Diabetes
Bradford VTS Clinical Resources
- by Dr Sabah Malik
- Last modified: 23rd March 2026
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Diabetes Management for UK GPs
Comprehensive clinical guide covering diagnosis, monitoring, treatment, and complications management. Updated with NICE 2026 guidelines on SGLT-2 inhibitors and GLP-1 receptor agonists.
Executive Summary
4.9 million
People living with diabetes in the UK (2023)
90%
Have Type 2 diabetes (preventable/manageable)
Every 2 minutes
Someone in the UK is diagnosed with diabetes
£10 billion
Annual NHS cost (10% of entire NHS budget)
Leading cause
Of preventable sight loss in working-age adults
1 million
People with undiagnosed diabetes in the UK
Understanding Diabetes
Diabetes mellitus is a group of metabolic disorders characterized by chronic hyperglycaemia due to defects in insulin secretion, insulin action, or both.
- Polyuria — excessive urination
- Polydipsia — excessive thirst
- Polyphagia — excessive hunger
- Ponderal loss — weight loss despite eating
Description: Autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency. Accounts for ~8% of all diabetes cases.
Key Features:
- Typically presents in childhood/young adults (can occur at any age)
- Acute onset with polyuria, polydipsia, weight loss
- Ketosis-prone (risk of DKA)
- Requires lifelong insulin therapy
- Associated with other autoimmune conditions (thyroid, coeliac)
Management:
- Multiple daily insulin injections or insulin pump
- Carbohydrate counting and dose adjustment
- Regular blood glucose monitoring
- Annual screening for complications
- Specialist diabetes team involvement
Description: Progressive insulin resistance and relative insulin deficiency. Accounts for ~90% of all diabetes cases. Strongly associated with obesity, physical inactivity, and family history.
Key Features:
- Usually diagnosed in adults >40 years (increasingly seen in younger people)
- Insidious onset, often asymptomatic initially
- Strong genetic component (40% risk if one parent affected)
- Associated with metabolic syndrome (obesity, hypertension, dyslipidaemia)
- Not ketosis-prone (except in severe illness)
Management:
- Lifestyle modification (diet, exercise, weight loss)
- Oral hypoglycaemic agents (metformin first-line)
- May eventually require insulin
- Cardiovascular risk factor management
- Regular monitoring and screening for complications
Description: Glucose intolerance first recognized during pregnancy. Affects 3-5% of pregnancies. Usually resolves after delivery but indicates high risk of future type 2 diabetes.
Key Features:
- Diagnosed during routine antenatal screening (OGTT at 24-28 weeks)
- Risk factors: obesity, previous GDM, family history, ethnicity
- Increases risk of macrosomia, birth trauma, neonatal hypoglycaemia
- 50% will develop type 2 diabetes within 10 years
Management:
- Dietary modification and blood glucose monitoring
- Metformin or insulin if targets not met
- Close monitoring during pregnancy
- Postnatal OGTT at 6 weeks
- Annual HbA1c screening thereafter
Description: Less common forms of diabetes with specific underlying causes.
Types Include:
- MODY (Maturity Onset Diabetes of the Young): Genetic defect in beta cell function. Autosomal dominant inheritance. Diagnosed <25 years. May not require insulin.
- Secondary Diabetes: Due to pancreatic disease (chronic pancreatitis, cystic fibrosis, haemochromatosis), endocrine disorders (Cushing's, acromegaly), or drug-induced (steroids, antipsychotics).
- LADA (Latent Autoimmune Diabetes in Adults): Slow-onset Type 1 diabetes in adults. Initially responds to oral agents but eventually requires insulin.
Diagnosis and Investigations
Accurate diagnosis requires appropriate testing and interpretation of results. Multiple diagnostic criteria exist.
