High risk groups 1–4

  • Those who score ≥ 12 on the Australian cardiovascular disease risk calculator
  • Aboriginal and Torres Strait Islander, middle eastern, Asian and Māori people
  • Those who smoke, are physically inactive, overweight or obese
  • Those who collectively have hypertension, dyslipidaemia, central obesity and hyperglycaemia (the Metabolic Syndrome)
  • Low birth weight or large for gestational age babies
  • Women with a history of gestational diabetes mellitus (GDM)
  • Women with a history of polycystic ovary syndrome
  • Those with a history of a cardiovascular and cerebrovascular disease
  • Psychosocial stress, depression or those on anti-psychotic medicines
  • Personal or family history of diabetes or autoimmune conditions

Considerations in pregnancy 5,6

  • Refer early to multidisciplinary team
  • Those with one or more risk factors above should be screened for GDM (or undiagnosed Type 2 diabetes) when pregnancy confirmed i.e. at 6–12 weeks then if normal, repeat at 24–28 weeks
  • Due to high risk of retinopathy, perform baseline eye exam in 1st trimester. If abnormal repeat in 2nd trimester. If not repeat in 3rd trimester
  • BP and urinalysis each visit
  • Early and frequent fetal monitoring due to increased risk of miscarriage and congenital malformations. Advise mothers to report reduced fetal movements
  • Strive for target HbA1c ≤ 6.5% (48 mmol/mol) without severe hypoglycaemia prior to conception and during pregnancy
  • Provide preconception lifestyle behaviour counselling and offer contraception until target HbA1c reached

Urgent referral

  • Refer to the Primary Clinical Care Manual for:
    • diabetic ketoacidosis (DKA) or a hyperosmolar hyperglycaemic state (HHS)
    • high risk foot complications i.e. infection +/- osteomyelitis, charcot foot or gangrene
    • hypoglycaemia i.e. BGL of < 4.0 mmol/L

1. What is diabetes? 1–4

  • Characterised by elevated blood glucose due to insulin deficiency, damaging blood vessels and nerves, leading to complications such as vision and dental loss, cardiovascular and kidney disease, sexual dysfunction and limb amputation
  • Common diabetes types are:
    • Type 1 diabetes mellitus
      • due to an autoimmune process leading to total insulin deficiency usually with rapid onset of symptoms requiring lifelong treatment
      • typically considered a disease of children and the young, however can occur at any age e.g. latent autoimmune diabetes in adults (LADA)
    • Type 2 diabetes mellitus
      • Four times higher in Aboriginal and Torres Strait Islander populations than non-Indigenous Australians, increases with remoteness
      • characterised by insulin deficiency and insulin resistance. In time, insulin production decreases, contributing to hyperglycaemia
      • the most common type, predominantly seen in adults, but also seen in young people due to genetics or in utero exposure to diabetes
    • Other causes of impaired insulin metabolism
      • insulin deficiency due to a disease process affecting the pancreas’s function e.g. pancreatitis, pancreatic cancer, cystic fibrosis. Treated with insulin
  1. Pre-diabetes
    • Also known as impaired glucose tolerance or impaired fasting glucose
    • Occurs when BGLs are elevated above targets but does not meet diagnostic criteria. See Table 1.
    • People with pre-diabetes

2. Diagnosis of diabetes 1–4,7

  • Routine scheduled health checks or opportunistic screening identifies people at high risk of diabetes. See Adult health checks, Child health checks
  • Those who score ≥ 12 (or other high risk category) against the The Australian type 2 diabetes risk assessment tool will have a diagnosis confirmed with a blood test. See Table 1.
  • Signs and symptoms of Type 1 diabetes are sudden onset of:
    • excessive thirst (polydipsia), hunger (polyphagia), urination (polyuria)
    • unintentional weight loss, abdominal pain or vomiting
    • elevated ketones, rapid breathing, acetone or sweet smelling breath,
  • People who develop Type 2 diabetes may be asymptomatic but can present with above and:
    • tiredness and lethargy
    • numbness/tingling in feet or legs
    • blurred vision
    • skin signs e.g. infections, itching, skin tags or dark patches of skin usually in the armpits, neck or groin (acanthrosis nigricans)

