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Diabetes-Referral guide

Manage in primary care –Impaired GTT  Impaired fasting glucose New diagnosis type 2 diabetes Minor self-treated hypoglycaemia Transient hyperglycaemia Well controlled diabetes ( diet or treated ) Stable micro-macro vascular complications

Referral to secondary care – Routine All with type 1 diabetes – managed in secondary care Age < 25 yrs Patient not achieving target HbA1c despite optimum management in general practice or
Worsening glycaemic control Erratic glycemic control Assessment for insulin initiation or intensification / change GLP-1 – assessment and initiation Patient on GLP-1 and considering GLP-1 initiation Considering or already on insulin pump Blood pressure – uncontrolled despite optimum management as per NICE guideline Diabetes complications as
Neuropathy – GI tract , hypotension , erectile dysfunction
Diabetes arthritis e.g carpal tunnel syndrome
Isolated nerve palsy e.g 3rd N , foot drop
Progressive mico-macro vascular complications despite max Rx
Retinopathy requiring laser treatment or grade >= 3 PCOS ( with or without diabetes ) Obesity management e.g bariatric surgery Secondary diabetes e.g
○ steroid use
○ acromegaly
○ psychoses treatment
○ pancreatitis Complex medical co-morbidities

Referral- Urgent- Hyperglycaemia and symptomatic Suspected ketoacidosis or non-ketotic hyperosmolar coma Severe hypoglycaemia
episode requiring 3rd party assistance or Health care professional help Children with newly diagnosis or suspected diabetes New diagnosis of Type-1 diabetes Infected , necrotic or gangrenous foot , ulceration or suspected charcot foot ( inflammatory syndrome characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy , trauma and perturbations of bone metabolism ) CKD 
 ○ creatinine > 150 or CKD 3
 ○ proteinuria : UACR >= 30 mg / mol
 ○ optimise risk factors then renal angle
 ○ rapidly declining kidney function
 ○ anaemia or bone disease
 ○ on dialysis ( likely to under specialist care already ) Worsening claudication symptoms 

Women with pre-existing diabetes who become pregnant ( refer on 1st contact ) Women who develop gestational diabetes ( refer 1st contact if not done already by e.g midwife ) Acute visual loss

Diabetes structured programme- XPERT- written by Dr Trudi Deakin ,according to their website it is based on the theories of patient empowerment , discovery , learning and patient centered care. They offer 4 programmes X-PERT Prevention of Diabetes ( X-POD ) , X-PERT diabetes , X-PERT Insulin , X PERT Weight DAFNE -dose adjustment for normal eating ( type 1 diabetes ) DESMOND – Diabetes Education and self-Management for Ongoing and Newly Diagnosed. Offers 6 programmes GERTIE- George Eliot Type 1 Diabetes Education programme BERTiE – for Type 1 diabetics SEREN structured education programme for children and young people with diabetes in Wales EPP Cwmru – offers diabetes self management programme via www.eppwales.org Scottish Diabetes patients – access via http://www.diabeteseducationscotland.org.uk/Patient.aspx

References

  1. Rogers, Lee C et al. “The Charcot foot in diabetes.” Diabetes care vol. 34,9 (2011): 2123-9. doi:10.2337/dc11-0844 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161273/
  2. Care Sep 2011, 34 (9) 2123-2129; Early referral for foot ulcers is vital, finds audit of diabetes care BMJ 2016; 352 (Published 31 March 2016) BMJ 2016;352:i1820
  3. Management and referral checklist for patients with diabetes : A guide for Lamberth GP Practices NHS England Diabetes Care- Alphabet Approach

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