Resources.kamsc.org.au

AIMS OF MANAGEMENT:
Remember, there is a clinical benefit for
improving all parameters even if target is not
Annually:
• all Aboriginal people over 15; children over 10 at risk
• HbA1c < 7%.
(> 120% ideal weight, acanthosis nigricans).
• Total cholesterol < 4mmol/L
• people with impaired glucose tolerance (IGT) or impaired
• HDL > 1mmol/L, TG < 2 mmol/L, LDL < 1.8 mmol/L.
fasting glucose (IFG) or at high risk.
• BP < 125/80.
Every 3 years:
• BMI 17 - 25kg/m2.
Non Aboriginal adults over 45 years of age.
• Waist Circumference: < 100cm.
How to Screen
• NO smoking.
• Venous glucose (random or fasting) if doing other tests
• See HEALTHY LIVING protocol.
• Every visit encourage appropriate lifestyle changes
• Alcohol 2 standard drinks / day maximum.
e.g. increase physical activity, weight loss,
• Exercise ≥ 20 minutes walking ≥ 4 days / week.
• Random capillary glucose (fingerprick).
smoking cessation and alcohol reduction.
• ACR < 3.5mg/mmoL.
** See flow chart on page 3 of this protocol ** • Offer individual education and dietary consultation with
appropriately trained health professional (e.g. Diabetes Educator, Dietician).
• People with IFG and IGT are at high risk of developing
diabetes and following HEALTHY LIVING advice will • Before starting or increasing medication review HEALTHY
Diagnosis MUST be confirmed with a laboratory
tested venous blood sample (all figures are in
• Avoid or minimize the use of glycaemic drugs (thiazides,
• Healthy eating, increased physical activity and attempts at
mmol/l).
weight loss are central to ideal control for all diabetics.
A high reading is a fasting venous blood glucose (FBG) ≥ 7 BASELINE EXAMINATIONS:
• Before increasing medication carefully
or random venous blood glucose (RBG) ≥ 11.1 (or capillary review adherence to existing therapy.
• BMI and waist circumference (WC).
• BP.
• Ensure influenza and pneumococcal vaccines are
DIABETES MELLITUS (DM):
• Visual acuity (VA).
without symptoms: 2 high readings on separate
occasions including at least one venous reading • Foot examination (see ‘FOOT CARE’ over).
• Check morning fasting capillary glucose (or random clinic
OR venous blood glucose > 20 mmol/L without cause (e.g.
• Carotid examination.
capillary glucose if fasting is not possible) preferably at BASELINE INVESTIGATIONS:
with symptoms (eg thirst, urinary frequency):
• ECG.
• If on medications other than metformin ask about
• BLOODS: creatinine, electrolytes, eGFR, lipids, LFTs, TSH,
See screening flow chart overleaf for indications for 75g oral glucose tolerance test (75g OGTT).
• URINE: dipstick and ACR.
• Retinal screening.
VC - Last Modified: May 6, 2011 4:08 PM
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley • 15/07/2009 NB: clients currently established on rosiglitazone should be
Starting dose:
discussed with the Regional Physician to determine the relative benefits and disadvantages for that individual of substituting 10 units subcutaneously: protophane at night or glargine at rosiglitazone with pioglitazone, or alternatively, to consider Consider aspirin 100mg daily (see CORONARY ARTERY substitution of the glitazone with insulin.
• Review weekly.
Consider statin in all people with diabetes for cardiovascular • Aim for morning fasting glucose of < 6 mmol/L or non-
risk reduction (see DYSLIPIDAEMIA protocol).
…is recommended if maximal oral therapy fails to achieve Hypoglycaemic medications
glycaemic control: HbA1c > 7.5% especially with
• Increase dose by 2-4 units every three days until glycaemic
significant complications – retinopathy, kidney disease,
1st line: Metformin 1g daily: EITHER 500mg BD OR XR
neuropathy, vascular disease or symptomatic hyperglycaemia.
preparation 1g daily, increasing over 2 weeks to maximum dose of EITHER 1g BD or XR preparation 2g once daily.
