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Hi, everyone. How's everyone doing? Um, could I just get someone in the chat to tell me if you can see and hear me and the screen? Ok. Ok, cool. You can see and hear me. Ok. So this is going to be our presentation on diabetes. We're going to be covering type one and two. So I'm going to be doing type one and my colleague newly is going to be doing type two. So as I'm sure you guys have seen in a lot of these tutorials, we are teaching things and every week at six on a Thursday, we give you presentations on core conditions for both A KT and Os. Everything's reviewed by doctors to ensure it's all accurate and look out for more tutorials. So, um, yeah, make sure you're following us on metal too before we begin type one diabetes. How do we all feel about it? Um, I'm just going to pop a pole. So just on a scale of 1 to 5, roughly how do you all feel about diabetes? Type one specifically? Ok. Most people are roughly in the middle around a three. Ok. Hopefully we can get that a little bit higher by the end of this um session. So I'm going to make a start. So in this section, I'm aiming to cover the pathophysiology, the features of type one diabetes, the investigations and management and some complications. But majorly focusing on one which will be revealed soon. So, pathophysiology starting off with the basics of any disease. Um type one diabetes is an autoimmune condition where the insulin producing cells of the islets, Sub langer hand in the pancreas are destroyed by the immune system. Now, to understand why this is an issue, we need to know why insulin is important for us. So unless we know why we need insulin, it's quite hard to understand what goes wrong when insulin is no longer in the body. So you've had a quick look at this question. Um I'm gonna put the pole up so have a guess or have a or it does have to be a guess if you know, just to answer, um, what is the role of insulin in the body? Yes, I'll just give it a few seconds more. It's between B and C. It seems ok. Let's have a look. So insulin, the role of it is to convert glucose into glycogen and that glycogen is stored in the muscle and the liver, there is also a very small amount that's stored in the brain. But in general, when we're talking about its pathophysiology, it's stored in the muscle and in the liver So essentially destruction of these insulin producing cells is going to mean there's less insulin available to convert the glucose into glycogen. And therefore more of it remains in your blood and your blood sugar levels go up. And that is why in diabetics, um blood sugar is kind of the measurement for how bad or how much better the disease is getting. Now, we are going to approach this from kind of a case based perspective. So from this question, a seven year old girl is brought into the GP by her mother because of a two week history of increasing thirst and frequent urination. Her mother reports that she has also been more tired than usual and has lost weight despite having a good appetite on examination, she appears pale and tired and her weight is below the 25th percentile for her age. Sorry, there is no fever rash or abdominal tenderness. Can anyone have a think what clues from the question point towards type one diabetes? As the main differential here, I can just put some ideas in the chat. Any features at all? From the question? Yeah. Yes. Th is one of them increased urination? Good. There's a couple more in there. Weight loss, good. Specifically weight loss despite having a um good appetite. Perfect. And the things that you can use in childhood onset. Yeah, that's the other one I was looking for. Amazing. So the fact that there's no fever rash or abdominal tenderness. Kind of mean, you can rule out something like gastroenteritis or um, et cetera, et cetera. There'll be other differentials that we'll look at. So the features of type one diabetes, um specifically are polydipsia and polyuria. Now, when it comes to features, I think often it's quite easy to just memorize a list. But if you understand why it happens, then it kind of sticks in your head a little bit more. So, Polydipsia is drinking more water, increased thirst. And there's a reason for this. It's because your body is attempting to dilute the high blood sugar levels. Everything in the body is in such a careful balance that as soon as one thing goes out of whack, it will try to compensate by doing the opposite. And in this case, it's no different with blood sugar. As soon as it rises, the body tries to get it back to its normal level. And one of the ways it does that is by diluting the sugar, polyuria is because high levels of glucose spill into the urine and because of osmosis or back from a level biology or even G CSE of all water is also going to be drawn with it due to the osmotic pressure. So increased sugar means water goes with it to dilute that sugar. Um weight loss, despite a good appetite, that happens because a lack of insulin means that glucose is prevented from entering the cells for respiration. And so instead of using glucose for respiration, which is what we naturally do. The body breaks down fat and muscle. Instead, fatigue is due to the inability to use glucose effectively. And recent onset kind of suggests it's like a, it's a way to distinguish between type one and two. Type one will have much more of a recent onset childhood onset um and a lot quicker symptoms, whereas type two necessarily won't have that. Ok. Now, in terms of um, investigating type one diagnosis, type one diabetes, there are cases which we will see where you don't really need any confirmatory tests. You kind of need to measure the blood sugar and you can make a clinical diagnosis based on some of those features, but sometimes you will need to have confirmatory tests, especially if the person is asymptomatic. So which two of these investigations do you think we would be using? Um, I'm going to put the pole up again one second. I, I know the poll only lets you do one answer unfortunately. So there's two correct answers. It could be ok. Ok. I oh, wait, one of the answers is repeating. Sorry, I just noticed that. Ok. So everyone's kind of picked between the correct two. Anyway. So, um, the investigations that we would do would be fasting glucose and random glucose, fasting glucose being over seven and random being over 11.1 we will look at what each of these mean in the next slide. But one thing to note is that in an asymptomatic patient, you need to meet this criteria two times um low C peptide um levels, C peptide is an autoantibody. And if you're in doubt between whether someone is a type one diabetic or a type two diabetic, then this and other autoantibodies would be what you'd use to distinguish. One of those antibodies would be option B, antiglutamic decarboxylase and C is wrong because the fasting glucose value that's