No 45 - AKT Summary for T2DM QOF

Type 2 Diabetes Mellitus – Summary of Initial Management and Monitoring

1. This post is a really brief summary of NICE guidance and QOF - should be useful for AKT and actually managing newly diagnosed diabetic patients or for a refresher on monitoring…

2. New diabetics need a few referrals, coding and adding to follow up clinics

3. They need annual BP, BMI, foot check, cardiovascular screen and bloods – HbA1c, LFT, U/E, lipids,

4. There are 6 oral medications, insulin, statins and antihypertensives

5. Each medication has different monitoring but if in doubt start with the full list above and then repeat every 3, 6 or 12 months until a stable low HbA1c is achieved.

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Relevant Guidelines and Summary Documents

Moran G M, Bakhai C, Song S H, Agwu J C. Type 2 diabetes: summary of updated NICE guidance BMJ 2022; 377 :o775 doi:10.1136/bmj.o775

https://cks.nice.org.uk/topics/diabetes-type-2/

Birmingham CCG T2DM Guideline

Suspect a diagnosis of type 2 diabetes if there is:

• Persistent hyperglycaemia.

• Polydipsia, polyuria, weight loss, tiredness; enuresis, behavioural changes,

• Impaired growth (in children);

• Signs of acanthosis nigricans (suggesting insulin resistance).

• Diagnosis = HbA1c >48 mmol/mol [6.5%]

• Random plasma glucose >11.1 mmol/l

• Fasting plasma glucose >7.0 mmol/L

• If symptomatic – a single reading is diagnostic, a repeat is sensible

• If asymptomatic, then 2x high readings = diagnostic

• Fructosamin = alternative with haemoglobinopathy

Management of a person with type 2 diabetes should include:

(Doctor Responsibilities)

1. NICE Quality statement 1: Borderline diabetic patients are offered an intensive lifestyle-change programme

   1. Send self-referral letter via Accurx

2. Quality statement 2: Offer structured education programme at diagnosis

   1. Refer to nurses, task reception

3. (No 3 seems to be missing on the website)…Quality statement 4: After 6/12 single therapy if HbA1c level > 58 mmol/mol (7.5%)

   1. Offer dual therapy

4. Quality statement 5: High risk patients are referred to the foot protection service.

5. Quality statement 6: Adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.

6. Refer for retinopathy screening

7. Advising on how to manage intercurrent illness and 'sick-day rules'.

   1. https://diabetesonthenet.com/diabetes-primary-care/how-to-advise-on-sick-day-rules/

8. Advising against routine self-monitoring of blood glucose levels.

9. Assessing for associated psychosocial problems and offering support.

10. Advising on sexual health, contraception, and pre-pregnancy counselling, if appropriate.

11. Advising on the importance of regular screening for complications, how to reduce risk, and offering management as appropriate.

12. For children:

    a.      Quality statement 1: referred to a multidisciplinary paediatric diabetes team on the same day.

    b.      Quality statement 2: offer a programme of diabetes education from diagnosis

    c.      Quality statement 6: offer access to mental health professionals

13. Advising on the importance of regular HbA1c monitoring, antidiabetic drug treatment (if appropriate), and individualized treatment targets, to reduce the risk of long-term complications.

T2DM Medical Management

1. Metformin (1) = 1st line

   1. Check U/E and eGFR before starting

   2. Annually eGFR if normal function, otherwise twice yearly

   3. Gradually increase dose

   4. Stop Metformin if eGFR <30 mL/min/1.73 m2 or acutely unwell

   5. Caution – renal impairment, acutely unwell

2. SGLT-2 inhibitors (4) = 2nd line for most people

   1. Caution – DKA risk, acutely unwell, low carb or keto diet, renal impairment, liver failure, lower leg skin lesions, hypotension, Lithium treatment, thrush and UTI risk,

   2. Must be documented that you warned about fournierres gangrene

   3. Due to the hypotension risk patients should be monitoring their BP at home. Consider reducing antihypertensives when starting.

   4. Gradually increase dose

   5. Check U/E and eGFR and LFT before starting

   6. Annually eGFR if normal function, otherwise twice yearly

3. Sulfonylureas (5)

   1. Caution – obesity (weight gain) or renal impairment

   2. Patients must be warned about hypoglycaemia and test their BM regularly

4. DPP-4 inhibitors (5)

   1. Check U/E and eGFR before starting and LFTs

   2. Annually eGFR if normal function, otherwise twice yearly

   3. Vildagliptin: LFT 3/12 for the first year, and periodically thereafter.

   4. Caution – renal impairment, liver failure, heart failure

5. Pioglitazone (1)

   1. Check LFT before starting

   2. Caution – heart failure, osteoporosis, high risk of bladder cancer, haematuria

   3. Reassess at 3/12 and 6/12

   4. Monitor LFT and signs of heart failure

6. GLP-1 receptor agonists (5)

   1. Caution – ketoacidosis, pancreatitis, renal impairment, hepatic impairment, GI disease, women of child bearing age, heart failure, thyroid disease, retinopathy

   2. Should only be started by a clinician confident in their use

7. QOF DM006 – Dx of nephropathy

   1. Proteinuria or micro-albuminuria – ACE-I or ARB

8. QOF DM022 in last 36 months recorded –

   1. age >40, CVD QRISK2 <10% on a statin

9. QOF DM023 in last 12 months recorded – History of IHD on a statin

   1. Elevated lifetime risk of cardiovascular disease

   2. Defined as the presence of ≥1 cardiovascular risk factor in someone aged <40 years = hypertension, dyslipidaemia, smoking, obesity, family history (in a first degree relative) of premature cardiovascular disease

   3. Start a statin

10. If dual therapy doesn’t control blood glucose then consider starting Insulin

Management of a person with type 2 diabetes should include:

(Nurse Responsibilities)

1.      Ensuring they have an individualized care plan, taking into account their age, preferences, co-morbidities, and risks and benefits of treatment.

2.      Advising on sources of information and support.

3.      Advising on always wearing or carrying some form of diabetes identification.

4.      Advising on lifestyle measures, such as diet, exercise and physical activity, weight loss, smoking, alcohol, and drug misuse.

5.      Ensuring young people are supported in the transition from paediatric to adult services.

6.      QOF DM017 – keep a register of all diabetes patients

7.      QOF DM002 in last 12 months recorded – BP <150/90

8.      QOF DM003 in last 12 months recorded - BP <140/80

9.      QOF DM004 in last 12 months recorded – total cholesterol < 5

10.   QOF DM005 in last 12 months recorded – ACR recorded

11.   QOF DM007 in last 12 months recorded – HbA1c <59

12.   QOF DM008 in last 12 months recorded – HbA1c <64

13.   QOF DM009 in last 12 months recorded – HbA1c <75

14.   QOF DM011 in last 12 months recorded – retinal screening

15.   QOF DM012 in last 12 months recorded – foot examination and risk score

16.   QOF DM014 in last 9 months recorded – referred to structured education

17.   QOF DM018 in last 12 months recorded – influenza and pneumococcal immunisation

18.   QOF DM019/20/21 without moderate/severe frailty – BP and HbA1c

19.   QOF DM022 in last 36 months recorded – age >40, CVD QRISK2 <10% on a statin

20.   SMOK002 in last 12 months recorded – current smokers offered smoking cessation = CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses