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 1ST 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 Acetone Smell 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. Is Admission Necessary ?
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 !