diabetes management in gp 09

8/4/2019 Diabetes Management in GP 09

1/47

Di

abe

tes

2

009/

10

DiabetesManagementin General

PracticeGudln for typ 2 D


2/47

An electronic version of these guidelines is available at

www.racgp.org.au

Any changes ater the printing o this edition and beore the next will be availableon this website.

This booklet is not intended to replace proessional judgement, experience andappropriate reerral. While every care has been taken to ensure accuracy, reerenceto product inormation is recommended beore prescribing. Diabetes Australia andthe RACGP assume no responsibility or personal or other injury, loss or damagethat may result rom the inormation in this publication.

Goas foroptmumdaetes

management

The chart on the flip side lists goals for optimum

diabetes management that all people with diabetes

should be encouraged to reach.

This chart has been specifically designed as a card for

you to pull out and place on your desk or nearby for

easy reference.


3/47

Natona

DaetesSercesScemeThe NDSS makes life with diabeteseasier to manage

if you hv pn wh d, rgr hm whh NDss nd hm o mng hr d.

Rgron fr nd don only onc.

th flp d of h pg gv nformon on hNDss nd how o rgr. i h n pcfcllydgnd crd for you o pull ou nd plc onyour dk or nry for y rfrnc.

n BGL 4 6 mmol/L (fasting)

n HbA1c 7%

n LDL-C < 2.5 mmol/L*

n Total cholesterol < 4.0 mmol/L*

n HDL-C > 1.0 mmol/L*

nTriglycerides < 1.5 mmol/L*n Blood pressure 130/80 mm Hg**

n BMI < 25 kg/m2 where appropriate

n Urinary albumin excretion < 20 g/min (timed overnight collection)< 20 mg/L (spot collection)

< 3.5 mg/mmol: women

< 2.5 mg/mmol: men (albumin creatinine ratio)

n Cigarette consumption Zero

nAlcohol intake 2 standard drinks (20g) per day for men

and women***

n Physical activity At least 30 minutes walking (or equivalent)

5 or more days/week

(Total 150 minutes/week)

Goas for optmumdaetes managementEncourage a peope wt daetes to reac tese goas

Docor hould condr:

n Prophylactic aspirin (75-325mg) daily unless contraindications

nAnnual ECGn Immunisation against influenza and pneumococcal disease

Te Natona Daetes Serces Sceme (NDSS) s an ntate of te Austraan Goernment

admnstered Daetes Austraa.

Tese goas are dered from Daetes Management n Genera Practce 2009/10

Pused eac ear Daetes Austraa n conjuncton wt te Roa Austraan Coege

of Genera Practtoners.

* National Heart Foundation Guidelines.** NHMRC Evidence-based Guidelines for the

Management of Type 2 Diabetes, 2004.*** NHMRC, Australian Guidelines to Reduce

Health Risks from Drinking Alcohol 2009.


4/47

DIABETES MANAGEMENT

inGENERAL PRACTICE

Ffteent edton 2009/10

supportng te educaton programs

of Daetes Austraa

Natona DaetesSerces Sceme

Te Natona Daetes Serces Sceme (NDSS) s an ntate of te Austraan Goernment

admnstered Daetes Austraa.

Why rgr?

The National Diabetes Services Scheme (NDSS) offers people with diabetes

access to diabetes-related products such as blood glucose testing strips,

and insulin pump consumables at heavily subsidised prices and free insulin

needles and syringes. For a full list of products and prices, download the

order form from www.ndss.com.au.

NDSS registrants can also access a range of free information and support

services. Encourage your patients to contact Diabetes Australia on

1300 136 588 to find out what services they can take advantage of to

improve their knowledge and management of diabetes.

Who lgl?

All Australians who hold a Medicare card and have been diagnosed with

diabetes are eligible to receive the benefits offered under the NDSS.

How o rgr

n Fill in the NDSS Registration Form (available from www.ndss.com.au).

n Registration has to be certified by a GP or diabetes educator.

n Registration is free and done only once.

For mor nformon

Refer your patients to Diabetes Australia:

Pone: 1300 136 588 Weste: www.ndss.com.au

(See pages 79 and 80 of this booklet.)


5/47

32 Dbs Mgm Grl Pr

CONTENTS

Section PaGe

edorl Pnl 2

Forword from h Prdn 5

Wh nw hghlghng gnfcn chng 6

Conrovr 6

inroducon 7

1 Dgno 9

1.1 Who needs to be tested or undiagnosed diabetes? 10

1.2 What type o diabetes? 11

2 amn 13

2.1 Initial assessment 13 2.2 Plan o continuing care 15

2.3 Reerral 16

3 th m pproch 17

3.1 Members o the team 17

3.2 Counselling the person with diabetes 19

4 inl mngmn 21

4.1 Nutrition 22

4.2 Physical activity 26

5 Hlh cr for d 28

5.1 Sel-monitoring 28

5.2 Medical monitoring 29 5.2.1 Quarterly review 29 5.2.1.1 Quarterly nursing review 30 5.2.2 Annual review 5.2.2.1 Annual nursing review 31 5.3 Systems or care 32 5.3.1 How Medicare supports the process 33 5.3.2 Required annual cycle o care 34 5.3.3 General Practice Management Plans (GPMP) 35

5.3.4 Team Care Arrangements (TCA) 35

6 Mdcon 36

6.1 Oral hypoglycaemic agents 36

6.2 Insulin treatment 41 6.3 Insulin delivery 43 6.4 Insulins available 45 6.5 Problems with medication 46 6.6 New technology 47

6.7 Surgical procedures 47

EDITORIAL PANEL

Gratitude is expressed to everybody who has contributed to these guidelines: The HealthCare and Education Committee o Diabetes Australia, The Australian Diabetes Educators

Association, Australian Diabetes Society, Dietitians Association o Australia, The Drugand Therapeutics Inormation Service, many general practitioners, endocrinologists,dietitians, diabetes educators and podiatrists.

Dr Peter HarrisSenior LecturerSchool o Public Health and Community Medicine,University o New South Wales, Sydney NSW

Dr Linda MannGeneral Practitioner

Leichhardt, Sydney NSW; Medical Educator, GP Synergy; RACGP Representativeon Editorial Panel

Jane LondonProgram Manager, Quality CareRoyal Australian College o General Practitioners

Dr Pat PhillipsDirectorEndocrinology, North West Adelaide Health Service, Adelaide SA

Carole WebsterNational Publications ManagerDiabetes Australia State and Territory Organisations

Appreciation is expressed to Dr Chris Holmwood who prepared theoriginal guidelines.

The Editors have considered and included relevant inormation within guidelinesand evidence recognised by the medical proession, including the NH&MRC andthe Australian Diabetes Society. This document is designed or irst line primarycare. More complex care is best addressed by a team.

ISBN: 978 1875690 190July 2009

This publication was reviewed by Diabetes Australia's Health Care and EducationCommittee and RACGPs National Standing Committee or Quality Care in 2009and is endorsed or publication until 2010.

Photocopying this publication in its original orm is permitted or educationalpurposes only. Reproduction in any other orm without the written permissiono Diabetes Australia (National Publications Division) is prohibited.

Printed August 2009 Copyright Diabetes Australia 2009

Diabetes Australia Publication NP 1055Printed by Pinnacle Print Management, Gorokan NSW


6/47

4 Dbs Mgm Grl Pr Frwrd frm h Prsds 5

Foreword from the Presidents

Grl prrs u prvd ms f h mdl r ppl wh yp 2 dbs. th mplxy f r fr hs mm dss rqurssysm r frm h pr m d h mly rfrrl mmuy dhspl bsd splss.

th urr gud, s ffh d, hs mpr rl prvdg rdbl summry f urr gudls d rmmds frm vrus surs h mgm f yp 2 dbs h grl pr sg.

imprly, hs d g luds spf ssus rlg rg dbs h abrgl d trrs Sr isldr ppul whh rfls h burd fhs dss wh hs grup. als ludd s ru r hkls fr pr

urss fr us udr h ll vrsgh f h grl prr.

Dr Gary DeedPresidentDiabetes Australia

Dr Chris MitchellPresidentRoyal Australian Collegeof General Practitioners

7 sck dy 48

8 Hyprglycmc mrgnc 50

8.1 Diabetic ketoacidosis 50

8.2 Hyperosmolar non-ketotic coma 52

9 Fcor complcng mngmn 54

9.1 Macrovascular disease 54

9.2 Hypertension 56

9.3 Dyslipidaemia 58

9.4 Renal damage 60

9.5 Eye damage 63

9.6 Foot problems 64

9.7 Neuropathy 66

9.8 Problems with medications 67

9.9 Complementary medicines 68

10 D nd rproducv hlh 69

10.1 Pregnancy 69

10.2 Gestational diabetes 70

10.3 Contraception 71

10.4 Hormone replacement therapy 71

10.5 Sexual problems 72

11 Drvng 73

12 trvl 75

13 D aurl 77

14 Nonl D srvc schm (NDss) 79

15 Royl aurln Collg of Gnrl Prconr 81

Furhr rdng 82

indx 83

inrn rourc 85

Gol for mngmn bck pg

Section PaGe


7/47

6 Dbs Mgm Grl Pr irdu 7

Whats new highlighting

significant changes

The 15th edition oDiabetes Management in General Practice (2009/10) containsthe ollowing signiicant changes to the 2008/09 edition:

Controversies:A new section to highlight current controversial issues (see below).

Goals for optimum diabetes management:Alcohol guidelines The NHMRCAustralian Guidelines to Reduce Health Risks rom Drinking Alcohol released inMarch 2009 recommend 2 standard drinks (20g) per day or men and women(see Optimum Diabetes Management lift out card, page 26 and outside back cover).

Section 5:Medicare Inormation relating to Medicare has been expanded

(see page 34).

Section 6: Glitazones the use o glitazones has been amended to relect latestproduct inormation (see page 37).

ControversiesHbA1c: epdmlgl vd hs suggsd h h lwr h Hba1, h lwrh rsk f rdvsulr vs bh yp 1 d yp 2 dbs. thr rrls ps mdr hgh rsk f rdvsulr vs dd supprhs lus.

