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CHAPTER11 Endocrinology
Diabetesmellitus
Diabetes mellitus (DM) is a common syndrome caused by lack, or d eectiveness, of endogenous insulin. It aects 3% of the UK population and is characterized by i blood glucose + abnormalities of carboh ydrate/ lipid metabolism.
Classication ofprimarydiabetes
Type 1 Occurs at any age but more common in those aged <30y.
Autoimmune disease— islet cell antibodies may be present initially.
Associated with other autoimmune disease and certain genotypes (HLA
DR3/ 4— although identical twin concordance 830%.). Patients are prone
to profound weight d and ketoacidosis. Insulin is needed from diagnosis.
0 Do not measure C- peptide and/ or diabetes- specic autoantibody titres
to conrm type 1 DM in adults.
Type 2 80– 90% patients with DM. ♂:♀ 83:2. Prevalence is rising.
Progressive disease resulting from d insulin secretion and insulin resistance.
Onset is often insidious; ½ have complications at diagnosis. Risk factors:
• Age >65y • Pre- diabetes
• Obesity • FH of DM (identical twin concordance 8100%)
• Ethnic group— South Asians/ Afro- Caribbeans have 5– 10× i risk
• PMH of gestational diabetes or a baby >4kg at birth
Latent autoimmune diabetes in adulthood (L ADA) 6– 10% of patients with
type 2 DM. Characterized by antiglutamic acid decarboxylase (GAD) antibodies. Associated with higher risk of ketoacidosis and i risk of progression to insulin dependence. Suspect if type 2 DM and:
• Absence of metabolic syndrome features
• Uncontrolled hyperglycaemia despite oral agents and/ or
• Other autoimmune diseases (e.g. thyroid disease, pernicious anaemia)
Maturity- onset diabetes of the young (MODY) 1– 2% of patients with DM.
Present <25y and there is a family history. Genetic syndrome with autosomal dominant inheritance. Gene mutations involved: HNF1- α (70%);
HNF1- β; HNF4- α; glucokinase. Gene testing is important to identify the
type of MODY, as treatment diers according to type.
Other (secondary) causes ofDM
• Drugs Steroids, thiazides
• Pancreatic disease Pancreatitis, surgery, pancreatic cancer,
haemochromatosis, cystic brosis
• Endocrine disease Cushing’s disease, acromegaly, thyrotoxicosis,
phaeochromocytoma, pregnancy
• Others Glycogen storage diseases, insulin receptor antibodies
H Blood glucose may be temporarily i during acute illness, after trauma
or surgery, or during short courses of blood glucose- raising drugs (see 2°
causes). If HbA1c ≥48mmol/ mol DM is likely.
Testing fordiabetes Figure 11.1 0 Consider referral for an urgent
(<2wk) direct access CT scan (or USS if CT is not available) to assess for
pancreatic cancer if aged ≥60y, weight d, and new- onset DMN.
* For patients with symptoms (polyuria, polydipsia, weight
If no symptoms, conrm FBG with a second sample; consider conrming an abnormal
HbA1c with a second sample.
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DIABETESMELLITUS
Which test to use?
Acutely unwell?
NO
<18y?
Possible type 1 DM?
Pregnancy?
Anaemia?
Abnormal Hb (e.g.
sickle cell,
spherocytosis)
YES
YES
any
NO
to
to
all
Check capillary
blood glucose;
admit as needed
Check fasting
blood glucose
(mmol/L)
Check
glycosylated
haemoglobin
(HbA1c)
(mmol/mol)*
Check second
fasting blood
≥7
glucose (FBG)*
Check glucose
6–7
tolerance test
<6
NORMAL
No evidence of
<42
42–47
≥48
DM
PRE-DIABETES
(Impaired glucose tolerance)
d), one FBG is sucient.