required for diagnosis is over seven, not over six. So what do each of these um, investigations mean? So fasting glucose, the stable kind of summarizes what it's used for how it's done and like, I guess how long it kind of lasts. So fasting glucose is the first like measurement you take after someone has woken up after an overnight fast as it says here. So just a blood test and you put it in one of those glucometer things have a picture of that at some point coming up and it will tell you someone's baseline glucose. It's as it says here used to screen for diabetes, both type one and type two. the normal should be under 5.6 by, in someone who is a diabetic, it'll be over seven. An oral glucose tolerance test is an alternative to a fasting glucose. And that's where you have an overnight fast and also a glucose challenge. It takes a little bit longer and you get multiple samples but it measures the response to glucose load over time. So it can give you a better image of how someone is kind of processing that glucose, I guess. And it's both confirmatory and it can also be used for gestational diabetes. So that's another application of it and interpretation of results normal 7.8. But in over 11.1 that would be confirmatory of diabetes, random glucose is just at any point in time doing the finger prick and in a normal person, it should be below 7.8. In someone who is diabetic, it will be over 11.1. Ok. So as I mentioned previously, there are some instances where it's difficult to distinguish whether someone has type one diabetes or type two diabetes. And in scenarios like this, what we do is measure the C peptide level and insulin autoantibodies. And if someone has those and as in the C peptide level is raised and insulin autoantibodies are present then that points towards type one over type two. So out of these, which ones do you guys think will point to will need further investigation or is more inducible between type one or two? Have a read through. Again, there are two correct answers but the pole will only let you do one. Um someone else will these slides be made public? Yes, all the slides will be on metal that will be uploaded. Bye. OK. OK. Have a read through these can be quite difficult to distinguish. Ok. So the answers are two and three. Question one, a 14 year old presents with weight loss, lethargy, ketones and glucose in the urine. There's quite a clear picture of type one diabetes here. So you don't need to do C peptide and autoantibodies to confirm that because a the ketones, the weight lo weight loss, the age of onset is all pointing you towards type one diabetes. The second one, a 32 year old obese man presents with polyuria, random glucose of 12.5. The reason why this is a query is because he's kind of on the border of someone who would be questioned for type one or type two. Obesity. Yes, is a risk factor for type two. But we can't quite distinguish just because he is on the younger end. Um and question three. Um, a 61 year old woman with a BMI of 23 presents with polyuria and polydipsia ketones are present in the session is recorded. Yes, ketones are present in the urine. A um The reason why this one again is a query is because a it's an atypical age for type one diabetes, but ketones are present. So you do have to query whether it is a type one diabetes. But because she's on the older end, we can't quite be sure whether it's type one or two. Cos this is quite a late presentation for someone who would have type one but her BM I her ketones all point towards type one. Um So we'd have to investigate it to distinguish which one. And question number 4, 58 year old obese man presents with polyuria and a random glucose is 12 millimoles per liter. Um Again, this one, no further investigation is required. He's 58 on the older end obesity, clear risk factor for type two diabetes and random glucose is also meeting the threshold. So you don't need to do further investigations. You'd manage him as a type two diabetic. What's the age bracket for? Type one? Um, there's not like an exact cut off of if you're over this age, you have type one, type two but from everything I've read and patients I've seen, it seems to be that like anyone who's kind of forties and over, you're leaning more towards type two younger, you would kind of be suspecting is the type one or type two. But of course, like lifestyle plays a huge factor in that as well. So people may be very healthy at 40. So it may not be that at 32. So who knows? But in general, yeah, in your thirties you're kind of questioning more. Does this person have type one? Sorry? Ok. So the management of type one diabetes, this is kind of split into monitoring and insulin. So, oh God, I'm sorry, guys not been feeling too well. Um, so the monitoring there's kind of two sections to this one is the long term monitoring, which is the HBA1C or the, the like the amount of glucose in your red blood cells. And you measure that every 3 to 6 months. This gives you more of like a long term overview and you're aiming for a target of 48 or lower. Number two is self monitoring of blood glucose, which is recommended that type one diabetics do at least four times a day specifically when they wake up and before and after meals as well. Cos that's when blood sugars are most likely to spike. If you're someone who exercises, if you're ill, which you'll get on to you later or if you have other medical conditions that coincide, then it's recommended that you measure and monitor more frequently. The targets for this are 5 to 7 millimeters when you wake up and 4 to 7 before meals. Now, the other part of the regime is of course insulin in someone who is a type one diabetic, they will need insulin. Um, but it's important to know diet is also insanely important, but it's just to say that no matter how good the diet is, type one diabetes, it can't be controlled by just diet. You do also need a supplement of insulin because your bodies are just not producing the insulin. So no matter how good your diet gets, it can't process that diet if that makes sense. But as a rule of thumb, complex carbohydrates, fiber, regular meals are all really important to make sure the insulin in the regime is as effective as possible. And you're full for as long as possible, essentially. So the insulin regime that's used in the UK most often is the basal bolus regime. And if you break those two words down, it kind of tells you exactly what this means. So the basil is your base, it's what your body needs, like a minimum amount of to maintain its functions. And as I've said here, it's the maintenance dose of insulin that regardless of what you do or what you eat won't change. An example of this is Lantus, which is a long acting insulin is the brand name is Lantus and the Bolus is the insulin that changes. So it's insulin that adds that you give yourself based on what you're eating, how often you're