Diabetes – Management

initial management

1. Education
2. Individualize targets
   1. age, concurrent illness and life expectancy, lifestyle and psychological wellbein
3. Blood glucose stabilization – Hyperglycaemia – Hypoglycaemia
   1. relieve symptoms of hyperglycaemia (eg polyuria, polydipsia, as well as more subtle changes related to general wellbeing)
   2. avoid acute complications of hyperglycaemia, such as diabetic ketoacidosis and hyperosmolar hyperglycaemia
   3. avoid hypoglycaemia
   4. reduce chronic complications.
4. Team
   1. MDT – Use Enhanced Primary Care Program + Team Care Arrangement to fund 5 allied health services per year
   2. Diabetic educator
   3. Dietician
   4. Podiatrist
   5. Endocrinologist
   6. Ophthalmologist – need ophthalmologist or optometrist initially & then at least every 2 years
   7. Pharmacologist – formal Formal Home Medicines Review (HMR) can be arranged by GPs
   8. Psychologist – depression common + can arrange for psychology through MHCP

Management plan – non pharmacological

1. Lifestyle measures
   1. Nutirition
   2. 30min moderate intensity exercise every second day as per physical therapist
   3. Smoking cessation
2. Complications check and treat – screen and treat
   1. Eyes
   2. Kidneys
   3. Feet
   4. Cardiovascular
3. Underlying psychosocial and mental health issues
   1. Screen for and address psychosocial issues including Adolescent and mental health comorbidities
   2. Identify barriers

• Lifestyle measures
  • Cardiovascular risk reduction: Diet as per dietician, 30min moderate intensity exercise every second day as per physical therapist.
• Lipids and Lower Blood pressure
  • Cardiovascular risk reduction: Create targets and consider statin and ACE-I.
  • Annual review of lipids, eGFR, UACR, foot exam, eye exam, physical activity, diet, medications, immunisations, smoking, management goals
• Insulin
• Therapeutics – Metformin etc
• Underlying psychosocial and mental health issues
  • Screen for and address psychosocial issues including Adolescent and mental health comorbidities.
• Smoking cessation
• Reviews:

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

The blood glucose profile

• In type 2 diabetes, the blood glucose profile has three components1
  • A flat baseline is set by the fasting blood glucose.
  • daytime baseline change:
    • usually an increase, in preprandial blood glucose (prepBG) occurs between breakfast and the evening meal. 
    • Less commonly, there is a decrease over this period.
  • The prandial blood glucose increases above baseline, generally
    • reaching a maximum within 1–2 hours and 
    • returning to baseline 3–4 hours after the meal.

Setting glycaemic targets

The general target for glycaemic control is 

• HbA1c ≤7%
• avBG of 8 mmol/L 
• prepBG of 7 mmol/L.

• avBG
  • over 24 hours
  • avBG mmol/L = 2 x HbA1c% – 6
• The prepBGs
  • before breakfast, lunch and the evening meal
  • approximately 1 mmol/L lower than avBG
  • reflects both basal and prandial glycaemia:
    • Preprandial mmol/L = 2 x HbA1c% – 7 

• For example, if the HbA1c is 6%, the HbA1c in mmol/mol is 42 mmol/mol
  • the avBG is 6 mmol/L
  • prepBG is 5 mmol/L

RECOMMENDED (HbA1c) TARGETS
Condition	HbA1c target
General target	≤53 mmol/mol (7.0%)
Diabetes of short duration and no clinical cardiovascular disease
Lifestyle modifications ± metformin	≤42 mmol/mol (6.0%)
Requiring any antidiabetic agent other than metformin or insulin	≤48 mmol/mol (6.5%)
Requiring insulin	≤53 mmol/mol (7.0%)
Pregnancy or preconception	≤42 mmol/mol (6.0%)
Diabetes of longer duration or clinical cardiovascular disease	≤53 mmol/mol (7.0%)
Severe hypoglycaemia or hypoglycaemia unawareness	≤64 mmol/mol (8.0%)
Major comorbidities likely to limit life expectancy	Symptomatic treatment of hyperglycaemia, aim for blood glucose level <15 mmol/L

Glucose monitoring in specific populations

• All Populations
  • If the HbA1c measurement is deemed inaccurate, glycaemic control should be assessed using:
    • Self-Monitoring of Blood Glucose (SMBG)
    • Continuous Glucose Monitoring (CGM)
  • To reduce glucose variability:
    • Strive for normalization of fasting and postprandial blood glucose levels.
    • This should be balanced against the burden of additional medications and their side-effect profile, even if the target HbA1c is met.

