Priority Topic: Diabetes

Key Feature 1: Given a symptomatic or asymptomatic patient at high risk for diabetes (ex: patients with gestational diabetes, obese, certain ethnic groups, and those with a strong family history), screen at appropriate intervals with the right tests to confirm the diagnosis.
Skill: Clinical Reasoning, Selectivity
Phase: Investigation, Hypothesis generation

Key Feature 2: Given a patient diagnosed with diabetes, either new-onset or established, treat and modify treatment according to disease status (ex: use oral hypoglycemic agents, insulin, diet, and/or lifestyle changes).
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

Key Feature 3: Given a patient with established diabetes, advise about signs and treatment of hypoglycemia/hyperglycemia during an acute illness or stress (i.e., gastroenteritis, physiologic stress, decreased intake.
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 4: In a patient with poorly controlled diabetes, use effective educational techniques to advise about the importance of optimal glycemic control through compliance, lifestyle modification, and appropriate follow-up and treatment.
Skill: Communication, Patient Centered
Phase: Treatment

Key Feature 5a: In patients with established diabetes: Look for complications (ex: proteinuria).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 5b: In patients with established diabetes: Refer them as necessary to deal with these complications.
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

Key Feature 6: In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Treatment

Diabetes is common, and it is continuing to be so as rates of overweight and obesity continue to climb. It can also be present for many years and start to cause damage to the small blood vessels and raise risk for multiple complications down the line, without becoming apparent to the individual walking around with high blood glucose, at least for type 2 diabetes, which is the type that is associated with the metabolic syndrome. Because of the prevalence, screening guidelines suggest screening all people who are 40 years and older for diabetes every 3 years, but screening should start sooner and more frequently for those at increased risk (ex: overweight or obese or with other comorbidities that increase risk, with a family history, with a personal history of gestational diabetes, who use medications associated with hyperglycaemia, and who are of any ethnicity other than white pretty much). The CANRISK tool is an online risk calculator to assess who might and who might not need blood work to assess for the presence of diabetes, and I prefer to start with that to avoid unnecessary blood work. However, if a patient is symptomatic (presenting with polyuria, polydipsia, nocturia, and blurred vision) they should have bloodwork done straight away to look for hyperglycemia.

If a patient has type 1 diabetes or symptomatic type 2 diabetes, they will need to be started on insulin straight away. If a patient has type 2 diabetes, depending on how severe it is (as measured by a recent HbA1c, generally measured every 3-6 months), a combination of lifestyle measures +/- oral antihyperglycemic agents can be tried first (and generally metformin is always the first agent). All patients warrant a referral to a dietician to get a handle on how structure their diet with this new diagnosis, which is really not easy! Patients with type 1 diabetes should be referred to see an endocrinologist straight away. There is much more to the management of diabetes than this, and it is important to spend time with patients to provide education and counseling on this life-changing diagnosis. I won't get into the details of the medication and lifestyle recommendations for diabetes here, as there is just SO MUCH one needs to know in order to manage diabetes. But the majority of the recommendations are similar to what physicians recommend for all people, which is to eat a healthy diet, get lots of exercise, avoid harmful substances, and do whatever it is that decreases stress on the body (ex: sleep, mental health, self-care). If interested, check out Diabetes Canada and all of its exhaustive resources for both patients and clinicians. There was a new publication this year of new diabetes clinical guidelines. All primary care physicians ought to be well-versed with these recommendations.

The reason for all of the recommendations (and there really are oh-so-many) is not in vain. It's to prevent short-term complications while mitigating the long-term ones. Short term complications include hypoglycemia, which may present with the following symptoms:

The other major short-term complication is symptomatic hyperglycemia, which may present with the following:

(Note that the presentation of acidosis typically occurs in patients with type 1 diabetes exclusively, although severe dehydration is a very real and life-threatening concern in patients with type 2 diabetes.)

