Management of T1DM Flashcards by Rosa Bock

what is the focus of treatment in T1DM

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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describe normal insulin secretion

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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what are the 2 main methods of insulin intake

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

insulin pump (CSII)

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what are patients advised about injecting insulin

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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who uses CSII

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

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CSII

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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what does CHO counting comprise of

insulin:CHO ratio

ICR (insulin:carb ratio)

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

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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basal bolus insulin regime

(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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which patients does basal bolus regime suit

those with T1DM and flexible lifestyles

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BD biphasic regime

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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once daily insulin regime

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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structured education

DAFNE: insulin dosing and carbohydrate estimating education

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advanced carbohydrate counting

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

suitable for patients on MDI or CSII pumps

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what is ACC composed of

insulin:carbohydrate ratio

and

insulin sensitivity factor

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what is insulin sensitivity factor

the drop in blood glucose for each unit of insulin taken

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what is the general management for a newly diagnosed diabetic

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

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what are the aims of insulin therapy

prevent hyperglycaemia

avoid hypoglycaemia

reduce chronic complications

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initial approaches to T1DM treatment

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

prandial insulin

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

compare prandial insulin analogues to soluble prandial insulin

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

give some examples of prandial insulin analogues

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

give some examples of soluble prandial insulin

Actrapid, Humulin S

what biochemical change has occurred in humalog (insulin Lispro)

amino acids lysine and proline have been switched

basal insulin - isophane

intermediate actvity peaks at 4-6 hours

analogue basal insulins

longer duration of action, less peak activity can be given once or twice a day eg Lantus (glargine) or Levemir (determir)

inuslin Glargine

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

what does Determir (Levermir) have a role in

intensive insulin regimes for type 2 overweight diabetics

how is metabolic control evaluated

home blood glucose monitoring - snap shot urine testing for glucose and ketones HbA1c continuous glucose monitor flash glucose monitoring

name the pros and cons of BG monitoring

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

ketonaemia level in blood

\>3mmol/L

home blood glucose monitoring

effective but infrequently used as requires both doctor and patient flexibility Monitor pre-prandial ± post-prandial provides snapshot

continuous glucose monitoring

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

flash glucose monitoring

picks up rapid changes in glucose there is no evidence of it improving HbA1c, however it does massively improve the patients quality of life

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

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

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

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

what are the factors affecting insulin absorption/action

temperature injection site injection depth exercise

lipohypertrophy

fatty lumps appear on skin can happen if you always inject insulin in the same site

IV insulin

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

Determir, Lantus and Humulin

basal insulins

insulin administration in the event of illness?

continue taking insulin as normal, monitor BG levels more frequently plenty of fluids

glucose control during strenuous exercise

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

prolonged moderate intensity exercise eg marathon

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

statin mechanism

* 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

adverse effects of statins

* muscle aches * abdominal discomfort * myositis

what effect do statins have on CV risk

reduce CV disease events

when should statins be avoided

pregnancy - cholesterol is needed for foetal development