DH diabetes report says GPs should test HbA1c annually in all high-risk over-25s
Exclusive GPs face a soaring workload on diabetes prevention under Government plans for practices to provide intensive lifestyle advice and annual glucose checks to everyone judged as at high risk from the age of 25.
The Department of Health's diabetes tsar wants GPs to assess all patients' records for diabetes risk from age 25, and is urging NICE to adopt tough new interventions for those identified as at high risk – even those with normal HbA1c levels.
Dr Rowan Hillson, national clinical director for diabetes, and a panel of senior NICE advisers have submitted recommendations to the institute as it draws up new guidelines on prevention of type 2 diabetes.
Draft NICE guidance published last year caused controversy after recommending GPs go through practice records and assess diabetes risk in all patients aged over 25. It said patients at high risk – such as those with a high BMI or a family history of diabetes – and with HbA1c levels of 6.0-6.4% should have intensive lifestyle advice and annual HbA1c checks.
But the new report goes even further, recommending the same interventions for high-risk patients with an HbA1c of less than 6.0%: ‘If clinically at high risk manage as above – provide intensive lifestyle advice and monitor HbA1c annually.'
The proposals have been signed off by all the major UK diabetes organisations, including the Association of British Clinical Diabetologists, the Primary Care Diabetes Society, NHS Diabetes and Diabetes UK.
A NICE spokesperson said the institute was considering the proposals with final guidance to be published in June: ‘This report was issued after the draft guidance came out and we are in touch with the group that developed it. Some of our group members including the chair are also members of this group.'
The guidance comes after a UK study published in Diabetic Medicine last month showed interventions in high-risk patients with HbA1c levels of 5.5-6.5% would strengthen diabetes prevention, but create a ‘disproportionately higher workload'.
Study leader Dr Parinya Chamnan, a researcher at the MRC epidemiology unit in Cambridge, said: ‘Using a cut-off of 5.5-6.5% could prevent twice as many cases of diabetes, but necessitated interventions in three to five times as many people. More than twice as many people needed to undergo treatment to prevent one new case.'
But Dr Martin Hadley Brown, chair of the Primary Care Diabetes Society and one of the new report's authors, insisted the recommendations would help ease cardiovascular risk in
patients still amenable to change: ‘Cardiovascular risk does not stop at an HbA1c of 6%.'
Dr John Ashcroft, a GP in Ilkeston and vascular lead for NHS Derbyshire County, said: ‘Studies have shown benefit at reducing progression to diabetes in a very selected group of patients with both impaired fasting glucose and impaired glucose tolerance. But it's expensive and questionable if it would have the same impact in the real world.'
Dr Richard Vautrey, deputy chair of the GPC, said the resource implications would have to be considered: ‘This would be a big change and have costly workload implications.'
Dr John Allingham, medical secretary of Kent LMC, said: ‘If the DH is proposing a formal pre-impaired glucose tolerance status perhaps it should be formalised via the QOF.'
Read the full guidance here