Right. So we are moving now to the last presentation and we hopefully will have some fun here because we will have some real life cases to discuss. So let's start with clinical case one. This is an 81 year old gentleman 81 type two diabetes for 25 years on on insulin for 10 years. Ischemic Heart Disease had a history of my age 78. But it's pretty well. He can walk four miles with no issues. He's hypertensive and when it comes to glycemic therapies, he is on Next insulin preparation, decent doses. He's on GLP one receptor agonists and S. G. L. T. Two inhibitor, which are quite important for cardiovascular protection and on a mixture of cardiac drugs. As you can see that's his weight. Bmi pretty good. I would say blood pressure very well controlled HB one c. 74 million more and is absolutely normal. LDL excellent. Triglycerides. Fine. And he's checking his sugar 23 times a day. He's running between 4.1 and 18.2 and says actually most of my readings are above 10 million more. He's pretty compliant with medication and diet. Very sensible gentleman is complaining of somatic symptoms, says I have to wake up several times a night to pass water. Otherwise he's pretty fit, particularly for ages, quite fit. He's got no symptoms of hyperglycemia. So remember 74 minimum per mole or 8.9% and he does have osmotic symptoms. So it's not a symptomatic, what would you do first ignore the H. B. On C. And tell the patient this is great given his age. Oh ask the patient to do eight point SMB G. To better assess fly. See me doing this only two or three times a day. Stop the S. G. R. T. To inhibit it. This is causing the osmotic symptoms. Let's just stop it for given his automatic symptoms. We need to urgently increase his insulin doses. Well there's no fear of hypoglycemia here given the absence of symptoms or no concerns over hypoglycemia or none of the above. So I'm hoping that you formed the view of what we should do. I mean you can't ignore the A. One C. Because he's symptomatic and remember he's 81 but he's a good 81. Now. Our submission to do 8.8 mpg. Now that can help to have a better idea of what's happening with his glucose. Stop SGL T. Two. I wouldn't I certainly wouldn't stop it because it's offering no vascular protection, urgently increase the dose of insulin. Well I wouldn't urgently increase the dose of insulin because I want to have a little bit more information on his glucose readings. None of the above. Actually I would go with none of the above because I would like to see more comprehensive glucose profile and I would like to see CGM data if you can't for whatever reason then perhaps to is your next best option. So he goes on C. G. M. And this is what the C. G. M. Shows his timing range is 31% and as you can see that the glucose readings are quite high. I can understand that he's having osmotic symptoms. Hypoglycemia is non existent although he does. He does sort of drop sometimes to levels close to four million more. So the main issue here is eating too much chocolate. Maybe very significant glucose variability, generally high glucose levels and additional postprandial peaks. Data are very helpful and confirm that no treatment changes are necessary. None of the above regarding chocolate. I don't know. He might but might not. Very significant glucose variability. That's incorrect because if you look at his glucose variability is less than 36% is only at 31%. So that's not the main issue. Generally high glucose levels and additional postprandial peaks. Yes that is certainly a problem. So three is correct. Data are very helpful, confirm no treatment changes are necessary. Well actually they don't confirm that at all. Or none of the above. I think three is the preferred answer unless you have something else in mind. So what is the best treatment option? Stop SGL T to treatment and increase insulin doses. Why would you stop the S. G. L. T. Two? I wouldn't stop GLP one receptor agonist. I would not stop that Change to Basal Bolus, insulin provided patient can cope. Now you may argue his 81 would he cope with Basil Bullets insulin? It all depends on the patient. The age is irrelevant. It depends whether the patient can do it. Some of my young guys can't do it. Some of the older guys can do it adding to his treatment highly unlikely to work given on a decent dose of insulin as it is. Needs to eat less and do more exercise. The guy is compliant with his diet as we said earlier and he walks regularly. He can do four miles. So I don't think that's the issue. I think three should be explored in this case. So you switch to basal bolus and essentially, what are your views here? The main issue here. Now, if you look at his A. G. P, you can see his time in target now is 70% with hypoglycemia, very mild hip at 1%. So many issue here. Not much really continue current treatment and of course discuss the hypoglycemia, which is always helpful to discuss. Now his glycemic variability increased. Remember it was 31%. Now is close to 36% and we need to move him to an insulin pump. Quite frankly, I'm not too bothered about his license variability. It's a bit more but remains below 36 I'm not worried about it. Hypoglycemia is a major problem and it's best to switch back to mix insulin. Not really hypoglycemia is at 1% and there's no great to hypoglycemia at less than three million liters. So I'm not too worried about it, it is time to stop either SGL T to inhibit or GLP one receptor agonist. As I said before, I wouldn't stop either. If hypoglycemia becomes an issue, I would reduce the doors of insulin particularly in the background. Okay. So this gentleman has done very well on basil borders Despite the fact that is 81. So people at an older age can cope with more complicated insulin regimen. And this is your before and after. You can see the timing range increased from 31 to 70%. Is very happy. No further osmotic symptoms. And he says, I'm feeling absolutely fantastic. So take home messages high. A one C. And older people should not just be accepted, particularly when symptomatic and technology helps to make safe and effective