Diagnosis and management of uncomplicated Type 2 Diabetes Mellitus in family practice

ABSTRACT

Background@#The cost of DM treatment in the Philippines is mainly shouldered by the patient. Most patients rely on “outof-pocket” expenses, namely, laboratory procedures and daily medications. There are guidelines available, unfortunately its dissemination and implementation rely on passive strategies. This clinical pathway is an attempt to operationalize these guideline recommendations in family and community outpatient practice. @*Methods@#The PAFP Clinical Pathways Group reviewed the published medical literature to identify, summarize, and operationalize the evidence in the management of patients with type 2 diabetes mellitus in family and community practice. The recommendations are time-bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions.@*Recommendations@#First Visit •Elicitsymptomsofhyperglycemiai.e.polyuria,polyphagia,polydipsia,nocturiaandweightloss(A-II) •Generalphysicalexaminationfocusoncardiac,renal,peripheralpulseretinopathy,neuropathy,skinandBMI(A-II) •ConductriskscreeningforasymptomaticandBMI≥25kg/m2or≥45yearsold(A-II) •RequestforFBSorRBSorOGTTorHgbA1C(A-I) •Notadvisabletogiveroutinevitaminsupplementationwithantioxidants,suchasvitaminsEandCandcarotene(A-I) •Structuredhealtheducationonlifestylechanges(alcoholandsmoking),moderateweightloss,regularphysicalactivity, reduced calories, sugar and dietary fat intake (A-III) •Arrangefordevelopmentandimplementationoffamily-focusedandcommunity-orientedintervention(A-III) •Patientisawareofdiabetestype2andmanagementplan(A-III) Second Visit •Reviewthelaboratoryresultsandestablishthediagnosisasdiabetestype2,pre-diabetesornon-diabetes(A-II) •Ifdiabetestype2orpre-diabetes,assessthepatientandfamily’sdietarypatterns,physicalactivityhabits,nutritionalstatus and weight history, diabetes understanding, psychological, social and community health support systems (A-III) •Evaluatesocialdeterminantsofhealth(SCREEM)(A_III) •Ifdiabetestype2,requestforlaboratoryteststodetectcomplicationortargetorgandamage(A-II).Ifnormal,repeat testing every year if there are risk factors and at least at 3-year intervals if there are no risk factors (B-III) •FirststepmedicationisMetformin500mgtwiceaday(A-I) •IfwithmarkedsymptomsandsignificantlyelevatedbloodglucoselevelsorA1C,considermetforminandinsulinfromthe outset (A-II) •Ifpre-diabetesmetformin500mgoncedailymaybeconsideredifthereisimpairedglucosetoleranceorimpairedfasting glucose or A1C of 5.7–6.4% (A-II) •Developandagreeonthemanagementplan(A-III) •Providediabetesself-managementeducationandcounselling(A-II) •Medicalnutritiontherapyfocusingonlimitationofcarbohydrateandfatintakeandweightloss(A-I) •Emphasizeincreaseinphysicalactivity(A-I) •Limitalcoholintake,smokingcessation(A-II) Involveafamilymember/caregiverinthediabetesself-managementeducationandcounselling,medicalnutritiontherapy, physical activity and limitation of alcohol intake (A-II) •Setupatelemedicineandotherdigitalapplicationtocomplementface-to-facemanagementofpatients(A-I) •Patientoutcomesare1)agreeonmanagementplanandgoals,2)Awareonmedications,doseandsideeffects,3)aware on what to do if hyoglycemia occur (A-III) Continuing Care •Reviewoftreatmentregimens(medicationadherence,mealplan,physicalactivitypatterns,andlifestylechange)and response to treatment (self-monitoring or A1C records) (A-II) •Checkforhypoglycemicepisodesandotheradverseevents(A-II) •Randomorfastingbloodsugartestingduringclinicvisitmaybedonetoguidetimelytreatmentchanges(A-III) •A1Ctestquarterlyortwiceayeardependingonresponsetotreatment(A-III) •Basedoninitialresponse,titratemetformindosefor3monthstoachievetreatmentgoal(A-I).Ifthediabetesisnotcontrolled by metformin after 1 month add basal insulin or another oral hypoglycemic drugs (A-I) (be aware of contraindications) •Enhancediabetesself-managementeducationandcounselling,medicalnutritiontherapy,physicalactivityandlimitation of alcohol intake (A-II) •Enhancethefamilymember/caregiver’sroleinthediabetesself-managementeducationandcounselling,medicalnutrition therapy, physical activity and limitation of alcohol intake (A-II) •Coordinatereferralforsocialandeconomicsupportforthepatientifneeded(A-III) •Empowercommunityhealthworkersanddiabeticpatientsforcoordinationandmonitoring(A-III) •Patientoutcomesshouldbe1)achievementoftreatmentgoals(A-I),2)improvedqualityoflife(A-I),3)satisfactionto management plan (A-III), 4) continuing compliance to diabetes self-management (A-III)@*Implementation@#We recommend that at the clinic level, self-reviews of chart records using the recommendations of this clinical pathway as the criteria may be done. Identification of barriers and developing interventions to promote compliance to the clinical pathway recommendations may be more effective.