Clinical Skill Series: Family Medicine- Outpatient Diabetes

Being able to manage and diagnose diabetic patients is a skill that is essential for primary care physicians. Diabetes can be a confusing topic. In this guide, I go through a blue print that will allow you to diagnose and understand the process of managing diabetes.

Important Things to Remember in Clinic:

Initiate annual testing for Diabetes starting at 40 years old, checking using fasting glucose, or HbA1C.

Remember that it takes 3 months for the red blood cells to be renewed, therefore if a patient is diabetic, testing therefore must be every 3 months, and include HbA1C and urinary micro-albumin.

If a patient is Diabetic, check for medication compliance, and always check to see if they already made an eye appointment , and a podiatrist appointment.

Check for nephropathy, asking the patient if they experience any numbness or tingling in extremities

Check to see if they need to be on hypertension and cholesterol medication, since (1) according to JNC8 guidelines if patient is Diabetic, and have 140/90 or greater, hypertensive medication should be started. If patient is Diabetic, then ACE/ARB is preferred first. (2) If patient is between 40-75 and is Diabetic, moderate to high intensity statins are needed. More details will be given later.

Diagnosing Diabetes

Fasting glucose: 126 or higher, fasting glucose, must be followed up with another fasting glucose

HbA1C: 6.5% or higher

Glucose Tolerance Test (2hrs): If greater or equal to 200 for resting glucose after given 75g of glucose

Random Glucose: 200 or higher

Pre-Diabetes+ Lifestyle Changes:

HbA1C: 5.7-6.4% mg/dL

Fasting Glucose: 100-125 mg/dL

Glucose Tolerance Test: 140-199 mg/dL

Patients who are Pre-diabetic:

Recommend: 150 minutes of exercise a week, and weight loss. Control other risk factors such as hypertension, and lipids. Don’t eat too much sweets.

The Flow-chart:

Although you can initiate any diabetic orals after 3 months, it is preferred that you choose according to side effects/ cost/ and risk of hypoglycemia. Here I present a flow chart that can be generalized for all types of patients.

Patients who are at risk for hypoglycemia: Old, Decreased Mental Cognition, Decreased ability to recognize hypoglycemia (patients on beta blockers), or Patients who as a job need to operate machinary.

Goals of HbA1C should be according to age/risk.

6-7% goal = younger

7-8% goal= older, and at risk for hypoglycemia

Remember the Brand Names! Side-effects and Contraindications!

The Oral Insulin Preferred is Degludec or Tresiba.

You should give medications that are cardio-protective, and decrease risk of heart attack/atherosclerosis for patients at high risk/ or have a history (color coded in chart)

The most cost effective: sulfonylureas, and TZDs. So you can use those medications instead.

You escalate by adding on another medication if patient isn’t meeting goals.

INSULIN + BASAL BOLUS

Knowing when to escalate to basal-bolus in a diabetic patient already on basal insulin or deescalate to orals is important.

In patients who are non-compliant= Keep them on orals

Patient who are compliant, and orals are not helping keep their HbA1C down = Escalate them to Basal-Bolus

Important : Patients whom you start immediately with basal insulin because of elevated HbA1C (10%), the objective is to try and wean them off basal, by adding orals.

  1. Start the patient at 10 U of basal insulin. Tell the patient to observe the morning fasting glucose. It should be under 120. Tell the patient to go up by 1 U every 3 days, when morning fasting glucose is above 120. Tell the patient to stop once it is under 120, or when patient has reached 0.5 x kg (body weight of patient)
  2. When the morning glucose is well controlled (between 90-120), or when the patient hit 0.5 x (total patient body weight), then it’s time to add meal time insulin. You can start with dinner time, and then start adding morning time and then lunch if HBA1C isn’t reaching goals despite daily glucose levels are controlled.
  3. You start the patient with 5 U of meal time insulin. The 2 hr post meal time should be below 180. If not, insulin is increased by 1 -2 units every day/days until below 180 for the 2 hr post meal time.
  4. You start the diary when patient is diagnosed diabetic. For full basal-bolus, always tell the patient to take a glucose level before all meals, so breakfast, lunch, dinner, and evening.

Memorize below:

If you have any questions, please refer to:

AACE Diabetic Guidelines

The Practice Guidelines from the American Diabetes Association.

Don’t hesitate to ask me: vinhd091@gmail.com.

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