Managing risks and other impacts of type 2 diabetes

Recommendation	Grade	References	Recommended as of:
Sick day management Sick-day management plans are an integral component of diabetes education. The development of a sick-day management plan along with education on sick-day management should be provided at diagnosis and reviewed or updated at regular intervals.	Consensus	1–3	14/11/2024
Sleep and diabetes Consider screening for sleep health in people with diabetes, including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs and worries about sleep. Refer to sleep medicine specialists and/or qualified behavioural health professionals as indicated.	B	4	14/11/2024
Planning surgical procedures When commencing a person with diabetes on sodium–glucose cotransporter 2 inhibitors (SGLT2i), clinicians should inform them about the risk of diabetic ketoacidosis (DKA) associated with clinical procedures, ideally with written information and management plans. It is advisable to document that the advice has been provided.	Consensus	5	14/11/2024
Dementia and cognitive decline Screening for early detection of mild cognitive impairment or dementia should be performed for adults 65 years of age or older at the initial visit, annually, and as appropriate.	B	6	14/11/2024
Dementia and cognitive decline In the presence of cognitive impairment, diabetes treatment plans should be simplified as much as possible and tailored to minimise the risk of hypoglycaemia.	B	7	14/11/2024

Recommended vaccines for people with type 2 diabetes are as follows:^8–10

• Influenza – annual vaccination is recommended for people with chronic conditions, including diabetes, that require regular medical follow-up or have required hospitalisation in the past year.
• Diphtheria, tetanus, pertussis – for all adults aged ≥65 years if they have not had one in the previous 10 years.
• Hepatitis B – consider for travellers to hepatitis B-endemic areas.
• Herpes zoster – consider for Aboriginal and/or Torres Strait Islander peoples aged 50 years and over, and for the general population aged 65 years and over (available for free in this age group under the National Immunisation Program).
• COVID 19 – assess as per current Australian Technical Advisory Group on Immunisation (ATAGI) advice.¹¹
• Pneumococcus – diabetes is considered a ‘Category B’ condition for increased risk of invasive pneumococcal disease. It is recommended that all adults with type 2 diabetes receive:
  • one dose of a pneumococcal conjugate vaccine (13vPCV, 15vPCV or 20vPCV [only people aged ≥18 years are eligible for 20vPCV]) at diagnosis (at least two months after any previous doses of a pneumococcal conjugate vaccine) and
  • one dose of 23vPPV 12 months after a pneumococcal conjugate vaccine (13vPCV, 15vPCV or 20vPCV; 2–12 months later is acceptable) and
  • a second dose of 23vPPV at least five years after the first dose of 23vPPV.
  • For people who have previously received doses of 23vPPV, it is recommended they receive an age-appropriate pneumococcal conjugate vaccine 12 months after their last 23vPPV dose. If they have already received at least two doses of 23vPPV, no further 23vPPV doses are recommended.
• Respiratory syncytial virus (RSV) vaccine – adults aged >60 years.¹²

‘Sick days’ are periods of minor illness (due to other causes) of around 1–4 days duration that require changes to a person’s usual diabetes self-management.

People with diabetes require careful individualised management during these periods to prevent:

• hyperglycaemic and hypoglycaemic emergencies
• hyperosmolar hyperglycaemic state
• DKA.

Refer below or to The Royal Australian College of General Practitioners (RACGP) and Australian Diabetes Society (ADS) clinical position statement ‘Emergency management of hyperglycaemia in primary care’.¹³

Provide telephone access or after-hours support to ensure continuity of advice and accessibility. Increase self-monitoring of blood glucose (SMBG) if required by individual circumstances (eg people at risk of hypoglycaemia or using a sulfonylurea or insulin). Advise on obtaining a blood ketone monitor and appropriate monitoring strips if a risk of DKA exists (SGLT2i use or pregnancy). Refer to the National Diabetes Services Scheme (NDSS) website for necessary forms.

