Ten tips for providing effective diabetes reviews

PCN pharmacy lead Gareth Malson offers his top ten tips for supporting people with diabetes to improve control of their condition at regular review

The prevalence of diabetes is continuing to rise at an alarming rate. In 2023-24, the national diabetes register increased by around 21 people every hour, with 4.6m living with diabetes in the UK by the end of that period.

Diabetes, particularly type 2 diabetes, is invariably associated with multimorbidity and polypharmacy, and GP practice pharmacists can play a vital role in supporting patients to manage the condition effectively.

The basis of an annual diabetes review is to complete the nine key care processes, but there is much more we can do at regular reviews to support patients to adopt lifestyle changes and get the most out of other measures and interventions.

Here are ten tips to follow whenever you are performing a diabetes review, to help better support your patients to get control of their diabetes and stay on track.

1. Remember control starts with diet and exercise

More so than any other long-term condition, sensible eating and regular exercise can have a profound impact on disease control for all types of diabetes. Indeed, even walking has been shown to be effective.¹

Type 2 diabetes can often be put into remission with appropriate lifestyle interventions. Those newly diagnosed with the condition will often see the diagnosis as the inspiration needed to make them eat ‘less carbs and more veg’ and spend more time moving than sitting, and it is important to take the opportunity to support them in this. Carbohydrate-laden foods such as chips or potatoes, rice, pasta and bread are often the source of unintended sugar intake – the Public Health Collaborative website offers patient friendly information on carbohydrate content.

The importance of a healthy lifestyle should be reinforced for all patients at annual review, but especially when disease control has slipped – in which case it still forms the basis of shared decision making discussions about escalating treatment.

2. Some metformin is better than none

A mainstay on pharmacy shelves since 1958, metformin is the first rung on the ladder of diabetes treatment. Cheap and effective, metformin’s ability to make insulin work better means it also complements all other diabetes treatments.

One study has shown it to be more effective when taken just before food.² However, most patients take it with or after meals to reduce the risk of gastric side effects, which can sometimes be incapacitating.

Occasionally, these side effects can be overcome with a switch to modified release preparation. For other patients, a dose reduction will often do the trick – and, ultimately, getting a smaller amount into the patient’s system is better than none, given its complementary action.

3. Keep tailoring glucose targets

Glycated haemoglobin, or HbA1c, is the recommended blood test used to measure diabetes control.

The target for this should be adjusted according to:

• Hypoglycaemia risk.
• Disease duration.
• Life expectancy.
• Other long term conditions.
• Patient preference and motivation towards treatment.

As such, HbA1c targets will change over time, and should be kept under review and agreed with patients.

In younger type 2 diabetic patients, the primary focus of treatment is to protect from the micro- and macrovascular harms of uncontrolled diabetes that build up over time, and clinicians should aim to keep HbA1c values towards 48mmol/mol or below (or 53mmol/mol if they are on insulin or a sulfonylurea).

In those who are severely frail, where avoiding excessive hyperglycaemia that can prolong infection or hospital admission becomes the primary focus, a target HbA1c of around 75 is acceptable.

In practice it is therefore a balancing act to achieve as low a HbA1c as possible while avoiding side effects. Working out where patients sit in between these contrasting situations takes practice, but the NICE patient decision aid can help.

4. Be clear when you should – and should not – use SGLT-2 inhibitors

Recently trial data demonstrating that SGLT-2 inhibitors reduce the risk of cardiovascular disease (CVD) and the progression of kidney disease resulted in NICE recommending one of these agents should be offered to or considered in those at high CVD risk, as soon as metformin therapy is established. This effectively means they should be offered or considered for most people with type 2 diabetes.

In practice, however, they may not always be suitable. Their association with genitourinary tract infections (likely related to their mode of action, which involves inducing glycosuria) and diabetic ketoacidosis in particular has limited their use a little.

Pharmacists should follow local medicines management guidance on suitability for SGLT-2 inhibitors carefully. In particular, where patients have a very high HbA1c (ie, >85mmol/mol), they should not be started – due to the potential increased risk of urinary tract infections and because at this glucose level, some doubt will exist over whether the patient has developed latent autoimmune diabetes (for which SGLT-2 inhibitors are contraindicated). They should also be avoided in those following a ketogenic diet and suspected type 1 diabetes (due to an increased risk of diabetic ketoacidosis).

Remember also their glucose lowering effect is only moderate, reducing to negligible in those with moderately impaired renal function or worse (although their cardiovascular and renal protective effects remain). Patients must always receive counselling on sick day rules.

5. Be consistent with weight-loss therapies

With celebrities all over social media extolling the virtues of GLP1-receptor agonists, it is not surprising that we are seeing a huge rise in the use of these highly effective treatments.

Clinicians conducting diabetes reviews in primary care will often be asked to start these treatments – by patients and consultants alike. This should be something that every GP surgery is able to do. If no one in the surgery can do this, liaise with your local diabetes specialist team to learn how – it is important to be able to advise on how to self-inject and how to counsel patients, in particular on how to reduce their dietary intake appropriately to avoid nausea and other gastrointestinal side effects, while ensuring they are receiving adequate nutrition and dietary fibre.

That said, be prepared to say ‘no’ if these requests are inappropriate. Currently, NICE only recommends their use in type 2 diabetes when metformin and two other oral antidiabetes drugs are ineffective, not tolerated or contraindicated.

Crucially, it does not recommend them in people with diabetes when the primary goal is weight reduction.

Watch this space however; with tirzepatide having been approved by NICE for weight loss in people with obesity (albeit with a slow roll out), this may well change over the next few years.

