Diabetes and Hypoglycemia

Question 1

What is the most likely diagnosis?

• polydipsia
• polyuria
• weight loss
• excessive tiredness

Answer 1

T1DM

Question 2

Main Ix for T1DM?

Answer 2

BM
fasting/random glucose

OGTT - exclude other causes

Question 3

what warrants T1DM diagnosis?

Answer 3

glucose >11.1mmol 
\+ 
- ketosis 
- <50yrs 
- weight loss 
- BMI <25kg/m2
- personal/family hx of diabetes

Question 4

Management of T1DM

Answer 4

Insulin - dependent on indvidual 
3 regimens 
multiple basal bolus 
mixed/biphasic 
Continuous insulin infusion/pump

Question 5

what is the most likely diagnosis?

hyperglycaemia
metabolic acidosis
ketonaemia

abdo pain, visual changes, polyuria/dipsia, visual disturbance, lethargy/confusion, kussmaul breathing
dehydrated

(known T1 diabetic)

Answer 5

DKA

Question 6

What is main Ix for DKA?

Answer 6

BM - >11.1mmol/L

ketones = 2+ in urine or above 3mmol/L in blood

Question 7

management for DKA?

Answer 7

1. replace fluids - isotonic saline (slow infusion to prevent risk of cerebral oedema)
2. IV insulin - 0.1unit/kg/hr - when glucose <15mmol/L can infuse 5% dextrose IV
3. correct electrolyte disturbances
4. continue long-acting insulin, withhold short-acting
5. diabetic nurse r/v prior to discharge

Question 8

How can I tell if DKA is resolved

Answer 8

should resolve within 24hrs

• pH>7.3
• blood ketone <0.6
• Bicarb >15mmol/L

if not resolved within 24hrs = Endo review

Question 9

what is most likely diagnosis?

polydipsia 
polyuria 
tiredness 
blurred vision 
acanthosis nigricans

Answer 9

T2DM

Question 10

what are the Ix for T2DM?

Answer 10

HbA1c - 48mmol or above

fasting >7mmol/L or random blood glucose >11.1mmol/L

(must to a repeat test if asymptomatic and it was an incidental finding)

Question 11

Mx for T2DM?

Answer 11

1. lifestyle changes
2. lifestyle + metformin
   - aim HbA1c of 48mmol/L
3. lifestyle + metformin + anti-diabetic
   - aim HbA1c of 53mmol/L
4. If HbA1c rises to 58mmol/L - consider triple therapy or insulin therapy

Question 12

what is the most likely diagnosis

polydipsia/uria (osmotic diuresis)
dehydration
fatigue/lethargy
N&V
tachy, hypotensive
abdo pain 
SOB 
altered consciousness/confusion
known T2 diabetic

Answer 12

HHS

Question 13

what is the diagnostic criteria for HHS?

Answer 13

1. hypovolemia
2. hyperglycaemia (no acidosis/ketonaemia)
3. increaed osmolality >320mOsm/kg

Question 14

Mx for HHS?

Answer 14

1. normalise osmolality (gradually)
2. IV 0.9% NaCl infusion - replace fluids and electrolytes
   - may be hypokalaemic? - add K+
3. insulin @ fixed rate 0.05/kg/hr - normalise glucose
   (avoid insulin infusion if significantly ketonaemia)

Question 15

‘Sick day rules’ - what medications to stop?

Answer 15

1. ACEi/ARB - prevent dehydration/AKI
2. Diuretics - prevent dehydration/AKI
3. NSAIDs - prevent AKI
4. metformin - prevent dehydration/lactic acidosis
5. sulfonylurea - prevent hypoglycaemia
6. SGLT-2 inhibitor - prevent dehydration or euglycaemic DKA
7. GLP-1 receptor agonists - prevent dehydration and AKI