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Endocrine > Treatment of Type 1 Diabetes > Flashcards

Treatment of Type 1 Diabetes Flashcards

1
Q

What are the aims of therapy?

A

Prevent hyperglycaemia, avoid hypoglycaemia, reduce chronic complications

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2
Q

What are the symptoms and effects of hyperglycaemia?

A 
Symptoms = thirst, tiredness, blurred vision, weight loss, polyuria, nocturia, fungal infections
Effects = cognitive, mood state, information processing, working memory, potential risk of DKA
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3
Q

What are some symptoms and cognitive effects of hypoglycaemia?

A 
Symptoms = pallor, sweating, tremor, palpitations, confusion, nausea, hunger
Effects = tense-tiredness, information processing, working memory, coma
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4
Q

What are some chronic complications of type 1 diabetes?

A

Microvascular and macrovascular disease, metabolic complication (DKA, HHS), psychosocial morbidity

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5
Q

How does normal insulin production work?

A

Secreted at low basal rate which accounts for about 50% of insulin produced, post-prandial insulin is secreted in relation to post-meal glucose

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6
Q

What are some examples of prandial insulins?

A

Insulin analogues = insulin aspart (Novorapid), lispro (Humalog), glulisine (Apidra)
Soluble insulin = Actrapid, Humulin S

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7
Q

What are some features of prandial insulin analogues?

A

Onset of action is after 10-15mins
Peak action is after 60-90mins
Duration is 4-5hrs

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8
Q

What are some features of soluble prandial insulin?

A

Onset after 30-69mins
Peak action is after 2-4hrs
Lasts for 5-8hrs

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9
Q

What are some examples of basal insulins?

A

Isophane basal insulin = Insulatard, Humulin I

Analogue basal insulins = Lantus (glargine), Levemir (determir)

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10
Q

What are some featurs of isophane basal insulins?

A

Intermediate/long acting, peak of activity 4-6hrs after administration

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11
Q

What are some features of analogue basal insulins?

A

Longer duration of action, less peak activity (flatter profile), may be given once or twice a day

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12
Q

What should most patients with type 1 diabetes be on?

A

Analogue basal insulin

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13
Q

What is the aim of basal-bolus regimes?

A

To mimic normal endogenous insulin production

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14
Q

How common is type 1 diabetes in young people?

A

Accounts for >90% of diabetes in young people <25 years

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15
Q

What is the inheritance of type 1 diabetes?

A

12-15% of young people <15 with diabetes have an affected first degree relative, children are 3x more likely to develop diabetes if there father is affected than if their mother is affected

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16
Q

How common is diabetes in cystic fibrosis patients?

A

20% of patients will develop secondary diabetes

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17
Q

How should most patients be treated?

A 
With MDI (3-4 injections per day) or CSII
Should use insulin analogues to reduce hypoglycaemic risk
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18
Q

What should prandial insulin be matched to?

A

Carbohydrate intake, pre-meal glucose and anticipated activity

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19
Q

What should intensive insulin therapy be delivered as part of?

A

A comprehensive support package

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20
Q

What should an intensified treatment regimen for adults include?

A

Either regular human or rapid acting insulin analogues

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21
Q

Who are basal insulin analogues recommended in?

A

Adults experiencing sever or nocturnal hypoglycaemia and who are using an intensified insulin regime

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22
Q

What is the most common insulin regime used in young active patients?

A

Basal (once daily)-bolus (with meals) regime

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23
Q

What is the target levels around meal times?

A

3.9-7.2 (4-7) mmol/L pre-meal

<10mmol/L 1-2hrs after the beginning of a meal

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24
Q

How common is the use of twice daily long acting insulin analogues?

