Diabetes – Management

Initial Management Plan

1. Patient Education and Individualized Targets

• Tailor management goals based on:
  • Age, concurrent illness, and life expectancy.
  • Lifestyle preferences and psychological well-being.
• Blood glucose stabilization:
  • Relieve symptoms of hyperglycemia (e.g., polyuria, polydipsia, fatigue).
  • Prevent acute complications like diabetic ketoacidosis and hyperosmolar hyperglycemia.
  • Avoid hypoglycemia.
  • Reduce risk of chronic complications.

2. Multidisciplinary Team (MDT) Approach

• Utilize the Enhanced Primary Care Program and Team Care Arrangement to fund 5 allied health services per year.
• Key members of the team:
  • Diabetes educator: Provides patient education and self-management support.
  • Dietitian: Develops tailored nutrition plans.
  • Podiatrist: Manages foot care and prevents complications.
  • Endocrinologist: Specialist management of complex diabetes.
  • Ophthalmologist/Optometrist: Eye exams at diagnosis, then at least every 2 years.
  • Pharmacist: A formal Home Medicines Review (HMR) can be arranged by GPs to optimize medication use.
  • Psychologist: Manage common comorbidities like depression; referrals can be arranged through a Mental Health Care Plan (MHCP).

3. Non-Pharmacological Management

• Lifestyle modifications:
  • Nutrition: Consult with a dietitian for a diabetes-friendly diet plan.
  • Physical activity: Aim for 30 minutes of moderate-intensity exercise every second day (or more), as guided by a physical therapist.
  • Smoking cessation: Strongly encouraged.
• Regular screening and treatment:
  • Eyes: Regular eye exams to detect retinopathy.
  • Kidneys: Monitor kidney function through eGFR and UACR.
  • Feet: Regular foot checks to prevent ulcers and neuropathy.
  • Cardiovascular health: Monitor and manage cardiovascular risk factors.
• Psychosocial and mental health:
  • Screen for and address underlying mental health conditions, such as depression and anxiety.
  • Pay special attention to adolescent and mental health comorbidities.

4. Lifestyle and Cardiovascular Risk Reduction

• Diet: Follow a heart-healthy, diabetes-friendly diet as per the dietitian’s advice.
• Physical activity: 30 minutes of moderate-intensity exercise on alternate days.
• Lipid and blood pressure management:
  • Set individualized targets and consider medications such as statins and ACE inhibitors for cardiovascular risk reduction.

5. Ongoing Reviews and Monitoring

Quarterly Review: 

1. SNAP intervention, review self monitoring, review sx, check weight / waist circumference, BP, foot exam. HbA1c at least 6 monthly. 

Yearly Review: 

1. Review goals of management
2. Check for diabetic complications – P/E cardio, peripheral nervous system, eyes, feet
3. Immunisations – influenza yearly, pneumococcal, tetanus (booster 50yrs)
4. Investigations – lipids, ACR/microalbuminuria, UEC, ECG 2^nd yearly if >50 w other CVD risk
5. Referrals – ophthalmologist/optometrist 2^nd yearly, allied health

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MDT

🩺 GENERAL PRACTITIONER (GP)

Assess

• Hypoglycaemia risk (especially with insulin/sulfonylureas)
• Psychological status (initial screening)
• Vision issues (refer for eye examination)
• Dental issues (refer for review)
• Cognitive impairment, sleep apnoea (refer where indicated)
• Driving fitness (initial and medical assessment)

Advise

• SNAP risk factors: smoking, nutrition, alcohol, physical activity
• Nutritional guidance and referral to APD
• Physical activity advice and referral to AEP/physio
• Pregnancy planning (incl. NDSS strip access)
• Sick day planning and medication guidance
• Immunisation
• Self-monitoring blood glucose support
• Insulin initiation and titration
• Psychological and emotional health
• Medication safety and interactions

Assist

• NDSS registration and glucose strip access
• GPMP and TCA coordination
• Address cultural and psychosocial concerns

Arrange

• Recall and register entry (diabetes register)
• Pathology and annual cycle of care review
• Driver’s licence assessment (when appropriate)

👩‍⚕️ PRACTICE NURSE

Assess

• Hypoglycaemia risk
• SNAP profile
• Sick day readiness
• Psychological symptoms

