Type 2 diabetes: a 2-hour session

Key messages to land

1. Test adults with symptoms, and those aged 40 and over with a BMI of 25 or more.
2. No symptoms: confirm with a second test on another day.
3. Hypoglycaemia is 3.9 mmol/L or less: sugar by mouth if awake, 50% glucose IV if not.
4. Ill with high glucose, vomiting or deep breathing: saline and refer.
5. Metformin first, then gliclazide, then insulin, reviewing every 3 months.
6. BP below 130/80, a statin from age 40, and feet checked every visit.

Running the skills station

• Insist on gloves, a new lancet each time and a sharps container.
• For the foot check, have participants remove their own shoes and socks in pairs if no volunteer patients are available, and test with eyes closed.
• Without monofilaments, teach the light touch test: tips of toes 1, 3 and 5 on both feet; loss of sensation likely if 2 or more are not felt.

Common misunderstandings

"Urine glucose is enough to diagnose"

Diagnosis needs plasma glucose or HbA1c. Urine glucose can raise suspicion only where blood testing is impossible.

"Glibenclamide and gliclazide are the same"

Gliclazide causes less hypoglycaemia and is preferred, especially at 60 and over.

"Insulin means the end"

Insulin is a normal step when tablets are not enough; human NPH at bedtime is simple to start.

"Aspirin for all people with diabetes"

Aspirin is only for people who have had a heart attack or ischaemic stroke.

Adapting the session

Replace the example medicines with those in your national protocol. In a humanitarian setting, use case 2 to discuss food insecurity and hypoglycaemia risk, and point to the page on continuity of NCD care in emergencies.

Case 1: The tired teacher

Mrs T, 51, BMI 30, has been thirsty and passing a lot of urine for a month. Her random plasma glucose is 16.2 mmol/L. Urine ketones are negative. She is alert and not vomiting.

1. Does she have diabetes?
   Answer: Yes. A random glucose of 11.1 mmol/L or more with symptoms is diagnostic; no repeat is needed.
2. How would you start treatment?
   Answer: She has symptoms, glucose below 18 and no ketones. Check a fasting glucose: if it is 15 mmol/L or more, treat as symptomatic hyperglycaemia with metformin 1000 mg twice daily and gliclazide 80 mg twice daily, review in 3 to 5 days, and teach about lows. If it is lower, follow the stepwise protocol.

Case 2: The retired farmer

Mr U, 67, has taken glibenclamide for years. He has had two episodes of sweating and confusion in the last month, both after missing lunch. His creatinine shows an eGFR of 45.

1. What is happening and what would you change?
   Answer: Hypoglycaemia from glibenclamide, which is not recommended at 60 and over. Switch to gliclazide at a lower dose, and review metformin dose for his eGFR per national guidance (metformin is contraindicated below 30). Teach him to carry sugar and eat regularly.
2. Does his kidney function need action?
   Answer: Yes. An eGFR of 30 to 59 is a reason for non-urgent referral under HEARTS-D, and his BP should be below 130/80.

Case 3: The callused foot

Mrs V, 58, has had diabetes for 9 years. She cannot feel the monofilament at 3 sites on her right foot, has callus over the ball of the foot and wears tight plastic shoes. Pulses are present. BP 138/84. She is not on a statin.

1. What is her foot risk and plan?
   Answer: High risk (neuropathy with callus). Check every 1 to 3 months; callus removal by a trained professional; advice on daily foot checks and footwear 1 to 2 cm longer than the foot; never barefoot.
2. What else should be done today?
   Answer: Treat BP (130/80 or more in diabetes), start a statin (aged 40 and over), and check urine protein, creatinine and the date of her last eye examination.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. Which fasting plasma glucose indicates diabetes?
   1. 5.5 mmol/L or more
   2. 7.0 mmol/L or more
   3. 11.1 mmol/L or more
   4. 15 mmol/L or more
2. Who should be tested even without symptoms?
   1. Everyone over 18
   2. Adults aged 40 and over with a BMI of 25 or more
   3. Only pregnant women
   4. Only people with foot ulcers
3. When should you check the urine for ketones?
   1. Never
   2. When glucose is 18 mmol/L or more, or there are symptoms
   3. Once a year
   4. Only after starting insulin
4. A woman on gliclazide is confused but can swallow; glucose 3.0 mmol/L. First step?
   1. 50% glucose IV
   2. 15 to 20 g of glucose or a sugary drink, recheck in 15 minutes
   3. Stop all medicines and send home
   4. Give insulin
5. Suspected DKA: what fluid while arranging transfer?
   1. 5% glucose
   2. 0.9% saline 1 litre over 2 hours, then 1 litre every 4 hours
   3. No fluid
   4. Oral fluids only
6. What is the first WHO PEN glucose-lowering medicine and dose?
   1. Gliclazide 80 mg
   2. Metformin 500 mg once daily
   3. Insulin 10 units
   4. Metformin 1000 mg twice daily
7. Metformin should not be used when eGFR is:
   1. Below 30
   2. Below 90
   3. Above 60
   4. Any value
8. What is the usual HbA1c goal?
   1. About 5%
   2. About 7.0% (53 mmol/mol)
   3. About 10%
   4. There is no goal
9. A foot with neuropathy and callus is:
   1. Low risk: check yearly
   2. High risk: check every 1 to 3 months
   3. Normal
   4. An emergency
10. Who should get a statin under HEARTS-D?
    1. Only people with chest pain
    2. Everyone with type 2 diabetes aged 40 and over
    3. No one
    4. Only people under 40

Answer key

1. B. Fasting plasma glucose of 7.0 mmol/L (126 mg/dL) or more; confirm on another day if no symptoms.
2. B. HEARTS-D: test adults aged 40 and over with a BMI of 25 or more.
3. B. Check ketones at 18 mmol/L or more, or with symptoms; 2+ or more in an ill person suggests an emergency.
4. B. Awake and able to swallow: sugar by mouth, recheck after 15 minutes, then a meal.
5. B. Start 0.9% saline before and during transfer.
6. B. After 1 month of lifestyle advice, start metformin 500 mg once daily and step up every 3 months.
7. A. Metformin is contraindicated with an eGFR below 30.
8. B. About 7.0%, relaxed (for example under 8%) for frequent lows, advanced complications or short life expectancy.
9. B. Neuropathy with callus or deformity is high risk; check every 1 to 3 months.
10. B. All people with type 2 diabetes aged 40 and over, without reducing access to glucose and BP medicines.