Diabetes Mellitus
– case studies
Jana Vinklerová
▪ Chronically raised blood glucose (hyperglycaemia)
▪ Insulin/Glucagon
• Insulin is responsible for lowering glucose levels
• Glucagon is responsible for increasing glucose levels
▪ Two major subtypes
• Type 1 diabetes – absolute insulin deficiency (5-15%)
• Type 2 diabetes – impaired insulin secretion and insulin resistance (85-95%)
• Prevalence: 8% of population
Definition of diabetes (metabolic disorder)
Diagnostic criteria FPG – fasting plasma glucose
DM > 7 mmol/l
PPG – postprandial glucose
DM > 11,1 mmol/l
HbA1c – glycated hemoglobin
DM ≥ 6,5% (48 mmol/mol)
CZ
HbA1c
(mmol/mol)
US/studies
HbA1c (%)
Octet of pathogenesis
Natural history of type 2 diabetes
Macrovascular and microvascular
complication of diabetes
6
Lowering HbA1c Correlates to a Lower Rate
of Cardiovascular Complications
7
• Metformin – basal treatment
• SU derivates
• Incretins:
– GLP-1 agonists
– DPP-4 inhibitors (gliptins)
• SGLT2 inhibitory (gliflozins)
• Pioglitazon
• Repaglinid
• Insulins
Treatment options
8
Guidelines
New/modern drugs
• DPP4 inhibitors (gliptins)
– Alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin
• GLP1 receptor agonists
– Exenetide, liraglutide, lixisenatide
• SGLT2 inhibitors (gliflozins)
– Canagliflozin, dapagliflozin, empagliflozin
Case study 1
– patient with a newly diagnosed type 2 diabetes
Family anamnesis: parents and brother – treated T2D
Personal anamnesis: 75 years, 67 kg, 164cm, hypertensis, after cataract
surgery
Current diseases: during autumn 2013 spontaneously lost weight 3
kg/3 month; September 2013 polyuria especially et night hours, after
checking with GP hyperglycaemia 19,6 mmol/l – sent to hospitalization
in internal medicine
Which testing would you suggest?
• Blood tests – glycaemia, liver function tests, lipids, thyroid hormones
• Hyperglycaemia 19 mmol/l, glycated hemoglobin 127 mmol/mol, slight
increase liver function tests, lipids and thyroid hormones normal
• Renal function
• Mikroalbuminuria 4,0 g/l
• Blood pressure
• Abdominal ultrasound scan
• Liver steatosis
• Eyes examinations
Which treatment
would you suggest?
Case study 1
– patient with a newly diagnosed type 2 diabetes
• Intensified insulin regimen (48IU/day)
• Education – lifestyle modification – food and excercise, glycaemia selfmonitoring
and insulin application, complications of T2D
• There has been a satisfactory compensation of diabetes
• Weight 60kg, BMI 22,3
• Fasting plasma glucose 6,7 mmol/l, postprandial glucose 8,9 mmol/l
• What is the next step?
Case study 1
– patient with a newly diagnosed type 2 diabetes
• Release into outpatient care
Would you do some additional testing?
What tests?
Case study 1
– patient with a newly diagnosed type 2 diabetes
• Concentration of C-peptid
What is the parametr?
What is it says?
Case study 1
– patient with a newly diagnosed type 2 diabetes
Would you change the current treatment?
Why?
How?
Case study 1
– patient with a newly diagnosed type 2 diabetes
• Fixed combination of PAD – Janumet 50mg/1 000mg tbl. BID with
Glyclada 60 mg BID
What are active ingredients/agents?
Why these drugs?
What is their mechanism of action?
What are their side effects and potential risks?
Case study 1
– patient with a newly diagnosed type 2 diabetes
• Janumet = sitagliptin (DPP-4 inhibitor) + metformin (biguanid)
• Glyclada = gliklazid (sulfonylurea)
Case study 1
– patient with a newly diagnosed type 2 diabetes
Diabetes was compensated:
• Fasting plasma glucose 5,4-6,2 mmol/l a and then 4,1-5,2 mmol/l
• Postprandial glucose up to 8,7 mmol/l and then maximally 8 mmol/l
• Glycated hemoglobin 59 mmol/mol
What is the next step?
Case study 1
– patient with a newly diagnosed type 2 diabetes
Withdrawal of sulfonylurea
With adherence to lifestyle fixed combination (DPP4i and metformin) is
adequate treatment for diabetes control
Case study 1
– patient with a newly diagnosed type 2 diabetes
Family anamnesis: father – impaired glucose tolerance
Personal anamnesis: 54 years, 65 kg, 170 cm, HbA1c 7,5%, chronic
pancreatitis, T1D diagnosed in 2005, hypertension without treatment,
after amputation of the thumb and the second toe of the left foot,
stopped smoking 2002
Current diseases: BP 135/85, long-term not-healed defect on left leg –
fifth toe, hyperkalemia (6,1 mmol/l), microalbuminuria
What treatment would you suggest?
Case study 2
– patient with type 1 diabetes
• Humulin R 6-8-6 IU + Lantus 8 IU et 7 p.m.
What is the next treatment step?
Case study 2
– patient with type 1 diabetes
• Furon 40mg ½-0-0, Lusopress 20 mg 1-0-0
• What are this mediactions? Their active ingredient and mechanism of action?
• Vitar soda a NaHCO3 patenteraly
• What is the cause of hyperkalemia?
• Amputation of the fifth toe + ATB based on culturing + local
treatment
Case study 2
– patient with type 1 diabetes
Thank you for your attention