Diabetes-Alphabet Strategy

Alphabet strategy for diabetes care

Advice-Smoking cessation physical activity diet weight control – aim for 5-10 % loss / year if over weight. Structured education- especially- 
 self-management beliefs knowledge skills driving occupation Regular follow up with Care Planning Annual Review is essential


 20 % with early severe complications will be persistent Diabetes Clinic non-attenders Ramadan advice Advice DiabetesUK membership.

Physical activity –choose activities that are enjoyed and fit into daily activities atleast 150 minutes ( 2 hrs 30 minutes ) of moderate intensity activity across the week or combinations of moderate and vigorous intensity activity resistance physical activity to improve muscle strength atleast two days a week minimize being sedentary ( sitting )

Weight management –encourage overweight and obese people to gradually reduce calorie intake
 explain 5-10 % weight loss in 1 year is a realistic initial target
 use evidence based behaviour-change techniques
 motivate and support to achieve and maintain – a healthy BMI
○ gen population 18.5- to 24.9
○ S Asian or Chinese descent 18.5 to 22.9 kg/m²
 Orlistat is an option

dietary advice- advice the right amount of calories for the level of activity ; daily usually
○ men 2500 kcals
○ women 2000 kcals many adults / some children may have too many calories usually from carbohydrates or fats
Ensure protein intake adequate
satiety: protein > fat > carbs Ensure >= 5 fruit & veg/spaced out through the day cut down on sugars carbs : more complex fat – cut down on total fat particularly saturated fat and partially replace with unsaturated fats ( sats to < 30g men, 20g women ) salt < 6 g/day do not confuse thirst with hunger smaller regular meals do not skip breakfast

Metformin- HbA1c rising despite participation intensive lifestyle program or unable to participate
 particularly if BMI > 35
 explain long -term lifestyle change can be more effective in preventing or delaying T2DM
 cont lifestyle advice
 check renal function before Rx , then x 2 yearly or more
 start low dose e.g 500 mg od , increase to 1500-2000 mg / daily
 if intolerant , consider metformin MR prescribe for 6-12 months
 monitor HbA1c or fasting plasma glucose at 3- month intervals and stop the drug if no effect

Orlistat- use clinical judgement on whether to offer orlistat if 
BMI > = 28.0 kg/m²
 discuss benefit and side effects
 advice low fat diet 
( < 30 % daily average as fat , over 3 main meals )
 review use after 12 weeks -if weight loss not atleast 5 % – stop treatment
 use orlistat for > 12 months only after discussing benefits & side effects

Diabetes remission protocol ( direct study ) If diabetes duration < 6 yrs : 830 kcal diet for around 12 weeks ( caliries from : protein 26 % , fat 13 % , carbs 61 % ). Then 400 kcal. meals reintroduced. Vitamins and minerals replete. Off all anti-diabetic and anti-hypertensive Rx. Optimal Physical Activity advised ( ideally 15000 steps/ day ). Relapse with weight gain treated 86 % chance of remission at 1 year if >= 15 kg weight loss. 57 % remission if 10-15 kg weight loss

Blood pressure –National Diabetes Audit target < 140/80 , <= 130/80 if kidney, eye damage or any CVD (A ) ie
ACEi or ARB Ca² blocker 
( C ) or
 D 
( indpamide ) 

CKD Prevention Micro Alb ACEi or ARB Ramipril 10 mg/ day shows 
○ stroke reduction , MACE and mortality reduction by 24 % Proteinuria 20-18 % reduction death / ESRD 
( losartan 100 mg od )

Cholesterol-National diabetes audit 
< 5 mmol/l
 NICE > 40 % reduction in non-HDL Chol Atorvastatin 20 mg od if > 40 yrs or duration > 10 yrs or established nephropathy or other CVD risk factors
 Atorvastatin 20 mg od if >= 10 % , 10 yr CVD risk on QRisk2 Atorvastatin 80 mg od
 CVD ( MI , angina , stroke , TIA , PVD ) initiate lower dose if older , low muscle mass , impaired renal function pr patient preference ) Atorvastatin 20 mg
 if > 40 % reduction in non-HDL C not achieved , increase dose Agree use of high-dose statin with renal specialist if eGFR < Ezetimibe 10 mg and / or Fenofibrate 160 mg / 200 mg may be useful in statin intolerance to reach targets
 Hydrophilic Pravastatin and Rosuvastatin less SEs ( simvastatin SE profile ↑ed with amlodipine , diltiazem , verampamil , > 250 ml of grapefruit juice daily )