Review medications (see Table 1).

A warning regarding the use of SGLT2i and DKA: SGLT2i carry a small but definite risk of a form of DKA, sometimes without significantly raised blood glucose levels (euglycaemic DKA).⁵ People should be periodically warned that the chance of developing DKA (which can be euglycaemic) is low, but advised of the symptoms and told to present to an emergency department if they develop any of these symptoms.¹³ People should be instructed on obtaining a ketone monitor and appropriate monitoring strips and they should inform treating doctors that they are taking an SGLT2i. Risk factors and warning signs should be incorporated into their management plan.⁵ Note that DKA/euglycaemic DKA should be considered in people who are taking an SGLT2i if they exhibit abdominal pain, nausea, vomiting, fatigue or metabolic acidosis.⁵

General practices and general practitioners (GPs) should consider routinely incorporating sick-day plans into a person’s documented management plans.

Sick-day management should be tailored to the individual and involve identifying  the underlying cause (always consider possible undiagnosed type 1 diabetes) and treating as appropriate. Underlying causes include:

• intercurrent illnesses, sepsis, infections (eg skin, urinary tract and chest infections), trauma, acute myocardial infarction and stroke
• the use of medications such as corticosteroids.

Special considerations

Diabetes carries a higher risk of morbidity and mortality from infection with COVID-19¹⁴ and influenza¹⁵, and GPs have an essential role in supporting people with diabetes.

In addition to addressing the extra vulnerability with sick days from illness such as COVID-19 and influenza, it is also essential to ensure other aspects of diabetes management are not neglected. Some simple steps to help GPs and people manage diabetes amid ongoing risks are outlined in the sections below.

Identify people in high-risk diabetes groups as a priority for focused clinical review, and proactively schedule timely in-person or telehealth appointments. High-risk groups include people who:^16–19

• have type 1 diabetes
• are aged ≥65 years
• have insulin-requiring type 2 diabetes
• are using SGLT2i agents (elevated risks of DKA)
• have multimorbidity or diabetes complications
• have unstable HbA1c ≥8.5% or with no recorded HbA1c in the past 6–12 months
• smoke.

However, all people with diabetes may need advice on preventive health, immunisations and sick-day management and timely access (if indicated) to antiviral agents.

Different groups have different considerations for sick-day management.

Type 2 diabetes managed with diet alone

• For worsening glycaemia, consider the introduction of medication and symptomatic management of hyperglycaemia.
• During inter-current illnesses, consider SMBG (refer to the NDSS website for necessary forms).
• People with type 2 diabetes may have impaired body systems that will make recovery slower.
• In addition, people may become dehydrated because of the osmotic diuresis.

Type 2 diabetes managed with oral or non-insulin glucose-lowering medication

• Worsening glycaemia may require urgent review by the GP or referral to a specialist diabetes service or hospital emergency department, or contact with an endocrinologist.
• Additional insulin (short-acting or prandial) may be temporarily required for persistent and extreme symptomatic hyperglycaemia (≥15 mmol/L), which may also require hospital admission.
• In people with nausea, vomiting and/or diarrhoea:
  • consider temporarily stopping metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs). Metformin may aggravate these symptoms, and GLP-1RAs may aggravate nausea or vomiting. There may be a risk of acute renal impairment due to dehydration
  • review and cease SGLT2i, metformin and GLP-1RAs if acute gastrointestinal illness is present because these medications may further aggravate dehydration and hypovolaemia.
  • note that DKA/euglycaemic DKA¹³ should be considered in people who are taking SGLT2i if they display abdominal pain, nausea, vomiting, fatigue or metabolic acidosis.⁵ Advise on the timely assessment for blood ketones using a home ketone monitor.

