Endocrinology

Question 1

Monitoring and surveillance for TIIDM

Answer 1

Goals

• Patient-specific
• Improve glycaemic control: stage HBA1C goal
• Avoid hypoglycaemia
• Prevent complications

Confirm

• HBA1C
• BSL trends
• Lipid profiles

Screen for complications regularly

• Micro: EUC, UACR/UPCR, neurological exam for VA, fundoscopy, PN, Charcot’s foot. I will make sure that F/U with ophthalmology & podiatry is uptodate. High-risk foot clinic if Charcot’s
• Macro: ECG (ischaemic), ABPI/dopplers (PVD), CTB/Carotids guided by history & examination (bruits)
• Autonomic: postural BP, monitor for gastroparesis & erectile dysfunction symptoms

Non-pharm

• CV risk factor Mx
  
  • Goals: Chol <4, LDL <2
  • Provide education on a healthy diet - involve dietician
    
    • Limit saturated fats, cholesterol, increase fibre, healthy carbohydrates, proteins
    • Mediterranean diet
  • Education on the importance of glycaemic control in preventing complications - involve diabetic educator
  • Exercise: losing weight is hard, previous attempts failed -> try walking group (social effect, mood effect, weight loss, better control)
  • Smoking/ETOH cessation would be a separate issue
• Sick day plan
  
  • Document, provide, glucagon kit, engage with family (as they must learn how to use it)
  • WH Metformin/SGLT2 (Flozins) but never stop Insulin
  • Maintain adequate hydration - present to hospital if unable to keep fluids down
• Infection prophylaxis - vaccinate, hygiene, foot care***, podiatry

Pharm

• Adjust Insulin to target
• Consider how you’d change OHG depending on the case

Question 2

How would you address this patient’s Morbid Obesity?

Answer 2

This is a difficult Mx problem that requires time, commitment, input from the MDT.

Goals

• Realistic weight loss: 5-10% in 6 months
• Modification of eating behavior & increase physical activity
• Work-up for Bariatric surgery
• Monitoring for complications

Non-pharmacological

• Address Eating behaviors
  
  • Foster self-efficacy: encourage goal-setting, self-monitoring (food diaries/calories/activity logs), regular weighing, phone apps
  • Remove triggers: remove snacks from the house, replace snacks with fruit and vegetables
  • Eliminate all caloric beverages - often the source of unwanted calories
  • Portion control and meal planning: consider structured meal programs
  • Slow-down eating process - a physiological signal to fullness
• Exercise
  
  • moderate intensity (brisk walking) ~1h/d for 4-5 days/week
• Dietary modifications
  
  • Rather than specific diet, I’d suggest dietary plan that the patient is most likely to adhere to
  • Involve dietician to review patient regularly: diet rich in fruit & veg, avoid eating out/take aways, decrease refined carbs/processed foods
  • Optifast is a good option (replace 1-3 meals / day, depending on motivation)
  • Mediterranean diet - balanced, healthy diet - good evidence reducing CV risks
• Include family into the behavioral programs
• Commercial weight-loss programs / Online programs

Pharmacological

• Liraglutide 3mg (Saxenda) is the 1st line: proven weight loss, cardiovascular event reduction
  
  • Monitor pancreatitis / gallstones
  • It is an injection
• Orlistat
  
  • GI side effects, faecal incontinence, spotting, flatus, discharges
• Phentermine & Topiramate
  
  • Can’t be used in CV disease, arrhythmia, anti-depressant (increases serotonin)
  • Dry mouth, constipation, paraesthesia, psychiatric, topiramate suppresses mood

Bariatric Surgery

• BMI >40
• BMI >35 + comorbidity (e.g. lipid/DM/HTN)
• Must be willing to change lifestyle required for sustainable weight loss
• Drug/Alcohol use / Psychiatric problem - contraindication

Screen & Manage complications

• Regular exam for BMI, BP, CV, Hepatomegaly, Pharynx
• 3 monthly Lipids, HBA1C, BP, sleep study, knee XR, LFTs, USS liver and ECG/TTE.