1. Complex Cases for Trouble-Shooting Camden LES Diabetes Conference and IPU Programme Launch Friday 20 th June 2014

2. Ms CB 67 years old Type 2 diabetes July 2000 Metformin MR 1g od; Glargine 54 units pm (Feb 2011); Liraglutide 1.2mg od (July 2012) BMI 41 PMH: CVA; AF; Graves disease Cholesterol 7.3 (atorvastatin 40mg nocte) CKD Stage 3 – EGFR hovering around 50 since 2008 (ramipril 1.25mg od) Hypertensive (Tildiem retard, doxazosin; losartan)

3. Miss CB ctd HbA1c 98.9 in April 2012 – referred CICS & commenced liraglutide DSN & dietitian f/u for 3/12 then discharged due to DNA Attended Apples & Pears but ‘didn’t get on with it’ Declined referral for brief intervention for physical activity (December 2013) March 2013: HbA1c 83.6, BMI not known BG machine broken. Advised to buy a new one February 2014: HbA1c 98.9 BMI 41 What next??

4. Mr TA 63 years old Type 2 diabetes 2006 Metformin 1g tds, sitagliptin 100mg od, pioglitazone 45mg od (adverse reaction to gliclazide) HGV driver PMH: Hypertensive disease, hyperlipidaemia, AF, CCF Amlodipine, furosemide, losartan, simvastatin, spironolactone BMI 45.1 (longstanding) HbA1c 97.8 (11.1%) on 17.9.13 BMI 24.1 Ex-smoker

5. Mr TA ctd August 2011: HbA1c 78.1 - referred to CICS for optimisation of oral diabetes medications and to see dietitian for weight loss Advised 3 to 4 months of diet and lifestyle change and consideration of insulin treatment if no improvement Declined to see the dietitian Not seen by CICS again ? Why February 2013: EMIS entry ‘HbA1c improving a little – is under the care of St Pancras Team’ August 2013: HbA1c 59.6 September 2013: Exercise intervention offered & declined

6. Mr TA ctd November 2013: Commenced prednisolone 40mg od for chest infection December 2013: HbA1c 91.3 28.2.14: Referred to RFH GFR 66; cholesterol 3.4 What are the issues here? What next?

7. Mrs KL 46 years old Type 2 diabetes since September 2011 Metformin MR 500mg & gliclazide 80mg bd BMI 36.4 HbA1c 62 (7.8) TC 4.4 on simvastatin 20mg nocte BP 136/84 on lisinopril 10mg od C/O frequent night sweats LMP 28.2.14 What next?

8. Mrs RB 79 years old, lives with family Type 2 diabetes 1995 Dementia, CKD stage 4 (creatinine 97; eGFR 22) HbA1c 75mmol/mol (9%) On Novomix 30: 36 units AM & 30 units PM Community nurses administer insulin 2 hours after breakfast and 2-3 hours after evening meal Also on Gliclazide 80mg BD She wants to fast for Ramadan What would you advise?