The Friday evening patient

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Dr Maeve Durkan & Dr Eoin O’Sullivan
The 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 ?
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- 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
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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
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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
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Metformin
Sulphonyurea
Insulin
Diet & Exercise
Newly presenting patient with Hyperglycemia
Is it DM1, DM2, DM2 & Glucose toxicity
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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 Hyperglycemia
Is it DM1, DM2, DM2 & Glucose toxicity
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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
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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
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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
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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 ?
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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
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Scenario 1
Well
Profiles : Good
28 mmol today
Missed lunchtime dose !
No constitutional
symptoms
• P 70, RR 18,BP 120/80
• No postural drop
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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
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Glucose
ABG
Serum bicarbonate
K+
Anion Gap
Phos
Mg
• ECG
Causes DKA : 4 i’s
• Infection
• Urinalysis / FBC
• Infarction
• ECG/ Enzymes
• Incompliance
• Profiles / History
• IDDM*
Severe Hypoglycemia
Is Admission Necessary ?
Is all Hypoglycemia the same ?
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New
Timing
Severity
Frequency
Management
Awareness
Co-morbidities ( CAD)
Identifiable precipitants … exercise, shopping
The Hypoglycemic Patient !
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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
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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
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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
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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
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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
• Unaware
• Mild
• Moderate
• Severe
• No gradation
• Critical
• Need to reset !
• Frequency
• Requiring Intervention
• Timing
Nocturnal Hypoglycemia
The Thief in The Night !
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