Resources.kamsc.org.au

Type II Diabetes
Targets:
• HbA1c ≤7% (53 mmol/mol)**
HbA1c can be used for screening, diagnosis and ongoing • Lipids: TC<4, TG<2, HDL>1, LDL<1.8 mmol/L Early detection and glycaemic control can prevent serious monitoring of diabetes. (See FLOWCHART) Interpretation of HbA1c:
• BMI <25kg/m2 • All Aboriginal people over 15 years of age.
• Waist Circumference (Female <88cm, Male <100cm) • Children over 10 years of age with any of the factors in Box 1 in consultation with Regional IF ≥5.7% send venous sample to lab (see flowchart) (**note targets may need to be individualized) • Anyone with impaired glucose tolerance (IGT) (also What about blood glucose?
Reduce overall CVD risk:
referred to as prediabetes) or at high risk according If someone has had a diagnostic HbA1c, they do not • Exercise ≥20min walking ≥4 days per week to AUSDRISK tool.
need to have an OGTT to confirm their diagnosis.
ype II Diabe
Every 3 years:
If a patient has had a random capillary glucose reading • Alcohol 2 standard drinks/day maximum • Non Aboriginal adults over 40 years of age should be of ≥5.5, then a HbA1c (if not done in last 12 months) screened with AUSDRISK tool, test as below if score is suggested to check for potential diabetes. A random • Dietary modification capillary glucose reading of ≥12.2 is likely to indicate diabetes and must be confirmed with a venous HbA1c.
Principles of Management
• Venous* OR point of care (POC) HbA1c. (*one • Review non pharmacological management at every
venous sample per year funded by MBS) See protocol for anyone with • Before increasing medication carefully review
Box 1 Risk factors for Aboriginal children ≥ 10 years
diabetes or prediabetes.
adherence to existing therapy.
Overweight or obese (>85th Centile BMI) • Every visit encourage appropriate lifestyle changes.
• If on medications other than metformin ask about Positive family history • Offer individual education and dietary consultation symptoms of hypoglycaemia.
Signs of hyperinsulinism (Acanthosis nigricans/PCOS) with appropriately trained health professionals.
• Avoid or minimise the use of glycaemic drugs Oral Hypoglycaemic Agents (OHAs)
Born to a mother with diabetes/gestational diabetes (thiazides, steroids, psychotropics).
1st line: Metformin commence 500mg daily (XR)/bd.
Pyschotropic therapy Up titrate to maximum 2g total daily over four weeks. (From Azzopardi et al, MJA 2012) Maximum daily dose Metformin
UEC, LFTs, TSH, Lipid Waist circumference Retinal Screening NB Metformin should be WITHELD in sepsis, MI, critical *ideally fasted, but not essential – label fasting vs non fasting illness or prior to contrast administration.
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: August 10, 2015 10:42 AM
Type II Diabetes
2nd line: ADD one of:
• Targets: morning fasting glucose of <6 mmol/L or • Gliclazide MR: 30mg MR daily, double dose every 4 non-fasting glucose levesl <8 mmol/L.
• Retinal screening, full foot check, ECG, lipids profile.
weeks to maximum 120mg daily, monitor for hypos.
• Isophane insulin (Protaphane Innolet) may be • Ensure influenza and pneumococcal vaccines are up • Sitagliptin 100mg daily. (NB also available as 50mg considered as an alternative, discuss with Regional and 100mg strength combined with 1000mg XR Women of child bearing age
NB: These agents will need to be reduced with declining Exenatide can be considered as an alternative second line agent in patients with BMI >25 and normal renal function who are willing to consider bd subcutaneous If pregnancy is being contemplated:
eGFR 45-60 => reduce dose as GFR declines below • Aim for HbA1c <6% before conception.
60, monitor for hypos This agent can be used in combination with insulin, but • Commence folic acid 5mg daily (note higher dose).
eGFR<45=> cease doses of both agents need to be adjusted cautiously. Seek • Pregnancy accelerates diabetic retinopathy. Conduct input from the Regional Physicians. retinal screening if a normal screen has not been eGFR 30-50ml/min => 50mg once daily documented in last 12 months.
eGFR <30ml/min => 25mg once daily Cease sitagliptin if commencing exenatide.
ype II Diabe
If pregnancy is not being contemplated:
IF patient remains above target on either of these, then the How to start:
• Ensure reliable form of contraception is being used. alternate 2nd line OHA may be added as a third agent.
• Commence at 5mcg daily, increase to 5mcg bd after 2-4 weeks if tolerated. Uptitrate in 5mcg intervals to total 10mcg bd. Review GI side effects before each If HbA1c is extremely high (eg ≥ 12% (108 mmol/mol)), insulin is the only agent proven to reduce glycaemia to Regional Physician Team
target. Therefore, it can be considered as part of first line • Monitor renal function.
Ensure 3 monthly follow up investigations up to date at time • Advise patient before commencement to report therapy in that context. of appointment. Alternatively, insulin should be added if not at target on abdominal pain. Check lipase and consider • Inadequate control of diabetes despite maximum maximal oral therapy. pancreatitis in this scenario.
• Consider alternative agents if ineffective at six • Total dose of insulin 100 units/day without improved Education required about: Insulin storage, administration glycaemic control.
and monitoring (especially for hypoglycaemia).
Follow up
• Unexplained hypoglycaemic episodes, multiple How to start:
complications and/or comorbidities.
3 monthly
• Any questions about exenatide.
Glargine insulin (Lantus)
Ask about medicines, symptoms of coronary artery • Continue OHAs at same dose.
• Commence at 10 units subcutaneously at the same protocol), diet, smoking and exercise.
• Check weight, BP, waist circumference, feet (See foot • Review at least weekly and monitor for • Pathology: HbA1c, UEC, LFTs, Urine ACR.
• Increase dose by 2-4 units as often as every three days until glycaemic targets met.
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: August 10, 2015 10:42 AM
Type II Diabetes
FOOT CARE
POC machine available?
Perform foot examination at baseline and annually, and stratify according to risk as below. If LOW risk – examine annually (does NOT need to see podiatrist). If HIGH risk – examine 3 monthly AND refer to see POC capillary HbA test
(< 39 mmol/mol) (≥ 39 mmol/mol) Present (or Hx of) Foot deformity / ype II Diabe
Take venous blood for laboratory HbA test (same day if possible) (< 39 mmol/mol) (≥ 48 mmol/mol) rescreen in 12 months (follow diabetes protocol) (follow diabetes protocol) Give healthy lifestyle advice, see
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: August 10, 2015 10:42 AM

Source: http://resources.kamsc.org.au/downloads/cd_dtii.pdf