Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
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.
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Further reading & references
- Diabetes UK
- Diabetes - type 1; NICE CKS, December 2014 (UK access only)
- Diabetes - type 2; NICE CKS, October 2015 (UK access only)
- Diabetes; NICE
- Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency
- Standards of medical care in diabetes - 2013; Diabetes Care. 2013 Jan 36 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 Feb 131(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 Aug 36 Suppl 2:S139-44. doi: 10.2337/dcS13-2035.
- British National Formulary; 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 Jan 26(1):62-70. doi: 10.1017/S0266462309990584.
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