Management of Type I DM

Question 1

What sort of educational strategies can be employed to support people with Type I DM?

Answer 1

Team based - DSN, practice nurse, dietician, podiatrist, doctors
Structured education - dose adjustment for normal eating etc

Question 2

Why can insulin not be administered orally?

Answer 2

IT is a polypeptide which is deactivated by the GI tract

Question 3

How long before eating is insulin given?

Answer 3

30 minutes

Question 4

Do all insulins act over the same period of time?

Answer 4

No, they may be rapid, short, intermediate or long acting

Question 5

What things should be taken into account when selecting the most appropriate therapy for a DM patient?

Answer 5

Patient choice
Lifestyle
Device

Question 6

Give some examples of insulin administration routines

Answer 6

Basal bolus - suitable for flexible lifestyle
Better for shift workers
Basal long acting to cover background and rapid or short acting to cover CHO at meal times

Twice daily mix - works best if lifestyle is fixed with regular meals
Minimises injections
Rapid acting mixed with intermediate acting

Question 7

What is a continuous subcutaneous insulin infusion (CSII)

Answer 7

An insulin pump which secretes insulin subcutaneously via a cannula. Provide a continuous infusion with mealtime boluses

Question 8

What adjustments can/may have to be made by the patient to help with type I treatment?

Answer 8

Lifestyle
Exercise
Driving 
Alcohol
Conception 
Drugs
Holidays
Employment

Question 9

What is a severe complication of hyperglycaemia?

Answer 9

Diabetic ketoacidosis

Question 10

What are hypo and hyperglycaemia examples of?

Answer 10

Acute metabolic upsets

Question 11

What must the BG level be for a diagnosis of hypoglycaemia? Are symptoms necessary?

Question 12

Give some reasons for hypoglycaemia

Answer 12

Food - too little/wrong type
Activity - during/after
Insulin - dose/injection technique
Alcohol

Question 13

What can an inability by the patient to perceive the normal warning signs of hypoglycaemia be associated with?

Answer 13

Recurrent severe hypoglycaemia
Long duration of the disease
Overly tight control
Loss of sweating/tremor

Question 14

How should hypoglycaemia be treated?

Answer 14

BG levels must be returned to safe levels and all patients should be advised to carry carbohydrates with them

Question 15

In what case should glucagon treatment for hypoglycaemia be avoided?

Answer 15

Where the hypoglycaemia is caused by sulphonylureas

Question 16

What should be addressed after a patient has recovered from a hypoglycaemic attack?

Answer 16

Wrong regimen? - dose/insulin
Control and monitoring
Hypo unawareness
Driving/work
Food/activity/insulin
Injection sites

Question 17

What recommendations should be made in respect to driving and hypoglycaemia?

Answer 17

Patients should be advised to check their BG within 2 hours of driving and should always carry carbohydrate with them
There must be no more than 1 severe episode in a year

Question 18

What is diabetic ketoacidosis?

Answer 18

Results from the breakdown of fat because of a lack of insulin. The lack of insulin prevent the cells from up taking glucose and therefore the body has to turn to fat stores to provide energy - ‘starvation in the midst of plenty’
It is usually accompanied by a high level of plasma glucose
May be called by infection/severe stress

Question 19

What three excesses combine in diabetic ketoacidosis?

Answer 19

Glucose
Ketones
Acidosis

Question 20

What are some symptoms of diabetic ketoacidosis?

Answer 20

Dehydration
Thirst
Abdominal pain
Acetone on breath
Nausea/vomiting
Tachycardia and low BP

Question 21

What are the principles of management of DKA in HDU?

Answer 21

Measure BG/U’s & E’s/ketones/bicarbonate/venous blood gases

GIVE IV saline

Give IV insulin

Give IV potassium in saline

May need antibiotics

May need LMWH, NG tube

Mortality rate 2%

Question 22

What are the basic treatment aims in facilitating the long term health and wellbeing of DM patients?

Answer 22

Optional BG control

• reduces microvascular disease e.g. retinopathy
• improves pregnancy outcome

Optimal BP control
- reduce nephropathy

Manage cardiovascular risk factors e.g. smoking, LDLs

Screen for early detection of complications - feet, eyes, kidneys

Question 23

What is the goal in terms of designing the optimum insulin regime for the patient?

Answer 23

To as closely as possible match the normal physiological profile of insulin seen in the non-diabetic individual

Question 24

Describe sensor augmented insulin pumps

Answer 24

Pumps the provide full integration of insulin delivery with real time BG monitoring - closed loop
Potential to act like an artificial pancreas

Question 25

Outline whole pancreas transplant for DM patients

Answer 25

Highly limited by donors
Often in combination with kidney transplant
Requires immunosupression
Usually curative (DM) but very high risk surgery

Question 26

What is the main indication for islet cell transplantation? Outline the treatment

Answer 26

Severe hypoglycaemia with unawareness
Often requires multiple transplants to achieve insulin dependence
Limited by donor availability
Requires lifelong immunosupression

Question 27

What are some potential future methods of preventing DMT1?

Answer 27

Vaccination to prevent autoimmune destruction of Beta cells

Treatment with oral or injected insulin before DMT1 develops