Advise

• Immunisation
• Blood glucose monitoring
• Insulin education
• Cultural sensitivity and wellbeing

Assist

• NDSS registration and strip access
• GPMP and CDM plan implementation

Arrange

• Diabetes register entry
• Cycle of care review
• Driver’s licence documentation

🧠 PSYCHOLOGIST

Assess

• Psychological state (depression, anxiety, adjustment)

Advise

• Provide therapeutic interventions for mood and coping
• Assist with trauma-related or culturally-sensitive issues

👁️ OPTOMETRIST / OPHTHALMOLOGIST

Assess

• Retinopathy and visual complications from diabetes

🦷 DENTIST

Assess

• Periodontal and oral health as part of diabetes complications

🩻 ENDOCRINOLOGIST

Assess

• Hypoglycaemia, insulin safety
• Secondary complications
• Pregnancy and contraception considerations
• Driver safety and medical fitness
• Medication interactions and optimisation

Advise

• Insulin titration and complex injectable therapy

💊 PHARMACIST

Advise

• Medication optimisation and adherence support
• Potential interactions or side effect monitoring

🍎 ACCREDITED PRACTISING DIETITIAN (APD)

Advise

• Personalised nutrition plans
• Pregnancy-related dietary advice

🏃‍♂️ ACCREDITED EXERCISE PHYSIOLOGIST (AEP) / PHYSIOTHERAPIST

Advise

• Tailored physical activity plans
• Address mobility or exercise barriers

👶 OBSTETRICIAN

Assess / Advise

• Preconception and antenatal diabetes management
• NDSS eligibility and safe monitoring

👥 ABORIGINAL HEALTH WORKER / SOCIAL WORKER

Advise / Support

• Cultural safety and advocacy
• Psychosocial support and care navigation

🧑‍🏫 CREDENTIALED DIABETES EDUCATOR (CDE)

Assess

• Blood glucose monitoring competency
• Medication understanding and barriers

Advise

• SNAP risk factor counselling
• Pregnancy planning and NDSS access
• Sick day and insulin management
• Psychological resilience and problem-solving

Assist

• NDSS registration and consumable access
• GPMP/CDM coordination support
• Cultural and psychosocial issues

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The Blood Glucose Profile in Type 2 Diabetes

In type 2 diabetes, the blood glucose pattern across a 24-hour period consists of the following components:

1. Fasting Blood Glucose (FBG)

• Reflects hepatic glucose output during overnight fasting.
• Typically sets the baseline for daily glucose levels.
• Target (per Australian guidelines): 4–7 mmol/L in most adults with T2DM.

2. Daytime Baseline Trends

• There may be a gradual rise in preprandial (pre-meal) glucose levels from morning to evening due to:
  • Progressive insulin resistance during the day.
  • Accumulated dietary intake or suboptimal insulin coverage.
• In some patients (e.g., those with strong basal insulin control), a fall in baseline may be observed if meals are small or physical activity increases across the day.

3. Prandial Glucose Excursions (Postprandial)

• Blood glucose rises post-meal, peaking at 1–2 hours after eating.
• Typically returns to near baseline within 3–4 hours, depending on insulin response, meal composition, and medication.
• Target postprandial glucose (2-hour): <10 mmol/L (per ADA/EASD), or <8–10 mmol/L per Australian consensus in T2DM.

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Setting Glycaemic Targets

HbA1c Goal

• General target: ≤7.0% (53 mmol/mol).
• More relaxed goals (e.g. ≤8.0%) may apply in elderly or high-risk individuals.
• More stringent targets (e.g. ≤6.5%) may be used in younger, well-motivated individuals without hypoglycaemia risk.

Average Blood Glucose (avBG)

• Approximate 24-hour mean glucose, correlating with HbA1c.
• Conversion formula (approximate):
  • avBG (mmol/L) = 1.59 × HbA1c (%) – 2.59
  • OR the simplified estimate:
    avBG (mmol/L) ≈ 2 × HbA1c (%) – 6

Preprandial Blood Glucose (prepBG)

• Measured before meals (usually breakfast, lunch, and dinner).
• Target: 4–7 mmol/L in most guidelines.
• Often ~1 mmol/L lower than avBG.
• Your proposed formula:
  • prepBG = 2 × HbA1c – 7
    is a reasonable approximation, but not universally validated. It’s acceptable for educational use but not diagnostic.

