ENDO/METABOLIC Flashcards
Epidemiology of T1DM in kids.
- What % have family hx?
- M vs F?
- Peak age?
F=M
Peak age between 5-15 years
20% have a family history of DM
S&S of DKA?
vomiting & abdo pain
dehydration
lethargy/drowsiness
confusion
Kussmaul respirations (deep sighing respirations)
smell of ketones
**DKA occurs in ~40% of children with new onset DM
Common S&S of T1DM in kids?
Weight loss
Polyuria, polyphagia, and polydipsia
**Polyuria may present as bed-wetting
Fatigue/tiredness
Polyuria is most consistent presenting concern, manifested as urinary frequency, nighttime polyuria, or secondary enuresis
Polyphagia and polydipsia are more commonly noticed when disease onsets in preschool years, when parents are able to monitor intake
Basic patho of T1DM?
Absolute insulin deficiency and impaired beta cell function.
Results from autoimmune destruction of the beta cells of the pancreas
Thought to be triggered by environmental factor (i..e, virus or toxin) in genetically susceptible individual
Management of DKA in kids is different because kids are have higher risk of ______
cerebral edema
A kid with a new diagnosis of Type 1 DM needs a strong interdisciplinary team. Who should this team include?
either a pediatric endocrinologist or pediatrician with diabetes expertise
dietician
diabetes nurse educator
social worker
mental health professional
What are the A1C, preprandial, and postprandial targets for a kid (<18 years) with Type 1 DM? (according to diabetes Canada)
A1C < or equal to 7.5
Fasting/preprandial PG: 4-8
2 hour postprandial PG: 5-10
**of course targets are more liberal in kids with issues with hypoglycemia or hypoglycemia unawareness
Mainstay of medical management of T1DM is?
Insulin
What is the “honeymoon period” in diabetes management in kids with T1DM, and how does insulin requirements change over time?
“Honeymoon period”
- up to 2 years after diagnosis
- target glycemic control and low insulin requirements; at the end of this period, may require more intensive management to continue to meet glycemic targets
Insulin requirements may increase in adolescents (sexual maturation process occurs in the setting of relative insulin resistance)- insulin requirements may increase to 1.5- 2 U/ kg during adolescence and then return to prepubertal levels at the end of teenage years.
What are the 2 main ways that insulin is given to kids with T1DM?
Two methods of intensive diabetes management have been used:
1) basal-bolus regimens (long-acting basal insulin analogues and rapid-acting bolus insulin analogues)
2) continuous subcutaneous insulin infusion (CSII) therapy
**Cribsiders stresses that you should start with basal-bolus for new diagnosis because patient needs to learn this system. If you start with pump and it malfunctions, they won’t know how to manage with basal-bolus unless they have this practice.
T/F Increased frequency of glucose monitoring for those with T1DM is associated with improved clinical outcomes
True :) Self-monitoring frequently is ESSENTIAL
(continuous glucose control is associated with less hypoglycemia)
What is the “closed loop” system of insulin management in T1DM>?
The closed-loop pancreas system, also known as the artificial or bionic pancreas system couples the use of an insulin pump with infusion of 1 or more hormones (insulin +/- glucagon), a glucose sensor and an algorithm for glucose control.
The closed-loop system allows for decreasing excursions in blood glucose levels while reducing the overall burden of self-care.
Promising results in small studies, larger studies underway now.
T/F Children with T1DM need to restrict carbohydrate intake and need a special diet unlike other kids
False!
Children with diabetes should follow a healthy diet as recommended for children without diabetes in Eating Well with Canada’s Food Guide
Nutrition therapy should be individualized (based on the child’s nutritional needs, eating habits, lifestyle, ability and interest) and must ensure normal growth and development without compromising glycemic control. T
**cribsiders also reinforces this…. the kid doesn’t need to restrict foods necessarily. They just need to be able to give themselves adequate insulin to manage the extra carbs, etc
How do kids/parents know how much bolus insulin to give the child with T1DM after eating?
Carbohydrate counting!