<7.8
<7
≥7
≥11.1
7.8–11
D
I
A
B
E
T
E
S
Figure11.1 Diagnosis of diabetes
Presentation
• Acute Ketoacidosis or hyperosmolar non- ketotic coma (E p. 1083)
• Sub- acute Weight d, polydipsia, polyuria, lethargy, irritability, infections
(candidiasis, skin infection, recurrent infections slow to clear), genital
itching, blurred vision, tingling in hands/ feet
• With complications Skin changes (E p. 327), neuropathy (E p. 329),
nephropathy (E p. 325), arterial (E p. 326) or eye disease (E p. 328)
• Asymptomatic Incidental nding or through risk stratication
Risk stratication
N
Use a risk stratication tool (e.g. Diabetes Risk Score or
QDiabetes) to assess all patients >40y, or >25y if of South Asian, Chinese, AfroCaribbean, or black African origin, from hard- to- reach populations (e.g. homeless) or with other medical conditions that predispose to DM (e.g. pancreatitis).
• If low/ intermediate risk Give lifestyle advice and reassess in 5y
• If high risk Or of South Asian/ Chinese ethnic origin and BMI >23kg/ m2,
check FBG or HbA1c. Management— Table 11.1
Pre- diabetes (non- diabetic hyperglycaemia) FBG 6.1– 6.9mmol/
L or HbA1c 42– 47mmol/ mol. Risk factor for DM and CVD. Follow- up with
annual FBG or HbA1c. 4%/ y develop DM. Oer lifestyle advice aiming to
normalize blood sugar— a 5% weight d results in 780% d risk of progression
to DM over 3y. Treat CVD risk factors aggressively.
Diabetes and pregnancy E p. 806
Further information
NICE (2011) Preventing type 2 diabetes:risk identication and interventions for individuals at high risk. M www.nice.org.uk/ guidance/ ph35
Table11.1 Diabetes risk stratication forhigh- risk patients
FBG (mmol/ L) HbA1c (mmol/ mol) Action
<5.5 <42 Provide lifestyle advice; reassess every 3y
5.5– 6.9 42– 47 Treat as for pre- diabetes
≥7 ≥48 Consider type 2 DM
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CHAPTER11 Endocrinology
Organization and monitoring ofcare
Aims ofdiabeticcare
• Alleviation of symptoms • Quality of life enhancement
• Minimization of complications • Education of the patient and
• d in early mortality
Features ofwell- organizedcare
• Use of a register and structured records (available as part of in- house
computer software)
• 6- monthly review with recall system and follow- up of defaulters
• Protocol for patient- centred care including provision of personal care
plans tailored to each individual and including self- management plans
• Provision of protected time for the clinic
• Availability of good- quality written information for patients
• Open access for patients to receive advice
• Multidisciplinary team covering all aspects of diabetes care— e.g. GPs,
diabetes nurse specialists/ assistants, educators, dieticians, podiatrists
• Quality monitoring through audit and patient feedback
• Continuing education for professional sta
Routine diabetic review Each patient with DM requires 6- monthly
review (or more frequent as necessary). This should include a thorough annual review of all aspects of disease and care. Reviews should cover:
• Problems Recent life- events; new symptoms; diculties with
management since last visit
• Review of:
• Indices of control, e.g. HbA1c
• Self- monitored results and discussion of their meaning
• Lifestyle— dietary behaviours; physical activity; smoking
• Diabetes education— including referral to a structured education
programme for those newly diagnosed and information on lifestyle, selfcare, support, and when to step up treatment/ seek further medical help
• Skills, e.g. injection technique for patients on insulin
• Foot care
• Review of blood glucose, lipid and BP therapy, and results
• Other medical conditions and therapy aecting DM
• Immunizations— inuenza ± pneumococcal vaccination
• Depression screening (E p. 173)
• Review of complications Annual review— more frequent if established
complications. Cardiovascular disease; nephropathy; neuropathy; eye
disease; foot problems; erectile dysfunction
• Review of services Annual review— more frequent if problems
• Analysis and planning Agreement on the main points covered, targets
for coming months, changes in therapy, interval to next review
• Recording Completion of structured record ± patient- held record
0 7– 10% of patients in long- term residential care have DM. Patients in
residential care with DM tend to be neglected. Agree a diabetes care plan
for each aected resident and ensure at least annual diabetic review.
family/ carers
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ORGANIZATION AND MONITORING OFCARE
Monitoring blood glucose All patients can achieve good levels of con-
trol (Table 11.2). Poorer control is acceptable in the elderly or others with
limited life expectancy as long as they are symptom free.
