DIABETES MELLITUS

Ahmed Al-Naher
FY2 Coventry
Case Scenario
52 male presents to GP with 3/12 lethargy and 2/52 thirsty
and drinking more than normal.
PMH HTN
Drinks alcohol socially, non-smoker
BMI 32
Urine Dip: glucose +++
Random Blood Sugar = 13
Contents

Diagnosis

Risk Factors

Complications

Investigations

Management

DKA + HONK
Type 1 vs Type 2
Type 1 = Inability to produce insulin (autoimmune process
against beta islet pancreas cells)

Type 2 = insensitivity to insulin over time

Gestational Diabetes = decreased insulin sensitivity
during pregnancy

Secondary Diabetes:
Pancreatic Disease/CF/Chronic Pancreaitis/Pancreatic Ca
Steroid use/ antipsychotics/ thiazide diuretics
Diagnosis
Random Glucose >11.1 mmol/L
Fasting Glucose >7 mmol/L
2x Fasting glucose samples to confirm
Or presence of symptoms
HbA1c >6.5% (48mmol/L)

OGTT two hour glucose after 75g glucose

IGT = normal fasting glucose and OGTT between 7-11

IFG = OGTT <7.8 but fasting glucose 6.1 6.9
Risk Factors
T1: Family Hx, Caucasian/Scandinavian, Juvenile onset

T2:
High BMI
Physical inactivity
South Asian/Afro-carribean/middle-eastern
Hx of gestational diabetes, IGT, IFG
Steroid use
PCOS
Family Hx
Presentation
Polyuria
Polydipsia
Lethargy
Recurrent infections
Complications
DKA (T1)
HONK (T2)
Presentation - case
67 male admitted feeling generally unwell, SOB, sweating
and lethargic over last 2 days.
He is a known Type 2 diabetic on insulin with PVD,
peripheral neuropathy and previous CVA. His BM is 5.6.
ECG showed residual ST elevation in anterior leads with
Q wave and reciprocal changes. Echo showed new septal
hypokinesia

The patient had no history of chest pain

Complications
Macrovascular: Stroke, MI, PVD

Retinopathy, Xanthelasma, Cataracts, Opthalmoplegia,

maculopathy

Peripheral Neuropathy, Diabetic amyotrophy, neuropathic

pain, Autonomic neuropathy

Nephropathy

Recurrent infections: Cellulitis, UTI, Thrush

Investigations
Bedside:
Urine Dip: Glucose, ketones, MC+S
BM Stix, Ketone Stix
ECG, BP
Neuro, eye, foot exam
ACR, eGFR, microalbuminuria
Injection sites

Bloods - HbA1c, lactate, pH, U+E, Lipids, LFT, TFT

Managing Risk Factors
Lifestyle Weight loss, Exercise
Education DESMOND (Diabetes Education and Self
Management for Ongoing and Newly Diagnosed)
Self-Monitoring of BM
Dietician, Low sugar diet
Smoking cessation
Foot Care
Eye screening
BP Control: ACEi, CCB, Diuretic, K sparing
Statins, Fibrates
Aspirin
Oral Hypoglycaemics
Biguanides increase insulin sensitivity: Metformin

Sulphonylureas: Gliclazide, Glibenclamide

Meglitinides: Repaglinide, Nateglinide
Thiazolidinediones: Pioglitazone
DDP-4 inhibitors: Sitagliptin, Vildagliptin
GLP-1 Agonists: Exenatide, Liraglutide
Orlistat
Ascarbose
Treatment Pathway
1) Lifestyle Interventions
2) Metformin
3) Metformin + sulphonylurea
4) Metformin + sulphonylurea + Thiazolidinedione or
GLP-1 agonist or DDP-4 inhibitor
4) Metformin + sulphonylurea + insulin
5) Increase insulin
Insulin Types
Rapid-acting: Lispro (Humalog), Aspart (Novorapid)
Short-acting: Soluble Insulin (Actrapid)
Intermediate Acting: NPH (Insulatard)
Long-acting: Glargine (Lantus), Detemir (Levemir)
Ultra long-acting: Degludec
Pre-mixed: Novomix 30, Humalog Mix25, Humumlin M3