eating, whether you're exercising, whether you're ill. And yeah, it's taken on the sugar content during the day, meals, exercise, illness, etcetera. And novorapid is an example of that. So that is the short acting one that you give in anticipation of a blood sugar spike. So if you know that you're going to eat a handful of jelly babies, then you would calculate that. Um some asked, this is not the same as biphasic regimes. This is not the same as a biphasic regime. No, um the biphasic regime, I'm not too sure exactly how that works, but this is different. Yes. Um Yeah, this is just a lot more adaptable and that's why this tends to be the one of choice because you can kind of alter it based on if you just want to eat. I don't know, some sweets in the middle of the day, then you can and you have the bolus to help you with that. Of course, it is a nightmare having to calculate everything and draw it up and inject yourself. But yeah, it means that at least it's possible. Ok. Next one, sick day rules when someone who is a type one diabetic is um first diagnosed. A lot of this is actually done within the community by the nurses. They play a huge role in the management of people with diabetes in general, but especially type one. And this is the kind of thing that patients really need to be educated on because firstly, it is super important that you don't stop taking your insulin because illness usually increases your blood sugar levels and that can cause you to go into a DKA which will come on to you later. So just to give you a little summary of what sick day rules, patients should be educated about. Their blood sugar should be uh monitored way more frequently like every 2 to 4 hours and you should adjust the insulin dose. So that means the rapid acting insulin probably will be increased because of the increase in blood sugar. But this will be separate for each person. The long acting insulin generally, it tends to stay the same. So your basal amount, your maintenance amount generally won't change. The rapid acting insulin is what will change stay hydrated just as anyone who is ill should. But especially important for someone who is a diabetic, maintain your carbohydrate intake because not only can your body very quickly increase its blood sugar content because the whole issue with diabetes is there's poor control. So you can also dip in blood sugar very, very quickly and that can lead to seizures and fainting and passing out. And yeah. So keep a hyperglycemia kit on hand, which will be, it could even be just, you know, if you need to have a quick pick me up having a sweet or gluco gel, et cetera, et cetera. Um And you should also check for urine ketones if the blood sugar is persistently high because that's an indication of um DK that you can manage the sooner you find out. Ok. Now, next question, a 24 year old woman presents to the ed with a two day history of nausea, vomiting, abdominal pain and increase in fatigue. She reports increased thirst and frequent urination over the past week. She has no significant medical history but mentions losing some weight unintentionally. Over the past month on examination, heart rate is 100 and 10 BP 90/60 respirate is 28 with a fruity odor on her breath. Her lab results reveal the following blood glucose is 22. Her ABG S show a ph of 7.25 and her carbonate as 14, her serum ketones are positive and urine analysis shows glucose and ketones present. There was obviously a very big clue in the previous slide. But what do you guys think is going on? Ok. No. Yeah, everyone's going straight for DK, which is correct. So will come on to DK. The reason why it's not HSS is because a this sensit typically affects more type two patients. And you can see from the history here, this is someone who's a young, had quick onset. Um It's more likely that this is type one and not type two. And also because there's acidosis and ketosis less likely to be the answer acute pancreatitis. Again, it could be a differential. Abdominal pain is common for this but because we're not given lipase or amylase data, more serum away from it. Lactic acidosis, you wouldn't see ketones in the urine gastroenteritis. Again, the nausea and vomiting could very much mimic DKA. But because of the hyperglycemia and the acidosis and the ketosis, we leaning towards DK. So DKA, um what is it and what the kind of features that we can look for? Now, DKA happens when your body starts to break down ketones because it doesn't have enough glucose or it doesn't have enough energy to use. So it uses ketones for energy and a product of this is the acidosis. Hence why your blood becomes incredibly acidic and you get ketones in your urine as well. So the features of DK A to look out for is acute onset. So from our question previously, the two day history points towards this history, suggestive of type one or previous type one diabetes. Um A history suggestive of this is nausea, vomiting, abdominal pain, increased thirst, urination. Um Sumo sign, does anyone know what this means? Can put some ideas in the chat that also completely? OK, if you've never heard of it? Yeah. OK. No. OK. So Sumo sign is a, it's like a very deep form of ventilation and you're struggling but your breaths are kind of and like I wish I could show a video on this, but um someone will be breathing like very labored, very deep breaths and it's a sign that they're in respiratory just dis distress. Obviously, um Acetone smelling breath is another very telltale sign of DKA and a question stem that has acetone smelling breath. Yes. After the regular breathing. Exactly. And um a telltale sign in a question stem of DK A is acetone swelling breath. The labs will also show acidosis and ketones as well. Management of DKA. So remember in an acutely unwell patient, you always take the A two E assessment first, always do that first. But this flow chart summarizes it pretty well. Remember DK ad treat the dehydration, K treat the potassium um potassium insufficiencies and the A treat the acidosis. So, dehydration, we always start with giving normal saline, even if somebody is very, very unwell, severely acidotic. The first point of call is always normal saline. Um It's usually given as a bolus, we'll come onto the prescriptions a little bit later. Um It's given as a bolus and you kind of increase it as you go along. But firstly, normal saline, always first point of call and you give it until the glucose reaches 12 to 14, then you correct the potassium. So if the potassium is under 3.3 you don't give insulin until it's corrected first. It's really important to correct the potassium first because insulin can make um hyperkalemia worse. So if the serum potassium is over 3.3 then you can start to give um give insulin. So yeah, like it's saying here, always correct your potassium before you give insulin and the insulin is given as an infusion, the prescription for that would