Elevated Blood Glucose and Anti-GAD Antibodies

2024.1 Case 6B

63-Year-Old Woman with : Elevated Blood Glucose and Anti-GAD Antibodies

Interpretation of Results

• Diagnosis: Latent Autoimmune Diabetes of Adults (LADA)
  • Evidence: Elevated anti-GAD antibodies, suboptimal response to lifestyle modification and oral hypoglycaemics.

Management Plan

Initial Management

1. Education and Support
   • Delivering Diagnosis: Thoughtfully and empathetically explain the diagnosis of LADA.
   • Patient Support: Address potential feelings of being overwhelmed and anxious, provide emotional support and reassurance.
2. Initiating Insulin Therapy
   • Insulin Regimen: Start an appropriate insulin regimen, explaining the use and importance of insulin in managing LADA.
   • Self-Monitoring: Educate the patient on self-monitoring of blood glucose levels.
3. Medication Adjustments
   • Discontinuing Oral Hypoglycaemics: Stop oral hypoglycaemic agents if they are ineffective.
   • Optimizing Thyroid Replacement: Review and adjust thyroid medications as needed.
   • Cardiovascular Risk Management: Manage cardiovascular risks through statins, antihypertensives, and lifestyle modifications.
4. Lifestyle and Diet
   • Nutritional Counseling: Provide dietary advice tailored to managing blood glucose levels.
   • Exercise Guidance: Recommend regular physical activity, considering the patient’s overall health.

Emergency Management

1. Recognition of Diabetic Ketoacidosis (DKA)
   • Signs and Symptoms: Recognize signs of DKA (e.g., hyperglycemia, ketonuria, acidosis).
   • Immediate Action: Initiate fluid resuscitation and arrange for urgent hospital transfer.
2. Acute Management of DKA
   • Insulin Therapy: Administer rapid-acting insulin.
   • Fluid Resuscitation: IV fluids to correct dehydration and electrolyte imbalances.
   • Monitoring: Continuous monitoring of blood glucose, ketones, and electrolytes.

Long-Term Management

1. Regular Follow-up
   • Endocrinologist Referral: Arrange follow-up with an endocrinologist for ongoing management.
   • Routine Check-ups: Schedule regular follow-ups for monitoring diabetes control and complications.
2. Driving Status
   • Assessment: Evaluate the patient’s fitness to drive and provide appropriate advice regarding driving with diabetes.
3. National Diabetes Services Scheme (NDSS)
   • Access and Support: Enroll the patient in NDSS for access to diabetes supplies and educational resources.

Sick Day Management

1. Education
   • Sick Day Rules: Educate the patient on managing diabetes during illness, including monitoring glucose more frequently, adjusting insulin doses, and staying hydrated.
   • Emergency Contacts: Provide information on when to seek medical help and emergency contact details.
2. Action Plan
   • Blood Glucose Monitoring: Check blood glucose and ketones more frequently during illness.
   • Insulin Adjustments: Adjust insulin doses as needed based on blood glucose levels.
   • Hydration: Ensure adequate fluid intake to prevent dehydration.

Common Pitfalls to Avoid

1. Misdiagnosis
   • Avoid: Assuming poorly controlled type 2 diabetes and escalating oral hypoglycaemics.
2. Assumptions and Confidentiality
   • Avoid: Making assumptions about non-compliance and breaking confidentiality by asking the patient’s partner about compliance.
3. Inappropriate Focus
   • Avoid: Focusing on smoking cessation and immunisations instead of managing daily blood glucose levels.
4. Reluctance to Initiate Insulin
   • Avoid: Delaying insulin initiation while waiting for endocrinologist opinion.
5. Failure to Recognize and Manage DKA
   • Avoid: Not recognizing DKA and inadequately managing it with oral glucose.
6. Disorganized Sick Day Advice
   • Avoid: Providing disorganized or inadequate advice for managing diabetes during illness.