Who / when
- Test adults with symptoms: thirst, passing a lot of urine, blurred vision, tiredness, weight loss.
- Test adults aged 40 and over with a BMI of 25 or more, even without symptoms.
- This protocol is for non-pregnant adults with type 2 diabetes. Suspected type 1 diabetes, and diabetes in pregnancy: refer.
Red flags: refer now
- Hypoglycaemia (glucose 3.9 mmol/L or less): shaking, sweating, confusion, fits, drowsiness. Treat now (see Treat).
- Possible ketoacidosis or hyperosmolar state: any ill person with high glucose, vomiting, abdominal pain, deep fast breathing, drowsiness or coma; urine ketones 2+ or more.
- Glucose 18 mmol/L or more that does not improve on treatment.
- Chest pain or stroke symptoms; sudden loss of vision.
- Infected foot ulcer, gangrene, or a cold, pale, painful foot.
- BP 180/110 or more with headache, breathlessness, blurred vision or confusion.
Ketoacidosis or hyperosmolar state: refer, and give fluids on the wayStart 0.9% saline: 1 litre over the first 2 hours, then 1 litre every 4 hours until the person reaches hospital.
Assess
- Symptoms, weight, BMI, waist, BP (every visit).
- Plasma glucose; HbA1c if available. If glucose is 18 mmol/L or more, or there are symptoms: check urine ketones.
- Feet: look for ulcers every visit; once a year check pulses, sensation with a 10 g monofilament, calluses and old ulcers.
- Urine protein (or albumin to creatinine ratio) and creatinine once a year.
- Eyes: retinal examination at diagnosis, then every 2 years.
- Smoking, alcohol, other medicines; ask about cough (diabetes raises the risk of TB).
Classify
No symptoms? Repeat the test on another day to confirm, preferably with the same test.| Test | Diabetes if | Notes |
|---|
| Fasting plasma glucose (8 to 14 hours without food) | 7.0 mmol/L (126 mg/dL) or more | Cheapest test. Venous and capillary fasting values are the same |
| Random plasma glucose | 11.1 mmol/L (200 mg/dL) or more | Only counts if the person has symptoms |
| HbA1c | 6.5% (48 mmol/mol) or more | Can mislead with anaemia, haemoglobin disorders or kidney failure |
| 2-hour glucose after a 75 g load | 11.1 venous (12.2 capillary) mmol/L or more | Cumbersome; rarely needed |
| Picture | Classify as | Go to |
|---|
| Ill, ketones 2+ or more, or signs above | Diabetes emergency | Red flags: refer now |
| Fasting glucose 15 mmol/L or more with symptoms, or glucose above 18, ketones under 2+ | Symptomatic hyperglycaemia | Start metformin and gliclazide together; review in 3 to 5 days |
| Fasting 7.0 to under 18 mmol/L, or random 11.1 or more | Type 2 diabetes, stable | Lifestyle for 1 month, then the stepwise protocol |
Treat
Stepwise glucose protocol (WHO PEN, as in HEARTS-D)
| Step | If the goal is not reached | Review |
|---|
| 1 | Diet and physical activity advice | 1 month |
| 2 | Start metformin 500 mg once daily | 3 months |
| 3 | Metformin 1000 mg once daily | 3 months |
| 4 | Metformin 1000 mg twice daily | 3 months |
| 5 | Add gliclazide 80 mg once daily; teach about hypoglycaemia | 3 months |
| 6 | Gliclazide 80 mg twice daily | 3 months |
| 7 | Refer, or start human insulin: NPH 10 units at bedtime, increase by 1 to 2 units every 3 days until fasting glucose is 4 to 7 mmol/L | 3 days, then 3 months |
- Metformin: no weight gain or hypoglycaemia. Do not use with eGFR under 30, severe liver disease, acute heart or breathing failure, alcohol misuse, or past lactic acidosis.
- Gliclazide is the preferred sulfonylurea, and the first choice if metformin cannot be used. Avoid glibenclamide at 60 or over, or where hypoglycaemia would be dangerous.
- Symptomatic hyperglycaemia (ketones under 2+): metformin 1000 mg twice daily and gliclazide 80 mg twice daily; review in 3 to 5 days, refer if not improving.
- Other medicines (SGLT2 inhibitors, now on the WHO EML; DPP-4 inhibitors; pioglitazone) are not routine: use them before insulin only if more affordable, per national guideline.
Protect the heart and kidneys
- BP: treat at 130/80 or more; aim below 130/80, with an ACE inhibitor and a thiazide (see the hypertension protocol).
- Statin for everyone with type 2 diabetes aged 40 and over (dose per national formulary), as long as it does not take money from glucose and BP medicines.
- Aspirin 75 to 100 mg daily only after a heart attack or stroke, not for prevention.
Treating hypoglycaemiaAble to swallow: 15 to 20 g of glucose, or a sugary drink, 1 to 2 teaspoons of sugar, or a cup of milk; repeat after 15 minutes if still low, then a meal. Unconscious, unable to swallow, or glucose 2.8 mmol/L or less: 20 to 50 mL of 50% glucose IV over 1 to 3 minutes.
Follow-up
- Every 3 months while adjusting treatment (sooner if symptoms); review in 3 days after starting insulin.
- Goal: HbA1c about 7.0% (53 mmol/mol). Without HbA1c: fasting glucose 7.0 mmol/L or less and 2 hours after food 9.0 or less.
- Relax the goal (for example HbA1c under 8%) with frequent hypoglycaemia, advanced complications or short life expectancy.
- Every visit: BP, feet, adherence, hypoglycaemia. Every year: urine protein, creatinine, foot risk. Eyes every 2 years.
- Frequent hypoglycaemia on gliclazide: reduce or stop it.
Counsel
- Diabetes is lifelong but can be controlled. Take medicines every day.
- Healthy meals for the whole family; less sugar; eat less if overweight.
- At least 150 minutes of moderate activity a week, over at least 3 days.
- No tobacco; avoid harmful alcohol.
- On gliclazide or insulin: know the signs of a low and carry sugar.
- Check feet every day; wear shoes that fit; never walk barefoot; come at once for any wound.
- Come back at once if vomiting, very thirsty, drowsy or breathing fast.
If you feel shaky, sweaty or confused, take sugar or a sweet drink straight away, then eat a meal. Always carry something sweet with you.
When to refer
- Same day: any red flag above; hypoglycaemia that does not resolve; suspected type 1 diabetes; eGFR under 30 or no urine.
- Not at goal despite taking oral medicines (and insulin) correctly.
- eGFR 30 to 59, or moderate or severe protein in the urine.
- Signs of peripheral vascular disease; any foot ulcer.
- BP above 130/80 despite two medicines; total cholesterol above 8 mmol/L.
- Vision loss, or no eye check for 2 years; painful neuropathy.
Sources
World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020. World Health Organization. Package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. World Health Organization. Guidelines on second- and third-line medicines and type of insulin for the control of blood glucose levels in non-pregnant adults with diabetes mellitus. 2018. World Health Organization. WHO Model List of Essential Medicines (23rd list, SGLT2 inhibitors added). 2021.