Diabetes Management in General Practice

Diabetes
Diabetes
Management
in General

Practice
Guidelines for type 2 Diabetes
2009/10

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An electronic version of these guidelines is available at
www.racgp.org.au
Goals for
Any changes after the printing of this edition and before the next will be available
on this website.
This booklet is not intended to replace professional judgement, experience and
appropriate referral. While every care has been taken to ensure accuracy, reference
optimum
to product information is recommended before prescribing. Diabetes Australia and
the RACGP assume no responsibility for personal or other injury, loss or damage
that may result from the information in this publication.
diabetes
management
The chart on the flip side lists goals for optimum
diabetes management that all people with diabetes
should be encouraged to reach.
This chart has been specifically designed as a card for
you to pull out and place on your desk or nearby for
easy reference.

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Goals for optimum
diabetes management
Encourage all people with diabetes to reach these goals
n BGL
4 – 6 mmol/L (fasting)
n HbA1c
≤ 7%
n LDL-C
< 2.5 mmol/L*
n Total cholesterol
< 4.0 mmol/L*
National
n HDL-C
> 1.0 mmol/L*
n Triglycerides
< 1.5 mmol/L*
n Blood pressure
≤ 130/80 mm Hg**
Diabetes
n BMI
< 25 kg/m2 where appropriate
n Urinary albumin excretion

< 20 μg/min (timed overnight collection)
< 20 mg/L (spot collection)
< 3.5 mg/mmol: women
Services
< 2.5 mg/mmol: men (albumin creatinine ratio)
n Cigarette consumption
Zero
n Alcohol intake
≤ 2 standard drinks (20g) per day for men
Scheme
and women***
n Physical activity

At least 30 minutes walking (or equivalent)
5 or more days/week
The NDSS makes life with diabetes
(Total ≥ 150 minutes/week)
easier to manage
Doctors should consider:
if you have a patient with diabetes, register them with
n Prophylactic aspirin (75-325mg) daily unless contraindications
the NDss and assist them to manage their diabetes.
n Annual ECG
n Immunisation against influenza and pneumococcal disease
Registration is free and done only once.
the flip side of this page gives information on the
NDss and how to register. it has been specifically
designed as a card for you to pull out and place on
* National Heart Foundation Guidelines.
your desk or nearby for easy reference.
** NHMRC Evidence-based Guidelines for the
Management of Type 2 Diabetes, 2004.
*** NHMRC, Australian Guidelines to Reduce
Health Risks from Drinking Alcohol 2009.
These goals are derived from Diabetes Management in General Practice 2009/10
Published each year by Diabetes Australia in conjunction with the Royal Australian College
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government
of General Practitioners.
administered by Diabetes Australia.

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DIABETES MANAGEMENT
National Diabetes
in
GENERAL PRACTICE
Services Scheme
Fifteenth edition 2009/10
Why register?
The National Diabetes Services Scheme (NDSS) offers people with diabetes
access to diabetes-related products such as blood glucose testing strips,
and insulin pump consumables at heavily subsidised prices and free insulin
needles and syringes. For a full list of products and prices, download the
order form from www.ndss.com.au.
NDSS registrants can also access a range of free information and support
services. Encourage your patients to contact Diabetes Australia on
1300 136 588 to find out what services they can take advantage of to
improve their knowledge and management of diabetes.
Who is eligible?
All Australians who hold a Medicare card and have been diagnosed with
diabetes are eligible to receive the benefits offered under the NDSS.
How to register
n Fill in the NDSS Registration Form (available from www.ndss.com.au).
n Registration has to be certified by a GP or diabetes educator.
n Registration is free and done only once.
For more information
Refer your patients to Diabetes Australia:
Phone: 1300 136 588
Website: www.ndss.com.au
(See pages 79 and 80 of this booklet.)
supporting the education programs
of Diabetes Australia
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government
administered by Diabetes Australia.