The recommended target remains


8/47

8 Dbs Mgm Grl Pr Dgss 9

Spf ssus rlg h rm f dbs h abrgl dtrrs Sr isldr ppul wll b hghlghd bxs hrughuh gudls. a srvv pprh hs b k h smsludd sur h prrs hv fd hy r bsd sld vd.

For the team approach to be successul there should be good communicationbetween members based on trust and respect. For example, the patient will otenrelate best to the general practitioner. The other team members should be ableto support that relationship and channel their input to management accordingly.

The role o the general practitioner ideally involves initial diagnosis, treatment,coordination o consultant and allied proessional care and continuing management

(including education and counselling o the patient and carers).

The importance of the patient-doctor partnership in the managemento diabetes cannot be overstated. The patient and the general practitionerneed to have an agreed understanding o the patients diabetes and associatedproblems and agree on the management strategies being adopted.

Inordertoprovideoptimumcare,thegeneralpractitionermusthaveadequaterecords and systems in place which will assist in the recall o patients or urtherinvestigations or continuing management. Adequate records are also necessaryin order to monitor outcomes both or the individual and within the widercommunity. A diabetes register at every practice is encouraged.

Ensure that all other preventive health care activities are included, whilemaintaining good diabetes health care.

Carers need to become involved in education and management decisions. Thisis particularly so in young people with diabetes, disabled patients and wheremajor dietary changes are required. Every carer needs to be well inormed on

recognition and treatment o hypoglycaemia, i the patient is treated with insulin,sulphonylureas or repaglinide.

1 Diagnosis

People in high risk groups need to be screened for undiagnosed type 2

diabetes. See following page for high risk categories.

The diagnosis o diabetes is made in one o the ollowing three ways but eachmust be conirmed on a subsequent day unless unequivocal hyperglycaemia withacute metabolic decompensation or obvious symptoms are present: Symptomsofdiabetesandarandom(nonfasting)bloodglucose>11mmol/L Fastingplasmaglucose7.0mmol/L 2-hourplasmaglucose>11mmol/Lduringanoralglucosetolerance

test (OGTT)

The OGTT is unnecessary to diagnose diabetes in people with an unequivocallyelevated asting or random plasma glucose. An OGTT needs to be perormed in aperson with an equivocal result. (See Fig. 1).

The test is carried out ater an overnight ast, ollowing three days o adequatecarbohydrate intake (greater than 150g per day). A 75g load o oral glucose isgiven and the diagnosis o diabetes can be made i venous plasma glucose levelfastingis7.0mmol/Lor2hourpostglucoseloadis11.1mmol/L.

Capillary blood glucose measurement using a desktop meter may be used fortesting for undiagnosed diabetes as long as it is confirmed by venous plasmameasurement. Urine testing is not sufficiently sensitive or specific as a screeningtest for undiagnosed diabetes.

Diabetes unlikely

Diabetes unlikely Diabetes likely

Diabetes likely

Impaired glucose tolerance

11.1

F: 5.5-6.9

R: 5.5-11.0F or R: 7.0

R: >11.1

Re-test yearly if

high risk

3 yearly if

increased risk

Diabetes uncertain

Oral glucose tolerance test

2hr glucose levels

F = Fasting R = Random

Fig. 1: Glucose levels venous plasma: mmol/L


9/47

10 Dbs Mgm Grl Pr Dgss 11

1.1 Who needs to be tested for undiagnosed diabetes?

Asymptomatic people at high risk o undiagnosed diabetes should be identiiedand screened by measurement o plasma glucose. This needs to be perormed bya laboratory (rather than with a blood glucose meter) and preerably on a astingsample. However a random sample may be used.

People at high risk or undiagnosed type 2 diabetes are:

Peoplewithimpairedglucosetolerance,impairedfastingglucose.

AboriginalandTorresStraitIslandersaged35andover.

CertainhighrisknonEnglishspeakingbackgroundpeopleaged35andover(speciically Paciic Islanders, people rom the Indian subcontinent, people oChinese origin).

Peopleaged45andoverwhohaveoneormoreofthefollowingriskfactors:

Obesity(BMI30kg/m2) Hypertension

All people with clinical cardiovascular disease (myocardial infarction,angina, stroke or peripheral vascular disease).

Womenwithpolycysticovariansyndromewhoareobese.

The AUSDRISK tool (www.health.gov.au) is used to identiy those at high risk o havingundiagnosed pre-diabetes or type 2 diabetes. To help prevent diabetes, some Divisions oGeneral Practice oer programs to patients who score highly or pre-diabetes.

The ollowing groups are also at high risk but urther studies are required toevaluate net clinical or economic beneit:

Womenwithhistoryofgestationaldiabetes.

Peopleaged55andover.

Peopleaged45andover,withafirstdegreerelativewithtype2diabetes.

Certain medications (especially glucocorticoids and atypical antipsychotics) canaect glucose metabolism and increase the risk o diabetes.

Pre-diabetes (abnormal glucose metabolism: impaired asting glucose(6.16.9 mmol/L)), also identiied by impaired glucose tolerance (2h glucose7.811.0 mmol/L) is a marker o increased risk o cardiovascular disease anddiabetes. Liestyle and other risk actors need to be assessed (see page 55) andpatients counselled and treated to reduce uture risk. Several trials have shown thatliestyle change can slow progression to diabetes. Obesity, particularly abdominalobesity, is central to the development o type 2 diabetes and related disorders.

Weight loss improves insulin resistance, hyperglycaemia and dyslipidaemia inthe short term, and reduces hypertension. Overweight and obese people shouldthereore be encouraged to achieve and maintain a healthy body weight.

Increased physical activity is particularly important in maintaining weight loss.Regular physical activity also improves insulin sensitivity; reduces plasma levels o

insulin in people with hyperinsulinaemia; improves dyslipidaemia and lowersblood pressure. Moreover, physical activity increases metabolically active muscletissue and improves general cardiovascular health. Increased physical activity alsoreduces the risk o type 2 diabetes.

Whilst use o metormin and glitazones have been trialled as pharmacologicalapproaches to diabetes prevention in this group with some success, liestylemodiication is more eective.

Periodic testing or undiagnosed diabetes is recommended in high risk individuals.All high risk people with a negative screening test are at risk o cardiovasculardisease and the uture development o type 2 diabetes, and need to be givenappropriate advice on SNAP risk actor reduction (Smoking, Nutrition, Alcoholand Physical activity).

Pregnant women need to be screened or gestational diabetes (see 10.2 on page 70).Routine testing o low risk asymptomatic people is not recommended.

th abrgl d trrs Sr isldr ppul hs hghr rsk fdvlpg dbs d s 10.5 13 ms mr lkly d frm dbs,mprd wh -idgus ausrls.

th prevalencef udgsd dbs h abrgl d trrs Srisldr ppul xds 5% ll hs vr 35 yrs f g. i smrgs h prvl pprhs 5% muh yugr g (s yug s18 yrs). th prvl f dbs rsk frs ludg mprd gluslr (iGt) xds 5% hs ppul gd udr 35 yrs f g.

th incidence f dbs h abrgl d trrs Sr isldrppul s 10 ms hghr h h grl ppul d rhs 2% pryr sm rgs (g: crl ausrl).

1.2 What type of diabetes?

Differentiationisbasedonage,rateofclinicalonset,bodyweight,

family history and urinary ketones.

Once a diagnosis is made it is important to determine the type o diabetes.Usually there is clear clinical evidence and dierentiation is easy.

Type 1 Type 2

Young (generally) Rapid onset Middle-aged (generally) Slow onset

Ketosis prone Insulin deicient Not prone to ketosis Insulin resistant

Recent weight loss Overweight Strong amily history


10/47

12 Dbs Mgm Grl Pr assssm 13

At present there are no practical or speciic markers or either group. While type1 diabetes occurs in the young it is by no means conined to that group. Similarly

while many people with type 2 diabetes are overweight, some are normal weight. Inact, most overweight people do not develop diabetes.

Remember that someone treated with insulin does not necessarily have type 1diabetes. In act, i insulin is started several years ater diagnosis, it is likely that theperson has type 2 diabetes.

Type 1 diabetes

This type o diabetes was previously known as Insulin Dependent Diabetes Mellitus(IDDM) or Juvenile Onset Diabetes.

Type 2 diabetes

This type o diabetes was previously known as Non-Insulin Dependent DiabetesMellitus (NIDDM) or Maturity Onset Diabetes. However, type 2 diabetes canoccur in children and adolescents i they are overweight or obese, have a amilyhistory o type 2 diabetes and/or come rom a high risk group.

There is a orm o late onset diabetes that is autoimmune and requires treatment with insulin within a relatively short period ater diagnosis (oten in the next2 years). This is known as Late onset Autoimmune Diabetes in Adults (LADA).These people tend to be young (3040 years), lean and have a personal and/or amily history o other autoimmune diseases (eg: hypo or hyperthyroidism).Testing or glutamic acid decarboxylase (GAD) antibodies can conirm thediagnosis and can prompt counselling the person about the likely time courseo diabetes progression and the possibility o other autoimmune disease.

Medication induced diabetes

Some medications, or example prednisolone and olanzapine, can producehyperglycaemia which can be associated with abnormal OGTT and the diagnosiso diabetes. This may require medication. Such patients require the usual diabetes

assessment and management, like others with diabetes. When the medication isceased, the requirement or hypoglycaemic treatment may change, but patientsshould still be considered to have diabetes or ongoing cardiovascular monitoring.They are also at risk o developing rank diabetes again.

2 Assessment

2.1 Initial assessment

Assessment includes appraisal of cardiovascular risks and

end-organ damage.

A detailed assessment needs to be made at irst diagnosis.

