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

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 ?

• Newly presenting patient with hyperglycemia

• The Changing phenotype of DM1

• The Changing demographic of DM2

Newly presenting patient with Hyperglycemia

Is 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 ?

DM1, DM2,Glucose toxicity

• Any testing for immediacy ?

• Any testing for future ?

• What are options initially– Metformin– Sulphonyurea– Insulin– Diet & Exercise

The Challenge

• Physical exam

• Vital signs Pulse, RR, BP

• Smell

• Urine Ketones 1+ vs 4+ Does it matter ?

• Serum Ketones …Do you check ?

DM1, DM2,Glucose toxicity

•What are options initially as 1ST Line

– Metformin– Sulphonyurea– Insulin– Diet & Exercise

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 ?

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 ?

Patient referred/ seen 6 weeks later

• Started on Janumet 50/850 BD• Symptoms settled• Weight plateaued• HbA1c 7.9%

• What do you think now ?

Anti-GAD-65 positive

What next ?

Anti-65-Antibody highly positive

• Is this DM1 ?

• Is this LADA ?

• Would I do things differently ?

Newly presenting patient with Hyperglycemia

Is 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 ?

Newly presenting patient with Hyperglycemia

Is 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 ?

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

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

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 ?

Glycemic Control as a Medical emergency

DM1 & DM2

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 ?

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

Clinical Signs

• Vital signs– Pulse : Tachycardia– Respiratory Rate : Tachypnoea– BP : Hypotension– Temperature : Febrile

• Acetone Smell

28 year old, DM 1 , BS 28 mmol

• 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

Investigations

• Serum ketones

• Urine ketones

• Glucose• ABG• Serum bicarbonate• K+• Anion Gap• Phos• Mg

• ECG

Causes DKA : 4 i’s

• Infection

• Infarction

• Incompliance

• IDDM*

• Urinalysis / FBC

• ECG/ Enzymes

• Profiles / History

Severe Hypoglycemia

Is Admission Necessary ?

Is all Hypoglycemia the same ?

• New

• Timing

• Severity

• Frequency

• Management

• Awareness

• Co-morbidities ( CAD)

• Identifiable precipitants … exercise, shopping

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 ?

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 ‘

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

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 ”

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 ?

Hypoglycemia

• Aware

• Mild• Moderate• Severe

• Frequency• Requiring Intervention• Timing

• Unaware

• No gradation• Critical• Need to reset !

Nocturnal Hypoglycemia

The Thief in The Night !