Endocrinology Continued Joanna Smith

Diabetes Mellitus Type 1 Type 2 Absolute insulin deficiency Autoimmune islet cell destruction Relative insulin deficiency Insulin resistance Insufficient production

Diabetes Mellitus – Diagnosis Symptomatic patient HBA1c Fasting glucose ≥ 7.0 mmol/l Random glucose ≥ 11.1 mmol/l Post 75g OGTT ≥ 11.1 mmol/l Above criteria on 2 occasions HbA1c ≥ 48mmol/mol (6.5%) A normal HbA1c does not exclude DM Asymptomatic patient

Diabetes Mellitus – Management Principles Normalise blood glucose levels Monitor and treat complications Modify risk factors e.g. CV disease

Diabetes Mellitus – Management Type 1 Always require insulin Different insulin choices depending on duration of action Type 2 Majority controlled on oral medication First line → metformin Second line → sulfonylurea, gliptins, pioglitazone Oral medication fails → insulin

T2DM – Lifestyle Modifications Diet Exercise Smoking cessation Lipids control BP control Antiplatelets

Any drug which may cause hypoglycaemia T2DM – Management Intervention Target HbA1c Lifestyle 48mmol/mol Lifestyle + Metformin Any drug which may cause hypoglycaemia 53mmol/mol NICE encourage relaxing targets on a case by case basis, especially in the elderly or frail

Diabetic Emergencies

Diabetic Ketoacidosis ↓ Insulin ↑ stress hormones and ↑ glucagon ↑ gluconeogenesis ↑ serum and urine glucose Osmotic diuresis Dehydration ↓ glucose utilisation Vomiting ↑ fat β-oxidation and ↑ fatty acids ↑ ATP and production of ketone bodies Ketoacidosis

DKA – Clinical Features Precipitants → stress, illness, stopping insulin, new T1DM Abdominal pain Vomiting Drowsiness Kussmaul Respiration Dehydration Ketotic breath

DKA – Diagnosis Need to show: Hyperglycaemia → BM/lab glucose ≥ 11.1 (or known diabetic) Ketosis → urinary or blood ketones ≥ 3mM or ≥ 2+ on urinalysis Metabolic acidosis → Blood Gas pH < 7.3

DKA – Immediate Management Oxygen IV Access Fluid replacement → 0.9% NaCl 1L over 1 hour Insulin → 50units Actrapid in 50mls 0.9% Saline → 1unit/ml Infusion at 6units/hour to start Continue basal long-acting insulin along with infusion Call for senior help Other considerations → ECG, NG tube, catheter, identify cause (e.g. infection), VTE Prophylaxis

DKA – Ongoing Management IV Fluids → rapid restoration of circulating volume, gradual correction of interstitial/intracellular deficits 1L 0.9% Saline over 2nd hour + Potassium if < 5 500ml 0.9% Saline over 3rd hour + Potassium if < 5 500ml 0.9% Saline over 4th hour + Potassium if < 5 Add in 10% dextrose when BM ≤ 14 A lot of blood tests!! Hourly lab glucose Titrate insulin infusion rate to BMs

Hypoglycaemia Blood Glucose < 4mmol/L Mild Hypoglycaemia Sweating Tachycardia Hungry Anxious Severe Hypoglycaemia (BM~ 2mmol/L) Confusion Dizziness Weakness Drowsy www.newhealthadvisor.com

Hypoglycaemia – Causes Mostly patients on insulin or sulphonylureas Lack of food Unaccustomed exercise Alcohol Excess Insulin Treat on basis of BM, but always confirm with lab glucose

Hypoglycaemia Conscious? No Yes ABCDE Stop IV Insulin 15-20g quick acting carbohydrate Glucotabs Fruit juice Glucogel ABCDE Stop IV Insulin 20g long acting carbohydrate Call for help IV 10% dextrose or 1mg IM Glucagon Yes No Unsuccessful after up to 3 repeats Successful

Hyperglycaemic Hyperosmolar Syndrome Common in frail and elderly 30% mortality Type 2 diabetes Hyperglycaemia (often > 30mmol/l) Not acidotic No ketonuria Relative insulin deficiency ↑ stress hormones and ↑ glucagon ↓ glucose utilisation ↑ gluconeogenesis ↑ glycogenolysis ↑ serum and urine glucose Osmotic diuresis Dehydration and hyperosmolarity

HHS – Clinical Features Severe hyperglycaemia Hyperosmolarity (>320mosmol/kg) Profound dehydration Prerenal uraemia Very high sodium Reduced GCS

HHS – Management 1. Fluids → 0.9% NaCl 1000ml 1st hour then 500mls each hour after (slower than DKA) 2. Insulin once rehydrated 3. Potassium replacement (aim 4.0-5.0) after 1st bag of fluids 4. DVT Prophylaxis

Hyperkalaemia

Hyperkalaemia K+ > 5.0 Most important intracellular cation 5.1-6.0 mmol/L = Mild > 6.0 mmol/L = Potentially serious > 7.0 mmol/L = Medical Emergency → requires treatment Most important intracellular cation Renally excreted

Hyperkalaemia – Causes Haemolysed sample Iatrogenic AKI/CKD Potassium sparing diuretics Addison’s disease Excessive release from cells – burns, rhabdomyolysis, massive haemolysis

Hyperkalaemia – Clinical Features Asymptomatic ECG Weakness Small P Waves Broad QRS Palpitations Tall, tented T waves Dizziness Sine Wave → VF → Asystole Chest Pain

Hyperkalaemia – Treatment ***Get Help*** 1. 10ml 10% Calcium Gluconate (If ≥ 7.0 mmol/l or ECG Changes) Give with continuous ECG monitoring Stabilises myocardium 2. 10units actrapid + 50ml 50% dextrose 3. 5mg Salbutamol nebs 4. Consider Calcium resonium or dialysis 5. Treat the cause

Interesting Case 47y/o male Clinic admission Type 1 diabetic, vomiting past 2 weeks Admitted to “sort pre-op”

Investigations & Management No ketonuria pH 7.32 on ABG Clinically very dry Cool to midarms CRT 5s

Immediate Management Hyperkalaemia Fluids Sliding scale

Hyperkalaemia – Treatment ***Get Help*** 1. 10ml 10% Calcium Gluconate (If ≥ 7.0 mmol/l or ECG Changes) Give with continuous ECG monitoring Stabilises myocardium 2. 10units actrapid + 50ml 50% dextrose 3. 5mg Salbutamol nebs 4. Consider Calcium resonium or dialysis 5. Treat the cause