History:

Specific symptoms: Predisposition to diabetes:

Glycosuria Age

Polyuria Family history Polydipsia Cultural group Polyphagia Overweight Weight loss Physical inactivity Nocturia Hypertension

Obstetric history o large babiesor gestational diabetes

Medication causing hyperglycaemia Personal or amily history

o haemochromatosis

Hyperglycaemia Autoimmune disease (personal Malaise/atigue and/or amily history o other Altered vision autoimmune diseases (eg: hypo or

hyperthyroidism))

Risk factors for complications General symptom reviewincluding: including:

Personal or amily history o Cardiovascular symptomscardiovascular disease Neurological symptoms

Smoking Bladder and sexual unction Hypertension Foot and toe problems Dyslipidaemia Recurrent inections

(especially urinary and skin)

Lifestyle issues:

Smoking Nutrition Alcohol Physical activity Occupation


11/47

14 Dbs Mgm Grl Pr assssm 15

Examination

Weight/waist: Body Mass Index (BMI) = weight (kg) divided byheight2 (m2)

Waist circumerence (see page 23).

Cardiovascular system: Blood pressure, lying and standing Peripheral, neck and abdominal vessels

Eyes: Visual acuity (with correction) Cataracts Retinopathy (examine with pupil dilation)

Feet: Sensation and circulation Skin condition

Pressure areas Interdigital problems Abnormal bone architecture

Peripheral nerves: Tendon relexes Sensation: touch (eg: with 10g monoilament) vibration

(eg: with 128 hz tuning ork)

Urinalysis: Albumin Ketones Nitrites and/or leucocytes

Investigations

Baseline: Renal unction: plasma creatinine (eGFR),micro-albuminuria

Lipids: LDL-C, HDL-C, total cholesterol, triglyceride

Glycaemia: glycated haemoglobin (HbA1c)

Other: Consider: ECGeverytwoyears,if>50yearsoldandatleastone

other vascular risk actor Microurine i high risk group (woman, neuropathy,

vaginal pessary) Thyroid unction tests i there is a amily history or

clinical suspicion

2.2 Plan of continuing care

Relieveacutesymptoms.

Optimisecontrolofglycaemiaandotherriskfactorsfor

complications.

Treatexistingcomplications.

Maintainotherpreventiveactivities.

Priorities of management

Patient and carer counselling includes identiying and addressing concerns whichmay be causing distress and adversely aecting management.

I the patient is symptomatic then treatment o hyperglycaemia needs to be promptbut i the patient is asymptomatic initial treatment can be more relaxed. The longterm medical goal is the prevention o complications.

Control o blood pressure and dyslipidaemia are important as well as glycaemiccontrol in preventing complications.

The overall aim o management is to improve quality o lie and preventpremature death:

Short term:

Reliefofsymptomsandacutecomplications

Long term:

Achievementofappropriateglycaemia

Reductionofconcurrentriskfactors

Identificationandtreatmentofchroniccomplications

Maintainotherpreventiveactivities(eg:immunisation)

Allpatientsshouldbeadvisedoftherisksofsmokingandoffered

assistance with smoking cessation.

Considerlowdoseaspirinforcardiovascularprotectionforallpeople

with diabetes.


12/47

16 Dbs Mgm Grl Pr th m pprh 17

2.3 Referral

Patientswithtype1diabetesoftenneedspecialistassessment.

Allpeoplewithtype2diabetesneedtoseeanophthalmologistor

optometrist initially and then at least every two years.

Diabetes educator:

Initially and then as patient becomes more amiliar with management,as considered necessary by patient, doctor or diabetes educator.

Dietitian:

Ideally initially, then as considered necessary by patient, doctor or dietitian.

Podiatrist:

Ideally initially, and then regularly i there is/are peripheral vascular disease, neuropathy,skin and/or nail problems and i there is diiculty in cutting toenails. Consider reerralto a high risk oot clinic i ulceration or intractable oot pain is present.

Ophthalmologist or optometrist:

Fundalexamination(dilatedpupils).

Thepresenceofcataracts needs to be checked.

Assessment: prepubertal children: reerral at puberty adults: reerral at time o initial diagnosis thereater at least every two years

Endocrinologist:

Children, adolescents and adults with type 1 diabetes i the general practitioneris not conident with management.

Pregnant women with established diabetes and women with gestational diabetes(see page 70 for screening recommendations).

People with diabetes and uncontrolled hyperglycaemia or withsigniicant complications.

Whl idgus ausrls r hgh rsk f my dsss d prmurdh, hy r lss lkly rv my sps f prvv r.idf f ps f abrgl d trrs Sr isldr bkgruds rl fr pprprly rgg rvs. GPs r urgd ruly sk ll ps f hy hv abrgl d trrs Sr isldrbkgrud s h hy my rg hs rsk grup ffvly.

3 The team approach

Considerreferraltoadiabeteseducatorordietitianforconsolidation

of education.

Apodiatristshelpneedstobesoughtifneuropathy,peripheral

vasculardisease,footabnormalityorcallusesarepresent.

Rebatesforattendanceatprivatedentistsandexerciseprofessionals

areavailableforpatientsundertheEnhancedPrimaryCareProgram,

aspartofaTeamCareArrangement.

In the team management o diabetes the patientis the central member.

For patients to be actively involved in their care they must understand thecondition, its eect on health and the practicalities o management. Goodcommunication between team members is important so that advice is consistentand not conusing or the patient.

3.1 Members of the team

The ollowing proessionals are important in the team approach to diabetes:

General practitioner

The general practitioner has the central role in coordinating management o the personwith diabetes and in education, counselling and sotening the technology/personinterace oten elt by people with a chronic condition. The general practitioner isthe point o irst contact and usually assumes responsibility or overall management.

Practice nurse

In many practices, the practice nurse is invaluable in establishing, managing andimplementing systems or diabetes care.

Diabetes educator

The diabetes educator can oten spend more time than the general practitioner hasavailable, consolidating the patients knowledge and skills regarding eating plan,physical activity, sel-monitoring, medication usage, oot care etc. The AustralianDiabetes Educators Association (ADEA) has established a credentialling program.Qualiied proessionals are "ADEA Credentialled Diabetes Educators". I available,the services o a diabetes educator are useul in the early stages and a continuingliaison can be established.


13/47

18 Dbs Mgm Grl Pr th m pprh 19

Dietitian

The role o the dietitian in the management o diabetes is paramount. Liestyle changesalone (healthy ood and regular exercise with ensuing weight loss) are suicient orglycaemic control in the majority o patients with newly diagnosed type 2 diabetes.Recommendations should be individualised to maximise cooperation. Early reerralto a dietitian is desirable to ensure detailed education on this most important aspecto management. I the general practitioner and practice nurse understand theprinciples o dietary advice, the dietary recommendations can be reinorced within thegeneral practice.

Podiatrist

The podiatrist renders expert preventive care. I there is evidence o neuropathy,macro-vascular disease, anatomical problems or a previous oot problem, early

reerral is desirable and regular review is necessary. Foot complications account orover 50% o hospital bed days occupied by patients with diabetes and are the mostcommon cause o non-traumatic amputation.

Ophthalmologist/optometrist

All people with diabetes need to be assessed regularly by an ophthalmologistor optometrist. Early detection o retinopathy, beore visual loss occurs, markedlyimproves prognosis or sight. Any deterioration in vision requires immediate reerralback to the ophthalmologist.

Oralhealthprofessional

Dental and periodontal problems are common in people with diabetes who needto see a dentist regularly (eg: yearly). Rebates or attendance at private dentists areavailable or patients under the Enhanced Primary Care Program, as part o a TeamCare Arrangement (see pages 33 to 35).

Exerciseprofessional

When initiating a physical activity program in a patient who has been relativelyinactive, the help o a physiotherapist with a special interest in exercise routines or anexercise physiologist may be o beneit. Rebates or attendance at exercise physiologistsare available or patients under the Enhanced Primary Care Program, as part o aTeam Care Arrangement (see pages 33 to 35).

Endocrinologist/diabetologist/paediatrician

The advice o a specialist physician may be valuable or people with complicatedproblems related to diabetes especially children, adolescents and adults withtype 1 diabetes or diabetes in pregnancy. A shared care approach by generalpractitioner and specialist will provide the best combination o specialised expertise

and continuity o care. In many cases the specialist will be part o an organised,multi-disciplinary diabetes care team which can provide a comprehensive diabeteseducation program.

Aboriginal Health WorkersWhr hy r vlbl, abrgl Hlh Wrkrs (aHWs) hv ky rl prvdg ulurlly pprpr d prl suppr d usllg,hus mprvg p udrsdg d dhr rm prgrms.

3.2 Counselling the person with diabetes

th dgss f dbs b vry srssful fr bh yugr d ldr ps.il dl f h d (: grf r) s rml. Bu f dl us,

dbs r b mprmsd.

Ps, whs dffuls wh pg h dgss mprms hrrm, my bf frm cgv Bhvur thrpy r hr psyhlglrvs. Grl prrs gg h hlp f psyhlgs, slwrkr r usllr. ths prrs my b ssd s pr f tm crarrgm wh Grl Pr Mgm Pl r udr h Br ass Psyhrss, Psyhlgss d Grl Prrs hrugh hMdr Bfs Shm iv.

th yugr p shuld bm fmlr wh h d, sul dd d hs p wh flgs f dpd md fr survvl.th ldr p fs rsg vulrbly skss, dsbly d lssf fu. Frs my lud jb sury, physl dsfgurm d lss f bly rbu prs rlshps.

The diagnosis o diabetes may have a proound eect on people engagedin certain occupations, eg: machinery operators, pilots, heavy vehicle drivers,divers, etc. While not always prohibiting many o these occupations, the diagnosiso diabetes may require careul career counselling.

Liestyles which have been established or many years are not easy to changeand health care proessionals cannot expect immediate adherence to the plano management. Assess the SNAP risk actors (Smoking, Nutrition, Alcohol andPhysical activity) and establish a long term liestyle plan.

It is important or the patient to have all the inormation available so thata common sense o purpose between the health care proessionals and the patientcan develop. This takes time and some patients may decide to reject advice.

Proessionals need to maintain an open approach and emphasise that helpis available when required.


14/47

20 Dbs Mgm Grl Pr il mgm 21

Weight reduction is oten diicult. A combined program o healthy eating, physicalactivity and education directed at behavioural changes is oten successul. Carer andpeer encouragement helps these behavioural changes.