Clinical History
Key questions to ask
Symptoms:
- Polyuria, polydipsia, polyphagia
- Weight loss (especially if eating normally)
- Fatigue, lethargy
- Blurred vision
- Recurrent infections (thrush, UTIs, skin infections)
- Slow wound healing
- Neuropathic symptoms (tingling, numbness)
Risk Factors:
- Age >40 years
- BMI >25 kg/m² (>23 for South Asian)
- Family history (first-degree relative)
- Ethnicity (South Asian, African-Caribbean, Black African)
- Previous gestational diabetes
- Hypertension or cardiovascular disease
- PCOS
- Medications (steroids, antipsychotics)
Physical Examination
Essential examination findings
General:
- BMI and waist circumference
- Blood pressure
- Signs of dehydration
- Acanthosis nigricans (insulin resistance)
Cardiovascular:
- Peripheral pulses
- Carotid bruits
- Heart sounds
Neurological:
- Peripheral sensation (monofilament, vibration)
- Ankle reflexes
- Proprioception
Feet:
- Skin integrity, ulcers
- Deformities (Charcot, clawing)
- Calluses, corns
- Fungal infections
Investigations
Laboratory tests and monitoring
Diagnostic Tests:
| Test | Normal | Pre-diabetes | Diabetes |
|---|---|---|---|
| HbA1c | <42 mmol/mol | 42-47 mmol/mol | ≥48 mmol/mol |
| Fasting Glucose | <6.0 mmol/L | 6.1-6.9 mmol/L | ≥7.0 mmol/L |
| Random Glucose | <7.8 mmol/L | - | ≥11.1 mmol/L |
| OGTT (2-hour) | <7.8 mmol/L | 7.8-11.0 mmol/L | ≥11.1 mmol/L |
⚠️ HbA1c Limitations
HbA1c may not be accurate in:
- Haemoglobinopathies (sickle cell, thalassaemia)
- Haemolytic anaemia, recent blood loss
- Iron deficiency anaemia, splenectomy
- Pregnancy
- Children and young people
Use fasting glucose or OGTT in these situations.
DIAGNOSING DIABETES
Symptomatic vs Asymptomatic Criteria
SYMPTOMATIC Patients
Symptoms of hyperglycaemia (polyuria/polydipsia, unexplained weight loss, visual blurring, genital thrush, lethargy) PLUS EITHER:
- HbA1c ≥ 48 mmol/mol (LAB TESTING) — Type 2 diabetes is diagnosed in adults who are not pregnant and do not have haemoglobinopathy or haemolytic anaemia
- Fasting Blood Glucose ≥ 7.0 mmol/L (x2 tests)
- Random Plasma Glucose ≥ 11.1 mmol/L
WHO guidance: Diagnosis should be confirmed with a repeat HbA1c test, unless clinical symptoms and plasma glucose levels > 11.1 mmol/L are present — in which case further testing is not required.
Always dip urine to check for ketones (if present, consider Type 1 diabetes or DKA).
ASYMPTOMATIC Patients
In the absence of symptoms — 2 abnormal results on separate days are required for the diagnosis.
Results interpretation:
- HbA1c > 48 mmol/L → repeat HbA1c test after 2 weeks → if HbA1c > 48 mmol/L then code Diabetes and set recall
- HbA1c 42-47 mmol/L → code and set "at risk of diabetes" recall
⚠️ Important Notes
- A diagnosis of diabetes has important legal and medical implications — be secure in the diagnosis
- A diagnosis should never be made on the basis of glycosuria
- A stick reading of finger prick should be confirmed by a venous sample, as per NICE guidelines
Using HbA1c in diagnosing diabetes
When HbA1c may not be accurate
HbA1c May NOT Be Accurate In:
- ALL symptomatic children and young people
- Symptoms suggesting Type 1 diabetes/pancreatic insufficiency (any age)
- Short duration diabetes symptoms
- Patient at high risk of diabetes who are acutely ill
- Taking medication that may cause rapid glucose rise (e.g., steroids, antipsychotics)
- Acute pancreatic damage/pancreatic surgery
- Patients with haemoglobinopathy — the labs test for this and will detect abnormalities
In these situations, use fasting glucose or OGTT instead.
Who to screen
Risk-based screening for type 2 diabetes
Screen if:
- > 40 years of age with two or more of the following:
→ Family history in a first-degree relative
→ BMI > 25 (or > 23 for South Asian ethnicity)
→ South Asian ethnicity
Screening frequency: At least every 5 years with a fasting blood sugar or HbA1c.
