DIABETES MELLITUS
Ahmed Al-Naher
FY2 Coventry
Case Scenario
• 52 male presents to GP with 3/12 lethargy and 2/52 thirsty
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and drinking more than normal.
PMH HTN
Drinks alcohol socially, non-smoker
BMI 32
Urine Dip: glucose +++
Random Blood Sugar = 13
Contents
• Diagnosis
• Risk Factors
• Complications
• Investigations
• Management
• DKA + HONK
Type 1 vs Type 2
• Type 1 = Inability to produce insulin (autoimmune process
against beta islet pancreas cells)
• Type 2 = insensitivity to insulin over time
• Gestational Diabetes = decreased insulin sensitivity
during pregnancy
• Secondary Diabetes:
• Pancreatic Disease/CF/Chronic Pancreaitis/Pancreatic Ca
• Steroid use/ antipsychotics/ thiazide diuretics
Diagnosis
• Random Glucose >11.1 mmol/L
• Fasting Glucose >7 mmol/L
• 2x Fasting glucose samples to confirm
• Or presence of symptoms
• HbA1c >6.5% (48mmol/L)
• OGTT – two hour glucose after 75g glucose
• IGT = normal fasting glucose and OGTT between 7-11
• IFG = OGTT <7.8 but fasting glucose 6.1 – 6.9
Risk Factors
• T1: Family Hx, Caucasian/Scandinavian, Juvenile onset
• T2:
• High BMI
• Physical inactivity
• South Asian/Afro-carribean/middle-eastern
• Hx of gestational diabetes, IGT, IFG
• Steroid use
• PCOS
• Family Hx
Presentation
• Polyuria
• Polydipsia
• Lethargy
• Recurrent infections
• Complications
• DKA (T1)
• HONK (T2)
Presentation - case
• 67 male admitted feeling generally unwell, SOB, sweating
and lethargic over last 2 days.
• He is a known Type 2 diabetic on insulin with PVD,
peripheral neuropathy and previous CVA. His BM is 5.6.
• ECG showed residual ST elevation in anterior leads with
Q wave and reciprocal changes. Echo showed new septal
hypokinesia
• The patient had no history of chest pain
Complications
• Macrovascular: Stroke, MI, PVD
• Retinopathy, Xanthelasma, Cataracts, Opthalmoplegia,
maculopathy
• Peripheral Neuropathy, Diabetic amyotrophy, neuropathic
pain, Autonomic neuropathy
• Nephropathy
• Recurrent infections: Cellulitis, UTI, Thrush
Investigations
• Bedside:
• Urine Dip: Glucose, ketones, MC+S
• BM Stix, Ketone Stix
• ECG, BP
• Neuro, eye, foot exam
• ACR, eGFR, microalbuminuria
• Injection sites
• Bloods - HbA1c, lactate, pH, U+E, Lipids, LFT, TFT
Managing Risk Factors
• Lifestyle – Weight loss, Exercise
• Education – DESMOND (Diabetes Education and Self
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Management for Ongoing and Newly Diagnosed)
Self-Monitoring of BM
Dietician, Low sugar diet
Smoking cessation
Foot Care
Eye screening
BP Control: ACEi, CCB, Diuretic, K sparing
Statins, Fibrates
Aspirin
Oral Hypoglycaemics
• Biguanides – increase insulin sensitivity: Metformin
• Sulphonylureas: Gliclazide, Glibenclamide
• Meglitinides: Repaglinide, Nateglinide
• Thiazolidinediones: Pioglitazone
• DDP-4 inhibitors: Sitagliptin, Vildagliptin
• GLP-1 Agonists: Exenatide, Liraglutide
• Orlistat
• Ascarbose
Treatment Pathway
• 1) Lifestyle Interventions
• 2) Metformin
• 3) Metformin + sulphonylurea
• 4) Metformin + sulphonylurea + Thiazolidinedione or
GLP-1 agonist or DDP-4 inhibitor
• 4) Metformin + sulphonylurea + insulin
• 5) Increase insulin
Insulin Types
• Rapid-acting: Lispro (Humalog), Aspart (Novorapid)
• Short-acting: Soluble Insulin (Actrapid)
• Intermediate Acting: NPH (Insulatard)
• Long-acting: Glargine (Lantus), Detemir (Levemir)
• Ultra long-acting: Degludec
• Pre-mixed: Novomix 30, Humalog Mix25, Humumlin M3
• Regimens:
• Once Nightly
• Twice Daily Biphasic
• Basal Bolus
• Continuous Pump
Prognosis
• T1 = increased risk of blindness, ESRF, CVD
• Control of BP, Lipids, BM and weight are prognostic
• T2 = 75% die of heart disease 15% die of stroke
• Every 1% rise in HbA1c level risk of diabetes related
death increases by 21%
Case Scenario
• 58 female T2DM, Portuguese, does not speak English,
not complying with medication or dietary advice, admitted
with hyperglycaemia and seizures. Continues to have
high BMs of >25 on wards and wishes to self-discharge.