Health care proessionals need to be sensitive to patient views concerningdiabetes and be ready to counsel. The normal stresses o daily living canaect diabetes control. Seek opportunities to help patients regain control,to improve sel esteem and to understand and control their condition.

There is a series o approved educational materials produced by Diabetes Australiawhich can be recommended to the newly diagnosed person with diabetes.

Education is ongoing and needs to continue or the rest o the persons lie. Diabetesknowledge, especially sel care skills (blood glucose monitoring, oot care, insulinadministration) need to be assessed regularly (eg: as part o the complication screen

at the twelve monthly review).

4 Initial management

Targets for glycaemic control in type 2 diabetes

Pre prandialbloodglucose(mmol/L)

Post prandialbloodglucose(mmol/L)

Comment

4 6.0 4 7.7 Normoglycaemia.

6.1 6.9 7.8 11.0 Minimises microvascular problems.

> 7.0 > 11.1 Consider more active treatment.

Associated with micro andmacro-vascular complications.

The IDF suggests a post prandial target < 7.8 mmol/L(2 hours post prandial)

The aim o treatment o type 2 diabetes is normal blood glucose levels(normoglycaemia). However, especially in the elderly, biochemical ideals shouldbe tempered by common sense and the need to remove symptoms andmaintain or improve quality o lie. It is important to be clear about the aimso treatment. Over-zealous management can result in severe hypoglycaemiaand may be associated with increased mortality. While there has been somediscussion raised by recent trials about ideal targets, the targets as listed above arecurrently accepted.

Patient blood glucose monitoring enables appropriate liestyle and medicationadjustment. Long term glycaemic control is monitored by measuring glycatedhaemoglobin (measured as HbA1c). The United Kingdom Prospective DiabetesStudy (UKPDS) showed reduced incidence and progression o diabetes relatedcomplications in subjects with a low HbAlc. The IDF suggests that an HbAlc>7%shouldpromptmoreactivehypoglycaemictreatment.

Working toward the target level is important but any signiicant reductionin HbA1c will improve patient outcomes.


15/47


4.1 Nutrition

Nutrition management involves controlling weight and the introduction

of a healthy eating plan.

Healthy eating is a critical component in the management o type 1 and type 2diabetes. In over 50% o people presenting with type 2 diabetes restriction o energyintake, increased activity and weight reduction will initially normalise blood glucoselevels. Medication is likely to be needed later.

Maintaining cooperation during weight reduction can be a major problem.A consistent coordinated approach by the general practitioner, dietitian and diabeteseducator helps the patient maintain the eort.

thr s vd h abrgl d trrs Sr isldr mmus rm rgs f sgf ss brrrs urus d ffrdbl fd.nurus fd ds s mr rurl d rm rs; s my b ssu lw s-m grups. Fd hs b sgfly lrdwh ppl hv ss pprpr fds d du bu ur.

Nutritional guidelines

While an appreciation o the dietary management o diabetes by the generalpractitioner or physician is important, detailed instructions need to be given by adietitian. To ind a qualiied dietitian in your area, contact the Dietitians Associationon 1800 812 942 or reer to your usual dietitian. Constant reinorcement o dietaryadvice usually results in enhanced cooperation and better control.

Healthy eating, body weight and regular physical activity are important objectivesin people with diabetes.

The ollowing criteria o overweight apply to those o European descent. Dierentcriteria may apply to other groups:

Body Mass IndexBMI (kg/m2) = Weight (Kilograms)

Height squared (Metres2)

ThehealthyBMIis18.5to24.9,overweight25to29.9,obese30.

As a rough guide the patients healthy weight (kg) is approximately:

Height (cm) 100

Alternatively waist circumerence (cm) can be used.

Healthy Overweight Obese

Men


16/47


Body weight

Loss o body weight will oten result in near normal glycaemic, blood pressure andlipid proiles. Oten an ideal body weight is not achievable and setting this as a goaldiscourages patients to attempt any dietary change. Many studies suggest that a

weight loss o 5 to 20% will improve glycaemic control. Thereore it is importantto encourage any degree o weight loss. A medium term goal or overweight patientsis 5-10% body weight loss.

Sources o hidden energy need to be identiied and minimised: or example alcohol,cakes and sweet beverages. A reduction in total energy intake o 2,000 kilojoules(475 calories) per day should result in a weight loss o 0.5 kg a week.

Carbohydrates

Carbohydrate oods which are rich in ibre and have a low energy density are the basis

o the eating plan and it is recommended that they contribute up to 50% o the totalenergy intake. Meals containing carbohydrate are spread evenly through the day.

Both the quantity o carbohydrate and the quality o carbohydrate will aect bloodglucose levels. The amount o carbohydrate has a larger eect on glycaemia thanthe quality.

The quality o carbohydrate is relected by its glycaemic index (GI) which indicatesthe post prandial glycaemic response to a particular carbohydrate ood. This will havea lesser but additional eect on blood glucose levels. The GI classiies carbohydrates asslow acting (low), moderate (medium) and quickly absorbed (high). Some oods havebeen GI tested in an accredited laboratory and the GI Symbol Program (sponsored byDiabetes Australia, Sydney University and the Juvenile Diabetes Research Foundation)indicates the GI o the ood on their labels.

The glycaemic load (GL) reers to both the quantity and the quality o carbohydrate.GL is the GI multiplied by the carbohydrate grams divided by 100. A lower GL(less than 80 GL per day) is desirable or people with diabetes.

In practice it is recommended that people with diabetes have one high ibre, lowGI carbohydrate ood at each meal. This would include wholegrain breads, rolledoats, low at, low sugar breakast cereals, pasta, beans, lentils and temperate ruits.Other carbohydrate oods can be included but in lesser amounts. These include rice,potato and tropical ruit.

Sugar does not need to be eliminated. Including a small amount o sugar as part o amixed meal or ood, eg: breakast cereal, does not adversely aect the blood glucose level.

Allowing small amounts o sugar as part o a high ibre, low at meal plan increases thechoice o oods available and may aid adherence.

Low carbohydrate, high protein diets may predispose the person to hypoglycaemiai they are taking a sulphonylurea, repaglinide or insulin. Those adopting these dietsshould be made aware o the risk and the appropriate precautions.

Dietary fat

It is recommended that at contribute to less than 30% o total energy intake.This has a beneicial eect on serum lipids and helps with weight reduction.

Saturated ats in the diet will have an adverse eect on general lipid proiles.

The most common sources o oils and ats are:

Add itives in co okin g Me at Dairyproducts Snack and takeawayfoods

Fried oods need to be avoided (even with polyunsaturated or monounsaturated oils).

Monounsaturated ats (-9 atty acids) as in olive oil or canola have a LDL-Clowering eect. Likewise seed sourced polyunsaturated oils (-6 polyunsaturated)lower LDL-C. Fish oils (-3 polyunsaturated oils) in doses o 5g/day lower

triglyceride levels. They also inhibit platelet aggregation and may protect againstthrombosis in diseased blood vessels.

The main thrust of management is to lower total fat intake and to find

substitutes for saturated fats.

Low at milk could be used as a substitute or whole milk and some lightmargarines have 40% o the at content o standard margarines. Alternativespreads are reduced at cottage cheese or ricotta cheese. Some margarines containplant sterols that reduce cholesterol absorption and cholesterol l evels.

There is considerable variation in the at content o meats, depending on thesource and cut. It is best to ask the butcher what is lean and what is not,especially since the new cuts are much lower in at.

Dietary protein

It is recommended that protein contribute 1020% o total energy. The average Australian diet achieves this without diiculty. Selection o type o protein

depends on patient preerences taking into consideration the at content oeach source.

Vegetable sources o proteins such as beans and pulses are very low in at.


17/47


Additional considerations

Alcohol

As many people with type 2 diabetes are overweight or obese, alcohol shouldbe minimised. Australian guidelines at the time o publication recommend2 standard drinks (20g) per day or men and women. Low alcohol beers are abetter choice than ordinary or diet beers.

alhugh abrgl d trrs Sr isldr ppl r lss lkly h-idgus ppl drk lhl, hs wh d r mr lkly drk hzrdus lvls. Hzrdus drkg s mr prvl mg idgusausrl mls d fmls gd 3544 yrs h h grl ppul.

Added salt in cooking and in oods needs to be minimised. Recommend the use o

low salt or no added salt products.

Although small amounts o sugar can be included, artiicial sweeteners may stillhave a role in management. Suitable sweeteners include aspartame, sucralose,acesulphame K, alitame, saccharin and cyclamates. In pregnant women it is best toavoid saccharin and cyclamates as they are thought to cross the placenta.

The inclusion o sugar alcohols, eg: sorbitol, is not recommended as these oerno advantage over sucrose in improving metabolic control, increasing cooperationor in managing weight loss.

4.2 Physical activity

Regularphysicalactivityimprovesmetaboliccontrolandreduces

other cardiovascular risks.

Patientsoninsulin,sulphonylureasorrepaglinidemayneedtotake

special precautions to prevent hypoglycaemia.

Appropriatecareoffeetduringphysicalactivity isimportant.

Increasing physical activity improves metabolic control in people with diabetes.Low level aerobic exercise (eg: brisk walking or hal an hour per day) has theollowing beneits:

Improvedglucosetoleranceasinsulinsensitivityincreases Increasedenergyexpenditureresultinginweightloss Increasedfeelingofwellbeing Increasedworkcapacity Improvedbloodpressureandlipidprofiles

Aerobic training which makes you pu and brings the heart rate up to 60% 70%o maximum (220 age [years] beats per minute) or a minimum o 30 minutes3 or 4 times per week, establishes and maintains itness and aerobic capacity.

Active Australia recommends >150 minutes per week of moderate intensityphysical activity (eg: walking).

When prescribing a physical activity program a careul history should be taken.Special attention needs to be paid to exertion-induced symptoms such as chest orabdominal discomort or syncope.

People with type 2 diabetes requently have silent macrovascular disease.Screening with a stress ECG is not indicated in asymptomatic individuals, butspeciic symptoms need to be actively investigated.