• Finger- prick capillary glucose monitoring Essential for all patients using
insulin or who are pregnant. In addition, oer to people with type 2 DM
if evidence of hypoglycaemic episodes or on oral medication that may i
risk of hypoglycaemia while driving or operating machinery
• Explain the range of suitable monitoring devices available and train in
the use of the selected method
• Frequency of self- monitoring varies according to need
• Set targets for preprandial glucose levels
• Assess skills (and meters) yearly or if problems self- monitoring
• Evaluate reliability of results by comparison with HbA1c results and
results obtained at review
• Glycosylated haemoglobin (HbA1c) Measure at least 2×/ y. Represents
average blood glucose control over the previous 6– 8wk
0 Patients with type 2 DM who are taking sulfonylureas or glinides must
check blood glucose regularly when driving, so will need blood glucose
meters and a supply of testing sticks.
Table11.2 Indices ofcontrol
Measure Target
Capillary blood
glucose (mmol/ L)
Urine −ve (postprandial sugars <0.5%)
HbA1ca (normal
20– 42mmol/ mol)—
measure every 2– 6mo
depending on control
Serum cholesterol Aim to d non- HDL cholesterol by >40% from baseline
BMI (kg/ m2) 25– 30
BP (mmHg) <140/ 80— uncomplicated type 2 DM
a
Adjust target to the individual; if very elderly or limited life expectancy, relax HbA1c aiming just
to keep the patient asymptomatic.
Fasting blood glucose on waking 5– 7
Pre- meals 4– 7; >90min after eating 5– 7
Before driving ≥5
Type 2 DM and:
• Drug causing hypoglycaemia ≤53mmol/ mol
• Diet controlled or drug not causing hypoglycaemia
≤48mmol/ mol
Type 1 DM ≤48mmol/ mol
<135/ 85— uncomplicated type 1 DM
<130/ 80— if any renal, foot, eye, or cardiovascular
complications of type 1 or type 2 DM
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Further information
NICE (2015, updated 2016)Type 1 diabetes in adults:diagnosis and management. M www.nice.org.uk/ guidance/ ng17
NICE (2015, updated 2017)Type 2 diabetes in adults:management. M
www.nice.org.uk/ guidance/ ng28
Patient advice and support
Diabetes UK F 0345 123 2399 M www.diabetes.org.uk
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CHAPTER11 Endocrinology
Management ofdiabetes:education
Education is an essential aspect of diabetic care. Diabetes is a chronic condition, and however well it is managed in the clinic, the patients must manage
their own disease the rest of the time. Everyone with DM should receive
education through a structured, quality- controlled education programme,
e.g. diabetes education and self- management for ongoing and newly diagnosed (DESMOND). Education enables patients and their carers to become equal partners in the management of their disease.
General knowledge Information about:
• DM, its progressive nature, complications, and aims of management
• Structure of diabetic services and ways to access them
• Equipment required and usage instructions— syringes, needles, blood
testing equipment, etc.
• Free prescriptions if requiring drugs or insulin to control diabetes
• Problems of pregnancy (♀ of childbearing age only)
• Alert bracelets/ tags— Medic- Alert (F 01908 951045 M www.
medicalert.org.uk) or Medi- Tag (F 0121 200 1616 M www.medi- tag.
co.uk) provide engraved jewellery, watches, and tags
Diet Patients do not need a separate diet from the rest of the family or
expensive ‘diabetes’ food products. Adiabetic diet is a healthy diet.