Type 2 diabetes managed on insulin

• All people should commence SMBG and, if needed, have adequate insulin delivery devices and pen needles and be advised to seek an urgent review by their GP or health professional when unwell or if their blood glucose is >15 mmol/L on two consecutive SMBG readings (at two hours apart), as per the action plan. Assess blood ketones in this setting if the person is using SGLT2i or they are pregnant.
• Blood glucose monitoring should be increased to every two to four hours if unwell. People on insulin may need to increase their morning intermediate or long-acting insulin dose by 10–20% if the glucose reading remains elevated and, depending on further blood glucose levels, modify subsequent doses of short-acting insulin during the day. For people on ultra-long-acting basal insulins, including glargine U300 or degludec insulins, GPs may need to seek advice from an appropriate specialist regarding dose adjustment because dose changes may take four to seven days to take effect. Advice on the additional use of oral agents and GLP-1RAs is listed in Table 1.
• Additional blood ketone testing (with appropriate self-monitoring equipment) may be incorporated if the person is using an SGLT2i, if there are symptoms suggestive of ketosis (eg nausea, vomiting, shortness of breath or fruity odour, abdominal pains, altered consciousness) or there is a history of DKA (refer to Emergency management of hyperglycaemia in primary care¹³). This should be a documented strategy in the person’s sick-day management plan
• Note that many people are only on basal insulin or a premixed insulin with oral medications. These people require appropriate medical advice, and may need acute medical advice or a prescription for additional rapid-acting insulin to use as a supplemental insulin dose.1 If uncertain, consult an appropriate specialist.
• People with gastrointestinal upset who are not eating, but who feel well and continue their usual activities, may need to reduce their insulin according to SMBG readings (especially rapid-acting insulin) to avoid hypoglycaemia. For more information, refer to the NDSS clinical guiding principles for sick-day management.

 

Table 1. Action plan for management of sick days in people with type 2 diabetes1,20
Commence action plan	Commence: when a person starts to feel unwell for any reason or if blood glucose is >15 mmol/L on two consecutive readings
Frequency of blood glucose monitoring	Monitor every 2–4 hours, or more frequently if blood glucose is low Ketones to be assessed with persistent hyperglycaemia ≥15 mmol/L on two occasions, two hours apart if using SGLT2i or the person is pregnant
Medication	Continue insulin or diabetes medications, but assess use of metformin, SGLT2i (dapagliflozin or empagliflozin) and GLP-1RAs, which may require cessation if vomiting or dehydration is a concern and recommenced once symptoms have ceased. Also review other medications, such as NSAIDs, sulfonylureas, ACEi/ARBs and diuretics
Food and water intake	There is potential increased risk of hypoglycaemia from insulin and sulfonylureas if appropriate intake of meals is not maintained People should try to maintain their normal meal plans if possible Fluid intake (eg water or oral rehydration solutions) should be increased to prevent dehydration, if appropriate Advise about alternative easy-to-digest foods, such as soups, if the person cannot tolerate a normal diet (some non-diet soft drinks may provide essential carbohydrate in this situation) If the person is vomiting or has diarrhoea, SGLT2i, GLP-1RAs and metformin should be reviewed or temporarily ceased and appropriate alternative glucose-lowering therapy be advised. Review doses of ACEi/ARBs and diuretics If illness is causing loss of appetite and a marked reduction of carbohydrate intake, SGLT2i should be ceased due to elevated DKA risks If blood glucose is >15 mmol/L, use non-glucose-containing fluids for hydration (assess for ketones if persistent) If blood glucose is <15 mmol/L, use oral rehydration solutions (may contain glucose) if needed If unable to tolerate oral fluids and blood glucose continues to drop, advise them to seek medical care
Seek assistance	Individuals and support people need to assess whether the person is well enough or able to follow the plan; if they are not well enough, they should call for help or attend hospital Recommencement of oral intake/normal diet may allow the re-introduction of diabetes medications
ACEi, angiotensin-converting enzyme inhibitors; ARBs, angiotensin II receptor blockers; GLP-1RAs, glucagon-like peptide-1 receptor agonists; NSAIDs, non-steroidal anti-inflammatory drugs; SGLT2i, sodium–glucose cotransporter 2 inhibitors.

