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Endovigilance in Diabetes

Endovigilance in Diabetes. Dr.Ganapathi.B Dept.Of Endocrinology St.Johns Medical College Bangalore. Introduction. Endocrine abnormalities in diabetes is not uncommon. Should be vigilant in diagnosing them in patients with diabetes.

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Endovigilance in Diabetes

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  1. Endovigilance in Diabetes Dr.Ganapathi.B Dept.Of Endocrinology St.Johns Medical College Bangalore

  2. Introduction • Endocrine abnormalities in diabetes is not uncommon. • Should be vigilant in diagnosing them in patients with diabetes. • Knowledge about these will help in simplifying the treatment and reduce the complications

  3. Endo vigilance

  4. Case 1 • 40 year diabetic ,10 yrs duration, Hba1c 8.1%,hypertensive • Requires 4 anti hypertensive medication . • Incidentally has hypokalemia which has been persistent. • What will you do now?

  5. We repeated the K levels - was consistently low. • Next step?

  6. Got TFTs –done –was normal • Not on diuretics /steroids . • What Next ?

  7. Got PAC/PRA levels • Ratio was 25 • Suggestive of a suspicion for Conns syndrome • Confirmed by salt loading test • Got CT scan adrenals - showed 1.5cms/2 cm adenoma • Underwent surgery • Hypertension better • Requiring only one anti hypertensive • Now has normokalemia

  8. Case 2 • Type 2 Diabetes ,obese BMI 33 , • C/o weight gain • Worsening glycemic control, • On basal bolus regimen • 2gms Metformin,Sglt2 inhibitors,dpp4 inhibitors,sulphonylurea • In spite of good compliance with diet and exercise • Weight gain and worsened Hba1c • What Next?

  9. Got overnight dexasupression test done • Was non supressible • Suggesting hypercortisolism • ACTH test done was high suggesting ACTH dependent Cushing syndrome • MRI - Sellar showed 7 mm adenoma • Preop managed with ketoconazole • Underwent TSS surgery • Better now • Weight loss of 15 kgs

  10. Case3 • Diabetes ,20 yrs duration Hba1c 7.8% • Mild pedal edema + • Creatinine 1.2mg/dl • Urine albumin -2+ • Na-131,k-5.6 • What next

  11. BP- 159/90mmhg • On anti hypertensives • Not on diuretics • Persistent hyperkalemia • What are we dealing with?

  12. Hyporeninemic hypoaldosteronism • Treated with furosemide • Stop ACE-I/ARBs. • May use diltiazem to reduce proteinuria. • Better now.

  13. Case4 • Type 2 Diabetes 3 years duration • On Metformin 500 Mg bid • C/o weight loss 10 kg • Now has worsening glycemic control • Diet/ exercise compliant • What next ?

  14. TFT- normal • No evidence of Koch’s • No hypercortisolemiaand hypokalemia • Chest X-ray normal • USG Abdomen nothing contributory • What next?

  15. Weight loss with worsening glycemic control-suspect pancreatic cancer • CT abdomen showed a small tumour in the head of the pancreas • Underwent partial pancreatectomy • Now better

  16. Case 5 • Type 2 Diabetic,30years ,3 yrs duration,on Metformin 500mg bid • Family H/o premature cad + • Father died at age 35 yrs • On rosuvastatin 10 mg • O/E • Has nodular swelling on the elbows • Hba1c 6.5% • Lipid profile 312/34/216/65 • What next.

  17. Familial hypercholesterolemia • Treated with 40 mg of rosuvastatin and 20 mg ezetemibe • LDL-c now 150 mg/dl • What next?

  18. Started on Cholestyramine • LDL-C 130 • What next ?

  19. Started on Niacin • LDL-c now 90mg/dl

  20. Case 6 • 22 year old female • Newly detected diabetes when presented with pain abdomenS/o pancreatitis • Normal developmental milestones and puberty • Noticed to have thin limbs since childhood • F/h/o similar facial features in father- expired ?MI

  21. Diagnosis ?

  22. Lab investigations

  23. She was managed initially with insulin infusion and IV fluids, followed by basal bolus insulin regimen • Pioglitazone • Metformin • Fenofibrate • Atorvastatin • Orlistat • Omega 3 fatty acids

