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Practice Nurse

Recognising and managing the complications of type 2 diabetes

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Approximately 2.9 million adults suffer from type 2 diabetes in the UK and it is thought that there are also around 850,000 people in the UK who have undiagnosed type 2 diabetes. The condition is associated with high levels of cardiovascular complications. By 2025, it is estimated that 5 million people will have diabetes in the UK. Effective treatment is of paramount importance, therefore, in order to reduce the numbers of people who suffer from these devastating and largely preventable complications.This resource, consisting of five assessment questions at intermediate level, tests your knowledge of the complications of diabetes based on national and international guidance. Complete the resource to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

On completion of this resource, you should have an understanding of:

The macrovascular complications of diabetes

The microvascular complications of diabetes

The general practice nurse’s role in assessing cardiovascular risk in people with diabetes

The general practice nurse’s role in detecting complications

Alphabet strategy for diabetes Available from 

http://www.abcdiabetes.co.uk/abc-for-healthcare-professionals/

Diabetes UK (2012) Diabetes in the UK Available from 

http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf

EASD hyperglycaemia guidelines available from 

http://care.diabetesjournals.org/content/early/2012/04/17/dc12-0413

Holt T and Kumar S (2010) ABC of Diabetes Wiley Blackwell West Sussex

NICE (2009) Type 2 diabetes Available from 

http://www.nice.org.uk/nicemedia/live/12165/44320/44320.pdf

Pardeep is a 45 year old South East Asian woman who has had type 2 diabetes for 8 years. She attends for her diabetes review. Her most recent HbA1c is 63mmol/mol (7.9%) and her lipid profile shows a total cholesterol of 4.5mmol/L, an HDL of 1.4mmol/L and an LDL of 3mmol/L. Her eGFR is 63ml/min. Her blood pressure is 132/77 mmHg and she is overweight with a BMI of 27.6 kg/m

. She is a medical secretary and lives with her husband. Her two children are away at university.

How would you assess Pardeep’s cardiovascular risk?

The NICE guidelines for managing type 2 diabetes state that people with type 2 diabetes should be considered to be at high risk of cardiovascular disease with few exceptions. This means there is no need to assess risk unless the patient has no other risk factors for cardiovascular disease (including having a healthy BMI). Although we often treat people with type 2 diabetes as if they require secondary prevention (i.e. as if they have pre-existing cardiovascular disease) they actually only need secondary prevention if they have a known diagnosis of cardiovascular disease. The UKPDS risk engine is accredited for use in people with diabetes

Go to the NICE guidelines and find the list of exceptions to the rule that diabetes should be treated as high cardiovascular risk

Question 1

Gladys, aged 79, has had type 2 diabetes for 27 years and her HbA1c is currently 62mmol/mol (7.8%). Her BP is 145/82 mmHg and her total cholesterol is 4.8mmol/L with an HDL of 1.2mmol/L and an LDL of 2.6mmol/L.

Which intervention is least likely to reduce her risk of cardiovascular complications in the future?

The STENO and UKPDS trials confirmed that multi-factorial interventions (glucose, BP and lipid management) reduced the risk of cardiovascular complications in people with diabetes. However, lipid lowering therapies and treatment for blood pressure seemed to have a better effect than improving glycaemic control and this was more noticeable in people with an established history of diabetes than it was in people who were newly diagnosed. Aspirin is no longer routinely recommended for primary prevention of CVD in people with diabetes as advised by the MHRA. It is fair to say that research evidence is harder to find in elderly populations; however, the HYVET trial which looked at treating hypertension in the very elderly showed that benefits remained in the over 80 age group although targets could be relaxed slightly

Select the next three people you see who are over 75 and being treated with anti-hypertensive medication. How close to target blood pressure readings are they? Has their medication been optimised? How do you feel about aiming for tighter targets in people over 80 with diabetes?

Dealing with emergencies in general practice: the patient with hyperglycaemia http://www.practicenurse.co.uk/index.php?page=14&id=667&cat=11

Hyperglycaemia; Prevention and management http://www.practicenurse.co.uk/index.php?page=14&id=580&cat=11

Hyperglycaemia and why it matters http://www.practicenurse.co.uk/index.php?page=14&id=542&cat=11

Gaede P et al (2003) Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes NEJM vol. 348 No. 5 Available from 

Beckett NS et al (2008) HYVET trial NEJM 358:1887-1898

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28659/

Question 2

National and international guidelines recognise that diabetes is a major risk factor for cardiovascular disease and this includes both macrovascular and microvascular complications.

Which of the following is not a microvascular complication of diabetes?

The microvascular complications of diabetes include neuropathy, nephropathy and retinopathy. Loss of sensation in the feet is a symptom associated with peripheral neuropathy; early satiety may be linked to autonomic neuropathy. Microalbuminuria occurs when small proteins can be detected in the urine as a result of damage to the filter system of the kidneys.

What is the local referral process to podiatry for people newly diagnosed with type 2 diabetes? Are all newly diagnosed patients referred or only selected ones? How does this fit with NICE guidance?

Diabetic footcare; Part 1 http://www.practicenurse.co.uk/index.php?page=14&id=707&cat=11

Diabetic footcare; Part 2 http://www.practicenurse.co.uk/index.php?page=14&id=708&cat=11

Patel V et al (2001) The HOPE study and MICRO HOPE substudy Available from 

Question 3

Pardeep needs to be tested for diabetic nephropathy as part of her annual review.

Which of the following statements about testing for diabetic nephropathy is correct?

Guidelines from NICE advise measuring urinary ACR annually using an early morning urine sample when possible. If the test is abnormal it should be repeated at least once within the next three months. Treatment should not be initiated until the diagnosis is confirmed. Proteinuria can be due to other causes such as a urinary tract infection so this should be excluded as a possible cause by taking a clinical history and carrying out further testing where indicated.

Do you have an evidence based protocol in place for ACR testing? If not, could you develop one based on the advice in these guidelines?

NICE (2008) Chronic Kidney Disease guideline 

http://publications.nice.org.uk/chronic-kidney-disease-cg73

Question 4

Diabetes is a common cause of cardiovascular complications.

Two-thirds of deaths in people with diabetes can be attributed to cardiovascular causes. In general, the most common complication of diabetes is myocardial infarction. However, in the African Caribbean population, stroke is more common. It is a sad fact that all the other answers are correct. Diabetic kidney disease is more common in people with T1DM than T2DM but there are more people with T2DM in general. Black and Asian ethnic minorities also have an increased risk of diabetic kidney disease. Retinopathy is more common in type 1 diabetes than type 2 and as this strikes younger people in general, this means that people in their 30s are suffering the consequences of diabetic eye disease.

Research suggests that not all younger people with type 1 diabetes have eye screening carried out. Find 5 patients with type 1 diabetes in your practice and see if they have any record of a retinopathy screen.

Diabetes UK (2013) Diabetic eye screening 

http://www.diabetes.org.uk/About_us/What-we-say/Improving-diabetes-healthcare/Diabetic-eye-screening/

Recognising and managing the complications of type 2 diabetes

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