Quick Guide to Conducting a Successful Diabetic Review in General Practice

For pharmacy professionals working in general practice, conducting reviews with patients living with Type 2 Diabetes is sometimes part of the daily job. Doing this effectively requires a holistic approach that encompasses both medication management and regular health checks. In this guide we provide an approach that covers key aspects such as medication review, HbA1c targets, and essential diabetic checks. For more comprehensive information, please refer to NICE Guideline NG28.

1. Preparation

Before the review:

• Patient Records: Review the patient’s medical history, recent test results, and previous consultation notes.
• Checklist: Prepare a checklist of items to cover during the review to ensure a comprehensive evaluation.

2. Initial Consultation

• Greeting and Rapport: Start with a warm greeting to put the patient at ease.
• Purpose Explanation: Explain the purpose of the review and what it will entail.

3. Medical History Review

• Current Symptoms: Ask about any new or worsening symptoms, such as fatigue, vision changes, or neuropathy.
• Lifestyle Changes: Discuss any recent changes in diet, physical activity, smoking, and alcohol use.
• Previous Interventions: Review the effectiveness of previous treatments and interventions.

4. Medication Review

• Current Medications: List all medications the patient is currently taking, including dosages and frequency.
• Adherence: Assess medication adherence and address any barriers, such as side effects or difficulty obtaining medications.
• Effectiveness and Side Effects: Evaluate the effectiveness of current medications and discuss any side effects experienced by the patient.
• Adjustments: Based on HbA1c levels and other factors, consider if any adjustments to medication are needed to optimise dosages.

5. HbA1c Targets

• Individualized Targets: Discuss individualized HbA1c targets based on patient age, comorbidities, and risk of hypoglycemia. Generally, targets are:
  • For adults whose type 2 diabetes is managed either by lifestyle and diet, or lifestyle and diet combined with a single drug not associated with hypoglycaemia, support them to aim for an HbA1c level of 48 mmol/mol (6.5%).
  • For adults on a drug associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%).
  • In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
    • reinforce advice about diet, lifestyle and adherence to drug treatment and
    • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
    • intensify drug treatment.
  • Older Adults: On a case by case basis, following discussion with the patient, it may be acceptable to relax HbA1c targets further, such as aiming < 8% (64 mmol/mol), depending on comorbidities and risk factors. Examples of such situations include the following:
    • they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
    • tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired awareness of hypoglycaemia, or they drive or operate machinery as part of their job
    • intensive management would not be appropriate, for example if they have significant comorbidities.
• Frequency of Testing: Determine the frequency of HbA1c testing (every 3-6 months).

6. Essential Diabetic Checks

• Blood Pressure: Measure and record blood pressure, aiming for a target of < 140/90 mmHg. Please refer to NICE Guideline NG136 for more detailed guidance on Hypertension management, including in Type 2 Diabetes.
• Weight and BMI: Check weight and BMI, discuss weight management if necessary.
• Foot Examination: Conduct a thorough foot examination to check for ulcers, infections, and neuropathy.
• Eye Examination: Ensure the patient has regular retinal screening to detect diabetic retinopathy.
• Kidney Function: Order tests for urine albumin-to-creatinine ratio (ACR) and serum creatinine to assess kidney function.
• Lipid Profile: Review the patient’s lipid profile and discuss statin therapy if needed.

7. Lifestyle Modifications

• Diet: Discuss dietary habits and provide guidance on a balanced, diabetes-friendly diet.
• Exercise: Encourage regular physical activity tailored to the patient’s abilities and preferences.
• Smoking Cessation: Offer support and resources for smoking cessation if applicable.
• Alcohol Consumption: Advise on safe levels of alcohol consumption.

8. Education and Self-Management

• Diabetes Education: Provide information on diabetes self-management, including blood glucose monitoring and recognizing signs of hypo- and hyperglycemia.
• Support Resources: Offer information on local support groups, diabetes education programs, and online resources.

9. Action Plan

• Goals: Set realistic and measurable goals for the patient to work towards before the next review.
• Follow-Up: Schedule the next appointment and any necessary tests or referrals.
• Documentation: Document all findings, decisions, and plans in the patient’s medical record.

10. Patient Engagement and Communication

• Patient Involvement: Involve the patient in decision-making and encourage them to ask questions.
• Clear Communication: Ensure that all explanations and instructions are clear and understandable.
• Feedback: Ask for feedback on the review process to improve future consultations.

Conclusion

While this is a quick overview, consider liaising with your specialist diabetes nurse or pharmacist with special interest in diabetes for further guidance. If you are interested in other guidelines for chronic conditions, please click here.