Primary Care Guideline on the frequency of blood self- in patients with type 2 mellitus not controlled by

Type 2 diabetes mellitus treated with:

Drug Class Examples Drug class Examples Diet and exercise alone Alpha glucosidase inhibitors Acarbose If any of these Meglitinides Nateglinide, Repaglinide

treatments are (Prandial glucose Biguanides Metformin given in regulators/Glinides)

DPP-4 Inhibitors Linagliptin, Sitagliptin, combination with a (Gliptins) Saxagliptin, Vildagliptin sulphonylurea or a Sulfonylureas Glibenclamide, Gliclazide, meglitinide then Glimepiride, Glipizide, GLP-1 Analogues Exenatide, Liraglutide, follow the guidance Tolbutamide (Incretin mimetics) Lixisenatide given for patients Thiazolidinediones Pioglitazone treated with a (Glitazones) sulphonylurea or These medicines can cause hypoglycaemia SGLT2 Inhibitors Dapagliflozin meglitinide Blood glucose monitoring may therefore be required in patients: who are not stabilised on treatment who are drivers (see DVLA guidance below) Regular blood glucose monitoring not necessary in other certain circumstances (see below) A supply of blood strips may be required (as an acute prescription) in certain circumstances (see below)

Blood glucose monitoring may be required in patients: with acute illness co-prescribed steroids (test at midday, before evening meal and two hours after evening meal) undergoing significant changes in pharmacotherapy or fasting, for example, during Ramadan at increased risk of hypoglycaemia/hypoglycaemia unawareness with unstable or poor glycaemic control (HbA1c >8.0% [64mmoL/mol]) with postprandial hyperglycaemia (due to the potential link with macrovascular disease) who are pregnant or planning pregnancy

DVLA guidance for diabetic patients managed by sulphonylurea or glinide tablets Driver Group DVLA Advice Group 1 (cars, motorcycles) It may be appropriate to monitor blood glucose regularly and at times relevant to driving Group 2 (buses, lorries) There is a requirement that the patient regularly monitors blood glucose at least twice daily and at times relevant to driving Note: The DVLA do not define how frequently blood glucose should be tested when advising ‘regularly’ and ‘at times relevant to driving’ for diabetic patients managed by sulphonylurea or glinide tablets, and it is therefore not possible to clarify the DVLA guidance further.

Prescribing Tips

NICE recommend that HbA1c is checked twice annually in all diabetic patients

The frequency of blood glucose monitoring required will vary for individual patients according to a number of factors such as the treatment regime in use, the target level of glycaemic control, the patient’s stability on treatment, the advice given by the DVLA for drivers, and other acute circumstances such as illness or pregnancy; this variety of factors means it is not possible to define a specific quantity of test strips that patients should be issued

Clinical judgement should be used in assessing individual patient requirements for the frequency of blood glucose monitoring required and the number of blood glucose test strips that should be issued; advice should be sought from a diabetes specialist if necessary

Patients who require blood glucose test strips as part of their regular treatment for diabetes can be issued with a repeat prescription; for those patients who require to monitor their blood glucose only in certain acute circumstances, then test strips should preferably be issued as an acute prescription

Prescribers are encouraged to regularly review how frequently their patient monitors their blood glucose and subsequently review the appropriate issuing of blood glucose test strips – patients should only ever be issued suitable quantities to meet their needs, and to prevent stockpiling and waste

The relevant directions for use should be added to the product dispensing label to enable better compliance

The expiry date of the test strips should be taken into account

A record of the patient’s driving status should be made in the patient notes—this can be read coded i.e. heavy goods driver, motor car driver, does not drive a vehicle.

Only one brand of test strips, relevant to the meter the patient is using, should be prescribed

References: 1. The Scottish Intercollegiate Guidelines Network (SIGN) Guideline No.116 Management of Diabetes (March 2010) http://www.sign.ac.uk/pdf/qrg116.pdf 2. Owens D, et al. Blood glucose self-monitoring in type 1 and : reaching a multidisciplinary consensus. Diabetes and Primary Care Vol.6 No.1 (2004) http://www1.accu-chek.co.uk/documents/AAConsensus.Final.pdf 3. DVLA At a glance Guide to the current Medical Standards of Fitness to Drive (2013) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200395/at_a_glance_1_.pdf 4. National Prescribing Centre Rapid Review: What are the DVLA blood glucose monitoring requirements for people with diabetes? (19th March 2012) http://www.npc.nhs.uk/rapidreview/?p=4937 5. National Institute for Health and Clinical Excellence (NICE) Guideline No.66 Type 2 diabetes (May 2008) http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf

Prepared by: Leanne Bartholomew, Senior Medicines Management Technician and Emma Harris, Medicines Management Pharmacist Version 1.0 October 2013 \\nhsswscfdc01\WSCF-DATA\Medicines Management\Practice Work\PROCEDURES\BGTS\Procedures\Final\BGTS type 2 non-insulin FINAL 141013.docx