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The studies carried out in Spain state in type 2 diabetics a prevalence of microalbuminuria of 23%; 5% for proteinuria; and between 4.8% and 8.4% for renal failure. Microalbuminuria is a determining factor of renal failure as well as an indicator of coronary heart disease and cardiovascular mortality (1; 2). Currently, diabetes mellitus is the first cause of inclusion in the renal replacement therapy programs which includes haemodialysis, peritoneal dialysis and renal transplant (1). Diabetic neuropathy is another microvascular complication of diabetes. It can appear as somatic neuropathy, where diabetic foot is included and its most common pathology is symmetric distal polyneuropathy, which affects at least 24.1% of the DM 2 population. Autonomous neuropathy affects between 20% and 40% of type 2 diabetics. The most frequent forms are digestive neuropathy (gastroparesia, diarrhoea), cardiovascular neuropathy (orthostatic hypotension) and impotence. Diabetic foot is the consequence of loss of sensitivity due to neuropathy or the existence of deformities. The existence of peripheral arteriopathy aggravates the prognosis. The amputation prevalence is from 0.8% to 1.4%; the incidence of ulcers is 2.67% (2). The appropriate assessment of cardiovascular risk, with the integrated action it conveys on all the risk factors, not only on hyperglycaemia, is a priority strategy to reduce the morbimortality of DM 2 patients (1). 4.2. Costs for DM 2 For DM 2 patients assisted in primary care, the average direct cost was 1.305€ per patient on an annual basis, according to the CODE-2 study. From this total estimation, 42% corresponds to pharmaceutical expenses, 32% to hospitalization costs and 26% to outpatient health care (1). According to a study held in Spain in 2002, between 6.2 and 7.4% of health care expenses were from diabetes. The direct expense of a diabetic patient almost doubles that of a non-diabetic patient (7). The average of annual visits of a diabetic patient to the family physician is estimated in nine visits, and between a third and a half of the visits to the endocrinologist are related to diabetes (7). 4.3. Organization and assistance to DM 2 patients in the Spanish National Health System Diabetes is diagnosed and seen mainly by primary care physicians and by referred endocrinologists; these two physicians deal with this disease depending on its severity and the complexity of the treatments. Strategy (1) states that 68.5% of the Autonomous Communities have standardised coordination between primary and specialist care, mainly through agreed protocols, improvement committees, clinical sessions and training activities. There are specific information or registration systems on diabetes in primary care in 73.7% of the Autonomous Communities, 15% in specialist care and 31.6% in public health. Variability is very wide. 32 CLINICAL PRACTICE GUIDELINES IN THE NHS
However, the quality of the assistance provided to people with diabetes and the health results are aspects which are difficult to evaluate. Most studies have been carried out in specific and hardly representative areas of the diabetic population as a whole or with methodological problems (i.e., the sampling was not randomized). A recent report carried out within a wide population, which included 430 health centres throughout Spain (8) and 1,907 diabetic patients, stated that 22.6% of the patients smoke, 49.4% have glycosylated haemoglobin beyond 7% and 31.5% present >30 kg/m2 body mass index (BMI). As regards other more controversial indicators, 61.3% suffer from cardiovascular risk, according to Framingham original ³20%; 5.6% reach LDL
Page 1: Clinical Practice Guideline on type
Page 4 and 5: A bibliographic record of this work
Page 7 and 8: Table of Contents Presentation 9 Au
Page 9 and 10: 11. Diabetic foot. Assessment, prev
Page 11: Presentation Care practice is becom
Page 14 and 15: Other collaborations Rosa Rico Itur
Page 16 and 17: 13. Which drug combination strategi
Page 19 and 20: Summary of recommendations Defi nit
Page 21 and 22: D CPG B B B B A daily single dose
Page 23 and 24: A B CPG Hypertense patients with DM
Page 25 and 26: Treatment for diabetic foot ulcers
Page 27: 1. Introduction Effective care for
Page 31 and 32: 3. Methodology Methodology. Evidenc
Page 33: 4. Epidemiology and sanitary impact
Page 38 and 39: 5.2. Risk factors for the developme
Page 40 and 41: 5.2.8. Diet and alcohol Type of die
Page 42 and 43: 5.2.12. Heart failure The associati
Page 44 and 45: The ADA does not recommend it for c
Page 46 and 47: Figure 1. DM 2 diagnostic algorithm
Page 48 and 49: 46 CLINICAL PRACTICE GUIDELINES IN
Page 50 and 51: 6.1. Impaired Fating Glucoseucose (
Page 52 and 53: 1++ An intensive intervention on li
Page 54 and 55: Different SRs (81-84) have assessed
Page 56 and 57: 7.1.4. Other dietary interventions
Page 58 and 59: Exchange system This system is base
Page 60 and 61: duration and intensity). Performing
Page 62 and 63: [RR 0.75 (CI 95%: 0.60-0.93)], and
Page 64 and 65: The optimum dose in most patients i
Page 66 and 67: without heart failure. In this stud
Page 68 and 69: B B B B Metillinides can play a ro
Page 70 and 71: Recommendations B A A B B B B When
Page 72 and 73: 8.2. Insulin therapy 8.2.1. Associa
Page 74 and 75: Slow-acting insulin analogues vs. N
Page 77 and 78: 9. Screening and treatment of macro
Page 79 and 80: The validity and applicability of a
Page 81 and 82: The RCTs and the meta-analysis are
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9.5.2. Pharmacological treatment of
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Recommendations B/D A B CPG Patient
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incidence was 0.3% after the first
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it is believed that microalbuminuri
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Summary of evidence 1++ In hyperten
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An SR on drugs to treat diabetic ne
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(241), the response rate to placebo
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11. Diabetic foot. Assessment, prev
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11.2.2. Peripheral arterial disease
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11.4. Other preventive measures The
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B D CPG B Diabetic foot screening m
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11.5.4. Antibiotic treatment for in
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2+ The culture has a limited value
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• Promote healthy lifestyles: die
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In another recent RCT (289), sMBG w
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12.3. Contents and methods of an ed
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Assessment of self-management recor
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13.4. Referral criteria to medical
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Appendices Appendix 1. Levels of Ev
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Appendix 2. DM 2 diet Estimating ca
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CLINICAL PRACTICE GUIDELINE ON TYPE
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GPL-1 Analogues Biguanides Glitazon
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Devices FLEXPEN (Novo Nordisk): OPT
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Treatment for an unconscious patien
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Appendix 6. Assessment of macro- an
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Appendix 8. Use of monofilament Mon
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Indicators of final outcomes • Nu
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Impaired Glucose Tolerance (IGT): I
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IGT INSIGHT Trial IV LDL LH LIFE Tr
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Bibliography 1. Estrategia en diabe
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33. Iso H, Date C, Wakai K, Fukui M
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64. Screening for type 2 diabetes.
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97. Thomas DE, Elliott EJ, Naughton
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129. Lincoff AM, Wolski K, Nicholls
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157. Natarajan S, Liao Y, Cao G, Li
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185. de GG. Low-dose aspirin and vi
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214. Rahman M, Pressel S, Davis BR,
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245. NZGG. Management of type 2 dia
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279. Norris SL, Nichols PJ, Caspers
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