FreeStyle Blood Glucose Meters

This module will focus on the complications of diabetes, which can be divided into two categories:¹

• Microvascular – damage to small blood vessels, e.g. diabetic retinopathy, nephropathy, and neuropathy (peripheral and autonomic)
• Macrovascular – damage to large blood vessels, e.g. coronary artery disease, peripheral vascular disease, and cerebrovascular disease

RISK FACTORS FOR MICROVASCULAR DISEASE

It is now well known that the major risk factors for the development of microvascular complications are a combination of:

• Duration of diabetes
• Glycaemic control
• Hypertension

However, other risk factors including ethnic origin and smoking have their part to play.

Factors associated with the development of diabetic complications. CVD: cardiovascular disease; T2D: Type 2 diabetes. Adapted from Marcovecchio et al. 2010.²

SCREENING FOR MICROVASCULAR COMPLICATIONS

Everyone with diabetes should be screened for complications at diagnosis. Finding signs of complications at this early stage is more likely in people with Type 2 diabetes who may have had undiagnosed elevated blood glucose for some time before their diabetes was detected.

Diabetic retinopathy represents the leading cause of blindness in working-age adults in Ireland. In fact, one person with diabetes goes blind in Ireland each week.¹

RETINOPATHY CAN BE DIVIDED INTO TWO MAIN CATEGORIES:

For patients with diabetes, it is possible for significant retinopathy to develop before vision is impaired. However, with early detection, diabetic retinopathy can be effectively treated.¹ 

Diabetic RetinaScreen is the national diabetic screening programme in Ireland, offering free regular screening to people with diabetes aged 12 years and over.² Using specialised digital photography, the screening programme detects any changes early, so treatment is more effective at reducing or preventing damage to sight.² The programme is being implemented and managed by the National Screening Service (NSS), part of the Health Service Executive (HSE), and is aiming to reach a population of over 190,000 people. 

Approximately 40% of diabetes patients will develop nephropathy, which can progress to chronic kidney disease, finally leading to end-stage renal failure.¹ Diabetes is the single most common cause of end-stage renal failure (ESRF) in the developed world.²

The five-stage development of ESRF³

There is an established sequence of events which leads to ESRF in both Type 1 and Type 2 patients with diabetes:

STAGE 1: GLOMERULAR HYPERFILTRATION

The earliest observation in development of nephropathy is an increase of up to 50% in the glomerular filtration rate (GFR).

STAGE 2: THICKENING OF GLOMERULAR CAPILLARY

Thickening of the glomerular capillary basement membrane is found histologically. It is unusual to develop microalbuminuria during the first years of diabetes; this phase is sometimes referred to as the ‘silent phase’.

STAGE 3: DEVELOPMENT OF MICROALBUMINURIA

Defined as a urine albumin level of 20-200 μg/min or 30-300 mg/24h which is not detectable by routine urine dipsticks.

STAGE 4: OVERT NEPHROPATHY

Overt diabetic neuropathy and macroalbuminuria – defined as a urine albumin level of >200 μg/min or >300 mg/24h which is detectable by routine dipsticks.

STAGE 5: END-STAGE RENAL FAILURE (ESRF)

Usually occurs 25-30 years after diagnosis, with glomerular closure and resultant decrease in proteinuria.

In Type 1 diabetes, microalbuminuria rarely occurs in the first 5 to 10 years and seldom before puberty. Consequently, the National Institute for Health and Care Excellence (NICE) guidance recommends screening for moderately increased albuminuria (or ‘microalbuminuria’) annually from the age of 12 years.^1,2 For Type 2 diabetes, the precise date of onset of the disease is difficult to determine, so screening should begin at diagnosis.³ There are several ways to screen for diabetic renal disease:⁴

• The albumin excretion rate can be measured from any timed sample – usually from a urine collection taken over 4 hours or overnight
• Timed urine collections over a 24-hour period
• The urinary albumin: creatinine ratio can be determined from a random, preferably early morning sample^1,2