Annual Screening Required For:
- Women with a history of gestational diabetes
- Hypertensives
- Patients with ischaemic heart disease, peripheral vascular disease, or stroke
Symptoms Requiring Testing:
- Polydipsia, polyuria/nocturia
- Weight loss & fatigue
- Recurrent UTIs
- Recurrent skin infections
- Recurrent thrush
- Neuropathic symptoms
- Changes in visual acuity
Referring to hospital
Clear criteria for admission, same-day, and routine referrals
🚨 Admission
Admit to hospital if the person is at risk of a hyperglycaemic emergency:
- 🚩 Vomiting or abdominal pain
- 🚩 Reduced conscious level
- 🚩 Heavy ketonuria
- 🚩 Dehydration requiring IV fluids
- 🚩 Hypotension
- 🚩 Serious intercurrent problem
⚠️ Same day referral
Refer to be seen on the same day if:
- The patient is acutely ill
- Consider Type 1 Diabetes/pancreatic insufficiency if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, and polyuria)
Early Referral
Diabetes and pregnancy requires referral to the hospital diabetes team
✅ DIAGNOSIS CONFIRMED - CODE AND SET RECALL – REFER TO NURSE
(30 minute appointment)
- Make sure the diagnosis is correct! Remember LADA, MODY, Type 3c (ask diabetes GPSI if unsure)
- Code for QoF, SPECIFY TYPE OF DIABETES, promote to major problem and add to summary
- Set diabetes recall for 6 months
- Provide patient information PIL from patient.co.uk. Signpost to Diabetes UK website www.diabetes.org.uk
- Arrange referral (S1 word referrals): PRACTICE NURSE WILL COMPLETE THIS
☐ Annual retinal screening
☐ Annual diabetic podiatry check
☐ Dietician - getting started sessions
☐ Offer diabetes education programme (local scheme: DICE)
Monitoring and HbA1c Targets
Regular monitoring and individualized HbA1c targets are essential for optimal diabetes management and complication prevention.
Important: Individualized Targets
HbA1c targets should be individualized based on patient factors including age, comorbidities, hypoglycaemia risk, life expectancy, and patient preferences. Avoid a one-size-fits-all approach.
| Population | HbA1c Target | Clinical Note |
|---|---|---|
| Diet controlled | 48 mmol/mol (6.5%) | Lifestyle modification only |
| Single drug (not causing hypos) | 48 mmol/mol (6.5%) | e.g., metformin, DPP-4, SGLT-2 |
| Drug causing hypoglycaemia | 53 mmol/mol (7.0%) | Sulfonylurea or insulin |
| Frail/elderly/comorbidities | 58-64 mmol/mol (7.5-8.0%) | Avoid hypoglycaemia |
| Limited life expectancy | 64-75 mmol/mol (8.0-9.0%) | Symptom control priority |
Glycemic control and HbA1c targets
Detailed guidance on target setting
Standard Targets
Diet controlled: HbA1c target 48 mmol/mol (6.5%)
On one drug not causing hypoglycaemia: HbA1c target 48 mmol/mol (6.5%)
On drug that may cause hypoglycaemia (e.g., sulfonylurea, insulin): HbA1c target 53 mmol/mol (7.0%)
When to Intensify Treatment
Consider intensifying drug treatment if HbA1c levels are not adequately controlled by a single drug and rise to:
- 58 mmol/mol (7.5%) or higher
Action: Add second-line agent, review lifestyle factors, check adherence
Relaxed Targets
Consider relaxing targets (e.g., to 64 mmol/mol or 8%) in patients with:
- Frailty or limited life expectancy
- High risk of hypoglycaemia
- Significant comorbidities
- Patient preference after discussion of risks/benefits
⚠️ Avoid Over-Treatment
Do NOT aim for HbA1c < 48 mmol/mol if on medications that can cause hypoglycaemia (sulfonylureas, insulin). Risk of severe hypos outweighs benefits of tight control.
