Tayside Diabetes MCN Handbook 
Management of Newly Diagnosed Patients with Osmotic Symptoms

  • 22% of patients presenting with Type 1 Diabetes are aged over 40 at diagnosis, including some in the over 65 population.
  • 6% of patients are diagnosed with Type 2 Diabetes at an age of less than 40, including some in their teens. The proportion of young Type 2’s is steadily rising.
  • Only a small proportion of patients with Type 2 Diabetes present with the osmotic signs and symptoms of polyuria, polydipsia and weight loss.


For all patients presenting with such signs and symptoms, at whatever age, it is crucial that:

  1. A diagnosis of diabetes is definitively made or excluded as urgently as possible – initially if possible by performing immediate capillary blood glucose testing with a near-patient meter.
  2. The Type of diabetes is established accurately.
  3. The correct initial management plan is followed.


The following patients are those in whom the differential diagnosis of early Type 1 or Type 2 Diabetes is difficult and need careful review:

  1. Patients with osmotic symptoms
  2. Patients with significant weight loss out of keeping with any lifestyle changes


Any such patient should have urine or blood ketone measurement.

All such patients found to have raised ketones in urine or blood (≥ 0.6 mmol/L ) should be discussed by telephone immediately with the on-call diabetes, general medical or paediatric team.


All newly diagnosed patients who are systemically unwell, in particular with vomiting or drowsiness, and have high blood glucose readings, regardless of blood or urinary ketone levels, should be discussed with the Acute Medical Team with a view to urgent admission.

Any patient about whom you are concerned can be referred to outpatient services by RMS or discussed with the on-call Diabetes team by telephone if required. If osmotic symptoms don’t settle or weight loss continues after initial management for ~ one month (see below), the referral should be marked “urgent”. All such patients should continue to have ketones checked until symptoms or weight loss resolves.

All newly diagnosed patients presenting with osmotic symptoms who do not have raised blood or urinary ketones, and all newly diagnosed patients aged less than 40 should have blood tested for (a) Anti-GAD Antibodies & (b) C- Peptide levels.


Initial Management in Primary Care of newly diagnosed patients presenting with osmotic symptoms who do not have raised blood or urinary ketones.

  • Encouraging high intake of sugar-free fluids and dietary change are key early measures in helping to improve symptoms.
  • All such patients should have blood glucose AND blood or urine ketones measured regularly, preferably by self-testing using a meter – appropriate meters and advice on test-strips can be provided via the DSN service (Phone 01382 632293). Such regular testing should continue until glucose levels have stabilised and symptoms settled.
  • Sulphonylurea drugs such as gliclazide have a relatively rapid glucose lowering effect, compared with other oral glucose lowering agents whose effect may not be optimal for several weeks. Gliclazide can be commenced immediately – usually considering an initial dose of 40mg bd (40mg od in the elderly) but considering up-titration in weekly increments to 80mg bd, dependent on home blood glucose readings and symptoms.
  • Metformin is the usual first line drug in the management of Type 2 Diabetes, but has a slow onset of action. Metformin should be added to gliclazide immediately, initially at a dose of 500mg od but titrated up over 4-6 weeks to 1g bd or its maximum tolerated dose.
  • Over the first four months, as metformin increases its effect, blood glucose levels may continue to fall and down-titration or eventual discontinuation of gliclazide may be necessary.