A diabetic man is diagnosed as having painful diabetic neuropathy in his feet. He has no other medical history of note.
What is the most suitable first-line treatment to relieve his pain?
Correct Answer A:
Diabetic neuropathy: NICE updated it's guidance on the management of diabetic neuropathy in 2010:
Gastroparesis:
A 46-year-old man presents as he is concerned about reduced libido, erectile dysfunction and excessive thirst. His wife also reports that he has 'no energy' and is generally listless. During the review of systems he also complains of pains in both hands.
Which one of the following investigations is most likely to reveal the diagnosis?
Correct Answer A: The above patient has symptoms consistent with haemochromatosis. The excessive thirst is secondary to untreated diabetes mellitus. Diabetes mellitus itself would not normally cause reduced libido or arthralgia.
Haemochromatosis: features:
Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia.
Epidemiology:
Presenting features:
Questions have previously been asked regarding which features are reversible with treatment:
*there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene.
**whilst elevated liver function tests and hepatomegaly may be reversible, cirrhosis is not.
A 64-year-old man with a history of type 2 diabetes mellitus is admitted with chest pain to the Emergency Department. An ECG shows ST elevation in the anterior leads and he is thrombolysed and transferred to the Coronary Care Unit (CCU). His usual medication includes simvastatin, gliclazide and metformin.
How should his diabetes be managed whilst in CCU?
Correct Answer D: The benefits of tight glycaemic control following a myocardial infarction were initially established by the DIGAMI study. These findings were not repeated in the later DIGAMI 2 study. However modern clinical practice is still that type 2 diabetics are converted to intravenous insulin in the immediate period following a myocardial infarction.
Myocardial infarction: management: A number of studies over the past 10 years have provided an evidence for the management of STelevation myocardial infarction (STEMI).
In the absence of contraindications, all patients should be given:
NICE suggest the following in terms of oxygen therapy:
With regards to thrombolysis:
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation:
An 18-year-old girl is admitted to the Emergency Department with an episode of sweating and dizziness. She is brought in by her father who has type 2 diabetes mellitus as he is worried she may be diabetic. He describes a number of similar episodes for the past two weeks. Her BM on admission is 1.9 mmol/l so the following bloods are taken:
What is the most likely diagnosis?
Correct Answer D: The raised insulin with low c-peptide level points to a diagnosis of insulin abuse. C-peptide levels would be raised in a patient following sulfonylurea abuse.
Hypoglycaemia:
Causes:
Other possible causes in children:
A 58-year-old man comes for review in the diabetes clinic. He was diagnosed as having type 2 diabetes mellitus around 10 years ago and currently only takes gliclazide and simvastatin. A recent trial of metformin was unsuccessful due to gastrointestinal side-effects. He works as an accountant, is a non-smoker and his BMI is 39 kg/m^2. His annual bloods show the following:
What is the most appropriate next step in management?
Correct Answer B: Pioglitazone is a possible option but may contribute to his obesity. There are also increasing concerns regarding the safety profile of thiazolidinediones, although the majority of negative data relates to rosiglitazone. Exenatide generally causes weight loss and is therefore useful in obese diabetics with suboptimal glycaemic control .
Diabetes mellitus: management of type 2: NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2009. Key points are listed below:
Dietary advice:
HbA1c:
Blood pressure:
The NICE treatment algorithm has become much more complicated following the introduction of new therapies for type 2 diabetes. We suggest reviewing this using the link provided. Below is a very selected group of points from the algorithm:
Starting insulin:
Other risk factor modification:
*many local protocols now recommend starting metformin upon diagnosis.
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