Monitoring Frequency
HbA1c:
- Every 3-6 months (stable, on target)
- Every 3 months (treatment changes, not on target)
- More frequently if clinically indicated
Self-Monitoring Blood Glucose (SMBG):
- Type 1: Multiple times daily
- Type 2 on insulin: As advised by diabetes team
- Type 2 on oral agents: Not routinely recommended unless specific indication
Blood Glucose Targets
Type 1 Diabetes:
- Fasting: 5-7 mmol/L
- Before meals: 4-7 mmol/L
- 2 hours post-meal: 5-9 mmol/L
- Bedtime: 5-7 mmol/L
Type 2 Diabetes (if monitoring):
- Fasting: 4-7 mmol/L
- 2 hours post-meal: <8.5 mmol/L
Complications of Diabetes
Diabetes complications are classified as microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (cardiovascular, cerebrovascular, peripheral arterial disease). Early detection and management are crucial.
- Nephropathy — kidney disease
- Eyes — retinopathy
- Retinopathy — vision loss
- Vascular — heart disease, stroke
- Erectile dysfunction
- Sensory loss — neuropathy, foot problems
Diabetic Retinopathy
Leading cause of blindness in working-age adults. Caused by damage to retinal blood vessels.
Screening:
Annual digital retinal photography for all diabetics. Refer urgently if proliferative changes or maculopathy detected.
Management:
Optimize glycaemic control, BP control, laser photocoagulation, anti-VEGF injections for maculopathy.
Diabetic Nephropathy
Progressive kidney damage leading to CKD and potential ESRF. Affects 20-40% of diabetics.
Screening:
Annual ACR (albumin:creatinine ratio) and eGFR. Microalbuminuria (ACR 3-30 mg/mmol) indicates early nephropathy.
Management:
ACE-I/ARB (even if normotensive), BP <130/80, optimize glycaemic control, SGLT-2 inhibitors for renoprotection.
Diabetic Neuropathy
Nerve damage affecting peripheral, autonomic, and focal nerves. Affects up to 50% of diabetics.
Screening:
Annual foot examination: 10g monofilament, vibration sense, ankle reflexes. Ask about symptoms (pain, tingling, numbness).
Management:
Optimize glycaemic control. Neuropathic pain: duloxetine, amitriptyline, gabapentin, pregabalin. Foot care education.
Diabetic Foot Disease
Combination of neuropathy, ischemia, and infection. Leading cause of non-traumatic lower limb amputation.
Screening:
Annual foot check: inspection, pulses, sensation, deformities. Risk stratify (low/moderate/high). Refer high-risk to podiatry.
Management:
Foot care education, appropriate footwear, regular podiatry. Urgent referral for ulcers/infection. Multidisciplinary foot team.
Cardiovascular Disease
Diabetics have 2-4x increased risk of MI and stroke. CVD is the leading cause of death in diabetics.
Screening:
Annual BP, lipids, cardiovascular risk assessment (QRISK). ECG if symptomatic or high risk.
Management:
Atorvastatin 20mg (primary prevention) or 80mg (secondary prevention), BP <140/80, antiplatelet if indicated, optimize glycaemic control.
Cerebrovascular Disease
Increased risk of stroke and TIA. Diabetes doubles stroke risk.
Screening:
Annual BP, cardiovascular risk assessment. Ask about TIA symptoms.
Management:
BP control, statin, antiplatelet therapy (aspirin 75mg if previous CVD), smoking cessation.
Peripheral Arterial Disease
Reduced blood flow to limbs. Increases risk of foot ulcers and amputation.
Screening:
Annual foot pulses, ABPI if symptomatic or absent pulses. Ask about claudication.
Management:
Smoking cessation, exercise, statin, antiplatelet. Refer vascular surgery if severe or critical limb ischaemia.
Lifestyle Management
Lifestyle modification is the cornerstone of type 2 diabetes management. Diet, exercise, and weight loss can significantly improve glycaemic control and reduce cardiovascular risk.
