Assessment

Indications for hospital referral at initial presentation include:^[1]

• Children and young people presenting with suspected diabetes should always be referred urgently, on the same day, for admission to hospital for initiation of insulin therapy.
• Adults who are clearly unwell, or who have ketones in their urine, or who have a blood glucose level greater than 25.0 mmol/l, should also be referred urgently for admission to hospital on the same day.
• Those who present with diabetic ketoacidosis or diabetic hyperosmolar non-ketotic syndrome will require immediate treatment in hospital.
• Young adults (aged under 30 years) should also be referred to a specialist diabetes team. The majority will require insulin therapy, but this can often be started without admission to hospital.

Clinical examination and investigations

• Measure height and weight, and calculate body mass index (BMI).
• Urinalysis: ketones and proteinuria. Arrange mid-stream urine (MSU) if protein is present.
• Identify any long-term complications of diabetes already present:
  • Cardiovascular assessment, including smoking status, blood pressure, lipids and ECG.
  • Examine feet for diabetic complications, including cardiovascular disease, neuropathy and foot complications, diabetic nephropathy and diabetes eye complications.
  • Test first-passed urine for microalbuminuria, eg by albumin:creatinine ratio.
  • Check renal function and electrolytes. Also check baseline liver function tests (fatty liver is more common in people with diabetes).
• Consider whether there may be an underlying disorder causing or associated with diabetes, eg pancreatitis, Cushing's syndrome, phaeochromocytoma.

Initial management

• Enter patient details on to the practice diabetes register (ie add the code for "Diabetes Mellitus" on patient computer record).
• Register the patient with the local eye disease screening programme (or refer to an optician for a diabetic check).
• Establish the patient's knowledge and educational needs.
• Explanation of the condition and its management should be tailored to the educational needs of the patient and take account of their social and cultural background.
• Ensure all people with newly diagnosed diabetes have the opportunity to share any initial anxieties and concerns about the diagnosis and the implications for their future lifestyle.
• Include advice on managing diabetes during intercurrent illness.
• The possible effects of diabetes on occupation, driving and insurance should be discussed. If the person concerned is a driver, they should be advised to inform their car insurance company, and the Driver and Vehicle Licensing Agency (DVLA), if on insulin, oral hypoglycaemics or experiencing diabetic eye complications.
• They should also be advised that they are exempt from prescription charges if started on medication for their diabetes.
• Books, leaflets, audio aids and visual aids for the patient to borrow.
• Diabetes UK: give information about Diabetes UK and details of the local Diabetes UK voluntary group. Diabetes UK also provides a very valuable resource for healthcare professionals and provides educational materials in many languages.

Initial treatment and care

• Management should be discussed with the patient and commenced as soon as possible.
• Advice on diet and exercise recommendations for people with diabetes.
• Prevention of coronary heart disease: all people with diabetes should be advised of the adverse effects of smoking and be offered advice and support to stop smoking. They should also be offered advice and treatment for any other cardiovascular risk factors, including blood pressure control, cholesterol-lowering drugs and low-dose aspirin.
• All patients with microalbuminuria or proteinuria should be started on an ACE inhibitor, if there are no contra-indications.
• Insulin therapy should be started immediately in those who are ill at presentation or who have a high level of ketones in their urine. Insulin should also be considered, regardless of age, if one or more of the following are present:^[1]
  • Severe symptoms
  • Acute onset
  • Marked weight loss
  • A first-degree relative has type 1 diabetes
• People aged less than 40 with diabetes who are asymptomatic and who have a BMI of 25 or above:
  • Should be advised to increase their physical activity levels, adopt a balanced diet and aim to reduce their calorie intake.
  • Insulin should be considered in those who are not obese.
• People aged over 40 with diabetes who are asymptomatic:
  • Should be advised to increase their physical activity levels, adopt a balanced diet and, if they are overweight or obese, aim to reduce their calorie intake.
  • If blood glucose control is not achieved within three months, treatment with oral hypoglycaemic agents should be commenced.
  • Insulin treatment should be considered if blood glucose control is not achieved with diet, increased physical activity and combined drug therapy.
• The initial care plan should be discussed and agreed, and a named contact identified who will be responsible for providing support and information. The date of the next appointment should be agreed. Regular reviews will be required initially.