NICE 2002/011
Issued: 5th March 2002

Press release

Diabetic retinopathy is the leading cause of blindness in people under the age of 60 in industrialised countries.

NICE has today issued two clinical guidelines to support the care of people with diabetes. They cover covering the screening for and early management of retinopathy (eye problems) and the prevention and management of renal (kidney) disease.

Professor Peter Littlejohns, Clinical Director NICE said, "Type 2 diabetes is affecting increasing numbers of people in England and Wales. With appropriate care at the right time the number of people affected by complications such as blindness or kidney problems can be limited and in some patients avoided altogether. I know that there has been a great deal written about diabetes and its management over the years, today's guidelines are not intended to reinvent the wheel, they do for the first time make clear to both professionals and patients the steps that the NHS can take to support people with type 2 diabetes in preserving their sight and kidney function."

The guidelines give recommendations to health professionals on regular screening and monitoring of people with type 2 diabetes, including:

  • People with type 2 diabetes should have an eye examination at least once a year and more frequently if they are experiencing problems with their eyesight
  • People with type 2 diabetes who experience a sudden loss of vision or who have a suspected detached retina should be seen by a specialist within one day
  • People with type 2 diabetes should have their kidney function checked at least once a year and more frequently if they are at high risk of renal disease
  • People at high risk of renal disease should be prescribed ACE inhibitors to manage their blood pressure (where appropriate)

The summary guidelines published by NICE are derived from full guidelines commissioned from a collaboration between the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Nursing and Diabetes UK. The guidelines are two of a series of five on type 2 diabetes. Other guidelines in the series, due to be published in Spring 2002, cover the management of renal disease, dyslipidaemia and blood pressure, and blood glucose. A guideline on foot care has been published by the Royal College of General Practitioners.

Ends

Notes for editors

General information

1. The five guidelines in the type 2 diabetes series were commissioned by the Department of Health before the National Institute for Clinical Excellence (NICE or 'the Institute') was formed in April 1999. The developers have followed closely the development brief that was agreed at the time of commissioning. The developers have worked with the Institute to ensure, in the time available, that the guideline has been the subject of validation and consultation with stakeholders. However, it has not been possible to subject it to the full guideline development process that the Institute has now adopted.
2. Copies of the full guidelines and the NICE short form guidelines are available on the NICE website, www.nice.org.uk, and on the National Electronic Library for Health's website, www.nelh.nhs.uk. Copies of the NICE guidelines are also available from the NHS Response line by telephoning 0870 155 455 and quoting ref. N0058 (retinopathy) and N0061 (renal).
3. Diabetes is a common condition in which the amount of glucose (sugar) in the blood is too high because the body is unable to use it properly. Normally, the pancreas produces insulin, which controls the levels of glucose in the blood. Diabetes occurs when the body does not produce enough insulin, or produces insulin but cannot use it properly.
4. Type 2 diabetes (also called non-insulin-dependent diabetes) develops when the body can still make some insulin, but not enough for its needs, or when the insulin that is produced does not work properly (known as insulin resistance). This type of diabetes usually appears in people over the age of 40, though it can appear in younger people.
5.

One of the effects of diabetes is that small blood vessels in the body may become damaged. This can cause a number of problems, which may affect:

  • blood glucose (sugar) levels
  • blood pressure levels
  • the feet
  • the eyes (diabetic retinopathy)
  • the levels of certain substances in the blood (for example, lipids such as cholesterol)
  • the kidneys (nephropathy or renal disease).
Diabetic retinopathy guideline
6. Diabetic retinopathy is the leading cause of blindness in people under the age of 60 in industrialised countries. It is also a major cause of blindness in older people.
7. The risk of visual impairment and blindness is substantially reduced by a care programme that combines methods for early detection with effective treatment of diabetic retinopathy. The key issue in screening for diabetic retinopathy is to identify those people with sight-threatening retinopathy who may require preventive treatment.
8. The number of times a patient will be asked to attend for appointments to monitor their eyes will depend on the results of the tests carried out when they are first diagnosed with diabetes or at their annual health check. The table shows a summary of the recommendations made in the guideline.
If: Treatment/management:
No damage or only mild signs of retinopathy Continue to check eyes annually
and
monitor plan of care, discussing with the patient the significance of early changes
and
look at blood pressure and blood glucose control
Retinopathy has recently appeared or has worsened since last examination
or
blood pressure or blood glucose levels are not being successfully controlled
or
patient has kidney problems

