Management of T1DM Flashcards
What are the aims of management of T1DM?
- Prompt diagnosis
- Encouragement of the appropriate self management skill set
- Correction of acute metabolic upsets at diagnosis and thereafter
- Facilitate long term health and well being
Autoimmune disease
A large group of clinical disorders which are
characterised by tissue or organ damage
mediated through aberrant immunological
mechanisms which are directed against
autoantigens
What is the aetiology/pathogenesis of T1DM?
- Genetic tendency + environment
- Islet inflammation/lymphocyte infiltration/ B cell damage
- Release of (non tolerated) B cell autoantigen or structural modification of B cell autoantigen
- Sensitisation of auto reactive T cells to islet cell antigen and inappropriate HLA expression on islet cells
- T cell recognition of autoantigen
- B cell destruction
What evidence is there that autoimmunity plays a role in the pathogenesis of T1DM?
- Association with Hashimoto’s, Grave’s, P.A., atrophic gastritis, Addison’s
- Lymphocytic infiltration in islets
- Islet cell ab (2°)
- Insulin ab / insulinr ab
- Ab to glutamate decarboxylase
- Evidence of response (clinical & experimental) to immunosuppressive therapy
Why is an early diagnosis of T1DM important?
-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
What are the 3 important steps in making an early diagnosis?
- THINK symptoms
- TEST immediately
- TELEPHONE urgently
What ‘THINK’ symptoms should you be aware of?
- Thirsty
- Thinner
- Tired
- Toilet more often
How should people be immediately tested?
- Finger prick capillary glucose test
- If >11mmol/l diabetes
Who should you telephone urgently?
Contact your local specialist team for same day review
What is a red flag symptom in children who are toilet trained?
A return to bed wetting or day wetting
What symptoms should you be aware of, particularly in the under 5s?
- Heavier than usual nappies
- Blurred vision
- Candidiasis (oral, vulval)
- Constipation
- Recurring skin infections
- Irritability and behavioural change
What are the symptoms of DKA?
- Nausea and vomiting
- Abdominal pain
- Sweet smelling ketotic breath
- Drowsiness
- Rapid, deep signing respiration
- Coma
What testing should not be carried out?
- DO NOT request a returned urine specimen.
- DO NOT arrange a fasting blood glucose test.
- DO NOT arrange an Oral Glucose Tolerance Test.
- DO NOT wait for lab results (urine or blood).
What current strategies are there to support people with T1DM?
- Education
- Nutrition and lifestyle management
- Skills training
- Insulin
What checks are important to carry out before administering insulin?
- Right insulin
- Right dose
- Right time
- Right way
What is insulin?
A polypeptide
Why does insulin need to be injected subcutaneously?
It is inactivated by the gastrointestinal tract therefore it needs to be injected subcutaneously (usual route) or intravenously (e.g. during illness or surgery)
What does insulin tend to do in the subcutaneous tissue?
In the subcutaneous fat the Insulin molecule in solution has a tendency to self-associate into hexamers
What do hexamers need to do before absorption through the capillary bed?
Hexamers need to dissociate into monomers before absorption through the capillary bed. Thus soluble insulin is given 30 mins before eating.
Why can rapid acting analogues be injected just before eating?
Rapid acting analogues do not associate and can be injected just before eating
How is the rate of absorption of insulin changed?
Changing the structure of insulin or binding it to other molecules will change the rate of absorption
What should the amount of insulin injected for meals equal?
The amount of insulin injected for meals should balance the carbohydrate intake consumed
Give examples of education available for T1DM patients.
-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
What structured education is given to T1DM patients?
- Set curriculum (DIANE)
- Deals with real life issues
- Food, exercise, travel etc
- Insulin, blood testing
- Hypoglycaemia
- Sick day rules
What types of duration of action are available for insulin?
- Rapid acting
- Short acting
- Intermediate acting
- Long acting
- Continuous sub cutaneous insulin
What are the important factors of insulin injection technique?
- Needle size
- Location
- Rotation
- Technique
Describe how insulin therapy regimens work.
- 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
What is included in a twice daily insulin regimen?
- Rapid acting mixed with intermediate acting
- Before breakfast (BB) and evening meal (BT)
What is included in a three times daily insulin regimen?
- Rapid acting mixed with intermediate acting BB
- Rapid acting BT
- Intermediate acting at bedtime BBed
What is included in a four times daily insulin regimen?
- Short acting BB BL BT
- Intermediate BBed or long acting insulin at a fixed time once daily
What adjustments may be required after a diagnosis of T1DM?
- Lifestyle
- Exercise
- Driving
- Alcohol
- Conception
- Holidays
- Employment
Hypoglycaemia
Hypoglycaemia refers to any episode of low blood glucose (<4mmol/l) with or without symptoms and may occur in patients taking insulin or sulphonylureas.
What are the possible reasons for a hypoglycaemic episode?
Imbalance between:
- Food (too little / wrong type)
- Activity (during /after)
- Insulin (or some Oral Hypoglycaemics) (dose, injection technique)
What are the causes of hypoglycaemia?