• She has severe retinopathy blindness and PVD and no
carers at home. She is prescribed a pre-mix regimen.
• What are the obstacles to safe management of this
patient?
• What services/ support can be arranged?
Medical Emergency: Hypoglycaemia
• BM < 3
• Symptoms: low GCS, seizures, clammy, sweaty,
tachycardic, behaviour change, slurred speech, shaking
• Risk: Strict BM control, Alcohol, malabsorption, Renal
failure, medication, lipohypertrophy, hypothyroid
• GlucoJuice/Glucotab 10-20g
• GlucoGel (Hypostop)
• 10% Dexrose IV 150-250ml
• Glucagon 1mg IM/SC
• Cerebral Oedema: Mannitol, Dexamethasone, 50% Dex
Medical Emergency: DKA
• Hyperglycaemia, Ketonaemia, Acidosis
• Ketones >3mmol/L
• BM >11
• pH <7.3, HCO3 <15
• Triggered by stress: Infection, Poor compliance,
endocrine crises, CVD, Alcohol, medication
DKA signs
• Polydipsia, polyuria
• Weight loss, lethargy
• Vomiting, Abdo pain
• SOB (Kussmaul’s respiration)
• Low GCS, confusion
• Dehydration: dry mucus membranes, reduced skin turgor,
sunken eyes, slow cap refill, tachycardia, low BP
• Pear Drop Breath
• Signs of infection: Fever, crackles, cellulitis
• Increased osmolality and anion gap
Specific investigations
• Serial BMs and Ketones
• Serial ABGs or VBGs
• Septic Screen: BCM, Urine Dip, CXR
• U+E including K
• Trop T, CK
• ECG
• Amylase
• CT Head
• Monitor BM, Ketones, Acidosis, mental state, fluid status
DKA Resuscitation
• Correct dehydration: Fast NaCl 0.9% initially
• Fixed Rate insulin infusion: 0.1 unit/kg
• Reduce BM ~3/hr to avoid cerebral oedema
• Continue baseline long acting insulin
• Run with NaCl 0.9% + KCl if <5.5
• 10% glucose once BM <14
• Treat underlying cause
• Once E+D convert back to normal insulin + DSN r/w
• Indications for ITU: haemodynamic instability, cardiogenic
shock, respiratory failure, severe acidosis, coma
Complications
• Cerebral oedema: headache, confusion, urinary
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incontinence, coma – main mortality in children
Hypoglycaemia – arrhythmia, coma
Hypokalaemia – cardiac arrhythmia
VTE
Retinopathy
ARDS/ Pulmonary oedema
• Prognosis worsens with age, low GCS
Medical Emergency: HONK
• T2DM
• Hyperglycaemia, high serum osmolality, no ketosis
• Osmotic diuresis -> intracellular dehydration
• Triggers: Infection, poor BM control, MI, CVA, endocrine
crises, Acute abdo, medication, metformin, alcohol, first
presentation
• Old age, dementia, steroid use
• Severe Dehydration
• Low GCS, confusion, seizures
• Lethargy, weakness
• Abdo Pain, N+V
HONK Mx
• Ix as for DKA
• Initial Fluid resuscitation
• Variable Rate Insulin infusion
• Run with 8 hourly NaCl + KCl
• Treat underlying cause
• Review medication
• LMWH
Final Case
• 87 yo male from nursing home with known glioblastoma
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multiforme admitted with worsening confusion, reduced
mobility and polyuria.
CT shows no new haemorrhage, infarct or mass effect
DHx frusemide, aspirin and dexamethasone
pH 7.2 lactate 2.9 BM 32
Urine: Blood + Leuk + Gluc +++ Nitrites +
• Initial management?
• Long-term treatment plan?
Questions?
• http://integrate.ccretherapeutics.org.au/Calculator/UkPds.
aspx