1. Delia Williams & Tania Bailey Diabetes CNS RMO Clinical scenarios

2. 42 year old Mori male Oct 13 Med Hx : T2DM/ dx 1 year ago/Gout HbA1c 98mmol/mol Dec 12 GFR > 90 ml/min/1.73m2 ACR 80 mg/mmol Meds: Allopurinol 100mg OD not taking Voltaren Presented ED post collapse/ confusion / exac gout L) toe 3. O/A: BG 40.5 mmol/mol BP 101/59 RR 18 T 35.9 GCS 15 GFR 68 Urea 33.1 mmol/L Osmolality 335 mOsm/kg body water Na+ 133 mmol/L K+ 4.8 mmol/L 4. HHS key points? Rx: insulin infusion what / where BGs: 1930 hrs: 40.5 2015 hrs: 22.9 2100 hrs: 19.4 2200 hrs: 16.4 When to transfer to s/s what to consider? 5. Date 28/10 29/10 30/10 Time 0700 1130 1700 2100 0745 1200 1700 2100 0130 BG 12.2 14.8 14.6 12.9 12.3 14.9 23.9 19.1 16 Novorapid 3 5 3 5 8 7 5 Date 30/10 31/10 Time 0730 1130 1400 2100 0740 1140 1630 2000 BG 17.2 19.4 21.4 17.2 13.9 21.6 23.2 19.8 Novorapid 7 5 7 3 8 8 7 * Commenced on prednisone 40mg OD What to consider when deciding on insulin? BG trends/ Diet / targets / patient variables / f/u /meds / . 6. Insulin Profiles 7. Insulin profiles Glargine / Lantus Glusiline /Apidra 8. 80 yr old Male Hx: T2DM / MI/CABG/PVD/Dementia HbA1c 67 mmol/mol Jan 14 GFR 54 LFTs - last 8/12 Bili 11 Alk phos 481 GGT 388 ALT 61 AST 62 Tot protein 77 Albumin 33 ED hypo 2.1 found by wife at 0830hrs 3 feb / readmitted 5 feb 4 x ambo callouts last 2/52 1 x hypo NSTEMI Fall not hypo UTI Current regime Humalog Mix 25: 23 10 -14 9. Date 26/1 27/1 28/1 30/1 Time 0800 1200 0800 1200 0800 0800 1700 0800 2400 BG 17.3 17.7 9.7 4.1 4.9 11.5 10.5 2.1 3.5 Notes cup fizzy cup fizzy H/Mix 25 23 10 14 Date 6/2 7/2 Time 0800 1200 1700 2100 0800 1200 1400 1800 2000 BG 2.8 8.6 12.6 14.8 6.6 2.7 10.2 15.6 16.8 Notes ED 23u Options? Considerations? 10. Dan 20 year old (shared ethnicity NZ European & Maori) Presented to ED with 3 week history of polydipsia, polyphagia, polyuria, lethargy and blurry vision Family/ Social history no autoimmune conditions, currently fit 16 weeks into army recruit training current BMI 27 (wt 99.8kg - prior to training 100-103kg) No previous ill health weight few years ago 130kg O/A: 16.30 Bloods RBG 44.2mmol/L, urinary Ketones neg, S.Creatinine 136ummol/L, eGFR 64, Na 128, K+4.9, BP 122/74 Pulse 51, RR18 O2 sats 100% RA Fluid replacement no insulin infusion - metformin Commenced on S/C insulin regimen: basal (lantus 20 units nocte) / bolus (apridra 10 units each meal and scale b) 22.30: Venous Blood Gases pH 7.35, PaCO2 56mmHg, Act Bicarb 30.4 (21-27), stand bicarb 27.3, Base Excess 5.1 (- 2 - +2.0), glucose 26.5mmol/L, lactate 1.0, Na 134, K+3.9 11. Next day - HbA1c 115mmol/mol BG profile After 3 6 days pre-meals 5 -10 2hrs PP7 -22mmols 3 - 4 weeks later: C-peptide 403 (350 700) Autoimmune markers- Glutamic Acid Decarboxylase (GAD) autoantibodies 50 (10U/ml) Insulinoma-Associated Antigen 2 (IA-2) >400 U/ml (>15U/ml) Islet cell cytoplasmic autoantibodies >40 (>10IU) Baseline investigations for ED presentation Glucose, V.Blood gases, U/Es, S. Creatinine, HbA1c, FBC, beta- hydroxybutyrate cultures (blood and urine), CXR, ECG 12. Latent Autoimmune Diabetes of Adults (LADA) Type 3 diabetes, Type 1.5 or slow developing DM 10% of T2DM patients have evidence of anti-islet cell autoimmune markers - Islet cell auto- antibodies (ICAs), glutamic acid decarboxylase (GAD) Non-insulin dependent on diagnosis Normal beta hydroxybutyrate Slow, variable and incomplete autoimmune destruction of beta cells Low but measurable C-peptide None or few - features metabolic syndrome 13. Criteria for diagnosis of LADA Consider age on diagnosis (>25 years ) Presence for circulating Islet autoantibodies (at least one) Lack of insulin requirement for at least 6 months after diagnosis Clinical features at diagnosis - presence of symptoms If not overweight - consider testing for GAD autoantibodies and C-peptide Family history of diabetes or autoimmune diseases Islet cell autoantibodies (ICAs) & insulin autoantibodies (IAA) not always present 14. 69 year old male exac COPD/T2DM Hx : IHD-stent/hyperlipidaemia HbA1c 58mmol/mol May 13 GFR 70 ml/min/1.73m2 Meds: Metformin 1gm BD Prednisone 40mg OD reducing 5mg/every 2 wks 15. Date 11/3 12/3 13/3 Time 0700 1130 1645 2150 0745 1630 2030 0745 1145 BG 7.3 8.6 19.8 14.2 9.2 18.3 14.7 6.9 7.8 Insulin Novorapid 4 u 1 u 4 u 3 u Date 13/3 14/3 15/3 Time 1615 2100 0755 1135 1700 0400 1145 1630 2200 BG 16.7 15.2 6.7 7.4 20.2 8.7 10.1 20.4 12.2 Insulin Novorapid 3 u 3 u 2 u