Table 1. Standard diagnostic criteria for Type 2 diabetes 1–4,7

Test

Diabetes unlikely

Pre-diabetes

Diabetes (likely)

Random blood glucose

4.0–7.8 mmoI/L

7.9–11.0 mmoI/L

≥ 11.1 mmoI/L

OR HbA1c

< 6%

(42 mmoI/mol)

6.0–6.4 %

(42–46 mmol/mol)

≥ 6.5%

(≥ 48 mmoI/mol)

OR fasting blood glucose

< 5.5 mmoI/L

5.5–6.9 mmoI/L

≥ 7.0 mmoI/L

OR oral glucose tolerance
test (OGTT) 2 hour result

< 7.8 mmoI/L

7.8–11.0 mmoI/L

≥ 11.1 mmoI/L

If patient is asymptomatic and result is close to normal, confirm diagnosis with a second test

3. Management of diabetes 1–4,7,8

  • The goals of managing diabetes are to improve quality of life and prevent complications or premature death by:
    • Lifestyle modifications
    • identifying and addressing comorbidities in conjunction with the Australian cardiovascular disease risk calculator such as:
      • Dyslipidaemia
      • Chronic kidney disease
      • Hypertension
      • Eyes and vision (child)
      • Eyes and vision (adult)
      • Coronary heart disease
    • frequent foot screening for peripheral neuropathy and vascular disease
    • maintaining target goals. See Table 2.
  • For further principles of clinical management of diabetes in adults see Resource 1.

Table 2. Target goals for management of diabetes 1–4,8,9

Assessment

Target

In-clinic or self-monitoring of blood glucose levels

  • Type 1:
    • 4–6 mmol/L fasting
    • 4–8 mmol/L two hrs postprandial
  • Type 2:
    • 4–7 mmol/L fasting
    • 5–10 mmol/L two hrs postprandial
    • for young adults 18–30 years
      • 4–6 mmol/L fasting
      • 4–8 mmol/L two hrs postprandial
  • Type 1 or 2 in elderly or those living alone with comorbidities
    • 6–8 mmol/L fasting
    • 6–12 mmol/L two hrs postprandial

HbA1c

(without significant hypoglycaemia)

  • < 6.5% if planning pregnancy or pregnant
  • < 6.5% young adults 18–30 years
  • < 6.5–7% adult
  • < 8.5% for elderly or living with comorbidities

Total cholesterol (TC)

  • < 4.0 mmol/L

LDL-C

  • < 2.0 mmol/L or < 1.8 mmol/L if established CVD

HDL-C

  • > 1.0 mmol/L

Non-HDL-C

  • < 2.5 mmol/L

Triglycerides (TG)

  • < 2.0 mmol/L

Blood pressure (BP)

  • < 130/80

Body mass index (BMI)

  • 5–10% loss for people overweight or obese with Type 2 diabetes
  • People with BMI > 40 or BMI 35–39 with comorbidities, pharmacological or surgical options should be considered

Urinary albumin excretion (ACR)

  • < 3.5 mg/mmol: women
  • < 2.5 mg/mmol: men
  • < 20 mg/L (spot collection)
  • See Chronic kidney disease

