CASE TITLE: DIABETES MELLITUS TYPE 2

Developed by: PROFESSOR TIM GREENAWAY

Date: 10 July 2008

Year: 5

LEARNING OBJECTIVES

After you have finished this case you should be able to:
1. understand the pathophysiology of Type 2 diabetes mellitus;
2. recognise features of the metabolic syndrome and their relationship to lifestyle,
genetic susceptibility and Type 2 diabetes mellitus;
3. be familiar with the management targets and screening protocol for long-term
management of Type 2 diabetes mellitus;
4. understand risk factor modification in the prevention and treatment of
complications associated with Type 2 diabetes mellitus; and
5. understand the multidisciplinary nature of Type 2 diabetes mellitus management.

SCENARIO
You are a senior medical student on a country general practice rotation. Your supervisor
asks you to prepare a case management plan for a new patient recently seen in the
practice

CASE DETAILS

Mr OB, a 46 year old man presented to his general practitioner for a routine health
assessment. He had not previously seen a doctor for over 15 years. He described his
general health to be good although he was aware of a family history of adult onset
diabetes involving a maternal uncle and a paternal cousin. He was not taking any
medications nor was aware of any drug allergies. He was a non smoker, consumed three
standard drinks of alcohol per day, worked in a sedentary occupation and undertook
minimal aerobic exercise.

LEARNING TASKS – FOR CLASS DISCUSSION

• What is the relationship between each of a) family history, b) age and c) weight and
risk of developing Type 2 diabetes?
• How does Type 2 diabetes differ from Type 1 diabetes mellitus?
• What are the current diagnostic criteria for Type 2 diabetes and who should be
tested?
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LEARNING TASKS FOR INDIVIDUAL PRESENTATION

1. Write a request for the biochemical investigations of this patient. (Richard Ward)

FURTHER CASE DETAILS

On examination blood pressure was 155/90mmHg and BMI was 34hg/M2 with a waist
circumference of 108cm. The serum lipid profile revealed a total cholesterol of
6.8mmol/L, triglycerides 6.7mmol/L and HDL cholesterol 0.8mmol/L. The random
capillary blood glucose was 10.8mmol/L, urine analysis was negative for ketones. A
75g glucose tolerance test revealed a fasting BSL of 7.3mmol/L and two hour BSL of
16.9mmol/L.

LEARNING TASKS – FOR CLASS DISCUSSION

• What patient information is available for newly diagnosed Type 2
diabetes.

LEARNING TASKS FOR INDIVIDUAL PRESENTATION

2. Prepare a case management plan outlining targets and multidisciplinary roles in
management of Type 2 diabetes. (Kelly Verdouw)

FURTHER CASE DETAILS

The patient was referred to the Diabetes Educator to be taught home blood glucose
monitoring and receive advice regarding a diabetes diet and the recognition, prevention,
and management of hypoglycaemia. Ophthalmological and podiatry reviews was also
organised. The patient was advised on an exercise strategy which involved at least ½ an
hour of brisk continuous walking daily and was provided with dietary advice. A weight
reduction target of 0.5-1kg per month to achieve a normal body mass index was
outlined. Advice regarding appropriate alcohol consumption was provided.

LEARNING TASKS FOR CLASS DISCUSSION

• What are the contemporary published management recommendations for
Type 2 diabetes mellitus management targets?

LEARNING TASKS FOR INDIVIDUAL PRESENTATION

3. Prepare a handout of advice a doctor should provide Mr OB regarding lifestyle
modification. Consider the role of diet, exercise and lifestyle in Type 2 diabetes
management. (Jessica Richardson)

FURTHER CASE DETAILS

The long term complications of Type 2 diabetes mellitus as well as strategies for their
prevention were discussed with the patient. A blood pressure target of 130/80mmHg was
recommended. A target of LDL cholesterol of <2.5 and triglyceride <1.8, and an HbA1C
target of <7.5%, (preferably <7.0%) was planned.
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The patient was reviewed following commencement of an appropriate diet and exercise
strategy as well as home glucose monitoring. Glucose readings had improved between 5-
8mmol/L fasting and 7-11mmol/L at other times during the day. The patient was
measuring blood glucose prior to breakfast, two hours after lunch and two hours after
the evening meal. The blood pressure remained elevated at 140/90mmHg and repeat lipid
testing showed only minor improvement with a cholesterol 5.6 and the LDL cholesterol
3.2mmol/L. An assessment of renal albumin excretion revealed a moderately elevated
albumin excretion.