Example

• HbA1c = 6% (42 mmol/mol)
  • Estimated avBG = 6 mmol/L
  • Estimated prepBG = 5 mmol/L

✅ This is consistent with expected physiological patterns.

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TARGETS

1. General Glycaemic Targets – NHMRC and RACGP guidelines.

Parameter	Target	Notes
HbA1c	≤53 mmol/mol (7.0%)	Most non-pregnant adults
Fasting/Preprandial	4–7 mmol/L	ADA/AUS consensus
Postprandial (2h)	<10 mmol/L	Peak glucose after meals
Average BG	~6–8 mmol/L	Derived from HbA1c, rough estimate

2. Targets for Glycaemic Control – The NHMRC stratification of normoglycaemia vs elevated risk:

Preprandial (mmol/L)	Postprandial (mmol/L)	Interpretation
4.0–6.0	4.0–7.7	Normoglycaemia
6.1–8.0	6.0–10.0	Elevated/at-risk
>8.0	>10.0	High risk/hyperglycaemia

3. Individualised HbA1c Targets – ADS 2019–2020 position statement on individualised glycaemic targets.

Condition	HbA1c Target
General target	≤53 mmol/mol (7.0%)
Short duration, no CVD	≤42 mmol/mol (6.0%)
Lifestyle only ± metformin	≤42 mmol/mol (6.0%)
Any other oral agent or GLP-1 RA	≤48 mmol/mol (6.5%)
On insulin	≤53 mmol/mol (7.0%)
Pregnancy or preconception	≤42 mmol/mol (6.0%)
Long duration or established CVD	≤53 mmol/mol (7.0%)
Severe hypoglycaemia or hypoglycaemia unawareness	≤64 mmol/mol (8.0%)
Major comorbidities/limited life expectancy	Symptomatic management, aim <15 mmol/L

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Glucose monitoring in specific populations

Self-Monitoring of Blood Glucose (SMBG) in Type 2 Diabetes

SMBG is recommended in the following situations for patients with type 2 diabetes:

• On medications that may cause hypoglycemia, such as insulin or sulfonylureas.
• When HbA1c results are unreliable, such as during intercurrent illness or conditions that affect red blood cell turnover.
• During intercurrent illness, to monitor for hypo- or hyperglycemia.
• In pre-pregnancy and pregnancy management, especially in individuals with established diabetes.

If HbA1c measurements are deemed inaccurate, glycemic control should be assessed using:

• Self-Monitoring of Blood Glucose (SMBG)
• Continuous Glucose Monitoring (CGM)

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Special Considerations in Glycaemic Monitoring

🔵 Renal Failure

• HbA1c Limitations: In advanced chronic kidney disease (CKD), HbA1c can be unreliable due to:
  • Altered red cell lifespan (shortened in dialysis)
  • Use of erythropoiesis-stimulating agents (ESAs)
  • Frequent blood transfusions
  • Uraemia affecting glycation process
• Alternative Markers:
  • Fructosamine and glycated albumin reflect shorter-term glycaemia (2–3 weeks) but:
    • Are affected by hypoalbuminaemia and malnutrition
    • Have limited validation in dialysis populations
• Recommended Monitoring:
  • Structured SMBG (self-monitoring of blood glucose) logs remain essential
  • CGM (Continuous Glucose Monitoring) can be considered, particularly in patients at high risk of hypoglycaemia or with erratic glucose patterns

🔹 Source: ADS/RACGP Guidelines, KHA-CARI Guidelines, KDIGO 2022 Diabetes in CKD Update

🔴 Pregnancy

• Diagnosis of Gestational Diabetes Mellitus (GDM):
  • Use 75 g Oral Glucose Tolerance Test (OGTT) at 24–28 weeks gestation
  • HbA1c is not recommended for diagnosis (due to haemodilution and increased red cell turnover)
• Monitoring:
  • SMBG is the preferred method for daily monitoring
  • Target glucose values (per ADIPS 2020):
    • Fasting <5.3 mmol/L
    • 1-hour postprandial <7.8 mmol/L
    • 2-hour postprandial <6.7 mmol/L
• CGM Use:
  • CGM is supported in:
    • Type 1 diabetes in pregnancy (for tight glucose control and hypoglycaemia prevention)
    • Selected cases of GDM or type 2 diabetes (case-by-case)

