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A new patient with type 2 diabetes: What should I do

Clinical Scenario 1. 45 year old manHGV driver2 stone weight loss6 month history of increasing thirst and polyuriaSmokes 20 cigarettes per dayAdmits to drinking 10 units of alcohol per dayBMI 32Saw GP 2 years ago for ED tried sildenafil unsuccessfully, was advised to lose weightNo family h

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A new patient with type 2 diabetes: What should I do

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    1. A new patient with type 2 diabetes: What should I do? Dr Craig Parkinson Department of Diabetes and Endocrinology The Ipswich Hospital 12th Jan 2010

    2. Clinical Scenario 1 45 year old man HGV driver 2 stone weight loss 6 month history of increasing thirst and polyuria Smokes 20 cigarettes per day Admits to drinking 10 units of alcohol per day BMI 32 Saw GP 2 years ago for ED – tried sildenafil unsuccessfully, was advised to lose weight No family history of type 2 diabetes Urinary analysis shows ++++ glycosuria, no ketones Random glucose 18 mmol/l Admission to hospital in Newcastle 5 weeks ago with abdominal pain – no further details known

    3. Clinical Scenario 2 36 year old woman Accountant Seeks medical advice regarding pregnancy Oligo-amenorrhoea for 3 years BMI 36 Screening investigations reveal glucose of 9.8 mmol/l OGTT shows 2 hour value of 12.1 mmol/l, HBA1c 8.7% Urine analysis reveals ++ proteinuria BP 150/88 Strong family history of type 2 diabetes – mother and brother affected Strong family history of ischaemic heart disease (mother MI aged 50)

    4. Clinical Scenario 3 40 year old woman Teacher Seeks medical advice regarding vaginal thrush Treated unsuccessfully with OTC therapies Admits to a 3 week history of tiredness, weight loss of 4 kg and thirst, polyuria and nocturia Blurred vision BMI 32 Screening investigations reveal glucose of 15.9 mmol/l No family history of type 2 diabetes

    5. Clinical Scenario 4 68 year old man Retired bank manager Routine assessment in well man clinic Incidental finding of a fasting glucose of 17mmol/l HBA1c 11% Microalbuminuria positive (ACR 7) BP 156/82 despite ramipril 10mg, amlodipine 10mg, bendroflumethazide 2.5mg and doxazosin 4mg daily eGFR 34 Known ischaemic heart disease – MI 2 years ago, poor LV function on ECHO. BMI 42 Has tried to lose weight using orlistat but could not tolerate this

    6. Confirm the Diagnosis Consider stress hyperglycaemia if patient unwell Diagnostic tests for diabetes (WHO criteria) Fasting glucose of =7mmol/l If asymptomatic confirm with second test OGTT (must be performed correctly) Fast from midnight 75g oral glucose in 300m of water Baseline venous plasma glucose and at 2 hours Diabetes confirmed if 2 hour value =11.1 mmol/l Fasting glucose of 6-6.9 implies impaired fasting glucose Impaired glucose tolerance Fasting < 7mmol/l, 2 hour level >7.8 but <11.1 HBA1c > 7% makes diabetes likely (sensitivity 98% but specificity lower)

    7. Confirm the Diagnosis DUK have formerly suggested that all patients with IFG have an OGTT IFG and IGT are not interchangeable. Represent distinct abnormalities of glucose metabolism (fasting v. post prandial) Both carry increased risk of: progression to type 2 diabetes Screeing? Metformin? Lifestyle modification should be advised Cardiovascular risk Assess in detail – Aspirin and Statin?

    8. Consider Diagnosis Is it type 2 Diabetes? Type 1 Usually young (<40) but may occur at any age Prone to ketoacidosis – may be mode of presentation Often rapid onset of profound symptoms with short history Weight loss marked Family history may be present but less typical Type 1 may occur in obese individuals

    9. Consider Diagnosis Type 2 Older age group Often obese Often asymptomatic Symptoms may be mild to moderate and often protracted Rapid weight loss unlikely (may hint at progressing pancreatinc malignancy – Abnormal LFTs common due to NASH) Strong family history (100% concordance between identical twins) Mode of presentations may be diabetic complication(s)

    10. Consider Diagnosis Grey Cases MODY Not linked to obesity 1-2% of those with diabetes Develops before age of 25 Strong genetic predisposition (Autosomal dominant inheritance)

    11. Consider Diagnosis MODY Six subtypes identified HNF1a (70%) – very sensitive to sulphonylurea therapy Glucokinase deficiency (10%) – often asymptomatic and usually no treatment required HNF4 a - birthweight > 4kg. SU appropriate but progression to insulin therapy likely over time HNF1ß (associated with renal cysts, uterine abnormalities) – insulin usually required Often treated with life (healthier diet and increased physical activity), some forms treatment with tablets or insulin most types of MODY can still lead to complications glycaemic and BP control and cholesterol LADA Ketone prone type 2 diabetes

    12. Consider Diagnosis The following characteristics suggest the possibility of MODY: Mild to moderate hyperglycemia (7-10 mm0l/l) discovered before 30 years of age. A first degree relative with a similar degree of diabetes. Absence of positive antibodies or other autoimmune condition in patient and family. Low insulin requirements (<0.5 u/kg/day) past usual honeymoon period. Absence of obesity or other problems associated with type 2 diabetes or metabolic syndrome Cystic kidney disease in patient or close relatives.

    13. Assess Complications

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