Endocrinology Internal Medicine

Type 2 Diabetes Mellitus (DM2) in primary care

Type 2 Diabetes Mellitus (DM2)
Encouraging patients to adher to proper glucose level regulating interventions is very important in diabetes.

Introduction – Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a growing disease and the prevalence today is about 4-5% of the population. In addition, 10-15% suffer from a precursor stage increasing risk of developing the condition. Women who have had gestational diabetes also belong to this high-risk group.

Underdiagnosement is a large problem as only about 2/3 of all patients with type 2 diabetes are properly diagnosed and receive treatment. Because the symptoms can be diffuse, the disease is often detected by chance, or by screening patients with known risk factors. The risk of getting sick increases with age. Women and men are equally affected.

Type 2 diabetes is part of the metabolic syndrome and involves an increased risk of serious sequelae such as renal impairment, cardiovascular disease, and premature death. It is of great importance to identify and treat patients at an early stage.

Primary care has the main responsibility for the diagnostics, treatment, and follow-up of adult patients with type 2 diabetes. Particularly complicated or difficult cases, all children and adolescents, as well as patients with type 1 diabetes and more unusual forms of the condition, are managed at specialist level in hospitals.

Treatment should aim to reduce the patient’s overall cardiovascular disease risk factors, by achieving nationally defined target values ​​for glucose control, blood lipids, and blood pressure.


Risk Factors – Type 2 Diabetes Mellitus

  • Lifestyle factors regarding diet, low physical activity, high alcohol consumption, smoking, stress
     
  • Hypertension, hyperlipidemia, obesity, abdominal obesity ( metabolic syndrome )
     
  • Older patients
     
  • Impaired glucose tolerance (IGT)
     
  • Gestational diabetes
     
  • Family History. To date, more than 40 risk genes have been identified
     
  • Depression

Etiology – Type 2 Diabetes Mellitus

  • Chronic hyperglycemia secondary to insulin resistance, or decreased sensitivity to insulin in the target organs, muscles, liver and adipose tissue.
     
  • After about 10-15 years of disease duration, there is usually also reduced production and/or reduced release of insulin from the pancreas.

Diagnostic Criteria

  • HbA1c ≥ 48 mmol/mol on two occasions, or 1 together with elevated β-glucose (fasting or after glucose challenge test) as follows:
  • fasting P-glucose (capillary or venous) ≥ 7.0 mmol / l on two occasions, alternatively:
  • Non-fasting P-glucose (capillary or venous) ≥ 11.1 mmol / l and symptoms of hyperglycemia, alternatively:
  • Oral glucose challenge test (measured by oral glucose tolerance test – OGTT) with 2h capillary value ≥ 12.2 mmol / l, venous value ≥ 11.1 mmol / l.
    Oral glucose loading is performed by first taking a capillary β-glucose test after 12 hours of fasting. Thereafter, the patient may drink 75 g of glucose (ordered from a pharmacy) dissolved in 250 – 350 ml of water for a maximum of 5 minutes. After 2 hours a new P-glucose is taken.

Differential diagnoses – Type 2 Diabetes Mellitus

  • Type 1 diabetes: autoimmune etiology resulting in the production of antibodies against the insulin-producing beta cells in the pancreas. Usually younger, normal-weight patients with rapid onset of disease, typical diabetes symptoms such as increased thirst/diuresis and weight loss, as well as ketonuria. Blood pressure and lipids are often within the normal range. Other autoimmune diseases may occur.
     
  • Pre-diabetes: 10-15% of the population has Impaired Glucose Tolerance (IGT) and/or Impaired Fasting Glycemia (IFG), with a high risk of developing diabetes.

    Diagnostic criteria :
    IFG (non-diabetic fasting hyperglycemia): fP-glucose 6.1-6.9 mmol / L.
    IGT (impaired glucose tolerance): OGTT (Oral Glucose Tolerance Test) 2-hour value: capillary β-glucose 8.9-12.1 mmol / L, venous β-glucose 7.8-11.0 mmol/L.
     
  • LADA (Latent Autoimmune Diabetes in Adults). Affects mainly people > 35 years . Also an autoimmune form of diabetes but slower symptom onset and disease development than type 1 diabetes. Often confused with type 2 diabetes on debut. Insulin production is retained for longer than type 1 diabetes but deteriorates faster than type 2 diabetes.
     
  • Gestational diabetes (GDM): fP-glucose 5.1 mmol / L, OGTT with P-glucose ≥ 10 mmol / l after 1h, or ≥ 8.5 mmol / l after 2h. If blood glucose is not normalized after delivery, GDM should be redefined as type 1 or type 2.
     
