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## Complete Summary

#### GUIDELINE TITLE

Management of type 2 diabetes.

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Management of type 2 diabetes.
Wellington (NZ): New Zealand Guidelines Group (NZGG); 2003 Dec. 143 p.
\[565 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [February 26, 2008, Avandia
    (rosiglitazone)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Avandia):
    A new Medication Guide for Avandia must be provided with each
    prescription that is dispensed due to the U.S. Food and Drug
    Administration\'s (FDA\'s) determination that this medication could
    pose a serious and significant public health concern.

-   [December 12, 2007,
    Carbamazepine](http://www.fda.gov/medwatch/safety/2007/safety07.htm#carbamazepine):
    The U.S. Food and Drug Administration (FDA) has provided
    recommendations for screening that should be performed on specific
    patient populations before starting treatment with carbamazepine.

-   [November 14, 2007, Avandia
    (rosiglitazone)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Avandia2):
    New information has been added to the existing boxed warning in
    Avandia\'s prescribing information about potential increased risk
    for heart attacks.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [August 14, 2007, Thiazolidinedione class of antidiabetic
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#rosi_pio):
    Addition of a boxed warning to the updated label of the entire
    thiazolidinedione class of antidiabetic drugs to warn of the risks
    of heart failure.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [October 6, 2006, Coumadin (warfarin
    sodium)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Coumadin):
    Revisions to the labeling for Coumadin to include a new patient
    Medication Guide as well as a reorganization and highlighting of the
    current safety information to better inform providers and patients.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Type 2 diabetes and associated complications including cardiovascular
disease, renal disease, eye disease, and foot disease

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Endocrinology\
Family Practice\
Internal Medicine\
Nephrology\
Ophthalmology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Nurses\
Patients\
Physician Assistants\
Physicians\
Podiatrists

#### GUIDELINE OBJECTIVE(S)

-   To provide an evidence-based summary of best practice in the
    management of some key aspects of type 2 diabetes in order to
    improve the outcome for people with diabetes

-   To assist decision-making by health care providers and people with
    type 2 diabetes

#### TARGET POPULATION

Adults in New Zealand with type 2 diabetes.

**Note**: Parts of this guideline also apply to the care of those with
type 1 diabetes.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Risk Assessment/Diagnosis**

1.  Fasting venous blood plasma glucose

2.  Oral glucose tolerance test (OGTT)

3.  Cardiovascular risk assessment

4.  Body mass index (BMI) measurement

5.  Total cholesterol (TC) and TC:high-density lipoprotein (HDL) testing

6.  Urinary albumin concentrations

7.  Serum creatinine testing

8.  Slit lamp biomicroscopy

9.  Neuropathy screening with 10 g monofilament and vibration perception
    thresholds

**Treatment/Management**

1.  Culturally appropriate approach

2.  Dietary education

    -   Cardioprotective dietary pattern

3.  Weight management

    -   Diet and physical activity

    -   Medication

    -   Surgery

4.  Increased physical activity, with attention to minimizing patient
    risk

5.  Smoking cessation

    -   Nicotine replacement therapy

    -   Bupropion or nortriptyline hydrochloride

6.  Screening and treatment for depression

    -   Mental health therapy

    -   Selective serotonin reuptake inhibitors

7.  Glycaemic control

    -   Control of glycated hemoglobin (HbA1c) levels

    -   Drug treatments: metformin, insulin secretagogues,
        alpha-glucosidase inhibitors (acarbose), glitazone, insulin

    -   Self management education

8.  Blood pressure management

    -   Drug treatments: beta-blockers, angiotensin-converting enzyme
        (ACE)-inhibitors, A2-receptor-blockers, aspirin, statins,
        warfarin

9.  Lipid management

    -   Drug treatments: statins, aspirin, beta-blockers, ACE-inhibitors

    -   Fibrate or combination therapy

10. Antiplatelet therapy with aspirin

    -   Computed tomography (CT) scan to exclude intracranial
        haemorrhage

11. Complementary and alternative therapies

12. Diabetic foot disease/Charcot\'s foot

    -   Foot care education

    -   Footwear modification

    -   Total contact casting

    -   Arterial revascularisation procedures

    -   Treatment of foot ulcers

        -   Broad spectrum antibiotics regimen

        -   Wound care including debridement

    -   Diabetic neuropathy drug treatment: tricyclic antidepressants,
        gabapentin, topical capsaicin, analgesia (such as paracetamol),
        carbamazepine

13. Referral to specialist as indicated

#### MAJOR OUTCOMES CONSIDERED

**Glycaemic Control**

-   Does improving glycaemic control (tight control) reduce
    microvascular and/or macrovascular complications of diabetes?

-   What should be the target level(s) of glycated hemoglobin (HbA1c)?

-   Which method of measuring HbA1c should laboratories use?

-   What are the potential risks of tight glycaemic control?

-   How does tight glycaemic control affect quality of life?

-   How should glycaemic control be monitored?

-   Which lifestyle interventions have been shown to improve glycaemic
    control?

-   Which medications should be used to improve glycaemic control?

-   When and how should insulin be used?

-   In teenagers and youth with type 2 diabetes, should targets for
    glycaemic control and modes of treatment be the same as for adults?

**Renal Disease**

-   What are the definitions of diabetic renal disease,
    microalbuminuria, and overt diabetic nephropathy?

-   What are the risk factors for the development of diabetic renal
    disease, and how should risk be stratified?

-   In people with diabetes, who should be tested for diabetic renal
    disease, when after diagnosis of diabetes should testing start, and
    should an attempt be made to achieve good glycaemic control before
    testing for diabetic renal disease?

-   Which test(s) should be used for early detection of diabetic renal
    disease and for monitoring of diabetic renal disease?

-   How often should testing for diabetic renal disease occur?

-   Which interventions have been shown to be effective for preventing
    the onset and for delaying the progression of diabetic renal
    disease?

-   When is specialist referral indicated in people with diabetic renal
    disease?

**Eye Disease**

-   How is diabetic retinopathy defined?

-   What are the risk factors for the development and progression of
    diabetic retinopathy?

-   In people with diabetes, who should be screened for diabetic
    retinopathy, and when after diagnosis of diabetes should screening
    start?

-   Which method(s) should be used to screen for diabetic retinopathy?

-   How often should screening for diabetic retinopathy occur?

-   Which interventions have been shown to be effective in preventing
    the onset of diabetic retinopathy, delaying the progression of
    diabetic retinopathy, and decreasing the risk of visual loss?

**Diabetic Foot Disease**

-   How is diabetic foot disease defined?

-   What are the risk factors for ulceration and for amputation in
    people with diabetes?

-   In people with diabetes, who should be screened for diabetic foot
    disease, when after diagnosis of diabetes should screening start,
    and how often should foot screening occur?

-   Which test(s) or method(s) should be used to screen for diabetic
    foot disease?

-   Which interventions have been shown to be effective in preventing
    and treating ulceration, and in preventing amputation?

-   Are there specific cultural issues which might affect the way in
    which foot examination and foot care should be carried out in
    particular groups of people with diabetes, for example Maori and
    Pacific peoples?

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The diabetes Guideline Development Team took a pragmatic approach to the
development of this guideline. Evidence-based diabetes guidelines were
published internationally in late 2001 and early 2002. As the diabetes
literature is extensive and three sets of international guidelines had
been rigorously and systematically developed, it was agreed that the New
Zealand Management of Type 2 Diabetes Guideline would be an adaptation
of some sections of these international guidelines. Where issues were
specific to New Zealand, such as issues for Maori and Pacific people
with diabetes, a literature search was undertaken, using the Scottish
Intercollegiate Guidelines Network (SIGN) search strategies, looking for
new evidence that had emerged since the publication of the international
guidelines. This search was done in May 2003. No papers were identified
which changed any recommendations.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

The Scottish Intercollegiate Guidelines Network (SIGN) diabetes
guideline and the Royal College of General Practitioners (RCGP) Blood
Glucose Management Guideline have different systems for grading both
levels of evidence and recommendations. The Guideline Development Team
discussed this issue extensively. A consensus decision was made to use
the levels of evidence as assigned to each statement by the original
guideline developers (either SIGN or RCGP).

**SIGN Levels of Evidence**

**1++**

High quality meta-analyses, systematic reviews of randomized controlled
trials, or randomized controlled trials with a very low risk of bias

**1+**

Well conducted meta-analyses, systematic reviews of randomized
controlled trials, or randomized controlled trials with a low risk of
bias

**1-**

Meta-analyses, systematic reviews of randomized controlled trials, or
randomized controlled trials with a high risk of bias

**2++**

High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**

Well-conducted case-control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**

Case-control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal

**3**

Non-analytic studies (e.g., case reports, case series)

**4**

Expert opinion

**RCGP Levels of Evidence**

**Ia**

Evidence from meta-analysis of randomized controlled trials

**Ib**

Evidence from at least one randomized controlled trial

**IIa**

Evidence from at least one controlled study without randomization

**IIb**

Evidence from at least one other type of quasi-experimental study

**III**

Evidence from non-experimental descriptive studies, such as comparative
studies, correlation studies, and case-control studies

**IV**

Evidence from expert committee reports or opinions and/or clinical
experience of respected authorities

**Appraisal of Other Guidelines**

The AGREE appraisal instrument was used by the guideline development
team to appraise the quality of the methods used to develop other
diabetes guidelines. The team decided to adapt three international
diabetes guidelines published in 2001 and 2002, which were assessed as
being well-developed, and suitable for adaptation to New Zealand
circumstances.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The New Zealand Guidelines Group (NZGG) convened a Guideline Development
Team. The team first met in April 2002. Three face-to-face meetings and
eight teleconferences were held. The team was divided into four
subgroups to undertake the initial work on the four main areas:

-   glycaemic control

-   renal disease

-   eye disease

-   foot disease.

