Neobook — clinical reference

Description

Clinical Presentation

Diagnosis

Monitoring

ICD-10 Code: E11.9

DESCRIPTION

Type 2 diabetes mellitus is a chronic debilitating metabolic disease characterised by hyperglycaemia with serious acute and chronic complications. It is an important component of the metabolic syndrome (See: Obesity in diabetes).
Most type 2 diabetes mellitus adults are overweight with a high waist to hip ratio
In adults the condition might be diagnosed only when presenting with complications, e.g.:
- Ischaemic heart disease
- Peripheral artery disease
- Stroke
- Deteriorating eyesight
- Foot ulcers
- Erectile dysfunction

CLINICAL PRESENTATION

Symptoms of hyperglycaemia are:

Thirst, especially noticed at night
Polyuria
Tiredness
Periodic changes in vision due to fluctuations in blood glucose concentration
Susceptibility to infections, especially of the urinary tract, respiratory tract and skin

Note:
It is important to distinguish type 2 diabetes mellitus from type 1 diabetes mellitus. Suspect type 1 diabetes mellitus among younger patients with excessive weight loss and/or ketoacidosis

DIAGNOSIS

Symptoms of diabetes plus a random plasma glucose ≥11.1 mmol/L
- Random is defined as any time of day without regard to time since last meal
OR
Fasting plasma glucose ≥7.0 mmol/L
- Fasting is defined as no caloric intake for ≥8 hours
OR
2-hour plasma glucose in a 75 g oral glucose tolerance test ≥11.1 mmol/L

Note:
If screening and not symptomatic: 2 positive tests done on separate days are required for diagnosis

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MONITORING

At every visit:

Finger-prick blood glucose
Weight
Blood pressure

Baseline:

Serum creatinine concentration (and calculate eGFR)
Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min
Urine protein by dipstix
- If dipstix negative, send urine to laboratory for albumin: creatinine ratio, unless already on an ACE-inhibitor. (See: Diabetic nephropathy)
- If dipstix positive, See: Diabetic nephropathy
BMI for cardiovascular risk assessment if appropriate (See: Prevention of ischaemic heart disease and atherosclerosis)
Blood lipids (fasting total cholesterol, triglycerides, HDL and LDL cholesterol)
Foot examination
Eye examination to look for retinopathy
Abdominal circumference

Annually:

Serum creatinine concentration (and calculate eGFR)
Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min
Urine protein by dipstix
- If dipstix negative, send urine to laboratory for albumin: creatinine ratio, unless already on an ACE-inhibitor.(See: Diabetic nephropathy)
HbA1c, in patients who meet treatment goals (3–6 monthly in patients whose therapy has changed, until stable)
Eye examination to look for retinopathy
Foot examination

TARGETS FOR CONTROL

Glycaemic targets for control:

Patient type	Target HbA1c	Target FBG*	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

*FBG: fasting blood glucose; PPG: post-prandial plasma glucose

In the elderly, the increased risk of hypoglycaemia must be weighed against the potential benefit of reducing microvascular and macrovascular complications
Prevent acute complications, e.g. hyperglycaemic and hypoglycaemic coma

Non-glycaemic targets:

Body mass index ≤25 kg/m2
BP ≤140/90 mmHg and ≥120/70 mmHg

Management of type 2 diabetes mellitus includes:

Treatment of hyperglycaemia
Management of chronic conditions associated with diabetes. For treatment of hypertension and dyslipidaemia after risk-assessment, see: Hypertension and Prevention of Ischaemic heart disease and atherosclerosis
Prevention and treatment of microvascular complications. See: Chapter: Microvascular complications of diabetes
Prevention and treatment of macrovascular complications. See: Cardiovascular risk in diabetes

GENERAL MEASURES

Lifestyle modification, including self-care practices
Refer to dietitian if available for annual follow up
Refer to support group if available
Education about diabetes and its complications
Increased physical activity, aim for 30 minutes 5 times a week
Appropriate weight loss if weight exceeds ideal weight
Discourage smoking
Moderate or no alcohol intake (≤2 standard drinks per day for males and ≤ 1 for females)
Education about foot care
All patients should wear a notification bracelet

Diet

Encourage:

Regular, evenly-spaced meals, with small portions
Nutritionally balanced meals, with a variety of healthy foods
Meals that consist of one meat dish option with an option of vegetarian for those who are vegetarian, one starch option, two vegetable options, one fruit option and water

