Is it type 2 diabetes?
Gerry Rayman
Type 1
vs
• More dramatic presentationshort history of severe
polydipsia & polyuria
• Younger
• Weight loss
• Ketones
• Strong FH of Type 1
Type 2
• Often no osmotic symptoms
• Age related
• More common amongst
certain ethnic groups
• Central obesity & other
features of metabolic
syndrome
• FH of Type 2
type 1 or type 2
• 32 yr old woman presents with 6 months of
lethargy and recurrent thrush
• Random blood glucose 11 mmol/l, BMI 27
• FH of type 2 diabetes in both parental GM
• No ketones
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Other ?
• Not diabetic?
• What else would you like to know?
Type 1 or Type 2
• 32 yr old woman presents with 6 months of
lethargy and recurrent thrush
• Random blood glucose 11 mmol/l, BMI 27
• FH of type 2 diabetes in both parental GM
• No ketones
Type 1 or Type 2
• 32 yr old woman presents with 6 months of
lethargy and recurrent thrush
• Random blood glucose 11 mmol/l, 76 kg, BMI 27
• FH of type 2 diabetes in both parental GM
• No ketones
• FBG 8.0
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Other ?
• Not diabetic?
• If none of above what else would you like to know?
Criteria for the diagnosis of diabetes
1.
2.
3.
HbA1C ≥ %.
OR
FPG ≥ mmol/l
OR
2-h plasma ≥ mmol/l) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma ≥ 11.1 mmol/l).
Criteria for the diagnosis of diabetes
1.
2.
3.
HbA1C ≥6.5%.
OR
FPG ≥ mmol/l
OR
2-h plasma ≥ mmol/l) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma ≥ 11.1 mmol/l).
Criteria for the diagnosis of diabetes
1.
2.
3.
HbA1C ≥6.5%.
OR
FPG ≥ 7.0 mmol/l
OR
2-h plasma ≥ mmol/l) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma ≥ 11.1 mmol/l).
Criteria for the diagnosis of diabetes
1.
2.
3.
HbA1C ≥6.5%.
OR
FPG ≥ 7.0 mmol/l
OR
2-h plasma ≥ 11.1mmol/l) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma ≥ 11.1 mmol/l).
Criteria for the diagnosis of diabetes
1.
2.
3.
HbA1C ≥6.5%.
OR
FPG ≥ 7.0 mmol/l
OR
2-h plasma ≥ 11.1mmol/l) during an OGTT.
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a
random plasma ≥ 11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be
confirmed by repeat testing.
Initial management
• Diet and exercise
• 12 months later HbA1c 7.2% on metformin 500
mg bd
• Lethargic but pleased at loss of 5 kilos
18 months since diagnosed
•
•
•
•
•
•
Weight reduced another 3 kg (BMI 24)
On maximum doses of metformin & gliclazide
Feeling ‘crap’
Thrush persists
Frequently off work
HbA1c 7.4%
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Other ?
• What else would you like to do ?
Case 1
• Refer her to the Diabetes Centre.
• 18 months of feeling crap with recurrent thrush,
8 kg weight loss, a BMI now 22 and only
adequate control despite max OHA
• Even though HbA1c satisfactory she must have
type 1 diabetes
• GAD (Glutamic Acid Decarboxylase) antibodies
>1000
• Within 4 weeks of insulin therapy remarkable
improvement in life.
Allen’s ladder
Elizabeth Hughes
Clung to life for 2
yrs weighed 45 lb
at age of 16yr
Case 2
• 29 yr man- BMI 24
• Age 17 yr, episode of ‘slightly’ high glucose when
had glandular fever (Romford)
• FGB 6.9 2011
• FBG 6.7 2012
• FBG 7.5 2013 HbA1c 7.2%
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Not diabetic?
• Any additional questions you would like to ask?
