Type II diabetes mellitus: Dutch family doctor standard
The proposed standard contains recommendations for the family doctor regarding the diagnosis, treatment and management of patients with type II diabetes mellitus who are not using insulin. In principle, a family doctor can independently provide the patient with full assistance.
The standard does not stipulate in which situations specialist consultation is necessary, since this issue can only be resolved on the basis of specific circumstances. Tactics for intercurrent diseases and diabetic complications are also not considered. Thus, the standard defines only a general approach to the diagnosis, treatment and management of patients with type II diabetes.
Diagnosis and treatment of type II diabetes mellitus in principle does not require special knowledge and equipment for examination.
The proposed tactics are based on modern scientific knowledge, and many doctors consider it practicable.
Cases when the data of the specialized literature are insufficient or contradictory are specially negotiated.
In such cases, tactics will be largely determined by the personal initiative of the family doctor.
The necessary conditions
A family doctor, as a rule, can independently treat and manage patients with type II diabetes mellitus. For this, the following aids are needed.
• A reflectometer for determining the glucose content in capillary blood. Quantitative definitions needed; if the doctor can conduct them on their own, then the determination can be done every 3 months at the next follow-up visit, which will be an additional stimulator for the patient to cooperate.
• Quetelet scale for quick determination of the Quetelet index (body weight in kilograms / body length in meters, multiplied by 2), which is an objective indicator of the presence of excess body weight.
• Nomogram to simplify the calculation of creatinine clearance based on its blood level, body weight and age.
• Special strips for detecting protein in the urine; these strips are used in the control every 12 months.
Urine ketone detection strips in combination with blood and urine glucose tests can be useful for differentiating conditions such as hungry acidosis, threatening ketoacidotic coma, and threatening hyperosmolar coma.
Regarding the organization of practice, the following recommendations can be made.
• Separate registration cards must be set up, such as a special registration card for type II diabetes. This saves time, makes maintenance more panoramic and complete.
• A system of prior arrangements is needed so that patients know when they should come.
• An assistant can perform control determinations (body weight, blood pressure, blood glucose and urine protein).
The appropriateness of special reception hours for monitoring patients with diabetes, for example, one hour per week, should be assessed.
The tasks of the family doctor include the diagnosis, treatment and monitoring of patients with type II diabetes.
An important role in the implementation of these tasks is played by the timely receipt of information.
The diagnosis of diabetes is based on a pathologically elevated blood glucose. Determination of glucose in urine is not suitable for diagnosis and control; however, glucosuria is an indication for determining glucose tolerance.
The following values are valid for capillary blood; when it is taken, an injection is best done on the side of the fingertip.
At present, the bulk of specialists agree to consider normal the values determined by WHO (from 1985); we bring them here.
Normal glucose is less than 5.5 mmol / L on an empty stomach and less than 7.7 mmol / L 2 hours after a load of carbohydrates. Above 6.7 mmol / L on an empty stomach and 11.1 mmol / L 2 hours after exercise are considered pathological. A carbohydrate-rich breakfast is served as a load (2 cups of tea with lots of sugar and 2 slices of bread with a thick layer of jam). There is no doubt about the diagnosis of diabetes in the presence of the main complaints characteristic of this disease, and when one of the indicators rises to the pathological level; or if two indicators, measured on different days, are elevated to a pathological level, even in the absence of complaints.
With a once-increased rate (unless the patient makes significant complaints), the diagnosis should not be rushed. As a first step, the administration of probable diabetic drugs can be stopped (the effect of this measure can be evaluated after about 6 weeks).
If the fasting glucose is in the range of 5.6 – 6.6 mmol / l, it is reasonable to determine its level 2 hours after exercise. If the glucose content is 7, 8 – 11 mmol / l, then the patient has impaired glucose tolerance. Annual monitoring of such patients can be recommended, with particular attention to risk factors for cardiovascular diseases, such as overweight, smoking, too high cholesterol and lack of physical activity.
When fasting glucose is less than 5.6 mmol / L, determination 2 hours after exercise is not shown: the probability of impaired glucose tolerance decreases as fasting glucose decreases.
If a diagnosis of diabetes is made, then based on the clinical picture, it is usually possible to accurately determine the type of diabetes. In doubtful cases, it is recommended to determine the content of ketones in the urine.