look something like this. So, um or sign you bleep all of that stuff. So when someone first comes in, you'd start them off on the normal saline, it'll roughly be 1 L for an hour, one hour and through an IV route once their blood glucose is over or under 14, sorry, an addition of 10% dextrose is needed so that they don't now become hypoglycemic. Um and then the serum potassium it's usually is high on admission, but it falls quickly when you give someone insulin. And again, it can result in hypokalemia, hypoglycemia, you want to keep it maintained. So, yeah, that's roughly what the prescription will look like. I've also added in here. Just to note the fixed straight insulin has to be prescribed separately of the patient's standard insulin dose. So this isn't just their short acting insulin. It's a fixed straight insulin drip that will be prescribed separately. Um You can look in the B NF what the kind of dosing for that will be for DK A and it's different for hyperkalemia and DK. So just make sure you don't get that muddled up and that about concludes my section of the presentation. I will hand over to Navy. Now, if you guys could please fill in the feedback forms, we'd be very grateful. We depend on them a lot. Thank you. Hi guys. Um I'm gonna send the feedback form now for Elena. If you could fill it for her half, that'd be great. And in the meantime, I'll get up my section. Um, so this ok, I'll give it 30 more seconds and then I'll crack on with this just cos a lot to cover for the alert and I don't wanna hold you guys any longer than you need to be. Ok. That was really long, uh really quick 30 seconds, but I'm just gonna crack on. Um So yeah, welcome to teaching things and thank you for coming along and being so engaged. Um, I'm gonna take on from what, um, an end on with and I'm gonna talk about type two diabetes. It's a really big topic. Um, it's got a lot of public health implications on it. So it'd be almost impossible to cover everything about it. Um, on. Yeah. So if you sorry about the feedback form, if you could just fill it in, um, if you, you can just fill it in for Elena, but if you can't, then you can wait until my presentation is, um, done as well. Um, yeah, we're doing it in bits this time round. Um, because we're finding it's easier for people to do both tutors if you do it once at the end of tutor one and at the end of tutor two, um, but I'll just crack on with, um, type two diabetes. So, yeah, so it's a really big topic. So for today we're gonna finish, we're just gonna do stuff on the diagnosis and management. Um, but if you do wanna hear more about it, just put it in the feedback form and I'm sure we can organize something of the sort. So before we start, for sure, I'm gonna send a poll out gauging how people feel about this topic and please don't be modest. Um, be completely honest. Ok. Ok. Kind of confident. That's good. Ok, hopefully, um, we can increase that to a number five by the end, but we'll see. Um, so what is type two diabetes sometimes? Um and this is kind of being phased out. Now, this is referred to as non insulin dependent diabetes. So it in its treatment, um, insulin is not really indicated for it and it's caused by a decrease in insulin secretion similar to type one but also an increase in insulin resistance. And you need both of these to kind of form type two diabetes. Now, it differs between patient and patient from person to person as to how much of the secretion plays a role or resistance plays a role. But you need both. Essentially. Um the path of physiology is is that increase free fatty acids from maybe diet and oxidative stress. And that attracting um proinflammatory cytokines causes insulin resistance and kind of as a result. Um your insulin production by beta cells will show up. So actually, what you'll find is in people with type two diabetes, um very, very early on, they'll actually have increased circulation of insulin in their, in their bloodstream um at the very start, but this doesn't mean that their sugar level is normal, um their sugar level if their control is not good. Um And because you're producing so much more insulin, um naturally your beta cells um are gonna get exhausted. And this is also kind of compounded by facts such as your increased um sugar levels actually toxic to your pancreas and um insulin whilst it helps control glycemic um levels in your, in your blood. Um it can actually activate inflammatory pathways. So unfortunately, whilst its glycemic control function is not, is reduced. It can, it still causes inflammation. And this adds to the fact that your beta cells are being damaged basically. And as a result, you have decreased insulin production and all of those previous factors come into play again and you have beta cell failure. So my question to you is, and um you can um think back to what een has said and you feel free to put it in the chart. How may someone with type two diabetes present? Ok. That's for us to go through then. Um So basically, it can present in a multitude of ways. It can present to the through the triad of hyperglycemia, which is polyurea polydipsia and weight loss, which is how Elena described it. Um It can prove and this is very acute so it can present very quickly. Um They all can also be over months or years. So the same can happen or they can have fatigue. Yes. So like someone said, and, and blurry vision, they may also present with candid infections that's often infections of the genital tract. Um and they can present with recurrent uti S as well. They can also present quite late on in their disease stage. Um And so present with actual complications or they may come in with risk factor which make may make you believe that they may have diabetes and so you crack on the investigations, but unfortunately, this is very much deemed a silent disease and this is often picked up on screening or if someone orders, um, a patient, a blood test for, um, for diabetes just to rule something out or rule it out or something, that's when it's picked up. So the question is, then how do we diagnose, um, um, what are the risk factors? First of all, sorry, and the risk factors, um this is uh a graphic by the Emirates Diabetes Society and they're describing it much better than I ever could. So this is um a group of risk factors basically that are split, split into non modified and modified uh modifiable and they basically, um if someone presents with any of these, you may want to do a test for diabetes and splitting risk factors into modifiable and non modifiable is actually a really good practice because you may have an OS Q station or a C PSE station where you have to counsel someone on managing their um diabetes and you're not gonna tell them to change things like their age or their ethnicity are you? But what you can do is you can um advise them on increasing physical activity, um lowering their BP, lowering their