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The Annual Review. How we evaluate the effectiveness of treatment. Diabetes UK checklist for annual review . Diabetes UK. (Accessed 2009). Assess clinical aspects.

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The Annual Review

How we evaluate the effectiveness of treatment.

Diabetes UK checklist for annual review

Diabetes UK. (Accessed 2009)

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. (Accessed 2009)

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

Do you know your numbers?

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

Clinical Goals

Diabetes UK Know your numbers 2008 Leceistershire Body Mass ready Reckoner for Adults

Clinical Goals

Diabetes UK Know your numbers 2008

Urine Testing

  • Why do we ask for a sample?

  • What do we test for?

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


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


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


Albumin Creatinine Ratio (ACR)

  • Diabetes patient test range:

    • Male<2.5mg/mmol

    • Female<3.5mg/mmol

NHS Tayside Diabetes Managed Clinical Network Handbook 2010


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


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


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

Blood glucose targets

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 (accessed 2009) (accessed 2009) (accessed 2009)

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)

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

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

Owens D et al. Diabetes and Primary Care 2005;7:9–21

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

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: (Accessed 2009)

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

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

Blood glucose monitoring

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

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 (Accessed 2009)Owens D et al. Diabetes and Primary Care 2005;7:9–21

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. (Accessed 2009) (Accessed 2009)

Owens D et al. Diabetes and Primary Care 2004;6:8–16

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

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, (Accessed 2009)

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 (accessed 2010) (accessed 2010) (accessed 2010) (accessed 2010)

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

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)

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


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

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

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

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

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

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 (accessed 2009) (accessed 2009)

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 (accessed 2009)

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

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

2.9 years

Novo Nordisk. Type 2 Diabetes Market Research

Treatment options for type 2 diabetes

Insufficient glycaemic control with lifestyle

Antidiabetic agents – EARLIER!

Nathan DM et al. Diabetes Care 2009;32:193–203

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

Injection sites and techniques

Injection sites

Insulin should be injected into subcutaneous fat

Several injection sites can be used:




Insulin should not be injected through clothing

Fastest absorption

Slowest absorption

Royal College of Nursing. (Accessed 2009)

Needle management

It is recommended that needles are used only once

After use, they should be detached from the device and disposed of in a sharps’ bin

Royal College of Nursing. (Accessed 2009)

Needle re-use issues

Can cause increased pain if blunt

Can bend or break

Non-sterile - increased risk of infections

Crystallisation of old insulin in the needle bore may block needle leading to altered insulin flow

  • Change in insulin concentration due to evaporation

  • Air can enter the insulin through the needle, which lowers the dose

  • Reusing needles can increase the number of complaints regarding needles and devices

Royal College of Nursing. (Accessed 2009)

Resuspending insulin

Cloudy insulin preparations need resuspending before use:

e.g., NPH insulin, premixed insulin

Clear insulins do not need resuspending:

e.g., insulin detemir (Levemir®),insulin glargine (Lantus®)

Resuspension should be performed before any of the other actions

If resuspension is required, invert or roll the pen in your hands at least 10 times before using

Royal College of Nursing. (Accessed 2009)

Performing air-shots (Priming)

A two unit air-shot should be performed before each injection

Check dose setting is at 0 and dial 2 units

  • Point device upwards (needle to ceiling) and tap gently with finger

  • Push button and a drop of insulin should appear at tip of needle

Injection technique



Needle insertion

  • Insert the needle at ~90º (or 45º if a longer needle is used)

  • Push needleall the way in

  • Push the buttonto inject the insulin

  • Leave the needlein place for 5–10 seconds

  • Remove the needle

  • If required, pinch skin before inserting the needle:

    • Squeeze skin between your thumb and two fingers

    • Insert the needle

    • Hold the pinch

    • Inject the insulin

    • Leave the needlein place for a count of 10

    • Release your grip on skin

    • Remove the needle

Getting the ‘pinch up’ right

Royal College of Nursing. (Accessed 2009)

Insulin practicalities

Practicalities: insulin storage

  • Storage requirements for insulin differ for each product. General guidelines are given below; please refer to individual prescribing information for further details

  • Insulin should be kept out of reach of children

  • *some insulins can be kept at up to 30ºC.

Royal College of Nursing. (Accessed 2009)

Practicalities: sharps’ disposal

Patients must ensure that they dispose of needles responsibly

Needles should be removed from devices before they are discarded

Used needles should be discarded in a sharps’ bin

Sharps’ bins and clippers are usually available on prescription

Filled sharps’ bins can usually be:

Returned to the practice for disposal

Collected by arrangement with local authorities

But, check your local/regional guidelines!

Diabetes UK. Position statement: safe disposal of needles and lancets (Sharps). (Accessed 2009).

Informing the authorities

Who needs to know about your diabetes?

DVLA must by law be informed if you manage your diabetes with insulin

If your insurance company asks you about diabetes then you must tell them

Some companies may refuse cover or charge more. If so, you should challenge them or consider going elsewhere

Diabetes UK (Accessed 2009)

Out-of-hours support

What should the patient/carer do if out-of-hours support is required?