eGFR

  • > 60mL/min

Cigarette consumption

  • See Smoking cessation

Alcohol intake

  • See Alcohol reduction

Physical activity

  • See Physical activity and sleep
  1. Supporting patient self-management 1–4,8,10
    • Provide patient education and resources including:
      • adjustment to diabetes diagnosis
      • knowledge, understanding, attitudes and beliefs of diabetes
      • the benefits of reducing body weight
      • improving foot care behaviours
      • BGL self-monitoring and improving glycaemic control as measured by HbA1c
      • reducing risk of cardiovascular events and microvascular complications, such as retinopathy and end stage nephropathy by Lifestyle modifications
      • see Resources 2–5
    • Refer to diabetes educator and to SMoCC, a phone service that supports patients manage their condition. See Resource 6.
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
  2. Social-emotional support 1–4,8,10
    • Regularly assess a patients level of distress from living with diabetes and refer as necessary. See Resource 5.
    • See Social-emotional wellbeing
  3. Sick day management plan 1,4,11
    • Sick days are periods of acute illness lasting 1–14 days that require changes to usual diabetes self-management practices
    • Develop a written sick day management plan at diagnosis and review or update at each visit. The plan empowers patients to:
      • recognise the signs and symptoms of illness
      • understand the impact illness can have on blood glucose and ketone levels
      • understand self-management interventions to minimise these impacts
      • recognise when, who and how to seek medical assistance and when to present to emergency
    • For sick day management plans (including during pregnancy) see Resource 7.
  4. Diet modification and weight control 1–4,8,10,12
    • Diabetes magnifies the effects of dyslipidaemia increasing acute MI risk
    • Encourage patient to maintain a healthy BMI. See
      • Diet and nutrition
      • Overweight and obesity (child) and Overweight and obesity (adult)
      • Dyslipidaemia
    • Consider a persons food security as inconsistent intake can result in hypoglycaemia with some sulphonyuareas and insulins
    • Refer to a dietitian
  5. Alcohol reduction 1–4,8–10
    • Drinking alcohol decreases blood glucose and masks symptoms of hypoglycaemia
    • Patients should avoid binge drinking and eat something when drinking alcohol
    • See Alcohol reduction
  6. Physical activity 1–4,8,10,12
    • Improves glucose tolerance (by increasing insulin sensitivity), blood pressure and lipid levels
    • Refer to exercise physiologist
    • See Physical activity and sleep
  7. Infections 1–4,8,10
    • Poorly controlled diabetes:
      • causes damage to blood vessels leading to poor wound healing and increases risk of infection
      • reduces white cell ability to combat infection
      • increases risk of chest, urinary tract, skin, dental, genital and kidney infections
    • Patients to be alert to any wounds; to cover and seek treatment immediately
    • Patients with cloudy, bloody or painful urination to seek immediate treatment
    • Vaccinate against common respiratory diseases. See the Australian Immunisation Handbook for recommendations
  8. Neuropathy 1–4,8,10,12
    • Peripheral nerve damage (neuropathy) results in pins-and-needles, pain or burning sensation in the feet, legs and fingers, which can lead to loss of sensation increasing the risk of ulceration and amputation
    • Central neuropathy results in positional hypotension, stomach paralysis and faecal or urinary incontinence, which reduces quality of life and life expectancy
    • Refer early to the MO/NP/podiatrist or diabetes educator for evaluation
  9. Foot care 1–4,8,10
    • Perform a foot check every visit for cuts, blisters, ulcers, calluses or foot deformity
    • Treat any identified problems the same day
    • Apply moisturising cream to dry/tough/thickened skin (not between the toes)
    • Patient education:
      • inspect feet daily for redness, calloused skin, blisters and between the toes for infections
      • use palm of hand to check sole of feet for stones, glass, bindi’s, etc
      • soak feet in warm water and use a pumice stone to remove old dry skin to prevent the heels from cracking
      • wear well-fitting footwear with clean soft socks inside and outside the house
      • prior to putting on shoes check inside for stones etc.
      • trim toenails frequently. If unable then seek help
    • Refer to the Primary Clinical Care Manual for an active or complicated foot wound
  10. Teeth and gums 1–4,8,10
    • Poorly controlled diabetes increases the risk of dry mouth, dental abscess, loose teeth and tooth decay
    • Refer for dental review every 6 months
    • See Dental caries and periodontal disease
  11. Eyes and vision 1–4,8,10
    • Poorly controlled diabetes increases the risk of eye sight damage including:
      • cataract (cloudiness of the lens): results in blurred vision, glare intolerance, poor night vision and difficulty interpreting colours. Surgery is required if lifestyle affected
      • Retinopathy: results from damage to small retinal blood vessels causing permanent visual distortion
      • Maculopathy (macula degeneration): results in central vision loss
    • Refer all newly diagnosed patients to an ophthalmologist or optometrist
    • Correction glasses are prescribed once BGLs are stabilised. See Resource 8.
    • Screen Eyes and vision (child) or Eyes and vision (adult) at routine health checks
  12. Sexual function 4
    • Poorly controlled diabetes causes:
      • damage to the autonomic nervous system responsible for sexual responses
      • deterioration in blood vessel and nerve function and sensation
    • Can lead to penile erection difficulties or vaginal dryness, atrophy and infections
    • See Sexual and reproductive health
  13. Pre-diabetes 1–4,10
    • Manage as above but with intensive lifestyle modification aiming for 5–10% reduction in body weight if overweight or obese
    • Perform annual HbA1c or OGTT. Reduce frequency if no deterioration in results and patient’s lifestyle behaviours have improved