NICE recommends that all adults with Type 1 or Type 2 diabetes, with or without detected nephropathy, should be asked to bring in a first-pass morning urine sample on a yearly basis.^1,2 This sample should be tested for evidence of urinary tract infection (UTI) and then sent for laboratory estimation of albumin creatinine ratio.⁵

If an abnormal result is recorded (in the absence of proteinuria/UTI) the test should be repeated at each clinic visit or at least every 3-4 months. The result can be taken to confirm microalbuminuria if a further specimen (out of 2 or more) is also abnormal.⁵

LABORATORY EVALUATION OF DIABETIC NEPHROPATHY:

Adapted from NICE Diabetes Type 2 - CKS 2015.³

Albumin excretion can vary markedly – by up to 40% – and there are many factors which can introduce inaccuracies into the results. While urine dipstick tests may be useful for initial screening, organising albumin: creatinine ratio (ACR) for men and women with a positive result will give a more accurate picture of their situation, and is the screen of choice both for the CKS and the International Diabetes Federation.^3,6

For patients with diabetes with confirmed nephropathy (including those with moderately increased albuminuria) NICE recommends starting ACE inhibitors with the usual precautions and titrating to full dose.^2,5 

DIABETES AND ESTIMATED GLOMERULAR FILTRATION RATE (EGFR)

The classification of diabetic nephropathy has classically been based on albumin excretion rates (AER). However, NICE and the American Diabetes Association (ADA) recommend measuring serum creatinine and estimating the GFR of adults with Type 2 diabetes, with or without detected nephropathy, annually at the time of ACR estimation.^5,7 Serum creatinine concentration, age, sex and ethnic origin are the four variables that factor into the calculation of eGFR using the Modification of Diet in Renal Disease (MDRD) equation. 

​Peripheral neuropathy is responsible for a decrease in sensation in the feet and lower legs and, less frequently, the hands. Autonomic neuropathy which affects the central nerves can cause many symptoms including postural hypotension and erectile dysfunction.

Symptoms of peripheral neuropathy

Symptoms of peripheral neuropathy can vary markedly from person to person, as can the descriptions they use for what they are feeling. However the main sensations can be described as:²

  – Pain, typically occurring in the feet and hands (i.e. glove and stocking distribution)
  – Pain with a ‘burning’, ‘shooting’, or ‘electric’ quality
  – Dysaesthesia and paraesthesia (e.g. a sensation of crawling, itching, numbness and tingling)
  – Sensory loss
  – Allodynia (a painful sensation resulting from a normally non-painful stimulus)

Peripheral neuropathy and the diabetic foot

Peripheral neuropathy is one of the four classical risk factors for developing diabetic foot problems.^3,4 These risk factors are:

• Deformity
• Peripheral neuropathy
• Ischaemia
• Infection

Diabetic foot problems are the most frequent manifestation of diabetic neuropathy¹ and are certainly the neuropathic problem all practice and district nurses with a responsibility for wound care will be very familiar with. Approximately 10% of people with diabetes will develop a foot ulcer in their lifetime.⁵ Treatment for foot ulceration may require hospital in-patient treatment, with patients spending an average of 14 days in hospital,⁶ and the recurrence rate for patients with healed diabetic foot ulcers is about 66%.⁷ Furthermore, despite the introduction of the National Diabetes Footcare programme in 2010, the number of patients in Ireland requiring lower limb amputation increased from 393 in 2013 to 440 in 2014.⁶

Many factors may precipitate foot ulceration and infection. Examination of the feet of people with diabetes should include:

TESTING OF FOOT SENSATION USING A 10 g MONOFILAMENT OR VIBRATION¹

The 10 g monofilament is a convenient and easy tool to use in primary care. The number and position of sites to be tested with a monofilament, however, varies markedly between guidelines, so local policy should be followed. It is important to remember that monofilaments deteriorate with use and so you should replace yours in line with the manufacturer’s instructions. People with diabetes who have lost their ability to detect the sensation of a monofilament have lost their protective pain sensation.²

PALPATION OF FOOT PULSES

To check blood flow into the feet, palpate the dorsalis pedis and posterior tibial pulses. Nurses familiar with Doppler ultrasonography for assessment of circulation when considering compression hosiery may find this a useful technique for assessing the circulation in the feet of people with diabetes.

