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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 2 Or BMI ≥ 30 kg/m 2 Or BMI ≥ 27.5 kg/m (South Asian/Chinese) Perform HbA1c (+FBC ) Exclusions Perform HbA1c – Point of Care Testing * Exclusions 1 apply (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 3 (non-diabetic hyperglycaemia) Offer brief intervention: If symptoms If no symptoms 1. Discuss risk of developing diabetes Refer same day 2. Help modify individual risk factors (immediately if Retest within 3. Offer tailored support services necessary)to GP 4 weeks Retest at next NHS Health Check (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 1. Risk of developing diabetes Diabetes 1 2. Benefits of a healthy lifestyle Exclusions apply 3. Modifying risk factors Retest HbA1c Retest at next NHS Health Check after 6 months (if any previous test ≥48mmol/mol) Or at least once a year (if ≥42 bu<48mmol/mol) (Or before if patient develops symptoms of diabete) Check Weight, BMI & BP at least once a year 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 120minutes <7.8 - <11.1 mmol/l then blood glucose 120minutes) Impaired Glucose Tolerance 1HbA1c should not be used to diagnose/exclude diabetes if: The patient has symptoms of less than 2 months duration, as an individual can be significantly hyperglycaemic without HbA1c having had sufficient time to rise. Fasting 6.1-6.9 mmol/l and If a patient is acutely unwell (for the same reasons as above) 120 minutes < 7.8 mmol/l Impaired Fasting Glycaemia In pregnancy. 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 (≥ 11.1mmol/l is diagnostic of diabetes in the presence of diabetes symptoms.) Check Weight, BMI, BP and HbA1c at least once a year 2If no Full Blood Count (FBC) record within last 12 months 3Symptoms: polyuria, polydipsia, unexplained weight loss. 4 If diabetes symptoms (as above) and/or multiple risk factors for *Relevant sites/ providers only: developing diabetes. 5Additional risk factors for diabetes: first-degree relative with diabetes, women using approved POCT equipment: who delivered baby weighting >4kgs or with diagnosis of Gestational Diabetes MellituAfinion, B-Analyst, Cobas B101, or with Polycystic Ovary Syndrome, severe obesity, acanthosis nigricans and is more DCA 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. Commonin 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 transfusionrequirements which 2 can adversely affect HbA1c results . 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 considerationsare “invisible” in certain of the available assays. An updated list on effects of frequentlyencountered Hb variants and derivatives on HbA1c measurementscan 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 . - 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