  24. Proposed new classification for syndromes of severe IR Endocrine Reviews

  25. Clinical Features that Increase the Suspicion of Lipodystrophy • Essential feature • Generalized or regional absence of body fat • Physical Features • Failure to thrive (infants and children) • Prominent muscles • Prominent veins (phlebomegaly) • Severe acanthosisnigricans Eruptive xanthomata Cushingoid appearance Acromegaloid appearance Progeroid (premature aging) appearance • Comorbid Conditions • Diabetes mellitus with high insulin requirements >200 U/day > 2 U/kg/day • Requiring U-500 insulin • Severe hypertriglyceridemia >500 mg/dL with or without therapy >250 mg/dL despite diet and medical therapy • History of acute pancreatitis secondary to hypertriglyceridemia Non-alcoholic steatohepatitis in a non-obese individual • Early-onset cardiomyopathy • Polycystic Ovarian Syndrome

  26. Case 7 • Type 1 DM -15 years duration ,on basal bolus regimen , • Now having recurrent hypoglycemia, • Compliance good , now c/o pigmentation of face • B12 deficient – being treated with B12 injections • Some improvement in facial pigmentation, • Having diarrhoea in the morning times, • Postural drop present with increase in heart rate • What next ? • Diagnosis ?

  27. Sr .Cortisol done - 3 mcg/dl. • Diagnosis –Adrenal Insufficiency. • Treatment with –hydrocortisone? OR predisolone ?

  28. Case 8 • 30 yrfemale,type 2 DM • Mother of 3,last childbirth 1 yr back, lactating • Was diagnosed GDM in 1st pregnancy ,and now has overt diabetes, • Now C/O difficulty in walking, getting up from the squatting posture,difficulty climbing stairs. • Hba1c -7.5% • On metformin 500mg bid, • No other co-morbid conditions • O/E CNS – reflexes normal ,power –lower limbs -4 minus • Other system normal • What next?

  29. Lipids –normal • Na/k normal • LFT /RFT –normal • Calcium -8.6mg/dl • ?

  30. Got vitamin D levels -<4 ng/dl • Po4- 2.1mg/dl • ALKpo4- 754 • PTH -254 pg/ml • Diagnosis –Oteomalacia

  31. Treated with calcium and vitamin D • Better

  32. Case 9 • Type 2 DM, 45 yrs old -5 yrs duration • On OHA’s –Metformin ,and DPP4 inhibitors • Falls from standing height –develops fracture • Not on pioglitazone /or SGLT2 inhibitors /anticonvulsants

  33. Type 2 diabetes • Expectation ; - Lower fracture risk but... • Fracture risk is higher

  34. BMD is predictive of fracture risk in T2Dm, But the relationship is different

  35. Sclerostin is increased in T2DM

  36. Skeletal Abnormalities in T2DM • Reduced Bone Quality? -Cortical -Trabecular - Matrix (AGE) - marrow fat

  37. Cortical Porosity may be Increased in T2DM 19 T2DM women vs 19 controls Cortical Porosity was 124% higher in T2DM at radius

  38. Cortical Porosity: Higher in T2DM with Fracture

  39. Cortical Porosity may be increased in T2DM with Fragility Fractures

  40. TBS predicts fracture risk in Diabetes

  41. Case 10 • Type 2 DM • 15 yrs duration ,on OHA’s/insulin • c/o E.D • Says loss of NPT present ,feels fatigued, • Hba1c -7% • BMI-30 • What next ?

  42. TMT –ve • Sr.Testosterone –low • FSH,LH –normal • MRI sella –normal

  43. Hypogoandism and T2DM International Journal of Impotence (200315, Suppl 4,S14-S20)

  44. The correlation between Testosterone, & IR European urology supplements 6 ( 2 0 0 7 ) 847–857

  45. Adipose Tissue and Testosterone Kapoor et al; Drugs Aging 2008; 25 (5): 34: 357-68

  46. Patients with diabetes or metabolic syndrome No symptoms or signs of clinical androgen deficiency Symptoms or signs of clinical androgen deficiency Total testosterone >200 ng/dl Total testosterone between 200-400 ng/dl Total testosterone <200 ng/dl Evaluate for etiologies of hypogonadism Not hypogonadal Free testosterone level normal Patient may have partial androgen deficiency, follow closely No other etiology of hypogonadism Glucose intolerance related hypogonadism Free testosterone level abnormal Proceed with evaluation for etiologies of hypogonadism Secondary etiology of hypogonadism How to Approach ???

  47. TRT and insulin resistance:Proposed Mechanisms • Low testo • Lipoprotein lipase activity TGLY uptake by adipose Tissue • Visceral adeposity •  Insulin resistance • TRT • Lipoprotein lipase activity •  TGLY uptakeby adipose • Tissue • Visceral adiposity •  Insulin resistance Kapoor et al,Clin Endocrinol 2005

  48. Thankyou

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