Who do I consult for a new diagnosis of diabetes?

Who to Consult for a New Diagnosis of Diabetes

For a newly diagnosed diabetic patient, the primary care physician should coordinate initial care with referral to a diabetes team consisting of an endocrinologist, diabetes nurse educator, dietitian, and mental health professional as needed.

Initial Management Approach

Primary Care Physician's Role

• The family physician is often the one who makes the initial diagnosis of diabetes 1
• 91% of family physicians report that they usually manage their patients' diabetes care, including patients with concomitant risk factors 2
• Primary care physicians should coordinate the initial care and ongoing management of diabetes 3

When to Refer to Specialists

1. Endocrinologist referral indications:

   • Type 1 diabetes (especially in children and adolescents)
   • Complex insulin regimens
   • Difficult-to-control diabetes
   • Presence of significant complications
   • Pregnancy with pre-existing diabetes
   • Unusual presentations suggesting monogenic diabetes

2. Diabetes Education Team:

   • The American Diabetes Association recommends that "ideally, every child newly diagnosed with type 1 diabetes should be evaluated by a diabetes team consisting of a pediatric endocrinologist, a nurse educator, a dietitian, and a mental health professional qualified to provide up-to-date pediatric-specific education and support" 3
   • This multidisciplinary approach is also beneficial for adults with newly diagnosed diabetes

Components of Initial Diabetes Care

Education Components

• Diabetes self-management education should begin as soon as feasible after diagnosis 3
• Initial education should focus on "survival skills" including:
  • Identification of the healthcare provider who will provide diabetes care
  • Self-monitoring of blood glucose
  • Explanation of home blood glucose goals
  • Recognition and treatment of hyperglycemia and hypoglycemia
  • Information on consistent eating patterns
  • Medication administration
  • Sick-day management 3

Specialist Consultations to Consider

1. Registered Dietitian:

   • Medical nutrition therapy is essential for all patients with diabetes
   • 60% of family physicians report lacking knowledge about nutritional issues 2

2. Ophthalmologist/Optometrist:

   • For type 1 diabetes: Initial dilated eye exam within 5 years of diagnosis
   • For type 2 diabetes: Initial dilated eye exam shortly after diagnosis 3

3. Nephrologist:

   • When there is uncertainty about kidney disease etiology
   • For advanced kidney disease (eGFR <30 mL/min/1.73 m²) 3

4. Mental Health Professional:

   • To address psychological impact of diagnosis
   • To enhance support and address barriers to successful management 3

Special Considerations

Children and Adolescents

• Children with newly diagnosed type 1 diabetes should be referred to a pediatric endocrinologist/diabetes team 3
• For children, hospitalization may be necessary if:
  • The center lacks experience in outpatient management
  • The child requires treatment for acidosis
  • The child requires intravenous hydration
  • The child is very young (e.g., <2 years)
  • The child is referred from great distances
  • There are psychosocial challenges that preclude outpatient education 3

Pregnancy

• Women with gestational diabetes should be referred to specialists in high-risk obstetrics
• After delivery, women with gestational diabetes should be screened for persistent diabetes at 6-12 weeks postpartum 3

Follow-up Care

• Regular follow-up with the primary care physician is essential for ongoing diabetes management
• The frequency of HbA1c testing should be at least twice yearly in patients meeting treatment goals with stable glycemic control, and quarterly in patients whose therapy has changed or who are not meeting glycemic goals 3
• Annual screening for complications (retinopathy, nephropathy, neuropathy) should be coordinated by the primary care physician

Common Pitfalls to Avoid

1. Delayed specialist referrals when indicated by complexity or poor control
2. Information overload during initial education - focus on survival skills first
3. Neglecting psychological aspects of a new diabetes diagnosis
4. Failing to screen for complications at appropriate intervals
5. Not providing adequate self-management tools (glucose meters, medication, supplies) at diagnosis

Remember that diabetes management requires a team-based approach, with the primary care physician often serving as the coordinator of care, while utilizing specialist referrals as appropriate based on the individual patient's needs and complexity.