Case 2
• FH father diagnosed age 40 only ever diet
controlled and paternal GM diet controlled age
97
• OGTT 2008 Basal 7.5 2 hour 7.3 mmol/L
(HbA1c 7.3)
15.0
10.0
5.0
Case 3
•
•
•
•
27 yr old female- BMI 24
Attending DESMOND training
Diagnosed type 2 following
OGTT 2012 Basal 7.2 and 2 hour 8.4 mmol/L
(HbA1c 6.8%)
Case 3
•
•
•
•
27 yr old female- BMI 24
Attending DESMOND training
Diagnosed type 2 following
OGTT 2012 Basal 7.2 and 2 hour 8.4 mmol/L
(HbA1c 6.8%)
• FH mother, maternal aunt and grandmother
What is Maturity-Onset Diabetes of
the Young?
• Maturity-Onset Diabetes of the Young or MODY affects 1-2%
of people with diabetes, although it often goes unrecognised.
The 3 main features of MODY are:
• Diabetes that develops before the age of 25
• Runs in families from one generation to the next
• Diabetes may be treated by diet or tablets and does not always
need insulin treatment
• Autosomal Dominant Inheritance. All children of an affected
parent with MODY have a 50% chance of inheriting the
affected gene and developing MODY themselves.
Why is it important to recognise it?
• There are different types of MODY for which the
treatments are quite different.
• The progression and risk of complications is different for
each type and quite different from type 1 and 2 diabetes.
• As it runs in families, it is important to advise other
family members of their risk of inheriting it.
• Pregnancy
Case 4
• 37 yr old who had insulin requiring gestational
diabetes in 2005 and 2009
• Over 18 months, persistent lethargy, stone
weight loss, thrush, nocturia x 3.
• Presents with ear infection, BMI 28- random
glucose 17.2
• Started on metformin
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Other ?
• What would you do ?
Case 4
• 3 months later referred- HbA1c 10.4
• Started on basal/bolus insulin
• 4 months later- resolution of thrush, nocturia
and lethargy.
• Most recent HbA1c 5.6%
• GAD antibodies >2000
Case 5
• Mrs A C aged 51
• Presents with 18/12 recurrent thrush, thirst, polyuria, nocturia x 3.
• PMH hypertension, depression, osteoporosis (traumatic wrist
fracture)
• FH- mother type 2 diabetes developed aged 79
• Medications- Ramipril, bendroflumethiazide, simvastatin,
alendronate
• BMI 32 and 8 kg gain in the last 2 yrs
• HbA1c 7.9%, FBG 8.9
Type 1 or Type 2
• Type 1?
• Type 2?
• Unsure ?
• Other ?
Case 5
• Mrs A C aged 51
• Presents with 18/12 recurrent thrush, thirst, polyuria, nocturia x 3.
• PMH hypertension, depression, osteoporosis (traumatic wrist
fracture)
• FH- mother type 2 diabetes developed aged 79
• Medications- Ramipril, bendroflumethiazide, simvastatin,
alendronate
• BMI 32 and 8 kg gain in the last 2 yrs
• HbA1c 7.9%, FBG 8.9
Case 5
• Mrs A C aged 51
• Presents with 18/12 recurrent thrush, thirst, polyuria, nocturia x 3.
• PMH hypertension, depression, osteoporosis (traumatic wrist
fracture)
• FH- mother type 2 diabetes developed aged 79
• Medications- Ramipril, bendroflumethiazide, simvastatin,
alendronate
• BMI 32 and 8 kg gain in the last 2 yrs
• HbA1c 7.9%, FBG 8.9
Case 5
• Mrs A C aged 51
• Presents with 18/12 recurrent thrush, thirst, polyuria, nocturia x 3.