The project manager drafted the four chapters for the subgroups. These
draft chapters were first reviewed and revised by the relevant subgroup
and then by the whole team. All other chapters, including resources and
appendices were also drafted by the project manager, then reviewed and
revised by the whole team. Chapters were re-drafted by the project
manager. Agreement was by consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

For the grades of recommendations used in this guideline it was decided
to use the Scottish Intercollegiate Guidelines Network grades of
recommendations, except in the sections on cardiovascular disease and
lifestyle management where the New Zealand Guidelines Group grades
described in the Assessment and Management of Cardiovascular Risk
Guideline are used.

**Levels of Recommendations**

**A**

The recommendation is supported by good evidence.

**B**

The recommendation is supported by fair evidence.

**C**

The recommendation is supported by non-analytic studies or consistent
expert opinion.

**I**

The evidence is insufficient, evidence is lacking, of poor quality or
opinions conflicting, the balance of benefits and harms cannot be
determined.

**Good Practice Point (GPP)**

Recommended practice based on the clinical experience of the Guideline
Development Team

#### COST ANALYSIS

**Economic Considerations**

Both a full economic analysis of interventions for diabetes and a
balance sheet were beyond the scope of this guideline. While the
economic impact of many aspects of diabetes care is unknown, several
recommended practices in this guideline have been found to be
cost-effective in economic studies. The Price Waterhouse Cooper report
also makes several recommendations which could reduce the serious
economic consequences of the rising prevalence of diabetes.

Intensive blood glucose control was shown to be clearly cost-effective
for those with type 1 and type 2 diabetes, and to be more cost-effective
among younger people with type 2 diabetes compared with older people.
Among people with type 2 diabetes, cost savings resulting from intensive
blood glucose control largely resulted from lower hospitalisation costs.

Achieving an average blood pressure of 144/82 mm Hg reduced costs and
improved health outcomes relative to moderate hypertension control
(154/86 mm Hg). Control of blood pressure below 150/85 mm Hg was found
to reduce the cost of complications and had a cost-effectiveness ratio
that compared favourably with many accepted health care programmes.

Several economic studies examining retinopathy prevention have
demonstrated that diabetic retinopathy screening programmes, which
include treatment facilities, are clearly cost-effective.

Although the literature on economic studies of preventive foot care
practices was limited, research suggests that aggressive, proactive care
may result in fewer lower extremity amputations and be cost-effective
and possibly cost-saving. A recent simulation model concluded that an
intensified lower extremity amputation prevention programme including
patient education, foot care, and appropriate footwear for people with
diabetes at risk or high risk for foot ulcers and amputations would be a
cost-effective or even a cost-saving strategy. The same modelling study
found that the provision of such a programme was not cost-effective in
low risk people with diabetes without specific risk factors.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The draft of this guideline was widely distributed to many organizations
including consumer groups, primary health organizations, district health
boards (DHBs), service and provider organizations, expert reviewers,
clinicians, and other health care practitioners for comment as part of
the consultation and peer review process. At the time of peer review,
the draft guideline was also available on the New Zealand Guidelines
Group (NZGG) Web site.

Comment was received from many individuals, groups and organizations
including consumers, health care practitioners and academics. Also, the
guideline was assessed using the AGREE tool. Comments were considered by
the Guideline Development Team and the NZGG, and amendments made.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the Levels of Evidence and Grades of Recommendation
(**A - C, I, and Good Practice Points \[GPP\]**) are given at the end of
the Major Recommendations field.

**Type 2 Diabetes in New Zealand**

**Diagnosis of Diabetes, Impaired Glucose Tolerance (IGT), and Impaired
Fasting Glucose (IFG)**

**C** Two fasting venous plasma glucose results greater than or equal to
7 mmol/L on two different days are diagnostic of diabetes and an oral
glucose tolerance test (OGTT) is not required.

**C** A random venous plasma glucose result of greater than 11 mmol/L on
two different days is diagnostic of diabetes.

**C** A fasting venous plasma glucose of 6.1 to 6.9 mmol/L indicates
impaired fasting glucose and an OGTT is recommended to assess for
diabetes or IGT.\*

**C** Some people with a fasting venous plasma glucose of 5.5 to 6.0
mmol/L show diabetes or impaired glucose tolerance with an OGTT.

**C** An OGTT is recommended in people with a fasting venous plasma
glucose of 5.5 to 6.0 mmol/L who are not of European ethnicity or who
have a family history of diabetes, a past history of gestational
diabetes, or other features of the metabolic syndrome.

**C** A fasting venous plasma glucose result of less than 5.5 mmol/L is
normal.

**GPP** Glycosylated hemoglobin (HbA1c) should not be used for the
diagnosis of diabetes.

\*A recent reexamination of the classification and diagnostic criteria
of diabetes recommended that the cut-off point for IFG should be reduced
from 6.1mmol/L to 5.6 mmol/L.

**Lifestyle Management**

**Dietary Interventions**

**A** Recommend a reduction in energy intake with weight loss as the
primary objective for people with diabetes or the metabolic syndrome who
are overweight or obese.

**A** Everyone with type 2 diabetes or the metabolic syndrome should
receive intensive dietary advice. Intensive dietary advice should be
given in individual/group sessions with a dietitian. Physical activity
should also be encouraged.

**A** Encourage people with type 2 diabetes or the metabolic syndrome to
gradually adopt a cardioprotective dietary pattern. Advise a reduction
in the intake of foods rich in saturated fatty acids or added sugars and
white flour bakery products.

Encourage a progressive replacement of these foods with vegetables,
fruit, whole grain, high-fibre products, and dried peas and beans
(legumes). Recommend an increase in the consumption of fish and include
a source of polyunsaturated fat (see Appendix B in the original
guideline document).

**A** Interventions that are known to reduce risk factors in people
without diabetes are also recommended for people with diabetes. Assess
salt and alcohol consumption and provide guidance for limited use.
Consider adding plant sterols/stanols to the diet.

**A** For the optimal improvement of all risk factors, especially body
weight and glycaemic control, employ intensive dietary interventions
that include continuous education, behaviour modification, goal setting,
and intensive monitoring.

**C** Identify and recommend qualitative dietary changes based on the
habitual dietary pattern, and then progress to quantitative advice to
promote the development of a structured eating plan.

**A** Specific dietary advice for people with diabetes and the metabolic
syndrome includes advice about the saturated fatty acid content of foods
and the quality of carbohydrate choices to encourage a high-fibre intake
of more than 40 g daily (see Appendix B in the original guideline
document).

**A** To control postprandial hyperglycaemia the following advice is
recommended:

-   include high-fibre foods with a low to moderate glycaemic index at
    each meal

-   distribute carbohydrate foods evenly throughout the day

-   avoid a large volume of carbohydrate-rich foods at any one meal

**A** Refer or re-refer to a dietitian for specialised tailoring of
advice and energy-balance assessments if treatment targets are not
achieved.

**A** Reduce sodium intake to no more than two grams per day (6 g sodium
chloride) by minimising added salt and limiting high salt containing
foods.

**B** People with diabetes may consume up to 2 to 3 standard drinks of
alcohol at one time with a minimal effect on blood glucose. They should
be advised that, if exercise and consumption of alcohol are combined,
there may be a greater lowering of blood glucose.\*

**GPP** Everyone with type 2 diabetes or the metabolic syndrome should
be offered a dietary review and tailored advice according to their
readiness for change, energy requirements, profile of risk, prescribed
medications, lifestyle, and cultural choices.

**GPP** Culturally appropriate dietary advice is of particular
importance for Maori and Pacific people with diabetes. Referral to Maori
and Pacific dietitians may be preferable, where possible.

**GPP** Use culturally appropriate dietary resources for people with
diabetes. Resources developed for the free annual check programme are
available in Maori and Pacific Island languages\*\*.

\*Grade of recommendation adjusted due to setting and sample sizes of
trials.

\*\*Pacific Islands Heartbeat (PIHB) has produced a resource entitled
*Eat for Health*, available in Samoan, Tongan, Cook Island, Niuean and
English versions (contact PIHB through the National Heart Foundation at
[www.heartfoundation.org.nz](http://www.heartfoundation.org.nz/)).

*Dietary Education*

**A** Use behavioural and motivational strategies in education and
counselling to achieve and sustain dietary change.

**A** Everyone with diabetes should receive intensive dietary advice on
interventions that have been shown to benefit people with their risk
profile.

**A** Intensive dietary advice should be given in individual/group
sessions with a dietitian.

**Weight Management**

**B** Encourage people with a 5-year cardiovascular risk above 15% or
with diabetes and a body mass index (BMI) greater than 25 (especially
anyone who has a BMI \>30) to commence graduated lifestyle change aimed
at weight reduction.

**A** For significant weight loss, recommend a reduction in energy
intake and an increase in physical activity.

**C** Discourage the use of weight loss programmes that promote the
exclusion of food groups from the cardioprotective dietary pattern or
that increase saturated fatty acids intake.

**GPP** Consider referral to weight management health care practitioners
for motivational counselling or specific energy balance assessment and
advice when general lifestyle advice does not achieve a sustained weight
loss.