treatment decisions in older people with diabetes, basal bolus insulin can be considered in older people. So let's let's take younger case here, not just focus on the type two. So we've got an 18 year old young lady type one diabetes for nine years, calm abilities. None but terrified, absolutely terrified of having future complications. Treatment Basil Ball is with lodging 30 units and as part 1 to 1.5 unit for 10 carbohydrates. If you look at her weight. She's only 54 kg. So she's on a decent dose of insulin but B. M. I. Is only 21 H. B. O. And C 6.4 or 47 minimum per mall. So it's looking, everything is looking pretty good. She got no glucose readings. She's on library but not connected to liberal views so we can review her glucose. He says all these fine and hypoglycemia is infrequent with good warnings and very keen to leave clinic as she needs to see a friend and you know when people are rushing it you always worry is there something else particularly when they are terrified of future complications? And actually we managed to get her glucose readings and look at that. So she has hypoglycemia exposure at 23% now. Which of the following is correct. This is excellent control supported by G. M. I. 5.8%. Well yes if you're looking at just a hyperglycemia I agree is excellent but the hype or less so this is useless. A sensor coverage is only 67%. Now this is something that is really important to look at looking at the sensor activity. So 67% of course you want to see it above 90% more data are needed to arrange a new appointment in 2 to 3 months now. I certainly wouldn't do that. Although it is only two thirds of the data collected. You can see this is due to the fact that the last four days are not collected Pretty good data collection for 10 days. So I wouldn't say this is useless hypoglycemia needs urgent attention. I completely agree with that. 23% hypoglycemia. That's not good enough, is it? Hypoglycemia is not an issue as it clearly related to censor compression. Now let's look at that in a bit more detail. Is this sense of compression? Not really because when you censor compression you get a line rather than sort of a changing baseline. This is pseudo hypoglycemia related to related to glucose variability exceeding 36%. That sounds fancy except it does not exist and is completely made up. So the right answer is certainly three. So options here spend time explaining that very tight control can be dangerous. Remember she's terrified of complications and reduced the dose of insulin office, psychology support, frequent reviews all of the above or none of them. But I think we all have those patients who are very worried about complications and quite happy to spend a long time in hypoglycemia and the only way to deal with them is to spend time spend time I find psychology support to be really helpful in these people and I have I'm very lucky to have a psychologist working with me in clinic so we can offer instant support for these patients. So the right answer here is for all of the above frequent reviews, psychologist support and spend time explaining that we need to reduce the doses of insight. So what happened here? So she's gone to hypo at 1% with timing target at 92% patients switched to an insulin pump lodging was reduced to 24 units and boulders to one for 10 cards, patients switched to a closed loop SGL T two I added to treatment, none of the above. So four is definitely incorrect, but it could be any of 12 or three and a lot of you would be thinking about this must have been switched to a closed loop and of course there's an indication for a closed loop in this lady. But actually all we've done is switched to an insulin pump and that had the desired effect. We didn't go for a full closed loop here And you can see the before and after. Very quick improvement. Indeed. And I'm far less worried than and she's very happy because the timing target is 92%. And the question was this sustained. Well actually it was time and target later on remained at 90%. Yes, the hypoglycemia is a bit higher at 4%, but nothing below three million more per liter or below 54 million. So that was certainly sustained. So take home messages. Some individuals with type one diabetes do not do not regard hypoglycemia as an issue. This needs to be handled sensitively and psychology input can be very helpful here. And frequent reviews are absolutely essential in these patients. What about a clinical case three? This is a 66 year old woman tattooed Abby's for 12 years on insulin for two years. Core mobility is heart failure. Ischemic heart disease had to my colony in functions and her exercise tolerance is very limited. Only 40 yards. She's hypertensive and she's got severe arthritis as well for glycemic therapy. She's on a mixture of Metformin, licalzi. Top doors, Degla deck small dose and S. G. L. T two inhibitor could not be given GLP one receptor agonist as she developed pancreatitis after starting that. And she's on a mixture of cardiac drugs. B. M. I. 27.6 block pressure. Not bad. A one C. Not good above 10% and her E G F. R. Is 44 in this case LDL 1.6 S. M. B. G. Done 123 times a day, Always above 10. It can be as high as 29 million liter. No symptoms of hypoglycemia. And this was her G. P. you can see the timing range is 11%. Okay, the time sensor is active. It says here only 62%. But I think we've got enough coverage to have a very good idea of what's going on. The main issue here is Brittle diabetes that will require a closed loop system. Is this brittle diabetes. Not really. This is just high glucose. Most of the time severe and so resistant. That is not responding to insulin. Well, that's not true because she's only 14 units of degla deck Hi Blue goes throughout needs more insulin. Well, I tend to agree with that scanning frequency is too low and no meaningful clinical judgment can be made. That's a mistake to say cannot be made can be made. We already discussed this and actually we can make a useful clinical judgment here. I'm a pediatrician and these cases are irrelevant to me. That may well be the case. But I