Diabetes Master Class - Type 2 Diabetes Management - Medical School Finals Revision - Dr Gill

so thank you for joining us today um we've been graced by professor vino patel uh one of the you know specialists in diabetes we have in the area um and to be honest he's a an international name in the field and he's going to give us a quick 10 minutes on approaching a finals case for diabetes [Music] so vinod thank you very much for giving us the time today i'm sure it was um you know only last week it seems we're examining final students last year but this year is slightly difficult so could you help us out by walking through a diabetic case they might experience at finals thank you very much for asking me to help you with this endeavor i think it's very good of you to do something to help our students especially during these times of covid so let me talk a little bit about a particular case and maybe talk through some ideas that our final year students should definitely know about so let's take for example somebody who's age 54 who's had diabetes for four years so type 2 diabetes for 4 years and the hemoglobin a1c is 74 millimoles per liter indicating poor control the blood pressure is 146 over 80 indicating that it's above the national diabetes audit guidelines and the cholesterol is 5.2 so as soon as they get that presentation what would you be hoping where would you hope that the students minds will go in terms of questions so in terms of questions you first of all want to work out lifestyle so what are the lifestyle factors how's the diabetes affecting them in the activities of daily living at home or in their occupation so once you've thought about that and got a good idea of how the condition is affecting the patient then you have to move on to clinical parameters to reduce their risk so in terms of lifestyle you definitely have to think about smoking have they had their flu vaccination is there diet good enough quality and low enough calories to mean that they sustain their body so the right amount of protein the right amount of fat but maybe the right amount of carbohydrate for the physical activity that they have such that they don't gain weight now often students can be worried about asking questions like that because they're concerned they might offend a patient for a finals case how would you really like to see a student phrase that question in terms of phasing that question it's a good idea to start off by talking to the patients and saying what do you want to achieve in relation to your diabetes and they might just say i really want my blood pressure well control well let's fix that then they might say i want my diabetes to be very well controlled well let's fix that i've got low glucose levels and that's affecting me at work well let's fix that so try and fix something that the patient is particularly worried about and that's how care planning works generally the patient's living with their condition they see the healthcare professional for probably an hour or two every year i think you know this from general practice james that we can't spend that much time with our patients so we have to navigate our patients through the system so they get the best quality of life but as clinicians we need to talk to our patients about how we can work with them to reduce the complications of diabetes and we all know the complications of diabetes common cause of blindness something like 40 percent of all the patients going to end stage renal replacement programs are actually due to diabetes we know about the increased risk of strokes increased risk of heart disease as well and it's a common cause of non-traumatic amputation so we have about three or four thousand amputations a year in patients with diabetes but i think the great news is for both primary care and secondary care is that if we do this small simple things well then we can reduce all the complications of diabetes by probably 50 percent and stop them having complications prematurely which which to my mind would mean under the age of 80. so we've got you've given us our poorly controlled diabetic and we've started off we find that find out their lifestyle factors where would you hope that a final student will go next in that consultation they'll need to concentrate on the big things like not smoking clearly then they'd have to think about the three main national targets and that is a blood pressure of less than equal 140 over 85 a cholesterol of less than equal five and diabetes control hemoglobin a1c individualized to the patient 58 millimoles per mole or less so that's the starting clinical position and then we need to use the appropriate agents around the management of that patient so if i could go through that very clearly and simply then for the blood pressure in almost all patients with diabetes you start off with an ace inhibitor because we know that it protects the kidney in patients with diabetes if the ace inhibitor cannot be tolerated you can use an arb such as losartan but many diabetologists including myself are happy to use arbs first they seem to be better tolerated and there's some evidence that there might actually be better than arbs for vascular protection so we have to use either for blood pressure and second line would be a diuretic such as indapamide or only in dapamite i would argue because we don't use bentofiazine because it's more likely to worsen diabetes control and then third line would be a calcium channel blocker such as amlodipine so that's the blood pressure done for the cholesterol the two important things to remember is that for primary prevention it's a torah setting 80 milligrams at night if they can't tolerate it you can use reservostatin which is often better tolerated or ezetimibe which is very well tolerated because it's not absorbed into the blood so ezetimite reduces cholesterol absorption the evidence base isn't as good as it is for satins though so the cholesterol is easy for primary prevention a tour of a set in 20. for secondary prevention and let's make it very clear what secondary prevention means james by secondary prevention we mean people who have had any disease associated with atheromatous disease tiaa's strokes angina myocardial infarction peripheral vascular disease but also atherosclerotic aortic valve for example or renal artery stenosis where it's been diagnosed so we've got a good checklist there that the students are also going to going to want to be eliciting that information in their history as well absolutely absolutely and the cholesterol is a torso in 80 milligrams for secondary prevention so in a way you've persuaded me to talk about my alphabet strategy haven't you which is recovered says a b c d e f g and an h i'm afraid so but we've covered a already that's the lifestyle smoking diet physical activity but also appropriate advice on flu vaccination pneumococcal vaccination and now vaccination against