Lecture 12, 13 & 14: Auto injectors, monitoring and paediatrics Flashcards
1
Q
Why are devices used to deliver insulin?
A
- Improved safety
- Improved dosing accuracy
- Patient compliance
2
Q
What are the classifications of devices?
A
- Single use
- Disposable
- Reusable
3
Q
What are the types of devices?
A
- Vial: Closed vessel containing insulin. Sealed with pressurised seal
- Cartridge: Disposable container which is inserted into a non-disposable pen device
- Pre-filled pen: Disposable container which is fully enclosed and disposed when finished
- Insulin pump: Continuous subcutaneous insulin infusion
4
Q
What are the advantages of a vial and syringe?
A
- Can use for multiple patients
- Larger size than other devices
- Good in secondary care
- Good for nursing admin
5
Q
What are the disadvantages of vial and syringe?
A
- Require syringe and withdraw (risk of bubbles)
- Measuring dose is difficult
- Not all insulins available as vial
6
Q
What are the advantages of cartridge?
A
- Used in non-disposable pen, preferable
- Easy to dial up to dose
7
Q
What are the disadvantages of cartridge?
A
- Used in non-disposable pen (not preferrable)
- If non-disposable pen breaks then no alternative to give insulin dose
- Not all insulins available as cartridges
8
Q
What are the advantages of pre-filled pens?
A
- There are differences between disposable pen devices (Flex pen (extends) compared to Solo star, Flex touch) (Doesnt twist out
- Not all insulins available as pre-filled pens
9
Q
What are the advantages of an insulin pump?
A
- Mirrors body and natural pancreatic function
- Can be used as closed loop with some blood glucose monitoring
- Only need 1 type of insulin (fast acting)
- Can deliver basal and bolus doses
- Different types of pumps depending on patient need/preference
10
Q
What are the disadvantages of insulin pumps?
A
- Requires high level of patient input/activity
- Need good dexterity to fill and use pumps
- If pump fails - can go into DKA quick (higher risk)
11
Q
What is the autoinjector design of delivery?
A
- Self-firing mechanism
- Either cartridge type injection (Epi pen), syringe type injector
-Designed for people with less medical expertise: emergency - 1/4 of needle remains in device
- However not yet used in practice
12
Q
What are the advantages of an autoinjector?
A
- Viscous solutions can still be self-injected
- Risk prevention from needle-stick injury
- Safe/accurate drug delivery device
- Can overcome needle phobia as needle shielded
- Reduces healthcare time
13
Q
What are some needle characteristics?
A
- Needle gauge: higher gauge thinner needle = less pain of insertion
- Needle length: longer = risk of IM instead of SC
- Syringe material: glass = excellent barrier properties, inert, plastic = stability issue and environmental impact
14
Q
What is an i.port device?
A
- Device worn on skin
- Flexible cannula inserted under skin and injected into
- Reduce needle stick injury but expensive
15
Q
Why is monitoring important?
A
- Allow people to understand the nature of the disease
- To determine optimum timing for initiating therapeutic intervention
- To guide day-day adjustment of treatment
16
Q
What are the 3 treatment targets?
A
- Hb1AC
- Blood pressure
- Lipids
17
Q
What are the 8 Core Care processes?
A
- HbA1C
- Lipids
- BMI
- Blood pressure
- Smoking status
- Foot exam
- Albumin: Creatinine ratio
- Serum creatinine
- extra: urine ketones (type 1)
18
Q
What are the conditions to discuss antihypertensive agents when under 80 with stage 1 hypertension?
A
- Target organ damage
- Cardiovascular disease
- Renal disease
- Diabetes
- Estimated 10yr risk of cardiovascular disease
19
Q
What are the categories of BMI?
A
- less than 18.5 = underweight
- 18.5-24.9 = Normal
- 25-29.9 = overweight
- 30 - 34.9 = obese
20
Q
Why is checking smoking status important?
A
- Smokers = 30-40% risk of developing diabetes
- Worsens peripheral vascular disease, CKD, retinopathy
- Can make it difficult to control diabetes
- Increase CVD risk
21
Q
What are some steps to keep healthy feet?
A
- Attend regular annual review
- Check feet everyday for signs of redness, pain, damage to skin or swelling
- Aware of any loss of sensation
- Always wear well-fitted shoes
22
Q
What is the urine albumin creatinine ratio?
A
- Look for protein in the urine
- Test in morning when urine conc = high
- Vessels are leaky when damaged
- Early marker for kidney function loss
- Add SGLT2 to protect kidney and heart
23
Q
What is HBA1C?
A
- Glycosylated haemoglobin (how much glucose stuck on haemoglobin)
- Tells you average CBG for last 2-3 months (life cycle of RBC)
- Finger prick: snapshot, HBA1C - better overview
24
Q
What can some HBA1C readings indicate?
A
- 48-58: in target
- 58-75: above target
- 75 above: high (risk of DKA)
25
When can HBA1C not be accurate?
- Iron deficiency anemia
- Blood transfusion
- Blood issues
- High levels of Vit D
- HIV infection
26
What are the rules about blood glucose monitoring for Type 1 diabetes?