INSPECTION FOR ANY FOOT DEFORMITY¹

Skin temperature is a good indication of skin perfusion; any increase or decrease in surface temperature suggests a problem. A good way to assess skin temperature variations is to run the back of the hand down the leg from the lower knee and along the foot to the toes. Looking at the skin is also important; look for absence of hair or decreased hair growth, nail changes and atrophic, dry or cracked skin. These all suggest peripheral and autonomic neuropathy.^3,4 Testing the range of motion with their foot is also useful. Lack of joint motion can lead to an increased risk of ulceration and amputation.^3,4

INSPECTION OF FOOTWEAR

It is important that people with diabetes wear comfortable shoes that provide protection against pressure. Unfortunately, such shoes are seldom in the height of fashion. Therefore, it is important to look at and discuss footwear, helping people with diabetes to understand the priority they need to give to comfort and support.⁴

AUTONOMIC NEUROPATHY

Autonomic neuropathy is a more insidious form of neuropathy than peripheral neuropathy. The autonomic nervous system controls the body’s involuntary functions such as heart rate, blood pressure, bladder function, digestion, vision, salivation, and perspiration. People with diabetes suffering from autonomic neuropathy can suffer a wide range of problems, including:¹

• Cardiovascular autonomic neuropathy – has been linked to postural hypotension and exercise intolerance which can cause cardiac arrhythmias, cardiovascular ischaemia, myocardial infarction and sudden death syndrome.²
• Gastrointestinal autonomic neuropathy – can delay stomach emptying and cause nausea, vomiting, weight loss and early satiety – feeling full even after a small meal. Gastric disruption can affect glucose digestion leading to erratic glucose control.
• Pupillomotor dysfunction – symptoms can include visual blurring and impaired adaptation to ambient light.
• Sudomotor dysfunction – can lead to excessive sweating (hyperhidrosis) in the trunk area and lack of sweat (anhidrosis), seen as dry skin, on the hands and feet.
• Hypoglycaemic unawareness – may allow blood glucose to drop dangerously low.
• Genitourinary autonomic neuropathy – including sexual dysfunction and bladder dysfunction, which may lead to incomplete bladder emptying, a weak urinary stream and ultimately to an increased risk of urinary tract infections.

SEXUAL DYSFUNCTION

AMONG WOMEN - The link between diabetes and female sexual dysfunction (FSD) has received less attention than ED, which has been heavily researched.³ FSD consists of:⁴

• Sexual desire disorders – including an absence of sexual thoughts and avoidance of sexual contact.
• Sexual arousal disorder – an inability to attain or maintain sufficient sexual excitement. This problem may manifest itself either as a lack of subjective excitement or lack of physical excitement, such as genital lubrication.
• Orgasmic disorder – difficulty with, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal.
• Sexual pain disorder – including pain associated with intercourse and vaginismus.

AMONG MEN
Autonomic neuropathy resulting from diabetes is one of the most common causes of erectile dysfunction (ED). The frequency of ED in diabetic men has been reported as up to 75%.⁵ ED can have a considerable impact on quality of life and may be perceived as a major problem by patients and their partners.⁶

• ED is an independent marker of increased cardiovascular disease.⁷ Health Service Executive Ireland and NICE recommend that all men with ED should have their risk of cardiovascular disease assessed^.8,9

There appears to be a link between diabetes and FSD. In patients with Type 1 diabetes, the presence of sexual dysfunction was significantly higher when compared to a control group of healthy women. Compared to the same control group, sexual desire was significantly reduced in patients with either Type 1 or Type 2 diabetes.³

The best way to screen for whether autonomic neuropathy is affecting the sexual functioning of men or women in your care is to ask them. Asking about sexual function may feel like an invasion of privacy, however sexuality and sexual health are important and nurses have a responsibility to address them with their patients. Aim to create an environment where issues of a sexual nature can be raised.

