This document describes several clinical scenarios involving patients with diabetes. The first scenario describes a 42-year-old Māori man presenting with hyperglycemic hyperosmolar syndrome. The second discusses an 80-year-old man with unstable blood sugars on his current insulin regimen. The third involves a 20-year-old man newly diagnosed with latent autoimmune diabetes of adults. The fourth outlines a 69-year-old man with unstable blood sugars while tapering prednisone. Each scenario provides background on the patient's history and current treatment, with blood glucose readings and considerations for modifying insulin therapy.

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