Isometric exercises such as heavy weight liting (high load, low repetition) mayincrease blood pressure, increasing the risk o vitreous haemorrhage and suddencardiac events. However, resistance programs using moderate weights and highrepetition can be part o an exercise program or those with diabetes and havebeen shown to improve glycaemic control.

People requiring insulin may need to increase their carbohydrate intake and/or decrease their insulin beore exercise. They need to also carry some reinedcarbohydrate with them. Similarly people with type 2 diabetes taking sulphonylureasor repaglinide may need to take extra ood and/or reduce their medication.

People requiring insulin need to be aware o potential delayed eects o physicalactivity on glucose levels, in particular delayed hypoglycaemia 612 hours atercessation o the activity. People with diabetes need to be advised to cease theiractivity i they develop cardiovascular symptoms or just eel unwell. However,patients with leg or buttock claudication need to be encouraged to continuephysical activity with intermittent rests when leg or buttock pain occurs since this

will gradually increase their capacity to exercise.

The importance o appropriate oot care and comortable, well-itting ootwear

during physical activity needs to be stressed, especially i there is neuropathy,vascular disease, abnormal oot structure or previous oot ulcer(s).

Lwr lvls f physl vy hv b rprd fr abrgl d trrsSr isldr ppls d ppl lvg rurl d rm rs. thr spr ss fls fr physl vy my abrgl mmus.


18/47

28 Dbs Mgm Grl Pr Hlh r fr dbs 29

5 Health care for diabetes

5.1 Self-monitoring

Self-monitoringisessential.

Homebloodglucosemonitoringisthemethodofchoicein

most patients.

Themethodandfrequencyoftestingneedstoreflect

therapeutic aims.

Blood glucose monitoring is recommended or all people with type 2 diabetes.A balance should be reached considering the patients age, need or ideal control and

ensuring long term cooperation. Despite some recent controversial studies, the currentview is that blood glucose monitoring is recommended.

Initially close supervision is recommended. A suggested initial schedule o testing is3 to 4 blood glucose tests daily (early morning, plus other tests beore + ater meals).Frequent consultation with health care proessionals is important.

Sel-monitoring needs to be individualised. Once control is established, reduction osel-monitoring requency to once or twice daily, 2 or 3 days a week is suicient. Inelderly patients testing on 1 or 2 days per week, varying the time, may be adequate.

Monitoring in type 2 diabetes need not be as intensive as with type 1 diabetes exceptwhen the normal pattern is broken (eg: travelling, the estive season, intercurrent illness,changes to medication and diet). The ideal would be blood glucose estimation beore +ater meals. A reasonable approach would include blood glucose estimation at dierenttimes o the day on 23 days each week.

Values beore meals give inormation about baseline glycaemia which is aectedby general actors such as weight, diet, activity and long acting medication. Valuesater meals give inormation about peak glycaemia which is aected by the baseline

level, the ood eaten and short acting medication (eg: repaglinide, acarbose or shortacting insulin).

People on either insulin or oral hypoglycaemic agents must be able to identiy hyposand understand treatment. Blood glucose monitoring can be o help.

Many people learn to adjust their treatment schedule according to blood glucose levelsand thus improve glycaemic control. People can measure their blood glucose usingreagent strips that are read in the meter and/or visually (or some strips). Meters today arequick, reliable and simple to use. Use o the meter should be demonstrated. People needto be competent in the technique o blood glucose monitoring beore treatment decisionsbased on the readings are made. All meters need regular quality control checks by theuser. All sel blood glucose measurement systems have quality control materials.

5.2 Medical monitoring

Regular ollow-up visits oer an opportunity or the general practitioner andpatient to explore the patients understanding, ears and concerns about diabetes.Some practices run diabetes clinics, oten delivered by practice nurses. The useo practice protocols, checklists and algorithms that have been developed by thedoctors and nurses in a practice ensures the practice nurse can undertake a largeproportion o the routine care (under the clinical oversight o the doctor).

The ollowing is a guide or the doctors oversight o patients. A suggested checklistor nurse activity appears at the end o each section. Results o nurse consultationshould be incorporated into the clinical record. As this checklist assumes theknowledge and clinical experience o a registered nurse, practices should use itaccording to the proessional and clinical status o their nursing sta.

5.2.1 Quarterly review

Discouragesmoking Reviewsymptoms

Checkweight,BP Reviewself-monitoring

Once control is achieved the routine visit should review:

History:

Review SNAP proiles (Smoking, Nutrition, Alcohol, Physical activity), patientsrecord o home testing and quality control results, oot symptoms.

Examination:

Check weight/waist, height (children and adolescents), blood pressure,eet examination i new symptoms or at risk (eg: neuropathy peripheralvascular disease).

Investigation:

Measure glycated haemoglobin (HbA1c) at least six monthly.

Watch or intercurrent illnesses such as urinary tract inections, thyrotoxicosis etcwhich may alter degree o control. Asymptomatic urinary inections are commonin patients with diabetes, especially older women.


19/47


5.2.1.1 Quarterly nursing review

Ask about: SmokingNutrition

Alcohol intakeHow much exercise and how oten

Any problems with medication

Check: Weight/waistHeight (children and adolescents)Blood pressureFeet examination without shoes, i new symptoms or at risk(eg: neuropathy peripheral vascular disease)

Review: Goals with patient to identiy speciic areas o ocus or doctor

consultation.

5.2.2 Annual review

Reviewgoalsofmanagement Checkfordiabeticcomplications

Updateimmunisationschedule Considerspecialistreferral

The yearly review is a time or more detailed assessment, updating the problem prioritylist and re-establishment o goals, and contractual arrangements or management.Eating plan, liestyle, home monitoring and treatment need to be reviewed.

There needs to be a ull system review checking or vascular, renal, eye, nerve andpodiatric problems. As there is an increasing trend towards involving specialist alliedhealth proessionals, the yearly visit is a good opportunity to coordinate ollow-up.

Full physical assessment:

Cardiovascularsystem Eyes

Peripheral nervous system Feet

Immunisations: Influenza once per year

Pneumococcal Non-Aboriginal and Torres Strait Islanders:< 65 single dose and revaccinate age 65 or ater10 years whichever later

>65singledoseandrevaccinate5yearslater Aboriginal and Torres Strait Islanders: < 50 single dose and revaccinate age 50 or ater10 years whichever later>50singledoseandrevaccinate5yearslater

Tetanus booster at age 50 (unless booster has been given within10 years)

Investigations: (annually i below target, more requently i being actively treated)

Lipids triglyceride; HDL-C, LDL-C and total cholesterolRenal microalbuminuria and plasma creatinine

Referral:

Ophthalmologist/optometrist second yearly with no retinopathy, morerequently i abnormal.

Diabetes educator, dietitian, podiatrist i patient has or has developed a problemrequiring review.

Pharmacist or a Home Medications Review i the patient is likely to haveproblems with medication (eg: taking more than 5 types).

Oral health proessional especially i peridontal disease is present.

5.2.2.1 Annual nursing review

Ask about: SmokingNutrition (last contact with dietitian or diabetes educator)

Alcohol intakeHow much exercise and how oten

Any problems with medicationAny changes in medication (by doctor/pharmacist or patient)Chest painVision (when last checked)

Any oot discomortWhen was last podiatry checkImmunisations (include Flu and Pneumovax)Family history and update

Check: Weight/waistHeight (children and adolescents)

Blood pressureFeet examination: without shoes, pulses, monoilament checkBlood glucose at examinationUrinalysisVisual acuity

Review: Goals with patient to identiy speciic areas o ocus ordoctor consultationLast care plan to identiy timely reerrals

Check: Registration with NDSS/membership Diabetes Australia


20/47


Records:

The use o a check list and a separate sheet in the patients notes (preerably attachedto the ront o the problem list) can be used to record the requency and results othese assessments.

Medical sotware incorporates acceptable orms o diabetes records. These accrueto support the annual cycle o care which can be used or the Medicare items(see page 33).

5.3 Systems for care

Diabetes is a complex disorder and requires a systematic approach to care.There is evidence that this approach in the general practice setting results inbetter outcomes.

A systematic approach to care is acilitated by the use o:

1. Disease register: This is a list o all patients in the practice with diabetes andbasic demographic data. The register can also include clinical inormation. Thisallows tracking o patients clinical status and their need or ongoing care.

2. Recall system: This acilitates timely recall o patients when certain aspects otheir care require review eg: recall or annual review, ophthalmologist review, etc.

3. Flow charts: Included in the patients notes these allow ollowing o clinicalparameters and lag when interventions or investigations are necessary.

4. Review charts: Included in the patients notes, these are checklists or annualand three monthly reviews to acilitate thorough coverage o all issues at thesemilestone consultations.

The RACGP and General Practice networks have resources to assist practices inestablishing such systematic approaches to the care o their patients with diabetes.

5.3.1 How Medicare supports the process

The Australian Government supports high quality care through a series onon-ee-or-service payments to general practitioners and general practices. Theseinclude the Enhanced Primary Care Program and the Practice Incentive Program.The Practice Incentive Program is only available to general practices either accreditedor working towards accreditation against the Royal Australian College o GeneralPractitioners Standards or General Practices.

As a result o these programs, services perormed by a number o allied healthproessionals (including diabetes educators, dietitians, psychologists, podiatrists,exercise physiologists and dentists) may attract a rebate when a patient sees them

within the Enhanced Primary Care Program. There are also Medicare items orgroup intervention services provided by eligible dietitians, diabetes educators andexercise physiologists within this system.

The National Integrated Diabetes Program was established to improve theprevention, early diagnosis and management o people with diabetes. Theinitiative includes a general practice incentive, a network o general practiceincentive and a community awareness campaign. The incentive program requirespractices to register and create a patient register and recall/reminder system, withadditional incentives or completing an annual cycle o care and urther incentiveor reaching target levels o care or people with diabetes.

Some people with diabetes will require complex medication schedules and a HomeMedication Reviewmay be useul. This involves a pharmacist assessing people whomay have problems with their medications, and recommending changes to improveeectiveness, saety and adherence.

