Type 1 Diabetes

Question 1

What causes T1DM?

Answer 1

autoimmune pancreatic

β-cell destruction leading to insulin deficiency and abnormal fuel metabolism

Question 2

How does T1DM present?

Answer 2

■Classically presents with
polyuria
(especially nocturia),
polydipsia, polyphagia,
and rapid, unexplained weight loss. Patients may also present with ketoacidosis.
■ Usually affects nonobese children or young adults.
■ Associated with HLA-DR3 and -DR4
■ Triggered by certain viruses, such as the Coxsackie B virus and enterovirus.

Question 3

What examination would you carry out in T1DM?

Answer 3

General examination.
Height/weight/BMI.
Examination of feet (eg, ulcers, loss of sensation).
Examination of eyes (eg, cataracts, diabetic retinopathy).
Blood pressure measurement.
Examination of peripheral pulses.

Question 4

How is T1DM diagnosed?

Answer 4

Fasting plasma glucose >7mmol/l
Random plasma glucose >11.1mmol/l
HbA1C is not for diagnosis of T1DM, but usually >48mmol/mol

Question 5

What is the long term management of T1DM?

Answer 5

Patient education is essential. Monitoring and treatment is relatively complex. The condition is life-long and requires the patient to fully understand and engage with their condition. It involves the following components:

Subcutaneous insulin regimes
Monitoring dietary carbohydrate intake
Monitoring blood sugar levels on waking, at each meal and before bed
Monitoring for and managing complications, both short and long term
Insulin is usually prescribed as a combination of a background, long acting insulin given once a day and a short acting insulin injected 30 minutes before intake of carbohydrate (i.e. at meals). Insulin regimes are initiated by a diabetic specialist.

Question 6

What can be problematic when treating T1DM with injections?

Answer 6

Injecting into the same spot can cause a condition called “lipodystrophy”, where the subcutaneous fat hardens and patients do not absorb insulin properly from further injections into this spot. For this reason patients should cycle their injection sites.

Question 7

How is T1DM monitored?

Answer 7

HbA1c

When we check HbA1c we are counting glycated haemoglobin, which is how much glucose is attached to the haemoglobin molecule. This is considered to reflect the average glucose level over the last 3 months because red blood cells have a lifespan of around 3-4 months. We measure it every 3 – 6 months to track progression of the patient’s diabetes and how effective the interventions are. It requires a blood sample sent to the lab, usually red top EDTA bottle.

Capillary Blood Glucose

This is measured using a little machine called a glucose meter that gives an immediate result. Patients with type 1 and type 2 diabetes rely on these machines for self-monitoring their sugar levels.

Flash Glucose Monitoring (e.g. FreeStyle Libre)

This uses a sensor on the skin that measures the glucose level of interstitial fluid. There is a lag of 5 minutes behind blood glucose. This sensor records the glucose readings at short intervals so you get a really good impression of what the glucose levels are doing over time. The user needs to use a “reader” to swipe over the sensor and it is the reader that shows the blood sugar readings. Sensors need replacing every 2 weeks for the FreeStyle Libre system.
The 5 minute delay also means it is necessary to do capillary blood glucose checks if hypoglycaemia is suspected

Question 8

What would be included in an educational package when discharging someone with T1dm?

Answer 8

1 Never stop Insulin – it is required for survival
2 Use of Insulin device, injection technique, injection sites, rotation of
injection sites
3 Out line of the basics of the chosen Insulin regimen
4 Sick day rules – how to manage acute illness with potentially increased
Insulin requirements, monitoring of BMs and urine ketones
5 Hypoglycaemia – recognising symptoms – precipitants and how to adjust
insulin
6 Smoking
7 Alcohol
8 Driving regulations and informing the DVLA
5 Hypoglycaemia – recognising symptoms – precipitants and how to adjust
insulin
6 Smoking
7 Alcohol
8 Driving regulations and informing the DVLA
9 Exercise
10 Diabetes U.K. – local contacts and website address
11 Contact with Diabetes Nurse Specialist and follow up
12 Principals of long term control – the association of good glycaemic control
with lower risks of microvascular and macrovsacular complications.
13 Planning a pregnancy.