7
CHAPTER 2
Diabetes mellitus Dr Brian Hurwitz, MSc, MRCP, MRCGP Professor John Yudkin, MD, FRCP Advice from: Ms Karen Hyland, SRD SUMMARY 1. Diabetes mellitus is diagnosed by finding a random plasma glucose >11 mmolJL, or a fasting plasma glucose >8 mmol/L. The prevalence in the general population is between 1-2% rising to approximately 4-9% in the age group 65+ (Williams, 1985; Croxson et al., 1991). It is more prevalent in people from the Indian subcontinent and in Afro-Caribbeans. 2. Approximately 75% of patients can be treated without recourse to insulin. The development of non-fasting ketonuria and/or significant weight loss suggests the onset of insulin dependence. These patients should be referred for specialist advice rapidly. 3. Chronic, uncontrolled hyperglycaemia greatly increases the risk of developing diabetic eye, nerve and kidney complications. 4. Treatment andfollow-up aim: * to abolish symptoms * to prevent and/or treat diabetic complications * to promote self-care and self-monitoring by patients * to avoid iatrogenic problems from overtreatment * to promote optimum nutrition for these patients. 5. Advice and assessment from the following specialists need to be built into the treatment plan: * dietitian * competent fundoscopist (eg optometrist, general practitioner, hospital specialist depending upon local circumstances) * chiropodist * diabetes education nurse and diabetes nurse specialist. 6. All patients need appropriate education about: * the nature of diabetes mellitus * the importance of good control and the early detection of complications * a healthy lifestyle * the consequences of diabetes for driving and insurance. 7. All patients with diabetes should be reviewed clinically at least once a year Diet, understanding of diabetes, selfmonitoring, metabolic control and complications should be assessed. More frequent clinical review is required in poorly controlled patients, or those with significant complications, or intercurrent illness. 8. For non-insulin treated patients, diet is the mainstay of treatment. Sulphonylurea drugs should be added to attain adequate control in non-obese patients, whereas metformin
is the hypoglycaemic drug of choice in the obese. Tolbutamide is less likely to cause serious hypoglycaemia than glibenclamide. Choice of treatment should pay due regard to side-effects, drug interractions, and costs. 9. A variety of insulin regimens can be used including: * once daily long-acting insulin * twice daily mixture of a short-acting and an intermediate-acting insulin * multiple short-acting insulin before meals together, with once daily long-acting insulin.
Introduction An average general practitioner's list of 2000 patients involves approximately 100 consultations a year with diabetic patients. Many of these consultations are likely to feature elements of diabetes management and advice. When to begin oral hypoglycaemics and which type to use, whether to decrease or increase the dosage or consider conversion to insulin, what to do about neuropathy or retinopathy, and whether to request specialist advice are questions which general practitioners frequently consider in the management of already established diabetic patients. Because only two new diabetic patients are likely to be discovered in an average list each year (Thorn, 1983), the diagnosis and initial investigation of diabetes are small fragments of a comprehensive structured approach to the primary health care of the condition. Although these guidelines start with diagnosis and investigation, the main focus is on co-ordinating long-term follow-up, on the prevention or early detection of complications, and monitoring glycaemic control.
Diagnosis Random plasma glucose >11 mmol/L or Fasting plasma glucose >8 mmolJL If the patient is asymptomatic and the glucose level is very close to one of these levels it should be confirmed to be above one of these thresholds on a subsequent occasion. If the blood glucose hovers below these thresholds, or the diagnosis is strongly suspected but not confirmed by these measurements, a glucose tolerance test will be definitive. First visit Presenting symptoms Note weight loss, precipitating illness, smoking, family history, past history, and medication.
8 Examination Check weight, blood pressure, legs for peripheral pulses and condition of skin, and reflexes. Check visual acuity and dilated fundoscopy (see below). Investigations * Urine: Check glucose, ketones, protein * Blood: Check glucose electrolytes and creatinine if proteinuria cholesterol if between ages 30-55.
and how well patients understand their condition. The level of general practitioner involvement in clinical management is a determining factor in the overall quality of care that patients receive. An equally important consideration is co-ordination of these different medical services. These management guidelines emphasize the extent to which general practitioners need to be co-ordinating care, as well as providing clinical care, for their diabetic patients.
