Complications of DM Tutorial Flashcards
47M - presents to GP with erectile dysfunction.
BMI = 33 kg/m2
BP = 148/99 mmHg
On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen.
Random capillary blood glucose is 25mmol/L
What is the likely diagnosis?
T2DM
Darkness could be because of abundance of insulin
What questions would you like to ask him next?
Do you find yourself going to the toilet more often / wake up in the middle of the night to go to the toilet?
Are you thirsty more often?
Any blurred vision?
Have you lost weight recently - check for T2DM and other pancreatic issues
Any other autoimmune conditions?
Family history of diabetes?
Do you smoke?
Do you exercise? How often?
Check hormone levels for low testosterone (erectile dysfunction sometimes confused with low libido)
How long have you had erectile dysfunction? - if he has had it for a long time, it’s likely to be related to CV risk factors e.g. circulation, atherosclerosis
More history:
Felt tired for some time and has noticed ~3kg of weight loss in the past 6 months and has significant thirst. The erectile dysfunction started a year ago and coincided with starting a new stressful job. He has a normal libido. His mother was diagnosed with T2DM aged 55 years.
What blood tests would you request to confirm your diagnosis and to help manage this patient?
HbA1c - confirm diabetes OR random BGL > 11.3
Oral glucose tolerance test
FBC - establish baseline before starting treatment
Urea and electrolytes
Testosterone, LH, FSH
LDL, HDL -check extent of dyslipidemia
The results come back:
HbA1c: 75 mmol/mol (20-41)
Total cholesterol: 6.7 mmol/L (<5)
Triglycerides: 3.2 mmol/L (<1.7)
HDL: 0.7 mmol/L (>1.2)
LDL: 5.2 mmol/L (<3)
Creatinine: 98 umol/L (55-110)
eGFR: >90 ml/min/1.73m2 (>89)
Urine albumin: creatinine 6 mg/mmol (>2.9)
Testosterone: 21 nmol/L (10-30)
LH: 7 u/L (2-12)
FSH: 6 u/L( 1.7-8)
Work through these blood results and describe what they show.
High HBA1c (and osmotic symptoms) = diabetes
high cholesterol, high triglycerides, low HDL, high LDL - dyslipidaemia
Normal creatinine and eGFR = normal renal function
[High albumin : creatinine ratio = glomerular damage - so he may be at the start of CKD. Or eGFR could be normal due to hypertension increased RPF]
Testosterone, LH and FSH are normal - no problems with the HPG axis
What are the principles of management in this case?
Lifestyle advice - exercise: lowers lipids, BP, lose weight. Diet: low in fats, refined carbs and salt. Low caloric diet. Stop smoking. Main goal is to lose weight to improve insulin sensitivity. Give anti-hypertensives like ACEi and ARB (alternative) to control BP e.g. ramipril. Warn patient about cough due to inhibited breakdown of bradykinin (spasmogen)
Second line treatment: follow-up appointments, if HbA1c is stlil high, give metformin. (helps insulin sensitivity and reduces HGO)
3rd line treatment = Metformin + sulfonylureas / SGLT-2 inhibitors / DPP-4 inhibitors / Pioglitazone
Eventually may have to take insulin
Monitor kidney function, BP and HbA1c regularly
Monitor retinopathy, neuropathy etc.
Structured education - educate patient about complications of diabetes, to express the importance of following treatment. Also teach patient about possible warning signs like DKA and HHS so he knows what to do.