Dietary Advice
Key Principles:
- Carbohydrate quality: Choose low GI carbs (wholegrain, vegetables, legumes)
- Portion control: Use plate method (½ vegetables, ¼ protein, ¼ carbs)
- Reduce sugar: Avoid sugary drinks, sweets, processed foods
- Healthy fats: Olive oil, nuts, oily fish. Limit saturated fat
- Fibre: Aim for 30g/day (vegetables, wholegrains, legumes)
- Regular meals: Avoid skipping meals, especially if on insulin/sulfonylureas
Referral: All newly diagnosed diabetics should be offered dietician review and structured education programme (e.g., DESMOND for Type 2, DAFNE for Type 1).
Physical Activity
Recommendations:
- Aerobic exercise: 150 minutes/week moderate intensity (brisk walking, cycling, swimming)
- Resistance training: 2-3 sessions/week (weights, resistance bands)
- Reduce sedentary time: Break up sitting every 30 minutes
- Start gradually: Build up slowly if previously inactive
Benefits of Exercise:
- Improves insulin sensitivity
- Lowers blood glucose
- Aids weight loss
- Reduces cardiovascular risk
- Improves mood and wellbeing
Weight Management
Weight Loss Benefits:
- 5-10% weight loss significantly improves glycaemic control
- May achieve remission of type 2 diabetes (especially if recent diagnosis)
- Reduces need for medications
- Improves cardiovascular risk factors
Strategies:
- Calorie deficit (500-600 kcal/day reduction)
- Consider very low calorie diet (VLCD) programmes (e.g., DiRECT trial)
- Behavioural support and goal setting
- Regular monitoring and follow-up
- Consider bariatric surgery if BMI >35 with inadequate control
Smoking Cessation
Smoking and Diabetes:
Smoking significantly increases risk of cardiovascular disease, nephropathy, retinopathy, and peripheral vascular disease in diabetics. Smoking cessation is one of the most important interventions.
Support Options:
- Refer to NHS Stop Smoking Service
- Nicotine replacement therapy (NRT)
- Varenicline or bupropion
- Behavioural support and counselling
- Regular follow-up and encouragement
Pharmacological Treatment
NICE 2026 guidelines recommend SGLT-2 inhibitors alongside modified-release metformin as first-line treatment for most newly diagnosed type 2 diabetes patients. This represents a major shift in UK diabetes management.
Diabetes management
Comprehensive approach to diabetes care
Lifestyle
- Diet and exercise advice
- Weight management
- Smoking cessation
Blood Pressure
- Target: < 140/80 mmHg (or < 130/80 if end-organ damage)
- ACE inhibitor or ARB first-line
Lipids
- Atorvastatin 20mg for primary prevention
- Atorvastatin 80mg for secondary prevention
Microalbuminuria
- ACE inhibitor or ARB regardless of BP
- Reduces progression to nephropathy
Antiplatelets
- Aspirin 75mg for secondary prevention
- Consider if > 50 years with CV risk factors
Which medication and when?
Treatment algorithm for type 2 diabetes
Step 1: First-Line Treatment
Modified-release metformin + SGLT-2 inhibitor (dapagliflozin or empagliflozin)
Personalize based on: heart failure, atherosclerotic CVD, early onset, obesity, CKD, frailty
Step 2: Dual Therapy
If HbA1c remains > 58 mmol/mol (7.5%) after 3 months:
- Add DPP-4 inhibitor (e.g., sitagliptin)
- OR Pioglitazone (if not at risk of fractures/bladder cancer)
- OR Sulfonylurea (if rapid glucose control needed)
Step 3: Triple Therapy
If HbA1c remains > 58 mmol/mol (7.5%):
- Add third oral agent from different class
- OR consider GLP-1 agonist if BMI > 35 kg/m²
Step 4: Insulin Therapy
If HbA1c remains > 58 mmol/mol (7.5%) despite triple therapy:
- Refer to specialist diabetes team
- Consider starting insulin (usually basal insulin first)
- Continue metformin + SGLT-2 inhibitor
Mechanism of Action:
Reduces hepatic glucose production, increases insulin sensitivity in peripheral tissues, delays glucose absorption from gut.
Dosing:
Start 500mg OD/BD with meals. Increase gradually to 1g BD (max 2g/day). Modified-release formulation better tolerated.