covid19 as well and looking out for symptoms and good infection control is part of that as well b the blood pressure we've covered see the cholesterol we've covered but there's another c which is ckd prevention so we must check the urine albumin correct in ratio in our patients on a yearly basis and treat it if it's present ace inhibitors and the blood pressure of 130 systolic or under d for diabetes control we've done to some extent but als but the main aspect of diabetes control is to avoid hypos because they can result in harm falls arrhythmias and other issues as well such as cognitive dysfunction so that's your diabetes control e is the idea that the eyes have to be screened yearly and it's with a significant eye disease they need to be referred to a hospital eye service for laser treatment usually or injections against vascular endothelial growth factors f is the patient must examine their foot on a daily basis inspection looking for warmth looking for any breaks in the skin looking for maceration between the toes looking for callus formation and deformities and numbness or even tingling so that's self-examination by the patient having good quality footwear as well to cushion the feet properly but every year the patient must have examination by healthcare professional that would be a podiatrist or a practice nurse or we have an associate diabetes practitioner who equally who does the job equally well as well so the patient that's uh i mean if any of our students could get that list out i think they'd be flying through finals already in terms of the diabetic control you've given us a patient they're hba1c78 they're not well controlled let's give them only on metformin where would you want the students to go in terms of their management plan further sure so metformin and lifestyle are first line then the next drug to introduce which we call at the first intensification when the hemoglobin a1c is above 58 millimoles per mole for example is to think about the agent most appropriate so looking at you if you're 20 years older and your hemoglobin a1c was raised i would probably go for glycoside because i know that your body needs to make it make some insulin and hopefully you monitor yourself carefully so so you don't get hypoglycemia the problem with the sulfonate urea is you get hypoglycemia but then if you're higher risk so for example you've got albuminuria you've got heart failure or you've had previous atheromatosis disease then the sglt2 inhibitors have the best evidence for an oral tablet in indeed for any class of agents so it should be metformin and then glycoside and then sgr2 inhibitor and if the glycoside is not well tolerated in people then the glyptins are good agents for lowering the hemoglobin a1c and in the long term they might give you benefits but there is no clear evidence from the literature but but i think it's very important that all new doctors know about the sgl2 inhibitors i think another important bit of learning for our fine year students and other such clinicians would be the so-called sick day rules so if our patients are ill with a flu-like illness or sepsis due to a urinary tract infection then then they must think about diabetic ketoacidosis so they have to check glucose levels more regularly and if they have reduced urine output nausea vomiting abdominal pain then they must check their ketones and there are certain groups of drugs that i want to mention that you must think about and the useful acronym is sad man s-a-d-m-a-n so the s stands for the sgl2 inhibitors so because they have a diuretic action their usage must be reviewed if somebody is ill okay and also they're associated with a condition called eu glycemic diabetic ketoacidosis so your glucose level might only be 12 but you might have gone into diabetic ketoacidosis so if you're ill check glucose levels and ketones for the s of the sadman drugs sgl2 inhibitors the a and there's two a's in sadman that's the ace inhibitors and arbs the d is diuretics for obvious reasons the m is metformin so metformin causes nausea you can and if you've taken it with any of the failures which means worsening kidney disease heart failure sepsis liver failure as well then you can precipitate lactic acidosis you have to be very careful with metformin then the n is non-steroidal anti-inflammatory agents which i absolutely hate prescribing in patients with diabetes because of the risk of worsening diabetic kidney disease general kidney disease but also it can worsen heart disease because you get fluid retention with these drugs thank you so to finish off as we would on a finals case we normally like to crack out you know a little bit of entertainment on the side of the examiners and we ask our students some questions what ex you know could you give us three questions that you'd like to ask a grade a student if you're examining them on a diabetic case sure so i would say a patient has come in who has a family history of diabetes and they're worried about diabetes what would you approach to this patient being so the approach to the patient would be once again lifestyle optimize the diet the physical activity and then then check the hemoglobin a1c then i would ask the student what hemoglobin a1c indicates high risk of diabetes we don't like the term pre-diabetes because that's giving in to the fact that the patient may develop diabetes high risk of diabetes is far better because you're saying to the patient you're at high risk of diabetes but with good lifestyle and maybe intervention with metformin as well you may reverse that process so that's our 42-48 42-47 inclusive as it were because 48 is diabetes if you have symptoms and if you only have 48 on a single occasion it just needs repeating 48 in the same lab on a different day it's diabetes or a fasting glucose level or seven or more with symptoms or a random of 11.1 or more with symptoms and the similar levels on the glucose tolerance test so i'd expect a student to know that okay and the final question for the students and the final question for the students i think would be can you tell me a little bit about diabetic eye disease what grades are associated with loss of vision and which ones do you have to monitor closely rather than worry about loss of vision so that would be the background diabetic eye disease with the micro aneurysms a few hard exudates but the sight threatening retinopathy is going to be the more severe maculopathy around in the macular area a new vessel formation which can lead to bleeding and retinal detachment super well vinno i can only say thank you very much for your time today i'm sure the students will be very grateful um and thank you thank you very much and all the best students um hopefully every single person will pass thanks james take care finals will come you will get through them life will go back to normal just keep your head in the game you'll be fine [Music] take