A

Very common = most patients (50-80%0 require their use

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25
What are some structured education programmes for patients?
Dose adjustment for normal eating (DAFNE), Tayside insulin management Should be started within 6 months of diagnosis
26
What is advanced carbohydrate counting?
Synchronising the amount of insulin taken to the amount of carbohydrates consumed
27
What patients are suitable for advanced carbohydrate counting?
Those on multiple daily injections (MDI) or on continuous subcutaneous insulin injections (CSII)
28
What is advanced carbohydrate counting composed of?
Insulin to carbohydrate ratio (ICR) and insulin sensitivity factor (ISF)
29
What do insulin pumps do?
Deliver continuous administration of short acting insulin subcutaneously
30
How do insulin pumps work?
Deliver background insulin dictated by basal rate = basal rates can be programmed in advance and may be set to different rates at different times of the day
31
What can be used to evaluate metabolic control?
Home blood glucose monitoring (SBGM), glycated haemoglobin (HbA1c), flash glucose monitoring (freestyle libre), continuous glucose monitor (CMS)
32
What are some uses of blood glucose monitoring?
Cornerstone of diabetes care, day-to-day diabetes management, insulin dose adjustment
33
What is the limitation of blood glucose monitoring?
Only provide snap shot at any given moment
34
What is the largest component of glycated haemoglobin?
HbA1c (60-80%) = formed by non-enzymatic glycation of haemoglobin on exposure to glucose
35
What are some features of HbA1c?
Increases in a predictable way in response to prevailing glucose, measure of average blood glucose over 6-8 weeks
36
What is the target range for HbA1c?
Between 48=58m/m
37
What are the limitations of insulin?
Any method of administration is unable to replicate human physiology, slow clearance, peak too slow to prevent post-meal hyperglycaemic spike
38
What are the factors affecting insulin absorption and action?
Temperature, injection site, injection depth, exercise, pen accuracy, leakage
39
Why should insulin injection sites be alternated?
To prevent lipohypertrophy
40
What are some safety issues with insulin?
Prescribing errors are common = wrong dose/type Preparations have similar names but different actions Abbreviation to "u" or "ui" can be misinterpreted as numbers rather than letters
41
Why are problems with insulin so common?
Commonly "self managed" and there is poor understanding of insulin management by healthcare professionals
42
What are the IHI "rights" of prescribing?
Right patient, medicine, dose, route, time, documentation, monitoring and storage
43
What must be taken into account when adjusting a patient's insulin dose?
Patient's usual regimen and dose, blood glucose monitoring and ketone monitoring, sepsis/acute illness, steroid therapy, age, lifestyle
44
What must be considered with new insulin initiation?
Age, lifestyle, current health status, unit/kg
45
What are the principles of insulin adjustment?
Review glycaemic control Adjust routine insulin proactively to optimise control Adjust dose prescribed prior to any problems
46
What can be some problems with insulin adjustment?
Reactive insulin adjustment can precipitate hypoglycaemia
47
What should happen to a patient's insulin if they are hypoglycaemic?
Don't omit insulin = treat the hypoglycaemia and administer insulin as usual
48
Is insulin considered high risk?
Yes = is high risk, high consequence medicine | One of the medicines most commonly associated with medication incidents leading to severe harm or death
49
How should all regular and single insulin (bolus) doses be measured and administered?
Using an insulin syringe or pen = never use an IV syringe
50
When should abbreviations be used when prescribing insulin?
Never = always use the full term "units"
51
What is required of all clinical areas and community staff treating patients with insulin?
Must have adequate supplies of insulin syringes and subcutaneous needles
52
What must always be used to prepare insulin for IV infusions?
Insulin syringes = infusions are delivered in 50ml IV syringes or larger infusion bags
53
How should type 1 diabetics be treated when going in for minor/fast surgery?
IV insulin isn't necessary if a rapid recovery is expected and the patient is expected to eat following surgery Avoid glucose infusions if possible Monitor blood glucose
54
What patients are at risk of hypoglycaemia when getting short surgery?
People prescribed oral hypoglycaemic agents and insulin
55
What are some examples of inhaled insulin?
Pfizer = Exubera MannKinds = Afreeza Aerogen Pharmaceuticals
56
What are the issues with inhaled insulin?
Non-linear dosing, cost, potential for lung cancer
57
What are some examples of oral insulin?
Generex = Oral-Lyn (oral spray) | Emisphere technology = encapsulated oral product
58
How do oral insulins work and what are some issues with them?
Portal delivery | Issues = cost, variable absorption, effects on concurrent diet and illness, only pre-prandial
59
What are some adjunct therapies used alongside insulin?
Metfromin, leptin, GLP-1, possibly SGLT2 inhibitors
60
What are the indications for pancreas transplantation?
Imminent or ERSD due to receive/with kidney transplant Severe hypoglycaemia/metabolic complications Incapacitating clinical or emotional problems
61
What is the aim of pancreatic islet transplantation?
Replace endocrine pancreas with hope of restoring glucose homeostasis
62
What are the indications for pancreatic islet transplantation?
Episodes of severe hypoglycaemia Severe and progressive long term complications despite maximal therapy Uncontrolled diabetes despite maximal therapy
63
What are the limitations of pancreatic islet transplantation?
Restricted number of donors, needs immunosuppression
64
What are the steps involved in pancreatic islet transplantation?
Pancreas donation and retrieval, islet isolation, islet culture for 24hrs, islet transplantation, close follow up for 4-6 weeks, immunosuppression
65
What are some features of the Edmonton protocol for pancreatic islet transplantation?
Steroid-free immunosuppression, use of second islet infusion as routine, 1 year insulin independence at 80-85%
66
Who are diabetes interventional trials aimed at?
Newly diagnosed patients = aim to preserve C-peptide levels and residual beta cell function
67
What were the targets of the initial diabetes interventional trials?
Conventional immunosuppressive agents
68
What are the targets of recent diabetes interventional trails?
Anti CD3 monoclonal antibodies, anti CD20 monoclonal antibodies (rituximab), cytokine-based approaches, CTLA-4 approaches

Endocrine (42 decks)

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