Diagnosis

• Symptoms

  • Single fasting blood glucose > 7

  • Random blood glucose >11.1

  • Single HbA1c > 6.5% / 48

• No symptoms

  • 2 x HbA1c > 6.5% / 48

  • 2 x fasting blood glucose > 7

  • 2 hour post-challenge blood glucose > 11.1

Consider secondary causes

• Drugs (antipsychotics, steroids), Haemochromatosis, Endocrine (Cushing’s disease, Acromegaly), Pancreatitis, Cystic Fibrosis

Consider T1DM

• < 40yo, thin, rapid progression, rapid weight loss, ketonuria, family history autoimmunity

• Consider glutamic acid decarboxylase (GAD) antibodies

Consider monogenic diabetes

• Multiple genetics syndrome including MODY, MIDD

• Consider if multiple people diagnosed < 25

Establish history before starting treatment

Specific symptoms

• Glycosuria - Polyuria, polydipsia, polyphagia, weight loss, nocturia

• Hyperglycaemia - Malaise, fatigue, altered vision

Predisposing factors

• Age, Family history, Cultural group, Overweight, HTN, GDM, Medications, Hx haemochromatosis, Family history autoimmune

Risk factors

• Personal or family history CVD, HTN, Smoking, Dyslipiademia, SNAP, Occupation

General symptoms

• CV symptoms, Neuro, Bladder, Sex, Foot and toe, Infections, Vision

Exam

• BMI

• BP lying and satnding

• Peripheral and neck vessels

• Eyes (Acuity, Cataracts, Retinopathy)

• Feet

• Peripheral nerves

• Urinalysis

Investigations

• UEC, Urine A/CR

• Lipids

• HbA1c

• Consider ECG if >50

• Consider TSH if family history autoimmunity

Management

Consider specialist advice if

• Persistent or severe hyperglycaemia > 20

• HbA1c > 11%

• Ketones

• Severe or frequent hypoglycaemia

Education

• Explain diagnosis

• Healthy Eating

  • Food and Diabetes

    • NDSS:

      • Carbohydrate Counting and Diabetes

      • Healthy Cooking Ideas Fact Sheet

      • Healthy Meal Ideas Fact Sheet

      • Healthy Snacks Fact Sheet

      • Understanding Food Labels

    • Hunter New England Local Health District / NSW Health resources:

      • Food and Diabetes – The First Steps

      • Mediterranean Diet and Health

• Physical activity

  • Aim for 30 minutes of moderate intensity exercise on most days

  • Increase to 60 minutes when able

  • Reduce periods of inactivity such as sitting

• Weight reduction

  • Aim weight loss of 0.5 to 1kg and a long-term weight loss of 5% total body weight

• Reduce cardiovascular risk factors

Blood glucose management

Glycaemic target

• Generally HbA1c < 7% / 53

• Aim < 6.5% if

  • Early disease

• Goals may be higher if

  • Older, comorbidities, risks hypoglycaemia

• Blood glucose goals

  • 5 to 7 fasting

  • < 10 after meals

Medication

Metformin

• 500mg daily initially to reduce GIT side effects, With or after food

• Titrate to maximum tolerated within 2 to 3 months

• Decreased glucose production, decreased glucose absorption, increase utilisation

• Effectiveness - Reduce HbA1c by 10 to 20 (1 to 2%)

• Low risk hypoglycaemia

• Weight loss or neutral

• Side effects - Diarrhoea, nausea, abdo cramps, B12 deficiency. GIT tolerance develops after 2 weeks

SGLT2 inhibitor - Dapagliflozin (Forxiga), Empagliflozin (Jardiance) and Ertuglifozin (Steglatro)

• Mechanism - Pee out glucose

• Effectiveness - 5 to 10 (0.5 to 1 %)

• Weight - 2kg weight loss

• Side effects - Glucose in urine, thrush, balanitis, UTI

GLP-1 agonists - Dulaglutide (Trulicity), Semaglutide (Ozempic), Liraglutide (Victoza)

• Mode - Decrease glucose production, decrease gastric emptying, decrease appetite

• Effectiveness - Lower HbA1c by up to 5 to 20 (0.5 to 2%)

• Weight loss - 2 to 5 kg over 30 weeks

• Side effects - Nausea, abdominal pain

DPP4 - Sitagliptin (Januvia)

• Mode - Decrease production, decrease appetite, decrease gastric emptying

• Effectiveness - Lower HbA1c by 5 to 10 (0.5 to 1%)

• Side effects - Headache, MSK pain, constipation

Screen and Monitor

• Renal Disase

• Eye Disease

• Foot Screening

• Dental check

Immunisations

• Flu, Tetanus, Shingles, Pneumococcal

Fitness to Drive

NDSS registration