Treatment of Type 1 Diabetes

Question 1

what are the main aims of T1DM therapy?

Answer 1

prevent hyperglycaemia
avoid hypoglycaemia
reduce chronic complications (micro, macro, DKA, psychological)

Question 2

how much insulin is secreted at a low basal rate?

Answer 2

accounts for 50% of insulin produced

Question 3

as well as basally, when else is insulin released?

Answer 3

post prandial insulin released in response to post meal glucose

Question 4

what types of insulin are available?

Answer 4

rapid acting analogue
short acting
intermediate acting
long acting
rapid acting analogue-intermediate mixture
short acting - intermediate mixture

Question 5

what is tge basal bolus regimen of insulin delivery?

Answer 5

attempts to mimic normal insulin
give bolus of rapid acting insulin after meals according to intake
constant basal insulin level from long acting insulin

Question 6

what is the twice daily insulin regimen?

Answer 6

less flexible than basal bolus

one dose in the morning and one at night

Question 7

once daily regimen?

Answer 7

one dose at night to carry through into next day

glucose spikes at every meal

Question 8

initial pharmacological approach to treating T1DM?

Answer 8

most should be treated with MDI (3-4 injections per day) or CSII
education in how to match prandial insulin dose to carb intake and anticipated activity
most should use insulin analogues to reduce hypoglycaemia risk

Question 9

how do you calculate amount of insulin to give at the start?

Answer 9

0.3 units per Kg body weight
divide it around 50% prandial and 50% basal
E.g: if total = 18 units
- lantus = 9 units before bed
- prandial = 3 units before each meal

Question 10

how is insulin adjusted?

Answer 10

target = 3.9-7.2 (4-7) mmol/l pre meal
target = <10 mol/l 1-2 hrs after beginning of meal

Question 11

how many T1DM patients needs twice daily long acting insulin?

Answer 11

50-80%

Question 12

what is advanced carbohydrate counting?

Answer 12

synchronizing the amount of insulin taken to the amount of carbohydrate consumed

Question 13

who is advanced carbohydrate counting suitbale for?

Answer 13

those on multiple daily infections (MDI)

for people on continuous subcutaneous insulin infusion (SCII) pumps

Question 14

what are the components of advanced carb counting?

Answer 14

insulin to carb ratio (ICR) - e.g 1 unit per 10g

insulin sensitivity factor (ISF) also known as correction factor (CF)

Question 15

how can carbohydrate amount in food be estimated?

Answer 15

food measurement
visual cues
food composition tables
food labels
websites
other technologies

Question 16

what is an insulin pump?

Answer 16

medical device that gives continuous administration of short acting insulin subcutaneously
can deliver background basal insulin and deliver manually activated bolus insulin to cover meals

Question 17

how can you evealuate metabolic control?

Answer 17

home blood glucose monitoring
home blood ketone monitoring
glycated haemoglobin (HbA1c)
continuous glucose monitor (mainly for people who live alone)

Question 18

what are the limitations of home glucose monitoring?

Answer 18

fingerprick tests only give a snapshot of any one moment

Question 19

what is HbAc?

Answer 19

largest component of the glycated haemoglobins
increases in a predictable way in response to prevailing glucose so can be used to measure average blood sugar over a longer period (2-3 months)

Question 20

how can the limitations of fingerprick testing be overcome?

Answer 20

continuous glucose monitoring

Question 21

what is the main difference between biological and artificial insulin delivery?

Answer 21

pancreatic secreted directly into portal system and rapidly prevents post meal hyperglycaemia and is rapidly cleared
artificial = injected into subcutaneous tissue, peaks too slow to prevent post meal hyperglycaemia, slow clearence

Question 22

what factors may effect insulin absorption/action?

Answer 22

pen accuracy
leakage
site of injection (can go into muscle instead of SC tissue)

Question 23

possible risks at injection sites?

Answer 23

lipohypertrophy

Question 24

important things to consider in insulin prescribing?

Answer 24

patients usual regimen
blood glucose and ketone monitoring
sepsis/acute illness
steroid therapy
age/lifestyle

Question 25

do you stop insulin if hypoglycaemic?

Answer 25

no

treat the hypo and administer insulin as usual

Question 26

pre-prandial glucose targets?

Answer 26

4-7 mmol

Question 27

post meal glucose targets?

Answer 27

<10

Question 28

why are problems with insulin delivery so common?

Answer 28

individual patients vary widely in their physiological response to insulin
many different types of insulin with different composition and delivery mechanism

Question 29

when might IV insulin be used?

Answer 29

DKA
role in hyperosmolar hyperglycaemic state (HHS)
acute illness
fasting patients who are unable to tolerate oral intake

Question 30

how do you monitor IV insulin delivery?

Answer 30

hourly blood glucose monitoring (aim for 5-12)
free of hypoglycaemia
check ketones if BG >12
check Us&Es daily at least
safe transition from IV to SC insulin

Question 31

what are the 2 types of pancreas transplantation and what are the indications for its use?

Answer 31

kidney-pancreas autotransplantation
islet autotransplantation
indications
- imminent or ESRD due to receive or with kidney transplant
- severe hypoglycaemia/metabolic complications
- incapacitating clinical or emotional problems

Question 32

what are the indications for pancreatic islet transplantation?

Answer 32

episodes of severe hypoglycaemia
severe and long term complications despite maximal therapy
uncontrolled diabetes despite maximal treatment

Question 33

what are the 4 key steps in islet transplantation?

Answer 33

pancreas donation and retrieval
islet isolation
islet culture
islet transplantation

Question 34

follow up from islet transplantation?

Answer 34

4-6 weeks close follow up

immunosuppression

Question 35

describe the outcome of islet transplantations?

Answer 35

initial rates of insulin independence are low

Edmonton protocol increased rate of insulin independence at 1 year to 80-85%