Diabates Type I Flashcards
what is HbA1c?
- hemoglobin A1c (aka glycosylated hemoglobin) tells us an average BG over the life of a RBC which is 8-12 weeks
- accurate bc the amount of glucose that combines with Hb (or glycates the hemoglobin) is directly proportional to the amount of sugar in the system at that time
- GOLD STANDARD for assessing glucose control over previous 6-8 weeks
- CGM download is becoming the new gold standard –> tell you percentage of time you are at blood sugar target range
pathophys of T1DM
- autoimmune dz
- causes destruction of beta cells
- leads to absolute insulin deficiency
- beta cell destruction can be slow or rapid
- can be associated with other autoimmune disorders
- usually slow in adults but rapid in kids
- in children, by the time we pick it up most of their beta cells are destroyed
markers of autoimmune destruction
- islet cell antibodies
- insulin antibodies
- glutamic acid decarboxylase 65 (GAD 65)
- protein tyrosine phosphate
frequency and average age of onset
- frequency: 5-15% of all cases –> this is the most common metabolic disease of childhood!!
- age: diabetes usually presents in children age 4 and older; peak onset = 11-13. Can present in adulthood (presentation at this age tends to be less aggressive with hyperglycemia without DKA)
presentation of T1DM
- usually present with polyuria, polydipsia, polyphagia
- other sxs = weight loss, fatigue, nausea, muscle cramping, blurred vision
- at presentation, pts typically in DKA or on the verge
dx of T1DM
-BG elevated. if they have even 3 of the sxs associated with T1DM along with BG >200mg/dl, this is DIAGNOSTIC!!
management of T1DM
- INSULIN
- NPH only if someone doesnt have insurance
- Determir (levamir) is good in pregnancy (category B)
- NEED BASAL INSULIN along with insulin for meals
- NPH and levamir for basal insulin
- Tresiba is the drug with the longest half life so its great for basal insulin
New insulins
- Tresiba U100 or U200 (has ultra long half life - 24hrs)
- Glargine U300 (Toujeo)
- Humalog U200
- Afrezza ultra fast acting (starts acting in 5 mins)
- Umalog U200 = good for people taking large volumes
adjunct to insulin
- primlintide (symlin): synthetic analogue of amylin
- affects post prandial glucose values by slowing gastric emptying, inhibiting glucagon production in the liver and appetite suppression –> leads to less post meal hyperglycemia and potential for weight loss
amylin
- neuroendocrine hormone cosecreted from beta cells with insulin
- if you are missing amylin, you are also missing suppression of glucagon
- amylin produces less post meal glucose spikes and people feel fuller faster
honeymoon period of DM dx
-pts body is still making insulin so their needs are less than they eventually will be
calculating total daily dose
- 0.3-0.5 x weight in kg as starting total daily dose
- if pt is 120 lbs, weight = 120/2.2 = 55kg
- half of the TDD will be the basal insulin and half will be used for meals
calculating how much insulin you need per meal
- rule of 500
- divide 500 by TDD –> if we decide that TDD is 16u, then 500/16 = 31 –> this means that you need 1u insulin for every 31gm of carbohydrate
calculating units insulin needed for various BGs
BG . Units insulin (for food) <210 . 2u 211-320 . 3u 321-430 . 4u >431 . 5u
modifiable risk factors
C ontrol your glucose, blood pressure and cholesterol!
E arly treatment of foot, eye, kidney, and heart problems
N o
S moking
E ducation about diabetes, nutrition and exercise
goal for pts with T1DM
-progress toward intensive insulin therapy (IIT) –> this could be long acting and rapid acting insulin (basal/bolus therapy) or continuous subcutaneous insulin infusion (CSII) with insulin pump.
standard insulin sensitivity
- 0.5-0.8 x body weight
- higher percentage because this is for people who are NOT newly diagnosed
intensive insulin therapy
- pts require basal insulin to cover hepatic glucose production hepatic glucose production in a fasting state and use meal time insulin to cover food ingested
- pts taught to adjust premeal insulin based on carb content of meals (I:CHO ratio)
CSII insulin pumps
- pumps use ONLY rapid acting insulin
- continuous infusion rate programmed to cover daily hepatic glucose production and insulin boluses are given for meals and to correct elevated glucose
- have programmable calculators with I:CHO ratios, sensitivities and targets
Off label medications
- GLP1 agonists –> slow rate food moves through stomach (also tells pancreas to make insulin but type I cant make insulin so this aspect of GLP1 agonists isnt helpful)
- SGLT2 inhibitors –> DONT USE because they can go into euglycemic DKA
- Metformin –> you can be type 1 when you’re 12 and when you’re 40 you look like type 2
Dawn phenomenon
-describes rise in BG that happens in early morning (2-8am) due to hepatic glucose production and nocturnal growth hormone release that exacerbates insulin resistance
Somogyi effect
-describes BG drops too low at night due to excess dinner time or bedtime insulin and the release of counter regulatory horones such as glucagon and epinephrine –> these cause liver to convert stores of glycogen to glucose and cause period of high BG following hypoglycemic episode
education for DM
- for long term success, biggest part of management is education
- pts need to learn how to self monitor blood glucose (SMBG) and learn appropriate diet
- also crucial to address psychosocial stressors
how to determine what type of diabetes it is
- if unclear, elevated FBG and C-peptide level <0.6ng/mL is suggestive but not diagnostic of T1DM
- C-peptide is formed during conversion of pro-insulin to insulin
- high positive titer of GAD65 Abs or islet cell autoAbs is also suggestive of T1DM
- AN EXCEPTION is the pt with T2DM who presents with very high glucose (>300), who temporarily has low insulin and/or C-peptide level but who will recover insulin production once normal glucose is restored