• Renal failure
  • Fructosamine and glycated albumin can be used as alternative glycaemic markers to HbA1c
  • however, low protein and albumin states limit their usage. 
  • Assessment of an SMBG diary over a period of time is likely to be more useful
  • CGM could also be considered.
• Pregnancy
  • A 75 g OGTT rather than a HbA1c test should be used to diagnose diabetes.
  • SMBG should be used for glucose monitoring and medication adjustment. 
  • CGM is another option, particularly for individuals with type 1 diabetes.
• Type 1 Diabetes
  • During Puberty
    • Natural increases in insulin resistance occur due to hormonal changes, such as elevated levels of growth hormone, cortisol, and sex hormones.
    • This can make maintaining stable blood glucose levels more challenging.
  • Under the National Diabetes Services Scheme, CGM is currently subsidised for
    • Eligibility Criteria
      • Children and Young People (up to 21 years of age) with Type 1 Diabetes:
        • Must be aged under 21 years.
        • Must have a valid NDSS registration.
        • Must have type 1 diabetes.
      • People with Type 1 Diabetes Aged 21 Years and Older with Certain Clinical Needs:
        • Must be aged 21 years or older.
        • Must have a valid NDSS registration.
        • Must have type 1 diabetes and meet specific clinical criteria, such as:
          • Frequent severe hypoglycemia without warning.
          • Significant fear of hypoglycemia leading to adverse clinical outcomes.
          • Impaired awareness of hypoglycemia.
          • Requirement for intensive clinical management due to frequent and severe hyperglycemia.
      • People with Type 1 Diabetes Who Are Pregnant, Planning Pregnancy, or Immediately Postpartum:
        • Must have a valid NDSS registration.
        • Must have type 1 diabetes.
        • Must be planning for pregnancy, currently pregnant, or up to 6 weeks postpartum.
      • People with Type 1 Diabetes and Additional High Clinical Needs:
        • Special consideration is given to individuals with type 1 diabetes who have additional high clinical needs that may not fit neatly into the other categories.
      • Carers of Children and Young People with Type 1 Diabetes:
        • Carers of children with type 1 diabetes may be eligible for subsidized CGM if they meet the relevant criteria.
    • Eligibility for NDSS Registration
      • 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 credentialed diabetes educator.

NUTRITION:

In >50% of people presenting w T2DM, restriction of energy intake + increased activity + weight reduction will initially normalize BGL. Medication is likely to be needed later.

AIM = BMI 18 – 24.9 OR can use WAIST CIRCUMFERENCE

• Often an ideal body weight is not achievable, suggest a wt loss of 5 – 20% which will improve glycaemic control
• Reduce energy intake to 2000KJ / day, equal wt loss 0.5kg / week
• Refer to dietician
• LOW GI + HIGH FIBRE food at every meal (ie: wholegrain breads, rolled oats, low fat/sugar cereal, pasta, beans, lentils, temperate fruits)
• Fats should account for <30% of diet
• AVOID saturated fats (additives in food, diary, meats, snack + takeaway food). 
• Recommend fish oils 5g/day
• Alcohol, follow Aus guidelines of ≤2 std / day men + women (20g)
• Avoid added salt in cooking
• NAFLD (Non-Alcoholic Fatty Liver Disease) common in ppl w T2DM, ax w abnormal LFT (esp ALT) + ‘bright liver’ on USS + other features of metabolic syndrome.
  • Can progress to cirrhosis. Mainstay rx lifestyle change.

PHYSICAL ACTIVITY:

• > 150 minutes / week of moderate intensity physical activity (ie: walking)
• Consider second yearly ECG if >50yrs & has at least one vascular risk factor (silent AMI common)
• If on insulin may need to incr carb load or decr insulin if exercising. Delayed hypoglycaemia can occur, 6-12hrs after cessation of activity

Cigarette consumption

• Zero per day

Alcohol consumption

• Advise ≤2 standard drinks (20 g of alcohol) per day for men and women

Blood glucose monitoring

• Advise 4–7 mmol/L fasting and 5–10 mmol/L postprandial 
• Self Monitoring 
• SMBG in patients with type 2 diabetes is recommended if
  • on agents that cause hypo’s (insulin, sulphonylureas.)
  • when HbA1c estimations are unreliable
  • when monitoring hypo/hyperglycaemia arising from intercurrent illness
  • during pre-pregnancy and pregnancy management for people with established

diabetes or gestational diabetes

• An initial schedule includes 3-4 BSL daily (early morning plus other tests before ± after meals). 

Quarterly Review:

 

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

Yearly Review: 

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

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.