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Diabetes

About

What is covered

This pathway covers the management of type 1 and type 2 diabetes in children, young people and adults, including diabetes in pregnancy and foot care.
Diabetes is 1 of the most common chronic diseases in the UK and its prevalence is increasing. In 2013, there were almost 2.9 million people in the UK diagnosed with diabetes. By 2025, it is estimated that more than 5 million people in the UK will have diabetes. In England, the number of people diagnosed with diabetes has increased by approximately 53% between 2006 and 2013, from 1.9 million to 2.9 million. The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.
Diabetes care is typically complex and time-consuming, drawing on many areas of healthcare management. The necessary lifestyle changes, the complexities of management, and the side effects of therapy make self-monitoring and education for people with diabetes central parts of management.
Foot care is particularly important in people with diabetes because delay in the diagnosis and management of foot problems increases morbidity and mortality and contributes to a higher amputation rate.
Diabetes in pregnancy is associated with risks to the mother and developing fetus. Additional care should be offered in the antenatal, intrapartum and postnatal periods to women with diabetes and their babies.

Updates

Updates to this pathway

25 August 2015 Major update on publication of the updated guidelines on type 1 diabetes in adults (NG17), diabetes in children and young people (NG18) and diabetic foot problems (NG19).

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Management of type 1 and type 2 diabetes, including diabetes in pregnancy and foot care

What is covered

This pathway covers the management of type 1 and type 2 diabetes in children, young people and adults, including diabetes in pregnancy and foot care.
Diabetes is 1 of the most common chronic diseases in the UK and its prevalence is increasing. In 2013, there were almost 2.9 million people in the UK diagnosed with diabetes. By 2025, it is estimated that more than 5 million people in the UK will have diabetes. In England, the number of people diagnosed with diabetes has increased by approximately 53% between 2006 and 2013, from 1.9 million to 2.9 million. The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.
Diabetes care is typically complex and time-consuming, drawing on many areas of healthcare management. The necessary lifestyle changes, the complexities of management, and the side effects of therapy make self-monitoring and education for people with diabetes central parts of management.
Foot care is particularly important in people with diabetes because delay in the diagnosis and management of foot problems increases morbidity and mortality and contributes to a higher amputation rate.
Diabetes in pregnancy is associated with risks to the mother and developing fetus. Additional care should be offered in the antenatal, intrapartum and postnatal periods to women with diabetes and their babies.

Updates

Updates to this pathway

25 August 2015 Major update on publication of the updated guidelines on type 1 diabetes in adults (NG17), diabetes in children and young people (NG18) and diabetic foot problems (NG19).

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Aflibercept for treating diabetic macular oedema (2015) NICE technology appraisal guidance 346
Empagliflozin in combination therapy for treating type 2 diabetes (2015) NICE technology appraisal guidance 336
Canagliflozin in combination therapy for treating type 2 diabetes (2014) NICE technology appraisal guidance 315
Dapagliflozin in combination therapy for treating type 2 diabetes (2013) NICE technology appraisal guidance 288
Liraglutide for the treatment of type 2 diabetes mellitus (2010) NICE technology appraisal guidance 203

Quality standards

Quality statements

Structured education

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education.
Process
a) Proportion of people with diabetes who are offered structured education from the time of diagnosis.
Numerator – the number of people in the denominator offered structured education from the time of diagnosis.
Denominator – the number of people diagnosed with diabetes in the past 12 months.
b) Proportion of people with diabetes who start structured education from the time of diagnosis.
Numerator – the number of people in the denominator starting structured education from the time of diagnosis.
Denominator – the number of people diagnosed with diabetes in the past 12 months.
c) Proportion of people with diabetes who complete structured education from the time of diagnosis.
Numerator – the number of people in the denominator completing structured education from the time of diagnosis.
Denominator – the number of people diagnosed with diabetes in the past 12 months.
d) Proportion of people with diabetes whose structured education has been reviewed and reinforced annually.
Numerator – the number of people in the denominator whose structured education has been reviewed and reinforced within the past 12 months.
Denominator – the number of people with diabetes diagnosed over 12 months ago.

What the quality statement means for each audience

Service providers ensure that staff are enabled to offer structured educational programmes that fulfil nationally agreed criteria and are ongoing and accessible to all people with diabetes and/or their carers.
Healthcare professionals ensure they offer structured educational programmes that fulfil nationally agreed criteria to people with diabetes and/or their carers as part of their ongoing care.
Commissioners ensure they commission structured educational programmes that fulfil nationally agreed criteria and are ongoing and accessible to people with diabetes and/or their carers.
People with diabetes and/or their carers receive a diabetes education course to suit their needs that is delivered by trained staff. A healthcare professional should check every year whether the person would find further diabetes education useful, and diabetes education should continue to be available.

Source guidance

Data source

Structure: Local data collection. Contained within NICE guideline CG87 audit support clinical criteria, criteria 1–4.
Process: a), b), c) and d) Local data collection. Contained within NICE guideline CG87 audit support clinical criteria, criterion 1. The National Diabetes Audit collects data on structured education.

Definitions

The NICE guideline on type 1 diabetes in adults (recommendation 1.3.4) states that any structured education programme for adults with type 1 diabetes includes the following components:
  • It is evidence based, and suits the needs of the person.
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self manage diabetes.
  • It has a structured curriculum that is theory driven, evidence based and resource effective, has supporting materials, and is written down.
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
  • The outcomes are audited regularly.
There are a number of structured educational programmes available for diabetes. Some programmes will be more suitable for type 1 diabetes, and others for type 2 diabetes. Educators should select a programme and time its delivery tailored to the needs of the learner and/or the carer.

