Diabetes, Prediabetes & HBA1C Protocols

Downloads & Links

Practice Leads

  • Doctors: Jas Dhillon
  • Nurse: Zoe Booth

Date Reviewed

6th July 2016

Date of Next Review

September 2017

hba1c-chart

This chart tells you what is considered good control (from www.diabetes.co.uk)

HbA1C ranges:

  • Non-Diabetic: 41 and below
  • Pre-Diabetes: 42-47
  • Diabetic: 48 and above

Patient not known diabetic & HbA1C in pre-diabetic range 

  • Task admin results: 'Please ask pateint to come in to see the nurse about their sugar test.  It's a little high and the nurse will tell you what this means.  Nothing terribly urgent, make an appointment within 4 weeks'.  15 minute appointment.  Make that appointment.
  • Add a journal note 'Asked to come in to discuss with nurse prediabetes and add to register'.
  • Task Nurse to add patient to prediabetes register.
  • Nurse:
    1. Double check patient on prediabetes register.
    2. Discuss what this prediabetic HbA1C means, what diabetes is, why we worry about it, the role of diet, exercise and weight control.  Give information leaflets on HbA1C, prediabetes, exercise, diet & weight control.
    3. Add to recall: HbA1C will need checking yearly – make sure they are not going up – if they are, bring the patient in again to discuss; otherwise they will become diabetic.
    4. Note: If HbA1Cs are going up -but still in pre-diabetic range 42-47 - and lifestyle is failing, then consider adding metformin.  But talk to Pardip first? [Metanalysis – metformin decreases the rate of conversion from prediabetes to diabetes.   NNT = 7-14 over 3 years].   Starting dose metformin 250mg bd and titrate up 3 monthly with subsequent HbA1Cs.

Patient not known diabetic & HbA1C in pre-diabetic range & gradually going up

  • Bring the patient in again to discuss what this means, what diabetes is, why we get worried about it, what they can do about it in terms of exercise, diet and weight control.   Explain strongly that if this goes on, they will become diabetic.
  • Use some motivational interviewing techniques, explore where the block to lifestyle measures is.   Understand the patient's perspective.
  • If HbA1Cs are going up -but still in pre-diabetic range 42-47 - and lifestyle is failing, then consider adding metformin.  But talk to Pardip first? [Metanalysis – metformin decreases the rate of conversion from prediabetes to diabetes.   NNT = 7-14 over 3 years].   Starting dose metformin 250mg bd and titrate up 3 monthly with subsequent HbA1Cs.

Patient known diabetic & routine HbA1C within range (≤48 ) = this does NOT mean everything is okay.

If they are a Type 2 Diabetic, it’s likely their diabetes is better or they MAY be OVERtreated

  • Review patient notes – was HbA1C done routine or acutely because of concerns.
  • Acute ones will probably need to come in for a Doctor’s Diabetic Review.  Ask them about symptoms of hypos (which would indicate that they are OVERtreated esp if on insulin or sulphonylurea).
  • Routine ones – call in for a Nurse’s Diabetic Review - ask them about symptoms of hypos (which would indicate that they are OVERtreated esp if on insulin or sulphonylurea).
  • If no hypos --> repeat HbA1C in 3m.
  • HbA1C target for Type 2’s:
    • If on one antidiabetic drug/lifestyle controlled: aim for around 48 mmol/l
    • If on 2+ antidiabetic drugs: aim for around 59 mmol/l
  • Features of hypos:
    • Shakiness, nervousness or anxiety.
    • Sweating, chills and clamminess.
    • Irritability, impatience, confusion, including delirium.
    • Rapid/fast heartbeat, lightheadedness or dizziness, hunger and nausea.

Patient known diabetic & routine HbA1C within range (≤48 ) = this does NOT mean everything is okay.

If they are a Type 1 Diabetic on insulin, a normal HbA1C is LIKELY to indicate that they are being OVERtreated

  • Call patient in for a Diabetic Review with Doctor.
  • Review patient notes.  Call patient in.  Make sure they are not OVERtreated by asking them whether they are having any symptoms of hypos?  If they are having hypos, refer urgently back to diabetic service. Seek advice from Clinical Lead if needs be.
  • HbA1c target:  aim for less than 59mmol/l  BUT really the target is dependent on the person and whether they are getting hypos or not.  If they are getting hypos at 59, their target may need to be set higher.  In this case refer urgently back to diabetes service or talk to diabetic lead.
  • Features of hypos:
    • Shakiness, nervousness or anxiety.
    • Sweating, chills and clamminess.
    • Irritability, impatience, confusion, including delirium.
    • Rapid/fast heartbeat, lightheadedness or dizziness, hunger and nausea.

Patient is a known diabetic and the HbA1c is above target range (≥ 59)

The GP should comment on the HbA1c result with an action plan

This will include one of the following;

  • If the patient has a diabetic review appointment already booked with the nurse, then the GP can write information on simple increases they would recommend to medication. The nurse can then discuss this with the patient at review. The change can then be implemented by sending a task to the diabetic GP if the patient is willing to have the medication increase. This is in conjunction with re-enforcing the lifestyle advice for diabetes. The interim diabetes recall then needs to be set for 3 months to re-check the HbA1c.
  • If there is no review appointment booked, then the patient should have a 20 minute appointment with one of the diabetic GPs (Sandhu, Dhillon, Hamblin)
  • If the patient is complex, they should have a 20 minute appointment with one of the diabetic GPs even if they have a nurse review appointment booked.
  • If the patient is not well controlled on 3 diabetic medications, developing side effects or complex, then consider referral on to Level 2 services.