Maeve C. Durkan MBBS.FACP, Mmed.Ed Consultant in Diabetes, Endocrinology & Metabolism
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Transcript of Maeve C. Durkan MBBS.FACP, Mmed.Ed Consultant in Diabetes, Endocrinology & Metabolism
Dr Maeve Durkan & Dr Eoin O’SullivanThe Cork Diabetes & Endocrinology
Group Bon Secours Hospital, Cork
Maeve C. Durkan MBBS.FACP, Mmed.Ed
Consultant in Diabetes, Endocrinology & Metabolism
The Challenge of The Friday Evening Patient
• What defines the emergency ?
• DM – Is it DM1 or DM2 / How to call it ?
• Severe Hypoglycemia – Do we need to admit ?
• - Do we need to refer ?
• Newly presenting patient with hyperglycemia
• The Changing phenotype of DM1
• The Changing demographic of DM2
Newly presenting patient with Hyperglycemia
Is it DM1, DM2, DM2 & Glucose toxicity
• 23 Year old female• 2-3 days polyuria, polydypsia,nocturia• No weight loss• No medical history• No family history• BMI 20• Blood sugar 14 ? What next ?
DM1, DM2,Glucose toxicity
• Any testing for immediacy ?
• Any testing for future ?
• What are options initially– Metformin– Sulphonyurea– Insulin– Diet & Exercise
The Challenge
• Physical exam
• Vital signs Pulse, RR, BP
• Smell
• Urine Ketones 1+ vs 4+ Does it matter ?
• Serum Ketones …Do you check ?
DM1, DM2,Glucose toxicity
•What are options initially as 1ST Line
– Metformin– Sulphonyurea– Insulin– Diet & Exercise
Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity
• 45 Year old male• 2-3 days polyuria, polydypsia,nocturia• No weight loss• No medical history• No family history• BMI 30• Blood sugar 14 ? What next ?
Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity
• 61 Year old female• 6 weeks polyuria, polydypsia,nocturia• 2 stone weight loss• No medical history• No family history• BMI 24• Blood sugar 24 / HbA1c 13.9%• What next ?
Patient referred/ seen 6 weeks later
• Started on Janumet 50/850 BD• Symptoms settled• Weight plateaued• HbA1c 7.9%
• What do you think now ?
Anti-GAD-65 positive
What next ?
Anti-65-Antibody highly positive
• Is this DM1 ?
• Is this LADA ?
• Would I do things differently ?
Newly presenting patient with Hyperglycemia
Is it DM1, DM2, DM2 & Glucose toxicity• 45 Year old male• 2-3 months polyuria, polydypsia , nocturia• Some weight loss• No medical history ( doesn’t attend GP regularly)• Family history DM2• BMI 35. Feels well • Blood sugar 24 ? What next ?
Newly presenting patient with Hyperglycemia
Is it DM1, DM2, DM2 & Glucose toxicity
• 45 Year old male• 2-3 months polyuria, polydypsia,nocturia• Some weight loss• No medical history ( doesn’t attend GP regularly)• Family history DM2• BMI 35. Feels unwell • Blood sugar 24 ? What next ?
Changing phenotype of DM1 Honeymoon, βcell regeneration , MODY ?
• 15 year old boy
• Polyuria & Polydipsia x 2-3 days hot weather
• Lean BMI 22
• No medical history ,
• Family history DM2 (father lean )
• BSugar 22 ,No ketones, (Biacarb normal)
DM1 or MODY? Or DM2
Father Insists on Diet• Sugars recorded as relatively normal on f/up
• HbA1c 6.5% - 7% x 2 years
• Drifting on A1c & commenced on Glucophage
• Well controlled by 18 months
• Within 12 – 18 months : Hba1c 10% & Weight loss
Anti-GAD 65-Antibody highly positive
• Is this DM1 ?
• Is this LADA ?
• How did he survive for so long without insulin?
• Would I do things differently ?
Glycemic Control as a Medical emergency
DM1 & DM2
28 year old, DM 1 , BS 28 mmol
Is this an emergency ?
How do we evaluate clinically ?
What are the precipitants ?
Criteria for hospital admission ?
28 years, DM1, 28 mmol
• Acute, chronic
• Profiles
• Preceding history– Well /Unwell – Symptoms : Polyuria, polydypsia,nocturia– Febrile, chest pain,– Nausea, vomiting, diarrhea– Anorexia ( Taking or discontinued insulin )
• Clinical impression : Well/ toxic/ Mental status
Clinical Signs
• Vital signs– Pulse : Tachycardia– Respiratory Rate : Tachypnoea– BP : Hypotension– Temperature : Febrile
• Acetone Smell
28 year old, DM 1 , BS 28 mmol
• Scenario 1• Well • Profiles : Good • 28 mmol today • Missed lunchtime dose !• No constitutional
symptoms• P 70, RR 18,BP 120/80 • No postural drop
• Scenario 2• Feels unwell• Profiles high x 2 days• Malaise x 24 hours• Nausea, anorexia• Held insulin...
– Because not eating!
• Polyuria,polydypsia• P 88, RR 24 , BP 110/70• Postural drop
Investigations
• Serum ketones
• Urine ketones
• Glucose• ABG• Serum bicarbonate• K+• Anion Gap• Phos• Mg
• ECG
Causes DKA : 4 i’s
• Infection
• Infarction
• Incompliance
• IDDM*
• Urinalysis / FBC
• ECG/ Enzymes
• Profiles / History
Severe Hypoglycemia
Is Admission Necessary ?
Is all Hypoglycemia the same ?
• New
• Timing
• Severity
• Frequency
• Management
• Awareness
• Co-morbidities ( CAD)
• Identifiable precipitants … exercise, shopping
The Hypoglycemic Patient !
• 28 year old patient with DM1• Presents at clinic• Wife noticed “ a bit off “• Blood Glucose 1.8
• What to do ?• Treat … and how ?• Treat successfully …and send home ?
36 year old Male
• DM 1 x 20 years• No complications• HbA1c 7.9-8.3%• Hypoglycemic events ‘ not an issue’• 4 episodes in last 12 months• No hospital admission
• ‘Those low blood sugars creep up on you ‘
38 year old female
• DM1 x 20 years
• No complications
• ‘Is a blood sugar of 2mmol to worry about’?
• Had driven 50 miles in car. BS 1.8 on arrival.
• No symptoms
28 year old female
• DM1 x 10 years
• Likes good control
• HbA1c 5.8%
• FBS 4, 2-hour 5-6
• No hypoglycemic episodes of concern
• Handbag falls open : Bottle of coke!
• “That’s for when I go low ”
26 year old male
• DM1 x 8 years
• No complications
• Always well controlled . hbA1c 7%
• No history hypoglycemia
• Now : Recurrent hypoglycemia x 3 weeks
• No intervention required
• What do you think ?
Hypoglycemia
• Aware
• Mild• Moderate• Severe
• Frequency• Requiring Intervention• Timing
• Unaware
• No gradation• Critical• Need to reset !
Nocturnal Hypoglycemia
The Thief in The Night !