• Aim for ≥50% of calorie intake from bre- rich carbohydrate, with
minimum fat (especially saturated), rened carbohydrate, and alcohol
• Adjust total calorie intake according to desired BMI. If overweight, aim
for initial 5– 10% weight loss. Consider referral for bariatric surgery if
referral criteria are met (E p. 153)
• Recommend ≥5 portions of fresh fruit or vegetables/ d
• Spread food intake evenly across the day
• Diet sheets are available from Diabetes UK and should be provided
• Ready- made meals, processed foods, and alcohol are often sources of
hidden sugar
Immunizations Oer annual inuenza and single- dose pneumococcal
vaccine to all patients with diabetes.
Psychological problems Discuss concerns about DM. Arrange coun-
selling/ refer to self- help resources as needed. Teenagers with diabetes can
be a particularly dicult group to manage. Often control is poor due to a
combination of rapid bodily changes and rebellion against the diagnosis of
DM. Support information and advice given in specialist clinics.
Exercise Encourage regular exercise.
• Review activity at work, and in getting to and from the workplace,
hobbies, and physical activity in the home
• Advise physical activity can i insulin sensitivity, d BP, and improve blood
lipid control
• If appropriate, suggest regular physical activity tailored to individual
ability (e.g. brisk walking for 30 min/ d; exercise prescription)
Smoking Advice on and assistance with smoking cessation (E p. 156).
Foot care E p. 330
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MANAGEMENT OFDIABETES:EDUCATION
Driving
Group2 licence (bus and lorry)
• On insulin and/ or sulfonylurea or glinide medication Inform the DVLA.
1y licence issued if full awareness of hypoglycaemia; no episodes of
severe hypoglycaemia in the past 12mo; monitoring capillary blood
glucose ≥2×/ d regularly (even when not driving), ≤2h before starting
a journey, and every 2h while driving. Must use a blood glucose meter
with >3mo memory
• Other antidiabetic medication Must notify the DVLA but can drive
• Diet controlled No need to inform the DVLA
Group1 licence (car and motorcycle)
• Insulin controlled Inform the DVLA. May drive if adequate awareness
of hypoglycaemia; ≤1 episode of severe hypoglycaemia while awake
in the past 12mo and last episode >3mo ago; capillary blood glucose
monitoring ≤2h before a journey and every 2h whilst driving
• Sulfonylurea or glinide medication No need to inform the DVLA. Must
be under regular medical review. May drive if adequate awareness of
hypoglycaemia; ≤1 episode of severe hypoglycaemia while awake in the
past 12mo and last episode >3mo ago. Capillary glucose monitoring as
for insulin if needed clinically— usually if new medication (<3mo), if any
episodes of hypoglycaemia and/ or d awareness of hypoglycaemia
• Diet controlled or other antidiabetic medication No need to inform
the DVLA
0 Drivers should also inform their insurance company. Other conditions
associated with DM (e.g. visual impairment, CHD) may preclude driving.
Employment Advise those on insulin that certain jobs are no longer
possible, e.g. working on scaolding or with dangerous machinery; joining
the police or armed services. Jobs without these hazards should pose no
problems although the patient might wish to tell his/ her employer. Special
advice may be needed for shift work.
Travel Be aware of insurers catering for diabetic travellers. Give advice
on:management of change in time zones (no change needed with oral medi-
cation or if taking insulin and <4h time dierence); transport and storage
of insulin (needs refrigeration in hot climates); keeping monitoring/ injection
equipment in hand- luggage; dierences in insulin types and concentrations
between countries; travel- related illness (especially gastroenteritis); need
for immunization/ travel insurance.
Further information
DVLA (2016, updated 2019)Assessing tness to drive:a guide for
medical professionals. M www.gov.uk/ government/ publications/
assessing- tness- to- drive- a- guide- for- medical- professionals
NICE (2015, updated 2016)Type 1 diabetes in adults:diagnosis and management. M www.nice.org.uk/ guidance/ ng17
NICE (2015, updated 2017)Type 2 diabetes in adults:management. M
www.nice.org.uk/ guidance/ ng28
Patient advice and support
Diabetes UK F 0345 123 2399 M www.diabetes.org.uk
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CHAPTER11 Endocrinology
Treatment oftype 2diabetes
• Always combine drug treatment of hyperglycaemia with lifestyle meas-
ures and modication of other risk factors for vascular complications.