**GPP** Review the indication for use of drugs that cause weight gain.
Offer weight management support to people requiring drugs that cause
weight gain.

**GPP** Only initiate pharmacological interventions as an adjunct to a
comprehensive weight management programme that includes diet and
physical activity and uses motivational and behavioural methods.

**GPP** Surgery may be considered for people with a BMI greater than 40.
Decisions should take into account both the absolute cardiovascular risk
and other health risks and comorbidities.

**Physical Activity**

**B** Physical activity is an integral part of the lifestyle advice for
people with diabetes.

**B** Everyone should aim to do a minimum of 30 minutes of
moderate-intensity physical activity (3 -- 6 metabolic equivalents
\[METs\]) on most days of the week.

**B** For people with time constraints, physical activity may be
accumulated in bouts of 8 to 10 minutes.

**B** People who are already doing 30 minutes of moderate-intensity
physical activity per day should be encouraged to do physical activity
of higher intensity or for longer to increase the beneficial effect by
further improving their cardiorespiratory fitness.

**C** A gradual introduction and initial low intensity of physical
activity should be recommended for sedentary people with diabetes.

**C** Advice about physical activity should be individually tailored and
diabetes-specific and should include implications for glucose
management.

**C** To maximise adherence, physical activity programmes should be
accompanied by ongoing support and should include advice tailored to the
individual´s stage of change.

**GPP** Physical activity programmes should be acceptable and
appropriate for each individual. Many people may prefer home-based
programmes. Some people with diabetes may prefer community-based group
programmes, such as marae or church-based programmes.

**GPP** Green Prescription and Push Play resources may be useful (both
available at [www.pushplay.org.nz](http://www.pushplay.org.nz/)).

*Minimizing the Risks of Physical Activity*

**C** People with existing complications of diabetes should seek medical
review before embarking on exercise programmes.

**C** Physical activity for people with diabetes with coronary heart
disease should begin at a low intensity and gradually increase over
several weeks.

**B** Individuals with a history of cardiovascular disease should
consult their doctor before they undertake vigorous physical activity.
Vigorous activity is generally not encouraged in people with diabetes
with impaired left ventricular function, severe coronary artery disease,
recent myocardial infarction, significant ventricular arrhythmias, or
stenotic valve disease.

**C** Individualised advice on avoiding hypoglycaemia when exercising
should be given to people taking insulin, including adjustment of
carbohydrate intake, reduction of insulin dose, and choice of injection
site.

**GPP** Advice on the spread of carbohydrate intake and/or a reduction
of medication before planned exercise may be important for people with
diabetes on oral therapies (especially those on sulphonylureas).

**Smoking Cessation**

**A** All smokers should be encouraged to stop smoking. Smoking
cessation has major and immediate health benefits for smokers of all
ages.

**GPP** The recording of current and past smoking habits is recommended
as part of comprehensive diabetes management.

**A** Nicotine replacement therapy (NRT) is recommended as first-line
pharmacotherapy in New Zealand. Bupropion or nortriptyline hydrochloride
for smoking cessation are recommended as second-line agents.

**C** Use NRT cautiously (after discussion with a specialist) in the
immediate period post myocardial infarction (4 weeks) and in those with
serious arrhythmias or severe or worsening angina.

**C** Nortriptyline hydrochloride is contraindicated during the acute
recovery period after myocardial infarction.

**Depression and Life Stress in People with Diabetes**

**B** Health care practitioners should be aware of the effects of
depression in people with diabetes.

**B** All people with diabetes should be screened for depression and
offered appropriate therapy.

**B** Selective serotonin reuptake inhibitors are recommended in
preference to tricyclic antidepressants for treatment of depression in
people with diabetes.

**GPP** Health care practitioners should be aware of the potential
effects of life events on stress levels and self-care behaviour in
people with diabetes.

**Glycaemic Control**

**A** Good glycaemic control should be a key goal of treatment, to delay
the onset and progression of diabetic microvascular disease and
macrovascular disease.

*Target HbA1c Levels*

**D** The goal of treatment is to achieve an HbA1c as close to
physiologically normal as possible, preferably less than 7.0%. For each
patient the risk of hypoglycaemia must be considered when determining
the target HbA1c, especially people treated with insulin, particularly
those with type 1 diabetes.

**GPP** The lower the HbA1c level the better. Any sustained reduction of
HbA1c is worthwhile.

**GPP** For people on metformin and/or peroxisome proliferator-activated
receptor (PPAR)-γ agonists (glitazones) who have no risk of
hypoglycaemia, the target HbA1c should be as low as possible. The target
HbA1c that is achievable for people on insulin secretagogues
(sulphonylureas) or insulin is likely to be higher because of the risk
of hypoglycaemia.

**GPP** The target HbA1c for an individual should take into account:

-   side effects of therapy, particularly severe hypoglycaemia

-   other risk factors for diabetes complications, such as age, BMI,
    blood pressure, and lipid status

-   presence of complications of diabetes, or comorbidities

-   individual choice

-   psychosocial circumstances

*Risks of Tight Glycaemic Control*

**A** People with diabetes and health care practitioners should make
every effort to avoid severe hypoglycaemia.

**GPP** Health care practitioners should be aware that more intensive
glycaemic control treatment increases the risk of hypoglycaemia.

**GPP** The risks of tight glycaemic control should be weighed against
the expected benefits in terms of delayed onset and rate of progression
of complications for the individual.

**GPP** Tight glycaemic control may not be achievable or advisable in
some people with type 2 diabetes, including:

-   those who have frequent hypoglycaemic episodes

-   those with hypoglycaemic unawareness

-   those who are frail or have significant comorbidities

-   those at risk of severe hypoglycaemia who live alone or have poor
    social support

**Monitoring of Glycaemic Control**

**D** Self-monitoring of blood glucose should be considered in
conjunction with appropriate therapy as a part of integrated self-care.
The purpose of blood glucose self-monitoring should be clear and agreed
with the person with diabetes.

**D** Blood glucose self-monitoring should be taught by appropriately
trained staff.

**D** HbA1c should be measured 3 to 6 monthly. The frequency of testing
depends on:

-   acceptability of HbA1c levels

-   stability of self-monitored blood glucose results

-   changes in diabetes therapies

**D** HbA1c should be measured using a National Glycosylated Hemoglobin
Standardization Program certified method and results should be Diabetes
Control and Complications Trial (DCCT)-aligned.

**GPP** Despite improvements in the standardisation of HbA1c assays,
repeated testing in an individual should ideally be carried out at the
same laboratory, to permit the best comparison between serial results.

**Lifestyle Interventions Shown to Improve Glycaemic Control**

*Self-Management Education*

**GPP** People with diabetes should be offered self-management education
at diagnosis and then on an ongoing basis, based on formal regular
assessment.

**GPP** People with diabetes should be encouraged to accept
responsibility for self-management of their diabetes, including the
appropriate lifestyle interventions and changes necessary to achieve
good glycaemic control.

**Pharmacological Interventions to Achieve Glycaemic Control**

*Combination Therapy*

**B** When glycaemic control deteriorates to unsatisfactory levels on
maximum doses of current therapy, another therapy should usually be
added.\*

\*Grade of recommendation in Royal College of General Practitioners
guideline: **B** (adjustment not necessary).

*Metformin Therapy*

**A** Metformin should be considered as the first-line oral therapy in
overweight people (BMI \>25) with type 2 diabetes.

**GPP** Metformin should not be used in situations where lactic acidosis
is likely. Suggested contraindications and guidelines for withdrawing
metformin are (Jones, Macklin, & Alexander, 2003):

-   stop metformin therapy if serum creatinine is greater than or equal
    to 0.15 mmol/L\*

-   withdraw metformin during periods of suspected tissue hypoxia (e.g.,
    due to myocardial infarction, sepsis)

-   withdraw metformin for three days after contrast medium containing
    iodine has been given, and start treatment with metformin only after
    renal function has been checked

-   withdraw metformin two days before general anaesthesia and reinstate
    when renal function is stable

**GPP** Metformin can be used for people with type 2 diabetes who are
not overweight.

**GPP** Gastrointestinal intolerance to metformin is relatively common
when initiating therapy (10--15%). Stepwise upward titration of the
metformin dose over several weeks and taking metformin with food will
often minimise side effects.

\*Any concentration of creatinine that is chosen as a cut-off point for
renal failure will be arbitrary in view of individual peoples\' muscle
mass and protein turnover, and caution should therefore be used in
prescribing metformin for older people with diabetes.

*Use of Insulin Secretagogues*

**A** Insulin secretagogues can be considered as first-line therapy:

-   if metformin is not tolerated

-   if metformin is contraindicated

-   in people who are not overweight

**A** Insulin secretagogues should be used in combination therapy in
overweight people on metformin when glycaemic control is not
satisfactory on metformin alone.

**A** Both health care practitioners and people with diabetes using
insulin secretagogues should be aware of the risk of hypoglycaemia and
be alert for its occurrence.

*Alpha-Glucosidase Inhibitors*

**A** Acarbose may be considered as an alternative glucose lowering
therapy in people unable to use other oral drugs.

**GPP** Acarbose must be started in small doses and titrated gradually.

**GPP** In the unusual situation of hypoglycaemia in people on acarbose
therapy (used alone or in combination), the use of oral glucose rather
than sucrose or fructose is recommended, to achieve a rapid increase in
blood sugar level.

