Dr Maeve Durkan Dr Eoin OSullivan The Cork

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

The Challenge of The Friday Evening Patient • What defines the emergency ? • DM – Is it DM 1 or DM 2 / How to call it ? • Severe Hypoglycemia – Do we need to admit ? • - Do we need to refer ?

• Newly presenting patient with hyperglycemia • The Changing phenotype of DM 1 • The Changing demographic of DM 2

Newly presenting patient with Hyperglycemia Is it DM 1, DM 2 & 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 ?

DM 1, DM 2, Glucose toxicity • Any testing for immediacy ? • Any testing for future ? • What are options initially – Metformin – Sulphonyurea – Insulin – Diet & Exercise

The Challenge • Physical exam • Vital signs Pulse, RR, BP • Smell • Urine Ketones 1+ vs 4+ Does it matter ? • Serum Ketones …Do you check ?

DM 1, DM 2, Glucose toxicity • What are options initially as 1 ST Line – Metformin – Sulphonyurea – Insulin – Diet & Exercise

Newly presenting patient with Hyperglycemia Is it DM 1, DM 2 & 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 ?

Newly presenting patient with Hyperglycemia Is it DM 1, DM 2 & 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 / Hb. A 1 c 13. 9% What next ?

Patient referred/ seen 6 weeks later • • Started on Janumet 50/850 BD Symptoms settled Weight plateaued Hb. A 1 c 7. 9% • What do you think now ?

Anti-GAD-65 positive What next ?

Anti-65 -Antibody highly positive • Is this DM 1 ? • Is this LADA ? • Would I do things differently ?

Newly presenting patient with Hyperglycemia Is it DM 1, DM 2 & 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 DM 2 BMI 35. Feels well Blood sugar 24 ? What next ?

Newly presenting patient with Hyperglycemia Is it DM 1, DM 2 & 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 DM 2 BMI 35. Feels unwell Blood sugar 24 ? What next ?

Changing phenotype of DM 1 Honeymoon, βcell regeneration , MODY ? • • • 15 year old boy Polyuria & Polydipsia x 2 -3 days hot weather Lean BMI 22 No medical history , Family history DM 2 (father lean ) BSugar 22 , No ketones, (Biacarb normal) DM 1 or MODY? Or DM 2

Father Insists on Diet • Sugars recorded as relatively normal on f/up • Hb. A 1 c 6. 5% - 7% x 2 years • Drifting on A 1 c & commenced on Glucophage • Well controlled by 18 months • Within 12 – 18 months : Hba 1 c 10% & Weight loss

Anti-GAD 65 -Antibody highly positive • Is this DM 1 ? • Is this LADA ? • How did he survive for so long without insulin? • Would I do things differently ?

Glycemic Control as a Medical emergency DM 1 & DM 2

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 ?

28 years, DM 1, 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

Clinical Signs • Vital signs – Pulse : Tachycardia – Respiratory Rate : Tachypnoea – BP : Hypotension – Temperature : Febrile • Acetone Smell

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

Investigations • Serum ketones • Urine ketones • • Glucose ABG Serum bicarbonate K+ Anion Gap Phos Mg • ECG

Causes DKA : 4 i’s • Infection • Urinalysis / FBC • Infarction • ECG/ Enzymes • Incompliance • Profiles / History • IDDM*

Severe Hypoglycemia Is Admission Necessary ?

Is all Hypoglycemia the same ? • • New Timing Severity Frequency Management Awareness Co-morbidities ( CAD) Identifiable precipitants … exercise, shopping

The Hypoglycemic Patient ! • • 28 year old patient with DM 1 Presents at clinic Wife noticed “ a bit off “ Blood Glucose 1. 8 • What to do ? • Treat … and how ? • Treat successfully …and send home ?

36 year old Male • • • DM 1 x 20 years No complications Hb. A 1 c 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 ‘

38 year old female • • • DM 1 x 20 years No complications ‘Is a blood sugar of 2 mmol to worry about’? Had driven 50 miles in car. BS 1. 8 on arrival. No symptoms

28 year old female • • DM 1 x 10 years Likes good control Hb. A 1 c 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 ”

26 year old male • • • DM 1 x 8 years No complications Always well controlled. hb. A 1 c 7% No history hypoglycemia Now : Recurrent hypoglycemia x 3 weeks No intervention required • What do you think ?

Hypoglycemia • Aware • Unaware • Mild • Moderate • Severe • No gradation • Critical • Need to reset ! • Frequency • Requiring Intervention • Timing

Nocturnal Hypoglycemia The Thief in The Night !