Several years ago the RCGP, RCP, RCN and the then British Diabetic Association (now Diabetes UK) began working together to develop evidence-based guidelines for type 2 diabetes. The guidance on foot care was released two years ago. The work was then subsumed by NICE, and the next two guidelines, on retinopathy1 and renal disease,2 have just been published. They provide a succinct overview of the evidence, with guidance on practical implementation.
The retinopathy guideline stresses the importance of tight control of blood glucose levels and blood pressure in diabetes eye care. It emphasises the importance of every individual with type 2 diabetes having an appropriate and acceptable retinopathy screening test.
Retinal photography and slit-lamp indirect ophthalmoscopy are listed as tests with acceptable levels of sensitivity and specificity. Direct ophthalmoscopy, however, is not acceptable as a screening test because it cannot achieve a sensitivity of 80% or higher.
Many parts of the UK have retinal screening programmes, but in some areas much work needs to be done to ensure that all diabetes patients have an appropriate annual eye screen.
Retinal screening and prompt, effective treatment of sight-threatening retinopathy can prevent blindness in individuals with type 2 diabetes, so PCTs must make retinal screening a priority.
The guideline lists the referral criteria for various types of diabetic eye problem, and categorises referral as immediate (within 1 day), urgent (within 1 week) or soon (within 1 month). It states that PCOs and trusts must develop local definitions of maximum waiting times for each category.
At present, many areas of the UK would struggle to meet these recommendations. Much work needs to be done to develop capacity for laser therapy and bring about short waiting times and create slots for urgent treatment.
The guideline on the prevention and early management of renal disease, recommends a yearly check for proteinuria and microalbuminuria for all those with type 2 diabetes. It states that urinary albumin:creatinine ratio or albumin concentration measurements need to be carried out annually using a laboratory or near-patient method.
In most practices a dipstick test for proteinuria forms part of diabetes patientsÍ annual review. Few centres routinely test for microalbuminuria, and doing these tests annually will involve considerable extra work.
Some laboratories do not yet have the facilities to measure albumin:creatinine ratios in large numbers of urine samples, and this extra capacity will need to be developed.
The guideline gives helpful recommendations on the care of individuals with microalbuminuria or frank proteinuria, stressing the need for very tight blood pressure control (135/75 mmHg or below), ACE inhibitor treatment, full CHD risk assessment and appropriate treatment and tight blood glucose control. Referral to a specialist is suggested if the serum creatinine performed annually rises above 150 µmol/l. However, few areas at present have the specialist renal clinic capacity to cope with such numbers.
I trust that the second part of the National Service Framework for Diabetes, on implementation, will address the issues of secondary care capacity and primary care incentive payments to enable these guidelines to be implemented.
- National Institute for Clinical Excellence. Clinical Guideline E. Management of type 2 diabetes. Retinopathy - screening and early management. London: NICE, 2002. www.nice.org.uk
- National Institute for Clinical Excellence. Clinical Guideline F. Management of type 2 diabetes. Renal disease - prevention and early management. London: NICE, 2002. www.nice.org.uk