BEFORE STARTING:
Show Metformin preparations to patient and discuss: • Patient/carer needs education about:
• Metformin: bd dosage, higher risk of GI side effects, smaller
3 monthly - Ask about medicines, symptoms of coronary
tablets (500mg) or fewer tablets (1g tablets).
artery disease (see CORONARY ARTERY DISEASE protocol), • Metformin XR – daily dose, larger tablet, less GI irritation.
recognition and management of hypoglycaemia.
• Check weight, BP, WC, feet (see ‘FOOT CARE’ over),
home monitoring using a glucometer is ideal, however • Estimated glomerular filtration rate (eGFR):
clinic monitoring may be all that is possible.
Annually - creatinine, electrolytes, eGFR, lipids, LFTs,
60 mL/min/1.73m2, maximum metformin dose 1g daily.
• Encourage patient to speak with someone already using
visual acuity, urine ACR, retinal screening and foot review (see • STOP metformin if patient septic, AMI, acutely unwell or
eGFR < 30 mL/min/1.73m2.
• Patient will require access to a secure fridge / or clinic fridge. Every 2 years - ECG.
2nd line: Check adherence to therapy; if adhering
and not well controlled: Add gliclazide MR 30mg
How to start:
daily, doubling dose every 4 weeks to maximum of 120mg daily.
• Continue metformin at current doses. Continue
3rd line: Check adherence to therapy, if adhering
gliclazide at current doses (unless pregnant).
and not well controlled:
• Use a once daily regimen:
(a) Commence insulin. See next column.
If pregnancy is being contemplated:
isophane insulin (e.g. Protaphane Innolet)
OR (i.e. INSTEAD of insulin, and NOT with insulin).
• Aim for HbA1c < 6% before conception.
(b) Commence pioglitazone if patient declines or is
if managing self monitoring and low risk of hypoglycaemia.
• Commence folic acid 5mg daily.
unsuitable for insulin, and has no contraindications. Start pioglitazone 15mg daily. Review BSL readings twice a week, if pregnant or contemplating pregnancy. • Pregnancy accelerates diabetic retinopathy. Conduct retinal
and if necessary, increase dose to 30mg after 6 weeks. screening if a normal screen has not been documented in Continue BSL reviews and after a 3monthly HbA1C check, increase dose to 45mg daily (maximum dose) if necessary glargine insulin - anytime at about the same time
If pregnancy is not being contemplated:
Absolute CONTRAINDICATIONS include Heart • Ensure reliable form of contraception is being used.
if problems with home monitoring or insulin storage. Consider tubal ligation for women who have finished child • Use with caution if high risk of CAD.
if unreliable food availability or home situation. • Do not use as an add-on to insulin.
VC - Last Modified: May 6, 2011 4:08 PM
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley • 15/07/2009 FOOT CARE
Perform foot examination at baseline and annually, and RENAL PHYSICIAN:
stratify according to risk as below. If LOW risk - examine
annually (does NOT need to see podiatrist). If HIGH risk
• eGFR < 30ml/min (see CHRONIC KIDNEY DISEASE).
- examine 3 monthly and to see Podiatrist annually.
• ACR > 100mg/mmol (see PROTEINURIA and eGFR > 60
HIGH RISk
(ALL OF)
(ANY OF)
PHYSICIAN:
• Inadequate control of diabetes despite maximum / optimal
• Total dose of insulin 150 units / day without improved
• Unexplained hypoglycaemic episodes, multiple
complications and / or comorbidities.
OPHTHALMOLOGIST:
DIABETES SCREENING FLOW CHART
• As recommended by retinal screening.
Need venous blood test for other reasons? *See diabetes case definition on Page 1 of this protocol VC - Last Modified: May 6, 2011 4:08 PM
Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley • 15/07/2009 Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley • 15/07/2009

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