Remote Primary Health Care Manuals

Diabetes

  • Type 1 diabetes — less common
    • Usually diagnosed in children and young people
    • Body is unable to produce enough insulin
  • Type 2 diabetes — much more common
    • Initially insulin resistance (increased insulin levels but body can not use it properly). Later the body makes less insulin
    • Very common in Aboriginal adults. Increasingly in children and young people
  • Heart attack at a young age is a major cause of death for people with diabetes
    • May be atypical — happens with no chest pain but with symptoms like tiredness or problems breathing
Red Flags — Urgent Medical Consult
  • Moderate to high ketones in urine/blood
  • Person sick with anything else at time of diagnosis
  • BGL more than 15mmol/L
  • Sudden onset vision change
  • Hight risk foot problem (eg infected wound, numbness)

Common problems with diabetes especially if high BGLs

  • High BP, abnormal lipids (blood fats)
  • Heart attack, stroke
  • Nephropathy (kidney disease), kidney failure
  • Retinopathy (eye damage) — causes loss of vision
  • Neuropathy (nerve damage) — causes foot ulcers, nerve pain, amputations
  • Serious infections, poor wound healing
  • Dental/oral disease, tooth loss
  • Erectile dysfunction in men
  • Depression

Risk factors for diabetes

  • Family history of diabetes — parents, sister, brother
  • Ethnicity — Aboriginal or Torres Strait Islander, Pacific Islander
  • Overweight or obese — calculate BMI
  • Waist circumference — women more than 80cm, men more than 94cm
  • Women — history of gestational diabetes or polycystic ovary syndrome
  • Impaired glucose tolerance or prediabetes
  • Medicines, eg corticosteroids, antipsychotics

Prevention

  • To lessen risk of developing type 2 diabetes or slow its progress — encourage healthy diet, physical activity, weight loss if overweight/obese
  • Early diagnosis of Type 2 diabetes through screening may prevent complications — routine  ​Adult Health Check
  • Targeted screening of at-risk children over 10 years
    • Overweight or obese, maternal history of diabetes in pregnancy
    • Parent, sister or brother with diabetes or dyslipidaemia
    • Acanthosis nigricans (dark patches of skin at folds or creases, eg neck, armpit)

Diagnosing prediabetes and diabetes

Diagnosis of diabetes needs

  • Diabetes (high blood glucose) symptoms and 1 abnormal test
    • Blood glucose meter readings can't provide a diagnosis — readings need to be checked with accurate testing method, eg venous blood glucose
  • If no symptoms — 2 abnormal tests done on different days
  • Any combination of abnormal OGTT, venous BGL, HbA1c
    • Do not use HbA1c if less than 4 months postpartum (after childbirth)
    • If two different tests are performed and only one is high the test with the high result should be repeated — diagnosis can then be made based on the repeated test
    • Caution in interpreting HbA1c if person has a condition that affects red blood cell turnover

Ask

About symptoms of high blood glucose

  • Type 1 diabetes — almost always rapid onset of symptoms, positive ketones, often slim build, may be no family history of type 2 diabetes
  • Type 2 diabetes — may be no symptoms until complications develop

Symptoms and signs of high blood glucose

  • Increased thirst or fluid intake
  • Passing urine often — especially at night
  • Weight loss
  • Tiredness
  • Frequent infections — thrush, balanitis, boils, UTIs
  • Eyesight problems
  • Acute dental/oral disease
  • If ketosis — vomiting or abdominal pain

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A (attention to ketones), pregnancy test
  • Head-to-toe exam
  • If BGL high — POC Test for ketones
  • If taking an SGLT2 inhibitor (eg empaglifozin, dapagliflozin) and unwell (abdominal pain, nausea, vomiting, fatigue) even if normal BGL

Table 4.12 Interpreting results for prediabetes and diabetes

Test Normal Prediabetes* Diabetes
HbA1c Less than 5.7% (39mmol/mol) 5.7–6.4% (39–46mmol/mol) 6.5% (48mmol/mol) or more
Fasting plasma glucose
(mmol/L)		 Less than 6.1 6.1 to 6.9 7 or more
Random plasma glucose#
(mmol/L)		 Less than 7.8 7.8 to 11 11.1 or more
2 hour glucose on OGTT
(mmol/L)		 Less than 7.8 7.8 to 11 11.1 or more

*Prediabetes is not relevant for people with type 1 diabetes. The prediabetes threshold of 5.7–6.4% is as per the American Diabetes Society guidelines
# Consider further testing with HbA1C or OGTT