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Carbohydrates

Strict control of carbohydrate intake:
- Encourage small portions of healthy carbohydrates, such as vegetables, fruits, whole grains (e.g. whole wheat bread, oats, brown rice, pearled wheat, maize meal porridge, sorghum porridge, samp, wheat rice), legumes (lentils, beans), and dairy products
- Discourage intake of less healthy, highly processed/refined carbohydrate foods, especially those with added fats, sugars, or salt (e.g. takeaways, deep-fried foods, pies, doughnuts, cakes, biscuits, white bread, sugary drinks)

Fruit and vegetables

Aim for 5 servings of fruit or vegetables per day (e.g. vegetables: spinach, morogo, cabbage, tomato, imifino (amadumbe, amaranth, cowpea, pumpkin and sweet potato leaves); fruit: apple, orange, naartjie, banana, mango, pear, peach)
Limit fruit to 2 servings per day, preferably in small portions throughout the day rather than all at one meal
Limit intake of starchy vegetables like potatoes, sweet potatoes, mielies, butternut, and pumpkin
Limit intake of concentrated fruit sources such as dried or tinned fruit, or juices

Legumes

Soy beans, dry beans, chickpeas, lentils, and split peas are an economical source of protein and fibre
They do contain starch, so contribute to total carbohydrate intake (see: portion sizes below)

Dairy

Advise fat-free or lower fat options

Meat, fish, and eggs

Encourage less fatty cuts of meat if possible
Encourage low fat cooking methods such as baking, grilling, or steaming. Trim excess fat from meat and remove skin from chicken before cooking
Encourage patients to eat oily fish e.g. sardines and pilchards 2-3 times a week
Limit eggs to 1 per day
Avoid processed meats such as polony and viennas

Fats

Replace unhealthy animal fats (fatty beef, pork, lamb and chicken) and tropical oils (e.g. coconut and palm kernel oil) with healthier fats (e.g. avocado pear, fatty fish such as pilchards and plant oils such as canola, olive, sunflower, or peanut butter)
Do not reheat oil, and use softer margarine where possible
Limit intake of takeaway foods, and rather prepare food at home most of the time

Sugar

Avoid sugar and sugary foods and drinks, such as: table sugar, honey, sugary drinks (fizzy drinks, fruit juices, energy drinks, sport drinks, sweetened flavoured milk/ drinking yoghurt, flavoured water), sweets, desserts and baked goods
If eaten on special occasions, advise in very small portions

Salt

Do not exceed a half teaspoon of salt per day. This includes hidden salt in processed foods (e.g. stock cubes, gravy and soup powders, deli meats like polony and viennas, takeaway foods, chips/crisps)
Avoid adding salt to food
Use less salt when preparing food. Use herbs and spices to enhance the flavour of foods instead of salt

Portion control guide

A portion is the amount of food that a person eats at one time, for a meal or snack.

Advise the following portion sizes:

Make protein (e.g. fish, chicken, or meat) food portions the size of the palm of your hand (about 90 g or 1/2 cup)
Make fruit, vegetables and starchy food (such as rice, pasta and potatoes) portions no greater than the size of your clenched fist (1 cup)
Make healthy fat portions the size of the tip of your thumb (1 teaspoon)
Make hard cheese or peanut butter portions the length of your thumb (1 tablespoon)

MEDICINE TREATMENT

Oral blood glucose lowering agents

Step-wise approach:

Add metformin to the combination of dietary modifications and physical activity/ exercise
Combination therapy with metformin plus a sulphonylurea is indicated if therapy with metformin alone (together with dietary modifications and physical activity/ exercise) has not achieved the HbA1c target
For persisting HbA1c above acceptable levels and despite adequate adherence to oral hypoglycaemic agents: add insulin and withdraw sulphonylurea
Ensure patient is adherent at each step
Oral agents should not be used in type 1 diabetes mellitus, renal impairment or clinical liver failure

STEP 1

Lifestyle modification plus metformin

Entry to step 1	Treatment and duration	Target
- Typical symptoms - thirst, tiredness, polyuria AND - Random blood glucose >11.1 mmol/L OR - Fasting blood glucose ≥7 mmol/L	- Lifestyle modification for life - Appropriate diet - Weight loss until at ideal weight Initiate drug therapy with: - Metformin - Assess monthly	- 2-hour post-prandial finger-prick blood glucose: 8–10 mmol/L OR - Fasting finger-prick blood glucose: 6–8 mmol/L AND/OR - HbA1c:7–8%

