Clinical Guidelines Task Force
Global Guideline for Type 2 Diabetes

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Correspondence, and related literature from IDF

Correspondence to: Professor Stephen Colagiuri, University of Sydney, Sydney, Australia. [email protected].

International Diabetes Federation, 166 Chaussee de La Hulpe, B-1170, Brussels, Belgium. [email protected].

Acknowledgements, and sponsors’ duality of interest

This update of the 2005 International Diabetes Federation (IDF) Global Guideline was supported by unrestricted educational grants from:

Eli Lilly

Merck Inc (MSD)

Sanofi-Aventis

These companies did not take part in any aspect of the development of the guideline.

Copyright

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the IDF. Requests to reproduce or translate IDF publications should be addressed to IDF Communications, 166 Chaussee de La Hulpe, B-1170, Brussels, Belgium, by fax at +32-2-5385114, or by e-mail at [email protected]

© International Diabetes Federation, 2012

ISBN 2-930229-43-8

Preface

There is now extensive evidence on the optimal management of diabetes, offering the opportunity of improving the immediate and long-term quality of life of those with diabetes.

Unfortunately such optimal management is not reaching many, perhaps the majority, of the people who could benefit. Reasons include the size and complexity of the evidence-base, and the complexity of diabetes care itself. One result is a lack of proven cost-effective resources for diabetes care. Another result is diversity

Levels of care

All people with diabetes should have access to the broad range of diabetes services and therapies and no person should be denied any element of effective diabetes care. It is recognised that in many parts of the developing world the implementation of particular standards of care is limited by lack of resources. This guideline provides a practical approach to promote the implementation of cost-effective evidence-based care in settings between which resources vary widely.

The approach adopted has

Methodology

The following methodology was used to develop the original guideline:

  • A broadly based group which included people with diabetes, health-care professionals from diverse disciplines, and people from non-governmental organisations was convened (see Members of the Guidelines Group).

  • Geographical representation was from all the IDF regions, and from countries in very different states of economic development (see Members of the Guidelines Group).

  • Designated individuals which expertise in the topic

Members of the Global Guideline Group

Pablo AschnerBogotá, Colombia
Henning Beck-NielsenOdense, Denmark
Peter BennettPhoenix, USA
Andrew BoultonManchester, UK
Ruth ColagiuriSydney, Australia
Stephen Colagiuri (chair)Sydney, Australia
Marion FranzMinneapolis, USA
Roger GadsbyCoventry, UK
Juan José GagliardinoLa Plata, Argentina
Philip HomeNewcastle upon Tyne, UK
Marg McGillSydney, Australia
Susan ManleyBirmingham, UK
Sally MarshallNewcastle upon Tyne, UK
Jean-Claude MbanyaYaoundé, Cameroon
Andrew NeilOxford, UK
Ambady RamachandranChennai, India

Global Guideline for Type 2 Diabetes

1Screening and diagnosis
2Care delivery
3Education
4Psychological care
5Lifestyle management
6Glucose control levels
7Clinical monitoring
8Self-monitoring
9Glucose control therapy
10Blood pressure control
11Cardiovascular risk protection
12Eye screening
13Kidney damage
14Foot care
15Nerve damage
16Older people
17In-patient care
Acronyms and abbreviations

Recommended care

SD1Each health service should decide whether to have a programme to detect people with undiagnosed diabetes.
 This decision should be based on the prevalence of undiagnosed diabetes and on the resources available to conduct the detection programme and treat those who are detected.
 Universal screening for undiagnosed diabetes is not recommended.
SD2Detection programmes are usually based on a two-step approach:
 Step 1 – Identify high-risk individuals using a risk assessment questionnaire.
 Step 2 –

Recommended care

CD1Offer care to all people with diabetes, with sensitivity to cultural wishes and desires.
CD2Encourage a collaborative relationship, by actively involving the person with diabetes in the consultation, and creating opportunities for them to ask questions and express concerns. Ensure that issues important to the person with diabetes are addressed.
CD3Offer annual surveillance of all aspects of diabetes control and complications to all people with type 2 diabetes (see Table CD1).
CD4Agree a care

Recommended care

ED1Make patient-centred, structured self-management education an integral part of the care of all people with type 2 diabetes:
 From around the time of diagnosis.
 On an ongoing basis, based on routine assessment of need.
 On request.
ED2Use an appropriately trained multidisciplinary team to provide education to groups of people with diabetes, or individually if group work is considered unsuitable. Where desired, include a family member or friend.
ED3Include in education teams a health-care

Recommended care

PS1In communicating with a person with diabetes, adopt a whole-person approach and respect that person's central role in their care (see Chapter 3: Education and Chapter 5: Lifestyle management).
Communicate non-judgementally and independently of attitudes and beliefs.
PS2Explore the social situation, attitudes, beliefs and worries related to diabetes and self-care issues.
Assess well-being (including mood and diabetes distress), periodically, by questioning or validated measures (e.g. WHO-5 [1]).

