Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Related guidance:
NICE NG28 Type 2 diabetes in adults: management (Updated August 2019)
NICE NG17 Type 1 diabetes in adults:diagnosis and management (Updated July 2016)
Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18) (Updated November 2016)
NICE type 2 adult pathway
Management of hyperglycemia in type 2 diabetes -European Association for the Study of Diabetes (EASD) 2018
The diabetes formulary for Somerset is a collaboration between CCG medicines management, secondary, community and primary care. The formulary is kept under review and reflects the latest guidelines.
The goal is to support people with diabetes in maintaining quality of life and minimising the risk of complications. This requires an individualised approach centred around the person with diabetes.
Principles
- knowledge – understanding diabetes is key to making informed decisions about self-management
- glycaemic control – appropriate glycaemic control reduces complications
-cardiovascular risk factor management – aggressive but appropriate management reduces complications
- regular follow-up – supports successful self-management
Lifestyle management
Lifestyle management is the cornerstone of diabetes care, including nutrition, physical activity, weight management, smoking cessation and psychological support.
Before any pharmacological interventions are considered for people with type 2 diabetes, there should be a 3 month period of diet & lifestyle interventions.
• Education - provide structured education to every patient and/or their carer at and around the time of diagnosis and review at least annually.
• Diet - provide individualised and ongoing specialist nutritional advice.
• Lifestyle - encourage weight loss, physical activity and smoking cessation

Pharmacotherapy
The expanding number of insulins and other glucose-lowering treatments and growing information about their benefits and risks provides more options for people with diabetes than ever, but can make decisions about the most appropriate option challenging. Support is available from the Somerset Diabetes Service, including -
MyDiabetesMyWay (https://somerset.mydiabetes.com/ ) – an interactive website and smartphone app for people with diabetes and their family, friends and carers. It provides accurate information and resources, which are equally useful for healthcare professionals. Access to personal data, in addition to the information resources, empowers people with diabetes to self-manage.
Advice, guidance and triage – a single point of access for non-urgent advice and all referrals into the diabetes service (except podiatry and dietetics). Queries will be answered within 3 working days. To make a referral open the EMIS document template, complete all the required fields and then email it to spn-tr.somersetdiabetesaandg@nhs.net DO NOT USE eReferrals. The response will appear in the documents inbox in EMIS via MESH.
Virtual Clinics – non-patient facing case discussion meetings in primary care. The specialist team visits the practice to discuss a cohort of patients identified by the primary care team and to provide more general education as well as updates on the Somerset Diabetes Service. The clinics are co-ordinated by Leanne Dalley (Leanne.dalley@somersetFT.nhs.uk )

Before any pharmacological interventions are considered there should be a 3 month period of diet & lifestyle interventions.
Education provide structured education to every patient and/or their carer at and around the time of diagnosis and review annually.
Diet provide individualised and ongoing specialist nutritional advice.
Lifestyle encourage weight loss and exercise.

Blood Pressure Control
Evidence from UKPDS indicates that control of blood pressure in people with hypertension & Type 2 diabetes achieves a clinically important reduction in the risk of deaths related to diabetes, complications related to diabetes, progression of diabetic retinopathy, and deterioration in visual acuity.
Blood glucose control
The VADT, ACCORD and ADVANCE trials show that tight control of blood glucose in long standing Type 2 diabetics (reducing HbA1c to below 53mmol/mol or 7%) may be harmful.
• Involve the person in decisions about their individual HbA1c target which may be above the general target of 48mmol/mol or 6.5% especially in long standing diabetes.
• Offer lifestyle advice and medication to help achieve and maintain the HbA1c target.
• Inform patients with a higher HbA1c that any reduction towards the agreed target is advantageous to their health.
• Avoid pursuing highly intensive management to levels of <48mmol/mol or 6.5%.
♦ Self-monitoring of blood glucose should be offered to a patient newly diagnosed with T2DM only as an integral part of his/her self- management education. Its purpose should be discussed and there should be agreement how the results should be interpreted and acted upon.
♦ Eye and kidney damage should be screened annually.
NB DH require that HbA1c should always be measured in millimoles per mol (mmol/mol) as well as by percentage. HbA1c of 6.5% is equivalent to 48mmol/mol.
Self monitoring of blood glucose
Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

the person is on insulin
or
there is evidence of hypoglycaemic episodes
or
the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery
or
the person is pregnant, or is planning to become pregnant.
Which test strips should I prescribe?
Somerset CCG recommends the use of devices which use strips not exceeding £9.25 per 50 strips. See section 6.1 Guidance on Blood Glucose Testing and Use of Test Strips for a full list of formulary approved strips.
Type 2 diabetes medications on a low carbohydrate diet.
For patients who choose to follow a low carbohydrate diet to improve their blood glucose control, guidance has been drawn up by our diabetes principals on how medications could be optimised. Website link here
The Low Carb Program has now been accepted as an NHS approved app for Android and IOS available here

Guide to HbA1c values expressed as mmol/mol:

HbA1c values