Diabetes Long

Question 1

What are some causes of diabetes?

Answer 1

T1DM, CF, Beta-thal major, Cushing syndrome
* Associations – Friederich ataxia, Wolfram syndrome (DIDMOAD), Duchenne’s, T21, Turners, Noonan’s, RSS, BWS, PWS

Question 2

Overall Mx of Diabetes?

Answer 2

1) Insulin - regime, who, when & how administered
2) Monitoring - what are their sugars, how often measured, HbA1C
3) Hypoglycaemic episodes – what do they do? Understanding of glucagon usage?
3) Exercise - Multiple advantages (better glucose shift into cells, increase insulin receptors, increase cardiovascular fitness & decrease macrovascular complications). Note that BSL may be lower 3-4 hours AFTER exercise
4) Diet - Aim for regular, balanced diet with dieticians help: 55% CHO (of which 70% should be complex CHO), 30% fat, 15% protein, Educate about low glycaemic index foods (aim for at least one food with low GI per meal)
5) Multidisciplinary team
6) Screen for complications
7) Pump - Carb ratio (g/unit), Insulin delivery (unit/hour), total insulin per day

Question 3

Risk of developing IDDM if you test positive for antibodies?

Answer 3

Anti-islet cell antibodies – 80-90%
Anti-glutamic acid decarboxylase antibodies – 80%
Anti-insulin antibodies – 30-40%

Question 4

Complications of diabetes?

Answer 4

1) General – poor growth, poor nutrition, delayed puberty
2) Microvascular - a) Retinopathy (98% 15yrs) – non-proliferative (microaneurysms, dot & blot haemorrhages, hard & soft exudates) & proliferative (neovascularisation, vitreous haemorrhages, retinal detachment); b) Nephropathy (25% 15 years) – microalbuminuria ( 20-200mcg/min), then proteinuria (>200mcg/min); spot albumin/creatinine ratio cost-effective in detecting microalbuminuria –> once detected treat with ACEI (beware of RAS with macrovascular disease)
3) Macrovascular – cerebrovascular, cardiovascular, peripheral vascular disease, nephropathy
4) Neuropathy – autonomic/peripheral (45% 25years)
5) Limited joint mobility – 40% of children
6) Autoimmune – coeliac (3-5%), Hashimoto’s thyroiditis (3-5%), Addison’s disease
7) Infection susceptibility
8) Psychiatric
9) Skin – lipohypertrophy (common), lipoatrophy (rare) – secondary to insulin impurity

Question 5

HbA1c and BSL aim in pre-school age children?

Answer 5

Higher sugars in younger kids to avoid hypo’s (because of impact on neurodevelopment)
* Pre-school – BSL 6-15; HbA1C <7.5%

Question 6

HbA1c and BSL target in school age child?

Answer 6

• School age – BSL 5-10; HbA1C <7.5%

Question 7

HbA1c and BSL aim in adolescent?

Answer 7

Tighter control in adolescents as this period very important in determining complication outcome
* Adolescent – BSL 4-8; HbA1C <7%

Question 8

When to start screening for diabetes complications if prepubertal diagnosis?

Answer 8

If prepubertal diagnosis = start screening 5 years after diagnosis or 11yo

Question 9

When to start screening for diabetes complications if postpubertal diagnosis?

Answer 9

If postpubertal diagnosis = start screening 2 years after diagnosis

Question 10

Diabetes clinical review: how often and what to check?

Answer 10

3 monthly
o Review BSL record
o BP, neurology, eyes, skin etc
o Growth & pubertal status

Question 11

Who should be part of the clinical team in a child with diabetes?

Answer 11

Diabetic educator (annual)
Ophthalmology (annual)
Dietician (annual)
Podiatry and psych
Paed/Endocrinologist (3 monthly)

Question 12

Diabetes check up investigations - what and how often?

Answer 12

o 3 monthly – HbA1C
o Yearly – TFT & microalbuminuria/renal function
o 2 yearly – coeliac, lipids, UEC, TFTs
o ECG – at least once or if evidence of cardiac complications

Question 13

Diabetes Sick Day Management principles?

Answer 13

1) Maintain hydration – if BSL >12 give fluid with no sugar; if BSL <12 give fluid with carbohydrates
2) Monitor BSL’s every 2 hours (hourly if hypoglycaemic) and ketones every 4 hours
3) If BSL >15 and ketones are >0.6, give 10% of daily dose as short acting insulin –> Repeat BSL in 2 hours and one further dose of 10% then hospital
4) If BSL <4, give food or mini-dose glucagon as appropriate
5) If pump malfunction and ketosis: Give Novorapid 25% of pump total daily dose, Recheck BSL/ketones every 2 hours for rest of night, Give insulin injection every 4 hours

Question 14

Risks with surgery in children with IDDM?

Answer 14

1) Infection
2) Hyperglycaemia – secondary to surgical stress and increased counter-regulatory hormones
3) Dehydration & hypoglycaemia – from fasting

Question 15

How to calculate corrected sodium in hyperglycaemia?

Answer 15

corrected sodium = Na + (glucose – 5.6)

Question 16

Risk factors for cerebral oedema in DKA?

Answer 16

hypernatremia, hyponatremia, first presentation DKA and children <5yo

Question 17

Symptoms of cerebral oedema + treatment?

Answer 17

Clinical – headache, deterioration in conscious state, hypertension, thermal instability, bradycardia
Treatment – mannitol 20% 0.5g/kg, severely reduce fluid input, nurse head-up, transfer ICU

Question 18

Red flag for poorly controlled diabetes in adolescent?

Answer 18

insulin requirements of >2 units/kg/day (though often increased insulin requirements in adolescents)

Question 19

Reasons why adolescent with diabetes might have poor control?

Answer 19

1) Practical issues – needles, supply, who does it, embarrassment, having to do injections at school etc
2) Insulin allergy and they aren’t telling you – change to human insulin, desensitising or steroids (if systemic symptoms)
3) Insulin resistance (RARE) – anti-insulin antibodies; change to highly purified insulin

Question 20

Mx for poorly controlled diabetes in adolescent?

Answer 20

1) Acknowledge it is a difficult time while also advising it is an important time in diabetic Mx
2) Education/Encouragement: a) Accept that adherence is not 100% and encourage positive things; b) Re-educate as children who are diagnosed in early years miss out on education part and need to be re-educated in the teen years
3) Role models & routine: Would basal bolus regime be better? – esp for the adolescent
4) Negotiation - Negotiate a role for the parents in the management of this child
5) Education re: specific issues - driving, alcohol, parties, pregnancy
6) Monitor for other complications e.g. deterioration in academic performance - a) Psych – depression, school bullying, poor self esteem, poor self image, “given up”, substance abuse, poor sleep, b) Medical – deterioration of diabetic control (increased lethargy), thyroid disease, visual impairment (microvascular disease), cerebrovascular disease

Question 21

Mx for Adolescent w diabetes who wants to drive?

Answer 21

1) Need medical practitioner to sign off
2) HbA1c <9% and willing to take care of themselves
3) BSL >5 before start driving and every 2hr check on the road

Question 22

Mx for adolescent with diabetes who wants to drink alcohol?

Answer 22

o Educate: EtOH suppresses hepatic glycogenolysis
o Drink responsibly
o Drink in groups
o Alternate non-alcoholic and alcoholic drinks
o Eat something beforehand
o Recovery/getting home: Have a designated driver, Have snack, Have someone wake them up in the morning to give them insulin & breakfast