think we learn from any case that is presented. So the right answer here is highly goes throughout number three. Best option referred to bariatric surgery 27. I wouldn't do that. Increased basal insulin first and consider adding cradle insulin if no adequate response. I think that is quite sensible approach. Some may argue which has got very high peaks after meals. That approach will not work. But let's give it a try and see what happens. Stop political aside and replaced with DPP four inhibitor. DPP four inhibitor is not going to bring down that very high glucose levels. Advised to get a dog and have regular walks for at least two hours a day. We know this lady is not well, her exercise tolerance is limited to 40 yards. So, that's not an option. Stop at over starting as it is worsening her diabetes control definitely not. She needs to stay on a statin. So this is what happened. Right? So, her timing range. Look, it was 11% and it improved to 56% with no hypoglycemia at all. So what happened basal insulin was gradually increased to 44 units patients feels great and no hypoglycemia. So she's still getting those peaks here and there. But jelly speaking, this is not bad at all. And she's only on basil. So this is your before on the left and after on the right. Very impressive improvement. So essentially your insulin was increased by 13 units. Take home messages. T. G. M. Is not only useful for M. D. I. But can help to tie trade basal insulin Generally. It is best to titrate basal insulin first before introducing Boris into selling in people with type two diabetes. Fourth and last case. This is an incident treated Type 2 63 year old male Security guard corps, mobility's hypertension, glycemic therapy. Metformin and human and 3 58 and 40 units. So almost 100 units a day and then at over starting B. M. I. is 35 c. 8.7% or 71 million more fr 43 LDL 1.8 no history of previous me and no history of heart disease. It's got no symptoms of hypoglycemia, Says he's dieting but struggling to lose weight. So b. m. I. 35 again, I repeat. This was the A. G. P. Right and it is sort of a full report for you if you want to see it in a different way and you know the the new way of reading the library view. It gives you some advice of what to do, which can be helpful, particularly if you're not very used to library to seeing a lot of library patterns. So the main issue here. The patient is on too little insulin. Remember the patients is almost 100 units. So that's not too little is it? His poor glucose profile is related to night shifts and he needs to change his job. Well the night shifts could be contributing. He's clearly eating around three AM or two AM. But that's not the only reason for the poor control is it is a resistance is one area that needs addressing. Well I tend to agree with that because his B. M. I. Is high and his insulin doses are generous and he's still having very high glucose levels. This is all due to poor diet that can be addressed with appropriate advice. And essentially this gentleman is saying that his compliance with his diet. So whether further dietetic support will help is questionable. We can try. It's always worth trying but I don't think it will bring it down that much Needs urgent vascular production and best to start guilty two inhibitor that will help to reduce glucose levels. The guilty two inhibitor may offer vascular protection here in terms of reducing his glucose levels less likely because his remember is only 42 and the glycemic effect of H. E. L. T two inhibitors are reduced drastically as your E. G. F. Or drops. So it may still offer vascular protection. But in terms of lycee mia. I don't think it's going to be that effective. You can see things actually improved quite a bit. What happened here. So options insulin pump was started. I would say that's quite a drastic approach and perhaps not needed at this stage moved to MD, insulin possibility. Morning insulin doses were gradually increased. I'm not so sure that's enough and I would expected more high post perhaps but possible GLP one receptor agonist started. Now there is certainly a possibility because that will make him make him lose weight and will use his insulin resistance. And certainly that would be my preferred choice here patient. Given simple dietary advice unlikely to have had such a drastic effect. Actually it's the GLP one receptor agonist was started. And you can see that those high peaks of glucose have gone down significantly in a relatively short period. You know you're talking about april to august so he has done pretty well indeed. So take home message is it is not always about increasing insulin doses in insulin treated diabetes patients. See GM helps to make decisions regarding non insulin therapies. And that's important. Take home message. So, before we close this symposium, you may be wondering what happened to those two cases that I presented at the very beginning. So remember we had the gentleman who was on mixed insulin preparation and this was his a G. P. was spending 59% of his time in target but a massive 14%. He was in hypoglycemia and all that we had to do is to switch to different ratios. So he was a 25. We switched to human mix 50 and as you can see the hypoglycemia improved significantly. Yes he's still 4% but very low is at 0%. So this is much better than before. Perhaps with a slight tweak with the doses and you and the patient is absolutely fine. What about the second case? So if you look at the second case On the left had pretty significant hypoglycemia. All we've done we stop the delicacy and the hypoglycemia as you can see disappears 24 hours later and then we can introduce other agents because the sugar levels that were a bit too high, introduce other agents that reduce the glucose without causing hypoglycemia. So I hope that you enjoyed this session and you enjoyed this case cases and thank you very much for your your attention. And also I would like to take the opportunity to thank the speakers for their presentations. Bye bye everyone
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