Diabetes

Summary of changes

Addition

  • Check ketones if unwell and taking a SGLT-2 inhibitor in Check section
  • Lower HbA1c cut off value (5.7 to 6.4%)
  • Addition of HbA1c target for young people: 48 mmol/mol (6.5%) if less than 18 years
  • BGL self monitoring recommended to person on insulin
  • Update of steps for medicines for type 2 diabetes to reflect 2021Australian type 2 diabetes management algorithm
  • Addition of caveat "diabetes educator/medical/nurse practitioner consult required for all insulin initiation and adjustments" and consider specialist input

Deletion

  • Remove "or less" in OR if severe CAD, elderly person- HbA1C 8% or less due to unnecessary risk of hypos. Removal of "Do not use HbA1c if under 18 years"
  • Removal of recommendation to start metformin/insulin for children, linkage to https://diabeteslifecourse.org.au/youth-diabetes/health-professional-resourcesand added to consider starting insulin if under 18 years with type 2 diabetes and HbA1c more than 8.5%

Medicines 

  • Deleted pioglitazone and glimepiride. Added gliclazide. Glargine insulin starting dose changed from 12 units to 10units if BMI 25 or less
  • Foot problems amended for clarification and linked to soft tissue injuries for antibiotic guidance
  • Update of oral medicines for type 2 medicines to reflect treatments availability and drug profiles

Other

  • Change to BGL 2h after meal 5-10mmol/L to be consistent with RACGP guidelines
  • Check ketones if high BP and/or taking a SGLT-2 inhibitor and unwell
  • HbA1c target for under 18yrs (48mmol/mol or 6.5%)
  • Doctor, nurse practitioner or diabetes educator consult if adjusting insulin dose

Primary references

  1. Northern Territory Diabetes Clinical Network (2019) Youth Diabetes – Health Professional Resources, accessed 18 October 2022.

  2. American Diabetes Association (2019) 'Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes', Diabetes Care, 42(Suppl 1):S13-S28, doi:10.2337/dc19-S002

  3. Australian Diabetes Society (2019) Diabetic Ketoacidosis (DKA) with SGLT2 Inhibitor Use, Particularly Perioperatively, accessed 9 August 2021.

  4. Australian Diabetes Society (2020) Living Evidence Guidelines in Diabetes, accessed 11 January 2022.

  5. Barr ELM, Barzi F, Rohit A, Cunningham J, Tatipata S, McDermott R, Hoy WE, Wang Z, Bradshaw PJ, Dimer L, Thompson PL, Brimblecombe J, O'Dea K, Connors C, Burgess P, Guthridge S, Brown A, Cass A, Shaw JE and Maple-Brown L (2020) 'Performance of cardiovascular risk prediction equations in Indigenous Australians', Heart, 106(16):1252-1260, doi:10.1136/heartjnl-2019-315889

  6. Bell K, Shaw JE, Maple-Brown L, Ferris W, Gray S, Murfet G, Flavel R, Maynard B, Ryrie H, Pritchard B, Freeman R and Gordon BA (2020) 'A position statement on screening and management of prediabetes in adults in primary care in Australia', Diabetes Research and Clinical Practice, 164:108188, doi:10.1016/j.diabres.2020.108188

  7. Buse JB, Wexler DJ, Tsapas A, Rossing P, Mingrone G, Mathieu C, D'Alessio DA and Davies MJ (2020) '2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)', Diabetes Care, 43(2):487-493, doi:10.2337/dci19-0066

  8. Dhatariya KK, Glaser NS, Codner E and Umpierrez GE (2020) 'Diabetic ketoacidosis', Nature Reviews Disease Primers, 6(1):40, doi:10.1038/s41572-020-0165-1

  9. Diabetes Australia (2016) Position Statement, A new language for diabetes, Improving communications with and about people with diabetes, Australian Diabetes Society, accessed 11 January 2022.

  10. Diabetes Care (2020) 'Standards of Medical Care in Diabetes-2020', Diabetes Care, 43(Suppl 1):S1-S2, doi:10.2337/dc20-Sint

  11. International Diabetes Federation Clinical Guidelines Task Force (2017) Global guideline for type 2 diabetes, accessed 28 June 2020.

  12. Peña AS, Curran JA, Fuery M, George C, Jefferies CA, Lobley K, Ludwig K, Maguire AM, Papadimos E, Peters A, Sellars F, Speight J, Titmuss A, Wilson D, Wong J, Worth C and Dahiya R (2020) 'Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines', Medical Journal of Australia, 213(1):30-43, doi:10.5694/mja2.50666

  13. Rosenstock J and Ferrannini E (2015) 'Euglycemic Diabetic Ketoacidosis: A Predictable, Detectable, and Preventable Safety Concern With SGLT2 Inhibitors', Diabetes Care, 38(9):1638-42, doi:10.2337/dc15-1380

  14. Royal Australian College of General Practitioners (2020) Management of type 2 diabetes: A handbook for general practice, RACGP, East Melbourne, Vic, accessed 3 October 2022.

  15. Titmuss A, Davis EA, Brown A and Maple-Brown LJ (2019) 'Emerging diabetes and metabolic conditions among Aboriginal and Torres Strait Islander young people', Medical Journal of Australia, 210(3):111-113.e1, doi:10.5694/mja2.13002

  16. Zhao Y, Jeyaraman K, Burgess P, Connors C, Guthridge S, Maple-Brown L and Falhammar H (2020) 'All-cause mortality following low-dose aspirin treatment for patients with high cardiovascular risk in remote Australian Aboriginal communities: an observational study', British Medical Journal Open, 10(1):e030034, doi:10.1136/bmjopen-2019-030034