Treatment Initial action If non-fasting ketonuria or weight loss, refer urgently to the diabetic clinic for consideration of insulin therapy. Otherwise a trial of diet alone should precede treatment with oral hypoglycaemic agents. If the patient adheres to the diet for 4-6 weeks but the fasting blood glucose remains >6 mmol/L, then diet alone is probably insufficient. Oral hypoglycaemic drugs should then be introduced in a stepwise fashion. Refer to hospital if the patient: * continues to lose weight or * develops ketones in non-fasting urine or * maintains a blood glucose >20 mmol/L. Thresholds of referral should be low for patients under the age of 40.
Guidelines for follow-up care Diabetes is a chronic condition which is almost always a diagnosis for life. Six major aims of treatment are: 1. To abolish symptoms of the disease 2. To maintain blood sugar within satisfactory range as, measured by either glycosylated haemoglobin or serum fructosamine 3. To prevent or treat early any complications that occur 4. To promote self-care, self-monitoring and self-treatment by patients in order to enhance the quality and quantity of life 5. To avoid iatrogenic problems such as hypoglycaemia or an obsessional approach to diet and monitoring blood glucose 6. To achieve optimum nutrition in order to promote glycaemic control and safe lipid levels. In addition to close medical supervision, a team approach is needed with substantial contributions, at different times, from: * Dietitian * Optometrist and ophthalmologist * Chiropodist * Practice nurse * District nurse * Diabetes education nurse and diabetes liaison nurse, if available. The degree of involvement of any of these specialists will vary with the type of diabetes and its duration, the presence of complications or concurrent medical problems,
Diet Diet is the mainstay of treatment and is equally important for insulin-dependent and non-insulin dependent patients. The current attitude is to advise on a high fibre, high carbohydrate, low fat diet, with calorie restriction for the overweight patient (body mass index >27 kg/m2)t. About 50% of energy should come from complex carbohydrates, and only 35% from fat, most of which should be monounsaturated or polyunsaturated. Sugar foods and drinks should be avoided. Dietary advice may be provided by using leaflets or booklets available from the British Diabetic Association.
Tablets Tablets should be started in the non-insulin dependent diabetic patient only after an adequate trial of diet (say 4 weeks), but the decision on whether tablets are justified in the quest to achieve the target blood glucose concentration is dependent on many variables related both to the patient's symptoms and other medical and social factors. 1. SULPHONYLUREAS
The most used and best known sulphonylureas are chlorpropamide, tolbutamide and glibenclamide. The newer preparations generally offer little further benefit. They all lower blood glucose by increasing insulin release from pancreatic ,8-cells in response to a given plasma glucose level. All the sulphonylureas tend to cause weight gain and are therefore more useful for patients within 120% of their ideal body weight (BMI120% ideal body weight; BMI >27) and is contra-indicated in patients with liver or kidney disease, and in those with a history of myocardial infarction. Approximately 20% of patients suffer abdominal symptoms such as pain, diarrhoea or indigestion, although this often settles down. Dosages and regimens MeMformin: 500 mg bd increasing to 850 mg tds. In poorly controlled patients, the maximum dose can be combined with the maximum dose of one sulphonylurea. 3. INSULIN
Insulin is essential for patients who continue to lose weight with worsening blood glucose control, and for patients with significant ketonuria. If the blood glucose is persistently over 20 mmol/L, or if the patient is unwell, vomiting or pyrexial, it is important to test the urine for ketones.
Dosages and regimens In general, younger patients are given a multiple injection regimen which increases flexibility of lifestyle - almost all of those under 40 newly presenting to the hospital clinic are now started on an insulin pen (eg NovoPen), which contains a short-acting insulin given at meal times, together with a single dose of long-acting insulin. Older patients are usually treated with once daily, long-acting insulin. The exact dosage and combination of insulins should be individually tailored to the patient's need and lifestyle by titrating dose against blood glucose control. However, there are a number of useful rules of thumb which can be helpful: 1. Total insulin dose usually lies somewhere between 0.21.0 units of insulin/kg body weight. 2. Patients usually require approximately two thirds of the total dose in the morning though this may depend on the exact regimen (a pen regimen involves a longer-acting insulin like Ultratard or Insulatard or Protaphane or Humulin I which may be administered at bedtime). 3. It is usually not necessary to adjust the dosage by more than 2-4 units (increase or decrease) in order to improve control unless a patient has ketones, in which case a rise of approximately 20% may be needed, or a patient has a bad hypoglycaemic episode, in which case a drop of 20% may be required. 4. In general, patients are started on human insulin and not pork or beef insulin. If, however, patients are well stabilized on an animal insulin, there is no reason to convert them to human insulin. Anxiety has been raised about the possibility that human insulin may give fewer hypoglycaemic warning symptoms, and may even be responsible for a greater risk of hypoglycaemic death, but this is no longer generally accepted. If a patient is anxious about using human insulin for these reasons it is logical, and appropriate, to convert to a porcine preparation. The three main insulin regimens in use are: 1. Once daily long-acting insulin especially in the elderly (eg lente or ultralente) 2. A twice daily mixture (or separate combination) of a short-acting and an intermediate-acting insulin (eg soluble and isophane, soluble and lente) 3. Short-acting insulin (eg soluble) at meal times via pen injector and a once daily longer-acting insulin (eg ultralente or isophane) usually given at bedtime.
