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The Annual Review

The Annual Review. How we evaluate the effectiveness of treatment. Diabetes UK checklist for annual review . Diabetes UK. http://www.diabetes.org.uk/Documents/Professionals/Patient_records_care_rec.doc (Accessed 2009). Assess clinical aspects.

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The Annual Review

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  1. The Annual Review How we evaluate the effectiveness of treatment.

  2. Diabetes UK checklist for annual review Diabetes UK. http://www.diabetes.org.uk/Documents/Professionals/Patient_records_care_rec.doc (Accessed 2009)

  3. Assess clinical aspects Review glucose measurements (e.g., HbA1c, self-monitored blood glucose readings) Examine for signs of microvascular and macrovascular disease Consider cardiovascular risk (blood pressure, lipids) Examine injection sites for lipohypertrophy Diabetes UK. http://www.diabetes.org.uk/Documents/Professionals/Patient_records_care_rec.doc (Accessed 2009)

  4. Document your consultation Document the review In the patient’s medical record In the patient’s personal take-home record card (if applicable) Ensure other members of the healthcare team are informed

  5. Do you know your numbers?

  6. Know your numbers? Workshop • In pairs or small groups please discuss the targets for: • HbA1c • Blood pressure • Cholesterol (total, triglycerides, LDL & HDL) • Waist circumference • BMI

  7. Clinical Goals Diabetes UK Know your numbers 2008 Leceistershire Diabetes.org.uk Body Mass ready Reckoner for Adults

  8. Clinical Goals Diabetes UK Know your numbers 2008

  9. Urine Testing • Why do we ask for a sample? • What do we test for?

  10. Urine Screening • Nephropathy (kidney disease) often occurs 15-25 years following onset of diabetes • It may seem to appear sooner in Type 2 patients, because diabetes may have been present but undiagnosed for several years • Development of renal disease is made worse by poor glucose control, hypertension, dyslipidaemia and smoking • Early detection and effective treatment can slow progression of nephropathy, therefore screening is vital NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  11. Urine testing • Diabetic nephropathy (kidney disease) is detected clinically by the presence of microalbuminuria or proteinuria • Urinary albumin creatinine ratio (ACR) is now the preferred measurement for diagnosing and monitoring diabetic nephropathy. • Microalbuminuria refers to urine albumin concentrations that are below the limit of detection of routine urine dipsticks • Proteinuria refers to urine albumin concentrations that are detectable by routine dipsticks (i.e. dipstick positive) • Dipstick testing of urine is not recommended for the diagnosis of proteinuria NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  12. Urine samples • A random sample can be sent to check for the albumin creatinine ratio (ACR) but some laboratories will require an early morning specimen • It is good practice to dip stick test urine at the point of care to check for the presence of blood and other abnormalities, such as if a urinary tract infection is suspected. NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  13. Albumin Creatinine Ratio (ACR) • Diabetes patient test range: • Male<2.5mg/mmol • Female<3.5mg/mmol NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  14. Other Tests for Renal Function • eGFR is estimated Glomerular Filtration Rate • It is calculated from the serum creatinine concentration, age and sex.  •  Creatinine clearance is a more accurate way to detect changes in kidney status than measurement of serum urea and creatinine • eGFR is blood test which can be requested at the same time as U&Es NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  15. How are the results interpreted? •  eGFR is used to measure the severity of kidney damage • There are 5 stages of CKD (Chronic Kidney Disease) • kidney function is normal in Stage 1 • kidney function is minimally reduced in Stage 2 NHS Tayside Diabetes Managed Clinical Network Handbook 2010 from http://www.diabetes-healthnet.ac.uk/HandBook/Handbook.aspx

  16. Renal Screening Summary • Screen all patients aged 12 and over • Test at diagnosis and at regular intervals, usually annually • Perform a dipstick test at the point of care • Send a random sample to the biochemistry lab for urine albumin creatinine ratio (ACR) • Check U&Es & eGFR

  17. Blood glucose targets

  18. Setting glucose targets • Overall aim: glucose control as close to normal as possible • Targets should be individualised to the patient, considering: • Age • Body mass index (BMI) • Cardiovascular (CV) risk (e.g., blood pressure, cholesterol, smoking) • Hypoglycaemia risk • Patient choice • QOF points are achieved if: • 40–50% of patients have latest HbA1c≤7% (≤53 mmol/mol)[max 17 points] • 40–70% of patients have latest HbA1c≤8% (≤64 mmol/mol) [max 8 points] • 40–90% of patients have latest HbA1c≤9% (≤75 mmol/mol) [max 10 points] QOF, Quality and Outcomes Framework http://www.diabetes.org.uk/Documents/Professionals/primary_recs.pdf (accessed 2009) http://www.nice.org.uk/nicemedia/pdf/CG87QuickRefGuide.pdf (accessed 2009)http://www.bma.org.uk/images/QOFchanges200910_tcm41-178932.pdf (accessed 2009)

  19. Glucose control Overall aim of diabetes treatments: To achieve near-normal glucose control (normoglycaemia) Blood glucose not too high, nor too low Glucose control is measured using: Day-to-day blood readings Laboratory assessments, e.g., HbA1c (%) (a measure of the average amount of glucose in blood in the preceding 2–3 months)

