Management of type 1 DM Flashcards by Heo Mun Ho

Describe the management of a patient with a new diagnosis of Type I Diabetes (6)

Encourage a self management mindset
Correct any acute metabolic upsets at diagnosis
Education about diet (carbohydrate) and lifestyle
Insulin – administration, technique and dose
How to do home blood sugar and ketone testing
How to manage a hypo

How well did you know this?

Not at all

Perfectly

Patient education resources on DM

STEP (Scottish type 1 educational programme)

DIANE

Online

diabetes UK
My Diabetes My Way

Group education session
-course to help understand + manage condition

How well did you know this?

Not at all

Perfectly

Strategies to support type 1 diabetics (3)

Patient education on their condition

from MDT
structured techniques to control BG

Teaching them to manage lifestyle

carbohydrate counting
exercise

Skills training

home BG monitoring
injection technique
how to deal with hypos

How well did you know this?

Not at all

Perfectly

What is DIANE

DiabetesInsulin Adjustment for Normal Eating
-a way of managing Type 1 diabetes and provides people with the skillsnecessary to estimate the carbohydrate in each meal and to inject the right dose of insulin

How well did you know this?

Not at all

Perfectly

Outline the principles of insulin therapy (4)

Right insulin - check the name

Right dose

Right time - morning/with food

Right administration - syringe/pen/pump

How well did you know this?

Not at all

Perfectly

Why can’t therapeutic insulin be taken orally

As it’s a peptide hormone, it would be denatured by the digestive processes before it could enter the blood

How well did you know this?

Not at all

Perfectly

How is insulin administered (2)

Subsutaneously -usually

IV - if acutely ill

How well did you know this?

Not at all

Perfectly

Modified v unmodified insulin

Modified
-those that are more readily absorbed from the injection site and therefore act faster than natural insulin injected subcutaneously, intended to supply the bolus level of insulin needed at mealtime (prandial insulin)

Unmodified
-those that are released slowly over a period of between 8 and 24 hours, intended to supply the basal level of insulin during the day and particularly at night (basal insulin)

How well did you know this?

Not at all

Perfectly

Basal v bolus insulin

Basal insulin, also referred to as background insulin, regulates your glucose levels in between meals, i.e. long acting insulin

Bolus insulin is extra insulin needed to manage your glucose levels after a meal, i.e. rapid or short acting insulin

How well did you know this?

Not at all

Perfectly

When unmodified insulin is injected, what does it have a tendency to do in the subcutaneous tissue and so what implication does this have on the time it has to be injected

the insulin molecules have a tendency to self-associate into hexamers which is not an absorpable form through the capillary bed

hexamers need to dissociate into monomers first before they can be absorbed

so unmodified insulin needs to be injected at least 30 mins before eating

How well did you know this?

Not at all

Perfectly

4 types of insulin analogues

Rapid acting
Short acting
Intermediate acting
Long acting

How well did you know this?

Not at all

Perfectly

If someone is on 1 unit insulin per 10g CHO, how many units of insulin is needed for a banana (typically containing 30g CHO)

3 units

How well did you know this?

Not at all

Perfectly

Why is it important to monitor BG levels at home (list a few reasons)

To adjust insulin dose if needed

To see if it’s suitable to drive (5mmol/l to drive)

How well did you know this?

Not at all

Perfectly

DKA occurs when blood ketones level are what or above

3mmol/l

How well did you know this?

Not at all

Perfectly

Treatment of DKA (3)

IV saline
IV potassium added to saline
IV soluble insulin (i.e. short acting)

ketone levels should decrease after 2hrs

How well did you know this?

Not at all

Perfectly

Name some examples of rapid acting insulin analogues

Insulin lispro (brand name - humalog)

Insulin aspart (brand name - novolog/novorapid)

How well did you know this?

Not at all

Perfectly

Name some examples of short acting insulin (aka regular or soluble insulin) analogues

Brand names:

Humulin R, S
Actarapid

How well did you know this?

Not at all

Perfectly

Name an example of intermediate acting analogues

hypurin isophane

intermediate acting insulins aka isoprene insulins or Neutral Protamine Hagedorn insulins

How well did you know this?

Not at all

Perfectly

Name some examples of long acting analogues (3)

Insulin glargine (brand name - Lantus)
Insulin detemir (brand name -  levemir)
Insulin degludec (brand name - tresiba)

How well did you know this?