Equality and diversity considerations

All information about treatment and care, including a structured patient educational programme, should take into account age and social factors, language, accessibility, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

Nutrition and physical activity advice

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.
Process
a) Proportion of people with diabetes who receive personalised advice on nutrition from either an appropriately trained healthcare professional or as part of a structured educational programme.
Numerator – the number of people in the denominator receiving personalised advice on nutrition from either an appropriately trained healthcare professional or as part of a structured educational programme.
Denominator – the number of people with diabetes.
b) Proportion of people with diabetes who receive personalised advice on physical activity.
Numerator – the number of people in the denominator receiving personalised advice on physical activity.
Denominator – the number of people with diabetes.

What the quality statement means for each audience

Service providers ensure that diabetes services provide access to personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.
Healthcare professionals ensure that personalised advice on nutrition and physical activity is provided to the person with diabetes when required.
Commissioners ensure they commission from a diabetes care pathway that incorporates access to personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.
People with diabetes are given advice on diet and exercise from a trained healthcare professional or as part of their diabetes course.

Source guidance

Data source

Structure: Local data collection.
Process: a) and b) Local data collection. Contained within NICE guideline CG87 audit support clinical criteria, criterion 2.

Definitions

An appropriately trained healthcare professional is one with specific expertise and competencies in nutrition. This may include, but is not limited to, a registered dietitian who delivers nutritional advice on an individual basis or as part of a structured educational programme.
The healthcare professional should provide and time the advice about nutrition and physical activity appropriate to the needs of the person with diabetes.

Equality and diversity considerations

All information about treatment and care, including advice on nutrition and physical activity, should take into account age and social factors, language, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

Care planning

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.

Quality measure

Structure
Evidence of local arrangements and provision of resources to ensure that people with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.
Process
a) Proportion of people with diabetes who are offered annual care planning including documenting and agreeing goals and an action plan.
Numerator – the number of people in the denominator offered annual care planning including documenting and agreeing goals and an action plan.
Denominator – the number of people with diabetes.
b) Proportion of people with diabetes who participate in annual care planning including documenting and agreeing goals and an action plan in the past 12 months.
Numerator – the number of people in the denominator participating in annual care planning including documenting and agreeing goals and an action plan in the past 12 months.
Denominator – the number of people with diabetes.
Outcome
Patient satisfaction with diabetes care using validated patient survey criteria.

What the quality statement means for each audience

Service providers ensure people with diabetes participate in annual care planning with documented agreed goals and an action plan, and to support this, provide training for healthcare professionals.
Healthcare professionals ensure they are competent to support people with diabetes to participate in their care and enable them to agree on specific achievable goals and an action plan in annual care planning.
Commissioners ensure services are commissioned that provide training for healthcare professionals and encourage people with diabetes to participate in their own care.
People with diabetes are involved in annual planning for their own care, which includes agreeing on the best way to manage their diabetes and setting personal goals.

Source guidance

Adapted from Joint Department of Health and Diabetes UK Care Planning Working Group (2006) Care Planning in Diabetes.

Data source

Structure: Local data collection.
Process: a) and b) Local data collection.
Outcome: Local data collection.

Definitions

Adapted from Joint Department of Health and Diabetes UK Care Planning Working Group (2006) section 3 Care Planning in Diabetes.
Care planning is defined as a process that actively involves people in deciding, agreeing and sharing responsibility for how to manage their diabetes. It aims to help people with diabetes achieve optimal health by partnering with healthcare professionals to learn about, manage, and cope with diabetes and its related conditions in their daily lives.
Care planning is underpinned by the principles of patient-centeredness and partnership. It is an ongoing process of communication, negotiation and joint decision-making in which both the person with diabetes and the healthcare professional(s) make an equal contribution to the consultation.
At each care planning consultation the healthcare professional(s) gives the patient the opportunity to:
  • share information about issues and concerns
  • share results of biomedical tests
  • discuss the experience of living with diabetes and address needs to manage obesity, food and physical activity
  • receive help to access support and services
  • agree a plan for managing diabetes
  • address individual priorities and goals
  • identify priorities and/or goals that are jointly agreed including jointly setting a goal for HbA1c
  • identify detailed specific actions in response to identified priorities which include an agreed timescale.
Care planning incorporates:
  • nutritional advice
  • discussing psychological wellbeing
  • managing obesity
  • structured education
  • screening for complications
  • smoking cessation advice
  • physical activity
  • Expert Patients Programme
  • agreeing goals for HbA1c
  • agreeing plans for managing diabetes
  • discussing goals
  • follow-up support by telephone.
A guide to implementing care planning in diabetes is available from Diabetes UK, NHS National Diabetes Support Team, Department of Health and Health Foundation (2008) Year of Care – Getting to grips with the Year of Care: a practical guide.

Equality and diversity considerations

All information about treatment and care, including care planning, should take into account age and social factors, language, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

Blood glucose control

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes agree with their healthcare professional a documented personalised HbA1c target, and receive an ongoing review of treatment to minimise hypoglycaemia.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes are able to agree with their healthcare professional a documented personalised HbA1c target, and receive an ongoing review of treatment to minimise hypoglycaemia.
Process
a) Proportion of people with diabetes with a measured HbA1c.
Numerator – the number of people in the denominator with a measured HbA1c.
Denominator – the number of people with diabetes.
b) Proportion of people with diabetes who have an agreed target for HbA1c including a recently documented HbA1c.
Numerator – the number of people in the denominator with an agreed target for HbA1c including a recently documented HbA1c.
Denominator – the number of people with diabetes.
c) Proportion of people with diabetes achieving their HbA1c target.
Numerator – the number of people in the denominator achieving their HbA1c target.
Denominator – the number of people with diabetes.
d) Proportion of people with diabetes who have received a review of treatment to minimise hypoglycaemia in the previous 12 months.
Numerator – the number of people in the denominator receiving a review of treatment to minimise hypoglycaemia in the previous 12 months.
Denominator – the number of people with diabetes.
Outcomes
a) Reduction in complications associated with diabetes.