Multiple issues affect sleep in people with diabetes and assessment of sleep hygiene and quality should be considered. Counsel people with diabetes to practice sleep-promoting routines and habits (eg maintaining a consistent sleep schedule and limiting caffeine in the afternoon).⁴ Diabetes management, such as hypoglycaemia, may affect sleep, and the presence of associated diabetes distress or depression impacts on being able to maintain healthy sleep. Obstructive sleep apnoea is linked to overweight and obesity and remains the most prominent sleep condition affecting many people with diabetes. Using appropriate sleep assessment tools (eg Epworth Sleepiness scale, OSA50 or STOP BANG) and referral to sleep specialists may be required.²¹

People with diabetes should be seen several weeks before surgery for assessment of glycaemic management and anaesthetic suitability, including their cardiovascular disease risks, and any treatment modifications instituted and stabilised from the time of referral before proceeding to surgery.

Attaining glycaemic goals (ie a glycated haemoglobin [HbA1c] approaching 7% [53 mmol/mol]) in the preoperative period has been shown to result in fewer complications and shorter hospital stays after surgery.²² A patient with an HbA1c ≥9% (75 mmol/mol) may need to have their surgery delayed until glycaemic management is optimised.²²

Preoperative care is the same for minor and major surgery. For prolonged procedures, blood glucose levels should be monitored intra- and postoperatively for several days.

Insulin may be required postoperatively for some people with type 2 diabetes.

Further information can be found in the Australian Diabetes Society’s Peri-operative diabetes management guidelines²² and the Australian Diabetes Society alert regarding DKA with SGLT2i use in people with diabetes.⁵

Rural GPs who perform operations and GPs who administer anaesthetics should refer to the Peri-operative diabetes management guidelines²² to guide the advice they give to people in their care.

In practice

Ceasing medication before surgery

Appropriate written instructions should be given to people beforehand.

People who are prescribed oral glucose-lowering medications except SGLT2i, and people on injectable GLP-1RAs:

• can continue their diabetes medications on the day prior to surgery (be aware that gastric emptying is affected by GLP-1RAs and this may affect anaesthetic risks; also note that ceasing weekly dosed agents may not alter these risks due to their long drug half-lives, so notify anaesthetic teams preoperatively if they apply to any clinical case)
• should omit their oral glucose-lowering medications on the morning of surgery, regardless of whether they are on the morning or afternoon list.

SGLT2i should be reviewed prior to surgery and procedures that require one or more days in hospital and/or require bowel preparation, including endoscopy/colonoscopy (two days prior to and the day of the procedure), to prevent DKA in the perioperative period.⁵ Other glucose-lowering medications may need to be increased in this period.⁵

Specifically, with SGLT2i use, the Australian Diabetes Society has guidelines for temporary cessation prior to procedures (noting that other glucose-lowering medications may need adjustment to variable glucose levels) as follows:⁵

• For surgery and procedures requiring one or more days in hospital, omit SGLT2i for at least three days (ie two days before the procedure and on the day of procedure). This may require increasing other glucose-lowering drugs during that time. If the SGLT2i is part of a fixed dose combination, this will lead to withdrawal of two glucose-lowering drugs unless the second drug is prescribed separately.
• For surgery and procedures including colonoscopy requiring bowel preparation with carbohydrate restriction commencing on the day prior to the procedure, omit SGLT2i for at least three days (i.e. two days before and on the day of the procedure).
• For day-stay procedures (including gastroscopy) that do not require bowel preparation, SGLT2i can be stopped just for the day of the procedure. However, fasting before and after the procedure should be minimised.