Do

Medical consult if

  • Person sick with anything else at time of diagnosis
  • BGL more than 15mmol/L — may be undiagnosed type 1 diabetes — urgent medical consult
  • Ketones in urine/blood moderate or high

Ketones in urine/blood can mean

  • Person has not eaten — will have normal or low BGL
  • Undiagnosed type 1 diabetes — medical consult, needs insulin urgently
  • Diabetic ketoacidosis (usually occurs in type 1 diabetes but can occur in type 2 diabetes). Will have high BGL (might not have high BGL if taking an SGLT2 inhibitor) — urgent medical consult

Ongoing care

  • Good diabetes care looks after whole person not just blood glucose
  • Develop shared care plan with specialist, diabetes educator, doctor, patient
  • For females of childbearing age — talk about

Type 1 diabetes

  • If suspected — urgent medical consult
    • Care will involve specialist consult
  • Always need insulin
  • Monitor BGL every day
    • Monitor BGL more often and monitor ketones when unwell — increased need for insulin. Not getting enough insulin can lead to ketoacidosis
  • Will still need basal insulin even if fasting

Gestational diabetes

Prediabetes

Includes impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and raised HbA1c

Type 2 diabetes

Management of type 2 diabetes

  • Comprehensive management of diabetes includes lifestyle change, managing blood glucose, BP, lipids (blood fats), kidney disease, cardiovascular risk in partnership with people and families
  • Good management reduces risk of complications — microvascular (eye, kidney and nerve damage) and macrovascular (heart attack, stroke, amputation)
  • Medical consult and paediatric/paediatric endocrinology consult for all young people diagnosed with type 2 diabetes
    • See — Diabetes across the lifecourse (Menzies school of health research) 

Blood glucose levels

HbA1c targets

High HbA1c levels increase risk of complications — any decrease in HbA1c is useful. Always be encouraging about improvements

  • Good average blood glucose over last 3 months — HbA1c 53mmol/mol (7%) or less

OR if a history of severe hypoglycaemia, limited life expectancy or elderly — HbA1c 64mmol/mol (8%)

OR individual target as per care plan

  • If less than 18 years of age — HbA1c 48mmol/mol (6.5%) 

BGL monitoring and targets

  • BGL self-monitoring helps person understand and manage diabetes
    • Most useful for people on insulin, during changes in drug treatment or if BGLs unstable
    • People with type 1 diabetes need to monitor BGL and ketones when unwell
    • If person on insulin can’t self-monitor — do in clinic 2–3 times a week
  • BGL targets should be individualised and documented in care plan
  • Suggested targets
    • Morning/fasting — 4–8mmol/L
    • Random/2 hours after meal — 5–10mmol/L

Medicines for blood glucose lowering in adults with type 2 diabetes

Must be prescribed by doctor or nurse practitioner

  • A patient-centered approach should be used to guide the choice of medicines
  • Considerations include cardiovascular comorbidities, hypoglycaemia risk, impact on weight, cost, risk for side effects and patient preferences
  • Early combination therapy can be considered in some patients with high BGL or HbA1c
  • Early insulin therapy can be considered in some patients with very high BGL or HbA1c or with symptoms
  • If HbA1c has not declined by more than 0.5% 3 months after a medication is started — check adherence and medical consult to consider change of medication
  • Recommend SGLT2 inhibitor as second line therapy if no contraindications AND patient preference AND any of
    • High risk or established cardiovascular diseases
    • High risk or established heart failure
    • Chronic kidney disease
  • Recommend GLP-1 receptor agonists as second line therapy if no contraindications AND patient preference AND any of
    • High risk or established cardiovascular diseases
    • Weight loss is a priority
    • Chronic kidney disease

Table 4.13 Medicines for blood glucose control in adults with Type 2 diabetes

Always
  • Include lifestyle measures — diet, weight control, physical activity
Step 1
  • Metformin
    • If metformin contraindicated — chose 1 medicine from Step 2 list
If target not reached in 3 months — reassess* AND move to Step 2 if needed
Step 2
  • ADD second medicine — check PBS approved combinations
    • Sulfonylurea
    • OR SGLT2 inhibitor
    • OR GLP-1 agonist
    • OR gliptin (DPP4 inhibitor)
    • OR insulin — continue oral medicine/s
If target not reached in 6 months — reassess* AND move to Step 3 if needed
Step 3
  • ADD third medicine from Step 2 list — check PBS approved combinations
*Reassess oral medicines
  • Check person understands lifestyle measures and medicine use
  • Check that medicine is being taken as directed
  • Check for underlying infection (eg thrush, UTI) or other medicines (eg steroids) that may make it hard to get good BGL levels
  • Consider a different diagnosis, eg latent autoimmune diabetes in adults

