Management of type 1 diabetes

Question 1

List some of the help sites/databases for type 1 DM patients and doctors

Answer 1

SIGN 116, SCI, my diabetes my way, DIANE, STEP, SIGN 154, diabetes UK/scotland

Question 2

What gene associations are linked to autoimmune diseases?

Answer 2

HLA

Question 3

What antibodies do we send away for type 1 DM to prove autoimmunity?

Answer 3

anti GAD - glutamate carboxylase

Question 4

What is the STEP programme and what is some information in which it provides?

Answer 4

Scottish type 1 educational programme
HbA1c - aim <58mmol/l- 7 day average
Blood glucose control

Question 5

How is type 1 DM diagnosed by symptoms and why is a prompt diagnosis important?

Answer 5

4 T's 
test - capillary glucose >11mmol/l
telephone urgently 
prevent DKA and death 
red flag = return to bed wetting

Question 6

How are people with type 1 DM supported? (4)

Answer 6

Education - team based eg DSN, practice nurse, dietitan and structured education eg DIANE
Nutrition and lifestyle management - CHO counting
skills training eg injection technique, BG monitoring, hypos
insulin -analogues, pens, pumps

Question 7

4 things you need to check before you inject insulin

Answer 7

right type
right dose
right time
right way

Question 8

Why is insulin given subcutaneous or IV?

Answer 8

polypeptide inactivated by GI tract

Question 9

What does insulin do in subcutaneous fat?

Answer 9

dissociate to hexamers then monomers and absorbed through capillary bed

Question 10

How long before soluble and rapid acting analogue insulin given before a meal?

Answer 10

soluble = 30 mins before due to needing to be converted and absorbed
rapid - do not dissociate and given just before eating

Question 11

How do you know how much insulin to take?

Answer 11

CHO in food

Question 12

Educations opportunities and resources for patients

Answer 12

leaflets, handbooks, DIANE, my diabetes my way, think check act, pregnancy, websites

Question 13

What is DIANE?

Answer 13

diabetic insulin adjustment for nutritional eating course

food exercise, travel, sick day rules and hypos

Question 14

What to do if you test and ketones levels slightly high?

Answer 14

give extra dose of insulin and recheck in 2 hours

Question 15

5 different types of insulin

Answer 15

rapid acting 
short acting 
intermediate acting 
long acting 
continuous subcutaneous insulin infusion (CSII)

Question 16

4 things important with insulin injection techniques

Answer 16

needle size
location
technique
rotation

Question 17

Normal insulin regimens

Answer 17

rapid acting and basal long acting bolus

2 daily, 3 daily, 4 daily

Question 18

What is continuous subcutaneous insulin infusion (CSII)?

Answer 18

insulin pump therapy with fast acting insulin to give basal insulin constantly and may need more in exercise
need to count CHO

Question 19

8 things which may require insulin adjustments

Answer 19

alcohol 
driving 
lifestyle 
conception 
drugs 
exercise 
holidays 
job

Question 20

What [BG] level is a hypo?

Answer 20

<4 mmol/l

Question 21

What is a hypo due to?

Answer 21

imbalance with:
food eg too little/wrong type
exercise - during or after
insulin egg OHA, technique, dose

Question 22

What groups are at risk of hypos?

Answer 22

extreme tight glycaemic control 
extremes of age 
malabsorption 
pancreactomy 
coeliac disease 
renal failure 
abrupt steroid withdrawl
pregnancy

Question 23

3 components of Edinburgh hypoglycaemia scale

Answer 23

autonomic
general malaise
neuroglycopenic

Question 24

Autonomic - Edinburgh hypo scale

Answer 24

sweating
palpitations
shaking
hunger

Question 25

Neuroglycopenic - Edinburgh hypo scale

Answer 25

``` confusion drowsiness odd behaviour speech difficulty incoordination ```

Question 26

General malaise - Edinburgh hypo scale

Answer 26

headache | nausea

Question 27

4 things the inability to perceive normal warning signs of hypos are associated with

Answer 27

loss of sweating/tremor overtight control long duration of disease recurrent severe hypos

Question 28

What should all patients on insulin or sulphonylureas carry?

Answer 28

CHO

Question 29

What can hypos cause?

Answer 29

coma, hemiparesis, brain damage

Question 30

Treatment of hypos

Answer 30

15-20g simple CHO eg dextrose, fruit juice I'm glucagon IV glucose long acting CHO

Question 31

What is found in a hypobox?

Answer 31

fruit juice, dextro energy, glucogel, 50% dextrose. hypo management protocol

Question 32

Cause of hypo after patient recovered - what causes hypos?

Answer 32

``` unaware of hypos wrong insulin regimen driving, work control and monitoring food/activity/insulin injection sites ```

Question 33

How to avoid hypos in insulin treated diabetes

Answer 33

``` review snacks avoid low glucose [BG] monitoring rotate and check injection sites change insulin regimen eg CSII alter insulin before and after exercise ```

Question 34

What are the rules with driving and diabetes/hypos?

Answer 34

insulin 2 hours before and during long journeys CHO in car no education = no driving no more than 1 hypo in past year

Question 35

Risk factors of hypos

Answer 35

infection, known type 1 DM, inadequate insulin

Question 36

Sick day rules

Answer 36

do not stop insulin and monitor [BG] regularly CHO maintained by fluids increase and adjust dose urine or blood for ketones

Question 37

How does DKA occur?

Answer 37

too little insulin and fat breakdown

Question 38

Symptoms of DKA

Answer 38

``` dehydrated tachycardia low bp ketones on breath abdo pain thirsty ```

Question 39

Investigations of DKA

Answer 39

``` glucose venous blood gas U+E, FBC culture blood and urine ECG, CXR urinalysis ```

Question 40

complications of DKA

Answer 40

``` hyper and hypokalaemia cerebral oedema - children aspiration pneumonia thromboembolism ARDS ```

Question 41

How to treat DKA in hospital

Answer 41

IV saline, IV insulin, IV potassium antibiotics heparin, NG tube

Question 42

Future diabetes type 1 treatment?

Answer 42

Sensor augmented pump - closed loop donor transplantation prevention