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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 Scottish Diabetes patients – access via

References The Charcot Foot in Diabetes Lee C. Rogers, Robert G. Frykberg, David G. Armstrong, Andrew J.M. Boulton,Michael Edmonds, Georges Ha Van, Agnes Hartemann, Frances Game, WilliamJeffcoate, Alexandra Jirkovska, Edward Jude, Stephan Morbach, William B.Morrison, Michael Pinzur, Dario Pitocco, Lee Sanders, Dane K. Wukich, LuigiUccioli Diabetes Care Sep 2011, 34 (9) 2123-2129; Early referral for foot ulcers is vital, finds audit of diabetes careBMJ 2016; 352 (Published 31 March 2016) BMJ 2016;352:i1820 Management and referral checklist for patients with diabetes : A guide for Lamberth GP Practices NHS England Diabetes Care- Alphabet Approach

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