  20. Explaining HbA1c to your patients What is HbA1c? Over time, glucose in the blood slowly attaches to a chemical called haemoglobin in red blood cells Glycosylated haemoglobin or HbA1c Once attached, the glucose will stay there for the life of the red blood cell, around 120 days The more glucose that is attached, the higher the HbA1c level will be Owens D et al. Diabetes and Primary Care 2005;7:9–21

  21. Explaining HbA1c to your patients Why should HbA1c be measured? HbA1c changes slowly so it provides an indication of the average glucose level in the preceding 2–3 months HbA1c should complement, and not replace, self-monitored glucose readings HbA1c should be measured every 2–6 months, until stable at desired level, and then 6 monthly (NCC-CC/NICE guidance) Lowering HbA1c has been shown to reduce the development of eye, kidney and nerve disease http://www.nice.org.uk/Guidance/CG66/Guidance/pdf/English Owens D et al. Diabetes and Primary Care 2005;7:9–21

  22. A new HbA1c assay • A number of assays are available for measuring HbA1c • Significant between-assay differences exist: • Problems for patients • Problems for clinical trials • The IFCC have now synthesised a definitive international reference material • New assay will provide results in mmol/mol IFCC, International Federation of Clinical Chemistry John WG et al. Clin Biochem Rev 2007;28:163–8

  23. Relating the new and the old numbers • Previous HbA1c (%) = (0.0915 x new IFCC result) + 2.15 • Easy way to remember = “minus 2, minus 2” rule • So if old HbA1c was 8%: 8 – 2 = 6 6 – 2 = 4 New HbA1c = 64 mmol/mol DCCT, Diabetes Control and Complications Trial Diabetes UK. HbA1c standardisation for clinical health care professionals. Available at: http://www.diabetes.nhs.uk/whats-on/downloads/hba1c_factsheets/hba1c_hcp_leaflet.pdf (Accessed 2009)

  24. Your turn! • Using the –2 –2 rule, what is the new mmol/mol HbA1c for: • 11%? • 6%? • 8%? 97 mmol/mol 11 – 2 = 9;9 – 2 = 7 42 mmol/mol 64 mmol/mol

  25. Your turn! • The –2 –2 rule only works for whole numbers • Using the equation: • What is the new mmol/mol HbA1c for: • 6.5%? • 7.9%? • 8.7%? = New HbA1c (mmol/mol) (HbA1c(%) – 2.15) x 10.929 48 mmol/mol 63 mmol/mol 72 mmol/mol

  26. Blood glucose monitoring

  27. Who should monitor? • Any testing & its frequency should be agreed on an individual basis • Any patient that tests should be appropriately educated • Insulin treated patients are likely to benefit from testing • There is no consensus about the clinical effectiveness for individuals with type 2 diabetes treated by tablets alone, HbA1c may be sufficient Diabetes UK 2010 Care recommendations. Self Monitoring of Blood Glucose

  28. Which type of monitoring? Glucose levels can be monitored at home in the blood or urine Urine testing is cheaper than blood testing, BUT: Glucose is usually only present in the urine during marked hyperglycaemia, so Urine testing is generally uninformative for insulin-treated patients Insulin-treated patients should use blood glucose monitoring to guide insulin dose adjustment Diabetes UK http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Self-monitoring_of_blood_glucose/ (Accessed 2009)Owens D et al. Diabetes and Primary Care 2005;7:9–21

  29. The importance of self-monitoring blood glucose Monitoring glucose is important for successful insulin treatment: It guides dose adjustment It allows patients to see the impact of behaviours and diet on glucose Patients should be encouraged to monitor blood glucose at appropriate intervals The most important aspect of self-monitoring is that patients use the results Diabetes UK. http://www.diabetes.org.uk/Documents/Professionals/primary_recs.pdf (Accessed 2009) http://www.nice.org.uk/Guidance/CG66/Guidance/pdf/English. (Accessed 2009) Owens D et al. Diabetes and Primary Care 2004;6:8–16

  30. Measurements of glucose in the blood The amount of glucose in the blood can be measured by the patient at different times: Fastingblood glucose is a measure of glucose in the blood after fasting/not eating overnight Pre-meal blood glucose is measured just before eating a main meal Post-prandial blood glucose is measured 1–2 hours after a meal

  31. When to take blood for testing Owens D et al. Diabetes and Primary Care 2004;6:8–16; Owens D et al. Diabetes and Primary Care 2005;7:9–21 Diabetes UK, http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Self-monitoring_of_blood_glucose/ (Accessed 2009)

  32. Recommended glucose targets for patients with type 2 diabetes If a patient has been given Ketostix and blood glucose is >13 mmol/l, patient should test urine for ketones NICE, National Institute for Clinical Excellence http://www.diabetes.org.uk/Documents/Professionals/primary_recs.pdf (accessed 2010)http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Self-monitoring_of_blood_glucose/ http://www.diabetes.org.uk/Guide-to-diabetes/Treatment__your_health/Monitoring/Blood_Glucose/Urine_testing/ (accessed 2010)http://www.nice.org.uk/nicemedia/pdf/CG87QuickRefGuide.pdf (accessed 2010) http://www.diabetesuffolk.com/ManagingDiabetes/Sick%20day%20rules.htm (accessed 2010)