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EDITORIAL PANEL
CONTENTS
Gratitude is expressed to everybody who has contributed to these guidelines: The Health
Section
PaGe
Care and Education Committee of Diabetes Australia, The Australian Diabetes Educators
Association, Australian Diabetes Society, Dietitians Association of Australia, The Drug
editorial Panel
2
and Therapeutics Information Service, many general practitioners, endocrinologists,
Foreword from the Presidents
5
dietitians, diabetes educators and podiatrists.
What’s new – highlighting significant changes
6
Controversies
6
Dr Peter Harris
introduction
7
Senior Lecturer
1 Diagnosis
9
School of Public Health and Community Medicine,
1.1
Who needs to be tested for undiagnosed diabetes?
10
University of New South Wales, Sydney NSW
1.2
What type of diabetes?
11
Dr Linda Mann
2 assessment
13
General Practitioner
Leichhardt, Sydney NSW; Medical Educator, GP Synergy; RACGP Representative
2.1
Initial assessment
13
on Editorial Panel
2.2
Plan of continuing care
15
2.3
Referral
16
Jane London
Program Manager, Quality Care
3 the team approach
17
Royal Australian College of General Practitioners
3.1
Members of the team
17
Dr Pat Phillips
3.2
Counselling the person with diabetes
19
Director
4 initial management
21
Endocrinology, North West Adelaide Health Service, Adelaide SA
4.1
Nutrition
22
Carole Webster
4.2
Physical activity
26
National Publications Manager
5 Health care for diabetes
28
Diabetes Australia State and Territory Organisations
5.1
Self-monitoring
28
Appreciation is expressed to Dr Chris Holmwood who prepared the
5.2
Medical monitoring
29
original guidelines.
5.2.1 Quarterly review
29
The Editors have considered and included relevant information within guidelines
5.2.1.1 Quarterly nursing review
30
and evidence recognised by the medical profession, including the NH&MRC and
5.2.2 Annual review
30
the Australian Diabetes Society. This document is designed for first line primary
5.2.2.1 Annual nursing review
31
care. More complex care is best addressed by a team.
5.3
Systems for care
32
ISBN: 978 1875690 190
5.3.1 How Medicare supports the process
33
July 2009
5.3.2 Required annual cycle of care
34
5.3.3 General Practice Management Plans (GPMP)
35
This publication was reviewed by Diabetes Australia's Health Care and Education
5.3.4 Team Care Arrangements (TCA)
35
Committee and RACGP’s National Standing Committee for Quality Care in 2009
and is endorsed for publication until 2010.
6 Medication
36
Photocopying this publication in its original form is permitted for educational
6.1
Oral hypoglycaemic agents
36
purposes only. Reproduction in any other form without the written permission
6.2
Insulin treatment
41
of Diabetes Australia (National Publications Division) is prohibited.
6.3
Insulin delivery
43
6.4
Insulins available
45
Printed August 2009 – Copyright Diabetes Australia 2009
6.5
Problems with medication
46
Diabetes Australia Publication NP 1055
6.6
New technology
47
Printed by Pinnacle Print Management, Gorokan NSW
6.7
Surgical procedures
47
2 Diabetes Management in General Practice

3

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Section
PaGe
Foreword from the Presidents
7 sick days
48
General practitioners continue to provide most of the medical care to people
8 Hyperglycaemic emergencies
50
with type 2 diabetes. the complexity of care for this common disease requires
8.1
Diabetic ketoacidosis
50
systematic care from the practice team and the timely referral to community and
8.2
Hyperosmolar non-ketotic coma
52
hospital based specialists.
9 Factors complicating management
54
the current guide, in its fifteenth edition, has an important role in providing a
9.1
Macrovascular disease
54
readable summary of current guidelines and recommendations from various sources
9.2
Hypertension
56
on the management of type 2 diabetes in the general practice setting.
9.3
Dyslipidaemia
58
importantly, this edition again includes specific issues relating to treating diabetes
9.4
Renal damage
60
in the aboriginal and torres Strait islander population which reflects the burden of
9.5
Eye damage
63
this disease within this group. also included is a routine care checklist for practice
9.6
Foot problems
64
nurses for use under the clinical oversight of the general practitioner.
9.7
Neuropathy
66
9.8
Problems with medications
67

9.9
Complementary medicines
68
10 Diabetes and reproductive health
69
10.1 Pregnancy
69
10.2 Gestational diabetes
70
10.3 Contraception
71
10.4 Hormone replacement therapy
71
Dr Gary Deed
Dr Chris Mitchell
10.5 Sexual problems
72
President
President
11 Driving
73
Diabetes Australia
Royal Australian College
of General Practitioners
12 travel
75
13 Diabetes australia
77
14 National Diabetes services scheme (NDss)
79
15 Royal australian College of General Practitioners
81
Further reading
82
index

83
internet resources
85
Goals for management
back page
4 Diabetes Management in General Practice
Foreword from the Presidents 5

