Management of Diabetes - Type 1 Diabetes Mellitus

Question 1

When living with a long term condition, how many hours a year are spent slef managing and how many are spent with a NHS professional?

Answer 1

Question 2

what is involved in person centred care?

Answer 2

Question 3

what are the aims of management of type 1 diabetes mellitus?

Answer 3

Prompt diagnosis

Self management skill set

Acute metabolic upsets at diagnosis and thereafter

Facilitate long term health and well being

Question 4

why is an early diagnosis important?

Answer 4

Scotland has 5th highest incidence of Type 1 Diabetes in the world

In Scotland 300 children under the age of 15 years are diagnosed with Type 1 Diabetes annually

1 in 4 are diagnosed in DKA, rising to 1 in 3 under the age of 5 years

In the UK 10 children die and 10 children suffer permanent neurological disability

Question 5

what are things to look out for in a possible diagnosis of diabetes?

Answer 5

thinner

thirsty

tired

using toliet more

Question 6

symtpoms of diabetes can be due to what 2 things?

Answer 6

blood glucose and blood ketone

Question 7

What is the benefit of managing HbA1c well at the starts?

Answer 7

Manage HbA1c good at the start and then this will have a legacy effect and work out better in the future

Question 8

what are some current strategies in place to support people with type 1 diabetes?

Answer 8

Education:

• Team based DSN, practice nurse, dietitian, podiatrist, doctors
• Structured education e.g. DIANE, Dose Adjustment For Normal Eating
• Person with diabetes is main team member

Nutrition and Lifestyle management e.g. CHO counting, physical exercise

Skills training e.g. Home blood glucose monitoring, injection technique, hypos, sick day rules

Insulin- analogues, pens, pumps

Question 9

What are the different types of insulin you can get and their duration?

Answer 9

Rapid acting insulins eg insulin lispro*, insulin aspart* (Humalog®,Novorapid®,Apidra®)

Short acting insulins eg soluble insulin, actrapid, Humulin S.

Intermediate acting insulins eg Isophane insulin;insulatard,HumulinI.

Long acting insulins eg glargine*, detemir*, degludec

Continuous sub cutaneous insulin infusion (CSII)

Question 10

What do you need to check before you inject insulin?

Answer 10

Right insulin – check the name

Right dose – check strength and how much insulin to give. Check the numbers very carefully

Right time – with food? At bedtime?

Right way – via syringe, pen or pump?

Question 11

Why is insulin taken IV and subcutaneously and not orally?

Answer 11

Insulin is a polypeptide which is inactivated by the gastrointestinal tract therefore it needs to be injected subcutaneously (usual route) or intravenously (e.g. during illness or surgery)

Question 12

What happens to the insulin in the subcutaneous fat?

Answer 12

In the subcutaneous fat the Insulin molecule in solution has a tendency to self-associate into hexamers

Hexamers need to dissociate into monomers before absorption through the capillary bed. Thus soluble insulin is given 30 mins before eating

Question 13

why can rapid acting analogues be injected?

Answer 13

Rapid acting analogues do not associate and can be injected just before eating

Question 14

Changing the structure of insulin or binding it to other molecules will change the rate of _________

Answer 14

absorption

Question 15

The amount of insulin injected for meals should balance the ___________ intake consumed

Answer 15

carbohydrate

Question 16

What do Insulin Therapy Regimens allow?

Answer 16

Suitable for a flexible lifestyle

Better for shift workers

Rapid (Short) acting insulin to cover CHO at meals 1 unit per 10g CHO

Basal long acting insulin as background

Question 17

Current Insulin Regimens:

Twice daily

Answer 17

Rapid acting mixed with intermediate acting

Before breakfast (BB) and evening meal (BT)

Question 18

Current Insulin Regimens:

Three times daily

Answer 18

Rapid acting mixed with intermediate acting BB

Rapid acting BT

intermediate acting at bedtime BBed

Question 19

Current Insulin Regimens:

Four times daily

Answer 19

Short acting BB BL BT

Intermediate BBed or long acting insulin at a fixed time once daily

Question 20

Insulin administration to _________ ___

Answer 20

subcutaneous fat

Question 21

Insulin administration to subcutaneous fat requires the correct what?

Answer 21

Needle size

Location

Rotation

Technique

Question 22

What things may be used to educate a patient?

Answer 22

Patient Handbooks

Leaflets

Websites

Pregnancy

Insulin Pump starts

Rolling Programs/Topics

Education Days

CGM starts

Apps CHO/fitness

Health care professional education

House of Care

On Line

My Diabetes My Way

Think Check Act

3rd Sector

Question 23

What are osme examples of when you would assess blood glucose control - home blood glucose monitoring and ketone testing

Answer 23

to adjust insulin dose, prior to driving, tighten control

Question 24

What is this shown?

Answer 24

Continuous Subcutaneous Insulin Infusion (CSII)

Question 25

what are some adjustments that may need to be made for someone living with type 1 diabetes?

