||Exenatide Byetta BydureonLiraglutide Victoza|
|Combinations||sitagliptin+metformin Janumetpioglitazone+metformin Competactvildagliptin +metformin Eucras|
Aspiration HbA1 c = 6.5% 7.0%
Audit/QOF HbA1c < 7.5%
this has been revised
Check annual serum creatinine and UACR (performed on a random sample of urine)
|microalbumiuria/proteinuria positive if UACR >2.5 in men or > 3.5 in women|
False +ve results may occur after strenuous exercise, UTIs or glomerulonephritis
If microalbuminuria or proteinuria is present exclude UTI and repeat twice more (within one month where possible) as it may become an irreversible nephropathy within 6 to 12 months.
If microproteinuria is still present refer to one of the inhouse diabetes team, otherwise check their records (or examine their eyes) to check for retinopathy. If retinopathy is not present or if they have microscopic haematuria then look for a nondiabetes cause of renal disease
|Once UACR ratio is > 6 it becomes less accurate indicator of diabetic nephropathy progression.If the ACR is > 6 send an MSU and repeat the test to exclude confounding variables.If confirmed then urinary Protein:Creatinine Index (PCI) should be requested instead thereafter.|
Ensure good glycaemic control (HBa1c target <7.5%)
Measure, assess and manage cardiovascular risk factors aggressively.
Initiate ACE inhibitor therapy for cardiovascular/renal protection.
Glycaemic control and Hba1c – HBA1c should be checked every three to six months.
BP Targets in diabetes
Aspiration BP<140/<80 but if CKD present BP <130/80
Audit/QOF BP<145/<85 but if CKD present BP <140/85
BP control reduces retinopathy, nephropathy, stokes, heart failure and MI. BP control is as important as glycaemic control
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 2.5 mg Ramipril daily (1.25mg if on lower dose concomitant diuretics) for one week with check U&Es and an increase to 5.0 mg Ramipril for a further three weeks. Recheck 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 (GP update)
Cholesterol targets in Diabetes
Aspirational Cholesterol < 4.0mmol/l and LDL <2.0
Audit/QOF Cholesterol <5.0mmol/l and LDL < 2.5
Type 2 diabetics > 40 years should be considered for a statin
However, the value of statins is limited in those with a low absolute risk (Low risk NICE 2008 = not overweight, non smoker, normotensive, no FH or premature CVD disease, no PMH of CVD disease, no macroalbuminuria AND no high risk lipid profile!)
Aged over 40 initiate simvastatin 40 mg, increase to 80 mg if target not met.
Aged under 40 consider simvastatin 40 mg if cardiovascular risk factors.
lf target not achieved: rosuvastatin 10 mg (if 10% drop needed) otherwise consider ezetimibe 10 mg once-daily.
lf cardiovascular risk is high, consider adding fenofibrate to statin therapy if triglycerides > 2.3 mmol/l
NICE on lipids, CV risk and diabetes NICE CG87
ACE inhibitor: ramipril 10 mg once-daily or lisinopril 20 or 40 mg for most people or
AR2B: (best evidence: losartan 100 mg once-daily, irbesartan 300 mg once-daily).
NB: No statins or ACE-lor ARBs in pregnancy, 15% fetal malformation.
Diabetes & Primary Care Vol 11 No 3 2009
ACE ARB in Diabetes
Irbesarten 150-300mg in type 2 nephropathy
candesarten in early retinopathy?
DAFNE & DESMOND
SIGN on cardiovascular risk in diabetics SIGN 2010, 116
|GeneralEnquiry||How have you been?”
1. Energy levels
2. Polydipsia polyuria
3. Recurrent infections skin, genito-urinary, respiratory
Sensory disturbance, weakness
Chest pain, SOB
Home blood sugar measurements
Compliance with treatment
Social history Smoking, alcohol, diet, exerciseHypos – The patient should always be asked to keep a diary of hypoglycaemic attacks, and should always carry a few glucose tablets these are absorbed within minutes and will abort a ‘hypo reaction.’
|Occupation||Medications (inc OTC herbals and vitamins)|
|Driving||Pertinent Past History and Pregnancy|
|Depression||Screening for depression in Diabetes and CHD
The two screening questions that have to be asked at the annual review.
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?”
If the patient answers ‘yes’ to either question then ask:
Is this something with which you would like help?
If yes, complete PHQ9 and refer GP if score is 10 or more
You must enter the Read code short cut /dep to code that this screening has been performed (you can also tick the appropriate box if using Systm1 template)
But please note there is no requirement to undertake screening if the patient is already on treatment for depression. In which case you must enter the exempting Read code = /exdep
|Drugs||compliance control guardian drugs – Statin BP -ACE inhibitor if microalbuminuria or raised urinary albumin-creatinine ratio|
|Examine||Ht Wt BMI Waist circumference BP|
|Eyes||Visual acuity and at least annual retinal screening|
|Feet||Peripheral neuropathy reflexes, sensation
Foot care infections, ulceration, footwearThe patient’s feet should be examined for both circulation and sensation, and the patient should be referred to a podiatrist if necessary. The need for daily foot washing (avoid hot water) and general hygiene, including dental hygiene, should be stressed.NICE CG10 Type 2 diabetes – footcare Jan 2004
|Ix||Urine microalbuminuria, UACR, ketones
FBC, U&Es, egfr glucose, HbAlc, lipids (LFTS – statin, glitazone)
|Discuss||Education, driving, Rx, support groups, complianceSmoking – Read code cessation advice & refer to Practice Nurse smoking cessation service.|
Retinal screening should be carried our annually by a trained person, refer to ophthalmologist if necessary.