Pathways – Dr Duncan Fowler

•Ipswich Hospital Diabetes Centre will have a more active role in supporting primary care pathways, through education, its advice line and email, outreach and face-to-face contact where appropriate•Pathways are usually out of date and can’t cover all eventualities•Care should be individualised and the integrated service will provide ongoing advice based on up to date data and medications• Having said that: pathways still have a role

Management of Hyperglycemia in Type 2Diabetes: A Patient-Centered Approach

Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Diabetes Care 2012;35:1364–1379Diabetologia 2012;55:1577–1596

Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations

Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations

Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations

Fig. 3. Sequential Insulin Strategies in T2DM Diabetes Care 2012;35:1364–1379Diabetologia 2012;55:1577–1596

Indications and therapeutic options for dual therapy in patients with Type 2 diabetes

Commonly occurring situationsIntermittent illnesses: • Stop metformin• Rehydrate with non-sugary drinks

Hypercholesterolaemia:• Atorvastatin – escalate up to 80mg, then refer for consideration of ezetimib

Erectile dysfunction: • Diabetes is a risk factor for erectile dysfunction but assessment and management of patients is similar • Medical, psychiatric, surgical, relationship, sexual and drug history• Clinical examination, including genital examination, blood pressure, heart rate and waist circumference• Serum lipids, fasting plasma glucose, recent HbA1c, morning testosterone and SHBG• Consider digital rectal examination and PSA

Combined oral contraceptive:• Diabetes poses no additional independent risk factor to venous thromboembolism to the established risk

factors

Other Pathways

Renal Impairment

Hypoglycaemia

Anti-platelet therapy – noting that NICE Clinical Guidelines have been superceded by some more recent evidence

GLP-1 agonists

SGLT2 inhibitors

Foot protection

Autonomic neuropathy, explosive nocturnal diarrhoea and neuropathic pain