Diabetes management guidelines:

Blood pressure – target 130/80 mmHg

Lipid management – target cholesterol <5
1. ACE-inhibitor or diuretic Enalapril 5 mg od or
Simvastatin 10 mg od (HS) up to 40mg od
Ditide 1 T od
2. ACE-inhibitor and diuretic
3. Add Ca2+-channel blocker Amlodipine 5 mg od
4. Add β-blocker HbA1c – target <7% Atenolol 25 mg od

For Type 2 DM:

1. Oral hypoglycaemic agent Metformin 500mg bd
2. Increase dose Metformin 500mg tds
3. Increase dose Metformin 850mg tds
4. Add Sulphonylurea Gliclazide 40 – 160 mg od
5. Add Pioglitazone or consider insulin regime instead.

Guardian drugs

 Aspirin 75 mg od
Indicated for those >30 years with any of the following: MI, angina, hypertension, diabetic
retinopathy, peripheral vascular disease or microalbuminuria.

 ACE-inhibitor e.g. Enalapril 5 mg od

Prevent complications to a greater
The Alphabet Strategy extent than the effects of lowering blood pressure.
Indicated in normotensive patients >55 years with any of the following: cholesterol > 5.2,
“Seven bitssmoker
HDL < 0.9, of highly effective Diabetes Care”
or microalbuminuria.
ADVICE:
 Strong
adherence Foot examination
to diet and
1. Neuropathy: vibration sense, ankle jerks, 10g monofilament testing
2. Vascularity: pedal pulses, claudication, other signs of peripheral vascular disease
3. Anatomy: check for deformities (e.g. pes cavus, claw toes, lost transverse arch, rocker
bottom soles) and Charcot’s joints
4. Infections: treat aggressively (admit for IV antibiotics)

medication, smoking cessation, exercise, weight reduction

 Stress role of diabetes education, dietician, podiatrist and diabetes
care nurses.
 Regular follow-up with complete Annual Review is essential. 20% of
patients with early severe complications will be persistent Diabetes Clinic non-
attendees. Advise Diabetes UK membership
 Lifestyles targets: weight reduction >5% if obese, fat intake <30% of energy
intake, saturated fat < 10% of energy intake, fibre>15g per 1000 calories,
exercise 4 hr/wk. Assess dietary NaCl intake.

BLOOD PRESSURE:
  Aggressive control of any BP > 140/80. If nephropathy/retinopathy, aim BP
< 130/80
 Step 1. A or D: A: (ACE-I or ARB) or D: (diuretic). Indapamide SR
1.5mg has less side-effects
 Step 2. A +D: A: (ACE-I or ARB) and D: (diuretic)
 Step 3. A+D+C: C: (Ca2+ blocker to above) or -blocker
 Step 4. Add Ca2+ blocker or -blocker or -blocker or spironolactone or other
diuretic or moxonidine

CHOLESTEROL:
 Treat as secondary prevention ( eg post MI and angina). Audit Target
Chol < 5
 Simvastatin 40mg or Atorvastatin 10mg best evidence: Rosuvastatin 10mg if
target not achieved
 Statin intolerant or target not achieved: Ezetimibe 10mg od. Fenofibrate for HDL
<1.0 (use statin 1st)
 BHS Targets: total cholesterol ≤ 4.0, LDL ≤ 2.0, HDL ≥ 1.0 or LDL reduction by
30%
 Plant stanol spreads reduce LDL by around 10%.

DIABETES CONTROL:
 Aim HbA1c%  7.0% where realistic: Metformin can also be used with
insulin. in Type 2
 Step 1. Metformin 500mg bd, to 500mg tds to 850mg tds
 Step 2. Add SU eg: Gliclazide, Glimepiride
 Step 3. Consider triple therapy with addition of TZD (Rosiglitazone or
Pioglitazone) in secondary care or add insulin Use insulin early if HbA1c% target
not achieved.
 Usual insulin regimes: Novomix 30 bd. Basal bolus with Novorapid and Glargine

EYE SCREENING:
 Screening for and effective management of Diabetic Retinopathy.
Retinal screening should be carried out annually by a trained person. Ideally
using a retinal camera. Aspirin/ACE-I in most patients

FEET SCREENING:
 Annual review essential yearly by GP, Practice Nurse or podiatrist. Examination
should include: pedal pulses, 10g monofilament testing. If neuropathic or
ischaemic foot referral to podiatry is essential as high risk of ulceration. If ulcers
refer urgently to foot at risk clinic.

GUARDIAN DRUGS:
 Aspirin 75mg od: Diabetes UK now advocates Aspirin prophylaxis against
CVD events in all patients (>30yrs) with any of the following: MI, angina,
hypertension, diabetic retinopathy, peripheral vascular disease and
microalbuminuria. This simple measure is grossly under-implemented.
 ACE-inhibitors have a special role in preventing diabetic
complications (MICRO-HOPE Study). CVD licence in normotensive patients
with risk factors (ramipril 10mg od): diabetes age > 55 with hypertension or
cholesterol > 5.2 mmol/l or HDL < 0.9 mmol/l or currently smoking or micro-
albuminuria. Lisinopril (20-40mg od) is additionally licensed for prevention of
progression of micro-albuminuria (with evidence for retinopathy prevention but no
license). Perindopril with Indapamide prevents stroke reoccurrence.
 Angiotension II antagonists proteinuria to retard progression to death and
ESRD (Losartan 100mg od, Irbesartan 300mg od). Losartan clear CVD end-point
reduction in hypertension versus atenolol