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HbA1c 47 - should I still get foot test?

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Hi! On Tuesday my latest HbA1c test result came in at 47 mmol/L. The online test result shows this as 'normal'. It used to be that 42-47 was pre-diabetic.
I rang my GP surgery today to make an appointment for nurse to do foot test, weight, blood pressure etc as I normally do after HbA1c test result.
The receptionist told me that as I am now in normal range I don't need to see the nurse for the foot and other tests. I said I was still in the pre-diabetic range and as far as I was aware I should still have the tests with nurse.

She did make an appointment for next week. Am I right that I should still have these tests?
And should I still be referred by nurse for the eye tests?

Have things changed since last year? Any advice would be appreciated.
 
Yes you should still get all your tests, I would have asked the nurse when they had found the cure for T2, and how come it hasn't been on the news.
The appointments for the eye screening has nothing to do with your surgery, the admin and appointments are managed by the NHS Diabetic eye screening programme
 
It was the receptionist who claimed I didn't need the follow up tests. She seems to think she is medically qualified.
I did think it was wrong as I got those tests previously when I got non-diabetic (39) and pre-diabetic results. I thought once you were on the diabetic register you got those tests every year, but I wasn't sure as I thought things might have changed in the last year.
 
It is still in the prediabetic range and you don’t suddenly become non diabetic after a diagnosis whatever levels you get. Please make the nurse at the appointed aware of the incorrect advice being given out by the reception. Hopefully she’ll act on it and get it stopped.
 
I don't like to complain about people, especially when they are low paid and might not have received adequate training for the role.
But incorrect guidance could lead to patients (not just diabetics) could lead to inadequate treatment. I think I will write a letter to the Practice Manager about this, not as a complaint, but suggesting that receptionists should get training in what they can advise patients, and not their interpretation of test results.
 
When the Newcastle diet became adopted by the NHS for T2D care, the NHS guidelines NG28 were updated to define remission and also what treatment to follow for those meeting that criterion. It has since been removed, and NG28 now makes zero reference to remission.

From memory, the recovery to non diabetic levels still required ongoing foot and retinopathy screenings but presumably this challenged the cost saving measures since I think it was open ended and it is no longer mentioned, Under the current guidelines, your GP or DN can withdraw all diabetic medication if you drop into non diabetic territory. My GP is struggling with this and is threatening to withdraw my support.

Looking at NG28, there has been a change in that all the provisions for review and eduction now refer speifically to "adults with Type 2 diabetes" so if your HbA1c is below the defined level for diabetes (48 unless you are one of those required to meet the new limit of 53 because of age or your medication) then you are technically not a diabetic, since In Remission or Resolved no longer seem to apply any more.

Note also that some medications are being withdrawn from people on keto diets,
 
That link is to the North West London CCG who make their local interpretations of the NHS directives. Not all CCG are required to follow this decision, as each will make their own regulations for the practices under their control, The NICE guideline covering T2 care is NG28 and that no longer sets out what is Remission or what happens when your BGL drops out of range defined in NG28. In all the references in NG28 making referral to Review, they are clearly associated to "Adults with Type 2 diabetes" at every mention. If you do not meet the criteria for Type 2 diabetes then annual reviews are no longer covered. If a local CCG decides to fund annual checks then they can mandate them. This is why my GP is insisting that I register my next HbA1c as being 53 or higher. I have been warned.

The other thing I noted is that retinopathy screening has been outsourced and now the GP must make referral to the organisation responsible for that. NG 28 no longer states that it should be annual.

Foot checks are no longer covered by NG28. There is a reference to a new guideline that replaces the previoius CG10 and CG119 for a new NG 19. This suggests a foot check will reduce the risk of damage etc, but is no longer mandatory and again is outsourced to local suppliers. Again it seems this should be covered by the CCG as a local issue.

Overview | Diabetic foot problems: prevention and management | Guidance | NICE

www.nice.org.uk
 
As you say ng28 does not mention remission. Personally I can’t recall the previous wording. Other nhs documentation do mention it but not in relation to standard of care as far as I can find so far.

Again s you say some ICB (what was a ccg) have continued to interpret the guidance in NG28 they way it was previously (Ie in remission remains diabetic and on the register and gets the checks). From what you are saying yours have decided to cut the costs and ditch it all - or is that your interpretation and assumption rather than theirs?

Who is saying a person in remission is no longer diabetic and where? I’ve never seen an NHS document that states this. There is no reference to being reassessed against the diagnostic criteria at each hba1c in order to maintain your 2 status. Remission isn’t a cure, it’s a lack of signs and symptom (for now), and in most cases it is effected by non medicated (diet) management, so the signs and symptoms would return if the management stopped.

It’s always been the case within the nhs once diagnosed T2, always a type 2. Nothing seems to have superseded this that I can find. The lack of definition and clarity of NG28 does not necessarily mean what you claim it does imo. It might, it might not. It all hinges on whether a previously diagnosed person who has achieved remission is still classed as diabetic or not, and that’s not being clarified as yet.

Perhaps it’s your area trying it on as a cost cutting exercise if that is indeed the way it’s being applied there, rather than the norm. Anyone else come across this issue?
 
HSSS said:
Because of medication safety (MHRA), your dr, your ICB’s formulary, or the NHS saying so ?
Click to expand...
My GP So far the UK has not followed the FDA which is carrying out special monitoring of those drugs in light of the experiences reported in their Yellow Card system and also anecdotally here in the Forum.