  33. Ways of self-monitoring blood glucose Test strips are the standard method: Quick and easy Obtain a drop of blood from fingertip with lancet Place blood on test strip Read with small test meter or by using a colour chart

  34. How to take blood for testing • The fingertip is usually recommended for blood testing • Guidelines: • Wash hands with soap and warm water, and dry well • Shake and lower hand below waist level • Massage the fingertips to improve blood flow • Use the sides of the fingers • Keep meter clean and free of blood stains • Remember to calibrate meter if necessary • Keep a written record of readings • Where fingertip testing is problematic, other sites can be used with certain meters (e.g., thigh or forearm)

  35. Key summary points • There are lots of challenges that we face in helping our patients achieve glycaemic targets • HbA1c measurements are changing • Glucose targets should be individualised to the patient

  36. Lifestyle

  37. Initial treatment options for type 2 diabetes Behavioural modifications such as diet and exercise may provide glycaemic control in some patients Lifestyle – diet and exercise are always the underlying theme of care Nathan DM et al. Diabetes Care 2009;32:193–203

  38. Lifestyle choices: increased weight is associated with mortality *Data adjusted for age, gender, smoking and duration of diabetes Mulnier HE et al. Diabet Med 2006;23(5):516–21

  39. Lifestyle: the importance of weight • Decreased calorie intake combined with increased physical activity can result in:1 • Weight loss • Improved glucose control • Improved cardiovascular fitness 1. The Look AHEAD Research group. Diabetes Care 2007;30:1374–83

  40. General diet principles Dietary advice should: Focus on maintaining and improving health Aim to support optimal metabolic and physiological outcomes: As near to normoglycaemia as possible (without hypoglycaemia) Management of body weight, dyslipidaemia and hypertension Be individualised and take into account: Shift patterns Nutritional inadequacies Cultural or religious beliefs Diabetes UK Nutrition Subcommittee. Diabet Med 2003;20:786–807

  41. General guidelines for diet composition Total carbohydrate Mono-unsaturated fat 60–70% of energy intake + = Diabetes UK Nutrition Subcommittee. Diabet Med 2003;20:786–807

  42. Physical activity need not involve a formal exercise regimen • Guidelines are the same as for people without diabetes • Aim for 30 minutes of activity, at least 5 days per week • Can include: • Gardening • Housework • Walking http://www.diabetes.org.uk/Guide-to-diabetes/Treatment__your_health/Keeping_active/Activities_to_get_you_started/ (accessed 2009) http://www.diabetes.org.uk/Guide-to-diabetes/Treatment__your_health/Keeping_active/Before_you_start/ (accessed 2009)

  43. Lifestyle choices: alcohol • Moderate alcohol consumption is OK • Heavy alcohol consumption may increase risk of hypoglycaemia • Never drink on an empty stomach • Do not substitute alcohol for meals • Try to avoid drinks with a high sugar content • Have a carbohydrate snack before bed if significant amounts of alcohol have been drunk http://www.diabetes.org.uk/Guide-to-diabetes/Food_and_recipes/Alcohol_and_diabetes/ (accessed 2009)

  44. Lifestyle choices: smoking • Smoking increases risk of diabetes complications • Cardiovascular disease • Mortality • Kidney disease • Neuropathy • Retinopathy(?) Smoking cessation advice should be a routine component of diabetes care Haire-Joshu D et al. Diabetes Care 1999;22;1887–98

  45. Lifestyle as a treatment choice • Appropriate lifestyle choices should always be encouraged in diabetes management1 • For the majority of patients, however, these changes will be insufficient to maintain long-term glycaemic control1 • Only 25% of newly-diagnosed patients maintained HbA1c<7% after 3 years using diet alone2 • This declined to 9% after 9 years On average, how long do you think someone diagnosed with type 2 diabetes remains on diet and exercise? 1. Nathan DM et al. Diabetes Care 2009;32:193–203 2. Turner et al. JAMA 1999;281:2005–12

  46. 2.9 years Novo Nordisk. Type 2 Diabetes Market Research

  47. Treatment options for type 2 diabetes Insufficient glycaemic control with lifestyle Antidiabetic agents – EARLIER! Nathan DM et al. Diabetes Care 2009;32:193–203

  48. Key summary points • Lifestyle changes are the first-line treatment for type 2 diabetes • Changes in lifestyle can reduce HbA1c and may cause remission • Most people are left too long on diet and exercise • Consider pharmacological treatments earlier, as soon as diagnosis of type 2 diabetes is made

  49. Injection sites and techniques

  50. Injection sites Insulin should be injected into subcutaneous fat Several injection sites can be used: Abdomen Thighs Buttocks Insulin should not be injected through clothing Fastest absorption Slowest absorption Royal College of Nursing. http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf (Accessed 2009)

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