Not every adult diabetic has type 2 diabetes mellitus. It can also be type 1, MODY ( maturity-onset diabetes of the young ), or LADA ( latent autoimmune diabetes of the adult ).
Think especially about forms of diabetes other than type 2 if your patient has a low BMI (< 25 kg/m 2 ).
In these patients, ask if there is a family history of diabetes or autoimmune diseases. Also, ask about the age at which the diabetes was discovered.
Think extra if signs of metabolic syndromes, such as hypertension and dyslipidemia, are missing.
Make sure that you can easily and quickly consult with your general practitioner or general practitioner. Consider referral to the second line with them.
The National Transmural Agreement on Diabetes mellitus type 2 provides recommendations when you consult the second line as a general practice: whether you consult the internist or refer to the internist.
Introduction
The National Transmural Agreement Diabetes Mellitus Type 2
In five cases, the second line (the internist) should be consulted or referred to: when there is a doubt about the diagnosis, when there are problems with glycemic control, when there are problems with the treatment of risk factors, when there is insufficient control of complications, and when there is a pregnancy or a pregnancy wish. I'll talk about one of the consultation and referral indications in this article: skepticism regarding the diagnosis
For type 2 diabetes mellitus, you provide the majority of patient care in primary care. Currently, primary care treats 90% of diabetes patients, where it used to be 80%. The care of the internist is complementary to the care in primary care. The practice nurse carries out the protocol part of primary care.
The general practitioner is crucial in the care of patients with type 2 diabetes, first and foremost in recognizing new diabetes patients through case finding during consultation hours and in diagnostics. If there are any other disorders, blood sugar dysregulation, queries that are not covered by the protocol, comorbidity, or problems, the GP is consulted. By comorbidity, I mean problems with vision, complaints of cardiovascular disease, (autonomic) neuropathy, sexual problems, depression, or cognitive disorders.
If necessary, you should be able to consult your doctor easily and quickly. Consultation with a general practitioner is also beneficial. In many care groups, the general practitioner and the practice nurse have the opportunity to consult with a general practitioner for diabetes. Some care groups organize meetings where you can present case histories to a general practitioner and an internist.
The National Transmural Agreement (LTA) describes the interfaces between primary and secondary care and provides recommendations for providing general practitioner or specialist care in the right way and at the right time. The LTA was drawn up by a working group of the Dutch College of General Practitioners (NHG) and the Dutch Internists Association (NIV).
Uncertainty regarding the diagnosis
Doubt regarding the diagnosis is an indicator that a general practitioner should refer to the second line, or in any event consult the second line, according to the National Transmural Agreement on Diabetes Mellitus Type 2. Type 2 diabetes must be recognized from other types of diabetes, including type 1, maturity-onset diabetes of the young (MODY), and latent autoimmune diabetes.
The accompanying article describes the characteristics of the different forms of diabetes in a table (see the table ). This flowchart and table are good resources, but we'll also need to keep using common sense. I will demonstrate this on the basis of two cases: Mr. De Jong and Mrs. Jansen.
The acting GP sees Mr. De Jong, a 35-year-old plumber, at her office. Mr. De Jong has had fasting glucose measured in recent months, with the result being 7.0 mmol/l and 7.4 mmol/l respectively. He has an HbA1c of 46 mmol/mol (6.4%), his BMI is 22.8 kg/m 2 and he has no history of diabetes in his family. His blood pressure is 114/70 mmHg, his LDL cholesterol level is 2.9 mmol/l. The acting GP proposes the patient start with metformin and simvastatin 40 mg and refers to the practice nurse to start the care.
The practice nurse looks back in the electronic file and sees that at the age of 28 the diagnosis of diabetes has already been made. At the time, Mr. De Jong's HbA1c was 46 mmol/mol (6.4%), his fasting glucose 7.4 mmol/l, and his BMI 21.1 kg/m 2 . After starting dobutamine, Mr. De Jong became dizzy and tired, there was a tendency to faint and Mr. De Jong started using many sweet drinks up to 5 liters per day (milk and sports drink).
The tolbutamide was then discontinued. In the following years, the HbA1c remained around 46 mmol/mol (6.4%) and the fasting blood sugar around 7.4 mmol/l without medication. The practice nurse consults with the acting GP with this information. After a search in the Dutch Journal of Medicine, they find the article by Suat et al. with the table. 3 The general practitioners and the practice nurse conclude that according to the table there should be type 1 diabetes (negative family history, BMI < 25). But… it cannot be that someone with type 1 has good blood sugar after 7 years without insulin.
Common sense is addressed. Could it be a MODY after all? The negative family history is strange given that MODY is inherited in an autosomal dominant manner, which means that Mr. De Jong's father or mother must have had a MODY. Mr. De Jong's father and mother were never diagnosed with MODY for one of two reasons: either the diagnosis was never made with his parents owing to a lack of complaints, or his father is not his biological father. Mr. De Jong is sent to an internist, who orders a DNA test. MODY type 2 appears to exist. Mr. De Jong is referred back to primary care when the internist makes the diagnosis. Mr. De Jong's diabetes does not require any more testing.