cholesterol things that they can actually do and losing weight is actually a really, really big one. And if there's one thing I want you to take away from. This is really, really go on about losing weight, obviously in a sensitive way because there is research that shows that um people who manage to lose 10 to 15 kg. I mean, if that's feasible, of course, it actually puts them into a better chance of um going into remission. So it's definitely something that um people should consider if they do have diabetes and they present with obesity, for example. So just gonna test you and seeing whether you had remembered what Elena had said, what is then the diagnostic criteria? If you do a blood test for someone with asymptomatic disease. Um I'm gonna send the pole out now and I know there's a lot of numbers um and a lot of value for it. But believe me, when I say that diabetes is very much a numbers game, unfortunately. So I'm just getting you guys used to it. Ok. Six responses. I think I'm gonna aim for that from now on um just in the, in terms of time. So, yeah, actually, I'm really glad that you guys selected the right answer, which is um the third one, a majority of you anyway. And um basically, um your fasting glucose um should um to be diagnosed with diabetes type two, your fasting glucose would be more than seven or your random plasma glucose would be more than 11.1 and your HBA1C would be more than 48. I'm really glad. Well, most of you pick two separate occasions, which is really good. Cos always remember if someone presents or if you test someone, like on screening and they've had no symptoms of diabetes and they come up with this, you are going to have to test them again on a separate occasion. Um, just to make sure this is if they present with no symptoms, but if they do have symptoms, then you can get away with these results. On just the one occasion, the guidance is not clear on what two different occasions mean, they literally just stay on another day. Um So I guess it depends on your local practice guidelines and, and such. So yeah, just to recap, um it would have to be one of these values and remember what these values mean and what kind of criteria you're looking for. So remember that seven is for fasting plasma glucose, 11.1 is for um random plasma glucose. Um No, you uh the question is, do we have to test all twice or just one? Um Usually um it would just be the one I imagine just to for continuity's sake, but this is very much dependent on whether you do all of them at the at one in the first go. Um But yeah, it really depends on your local, local guideline. Just what I say is one of these on two different occasions. Unfortunately, the diagnostic criteria is not very specific as it is for other conditions. So the question is, well, that leads on to my next um kind of to uh part really is how are these tests done? So the oral glucose tolerance test is where um the patient will fast for at least eight hours and nothing but still water is allowed. Um I don't know if some of you guys have done blood tests before or you had to fast and sometimes think like um black coffee or black tea is allowed. But I think for this one, make sure that they, you know, only drink still water. Then after eight hours of fasting, you do a blood test and that will tell you a fasting plasma glucose kind of as a test suggests and then um the patient will consume 75 g of glucose, which is sounds like a lot usually as a sugary drink and then around two hours later after that is taken, um they're gonna do more blood tests and kind of how Anna mentioned earlier, a random plasma glucose is just glucose, uh glucose measured at any point of the day. And um that has to be um around 11.1 or below for it to be a good result. Um So what about HBA1C? So HBA1C is a long term marker of glycemic control. So it measures how gly glycated or how sugary if you are, your red blood cells are over the past 90 days. Um, but unfortunately if someone has a HBA1C of less than 48 that doesn't mean they don't have diabetes. Um, so if you are still kind of concerned they may have diabetes. But the blood test comes out saying otherwise, um, you should repeat it really or maybe try doing another type. Um, it's because of it kind of measure of like a long term period of blood, um, glucose control. It's used to see how people are getting on with their medications. Um and how their diabetes is um, faring. Um There are contraindications for using HBA1C, which is what I'm doing with thorough history is always important to make sure that you're not actually ordering a test for someone who is not really suitable for it and I'm not gonna go through it just because of interest of time, but these slides will be available. So please go through it yourself. I also do want to add that if you guys do use question banks, a very common question is asking you what kind of conditions or blood conditions usually would underestimate or overestimate. Um HBA1C. Um So definitely go read that up as well because it may come up in your exams. So how do you treat diabetes? So, diabetes, um the initial treatment is lifestyle modifications. So really harring on, on what um a mo a modifiable risk factors are. It's also medical management. It's a drug treatment uh to reduce blood glucose and as part of that, it's assessing people's HBA1C, but also how they are in terms of kidney function and cardiovascular risk. And the reason why lifestyle important is such a, like, this is such an important part to know about diabetes because it's one thing to say to a patient. Oh, just change your lifestyle. But if I got diagnosed with diabetes and someone just told me to change my lifestyle, if I really go into the specifics, I'd be really annoyed and I think it could be a really, um, it could come up for the station on you counseling a patient on how, what exactly to do when it comes to managing their lifestyle. So stuff you can say is encouraging high fiber, low glycemic, um, sources of carbohydrates, which includes, which can and, and also including low fat dairy products and oily fish. Um avoiding foods such as saturated fats and trans fatty acids, sugary foods, of course. And ironically discouraging the use marketed of foods which are specifically for people with diabetes. Um, and also weight loss. So here, um, in the UK, in an overweight person, um, the target weight loss is 5 to 10% and, you know, doing more physical exercise or really changing your diet, for example, um can, uh, really help with that. But, um, when it comes to osteo stations, you know, you may come with a patient who, um, may have a really complex kind of socioeconomic background. You know, maybe they can't afford um a gym membership, for example, or, you know, as we all know that unhealthy foods are much more cheap than healthy food. So definitely, like, speak to a patient out on their own and tailor your