Insulin and surgery

Insulin requires individualised advice as follows, and is usually not completely omitted (never withhold basal insulin):

• long-acting (basal) insulin – continue as usual (including morning doses)
• rapid/short-acting (prandial) insulin – omit rapid/short-acting insulin if not eating; depending on timing of procedure:
  • morning procedure: withhold rapid/short-acting insulin (and all oral glucose-lowering medication)
  • afternoon procedure: take half the normal morning rapid/short-acting dose in the morning before a light breakfast
• premixed insulin – take one-third to half the usual morning dose on the day of the procedure.

People taking intermediate-acting (basal) insulin who are booked for afternoon procedures or are on prolonged fasting may need a reduced dose. Seek specialist endocrinology and anaesthetic advice before planned procedures.

People on a multiple daily insulin regimen might require perioperative glucose infusion and associated close blood glucose monitoring. Many hospitals have a protocol or working plan that should be followed for the individual in that service.

Insulin may be recommenced with oral intake, with appropriate SMBG to guide dose adjustments.

Recommencing oral medication

People on oral glucose-lowering medication, with the exception of SGLT2i, can generally recommence medications when they are able to eat meals. Specific advice is available in Australian Diabetes Society’s Peri-operative diabetes management guidelines.²²

SGLT2i should only be recommenced postoperatively when the person is eating and drinking normally or close to discharge from hospital. People who have had day surgery should only recommence SGLT2i once they are on full oral intake. It may be prudent to delay recommencement for another 24 hours; however, this must be balanced against the risk of hyperglycaemia.⁵

Metformin can generally be recommenced 24 hours after major surgery, provided there has been no deterioration in serum creatinine.²² For people using metformin and SGLT2i pre- and postoperatively, the maintenance of hydration and carbohydrate intake is important.

People undergoing colonoscopy

For colonoscopy preparation, Colonlytely or Glycoprep (rather than Fleet or Phosphoprep) should be used in people with renal impairment, who may become severely hyperphosphataemic with phosphate preparations.²³

The dietary modifications that are advised for colonoscopy preparation might alter glucose management and hypoglycaemic risks; instruction on appropriate SMBG testing may be required. It is also essential to avoid excessive carbohydrate restriction during the bowel preparation period if the person has been using SGLT2i.

On preparation days and the day of the procedure, commence SMBG and withhold all oral medications. Note that SGLT2i should be ceased three days before colonoscopy and only recommenced when the person is eating and drinking normally.⁵

Basal and/or rapid-acting insulin should be managed as above.

Premixed insulin should be managed as follows:

• on the day of bowel preparation, reduce premixed dose by half for all doses
• on the day of the procedure, arrange a morning procedure and use half the usual dose and glucose infusion.

Disability and diabetes

Among those aged over 50 years, people with diabetes had reduced life expectancy (–4.6 years), developed disability earlier (6–7 years) and lived longer in states of disability (1–2 years) than people without diabetes.²⁴ People with diabetes have increased odds ratios for mobility-related disability (1.71) and impaired basic activities of daily living (1.82).²⁵ The disability associated with diabetes may be related to vascular, neurological, cardiac and renal impairments and appears to be related to diabetes duration.^26,27

Fracture risk is elevated in people with type 2 diabetes independent of the presence of osteoporosis.⁷ For more information on osteoporosis, refer to Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age.²⁸

People with diabetes have a higher risk of falls, especially those using insulin or sulfonylureas compared with those not using these agents.^29,30

Longer-term lifestyle interventions, including physical activity and weight reduction, have been shown to reduce long-term disability.³¹

Cognitive decline and dementia

People with type 2 diabetes have twice the rate of cognitive decline as they age than people without diabetes. Increased rates of all-cause dementia, Alzheimer’s dementia and vascular dementia (1.5- to 2-fold risk) are independently associated with type 2 diabetes.³² Conversely, people with Alzheimer’s disease have twice the rates of type 2 diabetes and impaired glucose tolerance than those without. The exact underlying mechanisms are not yet proven, but unstable glycaemic management (including glycaemic variability), increasing age, depression and vascular complications have been observed to increase risk of dementia in type 2 diabetes and decrease cognitive performance.^33–35