Metformin, oral, 500 mg daily with meals
- Titrate dose slowly depending on HbA1c and/or fasting blood glucose concentrations to a maximum dose of 850 mg 8 hourly
- Contraindicated in:
  - Uncontrolled congestive cardiac failure
  - Severe liver disease
  - Patients with significant respiratory compromise
  - Renal impairment i.e. eGFR <30 mL/minute

In patients with renal impairment, adjust dose according to table:

eGFR	Metformin dose
eGFR >60 mL/min	Normal daily dose (see above)
eGFR 45–60 mL/min	Standard dose, measure eGFR 3–6 monthly
eGFR 30–45 mL/min	Maximum dose 1 g per day; measure eGFR 3–6 monthly
eGFR <30 mL/min	Stop metformin

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STEP 2

Add sulphonylurea:

Entry to step 2	Treatment and duration	Target
- Failed step 1: HbA1c > 8 % or fasting finger-prick blood glucose > 8 mmol/L despite adherence to treatment plan in step 1 and maximal dose of metformin for 2–3 months OR - 2-hour post-prandial finger-prick blood glucose > 10 mmol/L despite adherence to treatment plan in step 1 and maximal dose of metformin for 2–3 months	- Lifestyle modification AND - Combination oral hypoglycaemic agents, i.e.: - Metformin AND - Sulphonylurea	- 2-hour post-prandial finger prick blood glucose <8–10 mmol/L OR - Fasting finger prick blood glucose: 6–8 mmol/L AND/OR - HbA1c: 7–8%

Sulphonylurea derivatives
Glimepiride, oral with breakfast
- Titrate the dose by 1 mg at weekly intervals up to 6 mg daily (according to blood glucose levels)
- Usual dose: 4 mg daily.
- Maximum dose: 8 mg daily
- Preferred in the elderly

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Glibenclamide, oral, 2.5 mg daily 30 minutes with breakfast
- Titrate dose slowly depending on HbA1c and/or fasting blood glucose levels to a maximum of 15 mg daily.
- When ≥7.5 mg per day is needed, divide the total daily dose into 2, with the larger dose in the morning
- Avoid in the elderly and patients with renal impairment

All suphonylureas should be avoided in patients with renal impairment i.e. eGFR <60 mL/minute.

Sulphonylureas are contraindicated in:

Severe hepatic impairment
Pregnancy

Missing meals while taking sulphonylureas may lead to hypoglycaemia

STEP 3

Insulin therapy:
See: Type 1 Diabetes Mellitus, in Adults

Insulin is indicated when oral combination therapy fails
Continue lifestyle modification
Insulin therapy must be initiated and titrated by a doctor, until stabilised
Stop sulphonylurea once insulin therapy is initiated but continue metformin

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Education for patients on insulin therapy:

Types of insulin
Injection technique and sites of injection
Insulin storage
Self-monitoring of blood glucose and how to self-adjust insulin doses
Diet:
- Meal frequency, this varies according to the type and frequency of insulin, e.g. patients may need a snack at night about 3–4 hours after the evening meal
- Consistent carbohydrate intake for patients receiving fixed mealtime doses of insulin
Recognition and treatment of acute complications, e.g. hypoglycaemia and hyperglycaemia

Insulin type	Starting dose	Increment
Add on therapy - Insulin, intermediate to long acting, SC	10 units in the evening before bedtime, but not after 22h00	If 10 units not effective: increase gradually to 20 units (2-4 units increase each week)
Substitution therapy: - Insulin, biphasic, SC	Twice daily. Total daily dose: Start with 0.3 units/kg/day* divided as follows: LoEIII¹⁷⁸ - 2/3 of total daily dose, 30 minutes before breakfast - 1/3 of total daily dose, 30 minutes before supper	4 units weekly First increment is added to dose before breakfast Second increment is added to dose before supper

*Example of a dose calculation:
- For a 70 kg adult: 0.3 units x 70 kg = 21 units per day; divided as 14 units 30 minutes before breakfast and 7 units 30 minutes before supper.

REFERRAL

Urgent (same day)

Acidotic breathing
Dehydration and hypotension
Nausea, vomiting and abdominal pain
Ketonuria (more than 1+)
Hyperglycaemia >25 mmol/L
Gangrene
Sudden deterioration of vision
Serious infections

Note:
Consider IV infusion with sodium chloride 0.9%, before transferring very ill patients

Non-urgent

Pregnancy
Failure of step 3 to control diabetes
eGFR <30 mL/minute
Ischaemic heart disease
Cerebrovascular disease
Refractory hypertension
Progressive loss of vision

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2024 Edition

Type 2 Diabetes Mellitus, Adults