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NICE guidance on Type 2 diabetes
Education and Lifestyle- Offer a structured education at or around type of diagnosis with annual reinforcement and review eg DESMOND,X-PERT Dietary advice – refer for expert advice ○ encourage high-fibre , low glycemic index sources of carbohydrates eg fruit , vegetable , wholegrains and pulses ○ include low-fat dairy products and oily fish ○ limit intake of foods containing saturated and trans fatty acids Physical activity and weight loss ○ for obese target an initial weight loss of 5-10 % ( any wt loss is beneficial ) Individualized recommendations for carbohydrate and alcohol intake particularly in those on insulin and insulin secretagogue ( ↓↓ risk hypoglycemia ) Limited substitution of sucrose containing food or carbohydrates in the meal plan is allowable but to avoid excess energy intake NICE discourages use of foods marketed specifically for people with diabetes
Bariatric surgery-Bariatric surgery can improve quality of life and reduce risk of premature mortality in people with type 2 diabetes of less than 10 yrs duration ie before complications start to develop Expedited means people do not need to have tried non-surgical measures before they can be referred NICE mentions referral can be made as long as people are also receiving or will receive assessment in a tier 3 service or equivalent. BMI 35 and over + recent onset diabetes – offer an expedited referral BMI 30-34.9 + recent onset diabetes – consider assessment for bariatric surgery Asian family origin + recent onset diabetes – consider assessment for bariatric surgery
Blood pressure control Check BP atleast annually if no previous diagnosis of hypertension or renal disease Provide lifestyle advice If on antihypertensive Rx and new diagnosis of diabetes – review bp control and medication Make changes only if ♦ poor control ♦ current Rx inappropriate because of microvascular complications or metabolic problems
Lipid and CV risk- Do not offer antiplatelet Rx without cardiovascular disease Use validated risk assessment tools and see NICE guidance on Identification and assessment of CV risk
Blood glucose self monitoring –Do not routinely offer SMBG unless on insulin OR evidence of hypoglycemia episode OR on oral medication that may increase risk of hypoglycemia while driving or operating machinery OR pregnant or is planning to be pregnant
Consider short- term SMBG and review treatment if necessary if starting treatment with oral or IV corticosteroids OR to confirm suspected hypoglycemia Patients who have an inter-current illness are at risk of worsening hyperglycemia . Review Rx as necessary.If on SMBG -do a structured annual assessment which includes SMBG skills quality and frequency of testing how to interpret results and what action to take impact on quality of life continued benefit equipment
Eye disease- Explain , refer for annual eye testing -screening should be done ASAP and no later than 3 months from referral Arrange emergency review by an ophthalmologist for ♦ sudden visual loss ♦ rubeosis iridis ( neovascularization of iris ) ♦ pre-retinal or vitreous haemorrhage ♦ retinal detachment Arrange rapid review by ophthalmologist for new vessel formation Refer is any of these – based on guidance by National Screening Committee criteria ♦ referable maculopathy ♦ referable pre-proliferative retinopathy ♦ any sudden drop visual acuity
Erectile dysfunction Discuss during annual review Assess , educate and support -address contributory factors as CV dis and discuss Rx options Offer a PDE-5 inhibitor once CI ruled out Refer to a service offering medical , surgical or psychological Rx if PDE-5 Rx unsuccessful
Gastroparesis- Think of gastroparesis if ♦ erratic bl gl control OR ♦ unexplained gastric bloating or vomiting taking into account possible alternative diagnosis If vomiting caused by gastroparesis , explain ♦ no strong evidence that any available anti-emetic Rx is effective ♦ some people have had benefit with domperidone , erythromycin or metoclopramide ♦ strongest evidence with domperidonne . Take into account cardiotoxicity and potential interactions Consider alternating use of erythromycin and metoclopramide and use domperidone only in exceptional circumstances Refer if ♦ differential diagnosis is in doubt ♦ persistent or severe vomiting.
References Based on NICE guidance – Type 2 diabetes in adults : management ( 2015 updated 2017 ) NG 28