History:

Symptoms?

- Polydipsia?

- Polyuria?

- Blurred vision?

- Unexplained weight loss?

- Recurrent infections?

- Tiredness?

Risk factors?

PMH updated?

- Established atherosclerotic CVD?

- CKD (classification)?

- CHF?

FH updated?

- 1st degree relative with CVD (diagnosis and age at diagnosis)?

- 1st or 2nd degree relative with diabetes (type and age at diagnosis)?

Current medication updated?

Known drug allergies updated?

Alcohol units/week?

Smoking?

- Never smoked? - Stopped smoking (date)? - Number of cigarettes per day?

Examination:

Height?

Weight?

BMI?

Waist circumference?

BP?

Pulse rate?

Pulse regularity?

Acanthosis nigrans?

QRISK?

Investigations:

Checked if required lab results were available and requested outstanding parameters?

2 HbA1c levels with an at least 2 week interval?

Lipid profile?

Renal function?

Early morning first-void urine sample for ACR together with renal function?

ALT/AST?

Creatinine kinase (if persistent generalised unexplained muscle pain)?

TSH (if dyslipidaemia)?

Management:

Diabetes type 2 - General Patient Information explained and provided to patient?

Assessed for anxiety and depression, and managed appropriately?

Offered influenza immunization?

Offered pneumococcal immunization?

Advised about free prescriptions if antidiabetic medications are used?

Advised screening for complications will be arranged at diagnosis and then annually?

- Referred for retinopathy screening?

- Referred for foot screening and screening for peripheral neuropathy? 

- Performed screening for diabetic kidney disease 

- Assessed for cardiovascular risk factors?

- Screened for autonomic neuropathy?

Offered referral to a structured group education programme?

Checked if antihypertensive treatment or management change was required?

Offered atorvastatin 20 mg one daily for primary prevention as no established cardiovascular disease (CVD) and

- Younger than 85 years, and estimated 10-year risk of developing CVD 10% or more?

- 85 years of age or older, taking into account person's preferences, benefit and risks of treatment, and co-morbidities? 

- CKD?

Offered atorvastatin 80 mg once daily for secondary prevention of CVD?

Antidiabetic drug treatment indicated?

1) Contraindications (CI) for metformin?

2) QRISK > 10%?

3) Established atherosclerotic CVD?

4) CHF?

5) Hyperglycaemic with symptoms?

As 1-5) answered with no: standard-release metformin (MF) offered?

As only 1) answered with yes and no CI: DPP-4i (eg sitagliptin 5 mg once daily) offered?

As only 2) answered with yes and no CI: MF + SGLT-2i (eg dapagliflozin 10 mg once daily) offered?

As only 3) and/or 4) answered with yes and no CI: MF + SGLT-2i offered?

- For established atherosclerotic CVD and no CI eg empagliflozin 10 mg once daily?

- For CHF and not CI eg dapagliflozin 10 mg or empagliflozin 10 mg once daily?

As 5) answered with yes: need for immediate insulin therapy or treatment with a sulfonylurea (SU) depending on specialist advice considered?

Counselled regarding dosage regime and side effects and to start second anti-diabetic medication as soon as MF tolerability is confirmed?

Advised 'sick-day rules'?

Agreed on HbA1c target level of 48 mmol/mol (6.5%) or other individualised level?

Advised review in 3-6 months after HbA1c control or if required?

Signposted to www.desmond.nhs.uk?

Signposted to www.diabetes.org.uk?

Reference(s):

NICE CKS: Diabetes - type 2. August 2023