Some patients ind diabetes a signiicant burden. They may beneit rom thesupport o a psychologist, social worker or counsellor. Access to these practitionersis available under the Better Access to Psychiatrists, Psychologists and GeneralPractitioners through the Medicare Benefits Scheme Initiative.

Practice nurses do not have the ability to charge Medicare rebatable itemsfor care related to diabetes. General practitioners who work in urban areas

of workforce need can apply for grants to employ nurses (under the programStrengthening Medicare) as can rural practitioners through the ongoing ruralnurse program grants.

th Mdr Bfs Shdul m umbr 710 prvds fr dulhlh hk fr abrgl d trrs Sr isldr ppl gd 15 54 (lusv) wh hv hd h hk h prvus 18 mhs.Prpr f GP Mgm Pl (m 721) d rdg hdvlpm f tm cr arrgms (m 723) r ls pprprsupprs fr mprhsv mgm f dbs fr abrgl dtrrs Sr isldr ppl.


21/47


5.3.2 Requiredannualcycleofcare

1 Annual review: Reer 5.2.2, pages 30 and 31

2 GPMP/TCA: Reer 5.3.3 & 5.3.4, page 35

3 GPMP/TCA review: Reer 5.3.3 & 5.3.4, page 35

4 3 monthly review: Reer 5.2.1, pages 29 and 30

Issues under control?

Consider GPMP and TCA

Continue management

and monitoringschedule

Yes No

3 monthly review

Yes

2

3

4


12 monthly review

1

No

NoYes


Item numbers which can be used are:

In-surgeryconsultations Out-of-surgeryconsultations

Vocationally registered GPs

Lvl B 2517 2518

Lvl c 2521 2522

Lvl D 2525 2526

Non-vocationally registered GPs

Sdrd sul 2620 2631

Lg sul 2622 2633

Prolonged consultation 2624 2635

3 monthly GPMP

and TCA review

In addition, general practitioners working in accredited practices who haveapplied or PIP (Practice Incentive Program) will attract SIP (Service IncentiveProgram) payment or themselves and PIP payments or their practices(see www.medicareaustralia.gov.au).

The SIP cycle requires:

Blood pressure every 6 months

Ht/wt/waist (BMI) every 6 months

Feet exam every 6 months

Glycaemic control (HbA1c) once per year

Blood lipids once per year

Microalbuminuria once per year

Eye exam at least every 2 years

Smoking review once per year

Healthy eating plan review once per year

Physical activity review once per year

Sel care education review once per year

Medications review once per year

These are minimum levels o care or all people with diabetes and obviously morecare will be required or those with complications and co-risk actors.

5.3.3 General Practice Management Plans (GPMP)

These are documented plans developed by the general practitioner and patienttogether, that incorporate the patients needs, goals, how this is to be achieved andreerence to any other resources used. Templates or use are available via medicalsotware and General Practice networks.


il prpr: pybl 12 yrly dpdg d fr rvs 721

Rvw f pl: pybl vry 36 mhs, bu wh 3 mhs f 721 725

ivlvm GPMP dvlpd by hr prvdr 729

ivlvm r pl dvlpd by gd r fly 731

5.3.4 TeamCareArrangements(TCA)

These are an expansion o the GPMP which detail the allied health workers whoimplement any part o the GPMP.


Initial preparation: payable 12 yearly depending on need or revision 723

Review o plan: payable every 36 months, but not within 3 months o 723 727

Access to allied health and dental EPC items requires a GPMP and TCA, oritem 731 i in an aged care acility. GPMP and TCA can be developed andclaimed simultaneously.


22/47

36 Dbs Mgm Grl Pr Md 37

6 Medication

Multiple interventions and medications are needed to control the multiple riskactors associated with type 2 diabetes (hyperglycaemia, hypertension, dyslipidaemiaand increased thrombogenesis).

6.1 Oral hypoglycaemic agents

Medicationwillnotsubstitute forhealthyeatingandactivity.

Metforministhemedicationofchoiceintheoverweightpersonwith

type 2 diabetes.

Hypoglycaemiaandweightgaincanbeproblemswithsulphonylureas and repaglinide. Acarbose may cause flatulence and

diarrhoea. Liver enzymes need to be monitored during glitazone

therapyandfluidretentioncanoccur.Cautionisnecessaryin

cardiac failure.

Allergytoaspecificmedicationisacontraindicationtoitsuse.

I a trial o healthy liestyle or 6 weeks or more is unsuccessul in controlling bloodglucose in a person with type 2 diabetes, oral hypoglycaemic agents can be used(see chart page 40). I the patient is symptomatic at initial diagnosis or the bloodglucoselevelisveryhigh(>20mmol/L),medication can be used early to decreaseglucose levels and relieve symptoms.

Metormin is the medication o irst choice in people with diabetes (see chartpage 40). Metormin reduces hepatic glucose output and insulin resistance. Metorminhas been shown to signiicantly reduce the risk o diabetes-related morbidityand mortality in overweight patients. Renal impairment is the only absolutecontraindication to metormin (ie: a raised serum creatinine which usually relectssigniicantly impaired renal unction). Metormin should be used with caution in

people with hepatic or cardiac disease and those with a heavy alcohol intake.

Sulphonylureas increase insulin secretion and can be used ater a trial o healthyliestyle and metormin.

Acarbose is useul when blood glucose values remain high ater meals despite dietarymodiication. Acarbose inhibits the digestion o carbohydrate and thus slows therate o glucose delivery into the circulation. Acarbose needs to be taken at the timeo starting the meal and introduced gradually to avoid latulence and abdominaldiscomort. I hypoglycaemia occurs (because o concurrent sulphonylurea orinsulin treatment) glucose rather than other carbohydrates is required. Care isnecessary in those with renal impairment or gastro intestinal disease and liverenzymes need to be monitored.

Repaglinide causes a rapid, transient increase in pancreatic insulin secretion.Repaglinide can be used as mono therapy or with metormin to control post prandialhyperglycaemia. It should not be used in combination with sulphonylureas.

th glzs (hzldds) r hr lss f rl hypglym g dlud pglz d rsglz. ths gs r ffv lwrg bldglus by rdug sul rss.

Bh glzs b usd s dul hrpy wh mfrm r sulphylurs.

Pglz ls b usd rpl hrpy wh mfrm d sulphylur r mb wh sul. crds lud mdr svr rd flur.

Rsglz s dd rpl hrpy wh mfrm d sulphylurr mb wh sul. crds lud mld, mdr svr,r y hsry f rd flur.

Rsglz s rmmdd ps wh known shm hr dss,prulrly hs kg rs. Rfr Prdu ifrm fr mr dls.cr s ssry hs wh y dgr f rd flur r lvr dysfu dlvr zyms shuld b mrd.

tw lsss f mds w rg h glug-lk ppd (GLP-1) s.GLP-1 hs sul sr d hbs glug sr glusdpd mr. Bh fsg d psprdl glus r rdud.

th GLP-1 mms r jd mds whh bd h GLP-1 rpr(xd, By).

th GLP-1 hrs r rl mds d slw h brkdw f dgusGLP-1 (sglp, Juv).

Bh r smlrly ffv h hr rl hypglym gs. th GLP-1 mmsls d wgh lss d h GLP-1 hrs r grlly wgh url.

With sulphonylureas, special care needs to be taken, especially in the elderly,not to precipitate hypoglycaemia. When used as mono therapy, metormin,acarbose, glitazones and the GLP-1 agents will not cause hypoglycaemia. All the

sulphonylureas can cause hypoglycaemia. People taking sulphonylureas, repaglinideor insulin may need to notiy motor vehicle licensing authorities and their insurancecompany as these medications can aect driving perormance ( see page 73).

Start with a small dose and increase weekly or ortnightly until control occurs. I controlis not occurring check the patients understanding o management and monitoring skillsand i these are satisactory, look or other exacerbating actors such as occult urinarytract inection or medications which may interere with control.

I a patient continues to lose weight while on oral hypoglycaemic agents the dosemay be reduced and sometimes stopped.

Most people with diabetes will require increasing doses and additional medicationsas their diabetes progresses. Insulin therapy may also be required.


23/47


Sm dsdvg, rsd -mrbdy d hghr fmlyburd f hr dss r sgf brrr ffrdblyf mds fr h abrgl d trrs Sr isldr ppul.evd ls suggss h sm abrgl ppl r umfrbl skgmds dv, d h sumr md frm prvdd s fdfful udrsd, ulurlly pprpr d ulkly b ulsd.Md shrg s mm sm mmus.

The main side effects of metformin are:Anorexia, nausea, vomiting Diarrhoea, abdominal cramps, latulence Lactic acidosis (i renal, liver

or cardiovascular disease exist)The main side effects ofsulphonylureas are:Weight gain Symptomatic hypoglycaemiaAnorexia, nausea, diarrhoea,

skin rashesOccasionally blood dyscrasias

The main side effects ofglitazones are: Increased subcutaneous at and/or luid Decreased haemoglobin levels Increased risk o peripheral ractures

in women Possible increased risk o myocardial

inarction (rosiglitazone) Increased LDL-C (rosiglitazone)

The main side effects of repaglinide are: Symptomatic hypoglycaemia Nausea, diarrhoea, constipation Skin rashes, abnormal LFT

(Rare) hepatitis and/or jaundiceThe main side effects of acarbose are: Flatulence and abdominal bloating Non response to carbohydrates other

than glucose i hypoglycaemic (Rare) liver abnormalities

The main side effects of GLP-1agents are:

Mimetics exenatide: Nausea and vomiting Injection site reactions Possible pancreatitis

Enhancers sitagliptin: Upper respiratory tract symptoms Headache Nausea

Effectsofnon-diabetesmedicationsBeware o interaction with other medications which increase or decrease bloodglucose action:

Reduce blood glucose Increase blood glucose

AlcoholBeta blockersSulphonamidesMonoamine oxidase inhibitorsSalicylates in high doses*Gemibrozil

Adrenergic compoundsOestrogensGlucocorticoidsThiazide diuretics (high dose)Phenytoin

* Low dose aspirin (100-300 mg/d) does not cause problems. Increases effect of repaglinide.