Healthy eating and exercise Diet is the cornerstone of DM treat-
ment. Diet sheets are available from Diabetes UK. i physical activity is also
benecial (d weight, d lipids, and i insulin sensitivity).
Usage ofantidiabetic drugs Figure 11.2
Antidiabeticdrugs
Biguanides e.g. metformin 500mg tds. d gluconeogenesis and i peri
pheral utilization of glucose. Only eective if some endogenous insulin.
Hypoglycaemia is not a problem. Start with minimum dose and i every
month until control is achieved/ maximum dose reached. If not tolerated,
try MR preparation. Avoid/ stop if eGFR <30mL/ min/ 1.73m2.
Sulfonylureas (SU) e.g. gliclazide 80– 160mg bd. Augment insulin secretion;
only eective if some endogenous insulin production. All are equally effective. Advise to take before meals— warn about hypoglycaemia if meals
are omitted and need for blood monitoring if driver. Start at minimum
dose and i until blood sugar is controlled/ maximum dose is reached. Wait
≥1mo between adjustments. Main side eect is weight i.
Dipeptidylpeptidase- 4 inhibitors (DPP4i) ‘Gliptins’, e.g. sitagliptin 100mg od,
linagliptin 5mg od (useful if renal failure as excreted via the gallbladder).
Inhibit breakdown of glucagon- like peptide- 1 (GLP- 1). This d blood glucose
levels by i insulin secretion from the pancreas, d glucagon secretion, and
slowing gastric emptying. May cause hypoglycaemia (uncommon).
GLP- 1 mimetics e.g. exenatide, liraglutide, lixisenatide. i insulin secretion, d
glucagon secretion, and slow gastric emptying. Consider with metformin +
sulfonylurea if triple therapy has failed and weight d might benet other comorbidities, BMI ≥35kg/ m2 or BMI <35kg/ m2 but insulin treatment would
have signicant occupational implications. May cause hypoglycaemia— warn
about the need for blood glucose monitoring if driver. Avoid if eGFR
<30mL/ min/ 1.73m2 (<50 for some MR preparations). Continue after 6mo
only if HbA1c has d >11mmol/ mol and weight d is >3% of initial body
weight. 0 Rarely associated with ketoacidosis and pancreatitis.
Pioglitazone 15mg od. d peripheral insulin resistance. Does not cause hypo-
glycaemia. May i weight. Check LFTs before and regularly during treatment.
0 i risk of bladder cancer, bone fracture, uid retention, and heart failure;
avoid if risk factors for these conditions.
Sodium– glucose cotransporter- 2 inhibitors (SGLT2i) ‘Gliozins’, e.g.
canagliozin 100– 300mg od; dapagliozin 10mg od; empagliozin 10– 25mg
od. Act on the proximal tubules of the kidney to block reabsorption of
glucose back into the bloodstream resulting in d blood glucose. Cause
weight d; may cause UTIs and/ or genital thrush. Avoid if aged >75y or
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Diet and lifestyle modication.
If HbA1c <48, continue monitoring every 6mo
HbA1c >48
Start metformin
Target HbA1c <48
Not tolerated
HbA1c>58 despite optimal monotherapy
Metformin +
• DPP4i or Target
• Pioglitazone or HbA1c
• Sulfonylurea or <53
• SGLT2i
HbA1c >58 despite optimal dual therapy
TRIPLE THERAPY
Metformin +
• Sulfonylurea + DPP4i or
• Sulfonylurea + SGLT2i or
• Sulfonylurea + pioglitazone or
• Pioglitazone + SGLT2i
Target HbA1c <53
If HbA1c >58 despite triple therapy
Consider metformin +
Sulfonylurea +
GLP-1 mimetic
Figure11.2 Usage of antidiabetic drugs
TREATMENT OFTYPE 2DIABETES
If hyperglycaemic +
!
symptomatic give sulfonylurea
or short-acting insulin until
blood glucose is controlled.