advice for them essentially. But these are kind of the points you wanna make sure you hit. So if someone came to you and was like, I just want to change um, or control my diabetes on lifestyle changes, what would the target HBA1C be? And I will start this pill. Now, I don't know if my medal was lagging cos it says no, it was fine. Ok. Yeah. Ok. So actually, um if someone was controlling their diabetes just on lifestyle changes, the HBA1C would be the same as it is for the tests, diagnostic tests and it would be 48 millimoles per liter. And this value is also the same if people are on lifestyle changes and also the first line drug for diabetes, which is Metformin. So which class, what class is Metformin? See how much people know about this drug? Ok. So a lot of people have got the right answer. It is a Biguanide and um I'm gonna go through what Metformin is actually. So Metformin is the first line drug for people diagnosed with type two diabetes. And like most a lot of people say it is a Biguanide and is actually one, the only bide license, at least in the UK um for use for um type two diabetes. Um, and that's because of its side effects, which I will go through in a bit, but essentially how it works. It, it increases your sensitivity to insulin and decreases um kind of hepatic gluconeogenesis. Um And because it's a first line drug and because the prevalence of diabetes is only going up, um, you may be very well asked to, um, counsel a patient through Metformin use to how to take it um kind of rules if they miss it, for example, and what test to do before and during. So if you did have that station, you would tell the patient to take it once daily with breakfast or take it twice daily um with or after a meal at the same time each day. And that really um depends on what dosing that patient will require of Metformin. Um do not give Metformin to patients with reduced um kidney function. So if their G fr is less than 30 the way you would know someone's G fr is by doing use and e so, oh, sorry, make sure that you do um A&E test before you start someone on Metformin, make sure it's normal and then do so annually to make sure um that their renal function isn't being um affected. Um You'd also not wanna prescribe this for someone who has a ketoacidosis. Um and a low BM I and the reason is that this causes weight loss. So it would become, it would probably be more harmful to give it to someone who has like ABM I of like 15 or something. Um, 11 or something. So avoid it. Um So it's adverse side effects are gi upset, which is why you always start me more uh Metformin on a low dose and you titrate it up. Um, and another, or if it's not tolerable by a modified, um by standard release, um, you change it to modified release. Um, another side effect of um, bif are lactic acidosis and if someone had an AK I or had an intercurrent illness, you would stop Metformin just because of the risk of lactic acidosis. And the reason Metformin is the only by benign license for use in the UK because the other ones out there actually have very severe lactic acidosis and it would be more harmful to patients who prescribe um, those bides and it would be to, to control the, them control their um, diabetes. And a very common question, um, that comes on exam, um, exams is if someone had uh, a procedure with general anesthetic or um, or pro or use iodine con er, containing x-ray, then you'd stop it for, er, on, on the day and for two days after is a Metformin given before the meal to avoid glucose peak after. So I guess that can depend on your guidelines but usually, um, usually you can give it just be just around perhaps or just after. Um, we've learned that it could be with, um, or after. So that really depends on how you've been taught. Uh, but I will look back into that. Um So the next question is Jane comes in with confirmed type two diabetes and has significant cardiovascular disease. What additional drug class should you prescribe alongside Metformin? And I'll send this pill out now. Ok. Sick responses. I'm really glad no one said another bide and most people were listening. So that's good. Um And a lot of you have gotten, it's a mix, but a lot of you have gotten the right answer, which is an SGL two inhibitor, an SDL two inhibitor, SGL T two are basically kind of transported in the kidney which reabsorb glucose back into the blood. Um which if someone has high glucose in the blood, that's not what you want. So this essentially prevents that from happening. And as a side effect because of that, you get, you can get kind of sugary urine or kind of sugar um present in your urinary tract, which makes you very susceptible to UTI S because that's a great environment for bacteria to thrive in, thrive on. Um And another side effect or of the adverse effect is a four gangrene. Um And your glycemic DK A examples of SGL T two inhibitors are dapagliflozin, canagliflozin, et cetera and the way to remember it may be gliflozin. Um but um that might help for you or if you have any other methods, feel free to put it in the chat and it also results in weight loss. So next question is, do you start it before, at the same time or after Metformin? OK. So because FG LT two inhibitors are being increasingly prescribed, it's really important to know when you do it when you prescribe them. Um if someone's already on Metformin and um you prescribe it after. So when, if someone has increased risk of cardiovascular disease, you would wait and they're on Metformin, you'd wait until that treatment. Uh Metformin treatment has been established and um it's confirmed that that patient can actually have Metformin and then once that is confirmed, then you prescribe an SGL T two inhibitor. So what I mean, if someone's at higher risk of cardiovascular disease, what is it that I actually mean? So according to nice, um these are the indications for S tr two inhibitors. So chronic heart failure is one established atherosclerotic a sclerotic cardiovascular disease. So the following example, such as Coronary heart disease, ac sa previous Mr et cetera, even a stable angina. So if someone tells you in their history that they've had this um or it's on their notes anyway, give them a SGLT to inhibit it because it's, it's really good um in those settings especially um I don't know if you guys have heard of AQ risk or what it is. So, let's test it. What would, what would, what Q risk should someone have to qualify for an SGL to two inhibitor? Is it 5%? 20%? 