Many patients do not require frequent adjustment of insulin dosage but where control is poor consider the following principles for adjustment for regimens 1 and 2: * Abnormal fasting glucose requires adjustment of the intermediate-acting insulin dose of the night before. * Abnormal pre-lunch glucose requires adjustment of the morning's short-acting insulin or attention to midmorning snacks. * Post-lunch, or pre-supper abnormal glucose requires adjustment of the morning's intermediate-acting insulin, or attention to mid-afternoon snacks. * Pre-sleeping or noctumal hypoglycaemia requires adjustment of the evening short-acting insulin. In the case of a tds regimen of soluble insulin by pen injector with nocturnal Ultratard or an isophane insulin such as Insulatard the suggestions are different:
10 * Adjust Ultratard or Insulatard at bedtime dose if fasting blood glucose >8 mmol/L Decrease dose if hypoglycaemic on waking or fasting blood glucose 10 mm/L mid-morning or pre-lunch * Adjust soluble at lunch dose if blood glucose 10 mm/L mid-afternoon or pre-supper * Adjust soluble at supper dose if blood glucose 10 mmol/L mid-evening or bedtime. Assess blood glucose profiles taken over at least several days before making minor dosage adjustments. The cost of treatments is given in Table 1.
Haemoglobin Al (relatively more costly than a random glucose but still only about £3), or serum fructosamine estimation, gives an indication of average blood glucose levels over the preceding two to three months and may be useful if other methods of monitoring do not give consistent results. The normal range varies depending on laboratory, but is usually around 6.5-8.5%. Aim for: * Level below 9% in patients under 65 years of age. HbA1 is probably worth checking once a year.
Gliquidone
30 mg twice daily
£9.15
Tolazamide
250 mg twice daily
£7.40
Gliclazide
160 mg once daily
£6.40
Insulin-dependent diabetes Home blood glucose monitoring is a valuable component of self-monitoring and should be done instead of urine tests. Aim for: * Fasting blood glucose 150 mmol/L * Unstable insulin-treated diabetics. Diabetic care in general practice Diabetic care in general practice may be structured in one of the following ways: Miniclinics A special session may be held monthly with a nurse and one or two partners (in rotation) being responsible for clinical review and treatment changes. In some localities the local hospital diabetologist or senior registrar may attend to provide educational support and expert guidance at three monthly intervals. A variety of personal diabetic record cards are available to record clinical details. Diabetic day Patients are invited to attend for diabetic review on a particular day when the nurse is prepared for blood glucose measurements and urine tests, and can check visual acuity and put drops in the eyes. In some practices the nurse works as a nurse practitioner inspecting feet, checking reflexes and looking at injection sites. After this initial review the patients attend their own general practitioner in normal surgery hours with the results of the nurse assessment. This combines the advantages of a personal list with focused clinical review (Koperski, 1987). Nurse clinic Patients are reviewed monthly by a nurse and a specialist diabetic dietitian and referred to their general practitioner if there is concern about control or complications.
Follow-up investigations * Urine for protein (yearly to check for renal disease) and ketones if blood glucose >20 mmol/L, or patient vomiting or sick for some other reason.
12
* HbA 1 (6 monthly in insulin-treated patients) * Fasting blood glucose in non-insulin patients. Remember to tell the patients to omit their hypoglycaemic drugs as well as food prior to the blood test. * Urea and creatinine if proteinuria present, in which case an MSU should be checked. If infected, treat and re-check for protein when sterile. * Cholesterol, perhaps every 5 years, or more often if other risk factors present.