Good communication skills are an important part of any consultation. The Irish Diabetes Nurse Specialist Association (IDNSA) offer an online discussion forum to promote the exchange of information and knowledge among nurses working in diabetes care.¹ They also provide useful educational resources to support their members.¹ More information can be found at www.idnsa.ie 

PRECONCEPTION CARE FOR WOMEN WITH DIABETES

Information on pregnancy and contraception should be given to all women with diabetes of a childbearing age. For women with diabetes who are planning a pregnancy, diabetic complications should be assessed and treated if indicated. A preconception baseline retinal examination and assessment of microalbuminuria should be performed.²

  Advice for women with diabetes of childbearing age should include:²

• The importance of carefully planning a pregnancy and the fact that being pregnant with diabetes will require more frequent monitoring and interventions, with frequent contact with healthcare professionals
• How pregnancy and labour can affect and be affected by their diabetes and the increased risk of pregnancy complications associated with diabetes
• The need for effective contraception and avoiding pregnancy until they have good HbA1c control
• The need for regular self-monitoring and monthly HbA1c measurements prior to pregnancy with any improvement in HbA1c being encouraged
• The importance of losing excess weight prior to conception
• Information on hypoglycaemia and the treatment options of hypoglycaemia
• Information on hyperglycaemia – how to check for ketones at home (especially for women with Type 1 diabetes) and what to do if unwell (for all women with diabetes)
• The need to check that current medications are suitable for use in pregnancy
• Their baseline retinal and nephropathy results
• The advantages of healthy eating and taking folic acid supplements in an appropriate dose*
• Smoking cessation advice and the importance of cutting down or cutting out alcohol

* The normal daily dose for non-diabetic women who are either pregnant or trying to get pregnant is 400 micrograms (μg). Women with diabetes are advised to take a higher dose of 5 milligrams (mg) a day³

The macrovascular complications of diabetes are due to damage of larger blood vessels and include cardiovascular diseases (CVD) such as heart attacks and strokes.¹

THE CONSEQUENCES OF CVD FOR PEOPLE WITH DIABETES:²

DIABETES AND INCREASED RISK OF DEATH FROM CVD

People with diabetes have a reduced life expectancy of between 5 and 10 years. Approximately 70% of all deaths in people with diabetes are caused by CVD.³ For patients with Type 2 diabetes, more than half will already have signs of CVD at diagnosis.⁴ 

In every age group, more people with diabetes die from CVD compared with their non-diabetic counterparts, and this is particularly true for the young.⁵ Overall, diabetes increases the risk of CVD more in women than in men, so whereas in the general population women have less risk of cardiovascular death, amongst people with diabetes men and women are at equal risk.⁶ 

Many of the risk factors for CVD for people with diabetes are identical to the non-diabetic population, others are more specifically associated with the disease.

All the major risk factors for CVD – smoking, dyslipidaemia and hypertension – apply equally to people with diabetes. Even in their absence, diabetes is a risk factor for CVD in its own right. But when diabetes is combined with these major risk factors, the problems are exaggerated.¹

Diabetes and coronary heart disease – coronary heart disease events, whether fatal or non-fatal, are substantially more common amongst people with diabetes and tend to be more severe. The risk of developing CVD for people with diabetes is about 2-fold higher.¹

Diabetes and stroke – in the general population, about 85% of strokes are ischaemic (or atherothrombotic) in origin, which means they are caused by a blockage of the vessels that supply blood to the brain.² The remainder are haemorrhagic, which means they are caused by the rupture of a blood vessel in or around the brain. The risk of suffering an atherothrombotic stroke is two to three times higher in people with diabetes and they are more prone to irreversible brain damage caused by the ischaemia.³ People with diabetes are two times more likely to have a stroke within 5 years of diagnosis, when compared to the general population.¹

Diabetes and peripheral vascular disease – the effects of neuropathy of the feet in diabetic patients was discussed in a previous section of this module. However, when a diabetic patient presents with foot ulceration, ischaemia brought about by atherosclerosis may also be playing a significant part. A combination of ulceration and sepsis in an ischaemic foot – with or without neuropathy – carries a high risk of gangrene and urgent attention is required if amputation is to be avoided.⁴ Regrettably, people with diabetes are 15 times more likely to suffer an amputation when compared with the general population.¹ Features which can help you to distinguish feet with ischaemic involvement are shown in the table below.

