Uzma HaqueGP Reg.

Education & Lifestyle Adjustments Glucose control

Oral medications Insulin therapy

CV risk estimation Blood pressure Lipid modification End organ damage

Eye Kidney Nerve

Education Maintain blood glucose levels-diet Lipid modifications Smoking cessation Obesity advice Maintain psychological well being

Targets Renal/eye/CV damage- <130/80mmhg Others < 140/80 mmhg

If on Anti-hypertensives r/v 1-2 monthly until consistently below target

If stable Monitor 4-6 omnthly Monitor for SE

Age (40 years) CV risk (over 20%/10 years UKPDS) Total cholesterol <4.0 mmol/litre

HDL ≤ 1.4 mmol/litre LDL-C < 2.0 mmol/litre

If TG high check causes If >4.5 mmol/litre persistently Offer Fibrates

Assess lipid profile 1-3 months at first Then Annually

Offer Low-dose ( 75mg ) aspirin/clopidogrel

Age 50+ & BP <145/90 mmhg

Age < 50 & significant CV risk

Monitoring Investigation Interpretation Action

Annually, regardless of presence of nephropathy:● arrange ACR estimationon first-pass urinesample (or spot sample if necessary)● measure serumcreatinine● estimate GFR

If abnormal ACR1(in absence ofproteinuria/UTI):● repeat test at nexttwo clinic visits andwithin 3–4 months● microalbuminuria is confirmed if at least one out of two ormore results is alsoabnormal1.

Suspect renal disease other thandiabetic nephropathy andconsider further investigation/referral if ACR is raised and:● no significant or progressiveretinopathy, or● BP is particularly high orresistant to treatment, or● heavy proteinuria (ACR> 100 mg/mmol) but ACRpreviously documented asnormal, or● significant haematuria, or● GFR has worsened rapidly,or● the person is systemically ill.

If diabetic nephropathyconfirmed, offer ACEinhibitor with dosetitration to maximumdose (unless nottolerated).Substitute an A2RB ifACE inhibitors arepoorly tolerated.Maintain BP< 130/80 mmHg ifabnormal ACR

Gastropresis Erratic BGC/bloating/vomiting Metoclopramide/domperidone or refer

Erectile dysfunction r/v annually with men Phosphodiesterase-5 inh. If ineffective then refer

Foot problems- r/v annually Signs of Autonomic Neuropathy

Loss of warning signs for hypos Unexplained diarrhoea Unexplained bladder emptying

Diabetic symptomatic neuropathy management - a therapeutic summary

Enquire annually for neuropathic symptoms(paraesthesiae, burning sensations, shooting pains, other)

Assess severity if present(sleep disturbance, depression, interference with normal activities)

Maintain good blood glucose control

Non-severeOffer simple analgesiaMonitor for worsening

Monitor for worsening or remission

Add a trial of the cheapest (at maximum dose) of duloxetine, gabapentin, or pregabalin – monitor for response

controlled controlledUncontrolled*

SevereOffer local measures and trial of

tricyclic medication;monitor for response

Monitor for worsening or remission

controlled Uncontrolled*

Consider a trial of another of duloxetine, gabapentin, or pregabalin – titrate dose and monitor for response

Monitor for worsening or remission

controlled Uncontrolled*

Review for opiate analgesia, pain clinical referral and psychological support