Management of Type 1 Diabetes Flashcards
How to assess a newly diagnosed pt with T1DM?
- History
- Examination
- Investigations - bloods
Questions to ask in history for T1DM
- Onset - acute, short
- Osmotic symptoms - polyuria, polydipsia, weight loss, fatigue
- PMH - endocrinopathies eg Cushings, Acromegaly, thyrotoxicosis, PCOS
- FH - diabetes and ethnic origin
- Other autoimmune disease
- Exocrine pancreas function - pancreatitis?
- Meds
What drugs can cause T1DM?
- Steroids
- Levothyroxine
- Diazoxide
- Beta agonists
- Thiazides
- HIV drugs
Things to examine on someone with DM
- BMI - central obesity? signs of T2DM?
- BP - CV risk
- Signs of insulin resistance
- Precipitating cause exam - pancreas failure?
- Dysmorphic features - eg Downs, Klinefelters
- Feet examination - do on patient in every interaction with diabetes
- Refer for retinal screening
- Examine injection sites?
Signs of insulin resistance
- Central obesity
- Acanthosis nigricans - darkening skin in folds esp
- Hyperandrogenism in females - eg hirsuitism, acne
Bloods for diagnosed DM
- HbA1C
- U&Es - nephropathy?
- LFTs - fatty liver disease?
- FBC - anaemia of chronic disease?
- Thyroid function - Type 1 associated with hypothyroidism
- Lipid profile
- B-cell antibodies, anti-GAD, anti-islet cells
- Coeliac screen
Pathophysiology of T1Dm
- Absolute insulin deficiency
- Secondary to T cell mediated autoimmune destruction
- Anti glutamic acid decarboxylase (GAD), islet autoantigen (I-A2) present in most people
Overall management of T1DM
- Education
- Insulin therapy
Education for people newly diagnosed with T1DM
- Explanation of Diabetes
- Aims of treatment - why do we treat?
- Home monitoring - 4x daily
- Injection technique
- Dietary advice - flexible insulin therapy advice too
- Suggested targets
- Hypoglycaemia risk and management of this
- Annual screening info - bloods, urine and eye screening
- DVLA and insurance
- Pregnancy - avoid pregnancy until HbA1C <48mmol/L
When do patients with T1DM monitor blood sugar at home?
- 4x daily
- Fasted
- Pre lunch
- Pre dinner
- Bedtime
Targets for blood sugar levels T1Dm
- Premeal - 4.0-7.0mmol/L
- Post meal - 5-9mmol/L - but do not often monitor this usually unless problem
- HbA1C - 48mmol/mol (6.5%) or lower
Targets for BP and BMI T1Dm
BP <140/90 or <130/80 if kidney disease
BMI 20-25
Dietary advice for T1DM
- No restrctions with diet unless overweight
- Calculate insulin based on carbohydrate in meal usually
DVLA for people with Diabetes Mellitus
- Inform DVLA if on insulin
- Blood sugar must be 5 to drive
- Long journeys monitor every 2 hrs
- If have hypo, can drive 45 minutes after blood sugar levels have normalised (NOT AFTER FOOD BUT AFTER NORMAL)
What is DAFNE?
- Dose adjustment for normal eating
- Flexible insulin regime
- Insulin dose calculated based on carbohydrate in food
Normal daily insulin requirements
- 0.5-0.6 units/kg/day
- Adolescents may need 0.8-1unit/kg
How do we calculate physiological replacement for insulin?
- Split daily requirement into 2
- Basal (background dose) and bolus (mealtime, quick acting) insulin
What is background insulin affected by?
- Weight
- Stress
- Exercise
- Alcohol
How is bolus insulin calculated?
According to carbohydrate intake and exercise
Types of insulin regimes
- Basal bolus - flexible
- Twice daily fixed - premixed injection, not flexible, for pts with fixed lifestyle
- Twice daily free mixing - NOT really used now, mix long acting and short acting yourself
- Continious subcut insulin infusion (CSII)
Two types of background insulin
- Isophane
- Analogue - peakless, less risk of hypos, safer as slowly released from muscle
Names of examples of background insulin - isophane
- Insulatard - like insulation, slow
- Humulin I
- Insuman (basal)
Names of analogue background insulin
- Levemir - 2x daily
- Lantus - 1x
- Tresiba - 1x
Two types of bolus (fast acting insulin)
- Soluble
- Analogue
Not much difference between the two
Soluble bolus insulin examples
- Actrapid - used in DKA
- Humulin S
- Insuman (rapid) - like superman, allrounder as there is slow and rapid version
Humulin S for SPEEDY
Analogue quick acting insulin examples
- Humalog
- Novorapid
- Apidra
Funny log speeding down a river
Mixed insulin examples - two types
- Isophane with soluble
- Biphasic analogue
Isophane with soluble examples of mixed insulin
- Humulin M3
- Insuman Comb 15, 25 or 50
Biphasic analogues mixed insulin examples
- Humalog mix 25 or 50
- Novomix 30
How to remember which insulins are mixed?