4. Renal involvement Proteinuria is a sign of renal involvement unless urinary infection is present, in which case this should be treated until the MSU is sterile. Proteinuria starts as micro-albuminuria below the level at which the stix is sensitive and later becomes apparent as intermittent proteinuria. Manage by: * excluding urinary infection * keeping blood pressure
CHAPTER 2
Diabetes mellitus Dr Brian Hurwitz, MSc, MRCP, MRCGP Professor John Yudkin, MD, FRCP Advice from: Ms Karen Hyland, SRD SUMMARY 1. Diabetes mellitus is diagnosed by finding a random plasma glucose >11 mmolJL, or a fasting plasma glucose >8 mmol/L. The prevalence in the general population is between 1-2% rising to approximately 4-9% in the age group 65+ (Williams, 1985; Croxson et al., 1991). It is more prevalent in people from the Indian subcontinent and in Afro-Caribbeans. 2. Approximately 75% of patients can be treated without recourse to insulin. The development of non-fasting ketonuria and/or significant weight loss suggests the onset of insulin dependence. These patients should be referred for specialist advice rapidly. 3. Chronic, uncontrolled hyperglycaemia greatly increases the risk of developing diabetic eye, nerve and kidney complications. 4. Treatment andfollow-up aim: * to abolish symptoms * to prevent and/or treat diabetic complications * to promote self-care and self-monitoring by patients * to avoid iatrogenic problems from overtreatment * to promote optimum nutrition for these patients. 5. Advice and assessment from the following specialists need to be built into the treatment plan: * dietitian * competent fundoscopist (eg optometrist, general practitioner, hospital specialist depending upon local circumstances) * chiropodist * diabetes education nurse and diabetes nurse specialist. 6. All patients need appropriate education about: * the nature of diabetes mellitus * the importance of good control and the early detection of complications * a healthy lifestyle * the consequences of diabetes for driving and insurance. 7. All patients with diabetes should be reviewed clinically at least once a year Diet, understanding of diabetes, selfmonitoring, metabolic control and complications should be assessed. More frequent clinical review is required in poorly controlled patients, or those with significant complications, or intercurrent illness. 8. For non-insulin treated patients, diet is the mainstay of treatment. Sulphonylurea drugs should be added to attain adequate control in non-obese patients, whereas metformin
is the hypoglycaemic drug of choice in the obese. Tolbutamide is less likely to cause serious hypoglycaemia than glibenclamide. Choice of treatment should pay due regard to side-effects, drug interractions, and costs. 9. A variety of insulin regimens can be used including: * once daily long-acting insulin * twice daily mixture of a short-acting and an intermediate-acting insulin * multiple short-acting insulin before meals together, with once daily long-acting insulin.
Introduction An average general practitioner's list of 2000 patients involves approximately 100 consultations a year with diabetic patients. Many of these consultations are likely to feature elements of diabetes management and advice. When to begin oral hypoglycaemics and which type to use, whether to decrease or increase the dosage or consider conversion to insulin, what to do about neuropathy or retinopathy, and whether to request specialist advice are questions which general practitioners frequently consider in the management of already established diabetic patients. Because only two new diabetic patients are likely to be discovered in an average list each year (Thorn, 1983), the diagnosis and initial investigation of diabetes are small fragments of a comprehensive structured approach to the primary health care of the condition. Although these guidelines start with diagnosis and investigation, the main focus is on co-ordinating long-term follow-up, on the prevention or early detection of complications, and monitoring glycaemic control.
Diagnosis Random plasma glucose >11 mmol/L or Fasting plasma glucose >8 mmolJL If the patient is asymptomatic and the glucose level is very close to one of these levels it should be confirmed to be above one of these thresholds on a subsequent occasion. If the blood glucose hovers below these thresholds, or the diagnosis is strongly suspected but not confirmed by these measurements, a glucose tolerance test will be definitive. First visit Presenting symptoms Note weight loss, precipitating illness, smoking, family history, past history, and medication.
8 Examination Check weight, blood pressure, legs for peripheral pulses and condition of skin, and reflexes. Check visual acuity and dilated fundoscopy (see below). Investigations * Urine: Check glucose, ketones, protein * Blood: Check glucose electrolytes and creatinine if proteinuria cholesterol if between ages 30-55.
and how well patients understand their condition. The level of general practitioner involvement in clinical management is a determining factor in the overall quality of care that patients receive. An equally important consideration is co-ordination of these different medical services. These management guidelines emphasize the extent to which general practitioners need to be co-ordinating care, as well as providing clinical care, for their diabetic patients.
