Treatment of Type 1 Diabetes Flashcards
Why is insulin life-saving in type 1 DM?
Prevents Diabetic ketoacidosis (DKA)
What is the long-term goal of insulin treatment?
Prevent chronic complications of poor glycaemic control
What do the current guidelines recommend for HbA1c?
< 18 years: < 59mmol/mol
>18 years: < 53mmol/mol
What are the current guidelines regarding exercise in T1DM?
150 minutes of moderate-intense execise weekly
Spread over 3 days, no more than 2 consecutive days without
A carbohydrate snack should be given before exercise if blood glucose levels are below which point?
< 5.6 mmol/l
After diagnosis, when should insulin therapy be started?
ASAP
How does insulin administration aim to mimic physiological insulin release?
Combining a basal insulin with bolus dosing at mealtimes
Give 3 examples of long acting insulins
- Glargine
- Detemir
- Degludec
Which intermediate-acting insulin is often used for basal dosing?
NPH
(isophane insulin)
Give 3 examples of rapid acting insulins
- Lispro
- Aspart
- Glulisine
What is a frequent cause of nocturnal hypoglycaemia?
Dinnertime NPH (or other intermediate-long acting insulin)
Which other coexistant conditions contribute to more unstable diabetes?
- Coeliac disease
- Thyroid disease
- Addison’s disease
- Psychosocial stress
If there is a concern for noctural hypoglycaemia, what should a patient do?
Take a 3am blood glucose test
Why are both alcohol and exercise potentially dangerous in T1DM?
They can cause delayed hypoglycaemia
(by up to 24 hours)
In patients with uncontrolled postprandial hyperglycaemia, which adjunctive treatment can be used?
Pramlintide
What is pramlintide?
Amylin analogue
What is amylin and what is its physiological function?
A hormone secreted with insulin normally (not at all in T1DM) which promotes the acute 1st phase of the insulin response by:
- Slowing gastric emptying
- Promoting satiety
- Inhibiting inappropriate glucagon secretion
What is the recommened HbA1c level before conception?
< 48 mmol/mol
The target during pregancy is 43 mmol/mol
Why should women be evaluated before pregancy?
- Poor glycaemic control may damage foetus
- Retinopathy, nephropathy, neuropathy and CVD in the mother may worsen in pregnancy if it is present
Which condition is more common in pregnant women with diabetes?
Pre-eclampsia
Women with diabetes are at increased risk of having a baby with which type of defect?
Neural tube defects
(spina bifida, anencephaly etc.)
Which treatment is given to diabetic women to reduce the liklihood of their baby developing neural tube defects during pregancy?
Folic acid
(prior to (0.4mg) and during pregancy (5mg))
What is the first line treatment for T1DM in non-pregnant adults?
Basal-Bolus Insulin
Basal insulin (glargine, NPH, detemir or degludec)
AND
Bolus insulin (regular, lispro, aspart or glulisine) OR pump
What are the potential adjunct therapies for the first line T1DM treatment?
- Pre-meal insulin correction dose
- Amylin analogue (e.g. pramlintide)
What is the second line treatment for T1DM?
Fixed Insulin Dose
Insulin isophane biphasic
OR
Insulin aspart biphasic
OR
Insulin lispro biphasic
OR
Insulin degludec/insulin aspart
When would a fixed-dose insulin regimen be used?
- Already doing well on a fixed dose
- Cannot manage 3-4 daily injections
- Has trouble mixing insulin
What is the first line treatment for someone who is pregnant and has T1DM?
Basal-Bolus Insulin
Basal insulin (NPH or detemir)
AND
Bolus insulin (regular, lispro or aspart)
What is the second line treatment for someone who is pregant and has type 1 diabetes?
Basal-Bolus Insulin
Basal insulin (glarcine)
AND
Bolus insulin (regular, lispro or aspart) OR pump
This is different in different situations
How often should patients have their HbA1c checked?
- Meeting treatment goal (< 59 mmol/mol (< 18 years) or < 53mmol/mol (> 18 years) - Every 6 months
- Therapy is being modified or not meeting goal - Every 3 months
- Pregnant - Every month
If patients with T1DM also have atherosclerotic CVD, which treatment should they also be on as well as standard insulin and adjunctive treatments?
High-intensity statin
If patients have T1DM and are aged 40-75, without any atherosclerotic CVD or risk factors, what other treatment should they be on as well as standard insulin and adjunctive treatment?
Moderate-intensity statin
In all patients who have had type 1 diabetes for 5 years or more, yearly screening must take place for what?
- Increased urinary albumin secretion
- Serum creatinine
(estimated kidney glomerular filtration)
What characterises diabetic ketoacidosis?
- Hyperglycaemia
- Metabolic acidosis
What are the most common triggers or causes for DKA?
- Missed insulin
- Physiological stress such as infection or MI
In insulin deficiency (within a T1DM patient), what happens?
Stress hormones (glucagon, cortisol and catecholamines) raise blood sugars by stimulating ketogenesis
What follows from stress hormone release in a T1DM patient?
- Hyperglycaemia
- Ketosis
Why is DKA associated with dehydration?
Hyperglycaemia and ketosis cause osmotic diuresis which leads to dehydration
What are the symptoms of diabetic ketoacidosis?
- Dehydration (dry mouth)
- Metabolic acidosis
- SOB
- Abdominal pain
- Nausea
- Vomiting
- Altered snesorium
What does the treatment of DKA involve?
- Rapid rehydration
- Insulin infusion
- Correction of electrolyte imbalance and potassium repletion
- Treatment with bicarbonate (pH < 6.9 only)
What is the main complication of insulin treatment?
Hypoglycaemia
What is the definition of:
a) glucose alert value
b) significant hypoglycaemia
a) < 3.9 mmol/l
b) < 3.0 mmol/l
How can hypoglycaemia be treated assuming the patient can take oral treatment?
118ml (4 fl/oz) of fruit juice or sweetened fluids
or
Glucose tablets (15-20g CHO)
Blood sugar should be tested and the treatment effect should be apparent in 15 minutes
What is the treatment for hypoglycaemia if oral intake is not possible?
Injection of glucagon
or
IV dextrose
What is dextrose?
Form of glucose
(5% in water is used as a treatment for hypoglycaemia)
What is given to patients with T1DM, should they ever have a severe hypoglycaemic episode?
Glucagon kit
(this is useful when a patient cannot eat or drink)
Clinically significant hypoglycaemia is defined as what?
< 3mmol/l
