Management of the Newly Diagnosed Patient with Type Two Diabetes
Refer all patients to the Ward Dietitian.
The non-obese patient: if the patient is not ketotic, they may safely be given a trial of diet, and adding an oral agent if the presenting glucose level is very high (unless contraindicated, metformin is usually the drug of choice for initial oral therapy) rather than insulin. Recent significant weight loss, age <40, and severe hyperglycaemia (>14-16 mmol/L) all suggest that insulin treatment is likely to be required in the longer term. Sulphonylureas can cause hypoglycaemia and should be used with caution in the elderly and in patients with renal impairment. Use of sulphonylureas also has implications for vocational drivers.
The obese patient: weight reduction and exercise are the cornerstones of management. Many patients will also require metformin. The risk of developing lactic acidosis on metformin is increased in the presence of renal (creatinine ≥160 micromol/L, eGFR <30 mL/min), cardiac or liver disease and metformin should also be used with caution in the elderly.
Diabetes Nurse Specialists: are available to help with education and practical management e.g., home blood glucose monitoring, insulin injection technique, use of pen injector devices, sick day and 'hypo' management. Referrals should be faxed to the Diabetes Centre. If the patient needs to be seen within 24 hours, a phone call to back up the faxed referral is helpful. If recent glycaemic control is uncertain, consider ordering an HbA1c.