Treatment Initial action If non-fasting ketonuria or weight loss, refer urgently to the diabetic clinic for consideration of insulin therapy. Otherwise a trial of diet alone should precede treatment with oral hypoglycaemic agents. If the patient adheres to the diet for 4-6 weeks but the fasting blood glucose remains >6 mmol/L, then diet alone is probably insufficient. Oral hypoglycaemic drugs should then be introduced in a stepwise fashion. Refer to hospital if the patient: * continues to lose weight or * develops ketones in non-fasting urine or * maintains a blood glucose >20 mmol/L. Thresholds of referral should be low for patients under the age of 40.
Guidelines for follow-up care Diabetes is a chronic condition which is almost always a diagnosis for life. Six major aims of treatment are: 1. To abolish symptoms of the disease 2. To maintain blood sugar within satisfactory range as, measured by either glycosylated haemoglobin or serum fructosamine 3. To prevent or treat early any complications that occur 4. To promote self-care, self-monitoring and self-treatment by patients in order to enhance the quality and quantity of life 5. To avoid iatrogenic problems such as hypoglycaemia or an obsessional approach to diet and monitoring blood glucose 6. To achieve optimum nutrition in order to promote glycaemic control and safe lipid levels. In addition to close medical supervision, a team approach is needed with substantial contributions, at different times, from: * Dietitian * Optometrist and ophthalmologist * Chiropodist * Practice nurse * District nurse * Diabetes education nurse and diabetes liaison nurse, if available. The degree of involvement of any of these specialists will vary with the type of diabetes and its duration, the presence of complications or concurrent medical problems,
Diet Diet is the mainstay of treatment and is equally important for insulin-dependent and non-insulin dependent patients. The current attitude is to advise on a high fibre, high carbohydrate, low fat diet, with calorie restriction for the overweight patient (body mass index >27 kg/m2)t. About 50% of energy should come from complex carbohydrates, and only 35% from fat, most of which should be monounsaturated or polyunsaturated. Sugar foods and drinks should be avoided. Dietary advice may be provided by using leaflets or booklets available from the British Diabetic Association.
Tablets Tablets should be started in the non-insulin dependent diabetic patient only after an adequate trial of diet (say 4 weeks), but the decision on whether tablets are justified in the quest to achieve the target blood glucose concentration is dependent on many variables related both to the patient's symptoms and other medical and social factors. 1. SULPHONYLUREAS
The most used and best known sulphonylureas are chlorpropamide, tolbutamide and glibenclamide. The newer preparations generally offer little further benefit. They all lower blood glucose by increasing insulin release from pancreatic ,8-cells in response to a given plasma glucose level. All the sulphonylureas tend to cause weight gain and are therefore more useful for patients within 120% of their ideal body weight (BMI120% ideal body weight; BMI >27) and is contra-indicated in patients with liver or kidney disease, and in those with a history of myocardial infarction. Approximately 20% of patients suffer abdominal symptoms such as pain, diarrhoea or indigestion, although this often settles down. Dosages and regimens MeMformin: 500 mg bd increasing to 850 mg tds. In poorly controlled patients, the maximum dose can be combined with the maximum dose of one sulphonylurea. 3. INSULIN
Insulin is essential for patients who continue to lose weight with worsening blood glucose control, and for patients with significant ketonuria. If the blood glucose is persistently over 20 mmol/L, or if the patient is unwell, vomiting or pyrexial, it is important to test the urine for ketones.
Dosages and regimens In general, younger patients are given a multiple injection regimen which increases flexibility of lifestyle - almost all of those under 40 newly presenting to the hospital clinic are now started on an insulin pen (eg NovoPen), which contains a short-acting insulin given at meal times, together with a single dose of long-acting insulin. Older patients are usually treated with once daily, long-acting insulin. The exact dosage and combination of insulins should be individually tailored to the patient's need and lifestyle by titrating dose against blood glucose control. However, there are a number of useful rules of thumb which can be helpful: 1. Total insulin dose usually lies somewhere between 0.21.0 units of insulin/kg body weight. 2. Patients usually require approximately two thirds of the total dose in the morning though this may depend on the exact regimen (a pen regimen involves a longer-acting insulin like Ultratard or Insulatard or Protaphane or Humulin I which may be administered at bedtime). 3. It is usually not necessary to adjust the dosage by more than 2-4 units (increase or decrease) in order to improve control unless a patient has ketones, in which case a rise of approximately 20% may be needed, or a patient has a bad hypoglycaemic episode, in which case a drop of 20% may be required. 4. In general, patients are started on human insulin and not pork or beef insulin. If, however, patients are well stabilized on an animal insulin, there is no reason to convert them to human insulin. Anxiety has been raised about the possibility that human insulin may give fewer hypoglycaemic warning symptoms, and may even be responsible for a greater risk of hypoglycaemic death, but this is no longer generally accepted. If a patient is anxious about using human insulin for these reasons it is logical, and appropriate, to convert to a porcine preparation. The three main insulin regimens in use are: 1. Once daily long-acting insulin especially in the elderly (eg lente or ultralente) 2. A twice daily mixture (or separate combination) of a short-acting and an intermediate-acting insulin (eg soluble and isophane, soluble and lente) 3. Short-acting insulin (eg soluble) at meal times via pen injector and a once daily longer-acting insulin (eg ultralente or isophane) usually given at bedtime.
