Diabetologists-abcd.org.uk2

The ABCD prospective nationwide liraglutide audit is an independent audit supported by an unrestricted grant from Novo Nordisk Ltd ABCD prospective nationwide liraglutide audit – visit 1 data collection form
Please record patient name, gender and date of birth below Unique 6 digit personal identification number (generated as follows: Clinician initials (x3), sequential number per patient (starting at 001)) If ‘Yes’ please give details including type of licence if appropriate. Licence types include:
Duration of diabetes (in years) at this visit - PCV (Passenger Carrying Vehicle) subdivided into category B (taxi/ private hire) or D1 Not as far as I am aware
Test Results (test dates MUST be entered for all tests where results are reported (dd/mm/yyyy))
HbA1c please enter either %
or mmol/mol in correct cell
BMI will be auto-calculated when data is entered into audit spreadsheet If patient has had or may have had pancreatitis please give details Does the patient have or has the patient ever had thyroid disease of any sort and / or goitre? If the patient has or has had goitre or thyroid disease please give details Current antidiabetic treatment before initiation of liraglutide brand names, where shown, are for information purposes only Please add up the patient’s total daily metformin dose (including metformin in combination products) and enter the sum value into the metformin ‘Total Dose’ box pioglitazone + metformin rosiglitazone + metformin Item Code: UK/LR/0909/0421 Date of preparation: September 2009 Current antidiabetic treatment before initiation of liraglutide (continued) brand names, where shown, are for information purposes only Hypurin® Bovine Neutral Hypurin® Porcine Neutral Hypurin® Bovine Lente Hypurin® Bovine Protamine Zinc isophane insulin (highly purified animal) biphasic isophane insulin (animal) Mixtard® 30 Humulin® M3 Insuman Comb® 15 or medications which could affect glycaemic control Date of initiation of liraglutide (dd/mm/yyyy) / / To improve gastro-intestinal tolerability liraglutide should be initiated at 0.6mg for at least 1 week and then be increased to 1.2mg in line with SPC If yes please cross out the drug
Please add up the patient’s total daily metformin dose (including metformin in combination products) and enter the sum value into the metformin ‘New Dose’ box pioglitazone + metformin rosiglitazone + metformin isit 2’ data entry forms please send an email to: ABCDforms@bedgeburycomms.com detailing your request Hypurin® Bovine Lente Hypurin® Bovine Protamine Zinc isophane insulin (highly purified animal) biphasic isophane insulin (animal) Mixtard® 30 Humulin® M3 Insuman Comb® 15 or medications which could affect glycaemic control Patient opinion of antidiabetic treatment (where 0=lowest opinion & 6=highest opinion) Place ‘x’ on Visual Analogue Scale corresponding to patient’s satisfaction level with current treatment0

Source: http://www.diabetologists-abcd.org.uk/ABCD_Liraglutide_Audit_Visit1_Form.pdf