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What’s new – highlighting
Introduction
significant changes
This booklet is a guide to type 2 diabetes only.
The 15th edition of Diabetes Management in General Practice (2009/10) contains
Type 2 diabetes is a chronic condition which can result in disability and early death.
the following significant changes to the 2008/09 edition:
Management of the person with diabetes requires the skills of several professionals
Controversies: A new section to highlight current controversial issues (see below).
(general practitioner, specialist physician, diabetes educator, podiatrist, dietitian,
ophthalmologist or optometrist, exercise professional and dentist) and the active
Goals for optimum diabetes management: Alcohol guidelines – The NHMRC
Australian Guidelines to Reduce Health Risks from Drinking Alcohol released in
participation of the patient.
March 2009 recommend ≤2 standard drinks (20g) per day for men and women
The aim of this booklet is to provide guidelines for management of type 2 diabetes.
(see Optimum Diabetes Management lift out card, page 26 and outside back cover).
We hope that general practitioners will consult these guidelines in order to ensure
a high standard of care for their patients.
Section 5: Medicare – Information relating to Medicare has been expanded
(see page 34).
• The underlying aim is improvement in the duration and quality of life
Section 6: Glitazones – the use of glitazones has been amended to reflect latest
of patients.
product information (see page 37).
• Encourage patients to participate and take an active role in the
management of their diabetes.
Controversies
• Ensure that all other preventive health care activities are included,
while maintaining good diabetes health care.
HbA1c: epidemiological evidence has suggested that the lower the Hba1c, the lower
Any guideline should be flexible: management takes into consideration the patient’s
the risk of cardiovascular events in both type 1 and type 2 diabetes. three recent
age, educational level, cultural background, the current scientific knowledge, the
trials in patients at moderate to high risk of cardiovascular events did not support
availability of resources and the range of particular preferences of the patient and
this conclusion.
professionals involved.
The recommended target remains <7%. Note that over-zealous management
can result in severe hypoglycaemia and may be associated with increased
The overall goals in degree of control and lifestyle modification must be realistic.
mortality (refer page 21).
The general practitioner can have an important positive effect on patient lifestyle.
Education of a partner or other responsible carers is an important factor
Aspirin: Recently there has been discussion about the role of aspirin in reducing
in maintaining positive lifestyle changes in a patient. Similarly the general
cardiovascular events in those with type 2 diabetes but without evidence of clinical
practitioner can ensure that management is individualised to the person’s cultural,
cardiovascular disease.
educational and financial status.
It is suggested that doctors consider prophylactic aspirin (75–325mg) daily
The general practitioner is a key member of the therapeutic team. In many
unless there are contraindications (refer page 54 – 55).
instances the general practitioner may be the principal medical professional. In
Glitazones: in 2007 and 2008 rosiglitazone was reported to increase rates of
other instances there may be a "shared-care" arrangement between specialist and
myocardial infarction by 40% and both rosiglitazone and pioglitazone were
general practitioner, while in others, management of diabetes by the specialist
reported to precipitate heart failure, cause peripheral fractures and possibly cause or
may be preferable. In all situations the paramount consideration is the patient’s
worsen macular oedema.
well being.
It is noted that the indications for PBS subsidy include dual therapy with
sulphonylurea or metformin for both pio and rosiglitazone. Pioglitazone,
but not rosiglitazone, is subsidised for triple therapy with sulphonylurea and
metformin or therapy with insulin (refer page 37).
6 Diabetes Management in General Practice
introduction 7

