Diabetes screening, testing and pre-diabetes

• Diabetes (NHS Choices), Diabetes - type (CKS), Guide to diabetes monitoring/testing (Diabetes UK), Blood glucose testing strips and meters / Finger prickers and compatible lancets (MIMS), Pre-diabetes - impaired glucose tolerance (patient.info), QDiabetes (risk of developing type 2 diabetes over the next 10 years), QIntervention (how that risk could change with interventions)

Screening in DM

• Microalbuminuria is the earliest sign of diabetic nephropathy and is defined by a urinary albumin:creatinine ratio (ACR) of more than 3 mg/mmol. (RCGP, July 2024)

Type 1 diabetes

• Type 1 diabetes (NHS Choices), Insulin therapy in Type 1 diabetes (CKS), Transition to adult clinics (Diabetes UK), Insulin preparations (MIMS)

• Annual influenza vaccination and a single pneumococcal vaccination are recommended (with the adult preparation PPV23) for children requiring insulin or oral medication for treatment of diabetes – even if they have received all routine childhood vaccinations (which include PPV13). (RCGP, July 2024)

Type 2 diabetes

• HbA1c ≥48 (6.5%) or fasting plasma glucose ≥7.0. 

• Recommended that all patients be offered structured education at the time of diagnosis with annual reinforcement. Group education is the preferred choice unless patients are unable or unwilling to participate. (RCGP, July 2024)

• Lifestyle, metformin, sulfonylureas, gliptins, pioglitazone, GLP-1 mimetics, insulin, SGLT-2i, antihypertensives, statins. 

• Treatment targets HBA1c 48 (6.5%) or 53 (7.0%) if taking a drug associated with hypoglycaemia (e.g. sulphonylurea). 

• Antiplatelet therapy should not be offered to adults with type 2 diabetes who do not have cardiovascular disease. The risks of antiplatelet therapy in this instance as primary prevention outweigh the benefits. (RCGP, July 2024)

• Type 2 diabetes (NHS Choices) / Type 2 diabetes (CKS) / Insulin therapy in Type 2 diabetes (CKS)

July 2024

• You see a 67-year-old patient with known type II diabetes mellitus and cardiovascular disease. He is currently on metformin, but his glycaemic control is still not to target.

• Current NICE guidance on glycaemic management in type 2 diabetes uses cardiovascular risk as the key guidance in medication choice.

• Metformin is first line in someone with established atherosclerotic cardiovascular disease. As soon as metformin tolerability is confirmed, an SGLT2 inhibitor ('flozin') with proven cardiovascular benefit should be added. 

*Metformin should be prescribed with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73 m2 and stopped if the eGFR is below 30 ml/minute/1.73 m2.

DKA / HSS

• Hyperglycemia (e.g. BM>11) AND ketonaemia (e.g. >3mmol/L in blood, or >2+ in urine) AND acidosis

• Lack of insulin, anaerobic metabolism, ketones

• Precipitating factors: infection (pneumonia, UTI), physiological stress (surgery, trauma), drugs (e.g. steroids, diuretics)

• Blood ketones: <0. 6=N; 0.6-1.5 (repeat in 2 hours); 1.6-2.9 (increased risk), ≥ 3 (very high risk)

• Diabetic ketoacidosis (NHS Choices), Diabetic ketoacidosis - DKA (Diabetes UK), Management of the hyperosmolar hyperglycaemic state (HSS) in adults with diabetes (Diabetes UK)

Hypoglycaemia

• BM<3.5

• Hypoglycaemia is the most common endocrine emergency. Diagnostic criteria include a triad of low sugar, symptoms attributed to low glucose and improvement of symptoms on treatment. Symptoms of hypoglycaemia include hunger, dizziness, sweating, palpitations, tremor, blurred vision, altered conscious level and eventually coma.

• Management depends on the conscious level of the patient. In conscious patients, oral intake of 10–20 grams of oral glucose (two teaspoonfuls of granulated sugar or GlucoGel) should be sufficient. Carbohydrates should be given as soon as possible to replenish the glycogen stores in the liver. Oral glucose, in a quickly absorbable form, is first-line treatment for patients who are conscious and who have normal swallowing. (RCGP, July 2024)

• In patients with altered conscious level, 1 mg of glucagon should be administered intramuscularly immediately

Resources

• Mishra A, Quinn M. Endocrine emergencies. InnovAiT 2020; 13(3): 165–172.

• Hypos and hypers (Diabetes UK), Hypoglycaemia - low blood sugar (NHS Choices), Recognition, treatment and prevention of hypoglycaemia in the community (NHS diabetes/Trend UK, 2011), Diabetes and hypoglycaemia (diabetes.co.uk)

Diabetes in pregnancy (gestational diabetes)

• Gestational diabetes (NHS Choices), Gestational diabetes (RCOG), Gestational diabetes (diabetes.co.uk), Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period (NICE)

• Current estimates give an incidence of gestational diabetes affecting 5% of pregnancies. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes, 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The incidence of gestational diabetes is increasing as a result of higher rates of obesity in the general population and more pregnancies in older women (RCGP, July 2024)

• Following delivery any anti-diabetic agents are stopped, and blood glucose is checked in hospital to ensure that it is normal. A repeat fasting blood glucose should be offered to all women by their GP between 6-13 weeks following delivery and acted upon appropriately. Should the blood test be arranged after 13 weeks post-partum, a HbA1c can be used. (RCGP, July 2024)

Resources and training

• Assessing fitness to drive - a guide for medical professionals (DVLA), Diabetes UK (diabetes.org.uk), Dealing with illness (Diabetes UK), Diabetes.co.uk: the global diabetes community (diabetes.co.uk)​, Training, research and education for nurses in diabetes (Trend UK)