CLINICAL FEATURES OF NEUROPATHIC AND ISCHAEMIC FEET:⁴

The metabolic syndrome: defined as a cluster of closely related medical conditions which increase the risk of developing CVD and Type 2 diabetes. The main components of metabolic syndrome include obesity, dyslipidaemia, hypertension, hyperglycaemia and insulin resistance.⁵ Insulin resistance is a common factor in people with Type 2 diabetes; over 80% of people with Type 2 diabetes are insulin resistant.⁶ Metabolic syndrome increases the risk of diabetes 5-fold and heart disease by approximately 3-fold, and is present in 25% of the adult population worldwide.⁷

A person is said to have metabolic syndrome if they have:⁸

• Central obesity – defined by waist circumference with ethnicity specific values

Plus any two of the four factors listed below:

• Raised blood pressure (BP) – systolic BP ≥130 or diastolic BP ≥85 mmHg or treatment of previously diagnosed hypertension
• Raised triglycerides – ≥150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality
• Raised fasting plasma glucose – ≥5.6 mmol/L or previously diagnosed Type 2 diabetes
• Reduced HDL cholesterol – <40 mg/dL (1.03 mmol/L) in males, <50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormality.

HEALTHY DIET AND LIFESTYLE ADVICE

Maintaining a healthy lifestyle by improving dietary habits, managing weight, and keeping active can reduce the risk of CVD in people with diabetes.¹

The Diabetes Control and Complications Trial² showed that when compared with conventional insulin treatment, intensive insulin treatment aimed at lowering HbA1c levels for people with Type 1 diabetes reduced the risk of the following:²

• Retinopathy by 76%
• Neuropathy by 60%
• Microalbuminuria by 39%

For those with Type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS) showed that the risk of retinopathy and nephropathy decreased by 37% for every 1% decrease in HbA1c achieved.³

GENERAL ADVICE FOR A HEALTHY LIFESTYLE, DESIGNED TO REDUCE THE RISK OF CVD IN PEOPLE WITH DIABETES:⁴

DON’T SMOKE⁴

• Offer your patients advice and support on how to quit

MAINTAIN A HEALTHY WEIGHT

• BMI 18.5-24.9 kg/m2 for adults⁵

KEEP WAIST CIRCUMFERENCE LESS THAN⁴

• 102 cm for white and black men
• 92 cm for Asian men
• 88 cm for white and black women
• 78 cm for Asian women

KEEP BLOOD PRESSURE UNDER CONTROL⁴

• Target blood pressure level should be below 130/80 mmHg⁶

EAT A HEALTHY DIET⁴

• Eat at least 5 portions of a variety of fruit and vegetables each day
• Limit salt intake to no more than 5 g a day
• Eat 2-3 portions of fish per week, at least one of which should be oily (such as herring, mackerel, sardines, kippers, salmon, or fresh tuna)
• Reduce amount of fat in the diet
• Replace saturated fat, such as lard, with monounsaturated fats, such as olive oil

LIMIT DAILY ALCOHOL INTAKE⁴

• Max 14 units per week for women - not regularly drinking more than 2-3 units per day
• Max 21 units per week for men - not regularly drinking more than 3-4 units per day

BE PHYSICALLY ACTIVE

• For at least 30 minutes a day on most days of the week⁴

HbA1c is the classical marker of long-term glycaemic status and has been regarded as having ‘strong predictive value for diabetes complications’.¹ For people with Type 2 diabetes, the UKPDS study showed that a 1% reduction in HbA1c significantly reduced the risk of the major consequences of atherosclerosis.² Amongst people with Type 1 diabetes, the DCCT trial showed intensive management of blood glucose lowered the risk of a cardiovascular event by 42%.³