  • Pancreatic insufficiency: usually alcohol-induced. Can be characterized by diarrhea (sometimes steatorrhoea), weight loss, abdominal pain and bloating.
     
  • Drug-triggered diabetes (including cortisone): At the beginning of the medication course, glucose level elevations are often seen in the afternoons and evenings, while fasting glucose is normal.
     
  • Endocrine disorders such as Cushing’s syndrome that leads to overproduction of glucose-elevating hormones.
     
  • MODY (Maturity Onset Diabetes in Youth). A group of uncommon diabetic diseases caused by gene mutations inherited autosomally dominant. Debut is usually before the age of 30. Similar to type 2 diabetes with reduced insulin production, however without insulin resistance. Usually normal-weight patients without metabolic risk factors. Suspicion should be raised if insulin requirements are relatively low and GAD antibodies negative. The diagnosis is verified with DNA diagnostics at a medical clinic.
     
  • SIADH (syndrome of inappropriate secretion of ADH, including increased ADH secretion).
     
  • Genetic conditions (rare) associated with diabetes or impaired glucose tolerance.
     
  • Pancreatic cancer. New-onset diabetes may be the first symptom of pancreatic cancer.

Symptoms – Type 2 Diabetes Mellitus

Early in the course of the disease, the symptoms are usually few and cause no or minor problems. Longer duration of illness usually results in more pronounced symptomatology and can lead to complications of varying severity (see Complications section below).

  • Increased thirst
  • Increased diuresis
  • Fatigue, both physically and mentally
  • Repeated fungal infections, e.g. genital
  • Foot ulcers
  • Numbness in hands and feet
  • Vision impairment

Assessment – Type 2 Diabetes Mellitus

Medical history

  • How does the patient feel physically and mentally?
     
  • Family history of diabetes, cardiovascular disease, cerebrovascular disease, high blood pressure or hyperlipidemia?
     
  • Smoking? Previous smoker/package years?
     
  • Other diseases and drug treatments?
     
  • Social situation – especially important factor for the elderly. Does the patient need care at home?
     
  • Alcohol habits, preferably screening with AUDIT
     
  • Lifestyle; diet and exercise habits?
     
  • Cardiac and / or respiratory symptoms, such as effortless chest pain or dyspnea as signs of cardiovascular disease?
     
  • Vision problems?
     
  • Sex and cohabitation. Erectile dysfunction (ED) may be the first sign of more widespread arteriosclerosis.
     
  • At debut: Symptom development? Pregnancy? Signs of illness, such as infection or malignancy – may have triggered diabetes?

Physical Examination

  • General appearance: Nutrition status. Overweight / obesity / abdominal fat? Signs of decompensation (dyspnea, peripheral edema)? Need aids?
     
  • Mental Health
     
  • Cor / pulm : auscultation.
     
  • Blood pressure: Taken on the left arm as standard. Orthostatic blood pressure if needed.
     
  • Abdomen: Obesity? Hepatosplenomegaly? Ascites?
     
  • Extremities/Feet: Inspection. Hair? Injuries/wounds? Deformities?
     
  • Arterial insufficiency: Palpation of feet pulses, Ankle pressure (ABI) if required.
     
  • Neurology :
    Reflexes.
    Sensitivity peripheral especially hands, lower legs and feet. Vibration – tuning fork.
    Monofilament test for pressure/touch. This is done when the patient has closed his eyes. Start by testing the filament on the hand so that the person knows how it feels. Press the monofilament tip perpendicular to 3 test points under the foot (not on hardened, necrotic tissue or where there are wounds) for a maximum of 1.5 sec. The monofilament should be bent 0.5-1 cm for the correct pressure to be achieved. The patient is assessed to have a sensitivity decrease in the feet if the monofilament is not felt at >2 points on both feet.
    2-point discrimination (2-PD). Performed with sharp/blunt object (needle). Normal values ​​for 2-PD occur palm type: 0.5-1 cm, fingertips <0.5 cm, lateral forearm 4-5 cm. legs 4-5 cm, feet dorsally 2 cm and plantarly 0.5-1 cm, hallux 1cm.

Lab Tests – Type 2 Diabetes Mellitus

Below are suggestions for lab testing at debut and at follow-up.

Note that in the case of hyperglycemia symptoms or short diabetes duration, HbA1c should not be used for diagnostics. HbA1c <48 mmol/mol does not exclude diabetes. If necessary, extended or more targeted lab testing is performed.