- Names have numbers in them
- Eg Insuman Comb 15 has 15% short acting insulin and the rest is LA
How to calculate insulin requirements for person - example 60kg
- Daily requirement = 60x 0.5
- = 30 units / day
- 30 units / 2 to split into basal and bolus
- 15 bolus is divided into 3 means - 5 units short acting per meal
- 15 units basal insulin
- So could have 15 units of Lantus (LA) bedtime with 5 units of Novorapid with each meal eg
- If background dose is high, can split into two and have twice daily
What do we do if basic calculation for requirements is not working and they are still getting high blood sugar readings?
- Check if background dose is the problem - ask when getting high readings, if at dinner, ask patient to not eat dinner and take glucose reading. If still high, is bacground insulin problem, fix this. If normal, is bolus problem and move to step 2.
- Bolus problem? - insulin often 1:1 ratio for carbohydrates ie 1 unit of insulin for 10g of carbohydrate, if not working and high BM, maybe change to 2 units per 10g insulin.
Dose adjustments
- Basal insulin - replaces bacground requirements and should produce stable glucose +/- 2mmol/L if patient eats NO CHO - use this to test background glucose
- Bolus insulin - 1 unit to eveery 10g CHO usually
- Insulin sensitivity - common starting point is 1 unit of insulin will drop blood glucose by 3mmol/L - DEPENDS on person
When do we need to adjust insulin regime?
If get high or low reading on 3 or more occasions
Principles of dose adjustment
- Change one thing at a time - work in 4 periods per dam 6am-12, 12-4pm, 4-8pm, 8-12am
- Work on patterns only - if 3 or more high/low readings
- Do not wait for pattern though if overnight or fasting hypoglycaemia
- Use CHO free meals to adjust basal insulin
- Adjust bedtime insulin to the fasting glucose in morning
- Do not correct post hypo high readings - get stuck in cycle
- If high post meal readings, increase insulin:carb ratio
- DAWN phenomena is better adressed with insulin pump
What is Dawn phenomena?
- Wake up with high blood sugar
- Hard to tell if this is from gradual increase during the night?
- Or if blood sugar dips in night and then hormones push blood sugar back up - if this is the case MORE INSULIN will make this WORSE
- Check which one it is using continious glucose monitoring
When to check ketones in T1DM in general
- If blood sugar >14 mmol/L
- Sick day rules
Sick day rules for insulin two scenarios
- Minor illness - ketones <1.5mmol/L
- Severe illness - ketones >1.5mmol/L
Minor illness ketones <1.5mmol/L rules
- Check glucose and ketones every 4hrs
- Dont stop taking normal insulin
- (Dr Omer said increase all insulin by 10%)
Severe illness ketones >1.5mmol/L rules
- Increase basal insulin by 30-40%
- Check glucose and ketones every 2 hrs
- Take 10% of total daily dose every 2hrs
- If ketones do not fall after 2-4hrs or if ketones >3mmol/L seek urgent medical help
Normal ketone levels
Is <0.3mmol/L
Indications for insulin pump therapy
- Under 12 if multiple daily injections are inappropriate
- Children over 12 and adults if cannot get HbA1C controlled without severe hypos or remains high despite carefully trying to manage
What is insulin pump therapy?
- Dose adjustment is similar but no long acting insulin
- Provides flexibility with temporary basal rate and altered wave boluses
What is continious glicose monitoring (CGM)?
- Small sensor that sits SC and measures interstitial fluid glucose
- Because of this there may be a 6-15 min lag behind blood glucose
Indications for CGM
All people with T1DM in England under and over 18
Newer emerging therapies
- Closed loop system - CGM speaks to pump and works as pancreas
- Immune modulators - cure?
- Islet cell transplant - these have only been done when pt needs kidney transplant also has risk outweighs benefit otherwise, are on more meds after transplant
