Type 2 Diabetes & Insulin therapy (T2DM)

🔍 When to Suspect

May be asymptomatic, or present with thirst, polyuria, tiredness, blurred vision, or recurrent infections; consider in those with risk factors like age >40 (or >25 in South Asian, African-Caribbean or Black African people), obesity, or family history

From the full topic in The Ocean Library: Type 2 Diabetes & Insulin therapy (T2DM)

🧭 When to suspect

Type 2 diabetes is a progressive disorder of insulin resistance with relative insulin deficiency, producing chronic hyperglycaemia and a markedly raised risk of cardiovascular, renal, retinal and neuropathic complications. Suspect it in any adult with persistent hyperglycaemia, whether symptomatic or detected incidentally.

Symptoms may be mild or entirely absent, so a large proportion is found on screening or opportunistic testing. When present, classic features include polydipsia, polyuria (especially nocturia), blurred vision, unexplained weight loss, recurrent infections (thrush, balanitis, boils, urinary infection), fatigue, slow-healing wounds, or acanthosis nigricans (velvety dark pigmentation of skin folds signalling insulin resistance).

Raise suspicion further with age over 40 (or over 25 in South Asian, African-Caribbean or Black African people), obesity (the dominant modifiable risk factor), family history, polycystic ovary syndrome, previous gestational diabetes, hypertension, established cardiovascular or kidney disease, or use of diabetogenic drugs (corticosteroids, atypical antipsychotics, thiazides).

Test	Diabetes	Non-diabetic hyperglycaemia (“pre-diabetes”)
HbA1c	≥ 48 mmol/mol (6.5%)	42–47 mmol/mol (6.0–6.4%)
Fasting plasma glucose	≥ 7.0 mmol/L	6.1–6.9 mmol/L (impaired fasting glucose)
Random glucose / 2-h OGTT	≥ 11.1 mmol/L	7.8–11.0 mmol/L at 2 h (impaired glucose tolerance)

• Symptomatic patient – a single abnormal result is sufficient to diagnose, though a confirmatory test is sensible.

• Asymptomatic patient – do not diagnose on one result; repeat the same test (preferably) within about 2 weeks. If the repeat is normal, monitor rather than label.

• Stress hyperglycaemia – acute infection, trauma or circulatory compromise can raise glucose transiently and is not diagnostic.

• Children and young people – assume type 1 diabetes unless there are strong pointers to type 2 (marked obesity, strong family history, high-risk ethnicity, acanthosis nigricans).

• Consider insulin from the outset (or refer) if there is symptomatic hyperglycaemia, ketosis, marked weight loss, or doubt about the diabetes type.

Source: NICE NG28

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