10% or 25%? Uh I would have given the way down there. But yeah, so it's 10%. Yeah. Um And basically the key risk is if you guys haven't heard it already. Um It's a really, really important tool, especially in UK medicine. Um If you're from Nottingham, this is your moment to shine. This is basically an algorithm that was made by Nottingham um Emos and UK doctors and it's based on a UK population and it's to work out what is the risk that someone could have a heart attack or a stroke in the next 10 years? And the value of AQ risk being 10 or above is very important, not just in diabetes, but across um all of medicine, especially in preventive medicine and general practice because you identify from the staff who are at a risk of these serious events happening and you can get to the bottom of it or help them deal with it and prevent such um incidences very early on, which is what we all want to achieve. So this is a algorithm um flow chart even from past medicine, which is a very simple but like e nice to arise from kind of um chart uh to describe what I've just spoken about and I highly recommend it. It's even got what you would do if Metformin is contraindicated. So for cases such as um maybe chronic kidney disease or um a low BM I et cetera. So my next question is Anna is already on Metformin and is at the highest dose. So the question is, thank you for the question. Um What, what you say when I mean, starting them? Is it after Metformin on the same day or after Metformin has been used for a while? So I don't really, you can ask um an expert on this, but I don't really think you can work out if someone is used to Metformin just on one day. I think maybe you would ask them to go on it for a little bit. I don't know how long the little bit means depends on um how four GP practices are, I guess and if they have like side effects for it. Um So if they feel really sick, then you, they come back to you and then um you obviously change the Metformin kind of give it to like modified release. Um But definitely wait until you can confirm that they can tolerate the Metformin before you start the SGL T two. So that really depends on availability and kind of how free GPS are. Really, I'm sorry, that's not a really good pinpoint on to your question. But yeah, um So Anna is already on Metformin and it's to the highest dose, but her sugar control unfortunately is still poor. So, if she's already on Metformin, what is the new threshold? New, old? I don't know, it's up to you to add another drug and this toe out. Ok. So a lot of you guys know a lot of this already. So you should be picked for at the start to talk. But so actually, yeah, a lot of you guys got the answer right. And it is 58 and pay close attention to the question I specifically asked for, what is her HB AC 1 HBA1C threshold? So now she's already on another drug. What is her now? Target HBA1C and um apologies for the grammatical error in the question. I stand up. OK. So um actually the answer is 33 millime molds per liter. It's not quite 48 like previously. And I guess this is assuming that the sugar control is so low. Um And it's so bad really? Um that we just increase the threshold a little bit. So that's what you mean. I mean, when target, so threshold is the level someone was hit to get another drug. And target is what she should be aiming for now that she's on that drug. Um I hope I made sense. Um when I was reviving diabetes last year, it was very difficult for me to understand what they meant by 58 and 53. Um But I hope that this clears it up. So the question is what drug can you add? Um So you have multiple other drugs already. Um One example is a sulphonal urea and what they do is they address kind of the first half of diabetes. The path physiology that I talked about the start, which is it increases or helps increase the beta cells stimulating insulin, um secretion. So, secreting more insulin, um a adverse effect of that can be a hyperglycemia, um weight gain um or hyponatremia. Um and examples are like glipizides. So the eyes really or glimepiride exam um for example, um and the side effect, like I said is weight gain. So if someone comes in um and they're rather um obese, um it's up to you really to what really whether prescribing such a drug may be um useful for them or maybe as relevant to really look at your patients in their own context to um when you're prescribing additional drugs. Another example is a pioglitazone and this is um an early Dili Diazol know, finally got that um available and essentially um you know, this because um you know that that drug because all of these drugs end in zone. Um Another way to remember um this also causes weight gain. And another way to remember is that you can, I if you eat all the pies, then you can put on weight. Um Something that's very important to know about this is that um it causes fluid retention. And if you've done your cardiology block already you would know that in people with heart failure. Um Sorry, I'll just come back to that question. I was just gonna finish this one in people with heart failure, um you cannot give this drug because heart failure essentially is where your heart cannot pump out blood um across your body or sufficiently basically, and that results in fluid retention. So people with heart failure will and with puffy kind of um ankle, swollen, ankle, puffy face, for example, and this basically contributes to that. So it makes no sense to add, to give someone with heart failure, this to make sure that this person does not have heart failure in their history. Um Before you get this. So question is, is weight gain a side effect or does it help with weight gain for Sulphon or um urea? Um basically, it, it, it is weight, it does cause weight gain and that is a side effect. Sorry, I hadn't made that clear. Another um drug that you can give is a DPP four inhibitor and this increases incretin um which inhibits basically, which inhibits Glucagon. And with all the peas, you can remember that its side effect that that is an increased pancreatitis risk. So someone presents with um an increased risk of pancreatitis, maybe their kind of alcohol habits are not that great or um they have familial history perhaps, you know, you might want to think twice before you give something like this and um these are the Gliptin, you can remember this because DPP. So it looks like dip and then Glip kind of r um just a way to remember um all the different drugs. Um So the combinations of these drugs are as follows. You can give basically Metformin as a first line with the rest of these drugs. Um Sometimes Metformin may be contraindicated like I said before. So then you'd have to go back and um try out another type of combination. Um if this person still cannot control. So if Anna, I think it was still cannot get her HBA1C, um less than 53 then you think about triple therapy essentially and just um Metformin plus two of the drugs that we talked about or SGL T two as part of that, if their cardiovascular risk is high. Um Another drug which is often in the news uh for various reasons is a GLP one mimetic and it's similar to DPP four in the sense that it also um has an incretin like effect. It's also linked to severe pancreatitis. So think about your patient before you give this. Um and also can have nausea and