Then review medication
MONO
THERAPY
DUAL
THERAPY
OR
OR
fails
N
(HbA1c units are in mmol/ mol)
Metformin contraindicated
DPP4i or pioglitazone—target
HbA1c <48 or
Sulfonylurea—target HbA1c <53
• DPP4i + pioglitazone or
• DPP4i + sulfonylurea or
• Sulfonylurea + pioglitazone
Target HbA1c <53
Continue metformin and review
need for other anti-diabetic drugs
Start insulin—rst-line: NPH
(isophane) insulin od/bd ± shortacting insulin
If help needed for injecting, bd
NPH insulin needed and/or
disabling hypoglycaemia, consider
insulin detemir or glargine.
Consider short-acting insulin
analogue if patient prefers,
If
hypoglycaemia is a problem or
marked
meals
INSULIN
i in blood glucose before
321
eGFR <60mL/ min/ 1.73m2. 0 Rarely may cause diabetic ketoacidosis
even with normal blood glucose— warn patients.
Rapid- acting insulin secretagogues e.g. repaglinide, nateglinide. Stimulate insulin release. Rapid onset and short duration of activity. Take ½ h before
meals. Avoid if aged >75y. Hypoglycaemia is a common side eect. Warn
about need for blood glucose monitoring if driver.
Starting insulin E p. 322.
Lifestyle, drug and surgical treatment ofobesity E p. 152.
Further information
NICE (2015, updated 2017)Type 2 diabetes in adults:management. M
www.nice.org.uk/ guidance/ ng28
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CHAPTER11 Endocrinology
Insulin
First- line treatment for type 1 DM and used when diet plus oral therapy
have failed for type 2 DM. Local guidelines govern who does what.
• All drivers must notify the DVLA and their insurance company.
Insulin passports and patient information booklets Oer to all
patients receiving insulin. Provides a record of the patient’s current insulin
preparations and contains a section for emergency information. The patient
information booklet provides advice on the safe use of insulin.
Types ofinsulin
• Rapid- acting analogues e.g. insulin lispro— fastest- acting; peak 0– 3h after
injection; last 2– 5h; given just prior to meals
• Soluble (clear) human, porcine, or bovine e.g. Actrapid®— short- acting;
peak 2– 6h after injection; last 8h; give 15– 30min before meals
• Isophane (NPH, cloudy) human, porcine, or bovine e.g. HumulinI®,
Insulatard®. Intermediate- or long- acting. Peak action 4– 12h after
injection; lasts up to 30h. Taken od/ bd to provide background insulin
• Long- acting insulin analogues e.g. insulin detemir or glargine— last 24h;
provide background insulin; associated with d risk of hypoglycaemia
• Premixed Combination of short- + long- acting insulin, e.g. 30%:70%
Injection regimens
Type 1 DM Oer a multiple daily injection basal- bolus regimen as rst line.
Use insulin detemir bd as basal insulin therapy (od insulin detemir or insulin
glargine are alternatives) and a rapid- acting insulin analogue before meals.
Other options include:bd human mixed insulin regimen if multiple daily injections are not possible (or bd analogue mixed insulin if a human mixed
regimen causes unacceptable hypoglycaemic episodes).
0 Consider adding metformin to insulin therapy for adults with type 1 DM
and BMI ≥25kg/ m2 (or ≥23kg/ m2 if of South Asian origin).
