1. A Resource for Glycaemic management in Diabetes key messages Hypoglycaemia is dangerous: Beware in elderly/RF/CVS risk Sulphonylureas need education to avoid risk Do not escalate Rx if hypoglycaemia present Beware low HbA1C with insulin and sulphonylureas Individualise HbA1C target. Early tight control reduces later complications Newer agents have clear roles in appropriate patients as per NICE. They must be reviewed at 6 months and stopped if not achieving targets. eGFR matters – please check drug information Drugs do not replace lifestyle advice at any stage Take me to the Quick Guide Useful resources Lifestyle Individual Target Individual Target Hypo Advice Hypo Advice NICE Criteria NICE Criteria Drug Information Drug Information Management of Low eGFR Management of Low eGFR Author: Coastal West Sussex Diabetic group Review date: January 2014 Version: No. 2 Disclaimer: The information given in this document is accurate at the time of publication. Any links to other websites or documents contained in this resource does not constitute as an endorsement by the Diabetic Group or by Coastal West Sussex Clinical Commissioning Group.

2. Diet and lifestyle tried HbA1C > 48 (6.5%) Metformin HbA1C > 48 (6.5%) or individualised target Metformin + Gliclazide (Repaglanide if lifestyle erratic) HbA1C > 58 (7.5%) Insulin acceptable? Intensify Insulin +/- Metformin +/- Pioglitazone +/- Sitagliptin Start Insulin Symptomatic of hyperglycaemia requiring rapid control / low BMI Metformin contraindicated or not tolerated At risk from hypoglycaemia or Gliclazide side effects not tolerated / unacceptable HbA1C > 58 (7.5%) Metformin + Sitagliptin or Pioglitazone Consider Sulphonylurea pathway page 2 Consider Sulphonylurea pathway page 2 High BMI? See NICE criteria for GLP1 agonist use- (refer DSN fpr initiation) Consider Metformin +/- Gliclazide + Exenatide or Liraglutide Monitor 6/12 Target Target not met Change to insulin Do not fit NICE criteria for GLP1 agonist or Insulin unacceptable Consider triple RX Metformin Gliclazide + Sitagliptin or Pioglitazone HbA1C> 58 (7.5) Start Insulin +/- Metformin +/- Pioglitazone +/- Sitagliptin Quick Guide: Blood Glucose Lowering Therapy in Type 2 DM Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009) Hypo Advice Hypo Advice NICE Criteria NICE Criteria Hypo Advice Hypo Advice NICE Criteria NICE Criteria Individual Target Individual Target Lifestyle Individual Target Individual Target Insulin Button Insulin Button Insulin Button Insulin Button Insulin Button Insulin Button Hypo Advice Hypo Advice Hypo Advice Hypo Advice Hypo Advice Hypo Advice Drug Information Drug Information Useful resources Lifestyle Individual Target Individual Target Individual Target Individual Target Management of Low eGFR Management of Low eGFR Home Diagnosis

3. Sulphonylurea Pathway Gliclazide > HbA1C 52 (7%) or individualised target Metformin not tolerated or contraindicated then consider Sitagliptin or Pioglitazone Gliclazide + Sitagliptin or Pioglitazone > HbA1C 58 (7.5%) or individualised target Start Insulin Intensify Insulin regimen Hypo Advice Hypo Advice Individual Target Individual Target Hypo Advice Hypo Advice Take me back to the quick guide, page 1 Useful resources Lifestyle Drug Information Drug Information Individual Target Individual Target Management of Low eGFR Management of Low eGFR Home Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009) Metformin tolerated Return to Metformin pathway (page1) Consider stopping Gliclazide if initial response rapid Metformin tolerated Return to Metformin pathway (page1) Consider stopping Gliclazide if initial response rapid Poor initial response V low BMI Exclude underlying pathology May need insulin, (type1?) refer

4. Lifestyle interventions Education – Type1 Type2 Care Planning with individualised Targets Example diabetic care plan Year of Care Link Diet Who should see the Dietitian? Diet sheets Diet advice – Click here to access the Eat well with DM2 DUK web pagehere Weight Weight loss Help – click here to access the Why Weight page on the GP websitehere –Why Weight: Tel 0300 123 0892 Exercise Exercise Referral Smoking Stop Smoking advice: Tel 0300 100 1823 Mood Matters – MMG/TTT/Psychology Self Help signposting – Wellbeing hub Contact numbers Take me back to the quick guide Home

5. Hypoglycaemia Advice Hypoglycaemia IS DANGEROUS Always enquire about mild symptoms especially with HbA1C <7 Teach patients to actively pre-empt low blood sugar & know how to manage hypoglycaemia. Emergency treatment of hypoglycaemiaEmergency treatment of hypoglycaemia Ongoing management / advice for hypoglycaemiaOngoing management / advice for hypoglycaemia Patient leaflet – management advice on hypoglycaemiaPatient leaflet – management advice on hypoglycaemia Driving and hypoglycaemia advice Medical standards of fitness to drive Take me back to the quick guide Home

