1. Uzma Haque GP Reg.

2.  Education & Lifestyle Adjustments  Glucose control  Oral medications  Insulin therapy  CV risk estimation  Blood pressure  Lipid modification  End organ damage  Eye  Kidney  Nerve

3.  Education  Maintain blood glucose levels-diet  Lipid modifications  Smoking cessation  Obesity advice  Maintain psychological well being

5.  Targets  Renal/eye/CV damage- <130/80mmhg  Others < 140/80 mmhg  If on Anti-hypertensives  r/v 1-2 monthly until consistently below target  If stable  Monitor 4-6 omnthly  Monitor for SE

6.  Age (40 years)  CV risk (over 20%/10 years UKPDS)  Total cholesterol <4.0 mmol/litre  HDL ≤ 1.4 mmol/litre  LDL-C < 2.0 mmol/litre  If TG high check causes  If >4.5 mmol/litre persistently  Offer Fibrates  Assess lipid profile 1-3 months at first  Then Annually

7. Offer Low-dose ( 75mg ) aspirin/clopidogrel Age 50+ & BP <145/90 mmhg Age < 50 & significant CV risk

8. MonitoringInvestigationInterpretationAction Annually, regardless of presence of nephropathy: ● arrange ACR estimation on first-pass urine sample (or spot sample if necessary) ● measure serum creatinine ● estimate GFR If abnormal ACR1 (in absence of proteinuria/UTI): ● repeat test at next two clinic visits and within 3–4 months ● microalbuminuria is confirmed if at least one out of two or more results is also abnormal1. Suspect renal disease other than diabetic nephropathy and consider further investigation/ referral if ACR is raised and: ● no significant or progressive retinopathy, or ● BP is particularly high or resistant to treatment, or ● heavy proteinuria (ACR > 100 mg/mmol) but ACR previously documented as normal, or ● significant haematuria, or ● GFR has worsened rapidly, or ● the person is systemically ill. If diabetic nephropathy confirmed, offer ACE inhibitor with dose titration to maximum dose (unless not tolerated). Substitute an A2RB if ACE inhibitors are poorly tolerated. Maintain BP < 130/80 mmHg if abnormal ACR

9.  Gastropresis  Erratic BGC/bloating/vomiting  Metoclopramide/domperidone or refer  Erectile dysfunction  r/v annually with men  Phosphodiesterase-5 inh.  If ineffective then refer  Foot problems- r/v annually  Signs of Autonomic Neuropathy  Loss of warning signs for hypos  Unexplained diarrhoea  Unexplained bladder emptying