Many patients do not require frequent adjustment of insulin dosage but where control is poor consider the following principles for adjustment for regimens 1 and 2: * Abnormal fasting glucose requires adjustment of the intermediate-acting insulin dose of the night before. * Abnormal pre-lunch glucose requires adjustment of the morning's short-acting insulin or attention to midmorning snacks. * Post-lunch, or pre-supper abnormal glucose requires adjustment of the morning's intermediate-acting insulin, or attention to mid-afternoon snacks. * Pre-sleeping or noctumal hypoglycaemia requires adjustment of the evening short-acting insulin. In the case of a tds regimen of soluble insulin by pen injector with nocturnal Ultratard or an isophane insulin such as Insulatard the suggestions are different:
10 * Adjust Ultratard or Insulatard at bedtime dose if fasting blood glucose >8 mmol/L Decrease dose if hypoglycaemic on waking or fasting blood glucose 10 mm/L mid-morning or pre-lunch * Adjust soluble at lunch dose if blood glucose 10 mm/L mid-afternoon or pre-supper * Adjust soluble at supper dose if blood glucose 10 mmol/L mid-evening or bedtime. Assess blood glucose profiles taken over at least several days before making minor dosage adjustments. The cost of treatments is given in Table 1.
Haemoglobin Al (relatively more costly than a random glucose but still only about £3), or serum fructosamine estimation, gives an indication of average blood glucose levels over the preceding two to three months and may be useful if other methods of monitoring do not give consistent results. The normal range varies depending on laboratory, but is usually around 6.5-8.5%. Aim for: * Level below 9% in patients under 65 years of age. HbA1 is probably worth checking once a year.
Gliquidone
30 mg twice daily
£9.15
Tolazamide
250 mg twice daily
£7.40
Gliclazide
160 mg once daily
£6.40
Insulin-dependent diabetes Home blood glucose monitoring is a valuable component of self-monitoring and should be done instead of urine tests. Aim for: * Fasting blood glucose 150 mmol/L * Unstable insulin-treated diabetics. Diabetic care in general practice Diabetic care in general practice may be structured in one of the following ways: Miniclinics A special session may be held monthly with a nurse and one or two partners (in rotation) being responsible for clinical review and treatment changes. In some localities the local hospital diabetologist or senior registrar may attend to provide educational support and expert guidance at three monthly intervals. A variety of personal diabetic record cards are available to record clinical details. Diabetic day Patients are invited to attend for diabetic review on a particular day when the nurse is prepared for blood glucose measurements and urine tests, and can check visual acuity and put drops in the eyes. In some practices the nurse works as a nurse practitioner inspecting feet, checking reflexes and looking at injection sites. After this initial review the patients attend their own general practitioner in normal surgery hours with the results of the nurse assessment. This combines the advantages of a personal list with focused clinical review (Koperski, 1987). Nurse clinic Patients are reviewed monthly by a nurse and a specialist diabetic dietitian and referred to their general practitioner if there is concern about control or complications.
Follow-up investigations * Urine for protein (yearly to check for renal disease) and ketones if blood glucose >20 mmol/L, or patient vomiting or sick for some other reason.
12
* HbA 1 (6 monthly in insulin-treated patients) * Fasting blood glucose in non-insulin patients. Remember to tell the patients to omit their hypoglycaemic drugs as well as food prior to the blood test. * Urea and creatinine if proteinuria present, in which case an MSU should be checked. If infected, treat and re-check for protein when sterile. * Cholesterol, perhaps every 5 years, or more often if other risk factors present.
4. Renal involvement Proteinuria is a sign of renal involvement unless urinary infection is present, in which case this should be treated until the MSU is sterile. Proteinuria starts as micro-albuminuria below the level at which the stix is sensitive and later becomes apparent as intermittent proteinuria. Manage by: * excluding urinary infection * keeping blood pressure
