Diabetes in Primary Care Flashcards
How common is undiagnosed diabetes?
Estimated almost 1 million people with type 2 diabetes don’t know they have it = about 17%
How useful is retinopathy as a screening tool?
Not very = only 19.3% have retinopathy at diagnosis and it only develops after at least 3-5 years of consistent hyperglycaemia in the diabetic range
How is the population screened for diabetes?
Systematic population screening isn’t cost effective but = targeted screening of high risk patients is used
What should GPs and other community practitioners implement?
A two stage strategy to identify patients at high risk of type 2 diabetes and those with undiagnosed type 2 diabetes
How should risk assessment be carried out?
Using validated self-assessment or validated web-based tools then fasting blood glucose if indicated
What patient groups should be recalled annually for a fasting plasma glucose measurement?
Patients with impaired glucose tolerance or fasting glycaemia, patients with a past history of gestational diabetes
What patients groups should be screened opportunistically, preferably using fasting plasma glucose measurement?
Non-Caucasians, patients with a family history of type 2 diabetes, obese (especially centripedal) patients, women with polycystic ovarian syndrome
What symptoms would make you consider a diagnosis of diabetes?
Thirst and polyuria, unexplained weight loss or tiredness, pruritic vulvae, balanitis or recurrent UTIs, recurrent infections, burring of vision, discoloured/ulcerated feet, acutely unwell
What else is needed alongside classical symptoms to diagnose diabetes?
Random blood glucose >= 11.1mmol/L or
Fasting blood glucose >= 7.0 mmol/L or
2hr blood glucose after OGTT >= 11.1mmol/L
What is needed to diagnose a patient with no symptoms with diabetes?
Diagnosis shouldn’t be based of single blood glucose,
additional testing on another day with a value in the diabetic range is essential
When should a 2hr blood glucose after OGTT sample be used to make a diagnosis of diabetes?
If the fasting or random blood glucose levels are not diagnostic
How should a patient with ketonuria and severe symptoms be managed?
Urgent hospital admission
How should a patient with ketonuria with milder symptoms and weight loss be managed?
Discuss patient urgently with diabetic team
When should an oral glucose tolerance test (OGTT) be done?
If the fasting glucose is 6.1-6.9mmol/L
How is a OGTT performed?
Initial fasting glucose is measured, 75g anhydrous glucose or equivalent is administered, repeat plasma glucose measurement after 2hrs
What must a patient do before undergoing an OGTT?
They must have had no food or drink for 8-12hrs beforehand
How are patients with definite or likely type 1 diabetes referred to the specialist consultation service?
Via urgent telephone referral
When should referral to specialist consultation service be considered?
Patient with low or low-normal BMI
All children
Patients who are pregnant/considering pregnancy
Pre-existing chronic renal impairment
If patient <40 at diagnosis of type 2 diabetes
Whenever there is a specific clinical concern
How are most patients with type 2 diabetes followed up?
Mostly by GP in practice = often nurse led clinics, GP clinical lead for diabetes is present in most practices
Who must new diabetics be registered with?
The SCI-DC
How quickly should retinopathy screening begin after a patient is diagnosed?
Automatic appointment is made within three months for retinal photography after registering with SCI-DC
What education services can patients be referred to?
TDEP sessions
What baseline measures should be taken in all newly diagnosed diabetics?
BMI, BP, urinalysis (for protein etc), bloods, lipids
What is involved in the initial management of a new diabetic?
Provide initial support and info about type 2 diabetes
Identify and address other risk factors
Management of CV risk and glycaemic control
Foot screening and risk assessment
How long should lifestyle measures be trialled for?
3 months
What are some lifestyle changes that can be made?
Weight loss TAWMS if BMI > 30
Healthy eating, exercise, alcohol consumption (reduce), smoking cessation, lipids and BP management
What are some barriers to lifestyle changes?
Locus of control/self-efficacy, shame, stigma, lack of knowledge, depression, lack of resources, cost
Is depression a big issue for diabetics?
Yes = depression is more common in diabetics than the general population
What are the glycaemic targets for a healthy individual?
HbA1c < 58m/m
BP < 140/80mmHg
Statin indicated
What are the glycaemic targets for a patient with intermediate health?
HbA1c < 64m/m
BP < 140/80mmHg
Statins indicated
What are the glycaemic targets for a patient with poor health?
HbA1c < 69m/m
BP < 140/90mmHg
Should insulin be stopped in diabetic ketoacidosis?
NEVER stop insulin in suspected DKA = check ketones
How often should fluids be given in an acutely unwell type 1 diabetic?
100-200ml every hour
Why are carbohydrates given to acutely unwell type 1 diabetics regardless of blood glucose levels?
To facilitate insulin administration
If unable to take solids then take 200ml of liquid carbohydrates
What are some liquid forms of carbohydrates that can be given to an acutely unwell type 2 diabetic?
Pure fruit juice, Ribena, milk, flat coca cola, sugary lemonade
How should blood glucose and ketones be monitored in an acutely unwell type 1 diabetic?
Blood glucose monitoring every 4 hours
Check ketones in acutely unwell patient or during pregnancy
What should be done for type 1 diabetic with blood ketone level > 0.6mmol/L?
Consider extra insulin by increasing routine insulin dose by 10% if blood glucose levels are elevated
How does insulin requirement change during illness in a type 1 diabetic?
More insulin is often required = check blood glucose and ketones within 2hrs
What should the STAT dose of insulin be in an acutely unwell type 1 diabetic?
10-20% of patients daily insulin dose
When should type 1 diabetic patients be admitted to hospital when unwell?
Dysphagia, inability to keep fluids down, persistent vomiting or diarrhoea, strongly positive ketonuria/ketonaemia, when DKA is clinically obvious
What are the diabetic sick day rules?
Found on sick day cards = cards tell patients to stop taking medication with a tick next to it until they are well again
What normally happens to the blood glucose levels in an unwell type 2 diabetic?
Usually rises = short term hyperglycaemia can be tolerated
When can unwell type 2 diabetics be manged at home?
If no evidence of severe dehydration and the patient is able to increase oral fluids appropriately
How does illness change how a type 2 diabetic takes their medication?
Oral medication should be continued in most cases
Metformin should be temporarily stopped if there is severe infection or dehydration
When should unwell type 2 diabetics be admitted to hospital?
Severe dehydration, intractable vomiting