6. Know the other oral anti-diabetes therapy options

Other oral anti-diabetes medicines are used less frequently these days, but knowing the options is always helpful:

• DPP4-inhibitors (‘gliptins’) only generate modest improvements in disease control but are well tolerated, easy to take and don’t cause hypoglycaemia; they are useful particularly for older, frailer patients
• Pioglitazone’s association with a small increased risk in bladder cancer makes it a hard sell to patients, plus it can worsen heart failure and macular oedema. However, it is cheap, moderately effective and, complications aside, often well tolerated. NICE CKS provides a useful summary on how to assess their risk for individual patients.
• Acarbose is another option to try, although it tends to cause excessive flatulence.

7. Make the most of blood glucose monitoring

Blood glucose monitoring is by and large only merited when patients are put on treatments that cause hypoglycaemia – ie, sulfonylureas and insulin. However, like many ‘rules’, there are times when this one can be broken.

If you start someone on gliclazide or once daily insulin, they should be encouraged to do capillary blood glucose monitoring (fingerprick testing) once or twice daily before meals – you want to know how low the sugar is going so you can maximise treatment while minimising the risk of hypoglycaemia. Regular fingerprick monitoring is painful so there’s little point asking patients to test any more frequently than this – it will likely be fruitless, and could be counterproductive.

They should also check their glucose before driving (above 5 to drive). Some meters can connect to smartphone apps that record blood sugar readings into an online system that clinicians can access. This makes annual reviews much easier, as patterns of glucose control can be easily assessed and tracked over time.

For those with type 2 diabetes, NHS funded flash or continuous glucose monitoring (CGM) – eg, with Freestyle Libre or Dexcom One+ – is usually only warranted when patients are prescribed two types of insulin (ie, a basal-bolus regimen) although there are a couple of other circumstances permitted by NICE. However, anyone can request a free sensor to trial – and the amount of information that can be gleaned from this exercise can revolutionise a patient’s understanding of their condition. Sharing the reports produced by the CGM system can be truly empowering and enable dietary adjustments that can avoid the need for treatment escalation. I have used this approach on several occasions with patients with a HbA1c of around 100mmol/mol who could not understand why their sugars were so high. In less than a fortnight, they learned which foods were causing their sugars to spike and made dietary adjustments that improved their diabetes control radically. Some then choose to self-fund these sensors for ongoing monitoring.

8. Make sure all clinicians know about steroid effects

Corticosteroids can cause a sharp rise in blood glucose and destabilise diabetes control. NICE type 2 diabetes guidelines advise that we should consider fingerprick tests in anyone starting oral or intravenous corticosteroid treatment. In my experience, given it is difficult to predict how patients’ glucose levels will be affected, any patient with diabetes prescribed long-term corticosteroid treatment equivalent to 5mg prednisolone daily or more should be instructed to do fingerprick blood sugar monitoring – initially once daily 4-8 hours after the steroid dose is taken – in line with the Joint British Diabetes Societies (JBDS) guideline on managing hyperperglycaemia and steroid therapy.

The JBDS guideline instructs on how and when treatment should be escalated and monitored. In this circumstance, hyperglycaemia can only be treated successfully with gliclazide or insulin.

All clinicians that might initiate long-term corticosteroids (eg, prednisolone for polymyalgia) should be made aware that they should organise referral to the practice diabetes team at the same time. 

9. Remember HbA1c is not always reliable

HbA1c is a general measurement of how raised blood glucose has been, on average, over the past 3 months. While it is usually a good indicator of diabetes control, it is important to be aware of how other factors can affect HbA1c levels.

Firstly, while the result looks at the general picture over 3 months, it is little more biased towards glucose levels during the one month immediately before the test.

There are also genetic variations in haemoglobin that can render HbA1c ineffective as a marker of glucose levels – although biochemistry labs are typically very good at informing clinicians where this is the case.

In addition, certain conditions or treatments can affect the lifespan of red blood cells which in turn impact on HbA1c levels. The table below indicates some of the circumstances that can do this.

This underscores the importance of a comprehensive and holistic approach when reviewing patients, so you can pick up on any potential reasons why HbA1c has gone up or down and avoid potential mistakes with medication/dose changes.

Table. Conditions that can affect HbA1c levels

10. Consider ‘Path to Remission’ referral

Following the success of the DiRECT trial,³ Integrated Care Boards (ICBs) in England are now commissioning the ‘Path to Remission’ programme based on the same approach, subject to certain eligibility criteria (eg, patients must have been diagnosed with type 2 diabetes in the last 6 years).

The programme involves a three-month low calorie (800 calories per day) diet with all foods provided by the company providing the service. Patients receive support during the 3 months, followed by a 1-month transition period back to real food and a further 8 months of support and follow-up, to help embed long-term healthy eating habits.

The results from the DiRECT trial suggested 24% of patients on this programme managed to lose 15kg or more of weight (compared with 0% of the control group) and 46% put their diabetes into remission (compared with 4% in the control group).

This is a useful intervention to consider with eligible patients, particularly where patients are motivated to make significant dietary changes. For those based in Scotland, Wales and Northern Ireland, similar programmes are being adopted so it is worth checking whether it is available in your area.

As part of the referral process, you need to determine whether any existing diabetes or blood pressure medicines need to be stopped when the diet begins – since the intervention inevitably leads to a reductions in blood glucose and pressure almost immediately. In particular, treatment with SGLT-2 inhibitors must be stopped when starting this programme, due to the potential risk of ketoacidosis when taking these drugs alongside a very low-carbohydrate diet.

Gareth Malson is lead pharmacist for Chester East PCN, Regional Vice President – North West for the Primary Care Pharmacy Association and Training Programme Director – Advanced Practice at the School of Pharmacy and Medicines Optimisation, NHS England – North West