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South London NHS Health Check Diabetes Filter Pathway Filter criteria: Age 40-74 and BP: Systolic ≥ 140mmHg and/or Diastolic ≥ 90mmHg Or BMI ≥ 30 kg/m 2 Or BMI ≥ 27.5 kg/m (South Asian/Chinese) 2 1 Perform HbA1c (+FBC ) Exclusions Perform HbA1c – Point of Care Testing * Exclusions apply 1 (venous blood sample) If HbA1c ≥ 42mmol/mol (6.0%) Repeat HbA1c (+FBC ) (venous blood sample) Exclusions apply 1 HbA1c HbA1c ≥ 48mmol/mol (6.5%) HbA1c Type 2 diabetes very likely ≥ 42mmol/mol but <48mmol/mol ≥ 37mmol/mol (5.5%) < 42mmol/mol (6.0%) (≥6.0% but< 6.5%) Moderate risk of diabetes High risk of Type 2 Diabetes Offer brief intervention: If symptoms 3 If no symptoms (non-diabetic hyperglycaemia) 1. Discuss risk of developing diabetes Refer same day 2. Help modify individual risk factors (immediately if 3. Offer tailored support services necessary) to GP Retest within Retest at next NHS Health Check 4 weeks 5 (or every 3 years if additional risk factors for diabetes) HbA1c HbA1c ≥ 48mmol/mol <48mmol/mol (6.5%) (6.5%) HbA1c <37mmol/mol (5%) Diagnosis Offer an intensive lifestyle programme Low risk of diabetes Offer brief intervention: Type 2 Diabetes 2. Benefits of a healthy lifestyle Exclusions apply 3. Modifying risk factors Retest HbA1c after 6 months (if any previous test ≥48mmol/mol) Retest at next NHS Health Check Or at least once a year (if ≥42 but <48mmol/mol) (Or before if patient develops symptoms of diabetes) Check Weight, BMI & BP at least once a year Fasting <6.1mmol/l and 4 120 minutes < 7.8 mmol/l If high suspicion of diabetes an OGTT may be performed (Should be considered as exceptional) High risk of Type 2 diabetes (presumed normal glucose regulation on OGTT but high HbA1c) Fasting BG >7.8 and/or Oral Glucose Tolerance Test Fasting < 7mmol/l and 120 minutes ≥ 11.1 mmol/mol (fasting BG, 75g oral glucose then blood glucose 120minutes) 120minutes <7.8 - <11.1 mmol/l Impaired Glucose Tolerance 1 HbA1c should not be used to diagnose/exclude diabetes if: The patient has symptoms of less than 2 months duration, as an individual can be Fasting 6.1-6.9 mmol/l and significantly hyperglycaemic without HbA1c having had sufficient time to rise. If a patient is acutely unwell (for the same reasons as above) 120 minutes < 7.8 mmol/l In pregnancy. Impaired Fasting Glycaemia In patients aged 18 years or younger. In patients with suspected type 1 diabetes (e.g. presence of ketones) at any age. In patients taking medications that cause rapid glucose elevation (e.g. steroids & antipsychotic medications) Offer an intensive lifestyle In patients who have known genetic, haematological or illness-related factors that programme influence HbA1c and its measurement (see overleaf detailed guidance) In patients with known anaemia (Hb < 10.5g/dl) or taking iron supplement In the above circumstances, a random venous glucose sample must be checked Check Weight, BMI, BP and HbA1c (≥ 11.1mmol/l is diagnostic of diabetes in the presence of diabetes symptoms.) at least once a year 2If no Full Blood Count (FBC) record within last 12 months 3 Symptoms: polyuria, polydipsia, unexplained weight loss. 4If diabetes symptoms (as above) and/or multiple risk factors for developing diabetes. *Relevant sites/ providers only: 5 using approved POCT equipment: Additional risk factors for diabetes: first-degree relative with diabetes, women who delivered baby weighting >4kgs or with diagnosis of Gestational Diabetes MelliAfinion, B-Analyst, Cobas B101, or with Polycystic Ovary Syndrome, severe obesity, acanthosis nigricans and is morDCA Vantage prevalent in people of South Asian, Chinese, African-Caribbean and black African descent.Factors that interfere with HbA1c test results: 1- Inherited hemoglobin