If this test is positive, then it will almost always be about type 1, and in this case it is recommended to refer the patient to a specialist. If ketonuria is absent, then you can try diet therapy and the appointment of oral antidiabetic drugs with careful monitoring; the stages and duration of such trial treatment depend on the specific circumstances.
If the family doctor doubts the type of diabetes, the patient can be referred to a specialist for further diagnosis.
After the diagnosis of type II diabetes mellitus, it is advisable to determine the initial situation on the basis of medical history and examination results in accordance with the control observation scheme with an interval of 12 months.
Consultation with an ophthalmologist is also necessary if the family physician himself does not have the technique of ophthalmological examination.
During treatment, 2 goals are pursued: regulation of blood sugar level, optimization of body weight. Overweight is a risk factor for patients with diabetes; weight loss has a positive effect on relative insulin resistance. How tight control of glucose and body weight should be is definitely impossible to say. It was found that vulvar itching quickly disappears with a decrease in blood sugar, while the pain resulting from the recent development of diabetic neuropathy in most cases disappears with normalization of blood sugar; in general, the connection between the strict regulation of diabetes and the occurrence of complications has not yet been clearly established. It is very important to inform the patient well and reach an agreement with him regarding the goals to be pursued. This is especially true for body weight. The use of objective criteria to detect obesity and overweight provides a more rigorous assessment of these concepts. It is most convenient to use the Quetelet index (body weight in kilograms / body length in meters, multiplied by 2). The following gradations of the Quetelet index are distinguished: more than 30 – obesity, from 25 to 30 – overweight, less than 25 – the norm. In patients with type II diabetes mellitus, one should strive for Quetelet index values less than 25; values between 25-27 may be considered acceptable. Individual selection of the diet contributes to a better patient attitude to it; in solving this issue, the help of a nutritionist is almost always necessary. We must not forget about the need to increase the level of physical activity: this has a beneficial effect on glucose tolerance.
Regarding blood sugar levels, most authors now agree that even with type II diabetes mellitus, it is necessary to strive for normoglycemia (fasting glucose is less than 6.7 mmol / l). For most family doctor patients, this goal is achievable. Depending on the age, the nature of the patient’s complaints and some other features, an empty stomach glucose may sometimes be acceptable in the range of 6.7-8 mmol / L.
Although the best test is to determine your fasting glucose level, your doctor often faces the fact that patients come to have a glucose test after breakfast. In this case, a blood sugar content of less than 9 mmol / L 2 hours after exercise is a good indicator, values within the range of 9-10 mmol / L may also be acceptable. When determining at an arbitrary time of the day and / or after an arbitrary meal, a reliable interpretation of the results is impossible, mainly at lower rates. Carbohydrate-rich breakfast is preferred; if it is difficult to realize, then the load in any case involves a plentiful meal.
The lower limits of the blood glucose level are not given here, because they have practically no clinical significance: individual variations of the boundary values (below which hypoglycemic complaints may occur) are very wide.
In older people, these targets are quite difficult to achieve. It is recommended to adhere to the indicated scheme until approximately 75 years of age; the treatment regimen for patients older than 75 years mainly depends on the presence or absence of complaints.
The normalization of blood glucose with diet therapy, which in most cases is aimed at reducing body weight, deserves preference. It is not right to start medication immediately. It is not precisely established how long an elevated blood glucose level in an elderly diabetes patient may be considered acceptable.
At present, it is recommended that with overweight, medication should be started no earlier than 6 months after diagnosis, unless, despite adequate measures, the blood glucose level remains very high and the family doctor does not expect improvement without medication.
In patients older than 75 years, one should not strive for strict control of glucose levels; The indication for prescribing medication to such patients is mainly the presence of complaints persisting despite a diet and lifestyle changes.
Regular lifestyle patients rarely need medication for 6 months due to persistent complaints: even a very slight decrease in blood sugar at high initial levels usually entails a rapid decrease in the severity of existing complaints.
The question remains whether to give preference to oral medications or insulin.
The most acceptable and widely used treatment regimen is as follows.
They start with tolbutamide (orabet) at 500 mg per day: if necessary, increase this dose by 500 mg every 4 weeks to a maximum level of 2 g per day. If this treatment is not effective enough, tolbutamide is replaced with a second-generation sulfonylurea derivative [glibenclamide (daonil), glyclazide (diabetone) or glipizide (glurenorm)], if necessary, the dosage of these drugs also gradually increases every 4 weeks to a maximum level. If this medication is also ineffective, then metformin (glucophage) can be prescribed (from the biguanide group); they also start with 500 mg per day and, if necessary, increase the dose by 500 mg every 4 weeks to the maximum dosage (850 mg 3 times a day). If a satisfactory result is still not achieved, then, in principle, insulin treatment is indicated; however, in some situations, despite the unsatisfactory results when using oral medications, a decision is made not to switch to insulin treatment (for example, in patients older than 75 years).
