2. SpR / StR teaching in GIM 18 th November 2013 Nick Lewis-Barned

3. What you asked for 12 responses Some themes Answering practical questions Looking fro accessible resources

4. What you asked for Management of newly presenting diabetes – Distinguishing Type 1 and Type 2 diabetes – When safe not to admit (GP calls, high BGL) – Initial management of Type 1 / Type 2 When to worry about raised BGL in inpatients – Out of hours – Adjusting doses – Postnatal – Missed insulin dose – how to correct

5. What you asked for Concomitant illness – Starting treatment for the first time – Glucose targets – Short term illness / steroid therapy – Frail elderly, treatment safety and withdrawal Management of DKA / HHS – Transferring from iv to sc insulin – Maintenance of background insulin in DKA – Deciding doses in young adults / low body weight

6. What you asked for Deciding on insulin type (profiles) Type 2 diabetes stepped approach – Conventional agents – Newer agents Miscellaneous – What’s a good diet?Weight loss &Type 1 diabetes – How often is im glucagon ok? – Statin choices – Hypos and renal failure, glucose iv and pancreas transplant

7. Scenario 1 Phone calls from GPs to say they have patients with BMs 20-30+, who are well and don’t have ketones on urine dip. Struggle to know how best to manage, so sometimes end up admitting to just be able to assess them Is that the right thing to do and best use of services? Which of these ‘well’ hyperglycaemic patients should be assessed in hospital

8. Scenario 1 What are the key safety questions? What are the first steps? When would you start what and what might your follow up be? How would you decide an insulin dose if you though this was necessary? What are the key things the person would need to know / be able to do?

9. Scenario 2 Well Type 2 within infected leg ulcers and BGL 25+. Seen late at night having missed 6pm insulin on iv insulin and 10% glucose with BGL getting worse. Gave her her 80+ unit premixed insulin Could her evening insulin hang around and make her dip in the morning?

10. Scenario 2 What types of insulin do you know? How would you go about answering the question? Wat would you have done and why?

11. Insulin profiles – types of insulin Circulating insulin levels Soluble (Actrapid / Humulin S) Isophane (Insulatard / Humulin I) Rapid acting analogue (Novorapid / Humalog) Ultra long acting insulin (Detemir / Glargine) 024681012141618202422

12. Common insulin regimes 2 injections: The soluble and isophane insulin can either be given separately or premixed ‘b.d. mix’ Food / snacks 712710 5 Injections: In this regime background insulin is provided by twice daily medium acting insulin ‘split basal’ Short actingMedium actingLong acting Night time ‘Basal bolus’ 4 Injections: In this regime daytime background insulin is provided by long acting insulin

13. Scenario 3 54 year old woman. Significantly overweight (BMI 33). Glucose 25 on admission with MI. No ketones. After 3 days her BGLs are in the range of 13 – 18. What’s the best way to get her started on treatment?

14. Scenario 3 What factors wold help to decide your treatment choice? What are your choices beyond metformin and gliclazide? When might you consider these and why? If she also has COPD how would you manage exacerbations / steroid treatment?

15. What’s left? Key questions around DKA / HHS and insulin infusions

16. What you asked for Concomitant illness – Starting treatment for the first time – Glucose targets – Short term illness / steroid therapy – Frail elderly, treatment safety and withdrawal Management of DKA / HHS – Transferring from iv to sc insulin – Maintenance of background insulin in DKA – Deciding doses in young adults / low body weight

17. What you asked for Deciding on insulin type (profiles) Type 2 diabetes stepped approach – Conventional agents – Newer agents Miscellaneous – What’s a good diet?Weight loss &Type 1 diabetes – How often is im glucagon ok? – Statin choices – Hypos and renal failure, glucose iv and pancreas transplant