1. Dr Karen Greenhorn Bingley medical Practice

2. See Cases

3. Aims and Objestives Accurately Diagnose Diabetes Know Management options for treating Type 2 Diabetes Know the DVLA Guidance for Diabetes Aware of other endocrine problems and how to management them.

4. HBA1c >6.5% Can be used to Diagnose Diabetes BUT WHO states ‘The diagnosis of diabetes in an asymptomatic person should not be made on the basis of a single abnormal plasma glucose or HbA1c value.’ At least one additional HbA1c > 6.5% or a fasting plasma glucose > 7.0 or a random (casual) sample > 11.1 or from the oral glucose tolerance test (OGTT) It is advisable to use one test or the other but if both glucose and HbA1c are measured and both are “diagnostic” then the diagnosis is made. If one only is abnormal then a further abnormal test result, using the same method, is required to confirm the diagnosis.’ A value of less than 6.5% does not exclude diabetes

5. Interpreting the Oral Glucose Tolerance Test Impaired fasting glycaemia fasting sample of 6.1mmol/l to 6.9 mmol/l Impaired Glucose Tolerance 2–hour plasma glucose ≥7.8 and <11.1mmol/l Beware this comes back as normal in the pathology links Diabetic 2-hour plasma glucose >11.1mmol/l

6. Newly Diagnosed Type 2 Diabetic The 42 year old Asian gentleman with a random glucose of 11.6 and a fasting of 7.2

7. Management BP BMI Bloods (U+E, LFT, HBA1c, Lipids, TFT’s) Urine (ACR) Referral for retinal Screening Referral to EXPERT or dietitian Pulses, 10g monofilament testing and referral to podiatrist

8. Results BP168/92mmHg BMI37 HBA1c75mmol/mol (9.0%) Cholesterol6.7 ACR4.7

9. NICE Targets HbA1c<6.5% BP<140/80 mmHg, but if kidney, eye or cerebrovascular disease <130/80 LipidsCholesterol <4.0 mmol/l, LDL <2.0mmol/l

11. Metformin and Renal Impairment >60, continue 60-45, continue but monitor renal function more frequently (3-6/12) 30-44, prescribe with caution and use 50% of the dose, monitor renal function every 3/12, don’t initiate. <30 absolute contraindication. Stop if on it.

12. Management Case 2 A 67 year old lady with a BMI of 37 is taking maximum doses of metformin and ramipril and she is unable to exercise due to osteoarthritis of both her knees, comes to the diabetic clinic for the results of her blood tests. HBA1c 62mmol/mol (7.8%) BP 156/88 Other bloods OK What are her options?

13. Incretin Effect Incretin hormones (GLP1 and GIP) produced by GI tract in response to nutrient entry. Stimulates post-prandial secretion of insulin Suppresses post-prandial secretion of glucogon (reduces gluconeogenesis) Promotes satiety and reduces appetite.

14. DPP4 Inhibitors (Sitagliptin, Vildagliptin, saxagliptin) Inhibits the breakdown of GIP by inhibiting the enzyme DPP4 Licensed for any triple therapy. And can be used with insulin. Once daily tablet. (up to bd with vildagliptin) More effective if used early in the course of diabetes. Avoid if eGFR <50 S/E Headache. URTI. Weight neutral.

15. Incretin Mimetics (Exenatide and Liraglutide) GLP 1 Analogue It interacts with a specific receptor on the beta cell. Helps weight loss Sub cut injection (as rapidly degraded in the circulation) 60 minutes before meals. BD for exenatide, and (new once weekly), OD for Liraglutide

16. GLP1 Analogues (Exenatide, Liraglutide) Exenatide licensed triple therapy with sulphonylurea and metformin, Liraglutide triple therapy can also include a Glitazone. NOT licensed for monotherapy. NICE : HbA1c >7.5% and BMI > 35 in people of European decent or lower BMI (>30) if other ethnicity or weight loss would benefit other co-morbidities. eGFR avoid if <30 exenatide, <60 Liraglutide. S/E nausea very common. Hypoglycaemia more common if taken with a sulphonylurea. Acute pancreatitis.