🔹 Source: ADIPS 2020 Guidelines, NICE NG3, Australian Pregnancy Care Guidelines

🟠 Type 1 Diabetes in Puberty

• Puberty and Glycaemic Control:
  • Puberty induces physiological insulin resistance due to:
    • Elevated growth hormone, sex steroids, and cortisol
    • Increased hepatic glucose output and reduced insulin sensitivity
  • This results in higher insulin requirements and more variable glycaemia
• Clinical Considerations:
  • Adolescents may require:
    • More frequent glucose monitoring (SMBG or CGM)
    • Dynamic insulin dose adjustments (especially basal and bolus ratios)
    • Psychological support to address diabetes burnout, adherence issues, and body image concerns

🔹 Source: ISPAD Clinical Practice Consensus Guidelines, ADS Position Statements

✅ Summary

Situation	HbA1c Role	Recommended Monitoring	Notes
Renal Failure	Unreliable in advanced CKD	SMBG, CGM, limited fructosamine	Avoid HbA1c-based decisions in dialysis or ESA use
Pregnancy	Not used for diagnosis	OGTT for diagnosis, SMBG or CGM	Specific pregnancy targets apply (ADIPS)
Puberty (T1DM)	Still used, but adjust goals	SMBG/CGM, insulin titration	Pubertal hormones increase insulin resistance

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National Diabetes Services Scheme (NDSS) Subsidy for CGM

Under the NDSS, CGM is subsidized for certain eligible individuals with type 1 diabetes. The eligibility criteria are as follows:

1. Children and Young People with Type 1 Diabetes (up to 21 years):
   • Must be under 21 years of age.
   • Must have a valid NDSS registration.
   • Must have a diagnosis of type 1 diabetes.
2. People with Type 1 Diabetes Aged 21 Years and Older with Certain Clinical Needs:
   • Must be 21 years or older.
   • Must have a valid NDSS registration.
   • Must meet specific clinical criteria, such as:
     • Frequent severe hypoglycemia without warning.
     • Significant fear of hypoglycemia that affects quality of life.
     • Impaired awareness of hypoglycemia.
     • Need for intensive management due to frequent and severe hyperglycemia.
3. People with Type 1 Diabetes Who Are Pregnant, Planning Pregnancy, or Immediately Postpartum:
   • Must be planning pregnancy, currently pregnant, or up to 6 weeks postpartum.
   • Must have a valid NDSS registration.
4. People with Type 1 Diabetes and Additional High Clinical Needs:
   • Special consideration is given to individuals with additional high clinical needs not covered by other categories.
5. Carers of Children and Young People with Type 1 Diabetes:
   • Carers of eligible children may receive subsidized CGM if they meet the criteria.

NDSS Registration Eligibility

To register with the NDSS, individuals must:

• Be a resident of Australia.
• Have a Medicare card or Department of Veterans’ Affairs card.
• Have a diagnosis of diabetes confirmed by a doctor or a credentialed diabetes educator.

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Clinical Management Goals in Type 2 Diabetes

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🔵 Glycaemic Control

Parameter	Target	Notes
HbA1c	≤53 mmol/mol (≤7.0%)	Individualised based on age, comorbidities, risk of hypoglycaemia, and patient preference
	≤42 mmol/mol (≤6.0%)	Consider in younger, newly diagnosed, or preconception patients
	≤48 mmol/mol (≤6.5%)	When on oral agents other than metformin
	≤64 mmol/mol (≤8.0%)	For patients with severe hypoglycaemia or limited life expectancy

🧪 Lipid Targets

(Pharmacotherapy guided by absolute CVD risk, not single lipid values)

