GP Dr Matthew Lockyer explains why he is impressed by the new SIGN diabetes guideline and how it will affect his practice
I would recommend all GPs to read the new SIGN (Scottish Intercollegiate Guidelines Network) guideline on diabetes.1
I work as a clinical assistant in adult diabetes medicine but still found interesting facts about management in this area that were completely new to me and will affect my practice, e.g. tricyclic antidepressants are thought to worsen glycaemic control whereas SSRIs improve it. People with diabetes should therefore receive SSRIs as first-line treatment for depression.
The guideline points out that depressive and psychological disorders are commonly associated with diabetes, especially when complications are present.
The revised guideline also deals with managing children and young people with diabetes, lifestyle, management of cardiovascular disease, nephropathy, visual impairment, diabetic foot disease and pregnancy.
Each area is tackled in sufficient detail to help specialists in the individual fields, while remaining accessible for GPs to use on a broader canvas. This is an excellent guideline and likely to be useful to a wide spectrum of health professionals.
Part of its appeal is the clarity of presentation. The evidence base, grading of recommendations and practice points stand clear from the text, but the whole guideline is still easy to read. The underlying arguments are beautifully concise and the references extensive.
The guideline also discusses intensive treatment for glycaemic control and control of hypertension, especially in type 2 diabetes, in depth. The UKPDS is cited as evidence for outcome improvement, which is reassuring after recent published criticisms of this landmark study.2
The lifestyle section provides excellent support for the use of new treatments to help patients
The section on children and young people with diabetes reminded me to consider diabetes screening in children with cystic fibrosis, and the association between type 1 diabetes and coeliac and thyroid disease.
The guideline illustrates the high standards that will be needed to achieve optimum care of the rapidly growing population of people with diabetes.
The implications for drug treatments are considerable. For instance, we may have underestimated the cardiovascular risk for people with diabetes in terms of cholesterol-lowering treatments. This patient group has also been shown to benefit from intensive management of acute vascular events.
The guideline stresses that adverse coping measures may be associated with poor diabetes management. Cognitive therapy and psychological approaches may have a lot to offer in the long-term care of people with diabetes. A psychologist might be a valuable addition to the diabetes team, but at present there are not even enough diabetologists or diabetes specialist nurses.
The section on diabetic foot disease sets out the benefits of structured care. But the manpower to provide such care does not exist, and, like other areas of diabetes care, is going to require massive investment in staff and facilities.
We are still awaiting publication of the NSF for Diabetes. We know that our care of people with diabetes can be improved if properly resourced. These Scottish guidelines are excellent and will be well received. Let us hope that the NSF authors can show the same clarity of thought when their work is finally published.
- The Scottish Intercollegiate Guidelines Network. Management of Diabetes: a national clinical guideline. Edinburgh: SIGN, 2001. The guideline can be dowloaded from the SIGN website at http://www.sign.ac.uk
- Ewart RM. The case against aggressive treatment of type 2 diabetes: critique of the UK prospective diabetes study. Br Med J 2001; 323: 854-8.