Newly diagnosed type 2 diabetes in a lorry driver: negotiating insulin
Mr David Chen, 48, has newly diagnosed type 2 diabetes. HbA1c 86 mmol/mol (10.0%), BMI 33 kg/m², BP 148/92 mmHg, eGFR 90. He has no osmotic symptoms and his weight has been stable. He takes metformin 1 g twice daily. He holds a Group 2 (HGV) licence and drives long distances with irregular shifts; he often eats at service stations. His wife cooks at weekends. He is worried that starting insulin will mean losing his licence because a colleague with diabetes 'had his licence taken away'. He asks for 'tablets only' and proposes a very low-carbohydrate diet for three months before considering any change. He has no history of severe hypoglycaemia, no retinopathy on recent screening, and no cardiovascular disease. He is tearful when discussing work.
1. How would you open the consultation and explore his concerns? Give example phrases.
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I would start with an open question and set the agenda: 'What were you hoping we could cover today?' Then explore his ideas, concerns and expectations: 'What have you heard about insulin and your licence?' and 'What worries you most about starting it?' I would reflect his emotion - he is tearful - and avoid saying 'don't worry' before understanding the concern. I would ask specifically about his work patterns, what his colleague experienced, and what he has read or been told. I would summarise: 'So the biggest fear is losing your HGV licence, and you want to try diet first.' This shows I have listened and lets me correct misinformation later. I would also ask about symptoms, home glucose readings and what support he has at home, because the conversation about treatment options depends on whether he is catabolic or asymptomatic.
2. He says 'I can't go on insulin - I'll lose my job.' How would you respond, and what can you realistically offer him today?
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I would respond with empathy first: 'I can hear how frightening that is, and it makes sense that you are thinking about your job.' Then I would separate the fear from the facts: insulin treatment does need to be declared to the DVLA for a Group 2 licence and can affect licensing, but it is not an automatic loss of licence; the DVLA assesses diabetes control and hypoglycaemia risk. I would check the current guidance with him rather than rely on his colleague's story. I would not promise that he can avoid insulin. Given his HbA1c of 86 mmol/mol but no osmotic symptoms and stable weight, I would discuss a time-limited trial of an additional agent such as a GLP-1 receptor agonist if clinically appropriate, alongside dietitian support, with a clear review date. If insulin becomes necessary, I would involve the diabetes specialist team early and discuss the DVLA implications honestly.
3. What safety-netting and follow-up would you agree, given his shift patterns?
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I would agree: a review within 2–4 weeks, not three months, because his HbA1c is high; a dietitian referral; and a clear plan for checking glucose. Safety-netting would include: stop driving and seek advice if he feels hypoglycaemic; keep fast-acting carbohydrate in the cab; tell his employer only as required; check DVLA rules before any treatment change; and contact the practice if he develops thirst, weight loss or blurred vision. With irregular shifts, I would discuss timing of medication around driving and meals, and avoid a sulphonylurea if hypoglycaemia would be dangerous for his licence unless we have a clear monitoring plan. I would document what we agreed and give him written information.