Malady Wise

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Diabetes

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

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