Diabetes Lubna Sheikh

 Type 1: the body's failure to produce sufficient insulin  Type 2: resistance to the insulin, often initially with normal or increased levels of circulating insulin  Gestational diabetes: occurs in pregnancy  Secondary diabetes: 1-2% of patients with diabetes  Causes include: cystic fibrosis, chronic pancreatitis, cushing’s, thyrotoxicosis, steroids. What is it?

 Type 1  15% of those that have diabetes  Juvenile onset, but can occur at any age  HLA DR3 and DR4 and islet cell antibodies  Always need insulin therapy  At risk of ketoacidosis  Caucasian of Northern European ancestry  Type 2  85%  Usually diagnosed <30 years  Associated with excess body weight and physical inactivity  South Asian, African, African-Caribbean, Polynesian, Middle- Eastern and American- Indian ancestry

 Obesity  Lack of physical activity  Ethnicity  History of gestational diabetes.  Impaired glucose tolerance.  Low-fibre, high-glycaemic index diet.  Metabolic syndrome  Polycystic ovarian syndrome  Family history  Adults who had low birth weight for gestational age Type 2 - Risk Factors

Presentation  Ketoacidosis: hyperglycaemia, ketonaemia and metabolic acidosis  Polyuria  Thirst  Weight loss  Polydipsia  Lethargy  Complications:  Boils, staphylococcal skin infections, genital infections (recurrent)  Retinopathy, arterial disease  Polyneuropathy, erectile dysfunction

 BM  Fasting/Random glucose  Urinalysis: ketones and proteinuria  Blood test: FBC, U&E’s, LFTs, cholesterol, HbA1c Additional Tests:  ECG  Albumin:creatinine ratio  Amylase  CT abdo Investigations

Fasting glucose > 7 mmol/L and a glucose tolerance test OR Random glucose > 11mmol/L (usually on 2 separate occasions) Diagnosis

 Emergency:  Diabetic ketoacidosis (DKA)  Hyperglycaemic Hyperosmolar Non Ketotic state (HONK)  Hypoglycaemia  Long term  Macrovascular  Stroke, MI, Peripheral vascular disease  Microvascular  Neuropathy, nephropathy, retinopathy Complications

 Self-management  Education  Coping  Diet  Smoking  Regular monitoring  New Symptoms  Of cardiovascular, cerebrovascular, renal, ophthalmological or neurological complications of diabetes?  Erectile dysfunction  Screen for depression  Pregnancy and pre-pregnancy  Are they pregnant or planning on having any children?  Blood results  HbA1c  Home glucose monitoring results.  Non-fasting lipid profile.  Estimated glomerular filtration rate  Side effects of medication Diabetic Review

 Conservative  Lifestyle – weight loss, dietitian input, low refined sugar in diet, exercise regime  Smoking cessation  help and advice  Foot care  Eye checks  Medical  Type 1: Insulin regimes  Type 2: Metformin, Sulphonylureas, Glitazones, DDP4 inhibitors, Insulins  Control BP, cholesterol and other risk factors  Surgical  Islet cell transplants  Complications e.g. amputation Management

Medical Management Metformin  Increases insulin sensitivity  Normally first line treatment  Side effects: epigastric pain, anorexia and diarrhoea.  Metformin should not be used in cases of severe liver or kidney disease as lactic acidosis has been known to occur. Sulphonylureas  Promote insulin secretion in response to glucose  Should be avoided during pregnancy  They encourage weight gain – and therefore should not be first line treatment in obese patients.  They interact with warfarin  Main side effect: Hypoglycaemia

OnsetPeakDurationExample Short-acting30 minutes2-4 hours8 hoursActrapid Humulin S Intermediate1-2 hours4-12 hours16-24 hoursInsulatard Humulin I Long-acting1-2 hours4-12 hours20-35 hoursHuman Ultratard Humulin Zn Insulin

Insulin Regimens

A 52 year old man presents to his GP as he has been feeling lethargic and tired for the last few months. He has over the last 2 weeks also become very thirsty and is drinking more than normal. He reports no other significant symptoms. He suffers from hypertension which is managed with ramipril and has no known allergies. He works as a librarian and is overweight. He drinks socially and smokes 5 cigarettes a day. Clinical scenario 1

 How would you investigate this man?  What might urinalysis show?  How would you manage this gentleman?  What are the micro and macrovascular complications of diabetes?

A 7-year-old male patient presented to the emergency department at 2 AM with vomiting and abdominal pain. He had a 2-week history of polyuria and polydipsia, accompanied by a 20-pound weight loss and blurred vision. His medical history was unremarkable. BP on admission was 120/75. Clinical Scenario 2

 What signs might you see in this patient?  What causes the blurred vision?  How would you manage this patient?

 Rehydrate – give 1L Hartmann’s solution per hour for two hours, then reduce.  Insulin – give 6 units, then 6 further units per hour – adjust according to sliding scale  Potassium – give with caution while monitoring cardiac rhythm  Acidosis – if the pH is less than 7.30 get urgent advice; give IV HCO 3 if pH < 7.0.  Stomach aspiration – to help remove excess potassium  K+ is transported into cells from the blood in co-transport with glucose – in cases of a lack of insulin, this process does not occur. RIPAS