Updated NICE guidance 2016. Characteristics:
- random glucose >11,
- polyuria, polydipsia,
- excessive tiredness,
- weight loss.
WHO 1999 criteria – fasting normally <5.6, >7 diagnostic. Random >11 diagnostic (assuming there’s nothing sticky on the finger tested!!!). Glucose tolerance test (starts with fasting level) 2hr level >11.1 diagnostic, 7.8-11.1 is impaired glucose tolerance.
False positives – infection, recent surgery, uncontrolled thyroid disorder, starvation.
Epidemiology
Increasing rates in Europe. Scotland rate second only to Scandinavia. Marked increase in under 5s. Aiming for routine pump therapy within a few months.
Subtypes
Type 2 more often in S Asian, Hispanic, Afro-Caribbean. Clue is raised c-peptide – as this is co-produced with insulin, it means there is still endogenous insulin being produced (and cleared at more consistent rate than insulin, so more reliable, esp if on exogenous insulin). C-peptide also used to look for insulinoma or factitious hypoglycaemia. May also predict glycaemia control, complications and response to hypoglycaemic agents.
LADY – latent autoimmune diabetes of the young. More common? Different HLA type. Antibody positive but insulin sensitive and slow progress.
MODY – inability to produce insulin but normal beta cells. Eg KIR 6.2 mutations, within months of birth.
Management
Reduced ideal HbA1c target – 48mmol/l (6.5%).
No DAPHNE for kids.
Multiple daily injections from diagnosis, with level 3 carbohydrate (CHO) counting education, blood ketone testing strips. Other regimens eg BD, TDS only for where problems with compliance. See also pumps.
NICE guidance now includes Type 2 – suspect if strong FH, obesity, black/Asian origin, minimal insulin requirements (<0.5u/kg after “partial remission phase”), evidence of insulin resistance (viz acanthosis nigricans).
Optimal blood glucose range is 4-7 on waking and between meals; 5-9 after meals; 5+ when driving. At least 5 tests per day recommended, more frequently during physical activity and illness.But take into account:
- risk of hypoglycaemia;
- competitive sports;
- need to lose weight;
- life goals (careers, exams, foreign travel);
- any relevant co-morbidity.
Monitoring
Annual thyroid, hypertension, albuminuria checks from diagnosis; retinopathy testing from age 12. Type 2 don’t need thyroid but do need dyslipidaemia.
School
Most schools happy to give insulin. But no legal requirement. Lancets for school retract into cartridge.
Self-Efficacy
Encourage ownership of meters etc, downloading at home. Over 14 to get access to SCI-DC, as adults.