Of course, with any medication, contraindications, the possible interaction of drugs and other factors must be taken into account.
Monitoring is not only necessary to control blood sugar levels and possible complaints. Mortality of diabetes patients from cardiovascular diseases is increased: it is therefore important to control the risk factors of cardiovascular diseases. If the patient’s diabetes is well controlled, then monitoring every 3 months is sufficient; these visits take on average no more time than a regular consultation.
Once a year, an extended examination is performed, during which they pay attention to some specific points. If there are complaints and / or unstable blood sugar levels, the contacts between the doctor and the patient become even more frequent; with high blood pressure or very high cholesterol, control is also necessary more often than once a year. On the other hand, self-monitoring can reduce the number of visits to the doctor.
• Every 3 months Determine (mainly on an empty stomach) the glucose content in the blood, as well as body weight; You can also arrange for the patient to be weighed at home and tell the doctor the result.
It goes without saying that the doctor asks about well-being and complaints. It is recommended that you discuss issues such as reducing or increasing body weight, problems with dieting or taking medications. It should be clarified how much the recommendations given by the doctor are feasible in everyday life.
This aspect is extremely important: the patient’s management is aimed at correcting his lifestyle, taking into account the existing disease, if necessary.
• Annually Once a year, extended controls are performed. In addition to general well-being, the doctor finds out if there are specific diabetic complaints, such as thirst, polyuria, genital itching, or signs that may indicate the development of chronic complications: limb pain and / or twitching, sexual dysfunction, complaints of decreased visual acuity, complaints characteristic of angina pectoris, and complaints of intermittent claudication. In some cases, improving diabetes control results in less complaints.
In addition to correction of body weight, diet and possible medication, important aspects such as smoking and the level of physical activity are also discussed.
Even if the patient does not complain, a general examination should systematically look for signs of diabetic complications. Examine the feet (color and condition of the skin, possible infections), determine the condition of peripheral vessels (pulsation of a.dorsalis pedis) and monitor the Achilles tendon reflex. This allows you to identify developing ischemia and / or neuropathy. It turned out that the determination of vibration sensitivity is not a reliable method for detecting neuropathy.
Blood pressure control and, if necessary, treatment of hypertension are very important, because the combination of diabetes and hypertension is especially unfavorable. With annual monitoring, body weight is recorded.
In addition to determining the level of glucose in the blood, several other laboratory tests are performed: the concentration of creatinine, cholesterol and protein in the urine is determined. Based on the level of creatinine, using its nomograms, its clearance is determined and, depending on the result, the dosage of medications is changed. In isolated cases, this method allows to identify renal failure.
The cholesterol content allows you to clarify the risk profile of a patient with diabetes, on the basis of which nutritional recommendations can be given or the treatment regimen can be changed. In elderly patients, the determination of cholesterol level does not need to be repeated annually if normal values were obtained with two determinations.
By detecting protein in the urine, incipient nephropathy can be detected; in this case, blood pressure should be regulated very carefully.
Periodic determination of the content of HbA1c or fructosamines is not yet recommended: these definitions are uninformative or practically uninformative.
Ophthalmological examination should be carried out once in 1 – 2 years. The patient is referred to an ophthalmologist if the family doctor himself does not know the technique of this examination.
Education for diabetes is very important and should be part of each consultation, as the patient himself can greatly influence the course of the disease.
In addition to information about the course of the disease, the prescribed treatment and the significance, nature and purpose of control, the following questions can be discussed with the patient.
• Prognosis, late complications and how to prevent or delay their development.
• Caring for the feet. This is especially important for patients with signs of ischemia and / or neuropathy: adequate prophylaxis, which does not necessarily take a lot of time from a family doctor, can significantly reduce the frequency of foot amputations in patients with diabetes.
• Signs of inadequate diabetes control and patient action in this situation.
• Special circumstances, such as illness, travel, sports.
The possibility of self-control.
Mental and social consequences.
It is best to discuss these issues not all at once, but gradually, devoting time to this at each patient visit.