*Glitazone Therapy*

**A** Glitazone therapy can be considered for use in people with type 2
diabetes either as monotherapy or as combination therapy with either
metformin or a sulphonylurea. There are limited data available on the
safety of combined use with insulin.

**GPP** Glitazones should not be used in people with cardiac failure.

**GPP** After introduction of a glitazone, the effect on blood glucose
lowering may be delayed for at least 6 weeks.

*Insulin Therapy in Type 2 Diabetes*

**A** Insulin therapy should be offered to people with type 2 diabetes
inadequately controlled on optimised oral therapies.

**A** Insulin therapy can be used alone or in combination with oral
therapies.

**A** Health care practitioners and people with diabetes who are using
insulin should be aware of the risk of hypoglycaemia and be alert for
its occurrence.

**GPP** Insulin is often started with a once-daily dose of
intermediate-acting insulin, at night or in the morning, depending on
the individual\'s blood glucose profile. A once-daily nocturnal dose in
combination with continued oral medication is often a convenient way to
initiate insulin. A twice-daily or more intensive regime can also be
considered.

**GPP** It may be appropriate to consult a diabetes nurse specialist or
a diabetologist (or specialist physician) for advice when starting a
patient on insulin. Telephone advice may be sufficient.

**GPP** It is important to prepare people with type 2 diabetes, well in
advance, that insulin will almost certainly be required at some stage,
due to the progressive nature of the disease.

**GPP** For Maori and Pacific people with diabetes, it is particularly
important to prepare for the introduction of insulin well in advance and
to enquire about and address misconceptions about insulin therapy. A
common misconception, especially among older Maori and Pacific people,
is that starting insulin therapy means that one will die soon.

**Management of Children and Adolescents**

**GPP** Children and adolescents with type 2 diabetes should be under
the care of a specialist diabetes service.

**Diabetic Cardiovascular Disease**

**Cardiovascular Risk Assessment in People with Diabetes**

**C** Cardiovascular risk assessments are recommended annually from the
time of diagnosis for people with diabetes.

**C** Risk assessments should be provided at the primary care level by
health practitioners with appropriate training, infrastructure support,
systems for follow-up, and systems that improve quality.

**C** All those with cardiovascular disease should have comprehensive
risk factor measurements to determine the best management approach.

**Treatment Decisions**

**A** All treatment decisions should be based on an individual\'s 5-year
absolute cardiovascular risk.

**C** Everyone with risk factors should be involved in the
decision-making process regarding their treatment.

**C** The higher an individual\'s absolute risk of a cardiovascular
event the more aggressive management should be.

**A** Everyone with a history of a cardiovascular event and any risk
factor above optimal levels should be considered for treatment to reduce
their cardiovascular risk. Treatment should aim to lower the risk
factors to optimal levels.

**C** Everyone with isolated very high risk factor levels, either a
total cholesterol (TC) greater than 8 mmol/L or a TC:high-density
lipoprotein (HDL) ratio greater than 8 or blood pressure greater than
170/100 mm Hg should have drug treatment and specific lifestyle advice
to lower risk factor levels.

**A** Everyone with the specific genetic lipid disorders (familial
hypercholesterolaemia, familial defective apolipoprotein B (ApoB), or
familial combined dyslipidaemia) or diabetes with overt nephropathy
should be considered for treatment to reduce their cardiovascular risk.
Treatment should aim to lower the risk factors to optimal levels.

**A** Everyone with cardiovascular disease, a 5-year cardiovascular risk
of greater than 20%, genetic lipid disorders, diabetes, or the metabolic
syndrome should receive intensive lifestyle advice. Lifestyle changes
that have been shown to benefit people with these risk profiles include:

-   dietary change (**A**)

-   smoking cessation (**A**)

-   physical activity (**B**)

**A** Intensive dietary advice should be given in individual/group
sessions with a dietitian.

**C** People with a 5-year cardiovascular risk greater than 20% should
receive intensive lifestyle advice and drug treatment of all modifiable
risk factors simultaneously.

**C** People with a 5-year cardiovascular risk of between 15 and 20% are
likely to need treatment of all modifiable risk factors. Specific
lifestyle advice may be given for 3 to 6 months prior to drug treatment.

**C** Among people with a 5-year cardiovascular risk greater than 15%,
the aim of treatment is to lower 5-year cardiovascular risk to less than
15%.

**B** People with a 5-year cardiovascular risk between 10% and 20%
should receive specific lifestyle advice on a healthy cardioprotective
dietary pattern, physical activity, and smoking cessation from their
primary health care team. This advice should be followed for 3 to 6
months prior to considering drug treatment.

**C** People with a 5-year cardiovascular risk of less than 15% should
receive nonpharmacological approaches to treating multiple risk factors.

**B** People with a 5-year cardiovascular risk of less than 10% should
receive general lifestyle advice on a healthy cardioprotective dietary
pattern, physical activity, and smoking cessation.

**GPP** The order in which to start interventions should take into
account individual risk factor profiles, potential side effects, other
concurrent illness, adherence, personal preference, and cost. It is
appropriate to treat multiple risk factors simultaneously.

*Management of Blood Pressure*

**C** The higher the calculated cardiovascular risk, the more aggressive
the management of modifiable risk factors, including blood pressure,
should be.

**A** People presenting after an acute myocardial infarction should be
considered for a beta-blocker and angiotensin-converting enzyme
(ACE)-inhibitor regardless of blood pressure level, concurrently with
intensive lifestyle advice. This should be given in association with
other appropriate medication, such as aspirin and a statin.

**A** People presenting after an acute ischaemic stroke or transient
ischaemic attack should start blood pressure lowering medication unless
the person has symptomatic hypotension. This medication should be given
in addition to other appropriate medication, such as aspirin, a statin,
or warfarin, if indicated. Treatment should start concurrently with
intensive lifestyle advice. It is usually advisable to wait 7 to 14 days
before starting blood pressure lowering medication.

**C** Everyone with blood pressure consistently greater than 170/100 mm
Hg should have drug treatment and specific lifestyle advice to lower
risk factor levels.

**B** Within the blood pressure range 115/70 to 170/100 mm Hg, all
decisions to treat should be based on the individual\'s cardiovascular
risk.

**A** A cardioprotective dietary pattern is strongly recommended as an
integral component of blood pressure management.

**B** Dietary advice should include the limitation of both alcohol and
sodium consumption.

**B** Among people with a 5-year cardiovascular risk greater than 15%
the aim of treatment is to lower 5-year cardiovascular risk to less than
15%.

**A** Intensive blood pressure management is required (with early
consideration of an ACE-inhibitor) in all people with diabetes due to
the increased risk of renal complications.

**B** More than one drug is frequently required to lower blood pressure
to optimum levels.

**A** Aggressive blood pressure control is indicated in people with
diabetes and overt nephropathy, or diabetes and microalbuminuria, or
diabetes and other renal disease.

**A** People with diabetes and overt nephropathy or diabetes and
confirmed microalbuminuria should be started on an ACE-inhibitor or A2
receptor-blocker (if there are no contraindications) irrespective of
blood pressure levels.

**A** Most of the treatment benefit is achieved by reaching the
following blood pressure level:

130/80 mm Hg\* in people with diabetes or cardiovascular disease.

**GPP** A blood pressure lower than 130/80 mm Hg is preferable for
people with diabetes and overt nephropathy or diabetes with other renal
disease.

\*Where risk factor thresholds are given these should be interpreted as
approximate guides to clinical practice only.

*Management of Lipid Abnormalities*

**C** The higher the calculated cardiovascular risk, the more aggressive
the management of modifiable risk factors, including lipids, should be.

**A** People presenting after an acute cardiac event (myocardial
infarction or unstable angina) should start treatment with a statin
simultaneously with intensive lifestyle advice. Treatment should aim to
lower low-density lipoprotein-cholesterol (LDL-C) to less than 2.5
mmol/L.\* This should be given in association with other appropriate
medication such as aspirin, a beta-blocker, and an ACE-inhibitor.

**C** Lipids should ideally be measured at the time of the acute event.
Since the metabolic disturbance continues for 10 to 12 weeks after a
myocardial infarction, further measurements should be deferred for three
months.

**C** People presenting after an acute cardiac event with
hypertriglyceridaemia and a low HDL-C should be considered for a fibrate
or combination therapy.

**A** In people with venous coronary artery bypass grafting (CABG),
treatment should aim to lower the total cholesterol to less than 3.5
mmol/L and LDL-C to less than 2.0 mmol/L.\*

**B** Most people presenting after an ischaemic stroke or transient
ischaemic attack should start treatment with a statin.

**C** Everyone with a total cholesterol greater than 8 mmol/L or TC:HDL
ratio greater than 8\* should have drug treatment and specific lifestyle
advice to lower risk factor levels.

**B** Within the range of total cholesterol 4 to 8 mmol/L, all decisions
to treat should be based on the individual´s cardiovascular risk.

**B** People with low HDL-C and elevated triglycerides with a 5-year
cardiovascular risk greater than 15% should be treated with intensive
lifestyle interventions and are likely to need treatment with a fibrate
or combination drug therapy.

**A** A cardioprotective dietary pattern is strongly recommended as an
integral component of lipid management.

**B** Dietary advice should be tailored to the individual\'s risk factor
and lipid profile.

**B** Among people with a 5-year cardiovascular risk greater than 15%,
the aim of treatment is to lower 5-year cardiovascular risk to less than
15%.

**C** LDL-C should be used as the primary indicator of optimum lipid
management and should be used to monitor lipid-modifying treatment.