Hearing and sensory impairment

Hearing impairment is twice as common in people with than without diabetes across frequency ranges, and occurs often in younger people with diabetes. Risk factors include hyperlipidaemia, coronary heart disease, peripheral neuropathy and general poor health, but an association of hearing loss with blood glucose levels has not been consistently observed. Accompanying Impairments in smell, but not taste, have been reported in people with diabetes.^36–40

Diabetes is identified as one of the medical conditions that may impair driving ability. Impairment can be caused by:

• unexpected hypoglycaemia for drivers on insulin or sulfonylureas (main hazard)
• sensory or end-organ complications, particularly reduced vision or reduced sensation in the feet
• other comorbidities, such as sleep apnoea and cardiovascular problems.

Drivers with diabetes must meet specific national standards to ensure that their health status does not increase the risk of an accident. However, GPs should be aware that there are variations to these standards in individual states and territories, and should check with the relevant transport authority.

In practice

National medical standards for private and commercial licensing and a table to assist with the management of diabetes and driving (section 3.3.2) are found in Austroads’ and the National Transport Commission’s Assessing fitness to drive.⁴¹ This document was updated in 2022. Note that HbA1c measurements are not used to assess fitness to drive, and, for clarity, all references to HbA1c have been removed.

Private licences

• People taking glucose-lowering medications other than insulin do not necessarily require a conditional licence; however, they must have a medical review by their treating doctor every five years.
• People on insulin may have a conditional licence, requiring a two-yearly review. This must be granted as outlined in the national medical standards, with similar criteria as above.

For more information refer to Austroads and the National Transport Commission Assessing fitness to drive.⁴¹

Commercial licences

People with diabetes on any form of glucose-lowering therapy, including insulin, may be granted a conditional commercial licence. Specialist referral is required.

This licence is subject to yearly specialist review; if the person is on metformin alone, this review may be performed by the treating GP, by mutual agreement with the treating specialist. However, the initial recommendation of a conditional licence must be based on the opinion of a diabetes specialist.

Severe hypoglycaemia

The minimum period of time before returning to drive after an episode of severe hypoglycaemia is generally six weeks. A specialist’s assessment and agreement is required for all licencing categories.

Consumer education and resources

The NDSS’s consumer booklet Driving and diabetes⁴² provides a checklist and offers advice for people with diabetes to ensure that they have safe blood glucose levels before they drive.

The importance of taking extra precautions to maximise road safety and reduce the risks of road accidents caused by hypoglycaemic incidents is highlighted and should be actively promoted.

For example, drivers are required to perform a blood glucose check before they drive, and again during the journey if driving for more than two hours.

People with diabetes can travel safely, provided a few extra precautions are taken and the travel is planned.

Those not using insulin generally have few problems during travel. Immunisation status should be reviewed and updated prior to expected travel. The stress of travel may increase blood glucose levels slightly. The decreased activity experienced during a long plane trip, together with the amount of food given en route, often results in increased blood glucose levels. Increased activity and altered eating patterns on travelling to different destinations may also induce glucose variability and risks for hypoglycaemia. Glucose levels should return to normal once a more usual lifestyle has been resumed at the destination.

People should ideally have a medical consultation at least six weeks before the proposed travel, particularly if they are on insulin. This allows time to assess management and alter management as required. People might benefit from referral to a credentialled diabetes educator to go through their travel plans and help prepare a detailed travel management plan, including sick-day management and the use of SMBG.

Before travelling, people should:

• check routine immunisation status and other medical conditions
• obtain a covering letter from their doctor (refer below)
• pack extra food (if allowed by customs) and double the quantity of supplies of medication and monitoring equipment, dividing them between different luggage/bags in case one is lost or stolen (it is not advisable to pack extra insulin in checked-in luggage because insulin exposed to extreme temperatures of the cargo hold will lose efficacy)
• get advice about specific insurance needs
• familiarise themselves with Australian/other air security guidelines (refer below).