4. Medicines for diabetes 1–4,12–14

  • Reinforce the importance of taking medicines to assist maintaining BGLs
  • Medicines are reviewed and adjusted in conjunction with the MO/NP/pharmacist
  • See Figure 1. Management algorithm for blood glucose control in Type 2 diabetes
  1. Hypoglycaemics 1–4,12–14
    • Type 1 diabetes is managed with insulin adjusted for meals and activity. Refer to diabetes educator or MO/NP if patient is unable to self-adjust
    • Oral medicines are usually continued when using insulins as:
      • early cessation before BGL targets are achieved can result in hyperglycaemia
      • ongoing use can reduce weight gain
      • allows for smaller insulin doses and reduces hypoglycaemia or hyperglycaemia
    • Closely monitor for hypoglycaemia, especially with sulphonylureas and insulins
    • See Table 3. Medicines for diabetes and Table 4. Insulins
    • To calculate medicine dosage in CKD see Chronic kidney disease
  2. Insulin self-management education
    • Rotation of injection sites
    • Store insulin in refrigerator
    • Dispose of sharps. Provide and renew sharps container as required
    • Register with the National Diabetes Services Scheme (NDSS) to access needles, BGL monitors and other resources. See Resource 3.
    • Check BGL is > 5 mmol/L before driving. Notify road traffic authority of fitness to drive
    • Routine BGL monitoring to understand the impacts of daily routines, medicines, diet, exercise etc.
    • What to do if hypoglycaemic i.e. BGL < 4.0 mmol/L, shaking, sweating, racing pulse, confused, irritable, hungry or tired
    • Provide Resource 2.

Figure 1. Management algorithm for blood glucose control in Type 2 diabetes 12–14

Figure 1. Management algorithm workflow for blood glucose control in Type 2 diabetes

Table 3.  Medicines in diabetes1,7–9,12,15–17

Preferred medicines

Metformin

  • Usually first line therapy unless contraindicated
  • Measure eGFR at initiation, fasting BGL at 2 weeks, and HbA1c and eGFR at 3 months
  • Caution in the elderly
  • If changing from conventional tablets to XR, start with the patient’s usual daily dose
  • If > 2 g daily is required, use conventional tablets
  • XR tablets are preferred given with evening meal
  • Gastrointestinal intolerance is common and may be dose limiting. Give with food to minimise upset

Metformin

  • Initially 500 mg PO 1–3 tds, increasing to response (to a max. 3 g)
    • eGFR 30–60 mL/min then 25–50% of dose (to a max. 1 g daily)
    • eGFR 15–29 mL/min then 25% of dose (to a max. 500 mg daily). Contraindicated if GFR < 30 mL/min (seek specialist advice)
    • eGFR < 10 mL/min then avoid

Metformin XR

  • Initially 500 mg PO once a day (to a max. 2 g)

Dipeptidyl peptidase-4 inhibitors (DPP-4i)

  • Fasting and post prandial glucose
  • HbA1c 3 mthly
  • Hypoglycaemia risk when combined with sulphonylureas
  • These medicines are also available in combination with metformin

Alogliptin*

  • eGFR > 50 mL/min then 25 mg PO daily
  • eGFR 30–50 mL/min then 12.5 mg PO daily
  • eGFR < 30 mL/min then 6.25 mg PO daily

Linagliptin*

  • 5 mg PO once a day

Sitagliptin

  • eGFR > 50 mL/min then 100 mg PO daily
  • eGFR 30–45 mL/min then 50 mg PO daily
  • eGFR < 30 mL/min then 25 mg PO daily