Side Effects:
- GI upset (nausea, diarrhoea) — usually settles after 1-2 weeks
- Lactic acidosis (rare but serious) — risk increased in renal impairment
- Vitamin B12 deficiency with long-term use
Contraindications:
- eGFR <30 mL/min/1.73m² (STOP)
- Severe tissue hypoxia (MI, sepsis, heart failure)
- Acute kidney injury
Mechanism of Action:
Inhibit renal glucose reabsorption, causing glycosuria. Lower blood glucose independent of insulin.
Dosing:
Dapagliflozin 10mg OD, Empagliflozin 10-25mg OD, Canagliflozin 100-300mg OD. Take in morning.
Benefits:
- Cardiovascular benefits (reduced MI, stroke, CV death)
- Renoprotective (slows CKD progression)
- Weight loss (2-3kg)
- BP reduction (3-5 mmHg)
- No hypoglycaemia risk
Side Effects:
- Genital thrush (10-15% of patients)
- UTIs
- Euglycaemic DKA (rare but serious)
- Dehydration, postural hypotension
Mechanism of Action:
Mimic incretin hormones. Increase insulin secretion, suppress glucagon, slow gastric emptying, reduce appetite.
Dosing:
Semaglutide 0.25-1mg SC weekly, Dulaglutide 0.75-1.5mg SC weekly, Liraglutide 0.6-1.8mg SC daily. Subcutaneous injection.
Benefits:
- Significant weight loss (5-10kg with semaglutide)
- Cardiovascular benefits
- No hypoglycaemia risk (when used alone)
- Once-weekly dosing available
Side Effects:
- Nausea, vomiting (common initially, usually settles)
- Diarrhoea
- Pancreatitis (rare)
- Injection site reactions
Mechanism of Action:
Inhibit DPP-4 enzyme, increasing incretin hormone levels. Increase insulin secretion, decrease glucagon.
Dosing:
Sitagliptin 100mg OD, Linagliptin 5mg OD, Saxagliptin 5mg OD. Oral, once daily.
Benefits:
- Well tolerated
- No hypoglycaemia risk
- Weight neutral
- Once daily dosing
Side Effects:
- Generally well tolerated
- Pancreatitis (rare)
- Upper respiratory tract infections
Mechanism of Action:
Stimulate insulin secretion from pancreatic beta cells. Glucose-independent action.
Dosing:
Gliclazide 40-160mg BD, Glimepiride 1-4mg OD. Take with meals.
Benefits:
- Rapid glucose lowering
- Inexpensive
- Once or twice daily dosing
Side Effects:
- Hypoglycaemia (major concern, especially in elderly)
- Weight gain (2-3kg)
- Avoid in frail/elderly if possible
Mechanism of Action:
Increase insulin sensitivity in muscle and adipose tissue. Reduce hepatic glucose production.
Dosing:
Pioglitazone 15-45mg OD. Once daily.
Benefits:
- No hypoglycaemia risk
- Durable glucose lowering
- May improve lipid profile
Side Effects:
- Weight gain (3-4kg)
- Fluid retention, oedema
- Increased fracture risk (especially women)
- Bladder cancer risk (small increase)
- Contraindicated in heart failure
Types:
- Basal: Long-acting (Lantus, Levemir, Tresiba) — once daily
- Bolus: Rapid-acting (NovoRapid, Humalog) — with meals
- Mixed: Combination of basal and bolus — twice daily
Initiation:
Usually start with basal insulin (10 units OD at bedtime). Titrate by 2-4 units every 3-4 days based on fasting glucose. Refer to specialist diabetes team.