What the quality statement means for each audience

Service providers ensure local arrangements are in place to allow people with diabetes to agree and document a target HbA1c with their healthcare professional and receive ongoing review of treatment to minimise hypoglycaemia.
Healthcare professionals ensure they agree and document a target HbA1c with people with diabetes and ensure ongoing review of treatment to minimise hypoglycaemia.
Commissioners ensure they commission diabetes services that allow people with diabetes to agree and document a target HbA1c with their healthcare professional and receive ongoing review of treatment to minimise hypoglycaemia.
People with diabetes agree a target for HbA1c (a measure of blood sugar over 2–3 months) with their healthcare professional, and have their treatment reviewed continuously to help avoid low blood sugar (hypoglycaemia).

Source guidance

Data source

Structure: Local data collection. The National Diabetes Audit collect data on HbA1c levels.
Process: a), b), c) and d) Local data collection. The National Diabetes Audit collects data on HbA1c levels.
Outcome:
a) The National Diabetes Audit collects data on HbA1c levels.
Quality and Outcomes Framework (QOF) indicator DM 007 The percentage of patients with diabetes in whom the last IFCC HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months.
QOF indicator DM 008 The percentage of patients with diabetes, on the register, in whom the last IFCC HbA1c is 64 mmol/mol or less in the preceding 12 months
QOF indicator DM 009 The percentage of patients with diabetes, on the register, in whom the last IFCC HbA1c is 75 mmol/mol or less in the preceding 12 months.
b) Local data collection. Hospital Episode Statistics (HES) collects data on complications associated with diabetes and the English National Screening Programme for Diabetic Retinopathy collects data on incidence and severity of retinopathy in England.

Equality and diversity considerations

All information about treatment and care, including agreeing a target for HbA1c, should be tailored to the individual. It should be accessible to people with physical, sensory (for example, visual impairment) or learning disabilities, and to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate. Healthcare professionals will also need to consider cultural and religious requirements in relation to self management. For example, some religions include periods of fasting, and people with diabetes will need appropriate information about managing their blood glucose levels during these periods.

Medication

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.
Process
a) Proportion of people with diabetes who have received a medication review in the past 12 months.
Numerator – the number of people in the denominator receiving a review of medication in the past 12 months.
Denominator – the number of people with diabetes.
b) Proportion of people with diabetes whose blood glucose, blood pressure and blood lipids are managed in accordance with NICE guidance.
Numerator – the number of people in the denominator whose blood glucose, blood pressure and blood lipids are managed in accordance with NICE guidance.
Denominator – the number of people with diabetes.
c) Proportion of people with diabetes whose medications are not managed according to NICE guidance who have medical notes documenting clinical reasons for exception.
Numerator – the number of people in the denominator who have medical notes documenting clinical reasons for exception.
Denominator – the number of people with diabetes whose medications are not managed according to NICE guidance.
Outcome
Proportion of people with diabetes with a documented HbA1c level.
Numerator – the number of people in the denominator with a documented HbA1c level.
Denominator – the number of people with diabetes.
What the quality statement means for each audience
Service providers ensure that people with diabetes are able to agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.
Healthcare professionals ensure the person with diabetes understands and agrees with them to start, review and stop medication to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.
Commissioners ensure they commission services that enable the person with diabetes to agree with their healthcare professional to start, stop and review blood glucose, blood pressure and blood lipid lowering medications in accordance with NICE guidance.
People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure, and blood lipids (blood fats).

Source guidance

Data source

Structure: Local data collection.
Process: a) Local data collection. Quality and Outcomes Framework (QOF) indicator DM 006 The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro albuminuria who are currently treated with an ACE I (or ARBs).
b) Local data collection.
QOF indicator DM 007 The percentage of patients with diabetes in whom the last IFCC HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months.
QOF indicator DM 31 The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less in the preceding 15 months.
QOF indicator DM 17 The percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l or less.
NICE guideline CG87 audit support clinical criteria, criteria 6–21, 23–27, 30 and 34.
Process measure a) and b) will be measured by the next phase of the National Diabetes Audit in which all diabetes medications will be collected at patient level.
c) Local data collection.
Outcome:
The National Diabetes Audit collects data on HbA1c levels. Quality and Outcomes Framework (QOF) indicator DM 26 The percentage of patients with diabetes in whom the last IFCC HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months.

Definitions

People with diabetes will start, review and stop medications in accordance with NICE guideline CG87 recommendations 1.5–1.8 and NICE guideline NG17 sections 1.6, 1.7 and 1.13.
Healthcare professionals managing medications for people with diabetes should document the clinical reasons why NICE guidance is not followed for starting and stopping medications to lower blood glucose, blood pressure and blood lipids.

Insulin therapy

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes.

