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Contents
1 introduction ................................................................................................................ 1
1.1 The need for a guideline .............................................................................................. 1
1.2 Remit of the guideline.................................................................................................. 1
1.3 Definitions................................................................................................................... 2
1.4 Statement of intent....................................................................................................... 3
2 Key recommendations................................................................................................. 5
2.1 Lifestyle management................................................................................................... 5
2.2 Psychosocial factors..................................................................................................... 5
2.3 Management of type 1 diabetes.................................................................................... 6
2.4 Pharmacological management of glycaemic control in people with type 2 diabetes..... 6
2.5 Management of diabetes in pregnancy ......................................................................... 7
2.6 Management of diabetic cardiovascular disease ........................................................... 7
2.7 Management of kidney disease in diabetes................................................................... 7
2.8 Prevention of visual impairment................................................................................... 8
2.9 Management of diabetic foot disease............................................................................ 8
3 Lifestyle management.................................................................................................. 9
3.1 Delivery of lifestyle interventions................................................................................. 9
3.2 Structured education.................................................................................................... 10
3.3 Self monitoring of glycaemia........................................................................................ 12
3.4 Smoking cessation........................................................................................................ 16
3.5 Exercise and physical activity....................................................................................... 17
3.6 Weight management in type 2 diabetes........................................................................ 20
3.7 Healthy eating.............................................................................................................. 22
3.8 Alcohol........................................................................................................................ 23
3.9 Checklist for provision of information .......................................................................... 24
4 Psychosocial factors.................................................................................................... 25
4.1 The influence of psychosocial factors on diabetes control ............................................ 25
4.2 Screening for psychological distress............................................................................. 26
4.3 The effect of psychological interventions on diabetes outcomes................................... 27
4.4 Treatment of psychological distress.............................................................................. 28
4.5 Checklist for provision of information .......................................................................... 29
ContentsManageMent of diabetes
5 Management of type 1 diabetes................................................................................... 30
5.1 Diagnosis and epidemiology........................................................................................ 30
5.2 Initiating therapy at diagnosis....................................................................................... 30
5.3 Continuing management.............................................................................................. 31
5.4 Quality of life............................................................................................................... 36
5.5 Long term complications and screening ....................................................................... 37
5.6 Checklist for provision of information .......................................................................... 38
6 Pharmacological management of glycaemic control in people with type 2 diabetes... 39
6.1 Introduction................................................................................................................. 39
6.2 Targets for glycaemic control ....................................................................................... 39
6.3 Metformin.................................................................................................................... 41
6.4 Sulphonylureas............................................................................................................ 42
6.5 Thiazolidinediones....................................................................................................... 44
6.6 Dipeptidyl peptidase-4 inhibitors................................................................................. 46
6.7 Alpha-glucosidase inhibitors......................................................................................... 47
6.8 Meglitinides................................................................................................................. 48
6.9 Glucagon like peptide-1 agonists.................................................................................. 48
6.10 Insulin.......................................................................................................................... 50
6.11 Algorithm for glucose-lowering in people with type 2 diabetes.................................... 53
6.12 Checklist for provision of information .......................................................................... 54
7 Management of diabetes in pregnancy........................................................................ 56
7.1 Introduction................................................................................................................. 56
7.2 Contraception.............................................................................................................. 56
7.3 Pre-pregnancy care....................................................................................................... 57
7.4 Nutritional management............................................................................................... 59
7.5 Optimisation of glycaemic control ............................................................................... 59
7.6 Complications during pregnancy.................................................................................. 60
7.7 Fetal assessment........................................................................................................... 62
7.8 Gestational diabetes..................................................................................................... 63
7.9 Delivery....................................................................................................................... 66
7.10 Infants of mothers with diabetes................................................................................... 66
7.11 Postnatal care............................................................................................................... 67
7.12 Follow up of women with GDM .................................................................................. 68
7.13 Checklist for provision of information .......................................................................... 688 Management of diabetic cardiovascular disease.......................................................... 70
8.1 Epidemiology............................................................................................................... 70
8.2 Cardiovascular risk factors............................................................................................ 70
8.3 Primary prevention of coronary heart disease............................................................... 71
8.4 Management of patients with diabetes and acute coronary syndromes......................... 73
8.5 Management of patients with diabetes and heart failure ............................................... 76
8.6 Management of patients with diabetes and stable angina.............................................. 79
8.7 Management of acute stroke......................................................................................... 81
8.8 Peripheral arterial disease............................................................................................. 81
8.9 Checklist for provision of information .......................................................................... 81
9 Management of kidney disease in diabetes.................................................................. 83
9.1 Definitions................................................................................................................... 83
9.2 Prevalence and progression of kidney disease in diabetes............................................ 84
9.3 Screening for kidney disease in diabetes....................................................................... 85
9.4 Investigation of kidney disease in diabetes................................................................... 87
9.5 Prevention and treatment of kidney disease in diabetes................................................ 87
9.6 Management of complications..................................................................................... 93
9.7 Models of care ............................................................................................................. 94
9.8 Checklist for provision of information .......................................................................... 95
10 Prevention of visual impairment.................................................................................. 96
10.1 Risk identification and prevention................................................................................ 96
10.2 Screening..................................................................................................................... 97
10.3 Treatment..................................................................................................................... 100
10.4 Rehabilitation............................................................................................................... 102
10.5 Checklist for provision of information .......................................................................... 102
11 Management of diabetic foot disease .......................................................................... 104
11.1 Epidemiology and risk factors....................................................................................... 104
11.2 Risk stratification.......................................................................................................... 104
11.3 Patient education ......................................................................................................... 106
11.4 Preventative footwear and orthoses.............................................................................. 106
11.5 Management of active foot disease............................................................................... 107
11.6 Painful diabetic neuropathy.......................................................................................... 109
11.7 Checklist for provision of information .......................................................................... 110
Contents12 Provision of information.............................................................................................. 111
12.1 Sources of further information...................................................................................... 111
13 implementing the guideline......................................................................................... 112
13.1 Resource implications of key recommendations........................................................... 112
13.2 Auditing current practice.............................................................................................. 113
13.3 Additional advice to NHSScotland from NHS Quality Improvement Scotland
and the Scottish Medicines Consortium........................................................................ 115
14 the evidence base ....................................................................................................... 116
14.1 Systematic literature review.......................................................................................... 116
14.2 Recommendations for research .................................................................................... 116
14.3 Review and updating ................................................................................................... 118
15 development of the guideline ..................................................................................... 119
15.1 Introduction................................................................................................................. 119
15.2 The guideline development group................................................................................ 119
15.3 The guideline steering group........................................................................................ 122
15.4 Consultation and peer review....................................................................................... 123
abbreviations.............................................................................................................................. 125
annexes .................................................................................................................................... 130
References.................................................................................................................................. 144
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