The patient with newly diagnosed diabetes

The initial management of someone who has just been diagnosed as having diabetes mellitus can have a big effect on the course of the illness. It is essential to establish a clear understanding of the disease, the benefits of all aspects of management and to allay unnecessary fears and myths quickly. See also the separate Management of Type 1 Diabetes and Type 2 Diabetes Treatment and Management articles.

Assessment

Indications for hospital referral at initial presentation include:

• Children, young people and adults presenting with suspected type 1 diabetes should always be referred urgently, on the same day, for admission to hospital for initiation of insulin therapy.¹

• Children and young people with suspected type 2 diabetes should also be referred immediately (same day) to the multidisciplinary paediatric diabetes team.²

• Those who present with diabetic ketoacidosis or hyperosmolar hyperglycaemic state will require immediate treatment in hospital.

• Young adults (aged under 30 years) should also be referred to a specialist diabetes team.

Clinical examination and investigations^{3 4}

• Measure height and weight, and calculate body mass index (BMI).

• Urinalysis: ketones and proteinuria. Arrange midstream specimen of urine (MSU) if protein is present.

• Identify any long-term complications of diabetes already present:
  

  • Cardiovascular assessment, including smoking status, blood pressure, lipids and ECG.

  • Examine feet for diabetic complications, including cardiovascular disease, diabetic neuropathy and diabetic foot complications, diabetic nephropathy and diabetes eye problems.

  • Send urine for albumin:creatinine ratio (ACR) to assess for microalbuminuria.

  • Check renal function and electrolytes. Also check baseline LFTs (fatty liver is more common in people with diabetes).

• Consider whether there may be an underlying disorder causing or associated with diabetes - eg, pancreatitis, Cushing's syndrome, phaeochromocytoma.

Initial management^{1 2}

• Enter patient details on to the practice diabetes register.

• Register the patient with the local eye disease screening programme.

Education

See also the separate Diabetes Diet and Exercise, Self-monitoring in Diabetes Mellitus and Diabetes Education and Self-management Programmes articles.

• Establish the patient's knowledge and educational needs.

• Explanation of the condition and its management should be tailored to the educational needs of the patient and take account of their social and cultural background.

• Ensure all people with newly diagnosed diabetes have the opportunity to share any initial anxieties and concerns about the diagnosis and the implications for their future lifestyle.

• Include advice on managing diabetes during intercurrent illness and possible side-effects of treatments (including hypoglycaemia).⁵

• The possible effects of diabetes on occupation, driving and insurance should be discussed.⁶ If the person concerned is a driver, they should be advised to inform their car insurance company, and the Driver and Vehicle Licensing Agency (DVLA), if on insulin, oral hypoglycaemics or experiencing diabetic eye complications.

• They should also be advised that they are exempt from prescription charges if started on medication for their diabetes.

• Books, leaflets, audio aids and visual aids for the patient to borrow.

• Diabetes UK:⁷ give information about Diabetes UK and details of the local Diabetes UK voluntary group. Diabetes UK also provides a very valuable resource for healthcare professionals and provides educational materials in many languages.

Initial treatment and care

• Management should be discussed with the patient and commenced as soon as possible.

• Advice on diet and exercise recommendations for people with diabetes.

• Prevention of coronary heart disease:

  • All people with diabetes should be advised of the adverse effects of smoking and be offered advice and support to stop smoking.

  • They should also be offered advice and treatment for any other cardiovascular risk factors, including blood pressure control and cholesterol-lowering drugs.

  • Low-dose aspirin should not be routinely prescribed to all people with diabetes for primary prevention but is recommended for secondary prevention.

• Insulin therapy should be started immediately in those who are ill at presentation or who have a high level of ketones in their urine. Insulin should also be considered, regardless of age, if one or more of the following are present:⁸
  

  • Rapid onset of symptoms.

  • Substantial loss of weight.

  • Weakness.

  • Ketonuria.

  • A first-degree relative who has type 1 diabetes.

• Medication to control hyperglycaemia may be required at the time of diagnosis of type 2 diabetes or soon after. See the separate Antihyperglycaemic Agents used for Type 2 Diabetes article.

• All patients with microalbuminuria or proteinuria should be started on angiotensin-converting enzyme (ACE) inhibitor, if there are no contra-indications.⁹

• The initial care plan should be discussed and agreed and a named contact identified who will be responsible for providing support and information. The date of the next appointment should be agreed.

• Regular reviews will be required initially. See the separate Assessment of the Patient with Established Diabetes article.