• PMH hypertension, depression, osteoporosis (traumatic wrist
fracture)
• FH- mother type 2 diabetes developed aged 79
• Medications- Ramipril, bendroflumethiazide, simvastatin,
alendronate
• BMI 32 and 8 kg gain in the last 2 yrs
• HbA1c 7.9%, FBG 8.9
• DIAGNOSIS – Cushing’s Syndrome
Etiologic classification of diabetes mellitus
I. Type 1 diabetes
II. Type 2 diabetes
III. Other specific types
A. Genetic defects of b-cell function
1. MODY 3 (Chromosome 12, HNF-1a)
2. MODY 1 (Chromosome 20, HNF-4a)
3. MODY 2 (Chromosome 7, glucokinase)
4. HNF-1B (renal cysts-hepatocyte nuclear factor-1ß gene)
Other very rare forms of MODY
5. Transient neonatal diabetes (most commonly ZAC/HYAMI
imprinting defect on 6q24)
6. Permanent neonatal diabetes (KCNJ11gene encoding
Kir6.2 subunit of b-cell KATP channel)
7. Mitochondrial DNA
8. Others
B. Genetic defects in insulin action
Type A insulin resistance, Leprechaunism, Rabson-Mendenhall
syndrome, Lipoatrophic diabetes
C. Diseases of the exocrine pancreas
1. Pancreatitis
2. Trauma/pancreatectomy
3. Neoplasia (presenting with DM or existing DM that worsen)
4. Cystic fibrosis
5. Haemochromatosis
D. Endocrinopathies
1. Acromegaly
2. Cushing’s syndrome
3. Glucagonoma
4. Pheochromocytoma
5. Hyperthyroidism
6. Somatostatinoma
7. Aldosteronoma
8. Others
E. Drug or chemical induced
Vacor, Pentamidine, Nicotinic acid, Glucocorticoids, Thyroid hormone,
Diazoxide, b-Adrenergic agonist, Thiazides, Dilantin, g-Interferon, Statins
F. Infections
1. Congenital rubella
2. Cytomegalovirus
G. Uncommon forms of immune-mediated diabetes
1. “Stiff-man” syndrome
2. Anti-insulin receptor antibodies
H. Other genetic syndromes sometimes associated with diabetes
1. Down syndrome
2. Klinefelter syndrome
3. Turner syndrome
4. Wolfram syndrome (DIDMOAD)
5. Friedreich ataxia
6. Huntington chorea
7. Laurence-Moon-Biedl syndrome
8. Myotonic dystrophy
9. Porphyria
10. Prader-Willi syndrome
Case 6
• "It started last November. I'd had a bad cold and
cough. My GP did a blood test which showed a very
high sugar level - that's what revealed the diabetes.
• "The symptoms were tiredness, and drinking a lot of
water. But I do anyway.
• "There was weight loss but then I was already
making an effort to be careful about diet and to get
my gym sessions in.
• "Tiredness is part of the job. It is full on."
• Initially doctors thought I had Type 2 diabetes but 6
months later it was revealed to be Type 1 diabetes.
Case 6
• "It started last November. I'd had a bad cold and
cough. My GP did a blood test which showed a very
high sugar level - that's what revealed the diabetes.
• "The symptoms were tiredness, and drinking a lot of
water. But I do anyway.
• "There was weight loss but then I was already
making an effort to be careful about diet and to get
my gym sessions in.
• "Tiredness is part of the job. It is full on."
• Initially doctors thought I had Type 2 diabetes but 6
months later it was revealed to be Type 1 diabetes.
Case 7
• Macey aged 48 yr
• Trying to loose weight since Xmas 2012
• May, presented to GP with dramatic weight loss
over 2 month & thirst
• Diagnosed as type 2 diabetes and started on MF
• Read about Theresa May after discussion with
Practice nurse referred
• HbA1c >14.0%
• Now asymptomatic and managing well on
insulin
The Theresa May Syndrome!
What is the message
• 95% of patients will have type 2 diabetes but
1/20 will not
• The 5% are important
• How do we spot these?
• Think laterally- the mistake is to think “adults
have type 2 and children type 1, so this adult
must have type 2”
• You need to have the Sherlock Homes approachsniff out what is not quite right
Making the annual foot examination
assessment more interesting and
effective
• Using it to assess patient’s knowledge
• To educate the patient
• To have them on the right care pathway
Incidents per 1000 prevalent cases by CCG
Type 1 or Type 2
14 yr old caucasian girl presents with moderate thirst, polyuria, nocturia X3-4,
listleness
Blood glucose 32 mmol/l
Ketones +
BMI 32
Mother Type 2 diabetes BMI 34
What would be the correct approach?
Treat as type 1 diabetes
Treat as type 2 diabetes
Not sure- start on insulin
Not sure- diet and sulphonylurea
Not sure- diet and metformin
Type 2 diabetes
Very high c-peptide and insulin levels
Negative insulin anti-bodies
Managed on insulin and metformin
Acanthosis Nigricans