Oral medicines

  • Only take oral medicines when eating
  • If unwell and not eating — stop medicine until eating again

Metformin

  • Slow, gradual increase in dose to lessen chance of upset stomach
  • May take a few weeks to see full benefit
  • If stopped for more than 2 weeks — restart again slowly
  • If swallowing problems — use smaller slow-release tablets (500mg XR)

Table 4.14 Glucose lowering medicines in type 2 diabetes

Medicine Starting dose Maximum dose Comments
Metformin
Metformin
Metformin XR		 500mg once a day Normal release
  • Usually 2g total daily dose.
  • May use 3g daily if overweight or obese.
  • Up to 1g/dose
Slow release – XR
  • 2g once a day
  • If kidney disease — reduce dose
    • eGFR less than 15 — do not use
    • eGFR 15–30 — 500mg daily
    • eGFR 30–60 — 1g daily
    • eGFR 60–90 — 2g daily
  • Caution in liver disease or acute severe illness
  • Take with food to avoid upset stomach
Sulfonylureas

Gliclazide

Gliclazide MR

Normal release 40mg once a day (half a tablet)

Slow release
30mg once a day

Normal release 320mg daily, up to 160mg/dose

Slow release
120mg once a day
  • Take with food to avoid hypoglycaemia (low BGL)
  • Give advice on recognising and treating a hypo (low BGL)
  • Avoid use in pregnancy
  • Associated with weight gain
Gliptins — DPP4 inhibitors
Linagliptin​ 5mg once a day 5mg once a day
  • No need to adjust dose for kidney disease or liver disease

  • Avoid use in pregnancy

Sitagliptin 100mg once a day 100mg once a day
  • If kidney disease — reduce dose
    • eGFR 30–45 — 50mg once a day
    • eGFR less than 30 — 25mg once a day

  • Avoid use in pregnancy

SGLT2 inhibitors
Applicable to all SGLT2 inhibitors
  • Withhold if unwell, if not eating, 3 days prior to surgery
  • Check ketones if unwell — even if BGLs are normal
  • Risk of genital fungal infections and dehydration
  • Do not use if
    • Recurrent thrush in women, balanitis in men
    • History of ketosis
    • Severe liver damage/disease
  • Avoid use in pregnancy
Empagliflozin 10mg once a day 25mg once a day
  • Do not use if kidney disease with eGFR less than 30
Dapagliflozin 10mg once a day 10mg once a day
  • Do not use if kidney disease with eGFR less than 25
GLP-1 receptor agonists
Applicable to all GLP-1 receptor agonists
  • Risk of nausea usually settles within a few months
  • Do not use if
    • Severe gastrointestinal disorders
    • Pancreatic cancer
    • Pregnant
    • History of pancreatitis
Dulaglutide 1.5mg subcutaneous (injection) weekly 1.5mg subcutaneous (injection) weekly
  • Do not use if kidney disease with eGFR less than 15
Semaglutide 0.25mg subcutaneous (injection) weekly

Start with 0.25mg weekly for 4 weeks

THEN increase to 0.5mg weekly for 4 weeks

THEN increase to 1mg weekly

Maximum dose is 1mg weekly
  • Do not use if kidney disease with eGFR less than 30

Insulin

Diabetes educator/doctor/nurse practitioner consult required for starting and adjusting insulin — consider specialist input

  • All people with type 1 diabetes
  • Some people with type 2 diabetes
    • To improve blood glucose control at any time
    • Needed after having diabetes for a long time — due to reduced ability of pancreas to produce insulin

Consider starting insulin in type 2 diabetes when

  • Symptoms of high blood glucose
  • Diagnosed with type 2 diabetes and HbA1c is more than 11%
  • Under 18 years with type 2 diabetes and HbA1c more than 8.5%
  • Taking maximum tolerated dose of 2–3 oral medicines AND HbA1c above target
  • Other reasons can’t take oral medications, eg kidney failure

Starting insulin

  • Must be prescribed by a doctor or nurse practitioner
  • Get help from diabetes educator — can be by telehealth
  • Take time for patient education including injecting (preparation, site selection and rotation) and monitoring, thinking it over, talking with another patient on insulin
  • Talk with person about practical ways to store insulin
  • Explain symptoms of low blood glucose and what to do
  • Agree on plan for monitoring BGL and insulin dose — dose may need to be adjusted regularly to begin with
  • Check technique for giving insulin and injections sites at least once a year