We have this note on this site for Forxiga

FDA still have doubts over safety of dapagliflozin diabetes drug

America’s Food and Drug Administration (FDA) still have doubts over granting approval…
www.diabetes.co.uk
Its not keto diet
There is no BNF contraindication for Low Carb
But it happens

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a relatively novel class of oral medications for the treatment of type 2 diabetes mellitus (T2DM…
www.sciencedirect.com

These are Low Carb

Dapagliflozin and Atkins Diet in a patient with type 2 Diabetes Mellitus: A combination that should be avoided | ECE2018 | 20th European Congress of Endocrinology | Endocrine Abstracts

www.endocrine-abstracts.org

Low carbohydrate diet while taking dapagliflozin: A case report and review of literature - PubMed

Low carbohydrate diet while taking dapagliflozin: A case report and review of literature
pubmed.ncbi.nlm.nih.gov

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature - PMC

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a relatively novel class of oral medications for the treatment of type 2 diabetes mellitus (T2DM). Their use has increased recently due to their beneficial renal and cardiovascular outcomes, but ...
www.ncbi.nlm.nih.gov

At the moment the GLP-1 meds are not contraindicated for low carb diets, but there are reports that it may increase the risk of pancreatitis due to the higher fat intake. Gall bladder problems may also be exacerbated as has been reported in this forum but that may be the keto diet side effect. Increased constipation has also been reported and this can be severe but again that may be a possible diet side effect being made worse
Again these meds are known to cause pancreatitis, AKI, gall bladder issues ands a keto diet may axacerbate their effects. Higher risk of hypo. (see manufacturer website.) There is a slight risk of euDKA with this med. But Foxiga is only found in the UK market, and our Yellow Card system is not very well used so notification may take a while, NG 28 was last updated in 2022 and is not due for update until 2026.

It took over 10 years for the problems with Actos and Avandia to get to the NHS to take action. They banned Avandia in the UK but Actos is still available. I had two strokes while I was on Actos and my GP reluctantly stopped it because it was not contraindicated even after the scandal. But because I had the strokes I was taken off it. So yes, I am banging the drum. I actually got hold of the FDA licence test data for both meds, and they had several deaths during the trials in both meds. But because the participants in the study were all elderly diabetics on the stroke ward, they already had increased risks before they started, so the deaths were claimed as natural causes and unrelated to the medication.

That is why I critique study reports so deeply. They are generally hiding info and often in plain sight. I have seen studies where the conclusion and abstract bear no correlation to the data that the team recorded. Obviously the team said this is what we did and thiis what we saw, but the boss says this is what I think happened. The press will love me.

So, just because there is no contraindication showing in the BNF for a drug, does not mean that there are not some unpleasant surprises lurking. I find the FDA far more proactive and willing to issue warningss more readily. the UK is generally a couple of years behind. I always wondered why it was Farxiga in the USA, but Forxiga in the UK. same drug formulation apparently, but different prescribing and patient info it seems. Same with Gliclazide and Glipizide.

I see Thalidomide is on prescription in the UK still.
 
I’m well aware of the sglt issues with low carb and euDKA and posted on it a number of times. The info about gulp-1 meds having an association with DKA is new to me though. As you say the irritation of a previously underused and already stoned gallbladder may be the diet, as can the short term constipation if enough fluids are taken but I’m yet to hear of pancreatitis being caused by the diet itself.

My question wasn’t disbelief in your statement or argument with it, more that it implied various drugs (plural) being avoided which would mean not just sglt-2 (as it should be on keto or very low carb) and that it was a widespread thing. If it’s potentially a problem then it’s a good thing your dr won’t prescribe them surely? Odd when he’s forcing you to take another one that that definitely causes you problems though.

Thalidomide is strongly contraindicated in pregnancy. That doesn’t mean it’s not useful in other situations. Many drugs are like this, good for one condition, terrible for another situation. The crucial thing is knowing the situations to avoid.
 
I've had HbA1cs in the pre diabetic range since 3 months after my T2 diagnosis at the end of 2013, and GP stopped my metformin prescriptions in 2017. I've always had all my tests, but they're currently annual, and things slipped/got delayed a bit since COVID's reared its ugly head, but there's never been any issue of my no longer being eligible for tests.

My GP told me early on I'm "well controlled " but there's never been any mention of being in remission.
 
Every paragraph in NG28 has that phrase to show only T2 diabetics are affected by what the para is defining. Every para. Looking at it with a legal mind, they are covering their posteriors to an extraodinary degree. But the classification of T2D is missing from NG28.

The NHS has adopted the WHO criteria. That does indeed say that diabetes is lifelong, and dropping below an HbA1c of 48 is not indicative of change of status. So I wonder what the legal beagles would make of all those rewrites to make each paragraph specific to PWD type 2. But I think my GP is still able to stop my diabetes medication if I am below the NG28 limit that applies to me (<53). I am also non compliant with the dietary advice in the NG28

Diagnostic criteria for diabetes

www.diabetes.org.uk
 
I too have not seen any mention of pancreatitis being associated with low carb or keto diets, but I have seen gall bladder issues arise from the HF aspect of those diets.

Yes I too am confused about the SGLT2 med my doctor insists I take on pain of rustication. I think he is looking to stop my Glic dose, so he can then stop supplying me with test strips which NG28 advises for drivers on hypoglycemic medications. I think the SGLT2 is a substitute in disguise.

Your comment on Thalidomide is accepted, but it seems that any new drug being licenced triggers a rush to get it used and licenced for Uncle Tom Cobbley et al. Ferinstance statins, SGLT2, Ozempic.

ND diet fer T2D, weight loss, world wide obesity and anything else to be added to the shopping list? Must be able to cram in heart and kidneys to that one. And what happend to the Polypill? The heart lung and bumps a daisy statin+ aspirin + sweepings off the floor.
 
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