Hope/plan for the best and prepare for worst! These emergency short-term complications can be life-threatening, so it is best to try to avoid them as much as possible, best to be prepared for what to do should they occur, and best to know what to do to correct the problem. For prevention, it's all about good routine management of blood sugar levels, which involves managing lifestyle (diet and exercise), medications, and monitoring as indicated (varies depending on the type of medications and individual factors). No one said diabetes was a cakewalk! As well, when a patient is unwell to the point that it may be affecting what they are putting in their body or what is coming out of it, or if they are under undue stress, or if they are simply feeling at all unwell, it is critical that there is a plan in place to check blood glucose more frequently to pick up when their blood glucose may be outside a safe range (<4 or >14) so as to be able to intervene prior to rampant hypo- or hyperglycemia. If a patient is hypoglycemic, they need glucose, such as in the form of glucose tablets, and part of the  routine education of a patient with diabetes should include how to correct hypoglycemia. If unconscious, a loved one should give a glucagon injection and should know how to do this as well. If a patient is hyperglycemic >14 and not improving, they should be seeking medical care. Patients should also be given a "sick day" medication list to know which medications they should not be taking should they become unwell. If a patient presents to care with an episode of hypo- or hyperglycemia, it's important to search for the underlying reason to attempt avoiding recurrence and during an acute episode, to treat the problem that is still at hand (i.e., work the patient up for hypo- or hyperglycemia as indicated*). Please know that I am barely scratching the surface in terms of how to manage diabetes with this post - I almost feel guilty explaining so little. 

Given all of this, as well as the fact that people are just trying to live their lives, which is already no easy feat, it's no surprise that many patients have poorly controlled diabetes. I think starting with this empathic perspective and learning best practices in terms of evidence-based approaches to helping patients achieve better management is what we need to do to most effectively help our patients in both the short and the long-term. Often it can be hard for patients with type 2 diabetes that isn't severe enough to cause short-term complications to be motivated to adopt oftentimes challenging life modifications necessary for good glucose control. If hypertension is "the silent killer" and obesity an impossible disease to fight on an individual level, diabetes is like the intersection of those two evils. Even when the short-term complications do not manifest, the long-term complications - namely retinopathy, nephropathy, neuropathy, and increased rates of peripheral vascular disease, heart attack, stroke, and all-cause mortality - are ever-present. Dang. But like any issue where there is a lag in the consequence from when the behaviour occurred, it's just human nature to not be so motivated to change the behaviours. We need to work with patients in realistic ways and in as many supportive ways as possible (ex: including motivational interviewing, education, and regular engagement with their health care team) to help make health-conscious choices easier ones for them to make. This is also what I think we need to be striving for all people, but I digress. People are the masters of their domain and they will be the best judge of what is and isn't realistic in their life. 

You may have noticed way up there that I used the phrase "mitigate long-term complications." In an ideal world, with perfect blood glucose control, theoretically long-term complications could be altogether avoided. But alas the world is not perfect, although some patients get pretty darn good at managing their blood glucose despite this. But the bottom line is that all patients with diabetes are at increased risk for long-term complications and warrant screening and management accordingly. For the risk of retinopathy, patients need a referral for an annual ophthalmologic eye examination; for the risk of nephropathy, patients need annual testing for renal function and albuminuria, and if they develop chronic kidney disease, they warrant assessment by a nephrologist depending on the severity; for the risk of neuropathy, patients need annual diabetic foot exams. Generally these screening maneuvers should start 5 years after the diagnosis of type 1 diabetes and straight away for patients diagnosed with type 2 diabetes. There are other screening considerations as well, many of which are standard for the general population but perhaps recommended more frequently (ex: serum cholesterol), and others that depend on other patient factors (ex: baseline ECG). The Sample Diabetes Patient Care Flow Sheet for Adults is a great example of the multitude of complications the primary care physician needs to be mindful of screening for and tracking, all of which I really have only skirted around in this blog post.