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Specific issues relating to the treatment of diabetes in the aboriginal and
1 Diagnosis
torres Strait islander population will be highlighted in boxes throughout
the guidelines. a conservative approach has been taken on the statements
included to ensure that practitioners can have confidence they are based on
People in high risk groups need to be screened for undiagnosed type 2
solid evidence.
diabetes. See following page for high risk categories.
The diagnosis of diabetes is made in one of the following three ways but each
For the team approach to be successful there should be good communication
must be confirmed on a subsequent day unless unequivocal hyperglycaemia with
between members based on trust and respect. For example, the patient will often
acute metabolic decompensation or obvious symptoms are present:
relate best to the general practitioner. The other team members should be able
• Symptoms of diabetes and a random (non fasting) blood glucose > 11 mmol/L
to support that relationship and channel their input to management accordingly.
• Fasting plasma glucose ≥ 7.0 mmol/L
The role of the general practitioner ideally involves initial diagnosis, treatment,
• 2-hour plasma glucose > 11 mmol/L during an oral glucose tolerance
coordination of consultant and allied professional care and continuing management
test (OGTT)
(including education and counselling of the patient and carers).
The OGTT is unnecessary to diagnose diabetes in people with an unequivocally
• The importance of the patient-doctor partnership in the management
elevated fasting or random plasma glucose. An OGTT needs to be performed in a
of diabetes cannot be overstated. The patient and the general practitioner
person with an equivocal result. (See Fig. 1).
need to have an agreed understanding of the patient’s diabetes and associated
The test is carried out after an overnight fast, following three days of adequate
problems and agree on the management strategies being adopted.
carbohydrate intake (greater than 150g per day). A 75g load of oral glucose is
• In order to provide optimum care, the general practitioner must have adequate
given and the diagnosis of diabetes can be made if venous plasma glucose level
records and systems in place which will assist in the recall of patients for further
fasting is ≥ 7.0 mmol/L or 2 hour post glucose load is ≥ 11.1 mmol/L.
investigations or continuing management. Adequate records are also necessary
Capillary blood glucose measurement using a desktop meter may be used for
in order to monitor outcomes – both for the individual and within the wider
testing for undiagnosed diabetes as long as it is confirmed by venous plasma
community. A diabetes register at every practice is encouraged.
measurement. Urine testing is not sufficiently sensitive or specific as a screening
• Ensure that all other preventive health care activities are included, while
test for undiagnosed diabetes.
maintaining good diabetes health care.
Fig. 1: Glucose levels – venous plasma: mmol/L
Carers need to become involved in education and management decisions. This
is particularly so in young people with diabetes, disabled patients and where
F: 5.5-6.9
F: >7.0
major dietary changes are required. Every carer needs to be well informed on
F or R: <5.5
R: 5.5-11.0
R: >11.1
recognition and treatment of hypoglycaemia, if the patient is treated with insulin,
sulphonylureas or repaglinide.
Diabetes unlikely
Diabetes uncertain
Diabetes likely
Re-test yearly if
high risk
Oral glucose tolerance test
3 yearly if
2hr glucose levels
increased risk
<7.8
7.8-11.0
>11.1
Diabetes unlikely
Impaired glucose tolerance
Diabetes likely
F = Fasting
R = Random
8 Diabetes Management in General Practice

Diagnosis 9

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1.1
Who needs to be tested for undiagnosed diabetes?
insulin in people with hyperinsulinaemia; improves dyslipidaemia and lowers
blood pressure. Moreover, physical activity increases metabolically active muscle
Asymptomatic people at high risk of undiagnosed diabetes should be identified
tissue and improves general cardiovascular health. Increased physical activity also
and screened by measurement of plasma glucose. This needs to be performed by
reduces the risk of type 2 diabetes.
a laboratory (rather than with a blood glucose meter) and preferably on a fasting
sample. However a random sample may be used.
Whilst use of metformin and glitazones have been trialled as pharmacological
approaches to diabetes prevention in this group with some success, lifestyle
People at high risk for undiagnosed type 2 diabetes are:
modification is more effective.
• People with impaired glucose tolerance, impaired fasting glucose.
Periodic testing for undiagnosed diabetes is recommended in high risk individuals.
• Aboriginal and Torres Strait Islanders aged 35 and over.
All high risk people with a negative screening test are at risk of cardiovascular
• Certain high risk non English speaking background people aged 35 and over
disease and the future development of type 2 diabetes, and need to be given
(specifically Pacific Islanders, people from the Indian subcontinent, people of
appropriate advice on SNAP risk factor reduction (Smoking, Nutrition, Alcohol
Chinese origin).
and Physical activity).
• People aged 45 and over who have one or more of the following risk factors:
Pregnant women need to be screened for gestational diabetes (see 10.2 on page 70).
– Obesity (BMI ≥ 30kg/m2)
– Hypertension
Routine testing of low risk asymptomatic people is not recommended.
• All people with clinical cardiovascular disease (myocardial infarction,
angina, stroke or peripheral vascular disease).
the aboriginal and torres Strait islander population has a higher risk of
• Women with polycystic ovarian syndrome who are obese.
developing diabetes and is 10.5 to 13 times more likely to die from diabetes,
The AUSDRISK tool (www.health.gov.au) is used to identify those at high risk of having
compared with non-indigenous australians.
undiagnosed pre-diabetes or type 2 diabetes. To help prevent diabetes, some Divisions of
the prevalence of undiagnosed diabetes in the aboriginal and torres Strait
General Practice offer programs to patients who score highly for pre-diabetes.
islander population exceeds 5% in all those over 35 years of age. in some
The following groups are also at high risk but further studies are required to
regions the prevalence approaches 5% at a much younger age (as young as
evaluate net clinical or economic benefit:
18 years). the prevalence of diabetes risk factors including impaired glucose
• Women with history of gestational diabetes.
tolerance (iGt) exceeds 5% in this population aged under 35 years of age.
• People aged 55 and over.
the incidence of diabetes in the aboriginal and torres Strait islander
• People aged 45 and over, with a first degree relative with type 2 diabetes.
population is 10 times higher than the general population and reaches 2% per
year in some regions (eg: central australia).


