Management of T1D Flashcards
what are the glycemic goals of therapy for a nonpregnant adult and child
- A1c
- preprandial blood glucose
ADULTS: -A1c: < 7.0% -preprandial blood glucose: 80-130 CHILDREN: -Alc: < 7.5% -preprandial blood glucose: 90-130
immediate treatment goals for a person with T1D
- lower BS at least below 180 in order to provide relief of sx
- regain lost weight
- patient and family education: survival skills - insulin admin, meal planning, self-monitoring BG, urine testing, ER use of glucagon, sick day rules
long range tx goal for a person w/ T1D
- maintain near euglycemia
- maintain nl glycosylated hgb levels
- striver for normal growth and emotional development for children
- prevent macro and microvascular dz
- absence of hypoglycemia
know the insulin preps as rapid acting, short acting, intermediate and long acting. And basal vs. bolus.
covered in the tx of T1D
given a pt on insulin, use the knowledge of the onset, peak and effective duration of each insulin to do the following to select the best insulin regimen:
- provide basal and bolus coverage
- decrease risk of hypoglycemia
- improve a pts BG control
- determine TDD
- Basal: 50-70% of TDD
- Bolus: 30-50% of TDD - based on CHO intake (start w/ 1:15)
Given a patient with newly diagnosed type 1 diabetes:
-Explain the concept of intensive insulin therapy
Intensive insulin therapy tries to achieve a more physiologic replacement of insulin by giving long acting insulin that provides basal insulin and by giving a rapid acting or short acting insulin before meals to provide a bolus of insulin.
Given a patient with newly diagnosed type 1 diabetes:
-Select the best basal/bolus insulin regimen for that person (include the amounts provided by basal and bolus insulin—percent breakdown)
50 to 70% of the total daily dose should be a basal insulin
-Basal insulins are glargine (Lantus®), detemir (Levemir®) and NPH
30 to 50% of the total daily dose should be given in divided doses before a meal with rapid-acting or short-acting insulin (bolus)
-Bolus or Preprandial insulins are Novolog®, Humalog®, Apidra®
Given a patient with newly diagnosed type 1 diabetes:
-select the initial TDD insulin dosing for adults, children, and adolescents
- adults: 0.5-1.0 units of insulin/kg/day
- children: 0.4-0.8 units/kg/day
- adolescents: 1.0-1.5 units/kg/day
Given a patient with newly diagnosed type 1 diabetes:
-Explain the rule of 500 and how to use it to establish an insulin:carb ratio
- Rule of 500 is the carbohydrate coverage ratio
- 500 ÷ Total Daily Insulin Dose = 1-unit insulin covers so many grams of carbohydrate
- 1:15 is common starting point
Given a patient with newly diagnosed type 1 diabetes:
-Explain how the rule of 1800 is used to determine an insulin sensitivity factor
- use the “1800 rule” to calculate insulin sensitivity factor for people who use the rapid-acting insulin analogs lispro (brand name Humalog), aspart (NovoLog), and glulisine (Apidra)
- this is done by dividing 1800 by TDD of rapid-acting insulin
- if the total daily insulin dose is 40 units, the insulin sensitivity factor would be 1800 divided by 40 = 45 – 1:45
- meaning 1 unit of insulin would drop BG by 45 mg/dl
Given a patient with newly diagnosed type 1 diabetes:
-Explain how an insulin correction dose is used
- An insulin sensitivity factor is used to determine an insulin correction factor
- Insulin Correction factors are used to correct or adjust the premeal bolus insulin dose in order to cover the carbohydrate content in a meal plus “correct” a higher than desired blood preprandial blood glucose
Given a patient experiencing a hypoglycemic reaction:
-Identify common reasons for hypoglycemia
When the patient: -skips a meal -delays a meal -eats less at a meal than usual and does not adjust insulin -increases their activity -commits a dosage error Or medical causes: -altered liver/kidney fxn -hormonal def. -rapid gastric emptying -hypoglycemic unawareness
Given a patient experiencing a hypoglycemic reaction:
-Identify symptoms commonly associated with hypoglycemia
- Headache
- Shaking
- Sweating
- Feeling tired
- Weakness
- Hunger
- *Rapid onset
Determine the severity of the hypoglycemia
-Mild hypoglycemia
- Usually manifested as adrenergic symptoms (mediated by epinephrine)
- pts capable of self tx - oral ingestion of 10-15 g CHO should tx
- These symptoms are anxiety, sweating, tremulousness, tachycardia, hunger.
- Clinically significant hypoglycemia is defined as a glucose <54 mg/dL.
Determine the severity of the hypoglycemia
-Moderate hypoglycemia
- Includes adrenergic symptoms plus neuroglycopenic symptoms including headache, mood change, irritability, confused thinking, and slurred speech.
- These reactions are usually longer lasting, and the patients usually require assistance in obtaining a glucose source.
- A second dose of 10 to 15 grams of a simple sugar is usually required.
Determine the severity of the hypoglycemia
-Severe hypoglycemia
- Characterized by unresponsiveness, unconsciousness or convulsions.
- These reactions require emergency care with an intravenous dextrose or IM glucagon injection.
explain the rule of 15
Check blood sugar –> eat 15 gm of carbs –> wait 15 min for sugar to get into blood
identify the causes of lipodystrophies secondary to insulin admin
- lipoatrophy: associated w/ animal source insulin and now more so with Humalog; loss of adipose
- lipohypertrophy: d/t many months/yrs of repeated injections into the same site
- local allergy: common w/ animal sources
dawn phenomenon
- nl physiologic response to awakening
- BG rises in the early morning preparing a person for the day
- in nondiabetic: insulin levels woudl rise as well w/ the increasing BG
- in pts w/ DM: insulin levels don’t rise so hyperglycemia in the morning may result
Smogyi effect
- hyperreactive hyperglycemia in response to nocturnal hypoglycemia
- when BG falls too low (<60) the adrenal glands release catecholamines which stimulate glucagon release causing increase in glucose release from liver
- result: elevated BG in the morning
Identify the glycemic goals for children
- A1c goal of < 7.5%
- 90 to 130 mg/dL before meals
- 90 to 150 mg/dL bedtime and overnight
Identify the screening for other autoimmune diseases in people with T1DM
- thyroid dz: anti-TPO, antithyroiglobulin antibodies, TSH
- celiac dz: tissue transglutaminase or deaminated gliadin antibodies
interventions for preventing or decreasing the risk of CVD in children
- measure BP at every visit and tx w/ diet, exercise, and weight control. (ACEi if needed)
- screen lipid in children >10 and treat if abnl w/ diet (statin if needed). Goal is <100
- discourage smoking and cessation for those who do
screening and preventative interventions for children to prevent microvascular complications
- screen urine for albuminuria once child has had DM for 5 yrs
- normalize BP and improve glycemic control
- screen for retinopathy w/ a dilated and comprehensive eye exam age >10 or after puberty has started - whichever is early once child has had DM for 3-5 yrs
