ACHIEVING BEST PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
24
VOLUME 7 NUMBER 1 • MARCH 2010
who had been given specialist training and was supervised by
the two consultant diabetologists (GVG and JPW). Problems
concerning glycaemic control were referred to the diabetes
specialist nursing team. An algorithm was developed for
use in the clinic (Fig. 1). Patients were seen monthly in the
nurse-led clinic until BP control was at target, and they were
then discharged to routine diabetes care. Approximately one
year after discharge, patients were recalled for a follow-up
assessment.
Blood pressure measurement
Blood pressure was measured according to British
Hypertension Society guidelines.
10
Clinical management algorithm
Our treatment algorithm was adapted from a previously
validated and published protocol for BP control in type 2
diabetes without renal complications (Fig. 1)
12
and approved
Table 1.
Diagnostic definitions
Microalbuminuria
At least two separate early morning urine albumin:creatinine ratio levels
were
>
2.5 mg/mmol in men or
>
3.5 mg/mmol in women.
Nephropathy
Presence of persistent dipstix proteinuria (at least twice), or urinary
albumin:creatinine ratio
>
25 mg/mmol on at least two occasions, or 24-h
urine protein
>
500 mg. Retinopathy was also required for diagnosis of
nephropathy.
Figure 1.
Clinical management algorithm
DRUG CHOICE FACTORS:
• ACE inhibitor or angiotensin receptor blocker unless contra-indicated
• Other anti-hypertensive drug choices selected from:
Thiazide or loop diuretic
Beta-blocker
Calcium antagonist
Alpha-blocker
• Other factors:
Existing drug treatment
Contra-indications
Diabetic complications
Individual tolerance side effects
Compliance
• Cardiovascular risk: aspirin & statin unless contra-indicated
STEP ONE
• Health Promotion
• Non-pharmaceutical intervention
• Assess cardiovascular risk
• ARB/ACE therapy introduced with stepwise monthly
titration. Monitor renal function at each dose increase
STEP TWO
• If BP control sub-optimal, addition and stepwise
monthly titration of 2
nd
drug up to maximum dose
• If already at this stage add in 3
rd
drug
STEP FOUR
• If patient is resistant to treatment on triple
medication, discuss with physician
• If 4
th
drug added by physician, monthly titration to
maximum dose
CLINICAL MANAGEMENT ALGORITHM FOR PATIENTS WITH TYPE 2 DIABETES REFERRED FROM CONSULTANT CLINIC IF
MICROALBUMINURIA OR NEPHROPATHY PRESENT FOR INSTIGATION AND/OR TITRATION OF ACE/ARB THERAPY AND TO
IMPROVE SUB-OPTIMAL BP CONTROL (>130/80 mmHg) WITH ADDITIONAL ANTI-HYPERTENSIVE THERAPY
STEP THREE
• If BP control remains
suboptimal, addition and stepwise
monthly titration of third drug up to
maximum dose
• Consider 24-hour ABP
STEP FIVE
• If BP remains sub-
optimal, refer to physician
for drug review
• Consider 24-hour ABP
ABP = ambulatory blood pressure; ACE inhibitor = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure;
eGFR = estimated glomerular filtration rate; HDL = high density lipoprotein
