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Provide detailed and comprehensive patient education, support and reassurance.
Achieve control of presenting symptoms.
Achieve blood pressure control (≤130/80 mmHg supine).
Develop a diabetes care plan.
Emphasise the importance of the diet: good nutrition, adequate complex carbohydrates, protein, restricted fats and sugars.
Promptly diagnose and treat urinary tract infection.
Treat and prevent life-threatening complications of ketoacidosis or hyperosmolar coma.
Treat and prevent hypoglycaemia in those taking insulin and oral hypoglycaemic agents.
Organise self-testing of blood glucose for those on insulin.
Detect and treat complications of diabetes—neuropathy, nephropathy, retinopathy, vascular disease.
Ensure immunisation schedule, including influenza and pneumococcus, is updated.
++
Beware of the deadly metabolic syndrome (syndrome X or insulin resistance syndrome).
++
Upper truncal obesity (waist circumference) >102 cm♂: >88 cm♀ (European population) plus any 2 or more of the following
↑ triglycerides >1.7 mmol/L
↓ HDL cholesterol <1.0 ♂ : <1.3 mmol/L♀
fasting glucose ≥5.5 mmol
BP ≥ 130/85
++
This syndrome is associated with increased risk for the development of type 2 diabetes and atherosclerotic vascular disease. Aggressive treatment is required.
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Monitoring techniques
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Blood glucose estimation (fasting and post-prandial)
Urine glucose (of limited usefulness)
Urine ketones (for type 1 diabetes)
Glycated haemoglobin (HbA1c) (3-monthly)
Microalbuminuria (usually urine ACR, regarded as an early and reversible indicator of nephropathy)
Blood pressure
Serum lipid levels
Kidney function (serum urea/creatinine eGFR)
ECG
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Control guidelines are summarised in FIGURE 20.4 and TABLE 20.4.
++
++
++
++
The reference ranges vary in different laboratories.
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Blood glucose monitoring at home
++
This is done using a glucose meter (glucometer). A wide variety of meters and smart phone apps are available: patients will require advice about what suits them.
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Type 1 diabetes:
– four times a day (before meals and before bedtime) at first and for problems
– twice a day (at least once)
– may settle for 1–2 times a week (if good control)
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Goals of management5,6
All people with diabetes should be encouraged to maintain the following goals for optimum management of their diabetes:
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Type 2 diabetes:
– important for those on insulin, less important for oral medication (where monitoring HbA1c, gives similar outcomes in most circumstances)
– more useful for pregnant women, frail elderly, heavy machinery operators or symptomatic hypoglycaemia
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++
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Glycated haemoglobin is abnormally high in diabetics with persistent hyperglycaemia and is reflective of their metabolic control. The major form of glycohaemoglobin is haemoglobin A1c, which normally comprises 4–6% of the total haemoglobin.4 Glycohaemoglobins have a long half-life and their measure reflects the mean plasma glucose levels over the past 2–3 months and hence provides a good method of assessing overall diabetic control. It should be checked every 3–6 months.
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The three main objectives of the treatment of type 1 diabetes are:
++
maintain good health, free from the problems of hyperglycaemia and hypoglycaemia
achieve proper growth and maturation for children and protect the fetus and mother in a mother with type 1 diabetes
prevent, arrest or delay long-term macrovascular and microvascular complications
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Insulin regimens for type 1 diabetes5,8
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The most commonly used insulin injection preparations are the ‘artificial’ human insulins. Insulins are classified according to their time course of action:
++
rapid-acting and short duration (ultra-short)—insulin lispro, insulin aspart
short-acting—neutral (regular, soluble)
intermediate-acting—isophane (NPH) or lente
long-acting—ultralente, insulin detemir, insulin glargine
pre-mixed short/intermediate—biphasic (neutral + isophane)
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Also: continuous subcutaneous insulin infusion.
++
For less experienced GPs, shared care with an endocrinologist is recommended.
++
It is important to use the simplest regimen for the patient and to provide optimal education about its administration and monitoring. Full replacement of insulin is achieved by using 2, 3 or 4 injections per day. See TABLE 20.5 for available insulins.
++
++
The pre-mixed 2 injection (biphasic) system Give twice daily, 30 minutes before breakfast and before evening meal (e.g. Mixtard 30/70, Humulin 30/70—the most common)
3 injections per day
4 injections (basal-bolus) system
Short-acting insulin before breakfast, lunch and dinner (bolus)
Intermediate-acting or long-acting insulin at bedtime (basal)
++
Insulin requirements often vary significantly even in the same individual under different lifestyle conditions. The rapid-acting analogues can be taken with meals.
+++
Methods of giving insulin injections
++
Get the patient to develop a set routine, such as eating meals on time and giving the injection about 30 minutes before the meal.
++
Into subcutaneous tissue—the best place is the abdomen. The leg is also acceptable. It is advisable to keep to one area such as the abdomen and avoid injections into the arms, near joints and the groin. The injection should be given at a different place each time, keeping a distance of 3 cm or more from the previous injection. This reduces the risk of the development of lipodystrophy. The means of delivery is the insulin syringe or the insulin delivery pen.