Reaching target HbA1c levels is a complex mix of understanding, empowerment, commitment and is a fundamental aspect of the triangle of diabetes care, which aims to improve patient outcomes through a trio of diabetes management targets. Glycaemic variability (discussed in Module 1), another key part of the triangle, is also an important factor that increases metabolic stress and mortality in patients in acute states.^4,5 One area worth discussing is the patient’s blood glucose monitoring, as regular monitoring by both patients and healthcare professionals allows treatment to be frequently reviewed and modified where appropriate. NICE guidance recommends self-monitoring of blood glucose (SMBG) for patients on insulin treatment or oral glucose-lowering medication.⁶ In addition, SMBG is recommended as a method of assessing changes in glucose control following lifestyle adjustments, during intercurrent illness and to ensure safety during certain activities, such as driving.⁶ Furthermore, recent research has shown that the use of structured SMBG significantly improves glycaemic control and facilitates more timely/aggressive treatment changes in patients with non-insulin-treated Type 2 diabetes.⁷

In a large study conducted in the US amongst more than 24,000 people with either Type 1 diabetes or Type 2 diabetes treated with tablets or insulin, SMBG at the levels recommended by the American Diabetes Association (>3 times per day for Type 1 and at least daily for Type 2) was found to be significantly associated with better HbA1c levels (<0.0001).⁸

And – in the US again – an assessment of 228 patients making more than 3,000 clinic visits over a 3-year period showed the influence of interaction with a healthcare professional. The patients were classified according to whether SMBG was discussed during their clinic visit and, by the results of those discussions, into ‘regular’, ‘irregular’ and ‘not monitored’ performers of SMBG. As can be seen in the table below, regular discussion of SMBG at clinic visits significantly affected the percentage of patients achieving HbA1c levels ≤8.⁹

INFLUENCE OF HEALTHCARE PROVIDER’S CONTACT ON CLINICAL EFFECT OF SMBG:⁹

In the UKPDS trial, tight control of blood pressure was shown to reduce the incidence of microvascular events by 37% (p=0.0092).¹ NICE guidance recommends measuring blood pressure annually from the age of 12 in patients with Type 1 diabetes.^2,3 For patients with Type 2 diabetes, blood pressure measurements are recommended at least annually.⁴ Suggested follow-ups based on the results of blood pressure measurements are described in the table below.^4,5 People with diabetes need to understand that blood pressure medication is for life. Tight targets may be difficult to reach and can require at least three antihypertensive drugs.⁶

FREQUENCY OF BLOOD PRESSURE MEASUREMENTS FOR PEOPLE WITH DIABETES:⁴

As previously mentioned, the key to managing retinopathy is regular – at least annual – retinal examinations with referral for early treatment as necessary. Recently, uptake of retinal screening has improved. 80.9% of the people who were invited attended a screening between 2011-2012¹ compared with only 57.3% in 2005.² Continuing to encourage people with diabetes to attend retinal screening plays a vital role in the management of retinopathy.

PREPARING FOR RETINAL SCREENING

There may be concern about retinal screening and possible alarm if lesions are detected. Reassurance is important, alongside encouragement about the positive effects improved control of blood glucose and blood pressure may have. More information can be found at www.diabeticeye.screening.nhs.uk.

In Ireland in 2013, there were 371 lower limb amputations as a result of diabetes-related complications.¹ There is evidence that a combination of support and education about foot care, prophylactic foot care and, where appropriate, special footwear can reduce amputation rates by 30-50%.² One study identified that up to 92% of participants with diabetes were wearing inadequate footwear.³ Care and monitoring of neuropathic feet is essential, and this is only possible if the person with diabetes takes an active role. The following practical tips are suggested to help patients with diabetes care for their feet.^4,5-7

