Management of Newly Diagnosed Diabetes
Confirming the Diagnosis
Determine the risk of ketoacidosis and likely need for immediate insulin therapy
Patients not requiring immediate insulin
Check list for recently diagnosed diabetes
Impaired glucose tolerance and impaired fasting glucose
Algorithm for management of newly diagnosed patient
These will be linked to the following:
Confirming the diagnosis
In the presence of dehydration or heavy ketonuria, a presumptive diagnosis of
diabetes may be made on the basis of urinalysis and/or blood strip testing and
urgent referral is likely to be appropriate.
Otherwise it is essential that a diagnosis of diabetes is confirmed before the
patient is advised that he/she has diabetes and before treatment with diet or any
other agent is commenced.
Symptoms of thirst and polyuria or the finding of glycosuria should prompt blood
glucose measurement using a laboratory method. The diagnosis of diabetes
should not be made on the basis of portable blood glucose meter results alone.
The diagnosis can be made on the basis of symptoms (thirst and polyuria) and
one diagnostic blood glucose measurement. The values of blood glucose
indicative of diabetes are as follows;
 Random venous plasma glucose

Fasting plasma glucose

Venous plasma glucose
at 2 hours after a 75g oral glucose
load (the oral glucose tolerance test; See Appendix 1 ).
In the absence of symptoms the diagnosis is based on two diagnostic blood
glucose measurements on two separate days. On rare occasions therefore a
second oral glucose tolerance test may need to be performed before a diagnosis
of diabetes can be confirmed.
In the UK the 2000 WHO criteria were adopted from June 2000.
Interpretation of Plasma Glucose Levels (mmol/l)
Fastin
g
Venou
s
Capillar
y
Rando
m
Venou
s
Capillar
y
Diabetic range
5.5 <
11.1
6.1<
7.0
6.1 <
7.0
6.5 <
12.2
Check fasting glucose
Impaired Fasting Glucose (IFG) - 75g
OGTT required
75g OGTT required
Diabetes unlikely
Interpretation of 75g Oral Glucose Tolerance Test (WHO 2000)
Glucose
(mmol/l)
Fasting
2 Hour
Diabetes Mellitus
Venous
Plasma
Capillary
Plasma
Impaired glucose
tolerance
Venous
Plasma
<7.0
and
11.1
Capillary
Plasma
<7.0
and
12.2
Determine the risk of ketoacidosis and likely need for immediate insulin
therapy
The most important decision once the diagnosis has been made is to decide
whether the patient is at risk of ketoacidosis and likely to require immediate
insulin therapy.
Indications for immediate insulin therapy




Persistent non-fasting ketonuria
Marked weight loss in the normal or underweight patient
Vomiting and dehydration (will require immediate hospital admission for
intravenous therapy).
The initial blood glucose level or presence of primary symptoms of thirst and
polyuria are not good guides as to the need for insulin.
Hospital admission may be avoided in patients who clearly require insulin, but are
not dehydrated or in ketoacidosis, depending on the logistics of arranging to start
insulin at home on an urgent basis. Such patients should be discussed by
telephone with a member of the diabetes specialist team with a view to starting
insulin within 24 hours. These patients should receive immediate care from the
hospital diabetes team and may be admitted to hospital depending on the
practicalities of starting insulin at home.
Patients with signs of ketoacidosis or dehydration should be admitted to hospital
under the emergency admissions system.
Children under the age of fourteen should be discussed urgently on the
telephone with a paediatrician, and will normally be admitted to hospital.
Patients not requiring immediate insulin
The majority of newly diagnosed patients have Type 2 diabetes, and the
management approach can be more relaxed in timescale. The initial blood
glucose level or presence of primary symptoms of thirst and polyuria is not a
good guide as to the long term need for hypoglycaemic drug therapy. Patients do
not normally require oral hypoglycaemic agents until they have completed at
least two or three months on diet alone.
Group education facilities are available at a variety of locations throughout the
region for the initial education of Type 2 patients. All such patients should initially
receive dietary advice aiming to optimise body weight (see diet section). General
advice and the provision of the Diabetes UK diet leaflet is acceptable for initial
management, but all patients should be referred to a dietitian at an early stage for
more detailed and personalised advice.
Obese patients (BMI > 30kg/m2) inadequately controlled after a trial of diet but
showing evidence of weight loss may be left on diet alone as glycaemic control is
likely to continue to improve. Overweight and obese patients (BMI >25) not
achieving weight loss may be most appropriately treated with metformin (section
12.4.1) in a low starting dose to minimise gastrointestinal side effects. Patients
not overweight (BMI  25kg/m2) but inadequately controlled may be commenced
on a sulphonylurea (section 12.4.2). Employment and social issues may also
influence the choice of treatment.
Check list for recently diagnosed diabetes
Once the immediate issue of glycaemic control has been addressed it is
important to consider further educational topics and to ensure an adequate
physical examination for detection of established complications, which are often
present at diagnosis in Type 2 patients. The following checklist is suggested for
completion over the first few clinical contacts.
 Decide on initial blood glucose management and need for immediate insulin
or otherwise

Provide initial dietary advice and arrange for referral to a dietitian

Record weight (kg) and height (m) and calculate body mass index (BMI kg/m 2
ight in metres squared)

Record blood pressure

Record urinalysis for protein and ketones and glucose

Examine feet for signs of neuropathy, peripheral vascular disease or active
lesions

Provide foot care information

Decide on need for referral to a chiropodist

Perform or arrange for adequate retinal examination.

Record visual acuity (pinhole corrected if worse than 6/9)

Arrange biochemical assessment; serum creatinine, LFTs, lipid profile, thyroid
function, HbA1C

Early morning urine for albumin/creatinine ratio (microalbumin screen)

Record smoking status and advise as appropriate

Assess cardiovascular risk status (smoking, BP, family history, lipids,
proteinuria/microalbuminuria, established macrovascular disease).

Consider ECG to assess evidence of previous MI or left ventricular
hypertrophy.

Decide on appropriate patient self monitoring

Discuss hypoglycaemia and its management in all insulin and sulphonylurea
treated patients

Determine individualised blood glucose treatment targets

Provide support literature

Cover selected topics from the education checklist with the patient and
relevant individuals

Discuss driving/DVLA/insurance

Consider referral to a diabetes specialist nurse or hospital diabetic clinic

Consider causes of secondary diabetes, see Appendix 3 - Secondary
Diabetes

Ensure patient is registered with practice and regional diabetes register
Impaired glucose tolerance & impaired fasting glucose

These patients, like those with established diabetes, have an increased risk of
macrovascular disease and require assessment and aggressive management
of cardiovascular risk factors, dietary and lifestyle advice – See Diet and
Smoking and Diabetes.

Patients with impaired fasting glucose (IFG) ( 6.1mmol/l, < 7.0mmol/l) should
have a 75g OGTT as some will fulfil the criteria for diabetes mellitus on the
two hour value.

Patients with IGT & IFG should be entered into the practice diabetes register
if available.

Five per cent per year may go on to develop Type 2 diabetes and will then
need appropriate diabetes care.

A fasting or random blood glucose level should therefore be measured on an
annual basis, or earlier in the event of symptoms in people with IGT or IFG
and the results interpreted according to confirming the diagnosis
Algorithm see separate file for this diagram