T1 Diabetes Flashcards
What is T1DM?
- Autoimmune metabolic disorder resulting in hyperglycaemia due to absolute insulin deficiency.
- Two peak ages of onset - 5-7yrs, OR just before or at the onset of puberty especially during winter.
Aetiology of T1DM?
1) Genetics
2) FH
3) Molecular mimicry - environmental trigger and antigen on beta-cell surface.
PPx of T1DM?
- Genetically predisposed individuals - autoimmune process which damages pancreatic beta-cells leading to insulin deficiency - eventually no insulin.
- This results in increased glucagon - which will cause gluconeogenesis - increased ketones and hyperglycaemia.
Actions of insulin?
- Stimulates conversion of glucose to glycogen.
- Stimulates glucose uptake from blood.
- Reduces blood sugar
Clinical presentation of T1DM?
TRIAD FOR FEW WEEKS: POLYURIA, POLYDIPSIA, WEIGHT LOSS.
- Young children may develop secondary nocturnal enuresis.
- Rare cases - DKA
Diagnosis of T1DM?
1) Random blood glucose >11.1mmol/L OR
2) Fasting blood glucose >7mmol/L OR
3) Oral glucose test (rarely needed)
- Raised HbA1c helpful
- SCREEN FOR ASSOCIATED AUTOIMMUNE DISEASE - thyroid/coeliac
- T2DM suspected if FH, subcontinental children (Indian etc), and in severely obese children with signs of insulin resistance (acanthuses nigricans - dark skin on neck/armpits)
Treatment of T1DM?
1) MDT management and intensive educational programme for patents and child.
2) Insulin therapy:
- Rapid acting - Insulin aspart (fast onset and short duration)
- Long acting - Insulin Detemir
- Short acting - Actrapid (30-60min onset, 8hr duration)
3) Basal-bolus regime:
- Most children are started on an insulin pump or 3/4 times/day injection regimen with:
- Insulin aspart (rapid-acting) - before each meal and snack
- Insulin detemir - late evenings (cover for night) and/or before breakfast (insulin background for day)
Treatment NOTE for T1DM:
- Shortly after presentation when some pancreatic function is preserved - insulin requirements become minimal as remaining beta cells respond well to treatment and produce insulin. This is known as HONEYMOON PERIOD - it will go once beta cells are destroyed.
- Insulin must be continued during periods of illness, vigorous exercise and prolonged exercise requires reduction of insulin dose and increase in dietary intake.
Delivery of insulin?
- Continuous infusion of rapid-acting insulin from a pump.
- Injections using a variety of syringes and needles - into subcutaneous tissue of the upper arm, buttocks, lateral and anterior thigh, and abdomen, rotation of injection sites essential to prevent lipohypertrophy.
- Skin should be pinched up and insulin injected at a 45 degree angle.
Dietary regimen in T1DM?
- Diet and insulin regimen need to be matched
- Aim to optimise metabolic control and maintain normal growth
- Healthy diet with high complex carbohydrate and relatively low fat content
- Diet should be high in fibre - sustained release of glucose as opposed to refined carbohydrates (rapid swings in glucose levels)
Blood glucose monitoring/hypoglycaemia risk:
- REGULAR MONITORING REQUIRED
- Enables insulin and diet adjustments
- Children aim for 4-10mmol/L
- Adolescents aim for 4-8mmol/L
Hypoglycaemia: Unlikely to die from hypos, after period of low blood sugar glucagon will stimulate gluconeogenesis - once patient wakes up they will have normal sugars, main danger is decisions and behaviours during hypos.
Hypoglycaemia presentation?
1) Hungry, irritable, nausea, sweaty, tummy ache, pallor
2) Dizzy, decreased concentration, headache, drowsy, visual problems
Treating hypos?
- Mild: check glucose to confirm, 3-5 glucose tablets OR 60-100mls lucozade OR 100-200mls fizzy drink. Wait 10 mins, repeat if no improvement, check sugars after 15 mins.
- Moderate: If child not responding might be easier to give ORAL GLUCOSE GEL (quickly absorbed from buccal mucosa) - wait 10 mins and repeat if NO improvement, check sugars after 15 mins.
- Severe: DO NOT GIVE ANYTHING BY MOUTH, SC OR IM GLUCAGON (0.5mg in <5yrs, or 1mg in >5yrs), wait 10mins then when conscious give sugar.
AVOID giving foods containing fat - (chocolate e.g.) as this results in slower release of glucose.
Long term management aims of T1DM:
- Maintain normal childhood
- Normal growth and development
- Prevent long term complications
- Maintain HbA1C of 48 or less
Long term complications of T1DM?
- Reduction in life expectancy (23yrs)
- 2/3 times more likely of early death
- Delay in puberty
- Obesity (common in women - reduce insulin dose towards end of puberty)
- Renal disease (microalbuminaemia early sign)
- Hypertension - monitor yearly
- Retinopathy (monitor annually from puberty)
- Foot care - check for signs of injury/infection due to peripheral neuropathy development