Quality measure

Structure
a) Evidence of local arrangements for a structured programme for initiating and managing insulin therapy including training and support for the healthcare professionals and the patients.
b) Evidence of local arrangements and locally agreed criteria for healthcare professionals to demonstrate and document training and competencies in initiating and managing insulin.
Process
a) Proportion of people with diabetes starting insulin therapy that is initiated by a trained healthcare professional.
Numerator – the number of people in the denominator starting insulin therapy initiated by a trained healthcare professional.
Denominator – the number of people with diabetes requiring insulin therapy.
b) Proportion of healthcare professionals initiating insulin therapy who have documented appropriate training for starting and managing insulin.
Numerator – the number of healthcare professionals in the denominator having documented appropriate training for starting and managing insulin.
Denominator – the number of healthcare professionals initiating and managing insulin therapy.
c) Proportion of people with diabetes who receive ongoing structured support to initiate and manage insulin therapy.
Numerator – the number of people in the denominator receiving ongoing support to initiate and manage insulin therapy.
Denominator – the number of people with diabetes starting insulin therapy.

What the quality statement means for each audience

Service providers ensure adequate staff training in initiating and managing insulin therapy within a structured programme.
Healthcare professionals ensure they are competent in insulin initiation and ongoing insulin management within a structured programme by accessing training and are able to support people with diabetes in managing their treatment.
Commissioners ensure they commission services that provide training and assess ongoing competency of healthcare professionals for initiating and managing insulin therapy within a structured programme.
People with diabetes who need insulin receive help and support from trained healthcare professionals, including help with starting on insulin and managing their treatment. This should include advice on adjusting the dose of insulin according to their blood sugar levels.

Source guidance

Data source

Structure: a) and b) Local data collection. Contained within NICE guideline CG87 audit support organisational criteria, criterion 6.
Process: a), b) and c) Local data collection.

Definitions

Therapy with insulin includes insulin pump therapy.
A structured programme employing active titration of insulin doses encompasses for the patient:
  • structured education
  • continuing telephone support
  • frequent self-monitoring
  • adjusting doses
  • understanding diet
  • managing hypoglycaemia
  • managing acute changes in plasma glucose control values
  • support from an appropriately trained and experienced healthcare professional
  • injection technique including site selection and care
  • managing sick days.
And should be:
  • evidence-based
  • quality assured
  • built around a structured curriculum
  • delivered by trained educators
  • audited.
Trained healthcare professionals must demonstrate and document appropriate training in initiating and managing insulin therapy. This may include evidence of continuing professional development, knowledge and skills framework (KSF) and evidence of supervision.

Equality and diversity

All information about treatment and care, including insulin therapy, should take into account age and social factors, language, accessibility, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate. The needs of people who have experienced visual loss should be considered by healthcare professionals initiating and managing insulin therapy, and they may require additional ongoing support and referral to low vision services. Additional support should also be considered for people who have a physical impairment that may impede self management of insulin.

Complications

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes are assessed annually for the risk and presence of complications, and these are managed appropriately.
Process
Proportion of people with diabetes who are assessed annually for the risk and presence of complications of diabetes, and these are managed appropriately.
Numerator – the number of people in the denominator receiving an assessment for the risk and presence of complications during the previous 12 months and are managed appropriately.
Denominator – the number of people with diabetes.
Outcome
Reduction in the incidence of complications associated with diabetes.

What the quality statement means for each audience

Service providers ensure that diabetes services recall and review people with diabetes for the risk and presence of complications and provide resources to enable assessment and appropriate management.
Healthcare professionals ensure they are competent to assess people with diabetes for the risk and presence of associated complications and manage them appropriately.
Commissioners ensure they commission services that assess for the risk and presence of complications associated with diabetes and manage them appropriately.
People with diabetes are checked for additional health problems associated with diabetes (for example, eye, nerve or kidney damage, cardiovascular disease, fatty deposits in the blood vessels or sexual problems), and for the risk of developing these problems. Any risks or problems identified are properly managed.

Source guidance

Recommendations on the management of complications associated with diabetes are included in:

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection. The National Diabetes Audit and Hospital Episode Statistics (HES) collect data on complications associated with diabetes.

Definitions

Complications associated with diabetes may include:
  • retinopathy
  • neuropathy – sensory and autonomic
  • nephropathy
  • cardiovascular disease
  • peripheral arterial disease
  • sexual dysfunction.

Equality and diversity considerations

Services for diabetes should be designed and tailored to take into account local ethnicity and cultural requirements to ensure accessibility to all communities.

Psychological problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes are assessed for psychological problems, which are then managed appropriately.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes are assessed for psychological problems, which are then managed appropriately.
Process
a) Proportion of people with diabetes assessed for psychological problems.
Numerator – the number of people in the denominator receiving an assessment for psychological problems in the past 12 months.
Denominator – the number of people with diabetes.
b) Proportion of people with diabetes and psychological problems whose psychological problem is managed appropriately.
Numerator – the number of people in the denominator whose psychological problem is managed appropriately.
Denominator – the number of people with diabetes and psychological problems.

What the quality statement means for each audience

Service providers ensure that diabetes services assess and appropriately manage psychological problems in people with diabetes.
Healthcare professionals ensure they have adequate training to assess psychological problems in people with diabetes and are familiar with referral pathways to ensure psychological problems are managed appropriately.
Commissioners ensure they commission diabetes services that assess and appropriately manage psychological problems in people with diabetes.
People with diabetes are checked for psychological problems (such as depression, anxiety, fear of low blood sugar, eating disorders and problems coping with the diagnosis) and any problems identified are properly managed.

Source guidance

Data source

Structure: Local data collection.
Process:
a) Local data collection.
Quality and Outcomes Framework (QOF) indicator DEP 003 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have been reviewed not earlier than 10 days after and not later than 56 days after the date of diagnosis.
b) Local data collection.

