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Some basic concepts in diabetes.
Scenario A) A 54 year old man with a history of hypertension recently joined your patient list. As part of his new patient medical, the practice nurse requested blood tests as part of the practice hypertension protocol. The fasting glucose requested had a result of 6.5 mmol/l.
If this gentleman had a subsequent oral glucose tolerance test and the 2 hour glucose result was 8.5 mmol/l then what definition does this satisfy? In the context of the previous definition, what is the future risk of development of diabetes?
If there is a family history of type 2 diabetes, is there a significant risk of a family member developing type 2 diabetes
At patients at high risk of development of type 2 diabetes, which intervention (metformin, conventional advice, intensive lifestyle modification) was the most effective in prevention of development of type 2 diabetes
Diagnosis of Diabetes
Scenario B) A 64 year old man with a history of hypertension was reviewed by the practice nurse as part of a QOF review. His BMI was recorded as 33.1 and blood pressure was 145/90 mmHg. His hypertension bloods were requested as per practice protocol and a fasting glucose result revealed a blood glucose of 9.1 mmol/L. He had no symptoms of polyuria or polydipsia. His weight had remained unchanged for several months.
Scenario C) A 54 year old woman has a history of previous gestational diabetes diagnosed during 2 of her 3 pregnancies. She has had symptoms of polyuria and polydipsia noted for the last month. She has a BMI of 31. Her urine was dipsticked in the GP surgery and revealed +++ glucose but no ketones. A random BM in surgery was 11.4. A fasting glucose was then requested which was raised at 9.2 mmol/l and a diagnosis of type 2 diabetes was made.
Management of Type 2 Diabetes
General Points
In general, after the diagnosis of type 2 diabetes is made, initial management is dietary for the first three months. If, after this period, glycaemic control is unsatisfactory (HBA1C> 7%) then oral hypoglycaemic agents are indicated. However if, at time of diagnosis, the fasting glucose is >= 13mmol/L (and the usual diet for the patient does not have excessive sugar) then it is likely that the patient will require oral hypoglycaemic agents (as well as dietary advice) from the onset of management (1). In general the first-line agent for type 2 diabetes is metformin.
The primary care clinician should be aware of the possible insulin deficient type 2 diabetic patient. This patient will not be overweight. If there are no features of type 1 diabetes (e.g. ketonuria) then this patient will require early intervention with medication. In this case the first-line agent is a sulphonylurea. Also the primary care clinician should be aware that this patient may require earlier intervention with insulin than the usual phenotypic type 2 diabetic.
Diet in diabetes
Dietary modification in diabetes involves maintaining a higher intake of complex carbohydrates (with a low glycaemic index) rather than simple carbohydrates.
What is the glycaemic index?
Medication
Improving glycaemic control:
In general, metformin is the first-line oral hypoglycaemic medication in type 2 diabetes.
Monitoring Treatment
Day to Day variation in blood sugar
Is there trial evidence of advantage of blood sugar monitoring compared to urine testing for type 2 diabetics?
Blood sugar testing is often initiated in primary care once a patient has started medication
If blood sugar testing is employed then is the "ideal" pre-breakfast (fasting glucose) reading suggested by JBS2
Long-term sugar control
This is generally measured via the use of glycosylated haemoglobin (HbA1c). What is the basis of the measurement (and timing of measurement) of HbA1c?
How would HbA1c be affected if a patient had haemolytic anaemia?
There is data relating HbA1c to the mean plasma glucose
It is important to be aware of the findings of the UKPDS study.
This study provided evidence regarding the link between glycaemic control and microvascular disease. More recent data provides evidence of a link between macrovascular disease and glycaemic control
What is the target level for HbA1c?
Further oral glycaemic medication following metformin
Metformin is considered the first-line oral hypoglycaemic for type 2 diabetes and is titrated to 1g bd if tolerated. If glycaemic control is still suboptimal then the primary clinician has various choices in terms of other agents to employ:
Reference:
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