variants (hemoglobinopathies) : 1 HbA1c test can be unreliable for diagnosing or monitoring diabetes and impaired glucose regulation. • HbS: African & South or Central America (especially Panama), Caribbean islands, Mediterranean countries (such as Turkey, Greece, and Italy), India, and Saudi Arabia. • HbC: West African descent. • HbE : Asian, especially those of Southeast Asian descent. Common in Cambodia, Indonesia, Laos, Malaysia, Thailand, and Vietnam Also seen in southern China, India, the Philippines, and Turkey. HbSC: West African descent. Also found in East India, the Mediterranean, and the Middle East. Homozygous state: HbA1c test should not be used for patients with condition such as HbSS (sickle cell anemia), HbCC, HbEE or HbSC (sickled hemoglobin C disease). Even if an assay does not interfere with their variant, these patients may suffer anemia, increased red blood cell turnover and transfusion requirements which can adversely affect HbA1c results .2 2- Factors that influence Hba1c and its measurement 3 • Erythropoiesis Increased HbA1c: iron, vitamin B12 deficiency, decreased erythropoiesis. Decreased HbA1c: administration of erythropoietin, iron, vitamin B12, reticulocytosis, chronic liver disease. • Altered Haemoglobin Genetic or chemical alterations in haemoglobin: haemoglobinopathies, HbF, methaemoglobin, may increase or decrease HbA1c. • Glycation Increased HbA1c: alcoholism, chronic renal failure, decreased intraerythrocyte pH. Decreased HbA1c: aspirin, vitamin C and E, certain haemoglobinopathies, increased intra-erythrocyte pH. Variable HbA1c: genetic determinants. • Erythrocyte destruction Increased HbA1c: increased erythrocyte life span: Splenectomy. Decreased A1c: decreased erythrocyte life span: haemoglobinopathies, splenomegaly, rheumatoid arthritis or drugs such as antiretrovirals, ribavirin and dapsone. • Assays Increased HbA1c: hyperbilirubinaemia, carbamylated haemoglobin, alcoholism, large doses of aspirin, chronic opiate use. Variable HbA1c: haemoglobinopathies. Decreased HbA1c: hypertriglyceridaemia. 3- Practical recommendations: The relevance of above considerations are “invisible” in certain of the available assays. An updated list on effects of frequently encountered Hb variants and derivatives on HbA1c measurements can be found at: http://www.ngsp.org/factors.asp Assays used locally: • GSTT & King’s: Menarini H8040 column chromatography, not affectedby Hb variants. Anaemia: only if significant <10g/L for a noticeable effect on result. • Lewisham & Greenwich: Biorad Turbo ion exchange chromatography, affectedby some variants but able to detect short red cell life span. PRUH: HPLC method (Biorad) which is not affected by Hb variants. • NPT Afinion: boronate affinity separation, not affected by variants except HbF . 4 - A FBC is recommended if Hb variant status unknown or uncertain or clinically suspected anaemia (e.g. elderly, menorrhagia) or no Hb record in preceding 12 months. 1 SickleCell trait and other hemoglobinopathiesand diabetes: important information for providers, National Diabetes Information Clearinghouse, availableat http://diabetes.niddk.nih.gov/dm/pubs/hemovari-A1C/index.aspx 2 Factors that Interfere with HbA1c test results, National Glycohemoglobin Standardization Program, availableat http://www.ngsp.org/factors.asp 3 Use of Glycated heamoglobin(HbA1c) in the diagnosis of diabetes Mellitus, abbreviated report of a WHOconsultation, 2011, availableat http://www.who.int/diabetes/publications/en/ 4 Three of 7 hemoglobin A1c point-of-care instruments do not meet generally accepted analytical performance criteria, E. lenters- Westra & R. J. Slingerland, ClinicalChemistry, 1062-1072 (2014) Reviewed and updated: March 2015 South London Cardiovascular Prevention Group