6. Individualised Target Aim Hb1C 48-53mmol/mol (6.5-7%) Younger patient Newer diagnosis Low risk of hypoglycaemia No co-morbidities Micro-vascular complications Aim HbA1C 58mmol/mol (7.5% or higher) Older patient Long standing diabetes Multiple hypoglycaemic agents Cardiovascular risk Macro-vascular complication Take me back to the quick guide When setting a target HBA1C): Involve the person in decisions about their individual HbA1C target level, see above Encourage the person to maintain their individual target unless the resulting side effects (including hypoglycemia) or their efforts to achieve this impair their quality of life Offer therapy (lifestyle and medication) to help achieve and maintain the HbA1C target level Inform a person with a higher HbA1C that any reduction in HbA1C towards the agreed target is advantageous to future health Avoid pursuing highly intensive management to levels of less than 48mmol/l or 6.5 %. However in early disease tight control (HbA1C 48mmol/mol or 6.5%) holds better long-term outcome Home

7. Insulin Insulin should be initiated by qualified practitioners only. Dietitian input should also be sought at the same time Aims of treatment with insulin Leaflets: –Sick day rules –Implication of Ketone levelsImplication of Ketone levels –Simple dose adjustment instructions: QDS / Basal Bolus BD / pre-mix –Hypoglycaemia awareness (advice see hypoglycaemia page) Link to safe use of insulin on NHS Diabetes websiteLink to safe use of insulin on NHS Diabetes website Download the Insulin Passport Take me back to the quick guide Home Hypo Advice Hypo Advice

8. NICE Criteria DPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin) Continue DPP-4 inhibitor therapy only if there is a reduction of ≥ 0.5 percentage points in HbA1c in 6 months. Discuss the benefits and risks of a DPP-4 inhibitor with the person, bearing in mind that a DPP-4 inhibitor might be preferable to a Thiazolidinedione if: – further weight gain would cause significant problems, or – a Thiazolidinedione is contraindicated, or the person had a poor response to or did not tolerate a Thiazolidinedione in the past. GLP1 agonists (Exenatide/ Liraglutide) These should only be initiated by the team with special interest in practice Discuss the benefits of GLP1 agonist to allow the person to make an informed decision. Consider starting in: BMI ≥ 35 kg/m2 in people of European descent and there are problems associated with high weight, or BMI < 35 kg/m2 and insulin is unacceptable because of occupational implications or weight loss would benefit other co-morbidities. 6 month review Continue GLP1 Therapy only if the person has a reduction in HbA1C of ≥ 1.0 percentage point and ≥ 3% of initial body weight in 6 months. Thiazolidinedione (Pioglitazone) Continue Thiazolidinedione therapy only if there is a reduction of ≥ 0.5 percentage points in HbA1c in 6 months. Discuss the benefits and risks of a Thiazolidinedione with the person, bearing in mind that a Thiazolidinedione might be preferable to a DPP-4 inhibitor if: – the person has marked insulin insensitivity, or – a DPP-4 inhibitor is contraindicated, or – the person had a poor response to or did not tolerate a DPP-4 inhibitor in the past. Do not start or continue a Thiazolidinedione if any suspicion or risk of bladder cancer/ frank haematuria if the person has heart failure or is at higher risk of fracture. When selecting a Thiazolidinedione, take into account the most up-to-date advice from regulatory authorities, cost, safety and prescribing issue Click here to access the full NICE guidance Take me back to the quick guide Home Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)

9. Management of Low eGFR Take me back to the quick guide Home Prescribers should always check the latest product information in the relevant data sheet by visiting http://www.medicines.org.uk/emc/http://www.medicines.org.uk/emc/

10. Useful Resources Diagnostic criteria WHO. Quick summary chart Referral protocols Dietitian DSN Footcare clinic Information Leaflets For the patient: Diet sheets Driving and the new medical standards for people with diabetes Footcare instructions Hypoglycaemia dietary advice For the Clinician Mood Management Referral – needs link Preconception Consultation Emergency Hypoglycaemia Treatment Guidelines for Blood Glucose Meter testing use – Type1Type2 Useful Websites HBA1C conversion chart Link to safe use of insulin on NHS Diabetes website Click here to access the DVLA Guide to Medical Standards of fitness to drive Click here to access the Map of Medicine Click here to access the NICE pathway for a Diabetes overview Click here to access Diabetes UK Click here to access DUK – Understanding Diabetes Click here to access Diabetes Bible Contact Details Hospital contact details –Worthing Diabetes Centre 01903 285044 (9am – 4pm, Mon - Fri) –St Richards Diabetes Centre 01243 831614 (9am - 4pm, Mon - Fri) –Email Sc-tr.communitydiabetesservice@nhs.netSc-tr.communitydiabetesservice@nhs.net – Take me back to the quick guide Home