Diabetes
Over 36,000 people in Somerset are diagnosed with diabetes, which is more than 6% of the population.
Type 1 diabetes (0.5%) and Type 2 diabetes (5.7%). 10% of the annual NHS budget is spent on treatment. On this page you will find useful information and resources to optimise treatment of your patients and improve outcomes for this complicated long term condition.
Measuring annually the 8 care processes is key to determining the treatment regimes, and achieving the three treatment targets of HbA1c, blood pressure and cholesterol.
- Blood glucose level measurement (HbA1c)
Optimum level between 48 mmol/mol and 58mmol/mol. Targets are individual to patient. - Blood pressure measurement
<140/80 mmHg with no kidney, eye or cerebrovascular damage; <130/80 mmHg with evidence of kidney, eye or CV damage - Cholesterol
Total cholesterol should be 5.0 millimoles per litre (mmol/L) or lower - Kidney function testing (Urinary albumin)
<2.5 mg/mmol for men;
<3.5 mg/mmol for women. Ideal ACR < 3 for both - Kidney function testing (Serum creatinine) to calculate eGFR
- Weight check
Aim for a healthy weight between a BMI of 18.5 and 24.9 kg/m2 - Smoking status
Check smoking status at annual review - Foot examinations
Screening at least annually
Chronic Kidney Disease is often linked to diabetes, and fortunately we now have evidence to support outcomes in SGLT-2 inhibitors (gliflozins) which we hope will transform the treatment of type 2 diabetics with CKD, existing CVD and high CVD risk.
For any diabetes related medication queries please contact your ICB pharmacist.
Guide to medication in diabetes
Medication in diabetes should not just be focused on reducing Hba1c levels. The risks of diabetes require good cholesterol and blood pressure control. Non pharmacological interventions of weight control and smoking cessation, as well as regular foot and eye checks are important.
–Glycaemic control medication in type 2 diabetes
Blood glucose testing
Continuous Glucose Monitoring (CGM)
CGM measures interstitial glucose levels not serum levels, but gives a good indication of when blood glucose is rising or falling. isCGM or flash monitoring requires regular scanning of the sensor with a smartphone or meter. Real time rtCGM routinely updates your device without scanning.
Who qualifies?
Type 1 diabetes
All type 1 diabetics qualify for CGM on NHS.
Offer adults with type 1 diabetes a choice of real-time continuous glucose monitoring (rtCGM) or flash continuous glucose monitoring , based on their individual preferences, needs, characteristics, and the functionality of the devices available.
Somerset has approved GlucoRX Aidex (£780 per year) https://www.glucorx.co.uk/glucorx-aidex/ Dexcom One (£912 per year) https://www.dexcom.com/en-gb/dexcom-one-cgm and Freestyle Libre Link
Type 2 diabetes
Offer isCGM (flash) to adults with type 2 diabetes on multiple daily insulin injections if any of the following apply:
>they have recurrent hypoglycaemia or severe hypoglycaemia
>they have impaired hypoglycaemia awareness
>they have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood glucose by capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)
>they would otherwise be advised to self-measure at least 8 times a day.
Offer isCGM to adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose.
Consider real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for adults with insulin-treated type 2 diabetes if it is available for the same or lower cost. Dexcom One and GlucoRX Aidex are approved for this purpose.
Diabetes in pregnancy
Offer real-time continuous glucose monitoring (rtCGM) to all pregnant women with type 1 diabetes to help them meet their pregnancy blood glucose targets and improve neonatal outcomes.
Offer flash CGM to pregnant women with type 1 diabetes who are unable to use rtCGM or express a clear preference for isCGM.
Consider rtCGM for pregnant women who are on insulin therapy but do not have type 1 diabetes, if:
•
they have problematic severe hypoglycaemia (with or without impaired awareness of hypoglycaemia) or
•
they have unstable blood glucose levels that are causing concern despite efforts to optimise glycaemic control.
Flash monitoring Freestyle Libre
Easy read materials can be found on the Freestyle website.
GlucoRx AiDEX
First Realtime CGM product to be available in the Drug Tariff. AiDEX gives realtime updates every 5 mins with no need to scan. Suitable for over 14 years old.
RESTRICTED USE ONLY- GlucoRx AiDEX should be an option for all patients with type 1 diabetes as per NICE guidance.
Low calorie diet programme
The NHS is delivering a new programme which provides a low-calorie diet treatment for people who are overweight and living with type 2 diabetes.The programme is based on the DiRECT study which showed that this approach could help people lose weight, improve their diabetes control, reduce diabetes-related medication and even achieve remission (whereby blood glucose levels return to normal without the need for medication). Somerset has been chosen as a pilot site for interested participants. see link below to the Teamnet website
Prescribing in frailty
Frailty plays a big part in our decision making for diabetes related medication. HbA1c and blood pressure targets will differ from the general population.
SGLT-2 inhibitors
SGLT-2 inhibitors (gliflozins) have evidence to improve outcomes in diabetic patients, particularly those with a high risk of or established cardiovascular disease (CVD), heart failure and chronic kidney disease (CKD)
Type 2 diabetes and CKD
persistent proteinuria (ACR ≥3mg/mmol)
Chronic kidney disease (CKD) is a very common long-term complication of diabetes. An estimated 40 per cent of people with both type 1 and type 2 diabetes will develop CKD (Stages 1 to 5) during their lifetime. Evidence shows that if recognised early, kidney disease in diabetes can be effectively slowed down.