Medication for type 2 diabetes

CONTROL CONTROL

INCREASE

DOSAGE

REGULAR

REVIEW

INCREASE

DOSAGE

REGULAR

REVIEW

* ? Add ACARBOSE,REPAGLINIDE,

PIOGLITAZONE,SULPHONYLUREA

or INSULIN

* ? Add ACARBOSE,

a GLITAZONE,

SITAGLIPTIN

or start INSULIN

INSUFFICIENT CONTROL

WITH DIET, EXERCISE

CONTRAINDICATIONS TO

METFORMIN*

STARTMETFORMIN* STARTSULPHONYLUREA*

NO YES

NO NO

YES YES

YES YES

YES YES

MAXIMUM

DOSAGE

MAXIMUM

DOSAGE

CONTROL CONTROL

* These medications are available on the PBS. Repaglinide is not on the PBS but may be used in some patients. See

PBS guidelines for prescription information.

Sitagliptin, Metformin/sitagliptin can be used if sulphonylureas are contraindicated or not indicated.


24/47


Oralhypoglycaemicagentsavailable

Chemical name Brand name Tablet size Daily

dose range

Approx

duration

Frequency

(time/day)

Administration

(time/day)

Acarbose (a) Glucobay 50/100mg 150-600mg 3h 3 With meals

Glibenclamide (b) Daonil

Glimel

5mg

5mg

2.5-20mg 18-24h 1-2 With meals

Gliclazide (b) Diamicron

Genrx gliclazide

Glyade

Mellihexal

Nidem

80mg

80mg

80mg

80mg

80mg

40-320mg 18-24h 1-2 With meals

G li cl az ide ER* D iamicron MR

Oziclide MR

30mg

30mg

30-120mg 24h 1

Glimepi ri de (b) Amary l

Aylide

Diapride

Dimirel

Glimepiride Sandoz

1/2/3/4mg 1-4mg >24h 1 With meals

Glipizide (b) Melizide

Minidiab

5mg 2.5-40mg 16-24h 1-2 With meals

Met fo rm in (c ,e ) D iabex

Diaformin

Formet

Genrx metformin

Glucohexal

Glucohexal 1000

Glucomet

Glucophage

Metforbell

Metformin (Genepharm)

0.5/0.85g/1.0g

0.5/0.85g/1.0g

0.5/0.85g/1.0g

0.5/0.85g

0.5/0.85g

1.0g

0.5/0.85g

0.5/0.85g

0.5/0.85g

0.5/0.85g

0.5-3.0g 12h 2-3 With/after meals

Metformin ER* Diabex XR

Diaformin XR

Metex XR

Metformin XR

0.5g

0.5g

0.5g

0.5g

0.5-2.0g 24h 1 With evening meal

Metformin/

glibenclamide

(b,c,e)

Glucovance 250/1.25mg

500/2.5mg

500/5.0mg

up to

2000/20mg

18-24h 2-3 With meals

Metformin/

rosiglitazone

(c,d,e,f)

Avandamet 500/2mg

500/4mg

1000/2mg

1000/4mg

up to

2000/8mg

12-24h 2 With meals

Metformin/sitagliptin

(c, e, f, h)

Janumet 500/50mg

850/50mg1000/50mg

up to

2000/100mg

>24h 2 Without regard to meals

Pioglitazone d,e,f) Actos 15mg

30mg

45mg

15-45mg 24h 1 Without regard to meals

Repaglinide (g) NovoNorm 0.5/1/2mg 1.5-16mg 2-3h 1-3 With meals

Rosiglitazone (d,e,f) Avandia 4/8mg 4-8mg 24h 1-2 Without regard to meals

Sitagliptin (f,h) Januvia 100mg 100mg >24h 1 Without regard to meals

Exena ti de (g) Bye tta Twice da il y non- insu li n h ypog lycaemic agent . I nj ec t 5mcg bd subcutaneous ly one hou r

before two main meals and at least 6 hours apart. After one month increase to 10mcg bd.

Note: Oral agents need to be used with special care in the elderly. * ER = Extended Release(a) Care renal, gastrointestinal disease (e) Care renal, liver and cardiovascular disease(b) Sulphonylurea (f) Authority required(c) Metformin (g) Private script(d) Thiazolidenedione (h) Care renal insufficiency

6.2 Insulin treatment

Starting insulin in type 2 diabetes

Insulin may be required i adequate control has not occurred on maximum doseso oral hypoglycaemic agents. However, ensure that exercise and dietary managementare satisactory and exacerbating actors eg: intercurrent inection (see page 48)problems with medication (see page 67) have been excluded.

Insulin may be needed early in the condition when treatment is being started(the so-called primary ailure o oral hypoglycaemic agents that suggests thepatient actually has type 1 diabetes) or when the patient has later become reractoryto oral hypoglycaemic agents (so-called secondary ailure consistent with the usualprogression o type 2 diabetes).

I the patient is symptomatic then insulin is required. I there are no symptoms butfastingbloodglucoselevelsareconsistently>7.0mmol/L,thedecisionismoredifficult.

When deciding glycaemic targets and considering insulin treatment, take intoaccount: lie expectancy, existing physical and psychosocial problems and potentialproblems with insulin.

The selection o treatment goals, treatment schedules and monitoring schedulesneeds to be a decision arrived at ater discussion with the patient and may be thestimulus or a General Practice Management Plan (see page 35).

Initiation o treatment with insulin is regarded as a major step by most patients.They require encouragement and psychological support.

At this stage the help o a physician with a special interest in diabetes maybe useul.

Insulinisnotasubstituteforhealthyeating,activityandweight

control in type 2 diabetes.

Inappropriateuseofinsulinproducesweightgainandcontinuingpoor control.

Possibly to be discontinuedSeptember 2009


25/47


Step guide to insulin treatment in type 2 diabetes

People with type 2 diabetes requiring insulin can oten be managed with a singledaily dose o intermediate or long acting insulin added to their oral hypoglycaemicschedule. Quick acting insulin is not necessarily needed. A recommended startingschedule is a single dose o basal insulin (eg: 10 units at bedtime or breakast). Thebasal insulin can be isophane or glargine. Glargine may cause less hydroglycaemiathan isophane.

In the long term metormin can be continued or added to reduce insulin resistance(and dose) and to help reduce weight gain.

Step 1

Check that diet, activity and oral medication are appropriate and that complicatingmedical conditions are not present.

Step 2 Decide the time and type of insulin

Morning

Blood Glucose

Evening

Blood Glucose

Schedule

High OK Night-time basal

OK High Morning basal

High High Twice daily isophane/once daily glargine

Step 3 Dosage

Decide the dose: start low and go slow (eg: 10 units basal)Single dose: morning or evening

Less may be required in elderly, active, thin patients and more in the overweightand underactive.

Step 4 Adjust doses

Change doses in increments o 10 20% at intervals o 2 4 days.Mixed insulins may be needed.

Choosingtheinsulin

Short-acting insulin

The speed o onset and length o action is shortest or the insulin analogues,ollowed by human neutral insulin and then by bovine neutral insulin.

Intermediate insulin

The isophane/NPH preparations can be used in injectors or syringes and do notaect the kinetics o added neutral insulin. The isophane/NPH preparations havereplaced the insulin zinc suspension (lente type) preparations.

Long-acting insulin

The bovine isophane preparation is longer acting than the human isophanepreparations which may not provide 24-hour cover. The absorption proile o newanalogue basal insulin preparations (insulin detemir, insulin glargine) is longer,latter and more reproducible than previous long-acting preparations. At the timeo writing, only insulin glargine (Lantus) was subsidised by the PBS or insulintherapy in type 2 diabetes.

Pre-mixed insulin

Although the ixed proportions o intermediate and quick-acting insulin(eg: 30% neutral, 70% intermediate) may not be ideal or glycaemic control, thesepreparations are very convenient or patients to use.

Diet,exerciseandinsulin

The depot o insulin will work whether the person is eating or undertaking physicalactivity. Both exercise and eating should be regular to increase the predictability inblood glucose levels.

6.3 Insulin delivery

Sites for insulin injections

Abdominal wall: Generally astest and the most uniorm rate o absorption.

Legs: Slowest absorption (unless exercising). Acceptable site.

Arms: Not recommended.

Injections should be subcutaneous.


26/47


Syringes

Syringes are the most commonly used device or delivering insulin.Free insulin syringes and subsidised test strips or sel-monitoring are availablethrough Diabetes Australia to members and non-members alike. To be eligible,patients must register with the National Diabetes Services Scheme (NDSS)by contacting Diabetes Australia on 1300 136 588 (see page 79).

Patients oten reuse syringes but in situations where injections are givenby visiting nursing sta, single use only is recommended. In children it maybe desirable to reduce the number o uses o a single use syringe to keep theneedle sharp.

People can dispose o sharps (blood-letting lancets, syringes etc) in an approvedsharps disposal container. Arrangements or the collection o sharps vary in

dierent States and Territories (eg: local council, hospital). People can contactDiabetes Australia or advice.

Insulin pens

Insulin injectors are like large ountain pens with a cartridge o insulin inserted like anink cartridge. They make injections much simpler since drawing up is unnecessary.Older people may ind the Innolet injector easier to use because it is larger andmarkings are more visible.

With insulin injectors, multiple daily injection schedules become much easier andpeople can be more lexible in their sel-management.

Insulin pumps

Insulin pumps are used by some people with type 2 diabetes (refer 6.6 Newtechnology page 47). The pump is attached to the persons clothing and inusesultra short acting insulin at variable rates into the subcutaneous tissues throughan inusion set. Insulin pumps can be programmed to provide variable basalinsulin inusion rates throughout the day and can also provide preprandial doses

o bolus insulin.

Follow up

The insulin schedule and dosing should be reviewed at each consultationto review diabetes. The insulin dosage may need to be reduced i the person adoptsa healthier liestyle and/or loses weight.

