Diabetes, Annual Review (285)

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

The following information must be collected at every annual review visit

BMI;
BP;
Smoking habit;
Review of medication;
Foot examination – pulses, sensation, ulcers, infection, callus, deformity, amputation;
Eye examination – visual acuity, lens, retina. This will only be undertaken if the patient is not attending the retinal screening service or an ophthalmic clinic;
Urinary albumin/protein quantification (see microalbuminuria guidelines);
Blood sample – HbA1c, lipids, creatinine
Consider issues regarding driving – hypoglycaemic unawareness, avoidance of hypoglycaemia and management of hypoglycaemia while driving, notification to DVLA once receiving insulin therapy.

In addition, it is desirable that the following information is collected (if appropriate)

Duration and type of diabetes;
Osmotic symptoms;
Method of glucose monitoring;
Hypoglycaemic unawareness;
Frequency of severe hypoglycaemia;
Condition of injection sites;
Neuropathic symptoms;
Impotence;
Adherence to dietary advice;
Level of physical activity;
Alcohol intake;
Perception and understanding of condition;
Psychological well-being;
Ethnicity;
Screening for associated auto-immune disease;
Angina symptoms;
Claudication symptoms;
CHD risk quantification;
Screening ECG/ETT;
Co-morbidity;

- Ischaemic heart disease / MI / CABG / angioplasty / stent;

- Hypertension;

- Cerebrovascular disease;

- Peripheral vascular disease;

- Renal failure;

- Other.

And finally

Have appropriate referrals been made e.g. GP, specialist nurse, dietician, podiatrist, ophthalmologist, cardiologist, vascular surgeon, psychiatrist/psychologist?
Have patients been offered practical support with lifestyle change e.g. exercise referral scheme?
Consider issues regarding driving – hypoglycaemic unawareness, avoidance of hypoglycaemia and management of hypoglycaemia while driving, notification to DVLA once receiving insulin therapy.
Pre-pregnancy advice.
If indicated, referral should be made to an appropriate structured education programme as per the agreed education pathways for Type 1 and Type 2 diabetes respectively.