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Is it type 2 diabetes?

Is it type 2 diabetes?. Gerry Rayman. More dramatic presentation- short history of severe polydipsia & polyuria Younger Weight loss Ketones Strong FH of Type 1. Often no osmotic symptoms Age related More common amongst certain ethnic groups

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Is it type 2 diabetes?

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  1. Is it type 2 diabetes? Gerry Rayman

  2. More dramatic presentation- short history of severe polydipsia & polyuria Younger Weight loss Ketones Strong FH of Type 1 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 vs Type 2

  3. 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

  4. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Other ? • Not diabetic? • What else would you like to know?

  5. 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

  6. 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

  7. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Other ? • Not diabetic? • If none of above what else would you like to know?

  8. Criteria for the diagnosis of diabetes 1. HbA1C ≥ %. OR 2. FPG ≥ mmol/l OR 3. 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).

  9. Criteria for the diagnosis of diabetes 1. HbA1C ≥6.5%. OR 2. FPG ≥ mmol/l OR 3. 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).

  10. Criteria for the diagnosis of diabetes 1. HbA1C ≥6.5%. OR 2. FPG ≥ 7.0 mmol/l OR 3. 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).

  11. Criteria for the diagnosis of diabetes 1. HbA1C ≥6.5%. OR 2. FPG ≥ 7.0 mmol/l OR 3. 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).

  12. Criteria for the diagnosis of diabetes 1. HbA1C ≥6.5%. OR 2. FPG ≥ 7.0 mmol/l OR 3. 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.

  13. Initial management • Diet and exercise • 12 months later HbA1c 7.2% on metformin 500 mg bd • Lethargic but pleased at loss of 5 kilos

  14. 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%

  15. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Other ? • What else would you like to do ?

  16. 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.

  17. Allen’s ladder Elizabeth Hughes Clung to life for 2 yrs weighed 45 lb at age of 16yr

  18. 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%

  19. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Not diabetic? • Any additional questions you would like to ask?

  20. 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)

  21. 15.0 10.0 5.0

  22. 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%)

  23. 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

  24. 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.

  25. 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

  26. 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

  27. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Other ? • What would you do ?

  28. 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

  29. 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

  30. Type 1 or Type 2 • Type 1? • Type 2? • Unsure ? • Other ?

  31. 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

  32. 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

  33. 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

  34. Etiologic classification of diabetes mellitus •  I. Type 1 diabetes • II. Type 2 diabetes • III. Other specific types • Genetic defects of b-cell function • MODY 3 (Chromosome 12, HNF-1a) • MODY 1 (Chromosome 20, HNF-4a) • MODY 2 (Chromosome 7, glucokinase) • 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

  35. 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

  36. 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

  37. 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.

  38. 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.

  39. 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 Mayafter discussion with Practice nurse referred • HbA1c >14.0% • Now asymptomatic and managing well on insulin

  40. The Theresa May Syndrome!

  41. 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 approach- sniff out what is not quite right

  42. 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

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