Parameter	Target	Notes
Total Cholesterol	<4.0 mmol/L	—
HDL-C	≥1.0 mmol/L	—
LDL-C	<2.0 mmol/L	<1.8 mmol/L: for established atherosclerotic cardiovascular disease (ASCVD) . <1.4 mmol/L: for very high-risk patients (recent MI or multiple cardiovascular events, aiming for a ≥50% reduction from baseline LDL-C levels)
Non-HDL-C	<2.5 mmol/L	Better surrogate for atherogenic burden
Triglycerides	<2.0 mmol/L	Lifestyle modification preferred first

❤️ Blood Pressure Targets

Population	Target BP	Notes
General T2DM population	<140/90 mmHg	Minimum threshold
T2DM + albuminuria/proteinuria	<130/80 mmHg	KDIGO and RACGP recommend tighter control
T2DM + established CVD or stroke risk	<130/80 mmHg	For secondary prevention
T2DM + frailty / elderly	Individualised	Avoid orthostatic hypotension

🧫 Renal Function Monitoring

Parameter	Target	Notes
Urine Albumin-Creatinine Ratio (UACR)	Women: <3.5 mg/mmol Men : <2.5 mg/mmol	Detect microalbuminuria early
Timed Overnight Collection	<20 µg/min	Alternative method
Spot Urine Albumin	<20 mg/L	Threshold for microalbuminuria

💉 Vaccination Recommendations

• Routine Vaccines:
  • Influenza (annual)
  • Pneumococcus (as per age/risk-based schedule)
  • Diphtheria-tetanus-acellular pertussis (dTpa)
• Additional:
  • Hepatitis B: especially if not previously immunised or at risk
  • Herpes Zoster: as per age recommendations
  • COVID-19: strongly recommended (per ATAGI guidance)

Nutrition in Type 2 Diabetes Management

• Initial Glycaemic Normalisation: 50% of individuals may normalise BGLs with dietary change, weight loss, and activity alone.
• Weight Goals:
  • Aim for BMI 18–24.9 kg/m²
  • Or use waist circumference as surrogate (Men <94 cm, Women <80 cm)
  • A 5–20% weight loss can markedly improve BGLs and metabolic markers

• Energy Restriction:
  • ~2000 kJ/day restriction
  • Target 0.5 kg/week weight loss
• Dietary Recommendations:
  • Emphasise low GI, high-fibre foods:
    • e.g., wholegrain bread, oats, legumes, pasta, temperate fruits
  • Fat intake: <30% of total energy
  • Avoid saturated fats (processed foods, meats, takeaways)
  • Fish oils: 5g/day for cardiovascular benefit
  • Alcohol: ≤2 standard drinks/day (per NHMRC)
  • Salt: Avoid added salt in cooking (reduce hypertension/stroke risk)
• NAFLD Consideration:
  • Common in T2DM; may present with elevated ALT, ultrasound “bright liver”
  • Treatment: Lifestyle modification
  • Strongly recommend dietitian referral

🏃 Physical Activity in Type 2 Diabetes Management

• Target:
  • At least 150–300 minutes/week of moderate-intensity aerobic activity
    • OR
  • 75–150 minutes/week of vigorous-intensity aerobic activity
    • OR
  • An equivalent combination of both
  • Include muscle-strengthening activities on at least 2 days/week
• Cardiac Monitoring:
  • If >50 years + vascular risk: consider ECG every 2 years
  • Silent MI is common in T2DM
• Insulin Consideration:
  • Adjust carbohydrate intake or insulin dose around activity
  • Delayed hypoglycaemia may occur 6–12 hours post-exercise

🧍 Lifestyle & Monitoring Recommendations

Parameter	Goal	Notes
Smoking	Complete cessation	Goal: 0 cigarettes/day
Alcohol	≤10 drinks/week, ≤4/day No more than 4 standard drinks on any one day	Reduce liver stress (NAFLD), avoid BGL disruption Standard drink = 10 g of ethanol Abstain during pregnancy and breastfeeding
Blood Glucose Monitoring (SMBG)	Fasting: 4–7 mmol/L Postprandial: 5–10 mmol/L	CGM may be considered in high-risk patients

 

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Driving with Diabetes

Austroads Guidelines Overview:

• Provides a flowchart (Figure 10) for managing diabetes in drivers seeking a commercial licence.
• Drivers must notify authorities of significant health changes affecting driving.
• In some regions (e.g., SA and NT), doctors are mandatory notifiers for diagnosed conditions.