1. CASE FINDING. By post-prandial urinalysis for glycosuria :

       a) Screening - Over 40‟s at 5 yearly intervals, well person clinics, medicals ( new reg, insurance &
       occupational.). At risk groups: Asian, Afro-Caribbean, the obese, positive family history. Previous
       gestational diabetes should be tested 6-monthly for life.

        b) Symptoms - Thirst, polyuria, weight-loss, nocturia, incontinence, recurrent candidiasis, foot
       ulcers, neuropathic symptoms, general malaise.

 2. DIAGNOSIS. Fasting plasma glucose >7.0mmol/L; or random >11.1. Two laboratory samples needed if

       Type 1. Refer to consultant - seek urgent admission for vomiting patients and all children (regardless
       of symptoms). If moderate or more ketonuria, make urgent telephone request for OP appointment

       Type 2. GP care. On diagnosis :

       Explain complications, foot care, driving, smoking & alcohol, prescription exemption.
       Give BDA booklet.
       Arrange dietary advice.

       Retinopathy - refer to optomotrist (via Hospital scheme).

       Feet – as under “Annual Review” below.

       Registration – fill out the form for the Diabetic Register and send to the West Anglia Resource

3. MANAGEMENT Requires organisation for systematic annual review with an intermediate education
     and control contact at the 6-month point :

       The Annual Review should cover the following areas (more frequent reviews required for areas of
       concern) :

       a) Screening for complications :

              Retinopathy – confirm that patient has been screened and that arrangements are in place for
              the next check.

              Nephropathy – urinalysis & creatinine. Refer if creatinine >150mmol/L or positive
              proteinuria with 24hr protein >0.5g. If Type 1 for 5 yrs and negative proteinuria, early
              morning sample to laboratory for microalbumin. If albumin/creatinine ratio >2.5 repeat, if
              >3.5 for 3 successive samples treat with ace inhibitor.

              Feet – check pulses, ulcers, soft touch. (monofilament score out of 10), callosites for callus.
              If any abnormality, refer to chiropodist. Only refer to hospital if foot condition critical.
              Record as diabetic neuropathy if monofilament score <=8/10 bilaterally or post neuropathic
              ulcer or neuropathic pains (burning).
      b) BP control : Aim for 140/80 or lower.

      c) Glucose control :

               Diet initially for 3 months, unless symptoms persist.

               Oral hypoglycaemics. (Metformin if overweight). Avoid chloropropramide if aged 65 plus.

               Aim for HbA1c <7.0

      d) Cholesterol : Use the „Joint British Societies Coronary Risk Prediction Charts‟ which are suitable
              for diabetics without pre-existing CHD or familial hypercholesterolaemia.
                    Risk area : Red - treat with statins
                                  Orange- do fasting TC:HDL ratio may treat depending on family history
                                          ethnicity, triglycerides, proximity to next age band chart.
                                  Green- no treatment.
      e) Smoking : Encourage cessation.
      f) Weight : Encourage reduction. BMI<30.
      g) Blood Tests : Arrange HbA1c tests for review at 6-month intermediate contact.

      Send the completed annual review form to the West Anglia Resource Centre.

      The 6-Month Intermediate Contact between each annual review should include :

      a) Glucose Control : Hba1c – again aim for <7.0
      b) Follow up on any actions and/or problems identified at the previous annual review.
      c) Ensure that appointments for retinopathy and nephropathy are in place prior to next annual
      d) Arrange blood tests (HbA1c, creatinine, and cholesterol) prior to Annual Review.
      e) Education – review home monitoring and what to do (don’t reduce treatment if sick), foot care,
      smoking, alcohol, importance of diet, etc. Check on effects of any changes (eg, to injection which
      could affect driving).


      a)   100 % of all diagnosed diabetics to be offered annual review.
      b)   95 % of all diagnosed diabetics to attend for annual review.
      c)   80 % of all diabetics to have attended eye screening in previous 18 months
      d)   80 % of all diabetics to have satisfactory BP (<=140/80) at the annual review (1).
      e)   80 % of all diabetics to have satisfactory HbA1c (<=7.0) at the annual review (1).


SOUTH PETERBOROUGH PRIMARY CARE TRUST                                                 APRIL 2000.

References: UKPDS study

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