Travelling by air: Security guidelines

Australian air authorities stipulate the following security guidelines. If the person is not using an Australian carrier, it is advisable that the person checks with the chosen airline for applicable security guidelines.

• All diabetes supplies, including equipment, insulin and glucagon-delivery devices (eg syringes, pen needles, insulin pump consumables), carried on board must be in the hand luggage of the person who has diabetes and whose name appears on the airline ticket.
• The traveller’s name should appear on the oral medicines, insulin and/or glucagon prescription labels.
• It is advisable to carry legible prescriptions for all medications. The prescriptions must include the traveller’s name, the name and type of medication and the contact details of an attending medical practitioner.
• The NDSS card is accepted as primary proof that a person with insulin-treated diabetes needs to carry their diabetes equipment (eg insulin pen, pump, syringes, needles and glucagon kit) with them. Supplementary photographic proof of identity, such as a driver’s licence, may also be requested.
• It is advisable to carry a letter from the attending medical practitioner that outlines medical diagnoses, prescribed medications, whether insulin is used and, if so, the delivery device/s. The letter must stress the importance of the person having to carry medications with them and include the frequency of dosage. For those using an insulin pump, the letter must stress the need for the pump to be always worn.
• Some international regulations set limits on fluid containers that may be personally taken on board aircraft. People with diabetes who need to carry supplies of insulin are exempt. They will be required to present the insulin at the security point and carry proof of their condition and need for insulin.
• People wearing electronic devices to monitor blood glucose levels or to infuse insulin should check with the airline as to whether these devices can be operated during the flight.

Rights of people with diabetes during security check

People with diabetes who use an insulin pump are not required to remove their pump at the security point. If the security staff request this, the person with diabetes has the right to request access to a private consultation room, which security staff are required to provide. People with diabetes are also entitled to make this request if discussion about their condition is required.

For more information about travel and diabetes, consult the travel advice on the websites of Diabetes Australia and the Department of Home Affairs.

Insurance of all types may be an area difficult to navigate for people with diabetes and comorbidities. Diabetes Australia⁴³ can provide advice about rights, responsibilities and other tips regarding:

• private health insurance
• life and disability insurance
• income protection
• travel insurance.

People with type 2 diabetes, including those who use medication, can participate in recreational scuba diving. They must be otherwise qualified to dive and meet several criteria as outlined in the consensus guidelines for recreational diving with diabetes that were developed in 2005.⁴⁴

When evaluating people with diabetes for medical fitness to dive, first ensure that no other exclusionary conditions (eg epilepsy, pulmonary disease) exist.

The physiological demands of diving must then be considered. People with diabetes are at higher risk than the general diving population of medical complications such as myocardial infarction, angina and hypoglycaemia.

The Australian Diabetes Society has recommendations for people with insulin-treated diabetes regarding suitability for diving, the scope of diving and blood glucose management on the day of diving.⁴⁵

Fasting during Ramadan is one of the five pillars of Islam, and all healthy adult Muslims are obliged to refrain from eating and drinking from sunrise to sunset during this lunar month. The fast may last 11–19 hours, depending on where and at what time of year Ramadan occurs. People with an acute illness, such as influenza, may postpone fasting to other days when their acute illness has resolved. People with chronic illnesses, such as diabetes, are not obliged to fast and are able to donate to a charity as atonement; however, many still choose to fast.

Some Muslim people with diabetes might be more inclined to discuss fasting during Ramadan with their local imam rather than their GP; GPs may therefore need to ask people specifically whether they intend to fast.⁴⁶

The main concern for diabetes management during Ramadan is hypoglycaemia. Fasting can disrupt normal glucose homeostasis and lead to serious consequences. People who choose to fast should be warned of these complications. Regular monitoring of glucose may be required for people with diabetes using sulfphonylureas, insulin or feeling unwell with or without hypoglycaemia.