Type 2 DM Continue to oer metformin (if already taking). Review continued need for other antidiabetic drugs. Suitable insulin regimens:
• Once/ twice- daily intermediate/ long- acting NPH insulin— consider
adding short- acting human insulin separately or as pre- mixed
preparation if HbA1c ≥75mmol/ mol or HbA1c targets are not met
• Once- daily long- acting analogue (e.g. insulin detemir/ glargine) is an
alternative if help is needed to inject or if unwilling to inject bd
• If unacceptable hypoglycaemic episodes, consider an insulin analogue
(e.g. insulin detemir/ glargine) instead of human insulin. Biphasic
preparations containing short- acting insulin analogues are also useful if
blood glucose levels i markedly after meals
Administration Deep sc injection into upper arm, thigh, buttock, or
abdomen. Fat hypertrophy and scarring are minimized by rotation of injection sites. ‘Pen’ devices and syringe/ needle are equally eective. Prime the
needle using an ‘air shot’ (an empty needle d insulin dose by 72 units). Rock
‘pens’ containing pre- mixed insulins to mix contents. i absorption can occur
if a limb is exercised following injection.
N
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INSULIN
Insulin pumps Continuous infusion of rapid- acting insulin may be
considered in specialist settings if type 1 DM and ≥12y with repeated/
unpredictable hypoglycaemia or inadequate glycaemic control (HbA1c
>69mmol/ mol) despite optimized multiple injection regimen, or <12y and
multiple injection regimens are impractical or inappropriate.
Monitoring Check blood glucose preprandially ≥1×/ d at dierent
times— more often if multiple injection regimens, after dose changes, or
during intercurrent illness; ask patients to keep a timed/ dated diary of
readings (many meters do this automatically). Record episodes of hypoglycaemia. Target:blood glucose 4– 7mmol/ L pre- meals with hypoglycaemic
episodes kept to a minimum (4– 8mmol/ L pre- meals if <18y old).
Starting insulin forpatients with type 2 DM Use a structured
programme. Appropriate training is needed for all practice sta involved.
• Before starting— teach home blood glucose monitoring; reinforce diet
• Continue metformin ± other antidiabetic drugs
• Teach insulin injection technique— start 10 units of intermediate- or
long- acting insulin od
• Teach patients/ carers about safe disposal of sharps and hypoglycaemia
• Give instructions to i dose every 3– 7d until target levels are reached,
e.g. average fasting glucose >10mmol/ L— i by 6– 8 units/ d; 8–
10mmol/ L— i by 4– 6 units/ d; 6– 8mmol/ L— i by 2– 4 units/ d
• Provide a contact telephone number for advice; follow- up after 2– 3d
and then as needed; check HbA1c every 3mo until stable
Exercise d insulin dose acting at the time of exercise or take 1– 2 glucose
tablets before exercise then check blood glucose afterwards. Adjust alterations/ glucose dose with experience of eects of exercise.
Intercurrent illness Continue insulin in usual dose and keep a regular
check (≥qds) of blood glucose. Consider blood/ urine ketone monitoring
for adults with type 1 DM. Maintain glucose intake even if not eating (with,
e.g. Lucozade® or milk). If glucose >13mmol/ L, i insulin by 2 units/ d until
control is achieved or use top- up injections of short- acting insulin qds prn.
Admit to hospital if:condition warrants admission; unable to take glucose;
persistent vomiting and/ or dehydration; ketotic (check urine if blood sugar
>13mmol/ L).
Poorcontrol
• Exclude intercurrent illness
• Consider psychosocial factors
• Check injection sites are not scarred or hypertrophic
• Consider changing insulin dose— ask the patient to record a glucose
prole (blood sugar pre- meals and before bed)— if using >1 insulin
adjust 1 at a time i or d as needed; alter by ≤10% each time; allow
≥48h between dose adjustments; alter dose of insulin acting at the time
blood sugar is most out of control
• Consider diet and/ or gastroparesis
• Check insulin is being used correctly
Further information
NICE (2015, updated 2016)Type 1 diabetes in adults:diagnosis and management. M www.nice.org.uk/ guidance/ ng17
NICE (2015, updated 2017)Type 2 diabetes in adults:management.
Mwww.nice.org.uk/ guidance/ ng28
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