In new cases

  • Weight, waist size and BMI
  • Fasting P-glucose, HbA1c
  • Hb
  • CRP (excluded infection)
  • Na, K, and creatinine
  • Lipid status (S-Carbon, S-Tg, S-HDL, S-LDL)
  • ALAT (liver steatosis, alcohol)
  • B12
  • ECG
  • TSH / T4

Introduce annual follow-ups

  • Weight, waist circumference and BMI
  • Fasting P-glucose, HbA1c at least 2 times/year
  • Hb
  • Na, K, and creatinine (creatine in the elderly should be evaluated every month)
  • lipids profile (S-Carbon, S-T, S-HDL S-LDL)
  • U-stick (glucose, albumin, ketones)
  • U-albumin / creat ratio in pat <70 years
  • B12 at least every two years ( metformin interferes with uptake)
  • ECG at least every five years

Follow-up – Type 2 Diabetes Mellitus

Well-treated diabetes patients are recommended annual visits to both physicians and diabetes nurses, for example, two visits to the health center per year at about six months intervals.

More frequent monitoring is recommended in new onset of disease during optimization of treatment, difficulties with metabolic control or other complications.

Lifestyle intervention and drug treatment with metformin is the first-line treatment for glucose control for the majority of patients with type 2 diabetes.

Alternatively, or when metformin is contraindicated, a number of other glucose-lowering preparations are available.

Regardless of treatment, the disease is progressive and beta-cell function in the pancreas decreases over time, which is why insulin prescription often becomes relevant after about 10-15 years of disease duration. Insulin may also be indicated directly or earlier in the course of certain situations.

In addition to good glucose control, treatment and follow-up of diabetic patients aims to reduce other risk factors for cardiovascular and kidney complications, through active treatment of hypertension, hyperlipidemia, and microalbuminuria.


Annual check-up – Type 2 Diabetes Mellitus

 Diabetes Nurse

  • Check HbA1c. If necessary, also review of self-monitoring of P-glucose curves. Hypoglycaemia?
     
  • Physical examination including blood pressure, foot examination and follow-up of waist measurements and weight changes.
     
  • Provide information on the relationship between weight and metabolic control.
     
  • Regular dietary information, as well as discussions about the importance of physical activity. Physical activity on prescription.
     
  • Support/counseling to be able to achieve the set treatment goals, after consultation with the patient and the treating physician.
     
  • Consider the need for education. Group teaching conducted by educated staff has shown a good effect.
     
  • Offer a demonstration of the glucose meter. Measurement is recommended up to 2 times/week when there is a need, or more often in insulin therapy, hypoglycemia risk in SU preparation use.
     
  • Referral to other units/specialists if needed, such as a dietician or a foot therapist.
     
  • Referral for retinal imaging is sent immediately upon new diagnosis and then at least every three years.
     
  • Planning for continued follow-up.

Physician

  • Medical history and physical examination as above.
     
  • Analyze and assess lab tests and PE findings. Follow up glucose tests (fasting blood sugar and possibly post-meal / postprandial blood sugar). Do insulin side effects occur?
     
  • Define/discuss individual goals for glucose control. Feel free to establish a care agreement.
     
  • Evaluate whether the patient achieves recommended target values ​​with regard to glucose control, hypertension, lipids, and possibly kidney effects.
     
  • If necessary, reinsert/adjust/suspend drugs.
     
  • Follow-up of waist measurements and weight changes, as well as information on the relationship between weight and metabolic control.
     
  • Regular dietary information. Talk about the importance of physical activity. Physical activity on prescription.
     
  • Inform about disease development, possible complications of the disease and the importance of glucose control.
     
  • Assess the need for referral to specialist units.

Referrals – Type 2 Diabetes Mellitus

Emergency Department

  • High glucose levels and general effects such as tachycardia, hypotonia, confusion, mydriasis etc.
     
  • In case of severe hyperglycemia without symptoms – contact a medical consultant at a hospital for advice.
     
  • In dehydration, general effects (nausea, fever, confusion, etc.) and severe hyperglycemia (without ketonuria), which raises suspicion of hyperosmolar non-ketotic syndrome (HNKS). Most often suspected in the elderly with stroke or infection. May be the first manifestation of type 2 diabetes. Diagnostic criterion: P-glucose > 33 mmol / L.
     
  • Suspicion of diabetic ketoacidosis . P-glucose ≥ 14 mmol / L, pH <7.3 and P-ketones> 3 mmol / L.
     
  • Children and adolescents with suspected diabetes, regardless of type, should be referred to the pediatric emergency room on the same day. See the link for emergency treatment.
     
  • In case of strong suspicion of new onset of type 1 diabetes.

Medical clinic

  • Difficult to treat patient who does not respond as expected to glucose, blood pressure and / or lipid therapy despite adequate medication.
     