The patient commenced on lipid lowering therapy with an HMG CoA reductase
inhibitor, anti-hypertensive therapy with an ACE inhibitor and glucose lowering
therapy with metformin 250mg with breakfast and evening meal.

FURTHER LEARNING TASKS – FOR CLASS DISCUSSION

• What are the benefits of treating BSL in Type 2 diabetes?
• What are the benefits of treating BP and lipids in Type 2 diabetes?

FURTHER CASE DETAILS

Follow up was planned for medication adjustment and HbA1C monitoring at four
months following diagnosis and the patient was adhering well to it and appropriate diet
and exercise regimen and glucose reading largely ranged between 4-8mmol/L. The
HbA1C had improved to 6.8%. The cholesterol on treatment with Atorvastatin 10mg
daily was 4.3mml/L with an LDL cholesterol of 2.1mmol/L. Blood pressure on anti-
hypertensive therapy was 120/75mmHg. The patient had lost 5kg in weight and waist
circumference had diminished by 5cm. The renal albumin excretion had normalised.

FURTHER LEARNING TASK FOR iNDIVIDUAL PREPARATION

4. What is the long-term prognosis for glycaemic control and complications
in Type 2 diabetes? (Jessica Preece)

5. Practice OSCE: (Brenton McKewin)

STUDENT TASK: You are now a resident attached to the Endocrinology Unit at your
Hospital. You see a 54 year old gentleman, Mr Taylor. He continues to smoke 20
cigarettes daily and is known to have diabetic nephropathy (24 hour urinary albumin
excretion 700mg 18 months ago). He denies external chest pain or dyspnoea but has not
seen a doctor recently. His medications include metformin, a sulphonylurea, and a
calcium channel blocker. You are on your own – your registrar is sick and your
consultant is in the Bahamas.
Task: Advise the patient regarding cardiovascular risk factor management.
Some points to consider:
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1) What is his absolute risk of a cardiovascular event in the next 5 years?

2) What is his risk of significant coronary arterial disease currently (even without
symptoms)? Should you investigate him in this regard? If so, how?
3) What evidence is there for efficacy of treatment with respect to cardiovascular risk
factor reduction in this situation?

Websites:
• http://www.diabetes.org/for-health-professionals-and-scientists/resources.jsp
• http://www.dtu.ox.ac.uk/index.php?maindoc=/ukpds/faq.php Article by
Professor Robert Turner, et al, “Type 2 Diabetes – a common and dangerous
condition. Why UK Prospective Diabetes Study was needed and why its
results are important”, Diabetes Trials Unit, The Oxford Centre for Diabetes,
Endocrinology and Metabolism.
• www.idf.org

Journal Articles
• Rydén L et al., Guidelines on diabetes, pre-diabetes, and cardiovascular diseases
Eur Heart J 2007, 28; 88-136
• Heine RJ et al. Management of hyperglycaemia in type 2 diabetes, BMJ 2006;
333:1200-1204
• Executive Summary: Standards of Medical Care in Diabetes – 2008
(PDFS51.pdf) – attached
• Richard W. Nesto, LDL Cholesterol Lowering in Type 2 Diabetes: What is the
Optimum Approach? I (81.pdf) – attached
• American College of Endocrinology and American Diabetes Association
Consensus Statement of Inpatient Diabetes and Glycemic Control (19551.pdf) –
attached
• Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14
randomised trials of statins: a meta-analysis (DMstatinmed PDF) – attached
• Gaede, Peter, et al, Multifactorial Intervention and Cardiovascular Disease in
Patients with Type 2 Diabetes, New England Journal of Medicine, January 2003,
vol 348, no. 5 (Diabetes2.pdf) – attached
• Gaede, Peter, et al. Effect of a Multifactorial Intervention on Mortality in Type 2
Diabetes, New England Journal of Medicine, February 7 2008 (580.pdf) -
attached
• Bolen, Shari, et al, Systematic Review: Comparative Effectiveness and Safety of
Oral Medications for Type 2 Diabetes Mellitus, Annals of Internal Medicien,
2007, 386-399. (Bolen.pdf) - attached