Difficult diabetes

Torbay

7th December 2007

Is there easy diabetes?

Rare types of Diabetes History Investigations Treatments Complications Settings

Difficult history

Unusual history – rare diagnosis Extracting the right information e.g. hypos

may be concealed if risk to driving Assessing concordance with treatment

and its impact on results Difficult consultation

Difficult patients

54mCalled down to foot clinicMan with a hole in his right footNeeds admission.Patient refuses admission.

‘I can’t come in till next week’

What do you do?

Difficult management

LF 22fT1DM since 9Longstanding poor controlBasal-Bolus regime and TIFA trainingLast HbA1c 12.1%Come to clinic saying she wants to get

pregnant!Has already had one miscarriage.What do you do?

LF cont’Comes back to clinic 3 weeks later saying

she’s pregnant!

LF cont’ Intensive dietary, nurse and physician

support.HbA1c 10.3%Severe hypo’s without warning

Hypoglycaemic fit. Not brought in by paramedics Seen in next clinic - told to come in if further hypo Still not brought in by paramedics

What do you do?

LF cont’Eventually admitted.Further hypo on the ward.

Given milk and biscuits by nursing staff

Sugars extremely erratic with no apparent pattern

Random hyposWhat would you do?

A success?

AD 46f T2DMPoor control - HbA1c >10Metformin and basal-bolus insulin.Admits missing out her lunch-time insulin ‘as

I’m often out’What would you do?

What we did:GliclazideMetforminExenatideNocte insulin

Bloody drug company

DC 61 mT2DMMetformin 1g bd & Gliclazide 160mg bdHbA1c >8.5% for last two yearsDoes not want needles…

BUT has heard about inhaled insulin.

Bloody drug company

DC 54 mT2DMOn inhaled insulin! (Needle phobic)HbA1c improved from 12.8% to 8.6%What do you do?

Are we doing enough?

58 MT2DM - for three yearsWeight 91kgOn Metformin 500 tdsHbA1c 6.9%BP 124/72

Weight loss strategies

LifestyleDieticianExercise programmes

DrugsOrlistatRimonobantSibutramine

Surgery

Difficult setting

RS 54 mReferred from a clinic with ‘long standing

diabetes’Fasting sugar that morning 26.3mmolComplaining of polyuria (Nocte x 5) Currently taking metformin 500mg tds +

glibenclamide 15mg odWhat would you do?

Problems

Diabetes Clinic in UgandaMeds available

metformin +/- glibenclamide +/- insulin if patient can afford it (or if they’re lucky and

there has been a delivery that month) Investigations

Random/fasting glucose once a month if we have testing strips even for patients on insulin

Urine dipstix for protein That’s it

Any cases other centres would like to discuss?

Difficult investigations

Investigations that don’t add up Case 1 (AS)

35 year old maleT1DM for 4 yearsReports CBGs all greater than 10HbA1C 7.3%What do you do?