- Diagnosis and Classification of Diabetes
- Initial Assessment and Criteria for Specialist Referral
- Glycaemic Control in Type 2 Diabetes - Oral Hypoglycaemic Agents
- Indications for Insulin in Type 2 Diabetes
- Hypertension
- Dyslipidaemia
- Aspirin Therapy in Diabetes
- Retinopathy
- Nephropathy
- Neuropathy and Foot Ulcers
- Sexual Dysfunction in Men
- Diabetes in Pregnancy and Pre-conception Guidance
2. Initial Assessment and Criteria for Specialist Referral
The initial assessment should confirm the diagnosis of diabetes and include a classification of diabetes, a search for complications, and an assessment of other cardiovascular risk factors. It is also important to assess the patient’s understanding of their disease and commence patient education.
The following is recommended:
- Enter patient details on practice register
- Discuss general aspects of diabetes and history of illness
- Establish patient’s level of knowledge of illness and educational needs
- Measure height and weight and calculate BMI
- Measure blood pressure
- Test urine for protein and ketones; arrange MSU if proteinuria
- Take blood for glucose, HbA1c, U+Es, LFTs, Lipid profile
- Examine feet for diabetic complications
- Consider initial psychological, educational and lifestyle issues
- Refer for podiatry care if peripheral vascular disease, neuropathy, or classified as "at risk" diabetic foot – see section 10
- Ensure retinal screening organised
- Introduce Diabetes UK
- Arrange next appointment – regular and early reviews may be necessary until the patient has a good understanding of diabetes and metabolic control
Referral Guidelines
Emergency:
- Protracted vomiting/dehydration/drowsiness – admit via RMO
- Diabetic foot – if cellulitis, abscess, wet gangrene – admit/same day assessment
Urgent (telephone or fax within 24 hours)
- Newly diagnosed child
- Newly diagnosed patient if clearly unwell or ketonuria (++ or more) – telephone referral to Diabetes Registrar or Diabetes Office within 24 hours (at weekend contact RMO)
- Pregnant women – refer to ANC to be seen within 1 working week
- Other newly diagnosed patients with type 1 diabetes – refer to Diabetes Team within 48 hours
- Sudden visual loss will normally be referred to Eye Casualty
Routine
- All patients with type 1 diabetes will be reviewed at least every six months in the hospital clinic
- Uncontrolled BP despite 3 or more agents
- Patients with type 2 diabetes with HbA1c >8% on maximum oral agents or hyperglycaemic symptoms on maximum oral agents for consideration of insulin therapy
- Diabetic foot ulcer (Joint Vascular Clinic)
- Lipid levels above targets despite maximal lipid lowering agents
- Painful neuropathy, suspected amyotrophy, mononeuropathy
- Severe claudication or ischaemic rest pain (Joint Vascular Clinic)
- Proteinuria >0.5g/24 hours, microalbuminuria in type 1 diabetes or creatinine >200µmol/L (Joint Renal Clinic)
- Pre-pregnancy counselling
- Psychological difficulties including distress associated with diagnosis, fear of complications, needle phobia, frequent hospital admissions related to diabetes self-management
- Sexual dysfunction if sildenafil unsuccessful or for second opinion re diagnosis or suitability or another treatment.
- Patients with stable well-controlled type 2 diabetes with no progression of complications will normally be expected to be managed within primary care.