Endocrine - Level 2 Flashcards
Definition of T1DM?
o Absolute insulin deficiency causing persistent hyperglycaemia
o Most common is immune for 1A
o Some slower progression form occur later in life (LADA)
Pathology of T1DM?
o Islet cell antibodies lead to insulitis and destruction of B cells in Islet of Langerhans causing insulin deficiency
Epidemiology of T1DM?
- Peak age is puberty but can be any age
- Usually lean
- Associated with autoimmune diseases of thyroid, blood, etc
Aetiology of T1DM?
o HLA-DR3/4
o Family history of Type 1
Environmental triggers of T1DM?
o Autoantibodies appear early (Glutamic acid decarboxylase)
o Diet
o Coxsackie virus
Acute symptoms of T1DM?
- Young people with 2-6 week history of thirst, polyuria, weight loss
- Ketoacidosis
Subacute symptoms of T1DM?
- Over month/years (type 2 commonly)
- Thirst, polyuria, weight loss, fatigue, visual blurring, infections
Diagnosis of T1DM?
Symptoms of hyperglycaemia
Fasting PG (8-hours) of ≥7mmol/L or random PG ≥11.1mmol/L 1 abnormal reading if symptomatic, 2 if asymptomatic
One or more of:
Ketosis, rapid weight loss, age <50, BMI <25, family history of autoimmune disease
Management if T1DM diagnosed?
- If type 1 diagnosed – refer same-day to diabetes specialist team
Initial care of newly diagnosed T1DM?
- Offer structured education programme – DAFNE programmed 6-12 post-diagnosis
- Teach self-monitoring of blood glucose
- Lifestyle changes – stop smoking, strict diet (low fat, sugar, high carbs), regular exercise and low alcohol intake
- Yearly influenza and pneumococcal vaccine
- Inform DVLA/insurance if having insulin
Drug treatment in T1DM?
Insulin
Advice on self-monitoring in insulin management of T1DM?
Targets?
When to give real time glucose monitoring?
When is sensor pump therapy given?
At least 4 times a day, before meals and before bed
• Encourage 10x/day if – poor control, hypo frequency increases, period of illness, around sport
Targets
• FPG 5-7 on waking, PG 4-7 before meals, PG 5-9 at least 90 mins after eating
Real time glucose monitoring used when patient has:
• >1 severe hypoglycaemia, loss of awareness of hypoglycaemia, frequent (>2/week) hypoglycaemias affecting ADLs, fear of hypoglycaemia, hyperglycaemia persistently (HbA1c >75)
• Can have multiple daily injection insulin or CSC insulin pump
Sensor-pump therapy given when:
• Episodes of hypoglycaemia despite continuous SC monitoring
Insulin regimens in T1DM?
Offer Basal-bolus regimen 1st line
Continuous insulin SC infusion (pump)
2x day pre-mixed 70:30
Basal-bolus regimen in T1DM?
Basal-bolus regimen 1st line
Long-acting insulin detemir BD 1st line
o Alternative: OD insulin glargine or insulin detemir
Offer rapid-acting insulin analogues before meals (Humalog/Novorapid)
Can adjust for meals and infections better
Need to test sugars more, at school inject (psychological)
Continuous insulin SC infusion in T1DM?
Continuous insulin SC infusion (pump)
- Recommended (children >12 and adults) if multiple daily injections result in disabling hypoglycaemia (repeated and unpredictable hypos that results in persistent anxiety about recurrence and effecting ADLs) OR HbA1c >69mmol/mol on MDI therapy
- Gives basal infusion and bolus when eat
- Needle changed every 2-3 days
- Cannot use in sports, swimming, baths (if disconnected – DKA)
Pre-mixed insulin in T1DM?
2x day pre-mixed 70:30
• Consider BD human mixed insulin if MDI basal-bolus regimen not possible
• Not suitable for kids’ normal daily activity
• Difficult to control/change insulin dosages
Adjunctive treatments if insulin not achieving adequate glycaemic control in T1DM?
Sotagliflozin/Dapagliflozin with insulin
• If BMI >27, when insulin does not provide adequate glycaemic control
• On >0.5u/kg/day of insulin
• Stop if not a sustained improvement (>3mmol/mol) of HbA1c in 6 months
Sick day rules in T1DM?
Increases insulin need
Monitor blood glucose more regularly (up to 10x/day)
Consider ketone monitoring
Keep hydrated
Seek medical attention if unable to keep fluids down
Management of T1DM in hospital?
Aim for 5-8mmol/litre during surgery or acute illness
IV insulin if – unable to eat or predicted to miss more than 1 meal or acute situation (major surgery, high-dose steroids, inotropes, sepsis) or circulatory compromise
Use SC insulin (including rapid acting insulin before meals) if eating – enable self-administration if willing
Accessories needed in insulin therapy of T1DM?
Insulin injection device
Needles
Blood glucose meter, test strips and lancets
Urine ketones
Blood ketones meter, test strips and lancets
Sharps bin
Glucagon oral gel/injection
Other drug management given in T1DM?
- Statin
o Atorvastatin 20mg
If >40, diabetes for >10 years, established nephropathy, CVD risk factors (obesity, hypertension) - Antihypertensive (intervention if no risk >135/85, if albuminuria or 2 features of metabolic syndrome >130/80)
o ACEi
o Others: BB, low-dose thiazides, CCB
When to refer to nephrologist in T1DM?
- To nephrologist if eGFR <30
Follow ups in T1DM?
- Measure HbA1c every 3-6 months – target 48mmol/mol
- Annually
o HbA1c
o Height, weight, waist circumference, BMI
o Smoking status
o Assess erectile dysfunction (offer PDE-5i)
o Monitor for neuropathy
o Check injection sites
o Assess awareness of hypoglycaemia with Gold/Clarke score
How to screen for retinopathy in T1DM?
GP referral on diagnosis and annually
Emergency review by ophthalmologist if:
o Sudden loss of vision, rubeosis iridis, pre-retinal/vitreous haemorrhage, retinal detachment
Refer to ophthalmologist if:
o Maculopathy (exudates near fovea, macula)
o Pre-proliferative retinopathy (venous bleeding, reduplication, multiple round or blot haemorrhages)