Not at all

Perfectly

Name another way of administering insulin other than injection

Continuous subcutaneous insulin infusion (i.e. insulin pump)

Intermediate acting insulin is usually given with what other insulin

short acting

Mode of action of rapid acting insulins (e.g. humalog, novorapid)

when is it given
how long does it take to work after injecting
when does its activity peak
how many hours overall does it last

immediately before a meal

onset of about 15 minutes after injection

peaks about one to two hours after injection

lasts up to five hours

Mode of action of short acting insulins (e.g. actrapid, humullin R)

when is it given
how long does it take to work after injecting
when does its activity peak
how many hours overall does it last

Before meals

Onset of between 30 minutes and an hour

Peaks at 2-4hrs

lasts for approximately 8hrs

Mode of action of intermediate acting insulins (e.g. actrapid, humullin R)

how long does it take to work after injecting
when does its activity peak
how many hours overall does it last

onset of about two hours after injection

peaks in first 8 hours

lasts between 18 and 24 hours

Mode of action of long acting insulins (e.g. lantus, levemir) - how long does it take to work after injecting - when does its activity peak - how many hours overall does it last

Usually once or twice daily Consistent activity from within an hour after injecting up to 24 hours, no peak activity

How does continuous subcutaneous insulin infusion (insulin pump) work

Regular or continuous amount of insulin (usually in the form of a rapid-acting insulin analogue or soluble insulin), delivered by a programmable pump and insulin storage reservoir via a subcutaneous needle or cannula can increase/decrease dose manually when needed

Recommended first line insulin regimen for type 1 diabetics

Multiple daily injection basal-bolus insulin - rapid acting bolus insulin before meals AND - twice-daily long-acting basal insulin

List the different insulin regimens (3)

Multiple daily injection basal-bolus insulin (one or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin; alongside multiple bolus injections of short-acting or rapid acting insulin before meals) Mixed (biphasic) regimen (one/two/three insulin injections per day of short-acting mixed with intermediate-acting insulin) Continuous subcutaneous insulin infusion

Hypoglycaemia (an acute metabolic upset in DM) refers to an episode of BG

low blood glucose (<4mmol/l) with or without symptoms

Causes of a hypo (5)

not having enough carbohydrate at your last meal excessive exercise without having extra carbohydrate or without reducing your insulin dose (if you take insulin) taking more insulin (or oral hypoglycaemics) than needed inappropriate timing of insulin therapy drinking alcohol on an empty stomach

Those at risk of hypoglycaemia (4)

Cognitively impaired Very young/very old Those who have to tightly control BG Those with malabsorptive disorders, e.g. crohn's, coeliac

Do most isolated hypo episodes recover spontaneously in type 1 diabetics

Yes, most recover even if untreated and not associated with permanent damage

Symptoms/signs of a hypo (9)

- feeling shaky/tremor - sweating - feeling hungry - palpitations - confused/drowsy - anxiety/irritability - poor concentration - headache - nausea

Medical issues that puts you at risk of a hypo (5)

``` Tight glycaemic control Previous history of severe hypo Long duration of DM Poor injection technique Severe liver/kidney dysfunction ```

Lifestyle issues that puts you at risk of a hypo (4) *referring to anyone in general, not just diabetics

Increased exercise than usual Increasing age Alcohol Breast feeding

All patients taking insulin or sulphonylureas are advised to always carry what with them incase of what

Carbohydrate, e.g. fruit juice In case of a hypo

Complications of a severe hypo untreated (3)

Coma Hemiparesis Seizures

Emergency treatment of an episode of MILD hypoglycaemia (conscious, orientated, able to swallow)

15-20g of quick acting carbohydrate - 5 dextrosol tablets OR - 150 to 200ml of pure fruit juice

Emergency treatment of an episode of MODERATE hypoglycaemia (conscious, able to swallow but confused/ disorientated)

If co-operative, treat like mild hypo so 15-20g of quick acting carbohydrate (150-200ml fruit juice) If not co-operative but can swallow then -give 1.5-2 tubes of glucose gel squeezed into mouth between teeth and gums

Emergency treatment of an episode of SEVERE hypoglycaemia (unconscious or very aggressive)

Check ABC IV glucose over 10-15 mins

If unable to take oral carbohydrate during a hypo and you're out of hospital, what should you take

1mg intramuscular glucagon or glucose gel

If in hospital and go into a hypo where you're unable to take oral carbohydrate, what should be given

IV glucose/ dextrose (same thing)

After emergency treatment is given for a hypo and BG has raised to above 4, what follow up treatment should be given

20g of long acting carbohydrate, e.g. biscuits, bread, milk

What does a hypo box contain (emergency treatment of a hypo) (4)

Fruit juice 200ml Glucogel (glucose gel) Dextro energy (dextrose tablets) IV glucose

Ways to avoid a hypo in insulin treated DM (5)

``` Adequate BG monitoring Rotate and check injection sites Count carbohydrate intake Consider change in insulin regimen Alter insulin before and after exercise ```

BG level needed to drive

5mmol/l

What are the 'sick day rules' for an insulin treated diabetic who falls acutely ill (5)

NEVER stop insulin Increase/decrease insulin dose according to BG More frequency checks of BG Check urine/blood for ketones Maintain CHO intake by fluids if can't eat, e.g. soup, milk, fruit juice with sugar free drinks in between

What stores are broken down for energy when can't get glucose into cells due to shortage of insulin

Fat, which releases free fatty acids that the liver converts to ketones

In DKA, serum potassium is usually high due to extracellular shift of potassium but why is IV potassium given as treatment

Total body potassium concentration is low due to increased diuresis