++
Pinch a large area of skin on the abdomen between the thumb and fingers and insert the needle straight in. After withdrawing the needle, press down firmly (do not rub or massage) over the injection site for 30 seconds. Alcohol swabs are unnecessary.
+++
Guidelines for the patient5
++
Take your insulin every day, even if you feel ill.
Do not change your dose unless instructed by your doctor or you are competent to do so yourself.
++
Injection sites should be inspected regularly because lipohypertrophy or lipoatrophy can occur.
++
Have a prearranged action plan.
++
Never omit the insulin dose even if the illness is accompanied by nausea, vomiting or marked anorexia. More top-up insulin is usually required (rapid/fast acting).
++
Maintain glucose. Keep regular blood glucose checks (a concern if >15 mmol/L).
++
++
Encourage sporting activities. Careful planning (use expert help) and monitoring of blood sugar is required. Insulin doses may need to be adjusted before activities.
++
Additional carbohydrate may be needed.
++
Glycaemic targets for adults with type 1 diabetes
++
First-line treatment (especially if obese):
++
diet therapy
exercise program
++
Most symptoms improve within 1–4 weeks on diet and exercise.3 Prescribe and ask about exercise at every visit. Aim for an average of 20–30 minutes a day. Suggest variations such as social-type exercises. The secret to success is patient adherence through good education and supervision. The role of a diabetic education service, especially with a dietitian, can be invaluable. If unsatisfactory control persists after 3–6 months, consider adding an oral hypoglycaemic agent (see TABLE 20.6). The usual first-line agent is metformin, which reduces insulin resistance. If glycaemic targets are not achieved on monotherapy, usual practice is to add in a secretagogue, such as a sulfonylurea, which increases insulin production. Newer agents include DPP-4 inhibitors (oral gliptins), SGLT2 inhibitors (the gliflozins) and incretin mimetics (by injection).
++
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Consider metformin as the first-line agent for all patients with type 2 diabetes, irrespective of their weight, unless contraindicated. The usual starting dose is 500 mg once or twice daily. It has proven benefits over the sulphonylureas, especially in those that are overweight. Other benefits include no significant weight gain, no hypoglycaemia and an improved lipid profile. If monotherapy does not provide adequate glycaemic control, a combination of metformin with a sulfonylurea or other agent (see FIG. 20.6) is recommended.17
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When the first oral hypoglycaemics fail (secondary failure) one of the new agents can be added (e.g. a gliptin, acarbose, one of the glitazones). The glitazones can be used as monotherapy but are used more often in combination with metformin, sulfonylureas or insulin but not rosiglitazone.16 The newest treatment options in type 2 diabetes include:17
++
dipeptidyl peptidase-IV (DDP-IV) inhibitors known as gliptins, such as sitagliptin
sodium glucose cotransporter 2 (SGLT2) inhibitors taken orally, e.g. dapagliflozin, canagliflozin
glucagon-like peptide-1 receptor (GLP-1) agonist (e.g. exanatide-—twice daily dosing, liraglutide-—daily dosing) given by SC injection. These improve satiety and are associated with weight loss. Nausea is fairly common, but tends to settle. Pancreatitis is a rare but important side effect.
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The classic symptoms of hyperglycaemia may be present but more commonly patients experience general disability. Approximately 30% of type 2 patients eventually require insulin even after years of successful oral therapy. An algorithm for the management of type 2 diabetes is presented in FIGURE 20.6.
++
It is important not to delay the introduction of insulin. However, insulin will not substitute for healthy eating and activity.
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Starting insulin in type 2 diabetes14,18
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More than 30% of patients will eventually require insulin, often after 10–15 years of successful oral therapy.8 Before commencing insulin one should be assured that the patient’s lifestyle activities are being adequately addressed and that oral medication (at recommended maximum dose) is appropriate. There is no clear-cut rule about when to start insulin for patients with HbA1c >7%, but this can be as early as when drug therapy does not provide adequate control. Two golden rules are ‘don’t delay initiating basal insulin’ and then ‘start low and go slow’.18
++
When commencing patients on insulin, reassure them that the injections are not as uncomfortable as finger pricks and that they will feel much improved with more energy.
++
It is appropriate to refer to your diabetic team for shared care at this point—when starting insulin.
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Suggested stepwise approach14,16
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Titrate insulin therapy according to fasting blood glucose (6 mmol/L).
Increase insulin in about 4–5 U increments every 3–4 days (or more gradually).
Cease glitazone, acarbose, gliptin or SGLT2 inhibitor (if used).
++
If larger doses of insulin are required (NPH or mixed regimen), gradually withdraw sulfonylurea, continue metformin and review.
++
Note: The combination of a glitazone and insulin has been shown to improve control of diabetes sometimes to the extent of being able to reduce insulin dosage. In patients with type 2 diabetes needing relatively high doses of insulin, the addition of a glitazone is worth considering.