\*Where risk factor thresholds are given, these should be interpreted as
approximate guides to clinical practice only.

*Antiplatelet Therapy for People with Diabetes*

**A** Everyone with a 5-year cardiovascular risk greater than 15% should
be started on low-dose aspirin (75--150 mg/day) if there are no
contraindications.

**A** Aspirin is contraindicated in people with aspirin allergies or
intolerance, active peptic ulceration, uncontrolled blood pressure and
in people with other major bleeding risks.

**C** In people with diabetes who have a stroke, a computed tomography
(CT) scan should be performed prior to aspirin therapy to exclude
intracranial haemorrhage.

**Monitoring and Duration of Treatment for Cardiovascular Risk**

**GPP** Lifelong treatment is advised for people with diabetes.

**GPP** People with diabetes receiving medication should have their
lipids and blood pressure, glycaemic control, diet, and activity level
monitored every 3 months until adequate control is achieved, then every
6 months.

**Complementary and Alternative Therapies**

**GPP** Clinicians should enquire about the use of alternative and
complementary medicines when assessing cardiovascular risk or
prescribing medication.

**I** There is insufficient evidence to recommend the following
complementary and alternative therapies for the treatment or prevention
of cardiovascular disease:

-   herbal medicines, botanicals (Lin et al., 2001)

-   garlic (Banerjee & Maulik, 2002; Beaglehole, 1996; Neil et al.,
    1996)/ginkgo biloba/rosemary/horse-chestnut seeds/xin bao

-   acupuncture (Lin et al., 2001)

-   chelation (Villarruz, Dans, & Tan, 2002)

-   oriental medicine

-   aromatherapy

-   homeopathy

-   hypnosis

-   meditation

-   yoga/tai chi

-   intercessory prayer

-   Strauss heart drops (Aviles et al., 2001)

**C** Feverfew, garlic, ginkgo biloba, ginger, and ginseng may alter
bleeding time and should not be used concomitantly with warfarin (Miller
et al., 1998).

**C** St John\'s wort reduces serum digoxin levels and can enhance the
metabolism of Warfarin (Ernst, 1999).

**C** Herbs (e.g., karela and ginseng) may affect blood-glucose levels
and should not be used in people with diabetes (Miller et al., 1998).

**Diabetic Renal Disease**

**Risk of Diabetic Renal Disease**

*Blood Pressure Control*

**A** Good blood pressure control should be maintained in all people
with type 2 diabetes to reduce the risk of developing diabetic renal
disease.

**B** The target blood pressure should be less than 130/80 mm Hg.

**GPP** While a blood pressure less than 130/80 mm Hg is preferable, any
sustained reduction in blood pressure is beneficial.

*Glycaemic Control*

**A** Both the risk of developing diabetic renal disease and the rate of
progression of diabetic renal disease are reduced by maintaining good
glycaemic control.

**GPP** While the optimal HbA1c level is ideally as close to
physiologically normal as possible, preferably less than 7%, any
sustained reduction is beneficial.

**GPP** Health care practitioners should be aware that the risk of
developing diabetic renal disease is higher if multiple risk factors are
present.

**GPP** The prevalence of all stages of diabetic renal disease is
increased in Maori, Pacific peoples, and people of Asian descent. More
frequent monitoring of renal status may be prudent in people with
diabetes from these ethnic groups.

**Screening for Diabetic Renal Disease**

**D** All people with diabetes should have their urinary albumin
concentration and serum creatinine measured at diagnosis. For people
with no microalbuminuria and normal serum creatinine, these tests should
be repeated at least annually. Refer to the following good practice
point for exceptions.

**D** Urinary albumin:creatinine ratio should be measured by a
laboratory method where possible. If access to a laboratory is limited,
a near-patient test specific for albumin at low concentration may be
used, but a positive result must be confirmed by laboratory testing.

**D** Urinary albumin:creatinine ratio should be measured using a first
morning urine sample where possible; otherwise a random urine sample may
be used.

**D** An abnormal initial test requires confirmation by at least one
further test.

**GPP** People with urinary albumin:creatinine ratio greater than or
equal to 30 mg/mmol (indicating overt diabetic nephropathy or
proteinuria) and/or with serum creatinine greater than or equal to 0.15
mmol/L or a calculated glomerular filtration rate (GFR) of less than 60
ml/min/1.73m^2^ should be considered for referral to a specialist.
Further testing for microalbuminuria is not indicated in this group.

**Preventing Progression of Diabetic Renal Disease**

*Blood Pressure Control*

**A** Aggressive blood pressure control is indicated in people with type
2 diabetes who have diabetic renal disease.

**GPP** A blood pressure lower than 130/80 mm Hg is preferable for
people with type 2 diabetes and diabetic renal disease.

**GPP** The majority of people with type 2 diabetes who have diabetic
renal disease will require more than one antihypertensive agent in order
to achieve target blood pressure levels.

*Drug Therapy*

**A** People with type 2 diabetes and confirmed microalbuminuria or
overt diabetic nephropathy, should be started on an ACE-inhibitor or an
A2 receptor-blocker (if there are not contraindications) irrespective of
blood pressure levels.

**GPP** In the presence of significant bilateral renal artery stenosis,
ACE-inhibitor therapy is associated with acute renal failure and should
not be used.

**GPP** ACE-inhibitors should be used with caution in people with raised
serum creatinine. Serum creatinine should be checked one week after
starting ACE-inhibitor therapy. An increase in serum creatinine of up to
25% above baseline is not, by itself, an indication to stop
ACE-inhibitor therapy. However, a continued rise in serum creatinine may
signify renal artery stenosis, and should be investigated promptly.

*Management of Cardiovascular Disease*

**GPP** People with diabetic renal disease should have their
cardiovascular risk factors managed in the same way as people with
established coronary disease (beta-blockers, ACE-inhibitor therapy,
aspirin, lipid-lowering therapy, and smoking cessation).

**Referral**

**GPP** Referral to a specialist for an opinion or specialist management
should be considered for people with type 2 diabetes if:

-   serum creatinine greater than or equal to 0.15 mmol/L

-   calculated GFR less than 60 ml/min/1.73 m^2^

-   rapid increase in level of microalbuminuria or proteinuria

-   difficulty in achieving blood pressure targets

-   in situations where nondiabetic renal disease may be present or may
    coexist with diabetic renal disease:

    -   absence of diabetic retinopathy in a person with diabetic renal
        disease

    -   urinary abnormalities such as haematuria or casts (once
        infection has been excluded as the cause)

**Diabetic Eye Disease**

**Preventing the Development and Progression of Diabetic Eye Disease**

**A** Both glycaemic control and blood pressure control should be
maintained to prevent the onset and progression of diabetic eye disease
(retinopathy).

**B** People with multiple risk factors should be considered at
particularly high risk of developing diabetic retinopathy.

**GPP** As type 2 diabetes may be present for many years before
diagnosis, health care practitioners should be aware that retinopathy is
often present at the time of diagnosis.

**GPP** Health care practitioners should be aware that Maori and Pacific
people with type 2 diabetes are overrepresented among those with
retinopathy.

**Screening for Diabetic Retinopathy**

**B** Systematic screening for diabetic retinopathy should be provided
for all people with diabetes.

**A** People with type 2 diabetes should be screened for diabetic
retinopathy from the time of diagnosis.

**C** Retinal photography or slit lamp biomicroscopy carried out by
credentialled personnel should be used in a programme of systematic
screening for diabetic retinopathy.

**B** People with ungradable retinal photographs should be examined by
slit lamp biomicroscopy.

**B** Screening should occur at least every two years. For people with
no retinopathy, 2-yearly screening is acceptable, but the number and
severity of risk factors may indicate a shorter screening interval.

**GPP** All people with any degree of diabetic retinopathy should be
under the supervision of an ophthalmologist, who can specify the
appropriate monitoring interval for an individual, taking other risk
factors into account.

**GPP** People with diabetes who present with symptomatic visual loss
require assessment and examination by an ophthalmologist and are not
candidates for screening.

**GPP** While visual acuity should be checked in all people with
diabetes, health care practitioners should be aware that normal visual
acuity does not preclude the presence of sight-threatening retinopathy.

**Interventions**

**A** Good glycaemic control (HbA1c preferably as close to
physiologically normal as possible, ideally \<7%) and good blood
pressure control (\<130/80 mm Hg) should be the goals, to prevent the
onset and progression of diabetic eye disease.

**B** Any improvement in both glycaemic control and blood pressure
control is beneficial for reducing the risk of onset and progression of
diabetic eye disease, even if ideal target levels are not achievable for
an individual patient.

**A** All people with diabetes with sight-threatening diabetic
retinopathy or sight-threatening macular oedema should receive laser
photocoagulation.

**B** Cataract extraction should not be delayed in people with diabetes
who have coexisting diabetic retinopathy. Cataract extraction is
advisable when sight-threatening retinopathy cannot be excluded due to
the presence of the cataract.

**GPP** An ophthalmologist should assess people with diabetes who have
cataracts, to determine the optimum time for cataract removal.

**Diabetic Foot Disease**

**Screening for Diabetic Foot Disease**

**D** All people with diabetes should be screened for foot disease by a
health care practitioner. Screening should occur from the time of
diagnosis, then at least annually, if there are no features indicating a
high risk foot. More frequent examination (3--6 monthly) should occur if
there are features of a high-risk foot.