Arrange to examine eyes every 3 to 6 months
Patients sight suddenly gets worse
or
Signs of retinopathy become more severe		 Consider referring to an eye specialist within 4 weeks

Eye care emergency

Patients should be referred to an eye specialist urgently if tests show:

  • blood vessels growing in the wrong places within the eye
  • blood vessels bleeding into the eye

Patients should be seen by an eye specialist immediately if:

  • tests show that the retina has become 'detached'
  • patients suddenly cannot see in one or both eyes
  • patients see flashing lights or black spots
Renal disease guideline
9. The kidneys keep the right amount of water in the body and help filter out harmful waste, which then leaves the body as urine. Damage to the small blood vessels that supply blood to the kidneys can impair the filtering. When this happens important proteins, such as albumin, are lost from the blood into the urine. Also waste products, such as creatinine, are not removed properly. Damage to the kidneys is known as nephropathy or renal disease
10. Tests carried out when a patient is first diagnosed with diabetes or at their annual health check-up measure levels of albumin or other proteins in the urine and levels of creatinine in the blood. These are used to calculate the albumin excretion level. Treatment will depend on whether a patient has 'lower-risk' or 'higher-risk' levels and will depend also on whether or not they have any eye damage (retinopathy). The table below shows a summary of the recommendations made in the guideline.
If: Treatment/monitoring:
Albumin or other proteins are present in the urine Test urine twice more in the next month, where possible
Patient has lower-risk albumin excretion levels
  • Continue to check health every year
  • Agree a plan of care including advice on how to control blood glucose and blood pressure levels
Patient does not have signs of eye damage but does have higher-risk albumin excretion levels Look for some other cause of renal disease not associated with diabetes
Patient does have signs of eye damage (retinopathy) and have higher risk albumin excretion levels
  • Continue to keep close control of blood glucose and blood pressure levels
  • Offer treatment with ACE inhibitors to help manage blood pressure. Blood samples should be taken 1 week after the start of this treatment and whenever the dose is increased
  • Offer a combination of drugs if ACE inhibitors alone are not fully effective
  • Take urine and blood samples to measure albumin and creatinine levels at each visit
  • Measure, assess and manage risk of heart disease
Information on NICE
11. Copies of the NICE guidelines and full guidelines will be available on the NICE web site (www.nice.org.uk) on Thursday 21st February 2002.
12. Health professionals are expected to take the Institute's guidance fully into account when exercising their clinical judgement for individual patients. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer
13. The National Institute for Clinical Excellence (NICE) is a part of the NHS. Part of its work is the development of clinical guidelines. Clinical guidelines are produced to help health professionals and patients make the right decisions about health care in specific clinical circumstances. Research has shown that if properly developed, communicated and implemented, guidelines can improve patient care. Clinical guidelines sit alongside, and do not replace, the knowledge and skills of experienced health professionals.
14. NICE promotes clinical and cost effectiveness through its technology appraisals, clinical guidelines and audit tools. The Institute supports the work of those who make the complex treatment decisions - doctors, nurses, and other health professionals. The needs of the patient are central to NICE's work, and the Institute has forged strong links with patient groups and representatives.
15. Topics for the NICE work programme are selected by the Department of Health and the National Assembly for Wales. NICE advises the NHS on how these technologies can best be used. It is also responsible for the production of national clinical guidelines, promoting best practice throughout the NHS. To support and assess the implementation of such guidelines, audit tools are produced for use in the clinical setting.