1. Objectives & Standards
General Practice Audit: Sulphonylureas & Driving - Does Practice Reflect Guidance?
Gemma Napaul & Michelle Fleeman Warwick Medical School, University of Warwick
Background
Results
In 2014, there were 180,000 type 2 diabetics prescribed Sulphonylureas (SUs), an oral hypoglycaemic medication (Parkes et al., 2014). SUs have the ability to induce hypoglycaemic episodes which can present as dizziness, difficulty concentrating and reduced consciousness. These factors can impact awareness when driving.
Parkes et al. (2014) identified 575,000 diabetics with active driving licences in the United Kingdom, 13% of which were Group 2 holders.
Table 2: Standards with corresponding audit results
Standards
Target Compliance
Number Compliant
Percentage Compliant
A) Documented driving status
100%
31/45
69%
B) Documented licence type
5/42*
12%
C) Documented driving advice on initiation of medication
2/42* 5%
D) Documented driving advice on review
6/42*
14%
E) Documented hypoglycaemic episodes on review
26/45
58%
F) Documented whether patient had hypoglycaemic episodes
35/45
78%
Objectives & Standards
The Driving and Vehicle Licensing Agency (DVLA) is the regulating body for driving in the United Kingdom. The standards for this audit were created using DVLA guidance “Assessing fitness to drive: guide for medical professionals” updated on 19/02/2015. The audit standards A-F (target compliance 100%) are listed in the results section (Table 2).
This audit aims to investigate whether patients at Brookside Surgery have been made aware of DVLA guidance (Table 1) when considering, commencing or reviewing SU use and if not, identifying areas for improvement to ensure patient awareness.
Table 1: DVLA guidance of driving requirements while prescribed SUs
* 3 non-drivers
17 of the 45 patients had experienced at least one hypoglycaemic episode whilst prescribed SUs. Records showed 23 of 45 patients were prescribed BM testing strips, 65% of which were regularly monitoring. There was no evidence of patients testing blood glucose at times relevant to driving.
Group 1 (Car and Motorcycle)
Group 2 (Bus and Lorry)
! - May drive and need not notify the DVLA, provided: 
No more than 1 episode of severe hypoglycaemia in the last 12 months
If needed, detection of hypoglycaemia is by appropriate blood glucose monitoring at times relevant to driving and clinical factors, including frequency of driving
Under regular review 
It may be appropriate to monitor blood glucose at times relevant to driving.
! - May drive if the following are met but must notify the DVLA:
No episode of severe hypoglycaemia in the last 12 months
Full awareness of hypoglycaemia
Regular self-monitoring of blood glucose – at least twice daily and at times relevant to driving 
Demonstrates an understanding of the risks of hypoglycaemia
Has no disqualifying complications of diabetes that mean a licence will be refused or revoked, such as visual field defect
Discussion
Driving status documentation showed a fair compliance but was often an incidental finding unrelated to diabetes, while licence type documentation was poor. Compliance for driving advice on initiation and review can be significantly improved. During diabetic review, 58% of patients were asked about hypoglycaemic episodes, however 78% of patients had documented discussions about hypoglycaemic events elsewhere in their notes. This suggests that patients are aware of hypoglycaemic events and healthcare professionals are counselling regarding side effects of SUs but not documenting specifics of the conversation.
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Recommendations
1) Pro Formas
Create a pro forma for initiation of SUs to include:
Driving status, licence type
Tick box for whether driving advice has been given
Tick box for whether patient should inform DVLA
Adjust review pro forma to include the above and as follows:
Document whether patient has hypo-awareness
Whether patient had hypoglycaemic episodes in past year
Whether they were driving at the time
2) BM Testing Strips
Prescribe BM testing strips to Group 2 licence holders and advise monitoring twice daily and at times relevant to driving
Consider prescribing BM testing strips to Group 1 licence holders on an individual basis (dependent on mileage and occupation)
3) Dissemination & Re-audit
Distribute findings to healthcare professionals at Brookside Surgery
Ensure clinicians are up to date with current diabetic DVLA guidance
Re-audit in 1 year to ensure compliance with new initiation and review pro formas
Methods
A retrospective primary care audit of 45 patients (aged 45-92) prescribed SUs between registered at Brookside Surgery (patient population 3,528) within Coventry and Rugby CCG.
Data was collected from patient records. A pro forma was used which included driving status, licence held, driving advice, hypoglycaemic awareness, hypoglycaemic episodes, and whether Boehringer Mannheim (BM) testing strips were prescribed.
References
Driving and Vehicle Licensing Agency. Diabetes Mellitus: Assessing Fitness To Drive. [Accessed: December 2015].
Parkes A, Tong S, Fernandez-Medina K. The Forgotten Risk of Driving with Hypoglycaemia in Type 2 Diabetes: Considering Sulphonylureas and Glinides in the Context of the Driver and Vehicle Licensing (DVLA) Guidance. Transport Research Laboratory. October 2014: DIAB