DR HJ BODANSKY MD FRCP CONSULTANT PHYSICIAN LEEDS TEACHING HOSPITALS ASSOCIATE PROFESSOR, UNIVERSITY OF LEEDS

Transcription

1 DR HJ BODANSKY MD FRCP CONSULTANT PHYSICIAN LEEDS TEACHING HOSPITALS ASSOCIATE PROFESSOR, UNIVERSITY OF LEEDS

2 DIABETETES UPDATE 2015

3 AIMS OF THE SEMINAR Diagnosis Investigation Management When to refer How to liaise with a specialist

4 WHAT IS DIABETES? A syndrome of raised blood glucose, hyperglycaemia, due to various causes. It has acute and chronic complications. Patients often have high BP and high lipid levels.

5 DIAGNOSIS OF DIABETES Typical symptoms and high blood glucose, >11 mmol/l Fasting blood glucose >7mmol/l 75g OGTT HbA1c; 48 mmol/mol (6.5%)

6 Investigations HbA1c Renal function Liver function Lipids Thyroid function

7 MANAGEMENT DEPENDS ON THE TYPE OF DIABETES

8 TIP You can only make a diagnosis you have heard of. If you are not aware of the correct diagnosis, you cannot make it.

9 TYPES OF DIABETTES Type 1: insulin dependent Type 2 Pancreatic disorders Drug induced Endocrine disorders Genetic syndromes

10 TYPE 1 DIABETES Autoimmune destruction of the insulin producing islet beta cells Insulin deficient: insulin dependent Usually young, but can be ANY age Autoantibody tests: ICA, IA2, GAD Often other endocrine disorders in patient or family

11 TYPE 2 DIABETES Insulin resistant/deficient Not absolutely insulin dependent Strong family history Often obese or overweight Often hypertensive and hyperlipidaemic

12 DIABETES SECONDARY TO PANCREATIC DISORDERS Chronic or acute pancreatitis Calcific, tropical pancreatitis Pancreatectomy Pancreatic cancer Cystic fibrosis Haemochromatosis

13 DRUG INDUCED DIABETES Diuretics Steroids Antipsychotics e.g. Olanzapine Psychiatric drugs: weight gain

14 ENDOCRINE DISORDERS Acromegaly Cushing s syndrome Phaeochromocytoma

15 GENETIC SYNDROMES Friedreich s ataxia Dystrophia myotonica

16 GESTATIONAL DIABETES Diabetes appears during pregnancy Diabetes resolves after pregnancy At risk of diabetes in later pregnancy At risk of diabetes in future Pregnancy in the known diabetic case Diabetes arising or diagnosed in pregnancy

17 MODY Maturity onset diabetes in the young: Mason diabetes, Tattersall & Fajans Autosomal dominant pattern 1-2% of diabetic cases Onset under 25 Insulin not required initially Glucokinase, HNF 1A, HNF 4A

18 INSULIN THERAPY Twice daily mix: Novomix 30, Humalog Mix 25, Humulin M3 Basal bolus: basal od, fast acting with meals Pump therapy Insulin side effects: weight gain, hypoglycaemia

19 INSULIN PEN

20 INSULIN PUMP THERAPY

21 INSULIN PUMP THERAPY

22 FREESTYLE LIBRE

23 DIASEND SYSTEM

24 DIASEND SYSTEM

25 TABLET THERAPY Metformin, immediate or slow release Sulphonylureas e.g. gliclazide, glimepiride DPP-4 inhibitors,e.g.sitagliptin Glycosuric drugs, SGLT2 inhibitors, e.g.dapagliflozin

26 SGLT sodium-glucose cotransporter blockade

27 THE INCRETIN EFFECT FOOD STIMULATES GUT HORMONES AND ENHANCES THE RELEASE FO INSULIN

28 Incretins and glycaemic control 7,8 Ingestion of food GI tract Release of incretin gut hormones Active GLP-1 and GIP Pancreas Beta cells Alpha cells Glucose dependent Insulin from beta cells (GLP-1 and GIP) Insulin increases peripheral glucose uptake Blood glucose control DPP-4 enzyme rapidly degrades incretins Glucagon from alpha cells (GLP-1) Glucose dependent Increased insulin and decreased glucagon reduce hepatic glucose output Adapted from 7. Drucker DJ. Cell Metab. 2006;3: Miller S, St Onge EL. Ann Pharmacother 2006;40:

29 INCRETIN THERAPY Lowers glucose levels Weight loss Incretin mimetics: Byetta, Victoza, Bydureon, Lyxumia DPP4 inhibitors e.g. Januvia/sitagliptin

30 INCRETIN THERAPY VICTOZA PEN

31 WHAT DO YOUR PATIENTS DO ALL DAY?

32 The evolution of mankind 2.5 mn years 50 years 32

33 LIFESTYLE THERAPY AND WEIGHT CONTROL Diet Physical activity Bariatric surgery

34 LIFESTYLE THERAPY

35 LIFESTYLE THERAPY

36 AIMS OF THERAPY Control symptoms Avoid hyperglycaemia and hypoglycaemia Current targets: type 2 diabetes HbA1c <53. BP <130/80 Optimize weight Prevent complications

37 SCREENING FOR COMPLICATIONS Retinal imaging annually First pass urine albumin/creatinine ratio annually Foot examination for pulses, neuropathy annually

38 DIABAETIC COMPLICATIONS Retinopathy and blindness Renal impairment and failure Stroke Ischaemic heart disease Peripheral vascular disease Foot ulceration, infection, amputation Neuropathy Sexual disorders

39 MACULOPATHY

40 RETINAL HEAMORRHAGE

41 DIABETIC NEPHROPATHY HISTOLOGY

42 CEREBRAL THROMBOSIS

43 MYOCARDIAL INFARCTION

44 WET GANGRENE

45 DIABETIC NEUROPATHY

46 DIABETES & PSYCHIATRY Eating disorders Alcohol abuse Substance abuse Excess deaths among young diabetic heroin users, suicide

47 CATEGORIES OF ILLNESS Curable Treatable, but incurable Untreatable and incurable

48 TRANSFER OF TREATMENT CATEGORY A diabetic patient can transfer him/herself from treatable to untreatable with adherence issues, eating disorders or alcohol or drug abuse

49 TREATABLE TO UNTRATABLE Mrs CM, aged 53, type 1 diabetes Eating disorder untreatable Irregular eating, poor nutrition, low BMI Minimal insulin adherence Blind, autonomic & peripheral neuropathy, hypotension, foot ulcers, cardiac arrest, brain damage.

50 WHEN TO REFER When the aims of treatment have not been reached Diabetic complications

51 HOW TO REFER Referral letter or fax Phone if acute problem

52 THANK YOU FOR YOUR ATTENTION ANY QUESTIONS OR COMMENTS?