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RB Y2 Endocrine - 1 Diabetes > Management of T1DM > Flashcards

Management of T1DM Flashcards

1
Q

what is the focus of treatment in T1DM

A

supply insulin to the body - the main aim of treatment is to maintain as near a normal blood glucose as is practical and safe for the individual, to avoid hypoglycaemia and extreme hyperglycaemia

structured education programme, lifestyle advice, start a statin, control BP (ACE)

give foot care

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2
Q

describe normal insulin secretion

A

normally secreted at a low basal rate which accounts for half of insulin being produced

post-prandial insulin is secreted in relation to post-meal glucose

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3
Q

what are the 2 main methods of insulin intake

A

injected - syringe, disposable pen or re-usabel cartridge pen

insulin pump (CSII)

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4
Q

what are patients advised about injecting insulin

A

rotate the area they inject into, but always to inject into fatty tissue

sites of injection must be monitored as they are prone to inflammation, lipo atrophy and hypertrophy and possibly infection

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5
Q

who uses CSII

A

patients with type 1 diabetes who are struggling to achieve normoglycaemia with injected insulin

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6
Q

CSII

A

continuous SC administration of short acting insulin - background insulin level is dictated by basal rate which can be programmed in advance

patient manually delivers a bolus of insulin to cover meals - calculated by CHO counting

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7
Q

what does CHO counting comprise of

A

insulin:CHO ratio

ICR (insulin:carb ratio)

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8
Q

BG = 10, target BG = 6. Ate 50g for lunch, ICR 1:10. Inuslin sensitivity 1:2.

A
  • 1 unit insulin for every 10g carbs, and 1 unit insulin to lower BG by 2 mmol*
  • = 7 units insulin prescribed.*
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9
Q

basal bolus insulin regime

A

(QDS)

aims to mimic normal endogenous production

basal therapy controls blood sugar levels between meals and during sleep

bolus insulin controls blood sugar when you eat (fast acting )

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10
Q

which patients does basal bolus regime suit

A

those with T1DM and flexible lifestyles

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11
Q

BD biphasic regime

A

premixed basal and bolus insulin (eg Novomix 30) given twice daily with breakfast and evening meal by pen

useful in T1 and T2 DM with a regular lifestyle

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12
Q

once daily insulin regime

A

taken once before bed

optimum dose is worked up to slowly

good when switching from tablets in T2DM

One might consider retaining Metformin if needed for tight control and patient is unable to use BD regime.

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13
Q

structured education

A

DAFNE: insulin dosing and carbohydrate estimating education

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14
Q

advanced carbohydrate counting

A

synchronising the amount of insulin taken to the amount of carbohydrate consumed

suitable for patients on MDI or CSII pumps

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15
Q

what is ACC composed of

A

insulin:carbohydrate ratio

and

insulin sensitivity factor

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16
Q

what is insulin sensitivity factor

A

the drop in blood glucose for each unit of insulin taken

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17
Q

what is the general management for a newly diagnosed diabetic

A

structured education programme, lifestyle advice, start a statin, BP control, foot care

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18
Q

what are the aims of insulin therapy

A

prevent hyperglycaemia

avoid hypoglycaemia

reduce chronic complications

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19
Q

initial approaches to T1DM treatment

A

educated in how to match prandial insulin dose to carbohydrate intake, pre-meal glucose and anticipated activity

20
Q

prandial insulin

A

used to allow control of blood glucose during a meal - injected within 15 minutes of beginning the meal

21
Q

compare prandial insulin analogues to soluble prandial insulin

A

insulin analogues have a quicker onset of action, earlier peak and shorter duration than soluble

22
Q

give some examples of prandial insulin analogues

A

insulin lispro (Humalog), glulisine (Apidra), insulin Aspart (NovoRapid)

23
Q

give some examples of soluble prandial insulin

A

Actrapid, Humulin S

24
Q

what biochemical change has occurred in humalog (insulin Lispro)

A

amino acids lysine and proline have been switched

25
Q

basal insulin - isophane

A

intermediate actvity

peaks at 4-6 hours

26
Q

analogue basal insulins

A

longer duration of action, less peak activity

can be given once or twice a day

eg Lantus (glargine) or Levemir (determir)

27
Q

inuslin Glargine

A

marketed as Lantus

ultra long-acting

recombinant insulin analogue that has a prolonged, peakless activity

used to maintain blood glucose over night - single dose before bed time

28
Q

what does Determir (Levermir) have a role in

A

intensive insulin regimes for type 2 overweight diabetics

29
Q

how is metabolic control evaluated

A

home blood glucose monitoring - snap shot

urine testing for glucose and ketones

HbA1c

continuous glucose monitor

flash glucose monitoring

30
Q

name the pros and cons of BG monitoring

A

pros: glucose control, lifestyle exercise, carbohydrate counting
cons: painful, intrusive, discriminating

31
Q

ketonaemia level in blood

A

>3mmol/L

32
Q

home blood glucose monitoring

A

effective but infrequently used as requires both doctor and patient flexibility

Monitor pre-prandial ± post-prandial

provides snapshot

33
Q

continuous glucose monitoring

A

provides a more detailed review of an individuals glucose control

limitations due to cost, accuracy and acceptability

measures interstitial glucose - therefore a different range of values will be expected

34
Q

flash glucose monitoring

A

picks up rapid changes in glucose

there is no evidence of it improving HbA1c, however it does massively improve the patients quality of life

35
Q

essentially what are the glucose monitoring targets in relation to prandial control

A

to achieve with bolus insulin a BG that is a little bit higher 1-2 hours post meal than it was before

36
Q

what are the shortfalls of injected isulin in comparison to pancreatic insulin

A

normally pancreatic insulin is secreted diretly into the portal blood stream, rapidly preventing post meal hyperglycaemia and then rapidly cleared

insulin injection/pump has too slow a peak to prevent post-meal hyperglycaemia spike and has a slower clearance

also, amounts of insulin injected will not be as accurate as endogenous secretion

37
Q

what are the factors affecting insulin absorption/action

A

temperature

injection site

injection depth

exercise

38
Q

lipohypertrophy

A

fatty lumps appear on skin

can happen if you always inject insulin in the same site

39
Q

IV insulin

A

has a role in DKA, hyperosmolar hyperglycaemic state, acute illness and fasting patients who cant tolerate oral intake

40
Q

Determir, Lantus and Humulin

A

basal insulins

41
Q

insulin administration in the event of illness?

A

continue taking insulin as normal, monitor BG levels more frequently

plenty of fluids

42
Q

glucose control during strenuous exercise

A

check BG before

different types of activity have different effects on blood glucose - need to know intensity, duration etc

43
Q

prolonged moderate intensity exercise eg marathon

A

rapid fall in blood glucose

10 second sprint - skeletal muscle releases blood glucose. Decreases the risk of post exercise hypoglycaemia in T1DM

44
Q

statin mechanism

A
  • inhibit HMG CoA reductase, which causes de novo syntehsis of cholesterol in the liver
  • reduction of cholesterol in hepatocytes leads to an increased expression of LDL receptors by hepatocytes, leading to decreased circulating LDL cholesterol
45
Q

adverse effects of statins

A
  • muscle aches
  • abdominal discomfort
  • myositis
46
Q

what effect do statins have on CV risk

A

reduce CV disease events

47
Q

when should statins be avoided

A

pregnancy - cholesterol is needed for foetal development

RB Y2 Endocrine - 1 Diabetes (16 decks)

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