This seems like the most common management strategy
- They count the carbs in the meal and this determines how many units of insulin they receive
“Carbohydrate counting is a commonly used method of matching insulin to carbohydrate intake that allows increased flexibility in diet, although fat and protein content also influence postprandial glucose levels.” - diabetes Canada
If this is not an option, they can also take preprandial BGs to determine bolus dose (like we do with adults in the hospital)
Severe hypoglycemia in the home should be treated with?
Glucagon
- In children, the use of mini-doses of glucagon has been shown to be useful in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate
What is the most common causes of DKA in a child with established T1DM?
failing to take insulin or poor sick-day management.
What does sick day management look like in T1DM?
Sick-day management includes more frequent SMBG, ketone measurement during hyperglycemia and adjustment of insulin dose in response to monitoring
**This does NOT mean they stop taking their insulin!
In a kid with newly diagnosed T1DM, you want to consider screening for other autoimmune conditions. What might this include?
1) Thyroid issues: Serum TSH level + thyroid peroxidase antibodies
2) Celiac disease: Tissue transglutaminase + immunoglobulin A levels
3) adrenal insufficiency (8 AM serum cortisol and serum sodium and potassium) if unexplained recurrent hypoglycemia
Consider IBD if symptoms…
**Diabetes Canada outlines this nicely.
What is the deal with pancreatic autoantibodies and diagnosis of T1DM? Do all patients with T1DM test positive for these tests?
Measuring pacreatic autoantibodies:
autoantibodies against GAD65 (glutamic acid decarboxylase 65), IA2 (the 40K fragment of tyrosine phosphatase), insulin, and ZnT8 (zinc transporter 8)
Most patients with T1DM have one or more of the above pancreatic autoantibodies, indicating autoimmune destruction of pancreatic beta cells; this is sometimes referred to as type 1A diabetes. A minority of patients with clinical features of T1DM have no detectable autoantibodies and are categorized as having type 1B diabetes
Conversely, up to 30% of individuals with clinical characteristics of T2DM have positive autoantibodies and may have a slowly progressive type of autoimmune diabetes
What is C-peptide and how do we use it to differentiate between T1DM and T2DM?
The pancreas releases C-peptide when it makes insulin…so if the pancreas isn’t producing insulin (as in T1DM), you will see low C-peptide levels (even if the patient is receiving exogenous insulin)
We measure these levels for children with clinical characteristics that raise the possibility of T2DM. In a newly diagnosed patient, these tests should be performed after the child has recovered from the initial hyperglycemic stress because insulin and C-peptide levels may be suppressed by severe hyperglycemia (glucose toxicity) and acute illness.
In children with T1DM, levels of fasting insulin and C-peptide are inappropriately low relative to the concomitant plasma glucose concentration (ie, low or in the normal range despite hyperglycemia). By contrast, high fasting insulin and C-peptide levels suggest T2DM.
Why is it important to talk to young uterus-havers with T1DM about contraception?
Unplanned pregnancies should be avoided, as pregnancy in adolescent females with type 1 diabetes with suboptimal metabolic control may result in higher risks of maternal and fetal complications than in older women with type 1 diabetes who are already at increased risk compared to the general population
What psychological conditions are increased in kids with T1DM?
significant risks for psychological problems including: diabetes distress (104), depression (105), anxiety (105), eating disorders and externalizing disorders
**10%of adolescent females with type 1 diabetes meet the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) criteria for eating disorders compared to 4% of their age-matched peers without diabetes
Eating disorders should be suspected in those adolescent and young adult females who are unable to achieve and maintain metabolic targets, especially when insulin omission is suspected
Differentiate T1 and T2 DM in terms of patho (think insulin)
T1DM = insulin deficiency (d/t autoimmune destruction of the beta cells in pancreas)
T2DM = insulin resistance with relative insulin deficiency (impaired beta cell function but NOT AUTOIMMUNITY)
Which types of insulin are rapid acting and what are their onset & duration
Lispro, aspart, glulisine
Onset within 15 mins
Duration < or equal to 5 hours
Which insulin is short acting and what is the onset & duration?
Regular
Onset within 30 mins
Duartion 5- 8 hours
Which insulins are long acting.
Onset and duration?
Glargine, detemir, degludec
Onset varies from 1 hr to 2.5 hrs
Duration varies, typically 20-24 hours
Are girls or boys more likely to be diagnosed with T2DM?
Girls