  • Obscurity about diagnosis, suspicion of type 1 diabetes or other more uncommon forms of diabetes.

Nephrology

  • Chronic renal failure with estimated creatinine 150 µmol/l or GFR <30 ml/min and/or:
     
  • In the case of suspected kidney disease other than diabetes nephropathy, atypical course (eg increasing proteinuria and rising creatinine without retinopathy, proteinuria with hematuria), nephrotic syndrome.
     
  • Albuminuria> 3 g / day (moderate proteinuria and normal renal function is not a referral indication).

Opthalmology

Retinal imaging should be done every three years. Referral should also be written:

  • On debut
     
  • If visual impairment occurs between planned follow-ups

Diabetes foot care

  • As a rule, all foot ulcers that do not heal quickly should be assessed at diabetes foot care
     
  • Pronounced neuropathy with severe deformity and new ulcers
     
  • Critical ischemia. Circulation reduction with ankle pressure <80-100 mmHg and suspicion of gangrene
     
  • Suspected osteoarthropathy

Foot Therapeutics

  • Peripheral neuropathy and/or angiopathy with impaired peripheral circulation, foot deformities, amputation, hardening, dry skin or a previous diabetic ulcer.
     
  • Foot pulses should be palpable and ankle pressure> 80 mmHg.
     
  • Difficulties in physically managing their feet.

Dietician

In case of in-depth dietary counseling needed and/or complicating factors such as gluten intolerance, multiple comorbidities, etc.


Complications – Type 2 Diabetes Mellitus

Acute complications in type 2 diabetes are mainly hypoglycemia, and hyperglycemic hyperosmolar syndrome, ketoacidosis, lactic acidosis in metformin and normoglycemic ketoacidosis in SGLT2 inhibitor treatment. These conditions may be the result of late detection of illness, over-treatment, medication side effects and/or poorly managed diabetes.

Long-term complications arise secondary to prolonged hyperglycemia and include macro- and microangiopathy as well as neuropathy. There is an association between poorly managed diabetes (high fP-glucose and HbA1c values) and morbidity and mortality.

Untreated hypertension and hyperlipidemia also increase the risk of late complications.

Without treatment measures, late complications can cause several serious conditions such as acute myocardial ischemia, stroke, need for extremity amputations, blindness, and terminal renal insufficiency.

All in all, complications of type 2 diabetes cause both suffering, increased morbidity and mortality for patients, as well as a large cost to society.

Angiopathy

  • Micro- and macroangiopathy. Cardiovascular disease is the most common cause of death in type 2 diabetes. Macroangiopathy is usually present when the disease debuts. Coronary heart disease in combination with diabetes doubles mortality.
     
  • Eyes: proliferative retinopathy and macular edema cause visual impairment.
     
  • Feet: impaired blood circulation, often combined with decreased pain sensitivity, increases the risk of infection and poor wound healing. May result in osteoarthropathy, Charcot’s foot.
     
  • Genital: erectile dysfunction

Neuropathy

  • Peripheral neuropathy/polyneuropathy. Common symptoms include a reduced sensation of pain, temperature differences, vibration, or burning pain.
     
  • Mononeuritis more often affects patients with diabetes. Usually, n. Abducens and / or occulomotor nerves are involved.

Diabetic nephropathy

One-third of patients with type 2 diabetes have manifested diabetic nephropathy, ie albuminuria and/or renal impairment. Diabetic kidney injury is the most common cause of terminal renal failure.

Other

  • Type 2 diabetes is associated with several different cancers; eg pancreatic, liver, colorectal, endometrial and breast cancer.
     
  • Depression occurs twice as often in patients with diabetes than without the disease.
     
  • Cataracts debut earlier in type-2 diabetes. Other eye problems have also a higher incidence in patients with diabetes eg glaucoma, cranial nerve paresis, optic nerve involvement, pupil disorders etc.
     
  • Patients with diabetes are at increased risk for periodontitis and teeth loss.
     
  • Disorders of the musculoskeletal system with reduced range of motion in joints due to stiffness of the connective tissue (eg increased frequency of Dupuytren’s contracture , Frozen shoulder etc), are more commonly seen in patients with diabetes.

Prognosis – Type 2 Diabetes Mellitus

Patients with type 2 diabetes generally have a high risk of suffering from serious sequelae and premature death.

Complications can be prevented by early diagnosis of (pre) diabetes and adequate treatment of glucose levels and other risk factors such as hypertension and hyperlipidemia.

Mortality in diabetes has been declining in recent years, which can be partly explained by earlier detection and treatment. The increased prevalence of diabetes in recent years is believed to be associated with reduced mortality of the disease, ie patients with type 2 diabetes are living longer.


Further Reading