Maeve C. Durkan MBBS.FACP, Mmed.Ed Consultant in Diabetes, Endocrinology & Metabolism

1. Dr Maeve Durkan & Dr Eoin O’SullivanThe Cork Diabetes & Endocrinology Group Bon Secours Hospital, Cork Maeve C. Durkan MBBS.FACP, Mmed.Ed Consultant in Diabetes, Endocrinology & Metabolism

2. 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 ? • - Do we need to refer ?

3. Newly presenting patient with hyperglycemia • The Changing phenotype of DM1 • The Changing demographic of DM2

4. Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity • 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 ?

5. DM1, DM2,Glucose toxicity • Any testing for immediacy ? • Any testing for future ? • What are options initially • Metformin • Sulphonyurea • Insulin • Diet & Exercise

6. The Challenge • Physical exam • Vital signs Pulse, RR, BP • Smell • Urine Ketones 1+ vs 4+ Does it matter ? • Serum Ketones …Do you check ?

7. DM1, DM2,Glucose toxicity • What are options initially as 1ST Line • Metformin • Sulphonyurea • Insulin • Diet & Exercise

8. Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity • 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 ?

9. Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity • 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 ?

10. Patient referred/ seen 6 weeks later • Started on Janumet 50/850 BD • Symptoms settled • Weight plateaued • HbA1c 7.9% • What do you think now ?

11. Anti-GAD-65 positive What next ?

12. Anti-65-Antibody highly positive • Is this DM1 ? • Is this LADA ? • Would I do things differently ?

13. Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity • 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 ?

14. Newly presenting patient with HyperglycemiaIs it DM1, DM2, DM2 & Glucose toxicity • 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 ?

15. Changing phenotype of DM1 Honeymoon, βcell regeneration , MODY ? • 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

16. 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

17. 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 ?

18. Glycemic Control as a Medical emergencyDM1 & DM2

19. 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 ?

20. 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

21. Clinical Signs • Vital signs • Pulse : Tachycardia • Respiratory Rate : Tachypnoea • BP : Hypotension • Temperature : Febrile • Acetone Smell

22. Scenario 1 Well Profiles : Good 28 mmol today Missed lunchtime dose ! No constitutional symptoms P 70, RR 18,BP 120/80 No postural drop 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 28 year old, DM 1 , BS 28 mmol

23. Serum ketones Urine ketones Glucose ABG Serum bicarbonate K+ Anion Gap Phos Mg ECG Investigations

24. Infection Infarction Incompliance IDDM* Urinalysis / FBC ECG/ Enzymes Profiles / History Causes DKA : 4 i’s

25. Severe Hypoglycemia Is Admission Necessary ?

26. Is all Hypoglycemia the same ? • New • Timing • Severity • Frequency • Management • Awareness • Co-morbidities ( CAD) • Identifiable precipitants … exercise, shopping

27. The Hypoglycemic Patient ! • 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 ?

28. 36 year old Male • 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 ‘

29. 38 year old female • 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

30. 28 year old female • 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 ”

31. 26 year old male • 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 ?

32. Aware Mild Moderate Severe Frequency Requiring Intervention Timing Unaware No gradation Critical Need to reset ! Hypoglycemia

33. Nocturnal Hypoglycemia The Thief in The Night !