General practice management of type 2 diabetes


What needs ongoing assessment?
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The purpose of ongoing structured evaluation is to determine the impact of care and diabetes on the life of the person with diabetes. It is also to individually assess the impact of clinical management by assessing the person’s diabetes goals and risk factors. Review the use of medication every three or six months using the principles of the ‘Stop rule’ (refer to What if medication is not working – The ‘Stop rule’ under Section 8.2.2. Glucose-lowering agents).


History


Review the patient’s overall sense of wellbeing, ability to cope and self-manage with the diagnosis of diabetes, and what effect this is having on the person’s life. Establish their level of health literacy about their diabetes, and what to do in the event of problems arising.

Review lifestyle interventions, particularly SNAP profiles: (S)moking persistence or relapse, (N)utrition and diet, (A)lcohol intake and (P)hysical activity.

Enquire about possible diabetes complications as well as known comorbid conditions including psychological stress and/or depression (refer to Appendix C. Problem areas in diabetes questionnaire and Appendix D. Patient health questionnaire-2 tool).

Enquire about intercurrent illnesses (eg urinary tract infections, influenza, thyroid disease) that may alter the degree of control. Urinary tract infections are common in patients with diabetes, especially in females.

Enquire about symptoms of hypoglycaemia if the patient is on insulin and/or oral agents that can cause hypoglycaemia.

Enquire about the burdens of care/self management. Has the person been referred or received structured diabetes self-management education?42 Does the person experience any problems with medication taking, including side effects, forgetting or sometimes intentionally not taking medications as recommended? Consider alternative regimens or problem-solving with the patient if problems are significant.


Examination


To help re-evaluate therapeutic goals and assess for complications, check weight and waist, height (children and adolescents), BP, feet examination (refer to Section 10.5. Foot complications) if new symptoms or at risk (eg neuropathy ± peripheral vascular disease). Assess a patient’s record of SMBG testing (if utilised). Individually assess the need for further re-examination dependent on individual risk factors. For example, BP may need re-evaluation in two months ifelevated at systolic 140–159 mmHg/diastolic 90–99 mmHg, whereas BP at 160–179 mmHg systolic/100–109 mmHg diastolic may need reassessment within one month.93

Routine investigations are best organised before the review appointment.

To determine measurable diabetes goals for the individual patient:

  • Measure HbA1c as needed on an individual basis – this may be up to every third month (maximum) in a newly diagnosed patient, patients undergoing therapeutic changes or those outside of recommended ranges; stable patients at agreed targets may need less-frequent interval testing.
  • Base further investigations on re-evaluated clinical symptoms and history (eg a urine assessment may be considered, or investigation of emotional issues including depressive symptoms, diabetes-specific distress, or other diabetes-related issues suspected or identified in earlier consultations).


Refining the management plan


Review the goals and individual targets with the patient to identify specific areas for ongoing or interval therapeutic review.

Patient support – refer to structured self-management education (eg CDE). Does other allied health intervention need to be considered (eg psychologist, APD)?
Medication/therapy choices – adjustment of agent, dose, combinations, enquire about symptoms of hypoglycaemia. Review use of medication using the principles of the ‘Stop rule’ every three or six months.

Complication management – specific intervention/support/referral when indicated.


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  1. Colagiuri R, Girgis S, Gomez M, Walker K, Colagiuri S, O’Dea K. National evidence based guideline for the primary prevention of type 2 diabetes. Canberra: Diabetes Australia and the NHMRC, 2009..
  2. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of hypertension (Updated Dec 2010). Melbourne: National Heart Foundation of Australia, 2008.