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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
Q

What are some structured education programmes for patients?

A

Dose adjustment for normal eating (DAFNE), Tayside insulin management
Should be started within 6 months of diagnosis

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26
Q

What is advanced carbohydrate counting?

A

Synchronising the amount of insulin taken to the amount of carbohydrates consumed

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27
Q

What patients are suitable for advanced carbohydrate counting?

A

Those on multiple daily injections (MDI) or on continuous subcutaneous insulin injections (CSII)

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28
Q

What is advanced carbohydrate counting composed of?

A

Insulin to carbohydrate ratio (ICR) and insulin sensitivity factor (ISF)

29
Q

What do insulin pumps do?

A

Deliver continuous administration of short acting insulin subcutaneously

30
Q

How do insulin pumps work?

A

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
Q

What can be used to evaluate metabolic control?

A

Home blood glucose monitoring (SBGM), glycated haemoglobin (HbA1c), flash glucose monitoring (freestyle libre), continuous glucose monitor (CMS)

32
Q

What are some uses of blood glucose monitoring?

A

Cornerstone of diabetes care, day-to-day diabetes management, insulin dose adjustment

33
Q

What is the limitation of blood glucose monitoring?

A

Only provide snap shot at any given moment

34
Q

What is the largest component of glycated haemoglobin?

A

HbA1c (60-80%) = formed by non-enzymatic glycation of haemoglobin on exposure to glucose

35
Q

What are some features of HbA1c?

A

Increases in a predictable way in response to prevailing glucose, measure of average blood glucose over 6-8 weeks

36
Q

What is the target range for HbA1c?

A

Between 48=58m/m

37
Q

What are the limitations of insulin?

A

Any method of administration is unable to replicate human physiology, slow clearance, peak too slow to prevent post-meal hyperglycaemic spike

38
Q

What are the factors affecting insulin absorption and action?

A

Temperature, injection site, injection depth, exercise, pen accuracy, leakage

39
Q

Why should insulin injection sites be alternated?

A

To prevent lipohypertrophy

40
Q

What are some safety issues with insulin?

A

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
Q

Why are problems with insulin so common?

A

Commonly “self managed” and there is poor understanding of insulin management by healthcare professionals

42
Q

What are the IHI “rights” of prescribing?

A

Right patient, medicine, dose, route, time, documentation, monitoring and storage

43
Q

What must be taken into account when adjusting a patient’s insulin dose?

A

Patient’s usual regimen and dose, blood glucose monitoring and ketone monitoring, sepsis/acute illness, steroid therapy, age, lifestyle

44
Q

What must be considered with new insulin initiation?

A

Age, lifestyle, current health status, unit/kg

45
Q

What are the principles of insulin adjustment?

A

Review glycaemic control
Adjust routine insulin proactively to optimise control
Adjust dose prescribed prior to any problems

46
Q

What can be some problems with insulin adjustment?

A

Reactive insulin adjustment can precipitate hypoglycaemia

47
Q

What should happen to a patient’s insulin if they are hypoglycaemic?

A

Don’t omit insulin = treat the hypoglycaemia and administer insulin as usual

48
Q

Is insulin considered high risk?

A

Yes = is high risk, high consequence medicine

One of the medicines most commonly associated with medication incidents leading to severe harm or death

49
Q

How should all regular and single insulin (bolus) doses be measured and administered?

A

Using an insulin syringe or pen = never use an IV syringe

50
Q

When should abbreviations be used when prescribing insulin?

A

Never = always use the full term “units”

51
Q

What is required of all clinical areas and community staff treating patients with insulin?

A

Must have adequate supplies of insulin syringes and subcutaneous needles

52
Q

What must always be used to prepare insulin for IV infusions?

A

Insulin syringes = infusions are delivered in 50ml IV syringes or larger infusion bags

53
Q

How should type 1 diabetics be treated when going in for minor/fast surgery?

A

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
Q

What patients are at risk of hypoglycaemia when getting short surgery?

A

People prescribed oral hypoglycaemic agents and insulin

55
Q

What are some examples of inhaled insulin?

A

Pfizer = Exubera
MannKinds = Afreeza
Aerogen Pharmaceuticals

56
Q

What are the issues with inhaled insulin?

A

Non-linear dosing, cost, potential for lung cancer

57
Q

What are some examples of oral insulin?

A

Generex = Oral-Lyn (oral spray)

Emisphere technology = encapsulated oral product

58
Q

How do oral insulins work and what are some issues with them?

A

Portal delivery

Issues = cost, variable absorption, effects on concurrent diet and illness, only pre-prandial

59
Q

What are some adjunct therapies used alongside insulin?

A

Metfromin, leptin, GLP-1, possibly SGLT2 inhibitors

60
Q

What are the indications for pancreas transplantation?

A

Imminent or ERSD due to receive/with kidney transplant
Severe hypoglycaemia/metabolic complications
Incapacitating clinical or emotional problems

61
Q

What is the aim of pancreatic islet transplantation?

A

Replace endocrine pancreas with hope of restoring glucose homeostasis

62
Q

What are the indications for pancreatic islet transplantation?

A

Episodes of severe hypoglycaemia
Severe and progressive long term complications despite maximal therapy
Uncontrolled diabetes despite maximal therapy

63
Q

What are the limitations of pancreatic islet transplantation?

A

Restricted number of donors, needs immunosuppression

64
Q

What are the steps involved in pancreatic islet transplantation?

A

Pancreas donation and retrieval, islet isolation, islet culture for 24hrs, islet transplantation, close follow up for 4-6 weeks, immunosuppression

65
Q

What are some features of the Edmonton protocol for pancreatic islet transplantation?

A

Steroid-free immunosuppression, use of second islet infusion as routine, 1 year insulin independence at 80-85%

66
Q

Who are diabetes interventional trials aimed at?

A

Newly diagnosed patients = aim to preserve C-peptide levels and residual beta cell function

67
Q

What were the targets of the initial diabetes interventional trials?

A

Conventional immunosuppressive agents

68
Q

What are the targets of recent diabetes interventional trails?

A

Anti CD3 monoclonal antibodies, anti CD20 monoclonal antibodies (rituximab), cytokine-based approaches, CTLA-4 approaches

Endocrine (42 decks)

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