Type 1 Diabetes (Diabetes Week 10)

Question 1

Why do individuals with T1D require insulin?

Answer 1

autoimmune disease → beta-cells destroyed

Question 2

How does insulin therapy differ between children and adults?

Answer 2

Children: Insulin levels adjusted with diet
* when diet changes insulin requirements change (dosing is often harder)
* during growth and development frequent adjustments to diet to achieve normal growth
* Insulin resistance is common in healthy adolescents during pubertal growth spurts; challenging issue in adolescents with DM

Adults: Diet is more stable \ insulin requirements more stable

Question 3

What is the honeymoon phase?

Answer 3

When diagnosed they start insulin treatments right away but they then experience a honeymoon state where they are cured of diabetes, the pancreas naturally starts to secrete again where they dont need to inject at all but only lasts a few days to a year (variable) in the remission phase, which tells us the islets are still there just dont know why they stopped.
* Changes in islets way before autoimmunity arises so maybe the islets are messed up and triggering reaction against themselves but dont really know that much about TI

Question 4

How can type of insulin therapy vary?

Answer 4

• mode of insulin: Single injection vs multiple injections
• Type of Insulin: short acting vs long acting (consider peak of action)

Question 5

modes of insulin therapy

Answer 5

• multiple daily insulin injections (MDI: 3-4/day)
• or a continuous subcutaneous insulin infusion (CSII) (insulin pump) to maintian basal insulin secretion (similar to pancreatic function) with bolus pumping in response to eating. Pump can give baseline secretion and them some rapid acting

Insulin aspart or insulin lispro, in combination with adequate basal insulin, is preferred as this removes the rigidity of timing of just doing injections

Question 6

What is important to consider with insulin therapy?

Answer 6

Consider timing of meals
* factoring in gastric emptying of individual meals and postprandial rise in blood sugar levels .
* consider what time the insulin is adminstered, when it peaks and its duration

Question 7

How is the type of insulin (short acting vs. long acting) chosen?

Answer 7

Often consists of more than one type of insulin to account for the changes in a patients activity level, dietary intake and overall needs.

Question 8

Types of insulin dosing

Answer 8

Important to know type (short acting vs. long acting) and the associated onset, peak action & duration

Question 9

Timing and meals and insulin injections

Answer 9

• Important to time meals with peaking of insulin action
• consider the dosing of exogenous insulin or other medications that impact endogenous insulin production and/or secretion.
• Typically when prescribed exogenous insulin for treatment of diabetes (T1D or T2D), you should give insulin prior to eating (timing varies).
• If eating low GI foods you may be able to administer insulin at same time as meal consumption.

Question 10

Effect of exercise on insulin therapy

Answer 10

• High intensity exercise improves peripheral insulin sensitivity, and increases glucose uptake into peripheral muscle in both T1D and T2D
• Frequent exercise may result in reductions in insulin dosing
• Effect of exercise on blood sugar control in the patient on exogenous insulin therapy is important to consider when planning meal timing.

Question 11

overnight coverage for insulin therapy

Answer 11

In a normal healthy individual, lower levels of insulin circulating occur during sleep; this results in increased rates of glycogenolysis and gluconeogenesis which help keep blood sugars within the normal range but for T1D need to consider when the insulin will peak overnight
* Change the dose of insulin (lower the dose)
* Change the type of insulin therapy used to avoid peaking in the middle of the night (drawback is high blood sugars at nigiht)
* Consider late evening snacks with higher protein, lower GI to encourage prolonged postprandial glycemia.

Question 12

What is the dawn/ somogyi effect?

Answer 12

When patient’s experience lower blood sugars overnight, glucagon/catecholamine secretion increases. This can result in increasing glucose insensitivity, and increased rates of gluconeogenesis resulting in higher blood sugars:
* Often occurs in patients who take longer lasting insulin; particularly if no late night snack was consumed.

Question 13

What problems can occur with glycemic control in T1D if blood sugar is not monitored appropriately?

Answer 13

Two problems that can occur when blood sugar is not monitored correctly are:
* Insulin Reaction → hypoglycemia: Too much insulin in blood and not enough glucose to match
* Ketoacidosis → hyperglycemia: Do not have enough insulin in the body

Question 14

prevalence of insulin reaction and ketoacidosis

Answer 14

More common in Type1 Diabetes (less predictability in blood sugars)
* Can happen in Type 2 Diabetes but less occurence
* Preparation is important

Question 15

Risk Factors for Severe Hypoglycemia

Answer 15

• Prior episode of severe hypoglycemia
• Current low A1C (<6%)
• Hypoglycemia unawareness
• Long duration of diabetes
• Autonomic neuropathy (tingling)
• Adolescence
• Preschool-age children unable to detect or treat mild hypoglycemia on there own.

Question 16

Why is A1C <6% bad for children/adolescents with T1D?

Answer 16

• impairs growth
• impairs brain development

Question 17

What is the key feature of insulin reaction?

Answer 17

hypoglycemia

Question 18

Symptoms of insulin reaction

Answer 18

• Pale skin
• Confused
• Weak, shaky (could also be due to dehydration/ electrolyte balance)
• Cold, sweaty (could also be due to dehydration/ electrolyte balance)
• Possibly irritable
• most common: Confusion, sweating, neurological symptoms, Faint and dizzy

The only way to know for sure is to have your client check their blood sugars.

Question 19

What are common reasons for low blood sugar?

Answer 19

• Too much insulin for that time
• Too much exercise/stress
• Not enough food

Question 20

Insulin reaction treatment

Answer 20

• IV glucose (extreme cases)
• Glucose tablets
• Glucagon injections
• Juice/cola
• Candy/dextrose tablets
• Fluid will go in easiest and be absorbed fastest
• May have to experiment with how much exercise lowers blood sugar

Question 21

key feature of ketoacidosis

Answer 21

hyperglycemia

Question 22

Symptoms of ketoacidosis

Answer 22

• Red, flushed appearance
• Fruity smell on breath (from ketones)
• Dehydration
• Dry skin
• ketones may turn urine black
• n/v
• ↑ respiration and CO2 until respiration becomes laboured then both decrease

Question 23

Common reasons for high blood sugar

Answer 23

• Infection/illness (even sub-clinical levels): Effects insulin resistance and can exacerbate high blood glucose because it is catabolic
• Not enough insulin (most common)
• Overeating on a continuous basis, too much food (pretty rare and would probably be with not enough insulin)

Question 24

metabolic pathway of ketoacidosis

Answer 24

Dont need to know

Question 25

Treatment for ketoacidosis

Answer 25

• Insulin (small amount initially, watch response, may need to administer more)
• Rest
• Monitor fluids and electrolytes (may need)
• Exercise will only help if there is insulin present