Specialist diabetes nurse

Emergency number of general practice

Helpline run by insulin manufacturer (if available)

NHS direct: 0845 4647

999 if necessary

This slide may need to be adapted for different regions

Key summary points

Use a checklist:

to ensure that you have provided your patients with all the practical information that they need

to identify areas for ongoing education and support

Document that you have informed patients of legal requirements

Insulin delivery devices

Many devices are available: patients must be comfortable with their device

Patients are more likely to adhere to their insulin regimen if they feel comfortable with their injection device

Better adherence will improve their clinical outcomes

If the patient is unhappy with their device, they may not inject properly or they may miss injections

Arriving at the right choice of device

A range of injection devices is available:

Most are discreet in appearance and look like a pen

Two basic types: disposable and re-usable

Devices can accommodate special requirements, e.g., poor vision

Bohannon NJ. Postgrad Med 1999;106:57–8, 61–4, 68

Some commonly used devices

Autopen® 3 ml(Owen Mumford)

HumaPen® Memoir (Lilly)

NovoPen®4(Novo Nordisk)

Autopen® 24(Owen Mumford)

NovoPen®3 Demi(Novo Nordisk)

HumaPen® Luxura(Lilly)


Re-usable (cartridge)




Humalog® Pen(Lilly)


(Novo Nordisk)


(Novo Nordisk)



HumaPen, Humalog and KwikPen are registered trademarks of Eli Lilly; Autopen is a registered trademark of Owen Mumford; NovoPen, FlexPen and Innolet are registered trademarks of Novo Nordisk;Opticlik, Optiset, and Solostar are registered trademarks of Sanofi-Aventis

Example device to reduce the risk of needlestick injury

There are an estimated 100,000 needlestick injuries every year in the UK1

NovoFine® Autocover™

A single-use 8 mm 30G needle with automatic shield feature

Minimises accidental needlestick injuries and needle re-use

May hinder disease transmission by eliminating needle protrusion

Can be used to overcome needle anxiety by concealing the needle

Adapts to existing injection devices (except PenMate®)


Autocover is a registered trademark of Novo Nordisk

Key summary points

Different devices are available

Patient must be comfortable with the device to optimise self-management

Ensure that you take into account patient preferences for device

Device selection may affect insulin choice (and vice versa)

The effects of illness on insulin

Effects of illness on insulin requirements

Illness can affect insulin requirements for several reasons:

In general, blood glucose increases during illness

Blood glucose may rise even if patient is unable to eat

Diabetes UK. (Accessed 2009)

Sick day rules

Continue to take insulin

Test blood for glucose at least four-times daily:

Insulin dose may need to be increased

Test urine for ketones if blood glucose >13 mmol/l:

If positive, contact GP, nurse or hospital immediately

Try to eat normal meals; if unable to, replace meals with carbohydrate-containing drinks

Drink plenty of liquid

Contact named healthcare professional if at all uncertain about what to do

Diabetes UK. Suffolk Diabetes Service (Accessed 2009)

Hypoglycaemia: the basics

Hypoglycaemia overview


Is the main potential side effect of insulin

Results from an imbalance between insulin and food intake (i.e., too much insulin and not enough food)

Hypoglycaemic symptoms occur when blood glucose concentration falls below normal levels:

Technically defined as blood glucose <4 mmol/l

Symptoms may occur at higher concentrations if glucose levels were previously consistently too high

Royal College of Nursing. (Accessed 2009)

Hypoglycaemia can be mild or major

Early symptoms

Ability to self-treat

Mild hypoglycaemia




Blood glucose <4 mmol/l

Late, more severesymptoms

External assistance required

Major hypoglycaemia



Usually blood glucose <2.8 mmol/l

Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. (Accessed March 2010)

Hypoglycaemic symptoms

* Indicate most common. Henderson JN et al. Diabet Med 2003;20:1016–21

Royal College of Nursing. (Accessed 2009)

Treating hypoglycaemia

Royal College of Nursing. (Accessed 2009)

Causes of hypoglycaemia: some examples

Many things can contribute to hypoglycaemia, e.g.,:

Taking insulin at the wrong time

Missing insulin doses and overcompensating later

Inaccurate doses

Missing meals

Dietary changes without dose adjustments

Problems with injection technique or injection site

Failure to fully resuspend premixed or intermediate insulin



Other illnesses

Royal College of Nursing. (Accessed 2009)

Key summary points

Early in the support process, the main aims of hypoglycaemia discussions are to:

Raise awareness of hypoglycaemia

Ensure that the patient knows what to do if they experience hypoglycaemia

Ensure detail is appropriate to the patient:

Some patients are less responsive or less able to understand

Try to alleviate fear of hypoglycaemia:

May be a fear of the unknown

Today, while we’ve been talking…

























People have been diagnosed with diabetes in the UK














People have died fromdiabetes-related illnesses

Diabetes – an urgent global challenge

  • Diabetes:

  • Is the leading cause of adult blindness in developed countries1

  • Causes more limb amputations than any other disease2

1. IDF, Diabetes facts and figures

2. IDF Fact Sheet ; Why you should care

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