Diabetes – Diagnosis and assessment

1. Diabetes – Diagnosis and assessment M Nasim

2. Epidemiology • Global prevelance 4.6 % • Diabetic population has doubled up in last 13 years • Cluster observational survey - the authors concluded that screening of patients with a BMI of >or=27 and aged >50 by fasting glucose identified a substantial prevalence of undetected type 2 diabetes and IFG

3. Classification of Diabetes • IDDM • NIDDM • MODY • Maturity onset diabetes of the young is a form of diabetes which is distinct from typical non-insulin dependent diabetes mellitus in that: • onset is early in life • autosomal dominant inheritance • no requirement for insulin • fairly asymptomatic, picked up often at pregnancy • low disease related mortality • Gestational diabetes • Approximately 1 in 400 pregnancies are complicated by diabetes. 95% of diabetic mothers are insulin dependent.

4. Classification- secondary diabetes • pancreatic diseases causing diabetes • Pancreatitis • Pancreatic tumour • endocrine diseases causing diabetes • Acromegally • Cushing • Glucagonoma • Pheochromatosis • drugs and chemicals causing diabetes • Steroid induced • Thiazide diuretics • Phenytoin

5. Diagnosis • random venous plasma glucose concentration >= 11.1 mmol/l • OR a fasting plasma glucose concentration >= 7.0 mmol/l • If symptomatic – one reading • If asymptomatic – needs two readings • IFG • fasting plasma glucose >= 6.1 mmol/l but < 7.0 mmol/l • IGT • Fasting plasma glucose < 7.0 mmol/l and OGTT 2-hour value >= 7.8 mmol/l but < 11.1 mmol/l • The risk of subsequent conversion to diabetes is about 4.7% per year in Caucasians and higher in some ethnic minority groups • Increased mortality risk (1.5%) • Double mortality rate from CV causes

6. Aims of assessment of diabetic patient • To educate the patient - DESMONDS • To set goals for glycaemic control • To detect any complications of diabetes and treat them as appropriate. • To assess the patient's overall health and to treat any associated or coincidental illness, physical or mental. • To provide support and • Advice how they can best alter their lifestyle

7. Symptoms • Polydypsia, • Polyuria, tiredness, • weight loss, • Unexplained fatigue • Blurred vision • Repeat episodes of genital itching or thrush • Slow healing of wounds • Symptoms tend to develop quite slowly, over weeks or months

8. Examination • Weight, height, BMI • Smoking status • BP and pulse • Carotid bruits • Heart sounds • Peripheral pulses • Inspect footwear (for suitability) and the feet carefully for any deformity, ulceration, or peripheral vascular disease. • Check peripheral limb sensation – vibration sense using 128 Hz tuning fork, pinprick sensation with 'neurotips' and/or nylon monofilament probe

9. Legs for evidence of amyotrophy • Ankle and knee jerks • Inspect eyes, looking for any evidence of xanthelasmata, cataract formation or ophthalmoplegia • Visual acquity • Ophthalmoscopy- later would be digital retinal photography programme • Depression • Erectile dysfunction

10. Investigations • Lipid profile • HbA1c • U&Es • Estimated creatinine clearance / eGFR

11. Assessing and addressing modifiable risk factors • Glycaemic control and how to improve it • Smoking status and how to stop smoking if needed • Dietary patterns and how to modify them (can help with improving glycaemic control) • Exercise and how to incorporate regular physical exertion into one's life • Lipid status and any lifestyle modifications or medication required to improve it • Blood pressure and how to improve its control with medication and lifestyle modification • Avoiding weight gain or losing weight (pertinent to both type 1 and type 2 patients).

12. BP Target – British Hypertension Society • if no evidence of nephropathy • Optimal BP target – 130/80 • Audit standard – 140/80 • Threshold for intervention – 140/90 • if nephropathy • Target BP 130/80 • 125/75 when proteinuria 1g/24hr

13. HbA1c target – JBS2 • Ideal - <6.5% • Audit target – 7.5%