Managing diabetes in primary care – key points for nurses

Continuing our series highlighting recent presentations from Nursing in Practice 365 events, Diabetes specialist nurse Anwen Jones provides an update on some key principles in management of diabetes in primary care

Currently an estimated 5.8 million individuals are living with diabetes in the UK, 90% of whom are diagnosed with Type 2 diabetes while 8% have Type 1 diabetes and the remaining 2% other, rarer forms of diabetes.

While most diabetes management within primary care will relate to Type 2 diabetes, it is also very important for nurses in this setting to pick up on potential symptoms and signs of other types, such as Type 1 diabetes and LADA (latent Autoimmune Disease in Adults), to ensure timely diagnosis and treatment.

Diagnosis – keep all forms of diabetes in mind

Correctly diagnosing diabetes swiftly is important for both the physical and emotional health of the individual affected. It provides access to correct medication and a clear focus for the way forward. Acceptance of the diagnosis assists individuals to take ownership of their condition to self-manage and improve their overall health.

Type 2 diabetes

Symptoms include polyuria, polydipsia, recent unexplained weight loss, tiredness and slow healing wounds. Type 2 diabetes is diagnosed when venous blood sampled HbA1c is 48 mmol/mol or above. Consider any condition that adversely affects the production or lifecycle of the red blood cells, as this can lead to inaccurate HbA1c. For example, severe iron deficiency anaemia and recent blood transfusion would provide an inaccurate HbA1c result.

Type 1 diabetes

Consider Type 1 diabetes for any child or young adult with the random blood glucose of >11 mmol/L, which requires same-day urgent review by a specialist diabetes team. Symptoms can include polyuria, polydipsia, recent unexplained weight loss and tiredness.

LADA

This form of diabetes can present later in life and is often misdiagnosed as Type 2 diabetes. It is like Type 1 diabetes, being an autoimmune disease and requiring insulin therapy to treat hyperglycaemia, but it progresses slowly.

HbA1c levels will be above 48 mmol/mol and individuals can be asymptomatic or symptomatic with polyuria, polydipsia, recent unexplained weight loss and tiredness. Individuals can be misdiagnosed with Type 2 diabetes initially due to the similar presentation, but glucose responds slowly to oral medication and will require insulin therapy to improve glycaemic control.

Clinicians need to be aware of LADA and to consider it in anyone with a coexisting autoimmune disease such as hypothyroidism, who is over 30, not excessively overweight and has a family history of diabetes, and anyone who has been diagnosed with type 2 diabetes but despite good concordance with oral medication and lifestyle continues to have elevated glucose levels.

Diagnosis of LADA involves testing for glutamic acid decarboxylase (GAD) antibodies and nurses should follow local guidance for testing and referral.

Take a holistic approach to management

Type 2 diabetes management needs to cover both hyperglycaemia and cardiovascular protection. The NICE guideline on Type 2 diabetes management in adults, currently being updated, and the ADA/EASD (American Diabetes Association/European Association for the Study of Diabetes) guideline, now advise on how to prescribe classes of medication that will address both.

The associated risk of hypoglycaemia with some medication must also be considered. HbA1c targets can be difficult to achieve for some individuals and we must appreciate that targets may not be realistic or desirable for everyone. It is important that clinicians undertake a full holistic assessment and jointly agree the HbA1c target with the patient after considering co-morbidities, expectations, polypharmacy and frailty. NICE guidelines on Type 2 diabetes in adults recommend individualised targets considering frailty and co-morbidities. Note that with ageing, HbA1c becomes a less accurate marker of true blood glucose levels, such that older adults will require lower overall blood glucose levels to achieve the usual target HbA1c of 53 mmol/mol.

Communication is key

Annual reviews provide the opportunity to discuss any concerns and ensure all screening checks have been undertaken. Using an appropriate communication style such as motivational interviewing can be beneficial in strengthening personal motivation and to identify a personal goal.

It is important that clinicians are aware of how they communicate both verbally and non-verbally during the consultation. Ensure consultations are collaborative and engaging and avoid words such as ‘compliance’ and negative comments. Patients being told ‘to do better’, or threatened about ‘complications of diabetes’ can have a long-lasting impact on how they self-manage their diabetes.

Previously poor consultation experiences can leave the individual with a lasting negativity towards their diabetes and can increase the likelihood of non-attendance at future appointments.

Nurses play a key role in supporting individuals with diabetes, through evidence-based prescribing and an open, supportive empowering consultation. This will not only reduce the person’s disease burden but also their feelings of stigma.

Key points

Consider Type 1 diabetes in children or young adults who present with polyuria, polydipsia, unexplained weight loss or lethargy.
Consider the correct diagnosis of individuals if glucose levels do not improve with medication as expected – is it LADA?
Consider cardiovascular protection when prescribing to reduce risk factors.
Undertake a holistic review before agreeing on HbA1c targets, considering other co-morbidities and frailty.
Ensure appropriate use of language style during consultation and its longer lasting effects on individuals.
Ensure support and encouragement is offered during the annual review and all the screening tests and care processes are completed.
Promote education and clear communication to reduce the stigma that can be associated with living with diabetes.

Anwen Jones is Practice Nurse (NMP) with a special interest in diabetes in Ceredigion

Sources and further reading

Type 2 diabetes in adults: management. [NG28] Last updated 2022
Davies M et al. Management of hyperglycaemia in type 2 diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care2022;45(11):2753–86
Dubowitz N et al. Aging is associated with increased HbA1c levels, independently of glucose levels and insulin resistance, and also with decreased HbA1c diagnostic specificity. Diabet Med 2014;31(8):927-35

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