Insulin dosing

  • If Type 1 diabetes or prescribed insulin other than glargine — diabetes educator/nurse practitioner/medical consult
  • If Type 2 diabetes, on advice of doctor or nurse practitioner — other clinicians can titrate glargine according to Table 4.15
  • Record new dose on prescription each time it is changed
  • Review oral medicines — consider stopping any with side effects and adjusting insulin dose if needed
  • Start with once a day basal (intermediate/long-acting) insulin
    • Choose insulin (eg glargine) and injecting device (eg self-injecting pen)
    • Start with low dose and increase until target reached
    • If fasting (before breakfast) BGL high — give at bedtime
    • If fasting BGL on target but before evening meal BGL high — give in morning
  • Change to mixed insulin once or twice a day OR basal bolus insulin if
    • Fasting BGL in target BUT BGL 2 hours after meal or HbA1c high on once a day insulin and oral medicines
    • AND eating regular meals — higher risk of hypo (low BGL) with mixed insulin
    • AND can manage more complex treatment routine and self-monitoring
  • Continue most oral medicines and consider stopping sulfonylurea as BGL improve

Table 4.15 Glargine insulin treatment in type 2 diabetes

Glargine insulin​ Action
Starting dose

0.1 units/kg OR

BMI 25 or less — 10 units

BMI more than 25 — 15 units

Maximum dose
  • No set maximum dose
  • If dose high (greater than 70 units) — consider splitting dose between morning and night AND re-visit technique, ability to take insulin, diet and physical activity
Adjusting doses
  • If fasting BGLs above target — increase by 2–4 units 
  • Do not increase dose if fasting BGL less than 4mmol/L at any time in last week
Adjust dose — once or twice a week if
  • No hypos or low BGL symptoms
    • Do not increase dose if fasting BGL less than 4mmol/L at any time in last week
  • AND most recent HbA1c outside target range
  • AND
    • If daily monitoring — fasting BGL outside target range on 2 or more days in a row
    • If not daily monitoring — 2 or more clinic readings outside target range in 1 week
 Use fasting (before breakfast) BGL
  • If BGL less than 4mmol/L — decrease by 2 units OR 10% if dose more than 20 units
  • If BGL 4–7mmol/L — same dose
  • If BGL 7.1–10mmol/L — increase by 2 units
  • If BGL more than 10mmol/L — increase by 4 units

Complications

Foot problems

  • Diabetes foot disease is a chronic condition
  • Most common complication of peripheral neuropathy (nerve damage​) and peripheral arterial disease (blood vessel damage) — may lead to infection​, foot ulcers​, nerve pain, amputation
  • Any changes to the bony and soft tissue structure of the foot or to blood flow or sensation can cause an acute foot complication that needs to be referred quickly to a podiatrist and multidisciplinary team
Red Flags — Urgent Medical Consult

High Risk Foot — if any of the following podiatry referral

  • Peripheral neuropathy
  • Peripheral vascular disease
  • Foot deformity
  • History of foot wounds or amputations
  • End stage renal failure

Two or more of High Risk Foot — urgent podiatry referral

  • Foot wound with moderate or severe infection
  • Positive probe to bone test
  • Wet gangrene — discoloured skin, numbness, foul discharge
  • Active charcot foot (hot and swollen foot) 
  • Recent foot related hospital admission without a discharge plan

Ask

  • About any recent hospitalisations AND read discharge plan

Check

Do

  • Manage abnormalities in collaboration with multidisciplinary team — at minimum medical AND podiatrist consult
  • Dress wounds as needed — see Wound dressing
  • Treat infections — see Injuries – soft tissue
  • Identify ways to offload pressure on the wound — podiatrist can advise 

Follow-up

Table 4.16 Frequency of feet checks

High Risk Feet Low Risk Feet
3 monthly foot checks minimum Yearly foot checks
Teach daily foot care Teach daily foot care
Individualised management plan with podiatry

Eye disease

  • Includes diabetic retinopathy, cataract
  • Any change in vision needs to be assessed either as soon as possible by optometrist if gradual onset OR straight away by ophthalmologist if sudden onset
  • To lessen risk of blindness
    • Regular screening of vision — yearly fundoscopy or retinal photography
    • Good blood glucose levels and good BP
    • Encourage and support stopping smoking
    • If diabetic eye damage — more frequent eye specialist examinations
    • Laser treatment, if needed

Dental problems

Type 2 diabetes increases risk of more frequent and severe dental/oral disease — risk also increased by poor dental hygiene, smoking, high BGLs

  • Dental/oral disease makes it harder to manage diabetes
  • Problems include infections, bone/tooth loss, loose/painful teeth
  • Encourage good oral hygiene
  • Need regular visits to dentist — every 3 months if possible
  • Encourage and support stopping smoking