Diabetes mellitus Flashcards
Aetiology of T1DM
Genetic predisposition and environmental precipitants
Autoimmune disorder: T cell mediated destruction of pancreatic beta cells leading to insulin deficiency and hyperglycaemia
Clinical features of T1DM
Peak age of onset 5-7 years
Just before or at the onset of puberty
Several weeks of polyuria, polydipsia, weight loss, lethargy ± infection, poor growth, ketosis
May present as DKA: Acetone breath Vomtiing Dehydration Abdo pain Hyperventilation due to acidosis (Kussmaul) Hypovolaemic shock Drowsiness
Diagnosis of T1DM
Signs of hyperglycaemia with increased venous BM > 11.1mmol/L (random) or >=7mmol/L (fasting)
Or raised venous BM on 2 occasions without symptoms
OGTT rarely required in children
Check autoantibodies: islet cell autoantibody, anti-insulin antibody
Screen for other autoimmune diseases (TFT, thyroid, coeliacs)
Team for T1DM management?
Consultant paediatric Paediatric diabetes specialist nurse Paediatric dietician Clinical psychologist Social worker Adult diabetes team for joint adolescent clinics Parent/patient support groups
What education for T1DM?
Basic understanding of diabetes
Injection of insulin: techniques and sites
Blood glucose monitoring to allow insulin adjustment and blood ketones when unwell
Healthy diet
Encouragement to exercise regularly with adjustments of diet and insulin for exercise
Sick-day rules during illness to prevent ketoacidosis
Recognition and staged treatment of hypoglycaemia
Where to get advice 24h/day
Voluntary groups
Psychological impact of lifelong condition
Types of insulin? Examples?
Human insulin analogues:
Rapid acting insulin analogues e.g. Humalog, Apidra, NovoRapid
- Fast onset and shorter duration of action
Very long-acting insulin analogues: Insulin deter (Lever) Insulin glargine (Lantus)
Short acting soluble human regular insulin: Give 15-30m before meals Duration up to 8 hours Actrapid Humulin S
Intermediate acting insulin
Insulatard
Humulin I
Pretermied preparations of mixed rapid or short acting and intermediate acting insulins
Where can insulin be injected? What should you advise?
Subcut tissue of anterior and lateral thigh
Buttocks
Abdomen
Rotation of injection sites is essential to prevent lipohypertrophy or lipoatrophy
Skin should be pinched up and insulin injected at 45 degree angle
Shortly after insulin commenced, honeymoon period where insulin requirements become minimal - requirements subsequently increase during puberty
What insulin regimens?
Basal bolus with rapid acting insulin (Lispro, glulisine, aspired) being given before each meal plus long-acting insulin (Glargine, Detemir) in the late evening and/or before breakfast to provide background insulin (basal)
Aim for BM 4mmol/L - 7mmol/L before meals
What diet for T1DM?
Heathy diet Insulin doses match carbohydrate intake High complex carbohydrate Modest fat content High in fibre Carbohydrate counting allows patients to calculate their likely insulin requirements once their food choice for a meal is known
What factors increase blood glucose?
Insufficient insulin Food Illness Menstruation Growth hormone Corticosteroids SEx hormones at puberty Stree
What factors decrease blood glucose?
Insulin Exercise Alcohol Some drugs Marked anxiety/excitement Hot weather
What should be in care plan for T1DM?
Insulin: doses
Diet: What? When? Why?
Can blood glucose be monitored accurately - watch technique
What does carer do if blood glucose is not well controlled?
Does parent or acareer know what well-controlled means
Too much insulin? Signs: hunger, bolshy, faintness, sweating, abdo pain, vomtiing, fits, coma
Reversal with drinks or glycogen
What if child misses a meal or is sick after meal
What happens to insulin requirements during flu/illness
Emergency contact
What is MODY? Clinical features?
Mature onset diabetes of young
Autosomal dominant
Non-ketotic diabetes
Pancreatic beta cell dysfunction leading to impaired insulin secretion
FHx
Severely obese children
Signs of insulin resistance - acanthuses nigrcans (velvet dark skin on neck or armpits)
Long term diabetes control monitoring?
HbA1c - control over previous 6-12 weeks
Check 4x year
May be misleading if RBC lifespan (normal 120d) is reduced
HbA1c < 48mmmol/mol (<6.5%) is target
What are aims of long term mx of DM?
Normal growth and devleopment
Normal life
Good control through knowledge and good technique
Self-reliance
Anticipating and minimising hypoglycaemia
Maintain HbA1c <48mmo;l/mol