vomited. And these are your blue ties really. And um they have been shown to um cause weight loss, which is why I think it's very much in the news. Um You could, it depends what kind of, um G LP one, the method that you're giving um as to how you counsel the patient as I would put on the slides here. Um, and a way to remember is glutide, your glutide are G LP one mimetics. And if you are on, um, tr um if you are gonna give G LP one mimetics, you have to swap out one of the drugs first, essentially. So as I said, diabetes is a numbers game and it was really difficult for me to kind of figure out what they were asking um for which numbers. So here's a table which I hope is somewhat useful um to understand what kind of results you're looking for. If you wanna diagnose them with diabetes, depending on um what blood test you're doing or what stage of diabetes they're at. Um as I said before, the slides will be available. So you can always come check this out and then some questions uh to test your knowledge. So, Ben has come in with a HBA1C 63. His past medical history includes congestive cardiac failure. What drug is contra contraindicated? Ok. So majority or two thirds of you guys got the question. Got the answer right. Um It is ap liter zone. Um because like I said before that these are contraindicated in people um with um heart failure, which is what this person has. Sorry, faith, I'm just gonna finish this and I'll come to a question. Um Basically, um I understand why some of you may have put DAPI lilos in. But dapi lilos is actually given to someone who has a past medical history of cardiac failure because their risk of a cardiovascular event is so high. So, contraindicated means when someone is not, when a drug is not allowed at all in the person. And because this ben has come in with heart failure, you wouldn't give pioglitazone because it would increase fluid retention and that would make be symptoms a lot worse. The question is, what do you need to swap out one of the drugs to give the G RP one mimetic? So you wouldn't um if you've tried triple therapy and it's still not working cos that person's HBA1C is still exceeding 53. You wouldn't add a G LP. Um So I had, you have four drugs, you would swap one of them out. So you're still on three drugs. Um And one of them includes a G LP. Um mimetic. I hope that makes sense. You're not kind of adding on, you're swapping, swapping them out. Um Yeah, next question, Charlie comes in to uh who's known to diabetes clinic. He's come in with a painful ulcer on his scrotum. What drug could have caused this? So knowing this would be great. So that's what, that's what I'm testing you on. Yeah. OK. And, but all of you who answered, got it right. So this is a 48 gangrene and like I said before, the Gliflozin. So the SGLT two inhibitors can cause this and um this, you would think that this is a very common um complication uh or side effect of the SGL T two inhibitors. But actually it's not. But you think it is because medical school exams love asking you about it. So when it comes to SGL T two inhibitors, remember that they're good for people with high cardiovascular um disease. Uh and the risk of that and also that they can cause a four ganglion as well for your exams. So that is the end of our session just gonna go through what we did. So we did the presentation, the risk factors investigations and the lifestyle medical management. What we didn't cover are the complications and the acute presentation of type two diabetes, which is what Elena kind of alluded to earlier. The complications is such a big one. Diabetes is a massive disease. Um, that often requires a lot of MDT. Um, so I will touch up on the complications. Now, Karina asked, what was it called again? The condition, it's called a Fournier's gangrene. I'll go back to the slide that has it on. Um, at the end, just gonna touch on the complications and then, um, I'll go back to it. So the complications of diabetes, um, if you have kind of diabetes ward round, I'm like 100% sure that your consultant or whoever's leading it will ask you what are the complications, um, and split them into macrovascular microvascular. It's such a common thing. Um It's such a required thing to know. So the main complications can be split into macro and micro. And the macro ones are coronary artery disease, cerebrovascular disease. So, strokes and ti A s um peripheral arterial disease which often presents as diabetic foot. Um and the microvascular ones are like stuff like diabetic retinopathy, diabetic nephropathy and diabetic neuropathy. And um it's really important to kind of spot these complications and know what they are and how to manage them. Um diabetes that like I said is such a big, big disease. Um And there's no way that one kind of team can sort out its complication on its own. So, for example, for diabetic retinopathy, you are gonna have to get ophthalmology input for diabetic foot, you'll often see actually on your vascular patients. Um more. So um for nephropathy, um you would do urine tests and you do them yearly for diabetic foot as well. I'd also like to mention that going to a podiatrist, you should definitely recommend your patient to go to podia podiatrist and get vascular input because unfortunately, if you don't kind of take care of your foot, you can um you can kind of progress to um amputation, which is one of the worst things that you could possibly do. Um So very rarely um when someone presents with complications or if you have a osculation with complications, make sure that not only do you describe what complications are, but how you would manage how you'd bring an MDT kind of setting when it comes to taking care of your patient. Um, but that is all, it's a very, uh, whistle stop tour towards di do diabetes. Here are some resources that I found useful and use for this presentation. I use nice a lot. Um, they often are updated and I think they're the best kind of way, um, to know what to do in terms of medications, especially if you're in the UK. I also use Comma and Clark of the pathophysiology. The Oxford hand with a clinical medicine geek me, ask you to stop for counseling. I recommend. Please do SBA, so you don't forget what the numbers are and what the drugs are and their side effects and their names, et cetera. But that is the end. Thank you for sticking on. I'll send the feedback form out now. So if you could fill it for my half or for both of our halves, um If you hadn't already, that'd be great. Thank you. I'm going to, you can look back. Yeah, I'm gonna end the recording now for SBA. Did you use Passed? Um Yeah, I did, I use Passed and I use ResMed. They're not paying me to say this, but I did. Um Those are the main ones that I use for sure. Um So yeah, and obviously doing kind of your university provided um, questions as well. But yeah, thank you for coming along, um, and see you next week.