MODY2 is the result of a malfunctioning glucokinase in the beta cell of the pancreas. As a result, sufficient insulin is only produced when blood sugar is slightly higher than normal. It is important to distinguish the different forms of MODY. MODY type 2 requires no treatment and does not lead to cardiovascular complications. However, MODY2 should be treated in a pregnant woman, because MODY2 can lead to macrosomia (a large child) in a pregnant woman and often requires treatment with insulin during pregnancy.
It is therefore important for female relatives of Mr. De Jong to make a diagnosis if there is a wish to become pregnant.
In Europe, MODY3 occurs most frequently (about 60% of MODY, about 2% of all diabetic patients), followed by MODY2 and MODY1. MODY1 and MODY3 are often associated with progressive hyperglycemia and eventually with microvascular complications of the eyes and kidneys. Treatment with insulin is necessary for more than 40% of these patients. The type of MODY can be determined with the help of DNA testing. The general practitioner can use the help of an internist with this.
Mrs. Jansen
Mrs. Jansen, 65, has had diabetes mellitus for two years. She has a BMI of 23 kg / m 2. Mrs. Jansen is active and busy babysitting her hand-binding grandchildren aged 2 and 4. Diabetes runs in the family in one sister and two aunts. The practice nurse treats her with a four times daily insulin schedule: 10 units of long-acting insulin and 2, 3, and 8 units of short-acting insulin for breakfast, lunch, and dinner, respectively.
Mrs. Jansen regularly visits the dietician. At the practice nurse's office hours she reports that she has hypoglycemia almost every day and that there are also hypos at night. On the days that she is babysitting, there is often a hyperglycemic disorder when she eats pancakes with the grandchildren. In the nights after babysitting, there is often a hypo when grandma has been to the petting zoo with the grandchildren. Her HbA1c is 54 mmol/mol (7.1%),
The practice nurse wonders whether, despite the advanced age (LADA usually manifests itself before the age of 50), this patient may still have latent autoimmune diabetes of the adult (LADA). The GP requests a determination of antibodies against beta cells of the pancreas: anti-GAD (GAD = glutamic acid decarboxylase). The result is positive, confirming the diagnosis of LADA.
LADA is a type 1 diabetes that appears to be type 2 because it develops slowly and persons with LADA may often live without insulin for long periods of time. It is estimated that 15% of people diagnosed with type 2 diabetes actually have the LADA form; for patients with type 2 diabetes with a BMI < 25 kg/m 2 this is even 50%.
Ms. Jansen has comorbidity with Graves' disease (a thyroid disorder) and celiac disease (gluten hypersensitivity) and angina pectoris as a macrovascular complication. She, therefore, has several disorders as a result of antibodies against her own body cells. This is especially common in middle-aged women.
Often there is a co-occurrence of LADA, autoimmune thyroid disorders, and other autoimmune disorders such as pernicious anemia, vitiligo, alopecia, myasthenia gravis, or Sjögren's disease.
It is important that you also consider the possibility of LADA in people at an older age. Often the blood sugars are difficult to control, there are large fluctuations due to food and exercise. The latter is often only 6-12 hours after eating (in the night!). You should think of LADA in case of a low BMI, the absence of type 2 diabetes in the family, the absence of signs of metabolic syndrome (hypertension, dyslipidemia), and the presence of other autoimmune disorders in the patient or his family.
Insulin requirements are often low (less than 40 units per day). As long as the patient responds well to treatment with oral medication, care can very well take place in primary care. But if insulin treatment is needed, these patients are usually better off in secondary care for treatment:
Conclusion
Think of forms of diabetes other than type 2, such as MODY and LADA, with a low BMI. In these patients, ask the family history of the occurrence of diabetes or autoimmune diseases. Also, ask about the age at which the diabetes was discovered. Think extra if signs of metabolic syndrome are missing, such as hypertension and dyslipidemia. Consult with your GP and/or diabetes management GP and consider referral to the second line together with them.
Therefore, when it comes to type 2 diabetes, patients with this kind of diabetes require both first and second-line care. The second line is complementary to the first, but keep in mind that proper patient care occasionally necessitates assistance from the second line. In diabetic care, you may have to deal with the interaction between your primary care physician and a specialist.TheNational Transmural Agreement Diabetes mellitus type 2 provides recommendations when you consult second-line care as a general practice: when to consult an internist, when to refer.
BMI = body mass index; DM1 = type 1 diabetes mellitus; DM2 = type 2 diabetes mellitus; MIDD = maternally inherited diabetes and deafness; MODY = maturity onset diabetes of the young. * = The hyperglycemic complaints mentioned are: polyuria, polydipsia, nocturia and weight loss.Source: Simsek et al.3DM = diabetes mellitus; LADA = latent autoimmune adult diabetes; MODY = 'maturity-onset diabetes of the young'; MIDD = 'maternally inherited diabetes and deafness'; BMI = 'body mass index'.* Clustering of cardiovascular risk factors: hypertension, hypertriglyceridemia, insulin resistance, decreased HDL-cholesterol concentration, associated with large waist size.† Three consecutive generations.‡ Acute first presentation: hyperglycemia with weight loss and ketones in the urine.
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