*Assessment of the Diabetic Foot*

**C** Both 10-g monofilament and vibration perception thresholds (using
a biothesiometer) are appropriate methods for neuropathy screening.

**GPP** Assessment for high risk feet in people with diabetes by a
health care practitioner should always include:

-   direct visual inspection

-   assessment for peripheral neuropathy

-   assessment for peripheral arterial disease

**GPP** A 10-g monofilament is a convenient and cost-effective way to
assess for peripheral neuropathy. Monofilaments should be cleaned and
replaced regularly according to manufacturer\'s recommendations.

**General Management of Diabetic Foot Disease**

**B** Foot care education is recommended as part of a multidisciplinary
approach in all people with diabetes.

**C** People with diabetes and high-risk feet should be referred to a
specialist diabetic foot clinic or multidisciplinary foot care team,
where one is available. If access to a foot clinic is not possible,
people with high-risk feet should be under the care of a podiatrist.

**B** People with diabetic foot disease should be advised to wear
high-quality, cushioned soled running or sports shoes rather than
ordinary shoes.

**B** In people with high-risk feet, deformity, or previous amputation,
custom-built footwear or orthotic insoles should be used to reduce
callus severity and ulcer recurrence.

**GPP** Health care practitioners should be aware that the cost of
appropriate off-the-shelf footwear and of consulting a podiatrist to get
custom-made orthoses may be a barrier for many people with diabetes.

**GPP** The ability of the person to undertake regular foot self-care
and self-assessment should also be assessed by the health care
practitioner.

*Total Contact Casting*

**B** People with diabetes who have unilateral neuropathic plantar
ulcers should be considered for treatment using total contact casting to
optimise the healing rate of ulcers.

**GPP** Podiatrists or plaster technicians appropriately trained in
total contact casting technique, and preferably part of a specialist
diabetic foot clinic, are the appropriate people to carry out this
treatment.

*Arterial Revascularization*

**B** All people with diabetic foot disease with tissue loss and
arterial disease should be referred for consideration of arterial
revascularisation procedures.

*Treatment of Foot Ulcers*

**GPP** Treatment of a clinically infected diabetic foot ulcer should be
commenced with a broad spectrum antibiotic regimen in conjunction with
appropriate debridement. Subsequent antibiotic regimens may be modified
based on the swab culture and sensitivity results.

**GPP** Intravenous antibiotics are indicated in the presence of
cellulitis or osteomyelitis, and prompt referral to hospital is required
in these circumstances.

**GPP** Wound dressings for diabetic foot ulcers should be chosen with
consideration of clinical experience, cost, patient preference, and the
site of the wound.

**GPP** Wounds should be closely monitored, and dressings changed
regularly.

*Management of Painful Diabetic Neuropathy*

**A** For more severe neuropathic pain, tricyclic antidepressants are
indicated. The starting dose should be low and titrated upwards until
adequate pain relief is achieved.

**B** Gabapentin is effective in painful diabetic neuropathy that is
unresponsive to tricyclic antidepressant or anticonvulsant therapy and
is associated with fewer side effects than tricyclic antidepressants and
older anticonvulsants.

**A** Topical capsaicin should be considered for the relief of localised
neuropathic pain.

**GPP** For mild neuropathic pain, simple analgesia (such as
paracetamol) should be used as first-line therapy.

**GPP** Carbamazepine is another therapy to consider for more severe
neuropathic pain.

*Charcot\'s Foot*

**C** Diagnosis of Charcot\'s foot should be made by clinical
examination, supported by appropriate investigations.

**D** Total contact casting and non-weightbearing are effective
treatments for acute Charcot\'s foot.

**GPP** People with suspected Charcot\'s foot should be referred for
urgent specialist advice.

**Diabetic Foot Disease in Maori and Pacific People**

**GPP** Maori and Pacific people with diabetes are at high risk for
diabetic foot disease and amputation.

**GPP** Health care practitioners should be aware of the following:

-   It is culturally insensitive to expect Maori to wear outdoor shoes
    inside the house. A slipper with a rigid sole may provide some
    protection and be an acceptable alternative.

-   It may be appropriate to explain the need for more frequent
    vacuuming or sweeping of floors (to reduce the chances of minor
    trauma occurring) and for daily foot examination (by the person with
    diabetes or a relative).

-   Explain carefully the need for supportive, well-fitting shoes rather
    than jandals or sandals when outdoors.

-   Feet should not be placed on a pillow for examination or treatment.

-   Nails and wound debris should be disposed of appropriately. Find out
    the person\'s preference. They may prefer to dispose of nail
    clippings/debris themselves or may agree for the health care
    practitioner to dispose of them.

**GPP** For Pacific people with diabetes, health care practitioners
should:

-   explain carefully the need for supportive, well-fitting shoes rather
    than jandals or sandals when both indoors and outdoors

-   negotiate an acceptable plan of regular and continuing foot care
    with each individual

**Maori Perspectives**

**Treating a Maori Person with Type 2 Diabetes**

**GPP** Always treat the person with diabetes and their whanau. If the
person agrees, encourage whanau to come to appointments. Education,
dietary advice, and lifestyle advice should always include whanau.

**GPP** Be sensitive to different styles of communication and to Maori
protocol. Appropriate communication is very important.

**GPP** Consider that socioeconomic circumstances are likely to be
difficult. Consultation fees, medication costs, and access to transport
or a telephone may be issues.

**GPP** Find out what the person\'s attitudes and beliefs are concerning
their diabetes and their ability and willingness to implement change.
Find out what the barriers to change are for that individual and whanau,
and negotiate the changes that are possible and achievable. Expectations
of dietary change need to be realistic and culturally acceptable.

**GPP** Maori with diabetes may prefer to see Maori providers.

**Pacific Perspectives**

**Treating a Pacific Person with Type 2 Diabetes**

**GPP** Always treat the Pacific person with diabetes as part of their
family. If the person agrees, encourage family members to come to
appointments. Family members should always be involved in diabetes
self-management, including dietary and lifestyle management.

**GPP** Recognise that each of the Pacific groups is unique. Each island
group has specific characteristics which makes it different from its
Pacific neighbours even though there are general similarities. The
approach to the Pacific person should be specific depending on his or
her origin.

**GPP** Consider that socioeconomic circumstances are likely to be
difficult. There may be financial obligations (to the family and church)
that may take priority over personal and health needs. Other issues may
include difficulties with access to transport or to a telephone.

**GPP** Find out what the person\'s attitudes and beliefs are concerning
their diabetes, and their ability and willingness to implement change.
Find out what the barriers to change are for that individual. Negotiate
the changes that are possible and achievable. Modification of diet
should be realistic and culturally acceptable.

**GPP** Be aware that language is a barrier. When English is a second
language, colloquial English may be excellent. Encourage a bilingual
family member or practice nurse to assist with translation. Ideally,
Pacific Island ethnic specific translators should be made available to
services that provide for Pacific peoples.

**GPP** Pacific people with diabetes may prefer to see Pacific
providers. Rapport, trust, and building a relationship with the Pacific
person with diabetes is a core part of a diabetes service that is
usually more readily achieved by a Pacific provider. Pacific providers
in the area are a valuable resource and should be consulted for advice
on approaches to management of diabetes in Pacific peoples.

**Definitions**:

**Rating Scheme for the Strength of the Recommendations**

**A**

The recommendation is supported by good evidence.

**B**

The recommendation is supported by fair evidence.

**C**

The recommendation is supported by non-analytic studies or consistent
expert opinion.

**I**

The evidence is insufficient, evidence is lacking, of poor quality or
opinions conflicting, the balance of benefits and harms cannot be
determined.

**Good Practice Point (GPP)**

Recommended practice based on the clinical experience of the Guideline
Development Team

#### CLINICAL ALGORITHM(S)

The original guideline document provides the following clinical
algorithms:

-   Stepwise approach to glycaemic control

-   Cardiovascular risk assessment for people with diabetes

-   Identifying and managing diabetic renal disease

-   Identifying and preventing visual impairment and blindness

-   Preventing active foot problems and lower limb amputation

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=4562)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

As the diabetes literature is extensive and three sets of international
guidelines had been rigorously and systematically developed, it was
agreed that the New Zealand Management of Type 2 Diabetes Guideline
would be an adaptation of some sections of these international
guidelines. Where issues were specific to New Zealand, such as issues
for Maori and Pacific people with diabetes, a literature search was
undertaken, using the Scottish Intercollegiate Guidelines Network (SIGN)
search strategies, looking for new evidence that had emerged since the
publication of the international guidelines. This search was done in May
2003. No papers were identified which changed any recommendations.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Prevention**

In people with impaired glucose tolerance (IGT), three randomized
controlled trials have shown that prevention or delay in the onset of
diabetes is possible through lifestyle interventions (dietary changes
and increased exercise levels). The incidence of diabetes was reduced by
up to 58% in the lifestyle intervention group compared to the control
group. Although less effective, treatment with metformin has also been
shown to prevent progression from IGT to diabetes.

*Preventive Foot Care*

Although the literature on economic studies of preventive foot care
practices was limited, research suggests that aggressive, proactive care
may result in fewer lower extremity amputations and be cost-effective
and possibly cost-saving.

**Diet**

A cardioprotective dietary pattern lowers blood pressure, improves the
lipid profile and glycaemic control, and reduces the risk of clotting.

**Physical Activity**

Regular physical activity is associated with reduced risk of
cardiovascular disease morbidity and mortality.

**Glycaemic Control**

-   Tight glycaemic control reduces the risk of and slows the
    progression of microvascular and macrovascular complications.