Definitions

Psychological problems in people with diabetes may include:
  • depression
  • anxiety
  • injection related anxieties
  • fear of hypoglycaemia
  • eating disorders
  • problems coping with diagnosis.

Equality and diversity considerations

Treatment and care should take into account a patient’s needs and preferences. People with psychological problems and diabetes should have the opportunity to make informed decisions, including advance decisions and advance statements, about their care and treatment, in partnership with their practitioners. If patients do not have the capacity to make decisions, practitioners should follow the Department of Health’s advice on consent and the code of practice that accompanies the Mental Capacity Act.

At-risk foot

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes who are at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with diabetes at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance.
Process
a) Proportion of people with diabetes at risk of foot ulceration who receive regular review by a foot protection service in accordance with NICE guidance.
Numerator – the number of people in the denominator who receive regular review by a foot protection service in accordance with NICE guidance.
Denominator – the number of people with diabetes at risk of foot ulceration.
Outcome
a) Incidence of diabetic foot problems.
b) Rates of lower limb amputation.

What the quality statement means for each audience

Service providers ensure access to appropriate treatment and review by a foot protection service for people with diabetes who are at risk of foot ulceration in accordance with NICE guidance.
Healthcare professionals ensure that they identify and manage people with diabetes who are at risk of of foot ulceration in accordance with NICE guidance.
Commissioners ensure that they commission services so that people with diabetes at risk of of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance.
People with diabetes who are at risk of of foot ulceration have their feet and lower legs checked regularly by the foot protection service. The foot protection service is usually based in a health centre or GP clinic, and specialises in preventing and managing foot problems in people with diabetes.

Source guidance

Data source

Structure: a) and b) the National Diabetes Foot Care Audit collects data on foot sevices.
Process:
a) Local data collection. Quality and Outcomes Framework (QOF) DM 012 The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months.
Outcome:
a) Local data collection.
b) The National Centre for Health Outcomes Development measures admissions to hospital of patients with diabetes where a lower limb amputation is undertaken. The National Diabetes Audit collects data on amputation rates.
Further structure and process data is being developed within the pilot phase of the new National Diabetes Foot Care Audit and full implementation is planned within the National Diabetes Audit 2 from 2013. Available from www.hscic.gov.uk.

Definitions

The NICE guideline on diabetic foot problems (recommendation 1.3.6) classifies the risk of developing a diabetic foot problem as follows:
  • Low risk: no risk factors present.
  • Moderate risk: 1 risk factor present.
  • High risk: previous ulceration or amputation, on renal replacement therapy, or more than 1 risk factor present.
  • Active diabetic foot problem: ulceration, spreading infection, critical ischaemia, gangrene, suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain.
Risk factors as defined by recommendation 1.3.4:
  • Neuropathy (use a 10 g monofilament as part of a foot sensory examination).
  • Limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease).
  • Ulceration.
  • Callus.
  • Infection and/or inflammation.
  • Deformity.
  • Gangrene.
  • Charcot arthropathy.
Regular review will be in accordance with the NICE guideline on diabetic foot problems recommendations 1.3.7–1.3.12.

Inpatient care

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.

Quality measure

Structure
Evidence of local arrangements to ensure that all inpatients with diabetes are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.
Process
a) Proportion of staff on inpatient wards who are appropriately trained to care for people with diabetes.
Numerator – the number of staff in the denominator appropriately trained in the care of people with diabetes.
Denominator – the number of staff on inpatient wards.
b) Proportion of inpatients with diabetes who are provided with access to a specialist diabetes team.
Numerator – the number of inpatients in the denominator provided with access to a specialist diabetes team.
Denominator – the number of inpatients with diabetes.
c) Proportion of inpatients with diabetes on insulin therapy who are given the choice of self monitoring and managing their own insulin.
Numerator – the number of inpatients in the denominator given the choice of self monitoring and managing their own insulin.
Denominator – the number of inpatients with diabetes on insulin therapy.
Outcomes
a) Reduction in incidents relating to insulin causing harm.
b) Increase in patient satisfaction with their care in hospital.

What the quality statement means for each audience

Service providers ensure adequate staff training in diabetes care and access to a specialist diabetes team where required to ensure people with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.
Healthcare professionals ensure they are skilled and appropriately trained to care for people with diabetes and have access to a specialist diabetes team, and ensure that people with diabetes have the choice of self-monitoring and managing their own insulin.
Commissioners ensure they commission secondary services that assess the competency of the workforce, and have adequate staff education programmes to ensure people with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.
People with diabetes who are admitted to hospital are cared for by trained staff, including a specialist diabetes team if needed, and are given the choice of self-monitoring their blood sugar levels and, for those on insulin therapy, managing their own insulin.

Source guidance

Data source

Structure: Local data collection.
Process: a), b) and c) Local data collection. The National Diabetes Audit collects data on inpatient care.
Outcome:
a) The National Patient Safety Agency National Reporting and Learning System collect data on incidents relating to insulin causing harm.
b) The National Diabetes Inpatient Audit collects data on the clinical care and experiences of people with diabetes who were inpatients in hospital.

Definitions

‘Appropriately trained staff’ are defined as those with specific competencies in caring for people with diabetes.
People with diabetes admitted to hospital should be given the choice of self-monitoring and managing their own insulin as appropriate to the person with diabetes.

Diabetic ketoacidosis

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team.

