Diabetes Mellitus

1. Diabetes Mellitus Tom Salter F1 Warwick Hospital

2. Clinical Scenario This is Mr Balls he has presented to his GP feeling tired for 3 months... What are you going to ask? • Follow a Hx taking pattern that’s comfortable • Narrow down to a system • Have about 5 set questions in mind • R/O serious pathology • Don’t forget social and ICE

3. Clinical Scenario • 52 years old lethargic & tired 3/12 • thirsty & drinking more than normal for 2/52 • no other significant symptoms • Hypertension on Ramipril only • No known allergies • Works as librarian, drinks socially, non-smoker

4. Clinical Scenario What do you think is wrong with the patient? What would you like to examine? O/E: • Obese (BMI 32) • Systems examinations otherwise unremarkable

5. Clinical Scenario • What are your differentials and why? • Diabetes Mellitus • Chronic kidney disease • Diabetes insipidus • Thyroid disease (Hypothyroidism)

6. Clinical Scenario Investigations • Bedside • Urine dipstick (glucose and ketones), BM, ECG • Simple • Glucose, FBC (?anaemia), U+Es (?CKD), LFTs (fatty liver, albumin), TFT, • Urine MC&S, albumin and ?PCR (?CKD) • Radiological • ?CXR, ?USS Kidney • Special tests • ?Fluid deprivation test

7. Clinical Scenario Management Remember the blurb... “Managed in an MDT approach...” • GP, Practice nurse, district nurses, OTs dietician, retinal screening service, MDT diabetic foot clinic, consultant. • Have a rough idea what each member does!

8. Clinical Scenario • Conservative • Smoking cessation – help and advice • Lifestyle – weight loss, low GI diet, exercise • Foot care • Eye checks • Medical • Oral/Tablet control • Insulin • Control BP, cholesterol and other risk factors • Surgical • Islet cell transplants • Rx of Complications e.g. amputation

9. Diabetes Medical Management Metformin: Mode of action Suppresses hepatic gluconeogenesis Increases insulin sensitivity Effects Reduces diabetic complications, Reduces serum levels of LDL and Triglycerides Particularly important in overweight pts GI side effects, CI if eGFR <30ml (caution if <45)

10. Diabetes Medical Management Sulfonylureas: Mode of action Increase insulin secretion by Beta cells Need underlying insulin production Effects Reduce circulating glucose (risk of hypos) Generally avoided if overweight Increased risk of hypos if renal impairment

11. Diabetes Medical Management DPP-4 inhibitors: Mode of action Reduce circulating glucagon levels Effects ↑insulin secretion ↓gastric emptying ↓blood glucose Continue only if >0.5% ↓ in HbA1c

12. Diabetes Medical Management Thiazolidinediones (glitazones): Mode of action Activates nuclear receptors called PPARs effecting gene transcription Effects Decreased insulin resistance Increased free fatty acid & glucose metabolism Weight gain (↑ appetite) Pioglitazone only now (Rosi. ↑ CHD and MIs)

13. Insulin NICE recommends (3).. Cont. Metformin & Sulfonylurea 1st: Intermediate NPH (porcine) insulin ON or BD Or long-acting OD if difficulty injecting 2nd: Biphasic BD particularly if HbA1c >9% or problem with hypos 3rd: Add mealtime boluses as appropriate or consider switch to basal bolus or add thiazolidenedione Diabetes Medical Management

14. Nice T2DM Mx guidelines: http://bit.ly/GIVIAW

15. Insulin in Type 1 • How does the insulin Mx differ? • Loss of intrinsic insulin secretion – Basal-bolus insulin or S/C pumps needed • Usually a younger presentation • S/C pumps may allow a more normal daily routine • Pumps require good compliance

16. Diagnosis Criteria • What are the diagnostic criteria for diabetes? • Fasting Glucose level >7.0 mmol/L • Random Glucose level >11.1 mmol/L • One reading if symptomatic or two if asymptomatic • Also now HbA1c of 48 mmol/mol (6.5%) can be used for diagnosing diabetes (<6.5% does NOT exclude the diagnosis)

17. Diagnosis Criteria • Impaired Glucose Tolerance • 7.8 mmol/L - 11.0 mmol/L • 2 hours post 75g oral glucose tolerance test • Greater risk of CVD and DM than IFT • Impaired Fasting Tolerance • 6.1 mmol/L - 6.9 mmol/L • Fasting serum glucose

18. Prognosis • 75% of those with T2DM will die of heart disease • 15% of a CVA • The mortality rate from CVD is 5x higher in those with DM (1) • Over 60% of T1DM patients will NOT suffer serious complications. Especially if no complications by 10- 20 years post-diagnosis (5)

19. Complications of Diabetes • Cardiovascular: • Ischaemic heart disease, Cerebrovascular disease, Peripheral vascular disease • Renal: • Diabetic nephropathy caused by hyperfiltration of glucose and atheromatous changes to the blood vessels of the kidneys

20. Complications of Diabetes • Neuropathic: • Neuropathy of any nerve! • Autonomic (GU, GI, postural hypotension) • peripheral sensorimotore.g glove and stocking • mononuritis incl. CNs • Charcot’s foot, diabetic ulcers • PAIN

21. Complications of Diabetes • Retinopathy: • Background • Pre-proliferative • Proliferative • Maculopathy:

22. Acute complications HONK • a hyperosmolor hyperglycaemic non-ketotic state • T2DM • Usually as a result of dehydration and illness • Inability to take diabetic medication • Symptoms weakness, cramps, visual impairment, confusion seizures +/- nausia & vomiting (less than DKA)

23. Acute complications HONK Management: • A-E approach • Fluid resuscitation with normal saline • Electrolyte replacement esp. potassium • Insulin (aiming for SLOW reduction of serum glucose, approx 3mmol/hr) • Senior guidance for insulin sliding scale • VTE prophylaxis

24. Acute complications DKA • Ketonaemia (>3 mmol/L), or ketonuria (>2+) • Bicarbonate <15 mmol/L or venous pH <7.3 • Blood glucose >11 mmol/L or known DM (not a good indicator of severity) • Caused by infections, non-compliance, acute illnesses (e.g. PEs, thyroid disease etc), CVD/MI

25. Acute complications DKA Symptoms: polydipsia, polyuria, nausea & vomiting, abdominal pain Management: Correct dehydration with IV crystaloids Reduce glucose 3mmol/L/hour Regularly monitor potassium (ECG) Do not routinely give bicarbonate or phosphate Treat the underlying illness Continue to monitor fluid balance & electrolytes 1-2 hourly

26. Summary • Diagnosis >7.0mmol/L (fasting) >11.1mmol/L (random) • Minimise risk factors and maintain tight control • Diabetes complications: Heart, Kidneys, Eyes & Nerves PLUS DKA in T1DM, HONK in T2DM

27. References • http://www.patient.co.uk/doctor/diabetes-mellitus • http://www.patient.co.uk/doctor/management-of-type-2-diabetes • http://bit.ly/GIVIAW (NICE) • http://bit.ly/GKfqM1 (NICE) • http://emedicine.medscape.com/article/117739-overview