Management of Type 1 Diabetes Mellitus Flashcards
What are the aims of diabetic management?
Prompt diagnosis
Encouragement of appropriate self management skill set
Correction of acute metabolic upsets at diagnosis and after
Facilitate long term health and well being
What symptoms should be considered to allow for early diagnosis in diabetes?
Toilet (polyuria)
Thirsty (polydipsia)
Tired (fatigue)
Thinner (weight loss)
What are some categories of strategies to support people with type 1 diabetes?
Education
Nutrition and lifestyle management
Skills training
Insulin
What are some examples of structured education for diabetes?
STEP
HEIDI
DAFNE
What are some skills training for people with diabetes?
Home blood glucose monitoring
Injection technique
Managing hypos
Sick day rules
What should be checked before administered insulin needle?
Right insulin (check name)
Right dose
Right time
Right way
What is insulin?
Polypeptide which is inactivated by GI tract so needs to be injected subcutaneously or IV
Why does insulin need to be injected subcutaneously?
It is inactivated by the GI tract
What happens to insulin once it is injected into subcutaneous fat?
Self-associate into hexamers
Which needs to dissociate into monomers before absorption through capillary bed
Why should insulin be injected 30 minutes before a meal?
Needs to dissociate into monomers
How long before a meal should insulin be injected?
30 minutes before, unless it is a fast acting analogue which can be imjected just before eating
What are some examples of fast-acting insulin analogues?
Insulin lispro
Insulin aspart
What are some examples of long acting insulin analogues?
Insulin glargine
Determir insulin
What are some ways of educating people about their diabetes?
What does the amount of insulin need to be adjusted for?
Eating and activities
What do sick day rules refer to?
Guidance to keep blood sugar levels as close to normal as possible when suffering from being ill
What is the guidance for blood ketones levels?
Insulins have different durations of action, what are some categories?
Rapid acting
Short acting
Intermediate acting
Long acting
Continuous subcutaneous insulin infusion
What are examples of rapid acting insulin?
Insulin lispro
Insulin aspart
What are examples of short acting insulin?
Soluble insulin
Actrapid
Humulin S
What are examples of intermediate acting insulin?
Isophane insulin
Insulatard
Humulinl
What are examples of long acting insulin?
Glargine
Determir
Degludec
What does CSII stand for?
Continuous subcutaneous insulin infusion
What are some things that can change injection technique?
Needle size
Location
Rotation
Technique
What are some current insulin regiments?
Twice daily
Three times daily
Four times daily
For rapid (short) acting inuslin, 1 unit covers how much carbs?
1 unit per 10g of carbs
What insulin is used for twice daily regimen?
Rapid acting mixed with intermediate acting
Before breakfast and evening meal
What insulin is used for three times daily regimen?
Rapid acting mixed with intermediate acting before breakfast
Rapid acting before before dinner
Intermediate acting at bedtime
What insulin is used for 4 times daily regimen?
Short acting before breakfast, before lunch and before dinner
Intermediate acting before bed or long acting insulin at a fixed time once daily
What do adjustments to insulin need to be made for?
Lifestyle
Exercise
Driving
Alcohol
Conception
Drugs
Holidays
Employment
What are examples of diabetic emergencies?
Hypoglycamia
Hyperglycaemia (and diabetic ketoacidosis)
What is 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 possible reasons for hypoglycaemia?
Imbalance between food (too little/wrong type), activity and insulin
What are some examples of causes of hypoglycaemia?
What are some at risk groups of hypoglycaemia?
What are some symptoms of hypoglycaemia?
What is the 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 all patients treated with insulin or sulphonylureas for diabetes carry with them incase they suffer from a hypo?
Carbohydrates
What can happen if hypoglycaemia is prolonged?
Permanent neurological damage, coma or death
When are patients considered to have mild hypoglycaemia?
Conscious, orientated and able to swallow and not fasting
What is the treatment for mild hypoglycaemia?
Give 15-20g of fast acting carbohydrate
When are patients considered to have moderate hypoglycaemia?
Conscious and able to swallow, but confused, disorientated or aggressive
What is the treatment for moderate hypoglycaemia?
1.5-2 tubes of glucose gel
When are patients considered to have severe hypoglycaemia?
Patient unconscious/fitting, very aggressive
What is the treatment for severe hypoglycaemia?
Check ABC
Stop IV insulin, give IV glucose over 10 to 15 minutes as:
- 75ml 20% glucose or 150ml 10% glucose or 1mg glucagon IM once only
What should be done after a patient has recovered from hypoglycaemia?
Determine what caused the hypoglycaemia
What are some examples of things that can lead to hypoglycaemia?
Wrong regimen (dose/insulin)
Control and monitoring
Hypoglycaemia unawareness
Driving/work
Food/activity
Injection sites
What can be done to avoid hypoglycaemia?
Blood glucose monitoring
Rotate and check injection sites
Review snacks and diet (carb counting)
Consider a change in insulin regimen
Avoid low glucose
Alter insulin before and after exercise
What is the advice for driving and diabetes?
Check blood glucose before/within 2 hours of driving and during long car journeys should always carry carbohydrates
What are some risk factors of diabetic ketoacidosis (DKA)?
What is the clinical presentation of diabetic ketoacidosis (DKA)?
What does DKA stand for?
Diabetic ketoacidosis
What investigations are done for DKA?
What are some possible complications of DKA?
Hyper and hypokalaemia
Hypoglycaemia (arrhythmias, acute brain injury)
Cerebral oedema
Aspiration pneumonia
Arterial and venous thromboembolism
ARDS
What is the treatment of DKA?
Follow local DKA protocol:
- measure glucose/U and Es/ketones/bicarbonate/arterial blood gas
- give IV saline (5L over 24 hours)
- give IV potassium in saline
- may need antibiotics
- consider heparin
What are some sick day rules?
Never stop insulin
Increase/adjust insulin dose according to blood glucose
Perform more frequent blood glucose checks
Check urine or blood for ketones
Carbs intake must be maintained by fluids (such as fruit juice) if unable to tolerate food
How is long term health and well being facilitated in diabetes?
Optimal blood glucose control (HbA1c)
Optimal blood pressure control
Manage cardiovascular risk factors
Screen for early detection of complications
What are some things regarding future development and diabetes?
Technology that automatically administers insulin in response to blood glucose and meals
Further optimisation of subcutaneous insulin delivery
Donor transplantation (Islets or pancreas)
Other cell-based therapies
Prevention
