Interactive Case Discussion

By: Mohd Safwan Siti Noor Atikah

Mr. A 32 years old Malay male teacher Single

Presents himself to clinic as he worried about his weight and

health. He had been persistently gaining weight for last 2 years as he gained 18kg throughout those years.

Discussion Points 1
What further history would you elicit from this patient?

Further history
He was chubby since secondary school, which it was a boys school,

he doesnt have problem with his friends though he quite frequently teased by his friend due to his appearance. The problem started during his university time, he got difficulty in mingle around with his other female colleagues as he was not confident about his appearance. He found himself difficult to approach lady for a date even, because of the issue and end up single until now.

Further history
No polyuria, polydipsia, polyphagia, weight loss, nocturia, fatigue

and altered vision. He tried to lose his weight many times before but found difficult to be persistent and ultimately give up. Both her parents are overweight and diabetic. Doesnt smoke or taking alcohol.

 Further examination findings

Well looking obese man BP : 118/80mmHg Antropometric measurements;

Weight Height BMI Waist to hip circumference ratio 100kg 170cm kg/m2 34.6

Discussion Points 2
How to diagnose?

Common symptoms: Polyuria Polydipsia Tiredness Weight loss

Capillary Blood Glucose: 5.7mmol/L

Fasting Venous Plasma Glucose: 6.7mmol/L

OGTT FPG: 7.2 mmol/L 2 Hours PPG: 12 mmol/L

Discussion Points 3
Summarize his current problems. How would you manage this gentleman now? What is his target blood sugar? How to use the insulin injection?

Futher assess: Risk factor and DM complication

Relevant Examination

Cardiovascular Respiratory Abdominal

In this patient:

HbA1c: 7% TG: HDL: LDL: Albuminuria Creatinine/BUN Urine microscopy ECG

Normal

Summary of his Problem:

1. He is obese. 2. Having difficulty in exercise as hardly to do it persistently and ultimately give up. 3. Also having difficulty in diet control. 4. With family history of diabetes mellitus

Management of diabetes mellitus

Principle of management
PLIMS
Patient education Lifestyle modification Investigation Medication/Drug therapy Safety netting/Follow up

Patient education
Educator consist of doctor, nurse, assistant medical officer, health education officer, dietitian and others. Objectives: 1. To reassure and alleviate anxiety. 2. To understand the disease, its management and complication. 3. To promote compliance and self-care.

Content: Diet Exercise Medication Stop smoking, alcohol Complications (acute and chronic) Self-care/self blood glucose monitoring (SBGM)/foot care Psychosocial adaptation to diabetes (occupation)

Lifestyle modification
Physical activity Medical nutrition therapy (MNT): Prevention of diabetes 1. Weight loss 2. Balanced diet 3. Take high fibre diet

Management of diabetes 1. Meal timings should be regular & synchronised with medication time actions. 2. Diet consist of carbohydrate from cereal, fruits, vegetables, legumes, and low fat or skimmed milk. 3. Limit intake of saturated fatty acids, transfatty acids, and cholesterol to reduce risk of CVD. 4. Reduced sodium intake

Investigation
Venous plasma glucose - fasting plasma glucose (FPG) - random plasma glucose (RPG) - Oral glucose tolerance test (OGTT)

 Assessment of cardiovascular risk and end organ damage: - blood pressure - glycosylated haemoglobin (HBA1c) - BMI - lipid profile - renal profile - urine analysis particularly for albuminuria - ECG - eye; visual acuity & fundoscopy - feets; pulses & neuropathy

Drug management and Follow Up

Oral Anti-Diabetic (OAD) Agents

1. Biguanides (metformin) Does not stimulate insulin secretion, but lowers blood glucose by decreasing hepatic glucose production. Lower plasma glucose up to 20% as 1st line drug treatment esp. in overweight/obese patient. Should not be used in ptn with impaired renal function, liver cirrhosis, CCF, recent MI, or any other condition that cause lactic acid accumulation. -glucosidase inhibitors (AGIs) (acarbose) Act at the gut epithelium to reduce the rate of digestion of polysaccharides in the proximal small intestine by inhibit -glucosidase enzymes. Should be taken with meals.

2.

3.

Dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin) Act by inhibit DPP-4 enzyme. This enzyme break downs the incretins GLP-1 and GIP that are released in response to meal. By preventing GLP-1 and GIP inactivation, insulin will increase and glucagon is suppressed. This drives blood glucose levels towards normal.

DPP-4 inhibitor

_ glucose DPP-4 enzyme

prevent breaks down GLP-1 & GLP insulin = glucose

glucagon

4.

5.

Insulin secretagogues Sulphonylureas (Sus) SUs lower plasma glucose by increasing insulin secretion. Major SE is hypoglycemia, but 2nd generation Sus (glimepiride, gliclazide MR) cause less risk of hypoglycemia & less weight gain. Taken 30 min before meal. Insulin secretagogues Non-Sus or Meglitinides Short acting insulin secretagogues which lower plasma glucose by increasing insulin secretion, they bind to different site within the SU receptor. Taken 10 min before meal. Thiazolidinediones (TZDs) Act by increasing insulin sensitivity of muscle, adipose tissue, & liver to endogenous & exogenous insulin (insulin sensitizer)

Insulin therapy

Thank you