Therapeutics Question (DKA)

A 50-year-old gentleman, Mr Adam, was brought in to the Emergency Department by his

friends. He was found to have collapsed at work. He is known to have diabetes mellitus for
the past 10 years, on oral hypoglycaemic agents. According to his friends, he has been
feeling unwell for the past 2 days, complaining of chills, rigors and vomiting. Upon
examination, he is drowsy with a GCS of 12/15. He was breathing rapidly and his tongue
was dry and coated. There was infected ulcer on his right foot with surrounding erythema
and pus discharge. Physical examination did not reveal any other abnormality.
Initial blood investigations results:
Random blood glucose

27.2mmol/L

pH

7.21

PaO2

10.8kPa

PaCO2

5.1kPa

HCO3

11mmol/L

Urine

ketone +++

Q1. What is criteria for the diagnosis of diabetes mellitus?

Answer for Q1
ANSWER:
Criteria for the diagnosis of diabetes
1. HbA1C 6.5%. The test should be performed in a laboratory using a method that is NGSP certified
and standardized to the DCCT assay.*
OR
2. FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as
described by the World Health Organization, using a glucose load containing the equivalent of 75 g
anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma
glucose 200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 13 should be confirmed by repeat testing.

Q2. What is the most likely diagnosis for the presentation of Mr Adam?
Diabetic ketoacidosis with an infected foot ulcer. DKA is characterized by hyperglycaemia,
acidosis and ketonaemia. It usually occurs in Type 1 diabetics, but may occur in type 2 diabetics,
too.
Q3. What other investigations should be performed?

full blood count, blood culture and sensitivity, swab from foot ulcer for culture, renal profile,
ECG
Q4. Outline the initial management of this patient.
Correction of fluid loss with intravenous fluids monitoring of input and output. CVP monitoring
might be necessary in those with renal failure and congestive cardiac failure to monitor fluid
replacement.
Correction of hyperglycemia with insulin infusion.
Correction of electrolyte disturbances, particularly potassium loss. Potassium can be started with
fluid replacement unless there is hyperkalaemia.
Treatment of the infected foot ulcer with intravenous antibiotics eg. Unasyn
Blood glucose levels should be monitored regularly (hourly) to prevent hypoglycaemia , as this
may lead to rebound ketosis, necessitating a prolonged duration of treatment.
Mr Adams condition gradually improves. The next day, he is conscious and orientated. His blood
glucose levels have improved and single digit readings recorded. Urine ketone levels , when
checked, were not detected. However, a call from the lab assistant was received, to inform that
Mr Adams latest potassium level is 7.0mmol/L.
Q5.What should be the immediate management?
Stop any potassium replacement and medication that may contribute to the hyperkalaemia.
Perform an urgent ECG looking for signs of hyperkalaemia (tall,tented T waves, increased PR
interval, wide QRS complex, VF). 10mls of Calcium gluconate is cardioprotective. Short acting
insulin and glucose is also administered to move potassium into the cells. Calcium resonium aids
in the removal of potassium from the body. Potassium levels should be repeated after that.
Mr Adam is discharged after one week. He is reviewed in the clinic two months later. He is
currently on Metformin 1g bd . He has no immediate complaints and says that he is compliant to
his medication. He has also had no hypoglycaemic symtoms. His HbA1C is 8 % and fasting
blood glucose is 12mmol/L.
Q 6. Which group of drugs does metformin belong to? What is the mechanism of action?
Metformin is a biguanide anti-diabetic medcation. Metformin is effective only in the presence of
insulin, and its major effect is to decrease hepatic glucose output . Metformin increases insulinmediated glucose utilization in peripheral tissues (such as muscle and liver), particularly after

meals, and has an antilipolytic effect that lowers serum free fatty acid concentrations, thereby
reducing substrate availability for gluconeogenesis . As a result of the improvement in glycemic
control, serum insulin concentrations decline slightly. Metformin also increases intestinal glucose
utilization via nonoxidative metabolism.
Q7. What is the target for his blood sugar control?
Glycemic targets must be individualized. However, therapy in most patients with type 2 diabetes
should be targeted to achieve an HbA1C 7.0% in order to reduce the risk of microvascular and
macrovascular complications. Patients with type 2 diabetes should aim for fasting plasma
glucose (FPG) target of 4.0 to 7.0 mmol/L and 2-hour postprandial PG targets of 5.0 to 10.0
mmol/L.
Q8. What is the next step in his management?
Addition of one of the other classes of oral anti-diabetic agent at a low dose and increasing the
dose to obtain optimal control. An alternative would be to add on insulin.
Mr Adam asks about his blood pressure, which is noted to be 160/90mmHg in the clinic.
Q9. What should be the advice given?
Systolic BP should be targeted to <130 mmHg and diastolic pressure <80 mmHg. The BP should
be lowered even further to 125/75 mmHg in the presence of proteinuria of >1g/24 hours. ACE
inhibitors and ARBs are the drugs of choice, however, tight BP control should take precedence
over the class of antihypertensive drug used. This often will require combination therapy. A lower
target BP may be necessary to maximally protect against the development and progression of
cardiovascular and diabetic renal disease.
Q10. He also asks about his diet and asks regarding lifestyle modification.
What should be the advice given?
He should be advised to increase physical activity(exercise about 5 times aweek) and lose weight
(if indicated). A diet low in saturated fats, trans fat and cholesterol should be advocated. His
meals should be regular and the diet should consist of carbohydrate from cereals (preferably
whole grain), fruits, vegetables, legumes, and low-fat or skimmed milk. Total carbohydrate intake
should be consistent and evenly distributed throughout the day i.e. 3 main meals with 1 or 2
snacks in between without incurring any excess calorie intake.
Smoking cessation and reduction of alcohol intake should be encouraged.