-   Remission of depression is often associated with an improvement in
    glycaemic control.

**Blood Pressure Control**

-   Optimum blood pressure control, below 130/80 mm Hg, reduces the risk
    of and slows the progression of microvascular and macrovascular
    complications.

-   Achieving an average blood pressure of 144/82 mm Hg reduced costs
    and improved health outcomes relative to moderate hypertension
    control (154/86 mm Hg). Control of blood pressure below 150/85 mm Hg
    was found to reduce the cost of complications, and had a
    cost-effectiveness ratio that compared favourably with many accepted
    health care programmes

**Smoking cessation**

Smoking cessation has major and immediate health benefits for smokers of
all ages. Former smokers have fewer days of illness, fewer health
complaints, and view themselves as healthier. Within one day of
quitting, the risk of having a myocardial infarction is reduced. The
excess risk of heart disease is reduced by half after one year\'s
abstinence. The risk of a coronary event reduces to the level of a never
smoker within 5 years. In those with existing heart disease, cessation
reduces the risk of recurrent infarction or mortality by half.

**Medication**

-   Treatment with an ACE-inhibitor decreases the risk of cardiovascular
    disease complications in people with type 2 diabetes.

-   Beta-blockers are widely used in people with type 2 diabetes and
    have been shown to have a cardioprotective benefit in people with
    diabetes and cardiovascular disease.

#### POTENTIAL HARMS

**Risks of Physical Activity**

*Hypoglycaemia*

Physical activity with normal insulin dose and no additional
carbohydrates significantly increases the risk of hypoglycaemia during
and after exercise. If physical activity can be anticipated, a reduction
of the normal insulin dose (by up to 65% for vigorous physical activity
of up to 45 minutes) will significantly reduce the risk of hypoglycaemia
and delayed hypoglycaemia.

Injecting insulin into active muscle increases its absorption and the
risk of hypoglycaemia and should therefore be avoided. High temperatures
can also increase insulin absorption. This should be taken into
consideration in hot climates. A further reduction in insulin dose may
be required. People using oral antidiabetic drugs, such as
sulphonylureas, may also be at risk of hypoglycaemia during physical
activity.

*Myocardial Infarction or Sudden Death*

There is a small, transient increase in risk of myocardial infarction or
sudden death with vigorous activity in people with coronary heart
disease who do not undertake regular physical activity. The risk of
myocardial infarction was found to be approximately six times higher
during vigorous physical activity compared to the risk at rest. The
level of risk with vigorous activity depends on the individual´s
baseline level of physical activity. Assessing risk prior to starting a
physical activity programme and by beginning with exercise of a low
intensity and steadily increasing duration and intensity over a couple
of weeks, reduces this risk.

**Risks of Glycaemic Control**

The major risk of tight glycaemic control is hypoglycaemia. In the
Diabetes Control and Complications Trial (DCCT) study of type 1
diabetes, the intensive treatment group had a three times greater risk
of severe hypoglycaemia than the standard treatment group. Among people
with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS), major
hypoglycaemic episodes occurred in 0.7% treated with diet alone, 1.0% on
chlorpropamide, 1.4% on glibenclamide, and 1.8% on insulin. There is
increasing evidence to suggest that, in people on multiple daily insulin
injections, the use of insulin infusion pumps results in fewer severe
hypoglycaemic episodes, while achieving similar overall levels of
glycaemic control.

Another common adverse outcome of intensive glycaemic control treatment
is weight gain, which is greater in people on insulin than on oral
hypoglycaemic agents. In the UKPDS, mean weight gain was significantly
greater (3.1 kg at 10 years) in the intensive treatment group compared
with the conventional treatment group. Compared with the conventional
treatment group, people assigned insulin had a greater weight gain (4.0
kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7
kg). Weight gain is less with metformin treatment compared with insulin
or sulphonylureas.

Rapid improvement of glycaemic control can occasionally result in
short-term worsening of diabetic retinal disease and can occasionally
exacerbate symptoms of neuropathic pain in the lower limb. However,
long-term outcomes (after one year) remain beneficial.

**Dietary Intervention**

Attempts to lower risk without investigating dietary habits and weight
history may result in the need to use larger doses of medications or
combinations of medications due to inappropriate food choices and
sedentary behaviours. This contributes to the increased risk of side
effects and adverse drug interactions.

**Medication**

-   Regular use of aspirin (at a dose of \<300 mg/day) is associated
    with around a 2-fold increased risk of upper gastrointestinal
    bleeding (or perforation).

-   Treatment side effects

    -   Biguanides (metformin): Gastrointestinal symptoms (diarrhoea),
        lactic acidosis (very rare)

    -   Sulphonylureas (Insulin Secretagogues): hypoglycaemia

    -   Glitazones (peroxisome proliferator-activated receptor
        \[PPAR\]-γ agonists): weight gain, fluid retention, mild
        dilutional anaemia

    -   Alpha-glucosidase inhibitors: gastrointestinal symptoms

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Metformin\'s main contraindications are when serum creatinine
    [\>]{.underline}0.15 or creatinine clearance \<60 ml/sec, or there
    is significant liver impairment or severe left ventricular
    dysfunction.

-   Glipizide, gliclazide, glibenclamide, and tolbutamide are
    contraindicated when there is significant liver impairment.

-   Rosiglitazone is contraindicated during cardiac failure and should
    not usually be considered in combination with insulin therapy.

-   Nortriptyline hydrochloride is contraindicated during the acute
    recovery period after myocardial infarction.

-   Suggested contraindications and guidelines for withdrawing metformin
    are:

    -   stop metformin therapy if serum creatinine is greater than or
        equal to 0.15 mmol/L\*

    -   withdraw metformin during periods of suspected tissue hypoxia
        (e.g., due to myocardial infarction, sepsis)

    -   withdraw metformin for three days after contrast medium
        containing iodine has been given, and start treatment with
        metformin only after renal function has been checked

    -   withdraw metformin two days before general anaesthesia and
        reinstate when renal function is stable

-   Aspirin is contraindicated in people with aspirin allergies or
    intolerance, active peptic ulceration, or uncontrolled blood
    pressure and in people with other major bleeding risks.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Evidence-based best practice guidelines are produced to help health
    care practitioners and consumers make decisions about health care in
    specific clinical circumstances. Research has shown that if properly
    developed, communicated, and implemented, guidelines can improve
    care. While they represent a statement of best practice based on the
    latest available evidence (at the time of publishing), they are not
    intended to replace the health care practitioner´s judgment in each
    individual case.

-   These guidelines are to be used in conjunction with the New Zealand
    guideline for *The Assessment and Management of Cardiovascular Risk*
    which recommends that, as part of a cardiovascular risk assessment,
    a fasting plasma glucose is performed. These risk assessments are
    recommended 10 years earlier in those people at risk of developing
    diabetes. A summary of the relevant sections of that guideline is
    included where appropriate, specifically in the chapters on
    lifestyle management and diabetic cardiovascular disease. The
    complete guideline, *The Assessment and Management of Cardiovascular
    Risk* can be found at [www.nzgg.org.nz](http://www.nzgg.org.nz/)

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The Guideline Development Team recommended that multi-faceted strategies
be adopted to disseminate this guideline widely and encourage its use
throughout New Zealand. The guideline will be integrated into the
Ministry of Health´s existing free annual check programme for diabetes.
A number of strategies for managing cardiovascular risk and assessing
people at risk of developing diabetes are also identified in the
guideline for the assessment and management of cardiovascular risk. This
guideline is available at [www.nzgg.org.nz](http://www.nzgg.org.nz/).

**Dissemination of the Guideline**

The guideline should be disseminated as widely as possible. In addition
to making the complete guideline and guideline summaries available on
the New Zealand Guidelines Group website at
[www.nzgg.org.nz](http://www.nzgg.org.nz/), copies of the guideline
should be sent to the following key groups:

-   general practitioners

-   primary health care nurses

-   Independent Practitioner Associations and Primary Health
    Organisations

-   Maori health providers

-   Pacific health providers

-   Diabetes New Zealand Inc and affiliated diabetes societies

-   District Health Boards

-   local diabetes teams

-   disease state management nurses

-   diabetologists and specialist physicians

-   diabetes nurse educators and specialists

-   dietitians

-   podiatrists

-   renal physicians

-   ophthalmologists

-   optometrists

-   final year medical students

**Education**

Opportunities for education using this guideline include:

-   publication of a summary of key guideline recommendations in a
    weekly magazine with a general practitioner readership

-   working with relevant organisations to promote and facilitate
    educational programmes. The New Zealand Guidelines Group, with the
    support of the Ministry of Health, will work closely with District
    Health Boards, local diabetes teams, and Primary Health
    Organisations on implementation of the guideline in each region.

-   working with organisations (such as the New Zealand Family Physician
    journal) to prepare continuing medical education (CME) case studies
    and CME points-rewarded questionnaires for general practitioners,
    based on the guideline.

-   developing a facilitator\'s pack, suitable for use in regional
    continuing education targeted at specific groups (such as general
    practitioners, primary health care nurses, pharmacists, podiatrists,
    dietitians, and diabetes consumer organisations).

-   working together with Maori and Pacific stakeholders, to ensure that
    all resources based on the guideline for Maori and Pacific people
    with diabetes are appropriate, acceptable, and can be implemented.
    Examples include developing links with Maori provider organisations,
    Pacific provider organizations, and Pacific Island churches.