Glucagon-like peptide-1 receptor agonists (GLP-1RA)

  • Fasting and post prandial glucose
  • HbA1c 3 mthly
  • Not effective in combination with DPP-4i; both incretin mimetics

Dulaglutide

  • 1.5 mg subcut once wkly

Semaglutide

  • if eGFR ≥ 30 mL/min then 0.25 mg subcut, wkly for 4 weeks, increasing to 0.5 mg wkly. After another 4 weeks, increase dose further if required (to max. 1 mg wkly)

Liraglutide*

  • if eGFR ≥ 15 mL/min then 0.6 mg subcut, daily for 1 week, increasing to 1.2 mg daily. After another 1 week, increase dose further if required (to max. 1.8 mg daily)

Tirzepatide*

  • 2.5 mg subcut, wkly for 4 weeks, increasing to 5 mg/0.5 ml wkly. If target not met increase in 2.5 mg increments every 4 weeks (to max. 15 mg wkly)

*Check LAM and PBS for medicine indications and restrictions

Table 3. Medicines in diabetes (continued)11,7–9,12,15–17

Sodium-glucose co-transporter 2 inhibitors (SGLT2i)

  • eGFR at initiation and yearly thereafter
  • eGFR 6 mthly when 60–90 mL/min
  • eGFR when starting other medicines that reduce renal function
  • AST and ALT at baseline
  • UEC at baseline and 6 mthly thereafter
  • Associated with weight loss and urogenital infections
  • Cease at least 48 hrs prior to fasting for surgery/procedures due to risk of euglycaemic DKA
  • Co-prescribing in heart failure may allow for dosing at a lower eGFR
  • Not recommended if volume depleted or taking diuretics

Dapagliflozin

  • eGFR ≥ 45 mL/min then 10 mg PO daily
  • eGFR 25–45mL/min 10mg daily
  • eGFR < 25 mL/min avoid

Empagliflozin

  • eGFR > 30 mL/min then 10 mg PO daily initially (to a max. 25 mg)

Poorly tolerated or potential for adverse reactions

Sulphonylureas (SU)

  • Fasting plasma glucose 2 weeks post initiation
  • HbA1c at 3 months
  • May cause weight gain
  • May cause hypoglycaemia in the elderly and the presence of renal impairment

Gliclazide IR

  • 40 mg PO once a day or bd (to a max. 320 mg daily in divided doses)
  • eGFR < 50 mL/min use with caution and monitor closely

Gliclazide MR

  • 30 mg PO mane (to a max. 120 mg daily)
  • eGFR < 50 mL/min use with caution and monitor closely

Glimepiride

  • 1 mg PO daily before or with first meal (to a max. 4 mg daily)

Acarbose

  • At initiation perform postprandial glucose, HbA1c at 3 months and hepatic enzymes for hepatotoxicity
  • Flatulence, diarrhoea, abdominal pain and distension are common
  • Rarely used. Seek expert advice to help the patient weigh up the potential treatment harms and benefits

Thiazolidinediones (TZDs)

  • International diabetes management guidelines include thiazolidinediones as an option but favour other choices because of safety concerns
  • Seek expert advice to help the patient weigh up the potential treatment harms and benefits

*Check LAM and PBS for medicine indications and restrictions

  1. Guide to insulin treatment 1,2,4
  • Step 1. Ensure Lifestyle modifications and comorbidities are managed
  • Step 2. Decide the time and type of insulin. Usually daily basal insulin (glargine) before meal or premixed insulin twice daily before meals. See Table 4.
  • Step 3. Identify target range. See Table 2.
  • Step 4. Decide the dose, ‘start low and go slow’
    • single basal dose, morning or evening, usually 10 units (0.2 units/kg)
    • less in an elderly, active or thin patient and more in overweight, inactive patient
  • Step 4. Adjust doses:
    • titrate once or twice weekly at 1–2 units each time to achieve identified target

Table 4. Insulins 1,9,16

Insulin Type

Insulin name

Activity

Comments

Onset

Peak

Duration

Long acting

(analogues)