- Too much insulin/SU
- Inappropriate timing of insulin/SU
- Injection site problems
- Inadequate food intake/fasting
- Exercise
- Alcohol
Who is at risk of hypoglycaemia?
- Tight glycaemic control
- Impaired awareness
- Cognitive impairment
- Extremes of age
- Malabsorption/gastroparesis
- Hypoadrenalism/abrupt steroid withdrawal
- Coeliac disease
- Renal/hepatic impairment
- Pancreatectomy
- Pregnancy
How do most isolated hypo episodes resolve?
Even if untreated, most isolated hypo episodes recover spontaneously and are not associated with permanent damage. It is reasonable to reassure patients accordingly. Many patients will avoid strict blood glucose control in order to minimise their risk of experiencing hypoglycaemia.
What are the common autonomic symptoms of hypoglycaemia?
- Sweating
- Palpitations
- Shaking
- Hunger
What are the common neuroglycopenic symptoms of hypoglycaemia?
- Confusion
- Drowsiness
- Odd behaviour
- Speech difficulty
- Incoordination
What are the common general symptoms of hypoglycaemia?
- Headache
- Nausea
What is an inability to perceive normal warning symptoms of hypoglycaemia associated with?
- Recurrent severe hypoglycaemia
- Long duration of disease
- Over tight control
- Loss of sweating / tremor
What should patients on insulin or sulfonylureas carry with them?
Carbohydrate
What can hypoglycaemia cause?
- Coma
- Hemiparesis
- Seizures
- Death
What can happen if hypoglycaemia is prolonged?
If the hypoglycaemia is prolonged the neurological deficits may become permanent.
Is someone is conscious how should hypoglycaemia be treated?
15-20g simple CHO
- 5-7 dextrosol/4-5 glucotabs
- 200ml fruit juice
If unconscious and out of hospital, how should someone with hypoglycaemia be treated?
- 1mg I’m glucagon
- Glucogel/dextrogel
If unconscious and in hospital, how should someone with hypoglycaemia be treated?
-75-80ml 20% glucose OR -150-160ml 10% glucose OR -25-50mls 50% dextrose IV
What may a hypo box contain?
- Fruit juice
- Dextro energy
- Glucogel
- 50% Dextrose
- Hypo management protocol
After a patient has recovered from a hypo, what should you find out?
- Wrong regimen; dose/insulin
- Control and monitoring
- Hypoglycaemia unawareness
- Discuss driving / work etc
- Food/activity/insulin
- Injection sites
How can hypoglycaemia be avoided in insulin-treated diabetes?
- 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
What must diabetics be aware of regarding driving?
- Patients should be advised to check their blood glucose before/within 2 hours of driving and during long car journeys and should always carry carbohydrate in the car.
- No awareness then no driving
- No more than one episode of severe hypo (Group 1) in a year
What are the risk factors for T1DM?
- Known T1DM
- Inadequate insulin
- Infection
- Other precipitant
What are the symptoms of DKA?
- Polyuria
- Polydipsia
- Weight loss
- Weakness
- Nausea/vomiting
- Abdo pain
- Breathlessness
What are the signs of DKA?
- Dry mucus membranes
- Sunken eyes
- Tachycardia
- Hypotension
- Ketotic breath
- Kussmaul resp.
- Altered mental state
- Hypothermia
What are the sick day rules for insulin treated patients?
- 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
What does DKA result from?
Too little insulin leading to fat breakdown and is therefore usually associated with high glucose and fluid depletion
What may DKA be caused by?
- Infection
- Severe stress
- Insulin omission
What is the common presentation of DKA?
- Dehydrated
- Thirsty
- Abdominal pain
- Acidotic breathing (Kussmauls)
- Acetone on breath
- Tachycardic and low BP
What should be done immediately for suspected DKA?
- Rapid ABCs
- IV access established
- Vital signs
- Clinical assessment
- Full clinical examination
What initial investigations should be carried out for DKA?
- Glucose
- Venous blood gas
- Urinalysis/blood ketones
- U+Es, FBCs
- Culture blood and urine
- ECG and cardiac monitoring
- Consider CXR
What are the possible complications of DKA?
- 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
How should DKA be treated in hospital?
- Measure glucose / U and E’s / ketones / bicarbonate / arterial blood gas
- Give iv saline (5 l in 24 hours)
- Give iv insulin (drives glucose and potassium into cells)
- Give iv potassium in saline
- May need antibiotics
- Consider heparin, NG tube
- Mortality Rate 2%
How can long term health and wellbeing be facilitated?
- Optimal blood glucose control (HbA1c)
- Optimal blood pressure control
- Manage cardiovascular risk factors
- Screen for early detection of complications
How are they looking to further optimise SC insulin delivery?
Sensor augmented pumps
- Full integration of insulin delivery with real time blood glucose monitoring – CLOSED LOOP
- Potential to act like an artificial pancreas