DO NOT EXPOSE FEET TO EXTREMES OF HEAT OR COLD⁴

WEAR SHOES AND SOCKS THAT ARE NOT TOO TIGHT^5,6

CHECK FEET DAILY^5-7

WASH FEET EVERY DAY WITH ORDINARY SOAP AND WARM WATER. DRY THEM CAREFULLY – ESPECIALLY BETWEEN THE TOES^4,5

FOR DRY SKIN USE A MOISTURISING CREAM BUT NEVER USE BETWEEN THE TOES^4,5,7

CUT TOENAILS TO THE SHAPE OF THE END OF THE TOES ABOUT ONCE IN EVERY SIX TO EIGHT WEEKS⁷

ALWAYS WEAR FOOTWEAR – EVEN AT HOME^4,5

People with diabetes should be aware of the danger signs of a ‘foot attack’ – bright pink or red skin (darker patches if skin is black or brown), sores or cuts that do not heal, puffiness, skin that is hot to the touch – and should know to contact their healthcare professional if they are concerned. At a practical level, older men and women may find checking their feet, particularly the soles and the back of the heel, difficult and may need the help of a friend or relative. Placing a mirror on the floor can also help, or alternatively, long handled mirrors are available to help with foot checks. Also, simple advice on footwear purchase can be an important preventative tactic.

The beneficial effect of lowering blood pressure on renal disease (and overall cardiovascular mortality) in diabetes is well established. Therefore, in recent years debate has mainly been about which antihypertensive to use and what blood pressure targets should be set.¹ The Irish College of General Practitioners recommend a target for antihypertensive treatment in patients with diabetes of ≤140/80 mmHg.² However, for people with kidney, eye or cerebrovascular damage, NICE recommends a stricter target is set of <130/80 mmHg.³ 

Smoking and hyperlipidaemia are among the risk factors for development of CKD.⁴ They are also important risk factors for CVD, so people with diabetic nephropathy may benefit from stopping smoking and lipid reduction.⁵

Methods for preventing diabetic nephropathy:^3,6

• Screen for microalbuminuria at least annually, ideally from a first-pass morning urine sample
• Aim to control HbA1c levels < 53 mmol/mol (7%)
• Set blood pressure targets < 130/80 mmHg
• Start ACE inhibitors with the usual precautions
• Suggest diet interventions
• Advise on smoking cessation and lipid levels

The UK target for cholesterol in people at high risk of a CV event – such as people with diabetes – is 4 mmol/L for total cholesterol.¹ NICE guidance refers to high density lipoprotein (HDL) cholesterol and non-HDL cholesterol. Non-HDL cholesterol is your total cholesterol minus your HDL cholesterol and is not the same as low-density lipoprotein (LDL). When treating to target, NICE recommends a 40% reduction in non-HDL cholesterol.²

The Collaborative Atorvastatin Diabetes (CARDS) study reported in 2004 that statin treatment in people with diabetes significantly reduces CVD risks.³ Consequently, statins should be considered in everyone with Type 1 diabetes who:²

• Is older than 40 years or
• Has had diabetes for more than 10 years or
• Has established nephropathy or
• Has other CVD risk factors

Statins should be considered in everyone with Type 2 diabetes who has a 10% or greater 10-year risk of developing CVD, when calculated using the CVD prediction algorithm (QRISK²) assessment tool.²

NICE guidance recommends low-dose anti-thrombotic therapy, e.g. aspirin therapy (75 mg daily) or clopidogrel, for:¹

• Type 2 diabetes patients who are ≥50 years old with bp <145/90 mmHg
• Type 2 diabetes patients who are <50 years old with significant CVD risk factors

NICE does not recommend aspirin for the primary prevention of cardiovascular disease to adults with Type 1 diabetes.²

ADA recommend taking low-dose aspirin for:³ 

• Adults with diabetes who are at increased risk of cardiovascular disease and not at increased risk of bleeding.³ 

• Most men over 50 years of age and women over 60 years of age who have one or more additional heart disease risk factors.³ 

Aspirin should not be recommended for heart disease prevention for men under 50 and women under 60 with diabetes with no major additional heart risk factors, because of the potential adverse effects from gastrointestinal bleeding.⁴ When considering aspirin as a preventative therapy it is important to think about the associated potential risks of treatment, such as gastrointestinal bleeding. Therefore, each patient should be evaluated on a individual basis to ascertain their risk associated with therapy vs. the benefit of treatment.⁴