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 Management of Type 2 Diabetes articles.
Indications for hospital referral at initial presentation include:
- Children and young people presenting with suspected diabetes should always be referred urgently, on the same day, for admission to hospital for initiation of insulin therapy.
- Adults who are clearly unwell, or who have ketones in their urine, or who have a blood glucose level greater than 25.0 mmol/L, should also be referred urgently for admission to hospital on the same day.
- 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
- 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.
- Enter patient details on to the practice diabetes register.
- Register the patient with the local eye disease screening programme.
- 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).
- The possible effects of diabetes on occupation, driving and insurance should be discussed. 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: 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:
- Rapid onset of symptoms.
- Substantial loss of weight.
- 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.
- 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.
Further reading and references
Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency
Standards of medical care in diabetes - 2013; Diabetes Care. 2013 Jan36 Suppl 1:S11-66. doi: 10.2337/dc13-S011.
Copeland KC, Silverstein J, Moore KR, et al; Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics. 2013 Feb131(2):364-82. doi: 10.1542/peds.2012-3494. Epub 2013 Jan 28.
Raz I; Guideline approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care. 2013 Aug36 Suppl 2:S139-44. doi: 10.2337/dcS13-2035.
British National Formulary (BNF); NICE Evidence Services (UK access only)
Adarkwah CC, Gandjour A; Cost-effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in newly diagnosed type 2 diabetes in Germany. Int J Technol Assess Health Care. 2010 Jan26(1):62-70. doi: 10.1017/S0266462309990584.
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