Answer 25

Lifestyle Exercise Driving Alcohol Conception Drugs Holidays Employment

Question 26

what are osme emergencies that may occur due to type 1 diabetes?

Answer 26

Hyperglycaemia - Diabetic Ketoacidosis Hypoglycaemia

Question 27

WHat level of BG is hypoglycaemia?

Answer 27

Low blood glucose level \<4mmol/l

Question 28

Reasons for hypoglycaemia - Imbalance between what?

Answer 28

Food - too little/wrong type Activity - during/after Insulin (or some Oral Hypoglycaemics) - dose, injection technique

Question 29

What are hypoglycaemia causes?

Answer 29

Too much insulin/SU Inappropriate timing of insulin/SU Injection site problems Inadequate food intake/fasting Exercise Alcohol

Question 30

what are the groups at risk of hypoglycaemia?

Answer 30

Tight glycaemic control Impaired awareness Cognitive impairment Extremes of age Malabsorption/gastroparesis Hypoadrenalism/abrupt steroid withdrawal Coeliac disease Renal/hepatic impairment Pancreatectomy Pregnancy

Question 31

Patients should be advised about how to what?

Answer 31

avoid, recognise, and treat hypoglycaemia

Question 32

Loss of warnings of hypoglycaemia is associated with what?

Answer 32

recurrent severe hypoglycaemia long duration of disease over tight control loss of sweating/tremor pregnancy

Question 33

what is the treatment of hypoglycaemia?

Answer 33

All patients treated with insulin or sulphonylureas should be advised to carry carbohydrate with them

Question 34

hypoglycaemia can cause what?

Answer 34

Hypoglycaemia can cause coma, hemiparesis and seizures

Question 35

Prolonged hypoglycaemia cna lead to what?

Answer 35

If the hypoglycaemia is prolonged the neurological deficits may become permanent

Question 36

what is this

Answer 36

hpyo box

Question 37

how do you avoid hypoglycaemia in insulin treated diabetes?

Answer 37

Blood glucose monitoring Rotate and check injection sites Review snacks and diet –Carb counting Consider a change of insulin regimen eg basal bolus, CSII Avoid low glucose -“4 is the floor” (7 at bedtime & 5 to drive) Alter insulin before and after exercise DVLA

Question 38

what should you do when you blood ketones are at each different levels?

Answer 38

Question 39

what are the risk factors for DKA?

Answer 39

Known T1DM, inadequate insulin, infection, other precipitant

Question 40

what are the symptoms of DKA?

Answer 40

* Polyuria * Polydipsia * Weight loss * Weakness * Nausea/vomiting * Abdo pain * Breathlessness

Question 41

What are the signs of DKA?

Answer 41

* Dry mucus membranes * Sunken eyes * Tachycardia * Hypotension * Ketotic breath * Kussmaul resp. (Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure) * Altered mental state * Hypothermia

Question 42

how to treat an acute illness in insulin treated patients?

Answer 42

NEVER stop insulin Increase/adjust insulin dose according to blood glucose perform more frequent blood glucose checks check urine or blood for ketones carbohydrate intake must be maintained by fluids (eg fruit juice) if unable to tolerate food

Question 43

study this summary diagram

Answer 43

Question 44

Diabetic ketoacidosis = _______ + _______ + \_\_\_\_\_\_

Answer 44

Diabetic ketoacidosis = Glucose + Ketones + Acidosis

Question 45

Diabetic ketoacidosis caues what?

Answer 45

Dehydrated Thirsty Abdominal pain Acidotic breathing (Kussmauls) Acetone on breath Tachycardic and low BP

Question 46

what investigations are done for DKA?

Answer 46

Question 47

what are some complications of DKA?

Answer 47

Hyper and hypokalaemia Hypoglycaemia * Rebound ketosis * Arrhythmias * Acute brain injury Cerebral oedema * Children more susceptible * 70-80% diabetes related deaths in children \<12 Aspiration pneumonia Arterial and venous thromboembolism ARDS

Question 48

How can you facilitate long term health and well being?

Answer 48

Optimal blood glucose control (HbA1c): ## Footnote - to reduce microvascular disease e.g. retinopathy - to improve pregnancy outcome Optimal blood pressure control - to reduce nephropathy Manage cardiovascular risk factors - e.g. smoking, cholesterol Screen for early detection of complications - feet, eyes & kidneys

Question 49

what do sensor augmented pumps do?

Answer 49

Full integration of insulin delivery with real time blood glucose monitoring – CLOSED LOOP Potential to act like an artificial pancreas

Question 50

Current: Type 1 diabetes care

Answer 50

Possible Vision Type 1 Diabetes Care

Question 51

how do insulin pumps work?

Answer 51

Question 52

how does an infusion set work?

Answer 52

Question 53

what is the insulin reservoir?

Answer 53

Question 54

what are the advantages and disadvantages of an insulin pump?

Answer 54