1. Delia Williams & Tania Bailey
Diabetes CNS
RMO – Clinical scenarios

2.  42 year old Māori male – Oct 13
 Med Hx : T2DM/ dx 1 year ago/Gout
 HbA1c – 98mmol/mol Dec 12
 GFR – > 90 ml/min/1.73m2
 ACR – 80 mg/mmol
 Meds:
 Allopurinol 100mg OD – not taking
 Voltaren
 Presented ED post collapse/ confusion / exac gout
L) toe

3.  O/A:
 BG 40.5 mmol/mol
 BP 101/59
 RR 18
 T 35.9
 GCS 15
 GFR ↓68
 Urea 33.1 mmol/L
 Osmolality 335 mOsm/kg body water
 Na+ 133 mmol/L
 K+ 4.8 mmol/L

4.  HHS – key points?
 Rx: insulin infusion – what / where
 BGs: 1930 hrs: 40.5
2015 hrs: 22.9
2100 hrs: 19.4
2200 hrs: 16.4
 When to transfer to s/s – what to consider?

5. Date 28/10 29/10 30/10
Time 0700 1130 1700 2100 0745 1200 1700 2100 0130
BG 12.2 14.8 14.6 12.9 12.3 14.9 23.9 19.1 16
Novorapid 3 5 3 5 8 7 5
Date 30/10 31/10
Time 0730 1130 1400 2100 0740 1140 1630 2000
BG 17.2 19.4 21.4 17.2 13.9 21.6 23.2 19.8
Novorapid 7 5 7 3 8 8 7
*
•Commenced on prednisone 40mg OD
•What to consider when deciding on insulin?
•BG trends/ Diet / targets / patient variables / f/u /meds / ….

6. Insulin Profiles

7. Insulin profiles
 Glargine / Lantus
 Glusiline /Apidra

8.  80 yr old Male
 Hx: T2DM / MI/CABG/PVD/°Dementia
 HbA1c 67 mmol/mol Jan 14
 GFR 54
 LFTs - ↑ last 8/12
 Bili 11
 Alk phos 481
 GGT 388
 ALT 61
 AST 62
 Tot protein 77
 Albumin 33
 ED – hypo 2.1 found by wife at 0830hrs 3 feb / readmitted 5
feb
 4 x ambo callouts last 2/52
 1 x hypo
 NSTEMI
 Fall – not hypo
 UTI
 Current regime
 Humalog Mix 25: 23 – 10 -14

10. Date 26/1 27/1 28/1 30/1
Time 0800 1200 0800 1200 0800 0800 1700 0800 2400
BG 17.3 17.7 9.7 4.1 4.9 11.5 10.5 2.1 3.5
Notes ½ cup
fizzy
½ cup
fizzy
H/Mix 25 23 10 14
Date 6/2 7/2
Time 0800 1200 1700 2100 0800 1200 1400 1800 2000
BG 2.8 8.6 12.6 14.8 6.6 2.7 10.2 15.6 16.8
Notes ED
23u
•Options?
•Considerations?

11. Dan – 20 year old (shared ethnicity NZ European & Maori)
 Presented to ED with 3 week history of polydipsia,
polyphagia, polyuria, lethargy and blurry vision
 Family/ Social history – no autoimmune conditions, currently
fit – 16 weeks into army recruit training current BMI 27 (wt
99.8kg - prior to training – 100-103kg)
 No previous ill health – weight few years ago 130kg
 O/A: 16.30 Bloods – RBG 44.2mmol/L, urinary Ketones neg,
S.Creatinine 136ummol/L, eGFR 64, Na 128, K+4.9, BP
122/74 Pulse 51, RR18 O2 sats 100% RA
 Fluid replacement – no insulin infusion - metformin
 Commenced on S/C insulin regimen: basal (lantus – 20 units
nocte) / bolus (apridra 10 units each meal and scale b)
 22.30: Venous Blood Gases – pH 7.35, PaCO2 – 56mmHg,
Act Bicarb 30.4 (21-27), stand bicarb 27.3, Base Excess 5.1 (-
2 - +2.0), glucose 26.5mmol/L, lactate 1.0, Na 134, K+3.9

12.  Next day - HbA1c 115mmol/mol
 BG profile After 3 – 6 days pre-meals 5 -10 –
2hrs PP7 -22mmols
 3 - 4 weeks later:
 C-peptide – 403 (350 – 700)
 Autoimmune markers- Glutamic Acid Decarboxylase
(GAD) autoantibodies – 50 (10U/ml)
 Insulinoma-Associated Antigen 2 (IA-2) >400 U/ml
(>15U/ml)
 Islet cell cytoplasmic autoantibodies >40 (>10IU)
 Baseline investigations for ED presentation – Glucose,
V.Blood gases, U/E’s, S. Creatinine, HbA1c, FBC, beta-
hydroxybutyrate
 cultures (blood and urine), CXR, ECG

13. Latent Autoimmune Diabetes of Adults (LADA)
 Type 3 diabetes, Type 1.5 or slow developing DM
 10% of ‘T2DM’ patients have evidence of anti-islet
cell autoimmune markers - Islet cell auto-
antibodies (ICA’s), glutamic acid decarboxylase
(GAD)
 Non-insulin dependent on diagnosis
 Normal beta hydroxybutyrate
 Slow, variable and incomplete autoimmune
destruction of beta cells
 Low but measurable C-peptide
 None or few - features metabolic syndrome

14. Criteria for diagnosis of LADA
 Consider age on diagnosis (>25 years )
 Presence for circulating Islet autoantibodies (at
least one)
 Lack of insulin requirement for at least 6
months after diagnosis
 Clinical features at diagnosis - presence of
symptoms
 If not overweight - consider testing for – GAD
autoantibodies and C-peptide
 Family history of diabetes or autoimmune diseases
 Islet cell autoantibodies (ICA’s) & insulin
autoantibodies (IAA) not always present

15.  69 year old male – exac COPD/T2DM
 Hx : IHD-stent/hyperlipidaemia
 HbA1c – 58mmol/mol May 13
 GFR – 70 ml/min/1.73m2
 Meds:
 Metformin 1gm BD
 Prednisone 40mg OD – reducing 5mg/every 2 wks

16. Date 11/3 12/3 13/3
Time 0700 1130 1645 2150 0745 1630 2030 0745 1145
BG 7.3 8.6 19.8 14.2 9.2 18.3 14.7 6.9 7.8
Insulin
Novorapid 4 u 1 u 4 u 3 u
Date 13/3 14/3 15/3
Time 1615 2100 0755 1135 1700 0400 1145 1630 2200
BG 16.7 15.2 6.7 7.4 20.2 8.7 10.1 20.4 12.2
Insulin
Novorapid 3 u 3 u 2 u