Type 1 Diabetes

Question 1

What is the prevalence of diabetes under 18y

Answer 1

1/300-1/400

(second most common chronic illness in childhood)

Question 2

What is the etiology of T1DM

Answer 2

Autoimmune and genetic features

Question 3

What are the HbA1C targets (<6y, 6-12y, 13-18y) based on the Canadian Diabetes Association CPG?

What are general blood glucose targets?

Answer 3

<6y - <8% (evidence of poorer cognitive outcomes with tighter control/hypoglycemia)

6-12 - <7.5%

>13 - <7% (or lower if no hypoglycemic episodes)

Glucose targets 4-7

Question 4

How common is DKA in first presentation Type 1 Diabetes - if not in DKA how do they present?

Answer 4

20-40%

-weight loss, polydipsia, polyuria

Question 5

What is the cause of mortality in DKA, and how common is it?

Answer 5

Cerebral edema

Happens in <1% of DKA cases, but mortality 25% and morbidity 10-25%

Question 6

What are the risk factors for development of cerebral edema in DKA?

Answer 6

low bicarb/use of bicarb

low pH

high urea

high glucose

faster administration of fluids/higher rate of rise of Na

Question 7

What are the symptoms of DKA

Answer 7

fatigue

abdominal pain

nausea/vomiting - ‘gastro symptoms’

tachypnea

intercurrent illness

Question 8

What are the laboratory findings in DKA

Answer 8

Blood gas - high glucose, low pH, low bicarb, low CO2 (compensation), high lactate

Serum labs (CBC, lytes, AG, glucose, creatinine, urea + labs for etiology of decompensation) - high anion gap

Urine - glucose and ketones

Question 9

How do you calculate the anion gap?

Answer 9

Na - Cl - HCO3

Question 10

How do you calculate the effective osmolality?

Answer 10

2Na + sugar + BUN

Question 11

How do you calculate corrected sodium for glucose?

Answer 11

Na = Na + (glucose - 6) x 0.3

Question 12

What are your anion gap and bicarb targets for DKA correction?

Answer 12

AG - 12-15

bicarb - >18

Question 13

What are the signs/symptoms of cerebral edema

Answer 13

altered or fluctuating LOC

Cushing’s triad

headache

Question 14

What are the signs/symptoms of hypoglycemia

Answer 14

Neuro - altered LOC, confusion, hemiparesis, seizures

CVS - dizziness, syncope

Question 15

How do you adjust insulin during an intercurrent illness

Answer 15

Remember to continue giving your insulin even if unwell - check sugars to ensure not hypoglycemic

glucose >11 + mod/large ketones or glucose >17 - give 10-20% of total daily insulin as fast acting

Question 16

What is the start dosing for insulin?

Answer 16

0.5-0.6 u/kg/d

*may need to decrease to 0.2-0.5u/kg/d in honeymoon phase

*adolescents may need >1.5u/kg/d

Question 17

How is the TID insulin regimen dosed

Answer 17

Start with 0.5-0.7u/kg/d

2/3 of total insulin in AM

• 2/3 intermediate
• 1/3 rapid

1/3 of total insulin in PM

• 2/3 intermediate (give at bedtime)
• 1/3 rapid (give at supper)

Question 18

How is the basal bolus regimen dosed?

Answer 18

0. 5-0.7u/kg/d
   - 50% basal, 50% bolus
   - breakfast - rapid (1/3)
   - lunch - rapid (1/3)
   - supper - rapid (13)
   - bedtime - long acting

Question 19

What is the ISF?

Answer 19

Insulin sensitivity factor

ISF = 100/total daily dose

• each unit of rapid insulin will decrease BG by ISF
• helps make a sliding scale
  e. g. TDD = 10

ISF = 100/10 = 10

1u of rapid will decrease blood glucose by 10

(actual glucose-target glucose)/ISF = dose

Question 20

How do you adjust corrections if ketones +

Answer 20

multiply correction by 1.5 if ketones +

Question 21

How do you do carbohydrate corrections

Answer 21

CHO ratio = 500/ total daily dose of insulin

e.g. 50kg child on 50u insulin daily

500/50 = 10

1 unit of rapid for each 10g CHO ingested

Question 22

How do you treat hyperglycemia in a T1DM not in DKA

Answer 22

Give 10-20% of TDD as rapid insulin

Or give enough rapid insulin based on ISF to lower to 6-8

Question 23

What are the microvascular complications of diabetes (3)

Answer 23

nephropathy (microalbuminuria)

retinopathy

neuropathy

Question 24

What are common comorbidities of type 1 diabetes (6)

Answer 24

psychosocial/psychological disorders

eating disorders

dyslipidemia

hypertension

autoimmune thyroid disease

celiac disease

Question 25

What are the nephropathy screening guidelines (age, frequency, how to screen)

Answer 25

Annually starting at 12y with T1DM >5y

• first morning urine albumin:creatinine ratio >2.5mg/mmol
• diagnosis after 2 consecutive first morning positives

Question 26

What are the retinopathy screening guidelines (age, frequency, how to screen)

Answer 26

Annual after 15y, with >5y T1DM

Can increase to q2y if good control

Optometry

Question 27

What are the neuropathy screening guidelines (age, frequency, how to screen)

Answer 27

Postpubertal children with T1DM >5y

History - numbness, pain, cramps, paresthesias

Exam - sensation, vibration, light touch and reflexes

Question 28

What are the hypertension screening guidelines in T1DM (age, frequency, how to screen)

Answer 28

All children screened 2x/year

Question 29

What are the dyslipidemia screening guidelines in T1DM (age, frequency, how to screen)

Answer 29

<12y if + risk factors (e.g. obesity) or family history

>12y screen q5y

Question 30

What are the thyroid disease screening guidelines in T1DM (age, frequency, how to screen)

Answer 30

Screen at diabetes diagnosis with repeat q2y

• TSH, thyroid peroxidase antibodies
• more frequent screening if positive symptoms

Question 31

What are the celiac disease screening guidelines in T1DM (age, frequency, how to screen)

Answer 31

Need for screening is controversial

Test any patient with symptoms of celiac disease