**Tools**

Various tools to facilitate the use of this guideline could be
developed, such as:

-   incorporation of the guideline recommendations into electronic
    decision support systems such as PREDICT and general practitioner
    practice management systems (e.g., Med Tech 32, Houston and
    IntraHealth). The systems would provide prompts to users based on
    the guideline recommendations and allow practitioners to generate
    letters specifically for individuals with diabetes.

-   personal management plans for people with type 2 diabetes, which
    might contain individualized targets, current drug treatment, and
    key messages regarding diet, physical activity, smoking cessation,
    and preventive care.

-   development of an interactive tool that could be situated on both
    the New Zealand Guidelines Group and the Diabetes New Zealand Web
    sites. The tool would allow people with diabetes to enter results of
    blood tests, for example, and then get a comment or advice based on
    the guideline. Other options include quizzes, for example a quiz on
    preventive foot care, eye care or diabetic renal disease.

**Effective Implementation**

Changes in clinical practice resulting from the implementation of these
guidelines should be monitored. While different aspects of the guideline
implementation can be monitored and evaluated, data collected through
the national \"Get Checked\" programme could be utilised to this end.
The Ministry of Health is currently revising diabetes indicators
collected in primary care and collated by Primary Health Organisations
or Independent Practitioners Associations. The proposed revised
indicators are listed in Appendix G in the original guideline document.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Management of type 2 diabetes.
Wellington (NZ): New Zealand Guidelines Group (NZGG); 2003 Dec. 143 p.
\[565 references\]

#### ADAPTATION

As the diabetes literature is extensive and three sets of international
guidelines had been rigorously and systematically developed, it was
agreed that the New Zealand Management of Type 2 Diabetes Guideline
would be an adaptation of some sections of these international
guidelines.

These guidelines were:

-   Scottish Intercollegiate Guidelines Network (SIGN). Management of
    Diabetes (2001)

-   Royal College of General Practitioners (UK). Clinical guidelines and
    evidence review for type 2 diabetes. Four guidelines: foot problems,
    retinopathy, blood glucose management, renal disease (2000-2002)

-   Diabetes Australia Guideline Development Consortium. National
    evidence-based guidelines for the management of type 2 diabetes
    mellitus -- various draft guidelines available for public
    consultation. Guideline considered: foot disease (2001).

#### DATE RELEASED

2003 Dec

#### GUIDELINE DEVELOPER(S)

New Zealand Guidelines Group - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

Ministry of Health

#### GUIDELINE COMMITTEE

Guideline Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Team Members*: Dr Patrick Manning (*Chair*), Endocrinologist, Dunedin
Hospital, Dunedin\*; Ms Angela Bayley, Podiatrist, Wellington; Dr
Kirsten Coppell (*Project Manager 2003*), Public Health Physician,
Dunedin\*; Ms Marilyn Cullens, Senior Dietitian, Diabetes Centre,
Christchurch; Dr Rick Cutfield, Diabetologist, Waitemata Health,
Auckland\*; Mr Murray Dear, Vice-President, Diabetes New Zealand,
Consumer representative, Hamilton; Dr Mark Donaldson, Ophthalmologist,
Clinical Senior Lecturer, Discipline of Ophthalmology, University of
Auckland, Auckland; Dr Paul Drury, Diabetologist, Auckland Diabetes
Centre, Auckland; Ms Betty Dunn, Registered Nurse, Practice Nurse,
Whangarei; Dr Andrew MacGill, General Practitioner, Warkworth; Dr
Krishan Madhan, Renal Physician, Taranaki Base Hospital, New Plymouth;
Dr Justine Mesui, General Practitioner, Pacific peoples´ representative,
Auckland; Ms Luana Murray, President, Te Roopu Mate Huka O Aotearoa,
Maori consumer representative, Kaitaia; Dr Diana North, Medical
Director, National Heart Foundation of New Zealand, Auckland\*\*; Ms
Helen Pahau, Registered Nurse, Diabetes Nurse Specialist, Maori
representative, Gisborne; Dr Robert Scragg, Epidemiologist, Senior
Lecturer, Department of Community Health, University of Auckland,
Auckland; Ms Mary Sievers, Registered Nurse, Diabetes Nurse Specialist,
Waitemata Health, Auckland; Dr Mark Webster, Cardiologist, Greenlane
Hospital, Auckland\*\*; Dr Cathy Pikholz (*Project Manager until
December 2002*), Public Health Medicine Registrar, New Zealand
Guidelines Group, Auckland

\*Indicates team members who developed the original Primary Care
Guidelines for the Management of Core Aspects of Diabetes Care (1998).

\*\*Dr North and Dr Webster were also on the Guideline Development Team
for the Assessment and Management of Cardiovascular Risk guideline and
focused on areas common to both guidelines.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Declaration of Competing Interests**

Ms **Marilyn Cullens** has received funding to attend conferences or for
laboratory test kits for research purposes from:

-   Eli Lilly

-   Novartis

-   Abbott Laboratories

Ms **Angela Bayley** has received funding to attend conferences from:

-   Convatec

-   NZ Diabetes Foundation

-   NZ Society of Podiatrists

Dr **Rick Cutfield** has received funding to attend conferences or
advisory board meetings from:

-   Merck Sharp and Dohme

-   GlaxoSmithKline

-   Eli Lilly

Dr **Paul Drury** has received funding or consultation fees for clinical
trials, to attend meetings, and for delivering lectures from:

-   NovoNordisk

-   Servier

-   Eli Lilly

-   NHMRC Australia (the FIELD Study)

-   Pharmacia

-   The Direct Study

-   GlaxoSmithKline

-   Bristol-Myers Squibb

-   Ministry of Health, New Zealand

-   PHARMAC Sub-Committee on Diabetes

Ms **Mary Sievers** has received funding to attend a conference from
NovoNordisk.

The other members of the Guideline Development Team did not report any
competing interests.

#### ENDORSER(S)

Australasian Faculty of Public Health Medicine - Professional
Association\
Cardiac Society of Australia and New Zealand - Disease Specific Society\
Nurses Society of New Zealand - Professional Association\
Royal Australasian College of Physicians - Professional Association\
Royal College of Pathologists of Australasia\
Royal New Zealand College of General Practitioners - Medical Specialty
Society\
Sports & Recreation New Zealand - Professional Association\
Stroke Foundation of New Zealand, Inc. - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[New Zealand Guidelines Group Web
site](http://www.nzgg.org.nz/guidelines/0036/Diabetes_full_text.pdf).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   New Zealand Guidelines Group (NZGG). General summary management of
    type 2 diabetes. Wellington (NZ): New Zealand Guidelines Group
    (NZGG); 2003 Dec. 10 p. Available from in Portable Document Format
    (PDF) from the [New Zealand Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/0036/Diabetes_summary.pdf).

-   New Zealand Guidelines Group (NZGG). Evidence-based guidelines for
    management of type 2 diabetes: draft terms of reference. Wellington
    (NZ): New Zealand Guidelines Group (NZGG); 2003 Dec. 3 p. Available
    from in Portable Document Format (PDF) from the [New Zealand
    Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/0036/TOR_Diabetes.pdf).

-   Baxter J. Barriers to health care for Maori with known diabetes. A
    literature review and summary of issues. Wellington (NZ):New Zealand
    National Working Group on Diabetes; 2002 Sep. 69 p. Available from
    in Portable Document Format (PDF) from the [New Zealand Guidelines
    Group Web
    site](http://www.nzgg.org.nz/guidelines/0036/Diabetes_Barriers_report.pdf).

-   New Zealand Guidelines Group (NZGG). New Zealand cardiovascular
    guidelines handbook: developed for primary care practitioners.
    Wellington (NZ): New Zealand Guidelines Group (NZGG). 2005.
    Available in Portable Document Format (PDF) from the [New Zealand
    Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineCatID=53&guidelineID=101).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 21, 2004. The information
was verified by the guideline developer on July 19, 2004. This summary
was updated by ECRI on August 15, 2005, following the U.S. Food and Drug
Administration advisory on antidepressant medications. This summary was
updated by ECRI on January 11, 2006 following the U.S. Food and Drug
Administration advisory on rosiglitazone. This summary was updated by
ECRI on March 6, 2007 following the FDA advisory on Coumadin (warfarin
sodium). This summary was updated by ECRI Institute on September 5, 2007
following the U.S. Food and Drug Administration advisory on the
Thiazolidinedione class of antidiabetic drugs. This summary was updated
by ECRI Institute on September 7, 2007 following the revised U.S. Food
and Drug Administration (FDA) advisory on Coumadin (warfarin). This
summary was updated by ECRI Institute on November 6, 2007, following the
U.S. Food and Drug Administration advisory on Antidepressant drugs. This
summary was updated by ECRI Institute on November 28, 2007 following the
U.S. Food and Drug Administration advisory on the Avandia (rosiglitazone
maleate) Tablets. This summary was updated by ECRI Institute on January
10, 2008, following the U.S. Food and Drug Administration advisory on
Carbamazepine. This summary was updated by ECRI Institute on March 10,
2008 following the U.S. Food and Drug Administration advisory on Avandia
(rosiglitazone maleate).

#### COPYRIGHT STATEMENT

These guidelines are copyrighted by the New Zealand Guidelines Group.
They may be downloaded and printed for personal use or for producing
local protocols in New Zealand. Re-publication or adaptation of these
guidelines in any form requires specific permission from the Chief
Executive of the New Zealand Guidelines Group.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
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Date Modified: 11/10/2008