Quality measure

Structure
Evidence of local arrangements to ensure that people admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team.
Process
a) Proportion of people admitted to hospital with diabetic ketoacidosis who receive educational and psychological support by a specialist diabetes team prior to discharge.
Numerator – the number of people in the denominator receiving educational and psychological support by a specialist diabetes team prior to discharge.
Denominator – the number of people admitted to hospital with diabetic ketoacidosis.
b) Proportion of people admitted to hospital with diabetic ketoacidosis who receive follow up within 30 days after discharge by a specialist diabetes team.
Numerator – the number of people in the denominator receiving follow up within 30 days after discharge by a specialist diabetes team.
Denominator – the number of people discharged from hospital following an admission for diabetic ketoacidosis.
Outcome
Reduction in readmission rates within 12 months for people admitted with diabetic ketoacidosis.

What the quality statement means for each audience

Service providers ensure patients admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge with follow up after discharge by a specialist diabetes team.
Healthcare professionals ensure they know how to access a specialist diabetes team for all patients admitted to hospital with diabetic ketoacidosis that provides educational and psychological support prior to discharge.
Commissioners ensure they commission a service providing access to a specialist diabetes team prior to a patient’s discharge with follow up after discharge for all patients admitted to hospital with diabetic ketoacidosis.
People with diabetes admitted to hospital with diabetic ketoacidosis (a serious condition caused by a shortage of insulin) receive information and psychological support from a specialist diabetes team before and after they leave hospital.

Source guidance

Data source

Structure: Local data collection.
Process: a) and b) Local data collection.
Outcome: Local data collection. The National Diabetes Audit measures the incidence, prevalence and re-occurrence of ketoacidosis. Hospital Episode Statistics (HES) collects data on readmission rates.

Definitions

The opinion of the Topic Expert Group is that follow-up for people admitted to hospital with diabetic ketoacidosis should take place within 30 days of discharge by a specialist diabetes team.

Equality and diversity

All information about treatment and care, including advice on avoiding diabetic ketoacidosis, should take into account age and social factors, language, accessibility, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

Hypoglycaemia

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.
Process
Proportion of people with diabetes who have experienced hypoglycaemia requiring medical attention who are referred to a specialist diabetes team.
Numerator – the number of people in the denominator referred to a specialist diabetes team.
Denominator – the number of people with diabetes who have experienced hypoglycaemia requiring medical attention.
Outcome
a) Reduction in number of people with diabetes requiring medical attention as a result of a hypoglycaemic episode.
b) Reduction in rate of recurrence of an episode of hypoglycaemia requiring medical attention over 12 months.

What the quality statement means for each audience

Service providers ensure adequate provision for referral to a specialist diabetes team for people with diabetes who have experienced hypoglycaemia requiring medical attention.
Healthcare professionals ensure people with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.
Commissioners ensure they commission services that have clearly defined protocols to identify all people with diabetes who have experienced hypoglycaemia requiring medical attention and refer them to a specialist diabetes team.
People with diabetes are seen by a specialist diabetes team for advice and support after experiencing hypoglycaemia (low blood sugar) needing medical attention (for example, from a GP, paramedic, accident and emergency department or out of hours services).

Source guidance

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: a) and b) Local data collection.

Definitions

‘Hypoglycaemia requiring medical attention’ refers to an episode of severe hypoglycaemia that requires treatment by a GP, paramedics, accident and emergency department or out of hours services.

Equality and diversity

All information about treatment and care, including advice on avoiding hypoglycaemia, should take into account age and social factors, language, accessibility, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

Preconception care

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered preconception care and those not planning a pregnancy are offered advice on contraception.

Quality measure

Structure
a) Evidence of local arrangements to ensure that women of childbearing age with diabetes are regularly informed about the benefits of preconception glycaemic control and of any risks, including medication which may harm an unborn child.
b) Evidence that women with diabetes planning a pregnancy are offered preconception care.
c) Evidence that women with diabetes not planning a pregnancy are offered advice on contraception.
Process
a) Proportion of women of childbearing age with diabetes who are regularly informed about the benefits of preconception glycaemic control and of any risks including medication that may harm an unborn child.
Numerator – the number of women in the denominator informed about preconception glycaemic control and of any risks including medication that may harm an unborn child at their last diabetes consultation.
Denominator – the number of women of childbearing age with diabetes.
b) Proportion of women of childbearing age with diabetes planning a pregnancy who are offered preconception care from an appropriately trained healthcare professional.
Numerator – the number of women in the denominator offered preconception care from an appropriately trained healthcare professional.
Denominator – the number of women of childbearing age with diabetes planning a pregnancy.
c) Proportion of women of childbearing age with diabetes not planning a pregnancy who are offered advice on contraception.
Numerator – the number of women in the denominator offered advice on contraception.
Denominator – the number of women with diabetes not planning a pregnancy.

What the quality statement means for each audience

Service providers ensure local arrangements that provide information to women of childbearing age with diabetes on preconception glycaemic control and any risks including medication that may harm an unborn child, and ensure women with diabetes planning a pregnancy are offered preconception care, and those not planning a pregnancy are offered advice on contraception.
Healthcare professionals ensure women with diabetes of childbearing age are provided with information on preconception glycaemic control and on any risks including medication that may harm an unborn child, and are offered preconception care if they are planning a pregnancy or offered advice on contraception if they are not planning a pregnancy.
Commissioners ensure they commission care pathways that provide preconception advice for women of childbearing age with diabetes, and offer preconception care for women with diabetes planning a pregnancy and advice on contraception for those not planning a pregnancy.
Women of childbearing age who have diabetes are regularly given advice about the benefits of controlling their blood sugar before a pregnancy, and any risks such as medication that might harm an unborn baby. Women with diabetes who are planning a pregnancy are offered care leading up to the pregnancy. Women not planning a pregnancy are offered advice on contraception.

