Management of Type 1 Diabetes Flashcards
What are the aims of management of type 1 diabetes?
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
What are the HLA associations of type 1 diabetes?
B8
DR3
DR4
DR3/4
What is the disease mechanism in autoimmune type 1 diabetes?
HLA class 2 association
Islet autoantibodies
Beta-cell antigen specific T cells found in human islets
What is the pathogenesis of type 1 DM?
Genetic tendancy + environment
Islet inflammation / lymphocyte infiltration / beta cell damage
Abnormal beta cell autoantigen arises
T cell recognition to autoantigens
Beta cell destruction
What antibodies does a diabetes screening test detect?
Anti GAD antibodies
(glutamate decarboxylase)
What other autoimmune diseases are associated with type 1 diabetes?
Hashimotots
Grave’s disease
Addisons
What is the evidence that type 1 diabetes is an autoimmune disorder?
Asssocaited with other immune conditions
Lymphocytic infiltration in islets
Islet cell antibodies
Insulin antbodies
Glutamate decarboxylase antibodies
Evidence of response to immunosuppressive therapy
What is the major risk associated with late diagnosis of diabetes?
Diabetic ketoacidosis
Leading to complications such as death and permanent neurological disability
What are the symptoms of diabetes?
Thirsty
Thinner
Tired
Toilet
Thrush and balanitits
A return to bedwetting or day-wetting in a previously dry child is a “red flag” symptom for diabetes
In children under five also think:
heavier than usual nappies
blurred vision
candidiasis (oral, vulval)
constipation
recurring skin infections
irritability, behaviour change
What should you do if you suspect diabetes?
Test immediately - finger prick capillary glucose test
If result is greater than 11 mmol/l then telephone urgently - make a same day appointment with a local specialist team
What are the symptoms of diabetic ketoacidosis?
Nausea and vomiting
Abdominal pain
Sweet smelling ‘ketotic breath’
Drowsiness
Rapid, deep ‘sighing’ respiration
Coma
What are the current strategies to support people with type 1 diabetes?
Education:
MDT - practice nurse, dietician, podiatrist, doctors
Structured: DIANE (diabetes insulin adjustment for normal eating)
Person with diabetes is main team member (self-management)
Probably organisiations such as DiabetesUK - (relevant information, puts people in touch with other diabetic patients, campaigns for better quality of care)
Nutrition and Lifestyle Management:
CHO counting
Exercise
Skills training:
Home blood glucose monitoring, injection technique, hypos
Insulin - Analogues, pens and pumps
What things do you have to check before injecting insulin?
Is it the correct insulin?
Is it the correct dose?
Is it the correct time?
Is it the correct formulation (syringe, pen or pump)?
Why does insulin need to be injected subcutaneously?
It is inactivated by the GI tract
What are sources of patient information?
Patient handbooks
Leaflets
My diabetes my way
Diabetes, think check act
Diabetes UK
What should you do if you have blood ketones and blood sugar level is 14 or above?
What are the different durations of action of insulin?
Rapid
Short
Intermediate
Long acting
Continuous
What are the current insulin regimens?
Twice daily
Rapid acting mixed with intermediate acting
Before breakfast (BB) and evening meal (BT)
Three times daily
Rapid acting mixed with intermediate acting BB
Rapid acting BT
Intermediate acting at bedtime BBed
Four times daily
Short acting BB BL BT
Intermediate BBed or long acting insulin at a fixed time once daily
What is the mechanisms of insulin control without the need for injections?
Continuous subcutaneous infusion
When do you have to make adjustments to your control of diabetes?
Lifestly
Exercise
Driving
Alcohol
Conception
Drugs
Holidays
Employment
What is the definition of hypoglycaemia?
Any episode of low blood glucose (below 4mmol/l) with or without symptoms and may occur in patients taking insulin or sulphonylureas
What are the reasons for hypoglycaemia?
Food
too little / wrong type
Activity
during /after
Insulin (or some Oral Hypoglycaemics)
dose, injection technique
What are the autonomic symptoms of hypoglycaemia?
Sweating
Palpitations
Shaking
Hunger
What are the neuroglycopenic symptoms of hypoglycaemia?
Confusion
Drowsiness
Odd behaviour
SPeech difficulty
Incoordination
What are the general malaise symptoms of hypo?
Headache
Nausea
When do you experience loss of warnings of hypoglycaemia?
Recurrent severe hypoglycaemia
Long duration of disease
Over tight control
Loss of sweating / tremor
What are the complications of hypoglycaemia?
Coma
Hemiparesis - neurological defecits can become permanent if hypoglycaemia is prolonged
Seizures
What is the treatment of hypoglycaemia?
Simple CHO if able
If nill by mouth, take im glucagon or glucogel / dextrogel
If the patient is nill by mouth and is in hospital - take glucose IV or glucose/dextrose IV mixture
Follow up with long acting CHO
What can be found in a hypobox?
Fruit juice
Dextro energy
Glucogel
50% Dextrose
Hypo management protocol
What is important to establish after a hypo has happened?
Why the hypo happened?
Wrong regimen; dose/insulin
Control and monitoring
Hypoglycaemia unawareness
Discuss driving / work etc
Food/activity/insulin
Injection sites
How can you avoid hypos?
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 are the limitations to driving your car if you have diabetes?
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 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 guidance is given to those with diabetes when they become ill?
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 causes fiabetic ketoacidosis?
Usualy too little insulin causing fat breakdown
Associated with high blood sugar
Fluid deplete
May be caused by infection / severe stress / insulin omission
What are the counter regulatory hormones that increase when insulin levels are low?
Glucagon - increases lipolysis - ketacidosis
Cortisol - decreases glucose utilisation - hyperglycaemia
Growth hormone - increases proteolysis and therefore increases gluconeogenesis
Catecholamines - increase glycogenolysis
What is treatment for starvation ketoacidosis and normal ketoacidosis
Starvation: Carbohydrate to eat or drink - keep non-CHO fluids up as well
DKA: Give extra dose of fast acting insulin - dose is 1/6 of the daily intake
What are the initial investigatinos for DKA?
Rapid A,B,C
i.v. access
Vital signs
Clinical assessment
Full clinical examination
THEN
INVESTIGATIONS
Glucose
Venous blood gas
Urinalysis/Blood ketones
U+E, FBC
Culture blood/urine
ECG + cardiac monitor
Consider CXR
What are complications associated with 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 - there is a reduction in the oncotic pressure and so there is accumulation of water in the lungs
Treatment of DKA 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 do we facillitate long-term health and well-being?
Optimal blood glucose control (HbA1c)
to reduce microvascular disease e.g. retinopathy
to improve pregnancy outcome
Optimal blood pressure control
to reduce nephropathy
Manage cardiovascular risk factors
e.g. smoking, cholesterol
Screen for early detection of complications
feet, eyes & kidneys
What piece of technology has the potantial to act like a sensor augmented pump?
Sensor augmented pumps
Full integration of insulin delivery with real time blood glucose monitoring - closed loop
What is the structured education programme associated with type 1 diabetes?
STEP
Scottish Type 1 Education Programme
Structured education is always indicated in the care plan for diabetes patients
