• 22,000 people with diabetes die early every year.
• Type 2 diabetes is a leading cause of preventable sight loss in people of working age.
• It is a major contributor to kidney failure, heart attack, and stroke and lower limb amputation.
  
• One in six of all people admitted to hospital for other factors also have diabetes.
  
• Type 2 diabetes treatment accounts for just under nine per cent of the annual NHS budget. This is around £8.8 billion a year.
  
• There are currently five million people in England at high risk of developing Type 2 diabetes. If these trends persist, one in three people will be obese by 2034 and one in 10 will develop Type 2 diabetes.
  
• Type 2 diabetes is more common in people of African, African Caribbean & South Asian family origin.

Type 2 diabetes is a chronic metabolic condition characterised by insulin resistance. There is a decrease in pancreatic B cell function which increases the glucose levels in the blood.

Type 2 diabetes is normally diagnosed when the B cell function is less than 50%. This will continue to fall regardless of treatment.

Usually type 2 is diagnosed by diabetes symptoms, such as polyuria (excessive urination), polydipsia (excessive thirst) and polyphagia (increase in appetite). It can also be picked up during routine medical screening for example blood tests, urine test.

Diabetes screening tests include:

Fasting Glucose test (FGT)

A fasting glucose test will measure the Glycosylated haemoglobin (HbA1C) levels in the red blood cells. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, is considered as diabetic.

The World Health Organisations defines the following fasting glucose test results:

• Normal: Below 5.5 mmol/l (100 mg/dl)
• Impaired fasting glucose: Between 5.5 and 6.9 mmol/l (between 100 mg/dl and 125 mg/dl)
• Diabetic: 7.0 mmol/l and above (126 mg/dl and above)

Impaired fasting glycemia is a form of pre-diabetes.

Blood Glucose Monitors

These are normally used to monitor blood glucose levels in type 1 diabetics, but can be used to measure the blood glucose level as an indication to somebody who is presenting with polyurea, polyphagia and polydipsia.

The random reading should be below 11.1mmol/l for a normal reading and over 11.1mmol/l for a diagnosis of diabetes.

A Fasting Glucose test will be carried out to confirm the diagnosis or check for pre-diabetes, where the reading is approaching 11mmol.

Cause of Type 2 Diabetes

This maybe multi-factorial, but generally is due to the bodies inability to properly respond to insulin.

Risk factors include:

• Carrying too much excess body fat
• Having high blood pressure or cholesterol
• Having a close family member with type 2 diabetes
• Having previously had gestational diabetes
• Physical inactivity

Treatment

Aim of the treatment is to minimise the risk of long term micovascular and macrovascular complications by controlling the blood-glucose levels of HBA1c at or below the patients target levels.

See NICE guidelines below.

Patient should be encouraged to include weight loss, smoking cessation and regular exercise to reduce hyperglycaemia and cardiovascular risk as part of their treatment.

John is a 57-year-old Caucasian delivery driver. He smokes 15 cigarettes a day. He jokes that the only exercise he gets is for his arm, when he is watching football in the pub. He is overweight, you guess his BMI must be over 30 kg/m2 as John hasn't weighed his self for years. He routinely visits the pharmacy collecting medicines for patients but does not take any medication himself. He considers himself to be in relatively good health claiming that he has not been near his GP in the last 10 years. During a conversation John mentions that he has felt particularly tired of late and that he may be “passing water” more frequently than normal.

You offer to check John’s blood glucose levels and he agrees. You record a value of 8.9 mmol/L. What is this suggestive of and what further tests are necessary?

What is this suggestive of and what further tests are necessary?

He complained that he couldn't have his normal full English breakfast in his local cafe on the morning of his test as his GP had told him he needed to fast.

John came in the next week and told you he had rang the surgery and was given his results, he showed you the numbers he had written down. He said he was worried as the receptionist had told him that he had to make an urgent appointment with his GP to discuss his diagnosis,

John ask you what you think the doctor will say. (His FGT results are 6.8 mmol/l)

John's GP sent him for another test the next week, an oral glucose tolerance test (OGTT) which came back as:

FPG 6.9mmol/l: 2hr post 75g glucose 10.5mmol/l

What do you think his results indicate?

John is still working as a driver and is now 58 years old. Previously John was diagnosed as having impaired glucose tolerance. At his latest clinic appointment his random blood glucose was 11.3 mmol/L and his fasting plasma glucose (FPG) was 8 mmol/L. John's HbA1c was also recorded and found to be 59 mmol/mol (7.5%).

What is John’s diagnosis now?

John was depressed with the diagnosis as he had been watching what he was eating and was walking in the evenings twice a week. His BMI had remained unchanged, which he put down to stopping smoking. John's GP commenced metformin, building up to 500 mg three times a day over two weeks. John visits you five days after commencing metformin complaining of nausea and diarrhoea.

What action would you take?

John failed to tolerate any metformin product and was commenced on gliclazide 80 mg daily and increased to 320 mg daily (in 2 divided doses) after 3 months. His 6 month review has revealed that his BMI has increased to 29.5 kg/m2 and his HbA1c is still 59 mmol/mol. Adherence is not a problem and lifestyle issues are being addressed.

What therapy would you recommend and why?

Email: l.j.gallagher@gre.ac.uk
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Location: Kent, United Kingdom
Phone: 01634 202940
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