Regimens:
Once Nightly
Twice Daily Biphasic
Basal Bolus
Continuous Pump
Prognosis
T1 = increased risk of blindness, ESRF, CVD
Control of BP, Lipids, BM and weight are prognostic

T2 = 75% die of heart disease 15% die of stroke

Every 1% rise in HbA1c level risk of diabetes related
death increases by 21%
Case Scenario
58 female T2DM, Portuguese, does not speak English,
not complying with medication or dietary advice, admitted
with hyperglycaemia and seizures. Continues to have
high BMs of >25 on wards and wishes to self-discharge.
She has severe retinopathy blindness and PVD and no
carers at home. She is prescribed a pre-mix regimen.

What are the obstacles to safe management of this

patient?
What services/ support can be arranged?
Medical Emergency: Hypoglycaemia
BM < 3
Symptoms: low GCS, seizures, clammy, sweaty,
tachycardic, behaviour change, slurred speech, shaking
Risk: Strict BM control, Alcohol, malabsorption, Renal
failure, medication, lipohypertrophy, hypothyroid

GlucoJuice/Glucotab 10-20g
GlucoGel (Hypostop)
10% Dexrose IV 150-250ml
Glucagon 1mg IM/SC

Cerebral Oedema: Mannitol, Dexamethasone, 50% Dex

Medical Emergency: DKA
Hyperglycaemia, Ketonaemia, Acidosis
Ketones >3mmol/L
BM >11
pH <7.3, HCO3 <15

Triggered by stress: Infection, Poor compliance,

endocrine crises, CVD, Alcohol, medication
DKA signs
Polydipsia, polyuria
Weight loss, lethargy
Vomiting, Abdo pain
SOB (Kussmauls respiration)
Low GCS, confusion

Dehydration: dry mucus membranes, reduced skin turgor,

sunken eyes, slow cap refill, tachycardia, low BP
Pear Drop Breath
Signs of infection: Fever, crackles, cellulitis
Increased osmolality and anion gap
Specific investigations
Serial BMs and Ketones
Serial ABGs or VBGs
Septic Screen: BCM, Urine Dip, CXR
U+E including K
Trop T, CK
ECG
Amylase
CT Head

Monitor BM, Ketones, Acidosis, mental state, fluid status

DKA Resuscitation
Correct dehydration: Fast NaCl 0.9% initially

Fixed Rate insulin infusion: 0.1 unit/kg

Reduce BM ~3/hr to avoid cerebral oedema
Continue baseline long acting insulin
Run with NaCl 0.9% + KCl if <5.5
10% glucose once BM <14
Treat underlying cause

Once E+D convert back to normal insulin + DSN r/w

Indications for ITU: haemodynamic instability, cardiogenic
shock, respiratory failure, severe acidosis, coma
Complications
Cerebral oedema: headache, confusion, urinary
incontinence, coma main mortality in children
Hypoglycaemia arrhythmia, coma
Hypokalaemia cardiac arrhythmia
VTE
Retinopathy
ARDS/ Pulmonary oedema

Prognosis worsens with age, low GCS

Medical Emergency: HONK
T2DM
Hyperglycaemia, high serum osmolality, no ketosis
Osmotic diuresis -> intracellular dehydration

Triggers: Infection, poor BM control, MI, CVA, endocrine

crises, Acute abdo, medication, metformin, alcohol, first
presentation

Old age, dementia, steroid use

Severe Dehydration
Low GCS, confusion, seizures
Lethargy, weakness
Abdo Pain, N+V
HONK Mx
Ix as for DKA
Initial Fluid resuscitation
Variable Rate Insulin infusion
Run with 8 hourly NaCl + KCl
Treat underlying cause
Review medication
LMWH
Final Case
87 yo male from nursing home with known glioblastoma
multiforme admitted with worsening confusion, reduced
mobility and polyuria.
CT shows no new haemorrhage, infarct or mass effect
DHx frusemide, aspirin and dexamethasone
pH 7.2 lactate 2.9 BM 32
Urine: Blood + Leuk + Gluc +++ Nitrites +

Initial management?
Long-term treatment plan?
Questions?
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