Diabetes Mellitus

Description

General Measures

Referral

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DESCRIPTION

Types of diabetes:

• Type 1
• Type 2
• Other specific types, including pancreatic diabetes mellitus.
• Gestational diabetes mellitus – See Diabetes Mellitus in Pregnancy.

GENERAL MEASURES

• All patients require lifestyle modification.
• Type 2 diabetes mellitus patients: weight loss if weight exceeds ideal weight.
• Correct meal/energy distribution.
• Moderate or no alcohol intake.
• Encourage smoking cessation.
• Increased physical activity, aim for 30 minutes per day 5 times a week.
• Education about foot care is essential.
• Manage comorbid depression. See Depressive disorders.

Diagnosis

• In patients with symptoms of hyperglycaemia and any one of the following criteria:
  • Random plasma glucose >11.1 mmol/l; or
  • Fasting plasma glucose >7.0 mmol/l; or
  • 2-hour plasma glucose in a 75 g oral glucose tolerance test >11.1 mmol/l.
• In asymptomatic patients any one of the following criteria, confirmed by a repeat test on a separate day within 2 weeks:
  • Fasting plasma glucose >7.0 mmol/l; or
  • 2-hour plasma glucose in a 75 g oral glucose tolerance test >11.1 mmol/l.

LoE:III⁹

Classification

• After diabetes mellitus has been diagnosed, attempts must be made to classify the patient as type 1, type 2 or one of the other specific types (including pancreatic diabetes, genetic syndromes, infection and other causes). 
• For management of gestational diabetes, see Diabetes mellitus in pregnancy.

Monitoring

At every visit:

• Finger-prick blood glucose.
• Weight and calculation of body mass index.
• Waist circumference.
• Blood pressure.

Baseline:

• Serum creatinine concentration (and calculated estimated glomerular filtration rate (eGFR)).
• Serum potassium concentration, if on ACE-inhibitor or eGFR <30 mL/minute.
• Urine protein by dipstick.
  • If dipstick negative, request ACR, unless already on an ACE-inhibitor. Microalbuminuria is defined as 2.5 to 25 mg/mmol in men, and 3.5 to 35 mg/mmol in women (see Diabetic kidney disease.)
  • If dipstick positive, see Diabetic kidney disease.
• Blood lipids (fasting total cholesterol, triglycerides, HDL and LDL cholesterol.)
• Foot examination.
• Eye examination to look for retinopathy.
• Waist circumference.

Measure HbA1c:

• 6-monthly in patients who meet treatment goals, and
• 3-monthly in patients whose control is sub-optimal or if therapy has changed, until stable.

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Note
Monitoring of HbA1c implies that active clinical management will be implemented if the level is sub-optimal.

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Annually:

• Serum creatinine concentration (and calculate eGFR).
• Serum potassium concentration (if on ACE-inhibitor/eGFR <30mL/minute).

LoE:III¹¹

• Urine protein by dipstick. 
  • If dipstick negative, request ACR, unless already on an ACE-inhibitor. Microalbuminuria is defined as 2.5 to 25 mg/mmol in men, and 3.5 to 35 mg/mmol in women (see section Diabetic kidney disease.)
  • If dipstick positive, see section Diabetic kidney disease.
• Eye examination to look for retinopathy.
• Foot examination.
• Assessment for peripheral neuropathy.
• Oral and dental examination.
• Assessment for macrovascular disease.
• Resting ECG.

Targets for Control

Glycaemic targets for control:

Patient type	Target HbA1c	Target FPG*	Target PPG*
- Young, low risk - Newly diagnosed - No CVS disease	<6.5%	4.0-7.0 mmol/L	4.4-7.8 mmol/L
- Majority of patients	<7.0%	4.0-7.0 mmol/L	5.0-10.0 mmol/L
- Elderly - High risk - Hypoglycaemic unawareness - Poor short-term prognosis	<7.5%	4.0-7.0 mmol/L	<12.0 mmol/L

*FPG: fasting plasma glucose; PPG: post prandial plasma glucose.

Non-glycaemic targets:

• BMI ≤ 25 kg/m2.
• BP ≤ 140/90 mmHg and ≥ 120/70 mmHg.
• In the elderly, the increased risk of hypoglycaemia must be weighed against the potential benefit of reducing microvascular and macrovascular complications.
• In patients with severe target organ damage, therapy should be tailored on an individual patient basis and should focus on avoiding hypoglycaemia.

REFERRAL

• Inability to achieve optimal metabolic control.
• Complications that cannot be managed on site, especially ophthalmic, e.g. cataracts and proliferative retinopathy.
• Recurrent severe hypoglycaemia.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition