TYPE 1 DIABETES MELLITUS Flashcards
1
Q
What is the cause of type 1 diabetes mellitus?
A
Autoimmune destruction of pancreatic beta cells
2
Q
What is the main treatment for type 1 diabetes mellitus?
A
Insulin therapy
3
Q
What are the goals of therapy for type 1 diabetes?
A
- Prevent long-term complications
- Prevent treatment-induced hypoglycemia
- Maintain quality of life
4
Q
What is the target hemoglobin A1C (HbA1C) for most patients with type 1 diabetes?
A
Less than 7%
5
Q
What fasting plasma glucose (FPG) target is recommended for type 1 diabetes?
A
80 to 130 mg/dL
6
Q
What postprandial glucose (PPG) target is recommended by the American Diabetes Association (ADA)?
A
Less than 180 mg/dL
7
Q
What postprandial glucose (PPG) target is recommended by the American Association of Clinical Endocrinologists (AACE)?
A
Less than 140 mg/dL
8
Q
What is Intensive Insulin Therapy (IIT)?
A
Use of multiple daily injections (MDIs) or an insulin pump to mimic normal insulin secretion
9
Q
What alternative names are used for Intensive Insulin Therapy (IIT)?
A
- Physiologic therapy
- Multiple-component therapy
- Basal-bolus insulin therapy
10
Q
What are the critical components of Intensive Insulin Therapy?
A
- Frequent self-monitored blood glucose (SMBG)
- Defined target blood glucose levels
- Dose modifications according to individual response
- Understanding diet composition
- Balance of food intake, activity, and insulin dosage
- Accurate carbohydrate-to-insulin (C:I) ratios
- Use of correction factors (CFs)
- Patient education and ongoing interaction
11
Q
What was the main finding of the Diabetes Control and Complications Trial (DCCT)?
A
Improved glycemic control (HbA1C < 7%) significantly reduced microvascular complications
12
Q
What did the long-term extensions of the DCCT and UKPDS show?
A
Microvascular benefits of good glycemic control persisted for decades
13
Q
Which studies failed to show that aggressive glycemic targets reduced cardiovascular complications?
A
- ACCORD
- ADVANCE
- VADT
14
Q
True or False: All people with type 1 diabetes are candidates for Intensive Insulin Therapy.
A
True
15
Q
What patient characteristics predict greater success with Intensive Insulin Therapy?
A
- Motivation
- Willingness to perform frequent SMBG
- Time available for education
- Ability to recognize and treat hypoglycemia
- Supportive network
16
Q
What is necessary for the implementation of Intensive Insulin Therapy?
A
A cohesive diabetes team for frequent interaction
17
Q
What are the most common adverse effects of insulin therapy?
A
Hypoglycemia and weight gain
These are the primary risks associated with insulin therapy, particularly in intensive insulin therapy (IIT).
18
Q
What was the increased risk of severe hypoglycemia in IIT compared to conventional treatment as per the DCCT?
A
Threefold increased risk
This translates to 62 episodes per 100 patient-years of therapy.
19
Q
What can frequent episodes of hypoglycemia lead to?
A
Hypoglycemia unawareness
This condition is characterized by the loss of clinical warning symptoms like palpitations, sweating, and hunger.
20
Q
What unique risk is associated with insulin pump therapy?
A
Diabetic ketoacidosis (DKA)
DKA can occur due to pump malfunctions or infusion site problems that interrupt insulin delivery.
21
Q
What are the psychosocial and economic implications of IIT?
A
Time and commitment required from the patient
These factors can lead to negative psychosocial and economic outcomes.
22
Q
What does IIT aim to mimic?
A
Normal insulin secretion pattern
This includes continuous basal coverage and bursts of insulin after food intake.
23
Q
What is the function of basal insulin secretion?
A
Suppresses hepatic glucose production
This helps control blood glucose levels in the fasting state and premeal periods.
24
Q
How is basal insulin coverage typically accomplished in IIT?
A
With injections of long-acting insulin analogues or basal infusion on the insulin pump
This ensures a steady supply of insulin.
25
What does bolus insulin consist of?
Nutritional dose and correction dose
## Footnote
The nutritional dose manages glucose excursions after meals, while the correction dose reduces high glucose levels before meals.
26
What type of insulin is preferred for bolus coverage in IIT?
Rapid-acting or short-acting insulin preparations
## Footnote
These can also be delivered using the bolus function on the insulin pump.
27
What percentage of physiologic insulin secretion is typically basal and bolus?
Approximately 50% basal and 50% bolus
## Footnote
This balance is crucial for effective blood glucose management.
28
How is basal insulin administered in an MDI regimen?
Injected once or twice daily
## Footnote
This provides the basal insulin portion, which is about 50% of the total daily dose.
29
What type of insulin is injected before meals in an MDI regimen?
Rapid-acting or short-acting insulin
## Footnote
This provides the bolus insulin portion of the regimen.
30
What are premixed ‘biphasic’ insulin preparations?
Combines rapid-acting or regular human insulin with a protaminated form
## Footnote
They aim to imitate basal or bolus therapy with fewer injections.
31
What are the currently available bolus insulin preparations?
Rapid-acting analogues, short-acting regular human insulin, and ultrarapid-acting agents
## Footnote
Examples include aspart, glulisine, and lispro.
32
What is the recommendation regarding rapid-acting agents for patients with type 1 diabetes?
Use rapid-acting agents over short-acting agents
## Footnote
This is to reduce the risk of hypoglycemia.
33
What may necessitate the use of regular insulin in some patients?
Cost considerations
## Footnote
Despite the preference for rapid-acting agents, economic factors can influence treatment choices.
34
What is the classification of Insulin aspart (Fiasp)?
Ultra-rapid acting
## Footnote
Insulin aspart (Fiasp) is designed for rapid glucose control.
35
Which insulin preparation is inhaled?
Insulin human—inhaled (Afrezza)
## Footnote
Afrezza is a unique inhalable form of insulin.
36
Name two rapid-acting analogs of insulin.
* Insulin aspart (NovoLog)
* Insulin lispro U-100, U-200 (Humalog)
## Footnote
These insulins are used for managing blood sugar spikes after meals.
37
What is the onset time for regular insulin preparations?
30–60 min.
## Footnote
Regular insulin is often used for meal coverage.
38
Identify an intermediate-acting insulin preparation.
NPH (Humulin N, Novolin N)
## Footnote
NPH insulin is typically used for basal coverage.
39
What is the duration of Insulin glargine U-100 (Lantus)?
20–24 hours
## Footnote
Lantus is used for long-term glycemic control.
40
Which insulin preparation has no peak?
Insulin degludec U-100, U-200 (Tresiba)
## Footnote
This allows for more stable blood glucose levels.
41
What is the peak time for Insulin lispro U-100?
35–40 min.
## Footnote
The quick peak helps in managing postprandial blood glucose spikes.
42
Fill in the blank: The combination product 70% NPH/30% regular is known as _______.
Humulin 70/30, Novolin 70/30
## Footnote
This combination provides both basal and bolus coverage.
43
How long does Insulin detemir (Levemir) last?
5–8 hours
## Footnote
Levemir provides a consistent level of insulin over time.
44
True or False: Insulin glargine U-300 (Toujeo) has a duration of 36 hours.
True
## Footnote
This extended duration is beneficial for once-daily dosing.
45
What is the onset time for Insulin glargine U-300?
1 hour
## Footnote
This rapid onset helps in achieving stable insulin levels.
46
List the components of the combination product Humalog 75/25.
* 75% NPL
* 25% lispro
## Footnote
This combination is used for both basal and prandial control.
47
What is the duration of action for Insulin degludec?
36 hours
## Footnote
This long duration allows for flexible dosing schedules.
48
Identify the peak time for short-acting insulin.
2–4 hours
## Footnote
Short-acting insulin is typically used for meal coverage.
49
Fill in the blank: Insulin glulisine (Apidra) is classified as a _______ insulin.
Rapid-acting analog
## Footnote
It is used for controlling blood sugar spikes after meals.
50
How long does the effect of regular insulin last?
3–5 hours
## Footnote
This makes it suitable for managing blood glucose levels during meals.
51
What are the currently available basal insulin preparations?
Basal insulin options include:
* Long-acting analogues (detemir, glargine U-100, glargine U-300, degludec)
* Neutral protamine Hagedorn (NPH) insulin
## Footnote
See Table 3.1 for a complete list of products and their pharmacodynamics profiles.
52
What is a disadvantage of NPH insulin as a basal insulin?
NPH insulin has a distinct peak effect and does not last a full 24 hours.
53
How often must NPH insulin be administered in patients with type 1 diabetes?
Twice daily.
54
What are the pharmacodynamic advantages of insulin glargine U-300 and insulin degludec?
They have no peak effects and durations of action that exceed 24 hours.
55
What is the recommended timing for taking rapid-acting insulin?
5 to 10 minutes before meals and snacks.
56
When can rapid-acting insulin be taken 15 to 30 minutes before meals?
If the premeal BG is higher than 130 mg/dL.
57
When should fast-acting insulin aspart (Fiasp) be taken?
At the beginning of the meal or within 20 minutes after starting the meal.
58
What is the recommended timing for taking human regular insulin?
15 to 30 minutes before meals.
59
When should basal insulin be taken?
Once a day at the same time each day.
60
What should be done if nocturnal hypoglycemia occurs from taking glargine or detemir at bedtime?
Split the dose so that 50% is taken in the morning and the other 50% in the evening.
61
How frequently should doses of insulin glargine U-300 and degludec be adjusted?
Not more frequently than every 3 to 4 days.
62
What is the role of SMBG in diabetes management?
To permit well-informed adjustments in insulin doses.
63
How many times daily should patients on intensive insulin therapy perform SMBG?
At least four times daily.
64
When should patients test their blood glucose if they experience symptoms of hypoglycemia?
Always test before driving.
65
What is an insulin pump?
A small, lightweight, portable, battery-operated device for insulin delivery.
66
What are the two types of insulin pumps?
Patch pump and traditional pump.
67
What does a traditional insulin pump consist of?
A pump reservoir, infusion set, and cannula.
68
What is the function of a patch pump?
It is tubing free and attaches directly to the body.
69
What are the patient's responsibilities before insulin pump therapy can be initiated?
Commit 2 to 3 months to training and demonstrate BG monitoring ability.
70
What should patients keep logs of before starting insulin pump therapy?
BG readings, insulin doses, and food consumed.
71
What are the currently available insulin pumps?
MiniMed Paradigm Revel, Omnipod, t:slim X2
## Footnote
These insulin pumps are designed to deliver insulin continuously to manage diabetes.
72
What are the currently available continuous glucose monitors?
G4 Platinum, G5, G6, Guardian Connect, FreeStyle Libre Flash system
## Footnote
These devices continuously monitor glucose levels to help manage diabetes.
73
Which insulin pump is associated with Medtronic Diabetes?
MiniMed Paradigm Revel
## Footnote
Medtronic Diabetes offers several insulin pump models.
74
Which company manufactures the Omnipod insulin pump?
Insulet Corporation
## Footnote
Insulet Corporation specializes in insulin delivery systems.
75
What is the website for Tandem Diabetes Care?
www.tandemdiabetes.com
## Footnote
This website provides information about their insulin delivery products.
76
What is the MiniMed 670G equipped with?
Guardian Sensor
## Footnote
This combination helps in automated insulin delivery.
77
Fill in the blank: The FreeStyle Libre Flash system is a type of _______.
continuous glucose monitor
## Footnote
This system allows users to check their glucose levels without fingersticks.
78
True or False: The MiniMed 630G uses the Enlite sensor.
True
## Footnote
The Enlite sensor is used for glucose monitoring in this model.
79
Which continuous glucose monitor is offered by Abbott?
FreeStyle Libre Flash system
## Footnote
Abbott focuses on innovative diabetes management solutions.
80
What is the website for Dexcom?
www.dexcom.com
## Footnote
Dexcom specializes in continuous glucose monitoring systems.
81
What is insulin pump therapy?
A dosing strategy that mimics physiologic insulin secretion.
82
What are the benefits of insulin pump therapy?
Benefits include:
* Better, more precise glucose control
* Less glycemic variability
* Reduction in frequency and severity of hypoglycemia
* Ability to adjust basal rates throughout the day
* Extended bolus dose durations for high-fat meals
* Improved flexibility of lifestyle
* Ability to administer small amounts of insulin (as little as 0.025 units)
* Protection from overcorrection by tracking active insulin
* Integration with CGM technology
83
What are the limitations of insulin pump therapy?
Limitations include:
* Higher cost compared to MDI regimen
* Device must be worn 24 hours a day
* Requires highly motivated, competent patients
* Requires a higher level of training
* Needs strong support from a diabetes team
* Infusion site infections
* Risks of DKA if insulin delivery is interrupted
84
What is CGM?
Continuous Glucose Monitoring (CGM) devices report interstitial glucose levels in real time and provide insights into glucose trends.
85
What are the components of traditional CGM systems?
Components include:
* A sensor placed just under the skin
* A transmitter attached to the sensor
* A separate receiver that collects and displays glucose data
86
How frequently do CGM devices update glucose levels?
Every 5 minutes.
87
What is the purpose of alerts in traditional CGM devices?
To notify patients when glucose levels are too high or too low or are changing rapidly.
88
What is the difference between traditional CGM and intermittent or 'flash' CGM systems?
Flash CGM only communicates readings on demand, does not have alarms, and does not require calibration with SMBG.
89
What is the MiniMed 670G system?
The first hybrid closed-loop system that provides automated insulin delivery by adjusting basal insulin every 5 minutes based on CGM data.
90
What is carbohydrate counting?
A method used to estimate meal-time insulin doses by matching bolus insulin doses to food intake.
91
What are common foods that contain dietary carbohydrates?
Common foods include:
* Starch: cereals, grains, beans, bread, rice, pasta, starchy vegetables
* Sugar: lactose, fructose, sucrose
* Fiber: cellulose, hemicellulose, lignins, gums, or pectins
92
How is the number of carbohydrates counted?
By measuring and weighing foods and using nutrition labels or carbohydrate reference books.
93
What does the C:I ratio represent?
The ratio used to estimate how many grams of carbohydrate each unit of rapid-acting insulin will cover.
94
How do you determine an initial C:I ratio?
By dividing 550 by the total daily dose (TDD) of insulin.
95
What is an example of an initial C:I ratio?
For a TDD of 57 units, the initial C:I ratio would be 10:1.
96
How do you adjust the C:I ratio once established?
By monitoring BG records before and after meals and adjusting if 2-hour postprandial levels exceed 50 mg/dL.
97
What are common causes of high BG?
Common causes include:
* Missing an injection or bolus dose
* Menstrual cycle
* Decreased activity
* Stress, illness, or infection
* Underestimating carbohydrates
* Steroids or other medications
98
What is the dawn phenomenon?
A rise in BG occurs in predawn hours due to increased growth hormone and cortisol production
## Footnote
This phenomenon can affect blood glucose readings and management.
99
What can cause high BG due to bad insulin?
High BG can occur when insulin denatures due to:
* Exposure to moderate-to-extreme temperatures
* Being beyond expiration date
* Vial or pen device used longer than manufacturer’s recommendations
## Footnote
Proper storage and handling of insulin are crucial for its effectiveness.
100
What technical problems with insulin pumps can lead to high BG?
Technical problems can include:
* Incorrectly programmed settings
* Depleted battery
* Pump malfunctions
* Incorrectly primed tubing
* Air bubbles in tubing
* Dislodged, bent, or kinked cannula
* Occlusion at infusion site
* Infusion set in place longer than 72 hours
## Footnote
Regular checks and maintenance of insulin pumps are necessary.