Recommended care

LS1Offer lifestyle advice to all people with type 2 diabetes around the time of diagnosis.
LS2Review and reinforce lifestyle modification yearly and at the time of any treatment change or more frequently as indicated.
LS3Review and provide ongoing counselling and assessment yearly as a routine, or more often as required or requested, and when changes in medication are made.
LS4Advise people with type 2 diabetes that lifestyle modification, by changing patterns of eating and physical activity, can

Recommended care

TT1Advise people with diabetes that maintaining an HbA1c below 7.0%/53 mmol/mol minimises the risk of developing complications.
TT2A lower HbA1c target may be considered if it is easily and safely achieved.
TT3A higher HbA1c target may be considered for people with co-morbidities or when previous attempts to optimise control have been associated with unacceptable hypoglycaemia.
TT4An individual's HbA1c target should be regularly reviewed taking into account benefits, safety and tolerability.
TT5

Recommended care

MO1Monitor blood glucose control by measuring HbA1c using high-precision methods standardised to criteria aligned to the international reference values and subject to stringent quality assurance testing when no conditions are present in a patient that would preclude its accurate measurement.
MO2Measure HbA1c every 2 to 6 months depending on level, stability of blood glucose control and changes in therapy.
MO3Report HbA1c results in both DCCT-aligned units (%) and International Federation of

Recommended care

SM1Self-monitoring of blood glucose (SMBG) should only be made available to people with diabetes when they have the knowledge, skills and willingness to use the information obtained through testing to actively adjust treatment, enhance understanding of diabetes and assess the effectiveness of the management plan on glycaemic control.
SM2The purpose(s) of performing SMBG and using SMBG data should be agreed between the person with diabetes and the health-care provider.
SM3SMBG on an ongoing basis

Recommended care

GC1Begin oral glucose lowering medications when lifestyle interventions alone are unable to maintain blood glucose control at target levels (see Chapter 6: Glucose control levels).
Maintain support for lifestyle measures throughout the use of these medications.
Consider each initiation or dose increase of an oral glucose lowering medications as a rial, monitoring the response in 3 months.
Consider cost and benefit:risk ratio when choosing a medication.
Consider discontinuing ineffective therapies.

Recommended care

BP1Measure blood pressure at least annually, and at every routine clinic visit in people with known CVD, if found to be above target blood pressure levels at previous visits (see below), or if on blood pressure lowering treatment.
BP2Measure blood pressure with a validated meter in good working order and an appropriately sized cuff (large or normal depending on arm size).
Measure blood pressure after sitting for at least 5 minutes, with arm at heart level, using first and fifth phases of Korotkoff

Cardiovascular risk protection

Cardiovascular risk protection through blood glucose control, blood pressure control, and lifestyle interventions is dealt with elsewhere in this guideline (see Chapter 5: Lifestyle management, Chapter 6: Glucose control levels and Chapter 10: Blood pressure control). This section deals with cardiovascular risk assessment, lipid modifying therapy and anti-platelet therapy.

Recommendations

These guidelines are concerned with preventative diabetes care. No advice is given on the further investigation of retinopathy by an ophthalmic specialist, or the subsequent use of laser or other retinal therapy, of vitrectomy, or other tertiary care. It is noted that a substantive evidence-base does exist for these techniques in the prevention of visual loss.

Recommendations

These guidelines are concerned with preventative diabetes care. No advice is given on further investigation of kidney disease by a renal specialist, or subsequent tertiary care.

Recommended care

FT1Assess feet of people with diabetes as part of an annual review for lesions which require active treatment and for risk factors for ulcer and amputation:
1. History of previous foot ulceration or amputation, symptoms of peripheral arterial disease, physical or visual difficulty in self-foot-care.
2. Foot deformity (hammer or clawed toes, bone prominences); visual evidence of neuropathy (dry skin, dilated veins) or incipient ischaemia; callus; nail deformity or damage; footwear.
3. Detection of

Recommended care

NU1Diagnose sensorimotor nerve damage by history and examination (monofilament with or without temperature, non-traumatic pin-prick, vibration [tuning fork], ankle reflexes), and/or simple quantitative testing (e.g. biothesiometer vibration perception).
Use serum B12, thyroid function tests, creatinine/urea and medication history to exclude other causes.
NU2Diagnose symptomatic (painful) diabetic neuropathy by excluding other possible causes of the symptoms.
Manage by stabilising blood glucose

Recommendations

This chapter addresses aspects of diabetes care for older people (70 years and over) which are amenable to an evidence-informed intervention and have the potential to improve clinical outcome and quality of life.

In-patient care organisation

HO1All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record.
All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team.
HO2Designate a diabetes-trained health-care professional to:
 Manage and co-ordinate systems of care related to diabetes management of in-patients.
 Co-ordinate training of hospital staff in awareness of the needs of people with diabetes.

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