- At least 4 times a day upto 10 times if:
- increased hypos
- Driving
- Illness
- Pregnancy
27
What are the rules about blood glucose monitoring and type 2 diabetes?
- Dont routinely offer self-monitoring of blood glucose unless:
- On insulin
- Evidence of hypoglycaemic events
- On oral meds that can affect risk of hypo
- Pregnancy
28
What are the rules on driving and type 1 diabetes?
- Tell DVLA
- Measure before starting. Must be at least 5 mmol
- Measure 2 hrs after starting and every 2hrs after that
- If lower than 5 eat fast acting carbs and wait 45 mins and test again
29
What are the factors that affect blood glucose?
- Food, caffeine, alcohol, meds, sleep, activity
- Steroids: alter carb metabolism and induce insulin resistance
- Enteral feeds
- Anaemia: affects HBA1C
- Kidney function: insulin is renally excreted, require reduction in dose in AKI
30
Which diabetes requires ketone testing?
- All people with Type 1
- Either blood or urine
- As part of Sick day rules
31
What are the different types of continuous blood glucose monitoring
- Real time (rtCGM): sensor under the skin and gives readings to phone every 30 seconds and fills graph
- Intermittently scanned (isCGM) (Flash): Scan device against sensor and reads the number and gives trend
32
What is time in range?
- The percentage of time a person spends with their blood glucose levels in a target glucose range
- More time in this range can reduce long-term health complications
33
How do you diagnose diabetes in paediatrics?
- Use fasting glucose higher than 7
- 2hr plasma glucose over 11.,1 during oral glucose tolerance test - 75g glucose dissolved in water
- Dont use HbA1C routinely for diagnosis
- 4 Ts: Toilet, thirst, tired, thin
34
What are some diagnostic tools for paediatric diabetes?
- Diabetes associated antibodies - GAD, IA2, IAA or ZnT8
- C-peptide
- Autosomal dominant family Hx of diabetes
- Diabetes in 1st 6 months of life (neonatal diabetes)
- Hx of exposure to drugs known to be harmful (glucocorticoids, thyroid hormones, beta adrenergic agonists, thiazides)
35
What are the recommended health checks for paediatric type 1 and 2 diabetes annually?
- HbA1C: test for diabetes control (at diagnosis then every 3 months). Used to guide treatment and intensification and targets. National mean = 67.5
- BMI: measure of cardiovascular risk (at diagnosis then every 3 months)
- BP: measure of cardiovascular risk
- Urinary albumin: urine test for kidney function
- Thyroid screen: blood test for hyper/hypo thyroidism
- Eye screening
- Foot exams
- Commence at 12 years except Hba1c, height, weight, thyroid screening)
36
What are several factors associated with higher HbA1C?
- Being older
- Female
- Living in more deprived areas of England and Wales
- Non-white ethnicity
37
What are some complications of diabetes in paediatrics?
- Retinopathy
- Nephropathy
- Hypertension
- Juvenile cataracts
- Addisons disease
- Albuminuria
38
What can be given for psychological needs of children with type 1 diabetes and what about consent ?
- Offer child and family with emotional support, ongoing access to mental health professionals
- Children with frequent DKA more likely to have psychological conditions
- Oppurtunity should be given to make informed decisions, if under 16 family should be informed to help make decisions
39
What are the main treatment options for type 1 diabetes?
- Basal-bolus: gold standard
- Biphasic insulin
- CSII (Closed loop)
40
What are the main optimal traget ranges for type 1 diabetes when waking, before meals, after meals and driving?
- fasting of 4-7mmol/L on waking
- 4-7mmol/L before meals at other times of the day
- 5-9mmol/L after meals
- 5mmol/L when driving
41
What are the signs of a paediatric DKA?
- Cerebral oedema: serious and potentially fatal
- Headache
- Hypokalaemia: may need to suspend insulin infusion and should be managed in ITU
- Venous thromboembolism
42
How can Paediatric DKA be managed?
- High risk of aspiration: do not give oral fluids if vomiting
- No IV bolus for DKA if all possible and only 1 if needed
- Lower than standard fluid maintenance rate because large volumes of fluid increase risk of cerebral oedema
43
What are the features of paediatric type 2 diabetes?
- Overweight/obese
- Family history
- High risk ethnicity group (afro-carribean/south asian)
- Undetectable islet autoantibodies
- Elevated c-peptide
- Onset usually second decade of life: mean 13.5
44
What medicines are approved for use in paediatric diabetes
- Insulin and metformin (can be titrated upto 2000mg a day)
- Sulphonylureas approved in some countries
45
What should happen if a child is suspected to have diabetes?
- Should be referred to a specialist paediatric diabetes service. For type 1: same day referral
- Should attend clinic at least 4 times a year. More contact than adults
- Ensure continuity of care when moving to adult services
46
What are some additional considerations for paediatric diabetes?
- Safety: hypos do people know how to help
- ID bands
- Provision of meds, hypo and hyper treatment
- Technolgy: is it accessible
- Food
- School, after school club