Side Effects:
- Hypoglycaemia (major risk)
- Weight gain (2-4kg)
- Lipohypertrophy at injection sites
- Requires patient education and monitoring
Watch out for metformin and eGFR
Critical guidance on metformin dosing in renal impairment
🚫 STOP Metformin if:
- eGFR < 30 mL/min/1.73m² — STOP metformin immediately
- Acute kidney injury or severe dehydration
- Severe tissue hypoxia (e.g., sepsis, MI, heart failure)
⚠️ REDUCE Dose if:
- eGFR 30-44 mL/min/1.73m² — Maximum dose 1000mg daily (500mg BD)
- eGFR 45-59 mL/min/1.73m² — Maximum dose 2000mg daily (1000mg BD)
✅ SAFE if:
eGFR ≥ 60 mL/min/1.73m² — Standard dosing up to 2000mg daily (1000mg BD)
📋 Monitoring Requirements:
- Check eGFR at least annually in all patients on metformin
- Check eGFR every 3-6 months if eGFR < 60 mL/min/1.73m²
- Review metformin dose whenever eGFR changes
- Advise patients to STOP metformin during acute illness (sick day rules)
💡 GP Pearl: "Set up a search for all diabetics on metformin with eGFR < 45 — many will need dose reduction or stopping. This is a common cause of lactic acidosis admissions. Add eGFR to your diabetes annual review template."
Acute Emergencies
Diabetic emergencies require immediate recognition and management. DKA, HHS, and severe hypoglycaemia are life-threatening conditions requiring urgent hospital admission.
Diabetic Ketoacidosis (DKA)
Diagnostic Criteria (all 3 required):
- Blood glucose > 11 mmol/L (or known diabetes)
- Blood ketones > 3 mmol/L (or urine ketones ++)
- pH < 7.3 or bicarbonate < 15 mmol/L
Clinical Features:
- Polyuria, polydipsia, weight loss
- Nausea, vomiting, abdominal pain
- Kussmaul breathing (deep, rapid)
- Acetone breath (pear drops smell)
- Dehydration, hypotension
- Confusion, drowsiness, coma
Management:
- Immediate hospital admission
- IV fluids (0.9% saline)
- IV insulin infusion
- Potassium replacement
- Treat underlying cause (infection, MI)
Hyperosmolar Hyperglycaemic State (HHS)
Diagnostic Criteria:
- Blood glucose > 30 mmol/L
- Serum osmolality > 320 mOsm/kg
- No significant ketones or acidosis
Clinical Features:
- Severe dehydration (may lose 10-15L fluid)
- Confusion, drowsiness, coma
- Focal neurological signs
- Seizures
- Usually in elderly type 2 diabetics
Management:
- Immediate hospital admission
- IV fluids (0.9% saline) — slower than DKA
- Low-dose IV insulin (if glucose not falling with fluids)
- Thromboprophylaxis (high VTE risk)
- Treat underlying cause
Severe Hypoglycaemia
Definition:
Blood glucose < 4 mmol/L with symptoms, or < 3 mmol/L regardless of symptoms. Severe hypoglycaemia = requiring external assistance.
Clinical Features:
Autonomic symptoms:
- Sweating, tremor
- Palpitations
- Hunger
- Anxiety
Neuroglycopenic symptoms:
- Confusion, drowsiness
- Difficulty concentrating
- Slurred speech
- Seizures, coma
Management:
Conscious and able to swallow:
- 15-20g fast-acting carbohydrate (200ml Lucozade, 4-5 glucose tablets, 200ml fruit juice)
- Wait 15 minutes, recheck glucose
- If still < 4 mmol/L, repeat
- Follow with 10-20g longer-acting carbohydrate (sandwich, biscuits)
Unconscious or unable to swallow:
- DO NOT give anything by mouth
- Recovery position
- Glucagon 1mg IM (if available and trained)
- Call 999
- Hospital: IV glucose 10% 150-200ml over 15 minutes
Annual Reviews and Care Processes
NICE recommends 9 care processes as part of the annual diabetes review. Completing all 9 processes is associated with reduced complications and improved outcomes.
