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

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Presentation on theme: "Dr Maeve Durkan & Dr Eoin O’Sullivan The Cork Diabetes & Endocrinology Group Bon Secours Hospital, Cork Maeve C. Durkan MBBS.FACP, Mmed.Ed Consultant in."— Presentation transcript:

1 Dr Maeve Durkan & Dr Eoin O’Sullivan The 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 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 ?

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 1 ST Line –Metformin –Sulphonyurea –Insulin –Diet & Exercise

8 Newly presenting patient with Hyperglycemia Is 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 Hyperglycemia Is 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 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 ?

14 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 ?

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 emergency DM1 & 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 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

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

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

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

33 Nocturnal Hypoglycemia The Thief in The Night !


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