6.4 Insulins available

Type Brand Name Manufacturer Nature

ULTRA SHORT ACTING (peak at 1hr, last 3.5-4.5 hrs)

Insulin lispro Humalog+ Lilly Analogue

Insulin aspart NovoRapid+ Novo Nordisk Analogue

Insulin glulisine Apidra+ sanof-aventis Analogue

SHORT ACTING (peak at 2-5 hrs, last 6-8 hrs)

Neutral Actrapid Novo Nordisk Human

Humulin R Lilly Human

Hypurin Neutral Aspen Bovine

INTERMEDIATE ACTING (12-24 hrs)

Isophane Humulin NPH Lilly Human

Protaphane Novo Nordisk Human

Hypurin Isophane Aspen Bovine

LONG ACTING

Insulin detemir (up to 24 hrs) Levemir Novo Nordisk Analogue

Insulin glargine (24 hrs) Lantus sanof-aventis Analogue

PRE-MIXED INSULINS

Lispro 25%Lispro protamine 75%

Humalog Mix 25+

Lilly

Analogue

Lispro 50%Lispro protamine 50%

Humalog Mix 50+

Lilly

Analogue

Insulin aspart 30%Insulin aspart protamine 70%

NovoMix 30+

Novo Nordisk

Analogue

Neutral 30%Isophane 70%

Humulin 30/70

Mixtard 30/70

Lilly

Novo Nordisk

Human

HumanNeutral 50%Isophane 50%

Mixtard 50/50

Novo Nordisk

Human

The pharmacokinetics of the different insulins are patient dependent. Please review product information foreach product before prescribing. An empirical approach to dosage together with a go slow policy will resultin the smoothest fine tuning of management. Some of these insulins are available as injection devices, peninjectors, disposable insulin pens, cartridges and vials.

+ Very quick acting. Should be given immediately before eating.


27/47


6.5 Problems with medication

Insulin and sulphonylureas can cause symptomatic hypoglycaemia and

weight gain. Patients and their families need to be aware of the risk

and be able to manage hypoglycaemia.

Hypoglycaemia

Hypoglycaemia may arise due to excessive insulin or sulphonylurea dose, deicientcarbohydrate intake or unaccustomed exercise. The cause needs to be identiied andthe episode dealt with by reinorcing education, counselling the patient and perhapschanging treatment.

Those who are taking insulin secretagogues or insulin, striving or ideal control,the elderly, those on betablockers and those who live alone or have a high alcohol

intake are at special risk.

Ifthepatientisconscious,initialtreatmentshouldbewithoral

glucose or sucrose.

Ifthepatientisunconsciousgiveglucagon1mgsubcutaneously,

intramuscularly or intravenously. (Glucagon is available through the

PBSasGlucagenhypokit,suggestoneatworkandoneathome).

Carersandworkcolleaguesoftheatriskpersonwithdiabetes

should be familiar with the identification of hypoglycaemia and its

treatment including subcutaneous glucagon administration.

Ifthedoctorisavailableandglucagonfailstorestoreconsciousness,

administration of intravenous 50% glucose 2030 ml should follow

the glucagon.

Itisimportanttofollowresuscitationwithongoingmonitoringand

carbohydrate input.

Poor control

The general practitioner is in a unique situation to be able to identiy possibleactors which contribute to poor control. The general practitioner can explorethe patients understanding o diet, sel-monitoring, treatment, as well as anxietiesabout the condition. The general practitioner can also appreciate the dynamics

within the amily and socio-economic stresses experienced by the patient.

Factors worth considering in poor control are: Inappropriatefoodintake. Inappropriateinsulinororalhypoglycaemicusage. Irregularmetabolicdemand,eg:exercise,shiftwork. Intercurrentinfection(especiallyurinarytractinfection). Incorrectadministrationofmedication/insulin. Psychologicalstress.

6.6 New technology

Two new technologies which are used in the management o type 1 diabetes are nowbeing used in type 2 diabetes: insulin pumps and continuous glucose monitoringsystems (CGMS). Generally, these new technologies are prescribed and monitoredby specialist colleagues.

Insulin pumps inuse continuous (basal) subcutaneous insulin and extra bolusesas needed (eg: at meals or to correct high blood glucose values). Pumps oer thelexibility o having dierent basal insulin doses at dierent times o the day and obeing able to quickly change insulin delivery. Note that insulin pump consumablesare currently subsidised by the NDSS only or people with type 1 diabetes.

CGMS measure, record and can display blood glucose values derived rommeasurements in subcutaneous luid over a 24-hour period. There is a delay

between the calibration o glucose concentrations in blood and subcutaneous luid.The systems are calibrated by blood glucose values measured by the patient andentered into the device.

These two technologies can be combined and give inormation about blood glucoseand the capacity to lexibly deliver insulin. As yet they do not automatically adjustinsulin delivery according to the measured glucose values.

6.7 Surgical procedures

Management aims at reasonable glycaemic control beore, during and ater surgery.

People with diabetes should be seen several weeks beore surgery or assessment odiabetic control and anaesthetic suitability.

Minor or day only procedures usually involve asting rom midnight (i held in themorning) or a light breakast and then asting (i held in the aternoon). In eithercase oral hypoglycaemic agents should be withheld.

For colonoscopy preparation, Colonlytely rather than Fleet should be used inpatients with renal impairment who may become severely hyperphosphataemic

with Fleet.

Appropriate written instructions should be given to the patient beorehand.

Major surgery causes considerable stress to the patient. Metformin should beceased before major surgery. Pre-operative care is the same as or minor surgery,but blood glucose levels should be monitored intra operatively (i a prolongedprocedure) and post operatively or several days. Insulin is oten required postoperatively or people with diabetes.

Patients with diabetes treated with insulin will usually require peri-operative insulinand glucose inusions and close blood glucose monitoring.


28/47

48 Dbs Mgm Grl Pr Sk dys 49

7 Sick days

Lookfortheunderlyingcauseandtreat.

Increaseself-monitoring.

Ensurecontinuityofadvice(especiallyafterhours).

Usuallyanincreaseinmedication isneeded.

In any chronic condition it is inevitable that additional episodes o sickness will occur rom other causes. Sick day management needs to be part o normalpatient education.

Patients need to have a plan or sick days negotiated in advance. This plan

should include:

whentocallthedoctor

howoftentomeasurebloodglucoseandurinaryketones

whatmedicinestotake

howtoeat.

It is important that telephone access to a resource person is available. Telephoneadvice may be suicient when the patient is knowledgeable about diabetes buti any doubt exists, a ormal consultation needs to be arranged. The patient shouldmake contact i they have been unwell or a couple o days and not getting better,i they have moderate (or more) ketones in their urine, i the blood glucose is risingdespite taking medication or i they are unsure o what to do or their care.

Intercurrent illnesses, inections (urinary tract inections, boils), trauma, acutemyocardial inarction and stroke will worsen control. In addition the useo corticosteroids, beta agonists and diuretics may impair control.

The important aspect is to increase sel-monitoring:

bloodglucosemeasurement34times/day

checkingblood or urine or ketones i blood glucose is over 15 mmol/L(in type 1 diabetes).

Patients should try to maintain their normal meal plans i possible. Fluid intake(eg: water) should be increased to prevent dehydration. Advise about alternativeeasy-to-digest oods like soups i the patient cannot tolerate a normal diet. Somenon-diet sot drinks may provide essential carbohydrate in this situation.

Type 2 diabetes controlled with diet alone

Worsening control may require the addition o sulphonylurea or insulin temporarily.These patients are generally not ketosis prone but increased blood glucose levels willimpair the bodys immune mechanisms and make recovery slower. In addition theymay become dehydrated because o the osmotic diuresis.

Type 2 diabetes on oral hypoglycaemic agents

Worsening control may require the use o insulin temporarily. This may requirehospital admission. In patients with nausea, vomiting and/or diarrhoea, considerstopping metormin temporarily as metormin may aggravate these symptoms.

Type 1 diabetes and type 2 diabetes on insulin

Ps shuld rs hr mrg rmd r lg g sul ds

by 1020% d dpdg furhr bld glus lvls, mdfy subsqudss f shr g sul durg h dy. ths wh yp 1 dbs d shr ur fr ks f bld glus s hgh d hy fl uwll.

Ps wh gsrsl ups wh r g, bu wh fl wll du hr usul vs, my d rdu hr sul (splly qukg sul) vd hypglym.

i ll ss h udrlyg us shuld b dfd d rd d h dssf sul d rl hypglym gs shuld b rvwd.

th ausrl Dbs edurs ass hs dvlpd gudls d pfrm sk dy mgm. P frm s ls vlbl frmDbs ausrl (see Internet Resources on inside back cover).


29/47

50 Dbs Mgm Grl Pr Hyprglym mrgs 51

8 Hyperglycaemic emergencies

Lookforanunderlyingcausesepsis,myocardialinfarct.

Correctextracellularfluiddeficitandthenslowlycorrectwater

depletion and hyperglycaemia.

Monitorplasmaglucose,sodiumandpotassiumclosely.

Transfertoaspecialistunitifpossible.

Hyperglycaemic emergencies have a signiicant mortality. They are preventable inpeople known to have diabetes and their occurrence in this group signiies a majorbreakdown in medical management.

It is essential that sick day protocols are understood by patients and theircarers and that a knowledgeable resource person be contactable at all times(eg: the patients general practitioner or associate, endocrinologist, diabetesresource centre).

Adequate early management o sick patients with either type 1 or type 2 diabeteswill prevent hyperglycaemic emergencies. Thereore many cases will be in patientswith previously undiagnosed diabetes.

8.1 Diabetic ketoacidosis

An absolute insulin deiciency results in:

Increasinghepaticglucoseproduction.

Osmoticdiuresisanddehydration,potassiumandphosphatedepletion.

Increasingperipherallipolysis.Theliver,intheabsenceofinsulin,convertsfattyacids into ketoacids which cause the acidosis.

Signs o diabetic ketoacidosis include dehydration, hyperventilation, ketotic breath,disturbed conscious state and shock.

Also check or signs o some precipitating actor such as urinary tract inection,myocardial inarction, pneumonia.

diabetes management in gp 09

Documents