Detemir (Levemir)

90 mins

6–8 hrs

16 to 24 hrs

  • Subcut
  • Provides a constant basal insulin level
  • Do not mix with other insulins; inject separately

Glargine (Optisulin)

1–2 hrs

None

24 hrs

Glargine (Toujeo)

1–6 hrs

None

24–36 hrs

Ultra long acting combination

Ryzodeg 70/30

15 mins

1 hour

> 24 hrs

  • Subcut once a day or bd, immediately before largest daily carbohydrate meal(s)

Long acting premixed (analogues)

NovoMix 30

Humalog Mix 25

Humalog Mix 50

15 mins

1 hour

16–18 hrs

  • Subcut once a day or bd
  • Give immediately before meal(s)

Ultra short acting (analogues)

NovoRapid

Humalog

Apidra

15 mins

1 hour

4–5 hrs

  • Subcut immediately before food

Ultra short acting (analogues)

Faster-acting insulin aspart (Fiasp)

5–15 mins

0.5–1.5 hrs

3–5 hrs

  • Subcut at start of meal, or up to 20 mins after

Short acting (human)

Actrapid

30 mins

2–3 hrs

6–8 hrs

  • Subcut within 30 mins before meal

*Check LAM and PBS for medicine indications and restrictions

5. Cycle of care

Cycle of care summary for diabetes

Action

Dx

Frequency

Height

Regularly until stops growing

BP

12 mthly

Weight

3 mthly

Waist circumference

3 mthly

BMI

12 mthly

BGL

At each visit

Lifestyle modifications

3 mthly

Social-emotional wellbeing

12 mthly

Foot/amputation check

Every visit or more frequently if high risk i.e. current wound or ulcer history

Visual acuity

12 mthly

FBC

12 mthly

Liver function test (LFT)

12 mthly

UEC

12 mthly

eGFR

12 mthly; 3 mthly if abnormal

HbA1c

6 mthly; more frequent if target not met

Fasting lipids

12 mthly if stable on hypolipidaemics

Urinalysis

12 mthly

ACR

12 mthly; 3 mthly if abnormal

ECG

12 mthly

Influenza, pneumococcal and COVID-19 vaccines

Recommended. See the Australian Immunisation Handbook for schedule

HW/RN review

3 mthly plus prn foot checks

MO/NP review

12 mthly; wkly for active wound

Medicine review

3 mthly or as per MO/NP recommendation

Diabetes educator

6 mthly

Dietitian

12 mthly

Dentist

6 mthly

High risk foot service team

PRN i.e. if non-healing foot wound or if PVD or neuropathy or history of previous ulcer/amputation

Podiatrist

12 mthly; 2 mthly if previous ulcer/amputation

Physician/ Endocrinologist

On referral by MO/NP plus annually for those with a drivers licence on hypoglycaemic agents

Ophthalmologist

Retinal examination 12 mthly

Cycle of care summary for pre-diabetes

Action

Dx

Frequency

Height

Regularly until stops growing

BP

12 mthly

Weight

Measure every 3 mths and encourage 5–10% weight loss

Waist circumference

BMI

Fasting lipids

12 mthly if stable on hypolipidaemics

Random BGL

3 mthly

Fasting BGL

12 mthly

OGTT or HbA1c

12 mthly

Dietitian

3 mthly

ACVDR calculator

12 mthly

Lifestyle modifications

Each visit

MO/NP/RN review

12 mthly

6. References

7. Resources

  1. Clinical Guiding Principles for Sick Day Management of Adults with Type 1 and Type 2 Diabetes
  2. Diabetes Australia Resources and National Diabetes Services Scheme information for people with diabetes
  3. National diabetes services scheme (NDSS)
  4. Statewide Diabetes Clinical Network resources
  5. The Diabetes Distress Screening Scale
  6. Self-Management of Chronic Conditions (SMoCC) service and The health support service “My health for life”
  7. National Diabetes Services Scheme Sick day management plans
  8. Diabetes Australia Keep Sight to make it easier for people with diabetes to get their eyes checked

Last updated: November 2024

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