Diagnosis, assessment and initial management of Diabetes

 From Diabetes Management in General Practice 2011/2012 (Diabetes Australia)

What to recommend to a new diabetic:

1. Diet & Exercise - trial for 6 weeks (decrease saturated fats, eat small portions, change to low GI foods, exercise minimum 30mins 5 days per week). If unsuccessful, then...
2. Medications - 

• Oral hypoglycaemic agents. My my current favorites to use are metformin extended release, GLP-1 agonist ie Exenatide and DPP4 inhibitors ie Januvia or Galvus. Sulphonyureas is often used as a 2nd line agent after metformin but a local endocrinologist has advised that perhaps exenatide should be the next step due to lack of hypoglycaemic episodes as well as weight loss. Acarbose is also a very good agent but poorly tolerated due to excess bloating and flatulence.
• Insulin. Lantus, Mixtard, Actrapid are my go-to insulins. Remember to also prescribe Glucagen Hypo Kit - 1 at work and 1 at home.

• Antihypertensives

I tend to use Telmisartan ie Micardis, due to its excellent tolerability as well as positive effects on cholesterol, microalbuminuria and proteinuria, and reduced risk of myocardial infarctions, strokes and death from cardiovascular events. However, fosinopril ie Monopril is also a good option because there is no need to reduce the dose in renal impairment, but it does commonly cause in irritating cough

• Cholesterol

Hypercholesteraemia: Statins ie lipitor or crestor. If not tolerable or need stronger control add exetimibe (Ezetrol), then resins such as cholestyramine (Questran) or colestipol (colestig) for hypercholesteraemia

Hypertriglyceridaemia: Fibrates such as fenofibrate (Lipidil) or gemfibrozil (lopid).

• 100mg Aspirin if no contraindication

Referrals

• Diabetic educator - initially, then as needed
• Dietitian - initially, then as needed
• Podiatry - if issues with feet, or need help to cut toenails. Also worth getting it checked initially for potential problem areas
• Optometry/ophthalmology at least every 2 years
• Dentist - once to twice yearly checkup
• Renal physician - consider if getting proteinuria
• Endocrinologist - if sugars are difficult to control or significant complications, pregnancy, gestational diabetes, children/adolescents/adults with type 1 diabetes