- HbA1c — glycaemic control
- BP — blood pressure
- CHOL — cholesterol
- RENAL — kidney function (creatinine, eGFR, ACR)
- FEET — foot examination
- EYES — retinal screening
- BMI — body mass index
- SMOKE — smoking status
The annual diabetic review
Comprehensive checklist for annual diabetes assessment
📋 Annual Review Checklist
☐ HbA1c — target individualized
☐ Blood pressure — target < 140/80 mmHg (or < 130/80 if end-organ damage)
☐ Cholesterol — total cholesterol < 5 mmol/L, LDL < 3 mmol/L (or < 2 if CVD)
☐ Serum creatinine & eGFR — check renal function
☐ Urinary albumin — ACR for microalbuminuria screening
☐ Foot examination — neuropathy, pulses, ulcers
☐ Retinal screening — annual digital photography
☐ BMI — weight management advice
☐ Smoking status — cessation advice if applicable
💊 Medication Review
- Review all diabetes medications — doses, adherence, side effects
- Check for drug interactions
- Review metformin dose if eGFR < 60 mL/min/1.73m²
- Ensure on appropriate cardiovascular protection (statin, ACE-I/ARB if indicated)
🎯 Targets at a Glance
HbA1c
48-53 mmol/mol
BP
< 140/80 mmHg
Total Chol
< 5 mmol/L
📝 Documentation
- Record all 9 care processes in patient notes
- Document any referrals made (retinopathy, podiatry, dietician)
- Update diabetes register and QOF data
- Provide patient with written summary of review and targets
Measure HbA1c every 3-6 months (more frequently if treatment changes or not on target). Individualize targets based on patient factors.
Target HbA1c:
- 48 mmol/mol (6.5%) — diet controlled or single drug not causing hypos
- 53 mmol/mol (7.0%) — on drug causing hypoglycaemia (sulfonylurea, insulin)
- 58-64 mmol/mol (7.5-8.0%) — frail/elderly/comorbidities
Check BP at every review. Target <140/80 mmHg (or <130/80 if end-organ damage present).
First-line treatment:
- ACE inhibitor (e.g., ramipril 2.5-10mg OD) OR
- ARB (e.g., losartan 25-100mg OD)
- Add calcium channel blocker or thiazide diuretic if needed
Check lipid profile annually. All diabetics should be on statin for primary prevention.
Statin therapy:
- Primary prevention: Atorvastatin 20mg OD
- Secondary prevention: Atorvastatin 80mg OD
- Target: Total cholesterol <5 mmol/L, LDL <3 mmol/L (or <2 if CVD)
Check serum creatinine, eGFR, and ACR (albumin:creatinine ratio) annually.
Microalbuminuria (ACR 3-30 mg/mmol):
- Start ACE inhibitor or ARB (even if normotensive)
- Optimize glycaemic control
- Consider SGLT-2 inhibitor for renoprotection
- Monitor eGFR every 3-6 months
Annual ACR (albumin:creatinine ratio) screening for nephropathy. Early detection allows intervention to slow progression.
Interpretation:
- Normal: ACR <3 mg/mmol
- Microalbuminuria: ACR 3-30 mg/mmol — start ACE-I/ARB
- Macroalbuminuria: ACR >30 mg/mmol — refer nephrology if eGFR declining
Annual foot examination to assess neuropathy and vascular disease risk. Risk stratify and refer to podiatry if high risk.
Examination includes:
- Inspection (ulcers, deformities, calluses)
- 10g monofilament test (sensation)
- Vibration sense (128Hz tuning fork)
- Ankle reflexes
- Foot pulses (dorsalis pedis, posterior tibial)
High risk features (refer podiatry):
- Previous ulcer or amputation
- Loss of sensation
- Absent pulses
- Deformity (Charcot, clawing)
Annual digital retinal photography for all diabetics. Detects retinopathy before vision loss occurs.
Screening programme:
- Automated invitation from NHS Diabetic Eye Screening Programme
- Digital photographs of both eyes
- Graded by trained screeners
- Urgent referral if proliferative retinopathy or maculopathy
Record BMI annually. Offer weight management support if overweight/obese.
Weight loss benefits:
- 5-10% weight loss significantly improves glycaemic control
- May achieve remission of type 2 diabetes
- Reduces cardiovascular risk
- Consider referral to dietician or weight management programme
Record smoking status annually. Offer smoking cessation support to all smokers.
Smoking and diabetes:
- Significantly increases cardiovascular risk
- Accelerates nephropathy and retinopathy
- Increases risk of foot ulcers and amputation
- Refer to NHS Stop Smoking Service
- Offer NRT, varenicline, or bupropion