People in the very high- or high-risk groups shown in Box 1 should be actively discouraged from fasting during Ramadan.⁴⁶ This includes people at high risk of hypoglycaemia.

A post-Ramadan GP assessment is recommended.

Taking oral glucose-lowering agents during Ramadan

Guidelines recommend therapeutic choices to help minimise the risk of hypoglycaemia during Ramadan.^46,47

Insulin use during Ramadan

People taking insulin who wish to fast during Ramadan should have renal and liver function tests ordered, because both renal and hepatic impairment may precipitate or prolong hypoglycaemia in people with diabetes.

People taking insulin should be instructed on SMBG and individual adjustment of insulin doses based on glucose goals discussed before commencing Ramadan.

People taking the long-acting basal insulin analogue glargine have been shown to be able to fast safely with no significant increases in hypoglycaemic episodes.⁴⁶ Rapid-acting (meal-time) insulin should be given at fast-breaking evening meal-times.

If weight loss occurs due to fasting, people may need a reduction in basal insulin dose in the second half of the Ramadan period.

People with type 2 diabetes on premixed insulin twice daily should reduce the morning breakfast dose by 25–50% and take the normal evening dose with their sunset fast-breaking meal.⁴⁶ If postprandial hyperglycaemia develops as a result of the larger-than-usual sunset meal (iftar), which breaks the day’s fast, then consider changing the premixed insulin to 50:50 (for people on 30:70 or 25:75 premixed insulin). Alternatively, the premixed insulin dose can remain the same, with additional rapid-acting insulin given to cover the iftar meal. Rapid-acting insulin might also be required for people who have an additional evening meal before bedtime, when iftar is early.

Because eating patterns can vary significantly from person to person during Ramadan, GPs should develop individualised plans for insulin use for each person.

The British Islamic Medical Association provides useful information in its Ramadan compedium,⁴⁸ in particular a risk stratification table that includes a summary by condition/disease.

The Australian Diabetes Society has published the Management of people with diabetes who choose to fast during Ramadan position statement.⁴⁹

Exercising and diet during Ramadan

Regular or light exercise is allowed during Ramadan and should be encouraged. However, care should be taken to avoid hypoglycaemia and dehydration.⁴⁶ This is particularly an issue when Ramadan falls in summer months, due both to the higher ambient temperature and the greater number of daylight hours.

People should try to divide their daily calories between the breakfast (suhoor) the iftar meal. They should try to eat a well-balanced diet consisting of foods with a, low-glycaemic-index that are high in fibre, such as fruits and vegetables. 

Diabetes UK has information about fasting during Ramadan for people with diabetes and for imams.

Sick-day management
The NDSS and Australian Diabetes Educators Association have resources regarding sick-day management.

The Victorian Virtual Emergency Department (VVED) allows you to access urgent diabetes care 24 hours a day, seven days a week. The program is now open to all patients across Victoria.

Surgery
The Australian Diabetes Society has published the Peri-operative diabetes management guidelines and advice on use of SGLT2i perioperatively.

Dementia and diabetes
The British Journal of Diabetes has published and article on the Management of diabetes and dementia.

Trend Diabetes has published the For healthcare professionals: Diabetes and dementia: Guidance on practical management, which includes practical management of diabetes and dementia.

Driving
The NDSS has published the Driving and diabetes consumer booklet.

Austroads has published Assessing fitness to drive.

Diabetes and Ramadan
The Australian Diabetes Society has published a position statement on the Management of people with diabetes who choose to fast during Ramadan.

The International Diabetes Federation and the Diabetes and Ramadan International Alliance have published Diabetes and Ramadan: Practical guidelines 2021.

Diabetes UK has information about fasting during Ramadan for people with diabetes and imams.

The British Islamic Medical Association has published the Ramadan compendium,⁴⁸ which contains a risk stratification table that includes a summary by condition/disease.