17. Weight Loss Surgery Reuxen-Y-Bipass better than banding (can now be done laparoscopically) On average 82% REMISSION FROM DIABETES 14 years post surgery The greater the BMI the greater the benefit BUT Leads to malabsorption problems (B12, Calcium, anaemia), gastric dumping syndrome and rarely hypoglycaemia

18. Case 3 48 year old gentleman recently diagnosed with type 2 diabetes and has been to see the dietician who is concerned with the amount he is having to eat to maintain his weight and is concerned that he is actually a type 1 diabetic. He is on the maximum dose of glimepiride and HBA1c is 90mmol/mol (10.4). He feels well, what do you do?

19. Blood Glucose monitoring Type 1 or type 2 on intensive insulin regime. Pregnancy on insulin. QDS Type 2 on conventional insulin therapy. 2-3 times a week, more if not stable or unwell. Type 2 on insulin and Oral hypoglycaemics. At least OD varying the times. Type 2 on sulphonyluria.Only to identify hypo’s Diet alone or metformin or glitazone. DO NOT NEED. In motivated can be used to monitor lifestyle changes.

20. Case 4 A 28 year old Type 1 Diabetic has come for a medication review as he has been ordering a lot more strips recently, 2 boxes of 50 a week. On discussion he had become obsessed about having a hypo having been in hospital recently with a hypoglycaemic episode. His partner had treated it using hypostop gel and he was admitted for a few hours observation in hospital. He drives to work, what conversation should you have with him?

21. Severe hypoglycaemia Defined as requiring the assistance of another person. Changes to the standards for driving Group 1 vehicles (cars and motorcycles) The following changes introduced by the European Union have applied since September 2010. Must NOT have had more than one episode of severe hypoglycaemia within the preceding 12 months Must NOT have impaired awareness of hypoglycaemia which has been defined by the Diabetes Panel for Group 1 vehicles as an inability to detect the onset of hypoglycaemia because of a total absence of warning symptoms Further information can be obtained from the DVLA website – www.dft.gov.uk/dvla/medicalwww.dft.gov.uk/dvla/medical

22. Driving and Hypoglycaemia Must Test Blood Glucose before Driving If <4.0 MUST NOT DRIVE If <5.0 Have a snack before driving Check Blood Glucose every 2 hours when driving If having a Hypo must pull over, take keys out of ignition and sit in passenger seat for 45 minutes after it has been corrected.

23. Case 5 This 70 year old gentleman has recently been diagnosed with diabetes, what investigations should you do?

24. Cushing Syndrome

25. Cushings Syndrome Glucocorticoid excess Primary excess due to Adrenal adenoma/carcinoma Increased ACTH due to Pituitary or ectopic source. TEST U+E, Dexamethasone suppression test (1mg Dex at 11pm, no suppression), 24 hour free cortisol, CXR.

26. Case 6 A 32 year old lady has been complaining of being tired all the time! But also legs feel very weak, as though is going to pass out all the time and been loosing weight. What blood tests would you do if any?

27. Blood results FBC normal Glucose 4.2mmol/l Sodium 125mmol/l Potassium 6.2mmol/l Urea 10mmol/l Normal creatinine What is the diagnosis and what do you do?

28. Addison’s Disease Primary Hypoadrenalism and ACTH excess

29. Secondary Hypoadrenalism Long term steroid use Inadequate ACTH production (panhypopituitarism)

30. Case 7 A 48 year old lady is complaining of feeling tired all the time, difficulty loosing weight and dry skin. You do some blood tests which are all normal apart from a TSH of 7.8 and normal T4 What do you do?

31. Overt Hypothyroisim Symptomatic TSH >10 Reduced serum free or total thyroxine

32. Sub-clinical Hypothyroidism TSH 5-10 Normal Thyroxine levels Whether to treat is controversial EXCEPT IN PREGNANCY or trying to conceive. Risk of progression to overt is small (5% pa with antibodies, 2% pa without)

33. When to Treat IF SYMPTOMS trial of thyroxine for 6 months, if feel better can continue (50%). NO SYMPTOMS BUT ANTIBODIES not to treat but yearly surveillance.