Certain medications (especially glucocorticoids and atypical antipsychotics) can
affect glucose metabolism and increase the risk of diabetes.
Pre-diabetes (abnormal glucose metabolism: impaired fasting glucose
1.2
What type of diabetes?
(6.1–6.9 mmol/L)), also identified by impaired glucose tolerance (2h glucose
7.8–11.0 mmol/L) is a marker of increased risk of cardiovascular disease and
Differentiation is based on age, rate of clinical onset, body weight,
diabetes. Lifestyle and other risk factors need to be assessed (see page 55) and
family history and urinary ketones.
patients counselled and treated to reduce future risk. Several trials have shown that
lifestyle change can slow progression to diabetes. Obesity, particularly abdominal
Once a diagnosis is made it is important to determine the type of diabetes.
obesity, is central to the development of type 2 diabetes and related disorders.
Usually there is clear clinical evidence and differentiation is easy.
Weight loss improves insulin resistance, hyperglycaemia and dyslipidaemia in
Type 1
Type 2
the short term, and reduces hypertension. Overweight and obese people should
therefore be encouraged to achieve and maintain a healthy body weight.
– Young (generally) – Rapid onset
– Middle-aged (generally) – Slow onset
– Ketosis prone
– Insulin deficient – Not prone to ketosis
– Insulin resistant
Increased physical activity is particularly important in maintaining weight loss.
Regular physical activity also improves insulin sensitivity; reduces plasma levels of
– Recent weight loss
– Overweight
– Strong family history
10 Diabetes Management in General Practice

Diagnosis 11

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At present there are no practical or specific markers for either group. While type
1 diabetes occurs in the young it is by no means confined to that group. Similarly
2 Assessment
while many people with type 2 diabetes are overweight, some are normal weight. In
fact, most overweight people do not develop diabetes.
2.1
Initial assessment
Remember that someone treated with insulin does not necessarily have type 1
diabetes. In fact, if insulin is started several years after diagnosis, it is likely that the
Assessment includes appraisal of cardiovascular risks and
person has type 2 diabetes.
end-organ damage.
Type 1 diabetes
A detailed assessment needs to be made at first diagnosis.
This type of diabetes was previously known as Insulin Dependent Diabetes Mellitus
(IDDM) or Juvenile Onset Diabetes.
History:
Type 2 diabetes
Specific symptoms:
Predisposition to diabetes:
Glycosuria
– Age

This type of diabetes was previously known as Non-Insulin Dependent Diabetes
– Polyuria
– Family history

Mellitus (NIDDM) or Maturity Onset Diabetes. However, type 2 diabetes can
– Polydipsia
– Cultural group

occur in children and adolescents if they are overweight or obese, have a family
– Polyphagia
– Overweight

history of type 2 diabetes and/or come from a high risk group.
– Weight loss
– Physical inactivity
There is a form of late onset diabetes that is autoimmune and requires treatment
– Nocturia
– Hypertension
with insulin within a relatively short period after diagnosis (often in the next

– Obstetric history of large babies
2 years). This is known as Late onset Autoimmune Diabetes in Adults (LADA).

or gestational diabetes
These people tend to be young (30–40 years), lean and have a personal and/

– Medication causing hyperglycaemia
or family history of other autoimmune diseases (eg: hypo or hyperthyroidism).


– Personal or family history
Testing for glutamic acid decarboxylase (GAD) antibodies can confirm the
of haemochromatosis
diagnosis and can prompt counselling the person about the likely time course
Hyperglycaemia
– Autoimmune disease (personal
of diabetes progression and the possibility of other autoimmune disease.
– Malaise/fatigue
and/or family history of other
– Altered vision
autoimmune diseases (eg: hypo or
Medication induced diabetes

hyperthyroidism))
Some medications, for example prednisolone and olanzapine, can produce
Risk factors for complications
General symptom review
hyperglycaemia which can be associated with abnormal OGTT and the diagnosis
including:
including:
of diabetes. This may require medication. Such patients require the usual diabetes
– Personal or family history of
– Cardiovascular symptoms
assessment and management, like others with diabetes. When the medication is
cardiovascular disease
– Neurological symptoms

ceased, the requirement for hypoglycaemic treatment may change, but patients
– Smoking
– Bladder and sexual function
should still be considered to ‘have diabetes’ for ongoing cardiovascular monitoring.
– Hypertension
– Foot and toe problems

They are also at risk of developing frank diabetes again.
– Dyslipidaemia
– Recurrent infections

(especially urinary and skin)
Lifestyle issues:
– Smoking
– Nutrition
– Alcohol
– Physical activity
– Occupation
12 Diabetes Management in General Practice
assessment 13

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