Source guidance

Data source

Structure: a), b) and c) Local data collection. Contained within NICE guideline CG87 audit support organisational criteria, criteria 1–3.
Process: a), b) and c) Local data collection. NICE guideline CG87 audit support clinical criteria, criterion 36.

Definitions

Medication that may harm an unborn child includes, but is not limited to:
  • Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists
  • statins
  • oral anti diabetes hypoglycaemic agents with the exception of metformin.
‘Women of childbearing age with diabetes’ refers to all women with diabetes (excluding gestational diabetes) who have childbearing potential.

Referral for limb‑threatening or life‑threatening diabetic foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services, and the multidisciplinary foot care service is informed.

Quality measure

Structure
Evidence of local arrangements to ensure that people with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services and the multidisciplinary foot care service is informed.
Process
a) Proportion of people with diabetes with a with a limb-threatening or life-threatening diabetic foot problem who are referred immediately to acute services.
Numerator – the number in the denominator referred immediately to acute services.
Denominator – the number of people with diabetes with a limb-threatening or life-threatening diabetic foot problem.
b) Proportion of people referred to acute services with a limb-threatening or life-threatening diabetic foot problem about whom the multidisciplinary foot care service was informed.
Numerator – the number in the denominator about whom the multidisciplinary foot care service was informed.
Denominator – the number of people referred to acute services with a limb-threatening or life-threatening diabetic foot problem.
Outcome
a) Rates of lower limb amputation.

What the quality statement means for each audience

Service providers ensure that people with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services and that the multidisciplinary foot care service is informed.
Healthcare professionals refer people with a limb-threatening or life-threatening diabetic foot problem immediately to acute services and inform the multidisciplinary foot care service.
Commissioners ensure that they commission services that provide immediate access to acute services and a multidisciplinary foot care team for people with a limb-threatening or life-threatening diabetic foot problem.
People with diabetes who have a severe foot problem are referred to hospital immediately and the multidisciplinary foot care service is informed. The multidisciplinary foot care service is usually based at a hospital, and specialises in treating severe diabetic foot problems. Severe foot problems include having a diabetic foot ulcer and a fever or any other symptoms of blood poisoning (the medical name for this is sepsis); a foot ulcer and problem with the blood supply to the foot; a severe foot or bone infection; or gangrene (where the tissue in the foot has died).

Source guidance

Data source

Structure: a) Local data collection
Process:
a) and b) Local data collection. The process measures will also be included in the National Diabetes Foot care Audit from 2013.
Outcome:
a) The National Centre for Health Outcomes Development measures admissions to hospital of patients with diabetes where a lower limb amputation is undertaken. The National Diabetes Audit collects data on amputation rates.

Definitions

The NICE guideline on diabetic foot problems (recommendation 1.4.) defines the following as limb-threatening and life-threatening diabetic foot problems:
  • Ulceration with fever or any signs of sepsis.
  • Ulceration with limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease).
  • Clinical concern that there is a deep seated soft tissue or bone infection (with or without ulceration).
  • Gangrene (with or without ulceration).

Referral for active foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes care and should be read in full.

Quality statement

People with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the multidisciplinary foot care service or foot protection service within 1 working day and triaged within 1 further working day.

Quality measures

Structure
Evidence of local arrangements to ensure that people with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the multidisciplinary foot care service or foot protection service within 1 working day and triaged within 1 further working day.
Process
a) Proportion of people with diabetes with an active foot problem that is not limb-threatening or life-threatening who are referred to the multidisciplinary foot care service or foot protection service within 1 working day.
Numerator – the number in the denominator referred within 1 working day to the multidisciplinary foot care service or foot protection service.
Denominator – the number of people with diabetes with an active foot problem that is not limb-threatening or life-threatening.
b) Proportion of people with diabetes referred to the multidisciplinary foot care service or foot protection service with an active foot problem that is not limb-threatening or life-threatening who are triaged within 1 working day of being referred.
Numerator – the number in the denominator triaged within 1 working day.
Denominator – the number of people with diabetes referred to the multidisciplinary foot care service or foot protection service with an active foot problem that is not limb-threatening or life-threatening.
Outcome
Rates of lower limb amputation.

What the quality statement means for each audience

Service providers ensure that people with an active diabetic foot problem that is not limb-threatening or life-threatening are referred within 1 working day to the multidisciplinary foot care service or foot protection service and triaged within 1 further working day.
Healthcare professionals ensure that they refer people with an active diabetic foot problem that is not limb-threatening or life-threatening within 1 working day to the multidisciplinary foot care service or foot protection service to be triaged within 1 further working day.
Commissioners ensure that they commission services that allow people with an active diabetic foot problem that is not limb-threatening or life-threatening to be referred within 1 working day to the multidisciplinary foot care service or foot protection service and triaged within 1 further working day.
People with diabetes who have a foot problem are referred to the multidisciplinary foot care service or foot protection service within 1 working day unless the problem is severe. They should then have their problem assessed within 1 working day of the referral to decide what should to happen next.

Source guidance

Data source

Structure: a) Local data collection.
Process: a) and b) Local data collection. The National Diabetes Foot Care Audit collects data on foot services.
Outcome: a) The National Centre for Health Outcomes Development measures admissions to hospital of patients with diabetes where a lower limb amputation is undertaken. The National Diabetes Audit collects data on amputation rates.