Diabetes control – Diabetes control : Individually – agreed targets
NDA HbA1c <= 58 mmol/ ( 7.5 % )Type 2 initial treatment
○ Lifestyle -optimal diet , weight , physical activity

○ Metformin
500 mg bd
850 mg bd
1000 mg bd ( usual doses )
Consider B12 check
 First intensification – individualised to patient

If non- obese SU e.g gliclazide
start low dose e.g 40 mg od then titrate e.g 80 mg bd , 160 mg bd max
Note- hypo risk
If obese – DPP-4i ( weight neutral ) or
SGLT-2i ( weight loss )

If CKD adjust dose ( except linagliptin 5 mg )
Pioglitazone or GLP-1 RA sc also options
Consider insulin if ketones high , loosing weight , marked symptoms & glucose > 15 mmol/l or high HbA1c ( > 86 mmol/mol )
 Type 2 second intensification : Individualized to patient : Use appropriate 3rd line from above choices
 Type 3rd third intensification : individualised to patient- appropriate agent from above ? insulin ? GLP-1 agonist sc
Insulin regimes : NPH , glargine , levemir , degludec , toujeo overnight , biphasic bd , basal bolus regimes

GLP-1 agonists : Exanetide ( bd or once weekly ) liraglutide od , Lixisenatide od , dulaglutide ( once weekly ) in Hba1c >= 7.5 %. Consider instead of insulin or TZD in BMI >=35 , if problems with incd weight , occupation issues , insulin unacceptable or weight loss would benefit co-morbidities
Consider stopping unless HbA1c % >= 1 % better and >= 3 % weight loss in 6 months
 New Type 2 Guidelines : EASD / ADA guidance : If clinical CVD SGLT-2i or GLP-1RA with proven CV benefit is recommended . If CKD or clinical heart failure and atherosclerotic CVD a SGLT-2i inhibitor with proven benfit is recommended. GLP-1 RA is are generally recommended as first line injectible Rx

eye screening –BP & glycemic control esential Screen annually using a digital retinal camera Aspirin / ACE-i / ARB in most patients with retinopathy Consider fenofibrate – some evidence of reduced need for laser Rx in diagnosed retinopathy
Several national units use it for maculopathy 
( FIELD Study reduction in retinal laser and other outcomes by 34 % )

Foot care- All risk factors to be controlled aggressively Inspection , pedal pulses , 10 Mg MF testing If neuropathic or ischaemic , foot care advice and regular podiatry review is essential to prevent ulceration / amputation In the FIELD study there was a 36 % reduction in amputation using fenofibrate 160 mg od ? consider in individual cases with previous amputation ?

Guardian drugs-Aspirin 75 mg od when bp < 150 systolic : in any atheromatous CVD
 Clopidogrel 75 mg if further atheroma events on aspirin or aspirin intolerance
 ACEi reduce complications – Ramipril 10 mg od consider for most diabetics 
( Best evidence in type 2 diabetes )
 ARB Microalbuminuria
( best evidence : Irbesartan 300 mg od ) also if ACE not tolerated.
Proteinuria to retard progression to death and ESRD ( best evidence Losartan 100 mg od )

Chart reproduced with kind permission of Professor Vinod Patel MD FRCP FHEA MRCGP DRCOG MB ChB BSc ( Hons ) Professional Clinical Teaching Fellow : Diabetes and Clinical Skills Warwick Medical School University of Warwick Hon Consultant in Endocrinology and Diabetes , Diabetes and Endocrinology Centre George Eliot Hospital NHS Trust Nuneaton