Diabetes - Type 2 Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of adults age 18+ with Type 2 diabetes

This guidance does not cover:

  • Diagnosis of Type 2 diabetes
  • Secondary diabetes
  • Type 1 diabetes in adults
  • Diabetes in pregnancy
  • Diabetes in children & Young people.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

Hospital admission

  • Patient clearly unwell, vomiting without clear cause, moderate or large ketonuria, other severe illness
  • Foot ulcer with spreading sepsis and necrosis

Remember

  • Ketoacidosis may occur in patients with modestly raised blood glucose
  • People with type 2 diabetes are at risk of hyperosmolar state which has high morbidity and mortality

Seek advice urgently

  • Severe symptoms, blood glucose greater than 25 (particularly with mild ketonuria)
  • Newly diagnosed probable type 1 diabetes
  • New or Infected foot ulcer
  • Pregnant women with diabetes (type 1 and 2)

Investigations

Annual Review - Ensure that all patients with Type 2 diabetes have had the NICE eight care processes undertaken
  1. BMI measurement
  2. BP measurement
  3. HbA1c measurement
  4. Cholesterol measurement
  5. Record of smoking status
  6. Foot examination
  7. Albumin: creatinine ratio
  8. Serum creatinine measurement

Management

Consider the following in regards to initial and ongoing education
  • Explain to people and their carers that structured education is an integral part of diabetes care and it should include the following components:
    • Evidence Base
    • Specific aims and learning objectives
    • A structured curriculum delivered by trained educators, quality assured with outcomes audited
  • Refer to the nationally accredited structured education programme for adults with Type 2 Diabetes – DESMOND Referral Form
  • Review annually including assessment of the patient's knowledge of their diabetes and its management.
Blood Glucose control
  • Involve adults with type 2 diabetes in decisions about their individual HbA1c target.
    • Encourage to achieve target and maintain unless any adverse effects (including hypoglycaemia), or it impairs their quality of life.
  • In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol or higher: reinforce advice about:
    • diet, lifestyle and adherence to drug treatment
    • and support the person to aim for an HbA1c level of 53mmol/mol and Intensify drug treatment.
  • Consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:
    • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
    • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
Self-Monitoring of Blood Glucose
  • Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:
    • the person is on insulin
    • there is evidence of hypoglycaemic episodes
    • the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery
    • the person is pregnant, or is planning to become pregnant.
  • Consider short-term self-monitoring of blood glucose levels in adults with type 2 diabetes (and review treatment as necessary):
    • when starting treatment with oral or intravenous corticosteroids or
Blood Pressure Management - see guidance
Anti-Platelet Therapy
  • Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.

Referral

Referral Criteria

  • For people with Type 2 diabetes who are uncontrolled then they can be referred to the community diabetes specialist clinic initially operating within the GP Practice
  • Referral to the MYHT specialist diabetes clinic for:
    • Complex complications
    • Diabetes foot ulcers/'foot attack'
    • Gestational Diabetes
    • Pregnancy
    • Pre-conceptual care

Referral Instuctions

  • e-consultation is available for diabetes for both the Consultant Diabetologists and the Diabetes Specialist Nurses
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 02.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 03.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: END1 - 02.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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