Definitions

Active foot problems
The NICE guideline on diabetic foot problems defines active foot problems as ulceration, spreading infection, critical ischaemia, gangrene, suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Offer once-daily sulfonylurea if adherence is a problem.
Prescribe a sulfonylurea with a low acquisition cost (not glibenclamide) when an insulin secretagogue is indicated.
Educate the person about the risk of hypoglycaemia, particularly if he or she has renal impairment.
Continue thiazolidinedione therapy only if there is a reduction of ≥ 6 mmol/mol (0.5 percentage points) in HbA1c in 6 months.
Do not start or continue a thiazolidinedione if the person has heart failure or is at higher risk of fracture.
When selecting a thiazolidinedione, take into account the most up-to-date advice from regulatory authorities, cost, safety and prescribing issues.
Continue DPP-4 inhibitor therapy only if there is a reduction of ≥ 6 mmol/mol (0.5 percentage points) in HbA1c in 6 months.
Discuss the benefits and risks of a DPP-4 inhibitor with the person, bearing in mind that a DPP-4 inhibitor might be preferable to a thiazolidinedione if:
  • further weight gain would cause significant problems, or
  • a thiazolidinedione is contraindicated, or
  • the person had a poor response to or did not tolerate a thiazolidinedione in the past.
Antihypertensive medications can increase the likelihood of side effects such as orthostatic hypotension in a person with autonomic neuropathy.
Insulin glargine is recommended as a treatment option for people with type 1 diabetes.
Continuous subcutaneous insulin infusion (CSII or 'insulin pump') therapy is recommended as a treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that:
  • attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life
or
  • HbA1c levels have remained high (that is, at 69 mmol/mol [8.5%] or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care.
It is recommended that CSII therapy be initiated only by a trained specialist team, which should normally comprise a physician with a specialist interest in insulin pump therapy, a diabetes specialist nurse and a dietitian. Specialist teams should provide structured education programmes and advice on diet, lifestyle and exercise appropriate for people using CSII.
Following initiation in adults and children 12 years and older, CSII therapy should only be continued if it results in a sustained improvement in glycaemic control, evidenced by a fall in HbA1c levels, or a sustained decrease in the rate of hypoglycaemic episodes. Appropriate targets for such improvements should be set by the responsible physician, in discussion with the person receiving the treatment or their carer.
Liraglutide 1.8 mg daily is not recommended for the treatment of people with type 2 diabetes.
People with type 2 diabetes currently receiving liraglutide who do not meet the criteria specified, or who are receiving liraglutide 1.8 mg, should have the option to continue their treatment until they and their clinicians consider it appropriate to stop.
Discuss the benefits and risks of a thiazolidinedione with the person, bearing in mind that a thiazolidinedione might be preferable to a DPP-4 inhibitor if:
  • the person has marked insulin insensitivity, or
  • a DPP-4 inhibitor is contraindicated, or
  • the person had a poor response to or did not tolerate a DPP-4 inhibitor in the past.
Continue existing treatments for people whose neuropathic pain is already effectively managed, taking into account the need for regular clinical reviews.
When introducing a new treatment, take into account any overlap with the old treatments to avoid deterioration in pain control.
When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

All neuropathic pain (except trigeminal neuralgia)

Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)At the time of publication (November 2013), amitriptyline did not have a UK marketing authorisation for this indication, duloxetine is licensed for diabetic peripheral neuropathic pain only, and gabapentin is licensed for peripheral neuropathic pain only, so use for other conditions would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the Good practice in prescribing and managing medicines and devices (2013) guidance for doctors for further information..
If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
Consider tramadol only if acute rescue therapy is needed (see 'Treatments that should not be used' in the neuropathic pain pathway about long-term use).
Consider capsaicin creamAt the time of publication (November 2013), capsaicin cream (Axsain) had a UK marketing authorisation for post-herpetic neuralgia and painful diabetic peripheral polyneuropathy, so use for other conditions would be off-label. The summary of product characteristics states that this should only be used for painful diabetic peripheral polyneuropathy 'under the direct supervision of a hospital consultant who has access to specialist resources'. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the Good practice in prescribing and managing medicines and devices (2013) guidance for doctors for further information. for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Early clinical review

After starting or changing a treatment, carry out an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.

Regular clinical reviews

Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:
  • pain control
  • impact on lifestyle, daily activities (including sleep disturbance) and participationThe World Health Organization ICF (International Classification of Functioning, Disability and Health) (2001) defines participation as 'A person's involvement in a life situation'. It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.
  • physical and psychological wellbeing
  • adverse effects
  • continued need for treatment.

Referral

Consider referring the person to a specialist pain service and/or a condition-specific serviceSpecialist pain services are those that provide comprehensive assessment and multi-modal management of all types of pain, including neuropathic pain. A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services. at any stage, including at initial presentation and at the regular clinical reviews, if:
  • they have severe pain or
  • their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation or
  • their underlying health condition has deteriorated.

Further information

For more information on the pharmacological management of neuropathic pain in adults in non-specialist settings, see the neuropathic pain pathway.

Glossary

> 2.5 mg/mmol for men and > 3.5 mg/mmol for women.
Raised blood pressure, higher waist circumference, low HDL cholesterol, high triglyceride.
A team with expertise in protecting the foot; typically members of the team include podiatrists, orthotists and foot care specialists.
A circle centred on the fovea, with a diameter the distance between the temporal border of the optic disc and the fovea.
A team of highly trained specialist podiatrists and orthotists, nurses with training in dressing diabetic foot wounds and diabetologists with expertise in lower limb complications.

Paths in this pathway

Pathway created: May 2011 Last updated: August 2015

© NICE 2015

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