Summary of NICE, SIGN and QOF



General Diabetes Management

NICE SIGN
Glycaemic targets
  • HbA1c<=6.5% for initial therapy
  • HbA1c<=7.5% for 3rd-line agent or insulin
  • HbA1c<=7.0%
  • HbA1c<=6.5% may be appropriate at diagnosis
Glycaemic control drug ladder
  • 1st line metformin (or SU if not overweight)
    • review metformin if eGFR<45, stop metformin if eGFR<30
  • 2nd line SU
  • 3rd line insulin with MU & SU
    • use NPH insulin initially, either od or bd
  • alternative 3rd line DPP4 or TZD
    • continue DPP4 or TZD only if fall in HbA1c of >=0.5% after 6 months
  • alternative 3rd line GLP1 if BMI>35, or weight loss likely to benefit, or occupational reasons to avoid insulin
    • continue GLP1 only if fall in HbA1c of >=1.0% and body weight of 3% after 6 months
  • 1st line metformin (or SU if not overweight)
  • 2nd line SU
  • 3rd line TZD or DPP4 or insulin or GLP1
Blood pressure
  • 140/80 mmHg as general target
  • 130/80 mmHg if retinopathy, nephropathy, vascular disease
  • ACEI or ARB if high urine ACR, irrespective of BP
  • 1st line: ACE/ARB
    • in Afro-Caribbeans, combine with CCB/D
    • CCB is 1st line if pregnancy possible
  • then add CCB/D
  • 130/80 mmHg as general target
  • lowest achievable level in diabetic nephropathy
  • ACEI or ARB if high urine ACR, irrespective of BP
  • ladder: ACEI/ARB, CCB, D
Cardiovascular protection

Risk allocation:

  • high risk unless normal weight, BP, renal function & lipids, and non-smopker and no FH
  • non-high risk: use UKPDS calculator

Interventions:

  • T2DM aged >40: statin if high risk group, or UKPDS 10-yr estimate >20%
  • T2DM aged <40: consider if high risk group
  • avoid if pregnancy a possibility
  • targets: chol <=4 mmol/l, LDL <=2 mmol/l
  • consider fibrates if TG>4.5
  • no routine aspirin
  • T2DM aged >40: simva 40 or atorva 10 irrespective of baseline lipids
  • T1DM aged >40: consider simva 40
  • acute coronary syndrome: atorva 80


Quality Outcomes Framework for Diabetes

Code Requirement Points Payment stages
DM19 Register of all with diabetes aged >17 including type of diabetes 6
DM2 Record of BMI in last 15 months 3 40-90%
DM5 Record of HbA1c in last 15 months 3 40-90%
DM23 Last HbA1c <=7.0% in last 15 months 17 40-50%
DM24 Last HbA1c <=8.0% in last 15 months 8 40-70%
DM25 Last HbA1c <=9.0% in last 15 months 10 40-90%
DM21 Record of retinal screening in last 15 months 5 40-90%
DM9 Record of peripheral pulses in last 15 months 3 40-90%
DM10 Record of neuropathy screening in last 15 months 3 40-90%
DM11 Record of BP in last 15 months 3 40-90%
DM12 Last BP <=145/85 in last 15 months 18 40-60%
DM13 Record of microalbuminuria testing in last 15 months 3 40-90%
DM22 Record of eGFR in last 15 months 3 40-90%
DM15 ACEI or ARB prescribed for patients with microalbuminuria 3 40-80%
DM16 Record of total cholesterol in last 15 months 3 40-90%
DM17 Last total cholesterol <=5 in last 15 months 6 40-70%
DM18 Influenza immunisation in preceding 1 Sep to 31 Mar 3 40-85%