101
What dietary factor can cause high postprandial BG readings?
Coffee (caffeine) can raise BG after consumption due to:
* Increases in epinephrine
* Free fatty acid mobilization
* Subsequent worsening insulin resistance
## Footnote
This effect can occur even with black coffee, without cream or sugar.
102
What is a common issue with cereal consumption related to BG?
Patients often experience a rise in BG after consuming cereal, which may require a lower C:I ratio due to:
* Glycemic index of cereals
* Greater insulin resistance in the morning
## Footnote
Adjustments in insulin may be necessary for managing BG levels effectively.
103
What is a source of high BG readings from food testing?
Residual food or dextrose on fingers can lead to high BG readings
## Footnote
It is important for patients to wash hands or wipe the first drop of blood before testing.
104
What types of meals may require more insulin due to high fat content?
Restaurant meals such as:
* Chinese food
* Mexican food
* Pizza
* Fried foods
## Footnote
These meals can cause insulin resistance and delayed digestion, necessitating split or extended bolus doses.
105
What is correctional insulin used for?
Correctional or supplemental insulin is used to reduce high BG detected before meals
## Footnote
This helps in managing pre-meal blood glucose levels effectively.
106
How is the initial correction factor (CF) estimated?
The initial CF is estimated by dividing 1650 by the TDD
## Footnote
In clinical practice, the CF formula constant can range from 1500 to 1800.
107
What was the initial CF calculated in the example provided?
The initial CF was calculated as 50:1
## Footnote
This means 1 unit of rapid-acting insulin will lower the BG about 50 mg/dL.
108
Fill in the blank: A high BG CF is the expected amount that _______ will decrease the BG under normal circumstances.
one unit of insulin
## Footnote
This is essential for determining how much correctional insulin to administer.
109
What is the C:I ratio in the example provided?
20:1
## Footnote
This ratio is used to calculate the amount of insulin needed per carbohydrate intake.
110
How many units of insulin are needed to cover a meal consisting of 80 g of carbohydrates with a C:I ratio of 20:1?
4 units
## Footnote
Calculation: 80 g / 20 = 4 units of insulin.
111
What is the correction factor (CF) in the example given?
60:1
## Footnote
This factor is used to calculate the amount of insulin needed to correct high blood glucose levels.
112
How do you calculate the correctional insulin needed if the preprandial blood glucose is 220 mg/dL and the target is 100 mg/dL with a CF of 60:1?
2 units
## Footnote
Calculation: (220 mg/dL - 100 mg/dL) / 60 = 2 units.
113
Using the previous calculations, how many total units of insulin should be taken before the meal?
6 units
## Footnote
4 units for carbohydrates + 2 units for correction.
114
When is a correction factor (CF) recommended to be used?
Before meals or at least 5 hours after the last bolus
## Footnote
This helps prevent hypoglycemia due to the accumulation of active insulin.
115
What should be done if a postprandial blood glucose reading is above 300 mg/dL?
Take a partial correction
## Footnote
Use one half of the usual premeal CF for safety.
116
What is the target level for blood glucose corrections between meals?
150 mg/dL
## Footnote
This is the expected blood glucose level 2 hours postprandial.
117
What is an example of using a half correction factor (CF) when postprandial glucose is 300 mg/dL?
1.3 units
## Footnote
Calculation: (300 - 150) / 60 = 2.5 units; half CF = 2.5 / 2 = 1.3 units.
118
How do you calculate an initial basal rate for insulin pump therapy?
Reduce TDD by 25% and use 50% of this reduced dose
## Footnote
This ensures a smooth transition from multiple daily injections (MDI) to insulin pump therapy.
119
What is the initial basal rate calculation if the current TDD of insulin is 50 units?
0.8 U/hr
## Footnote
Calculation: TDD reduction to 37.5 units, half is 18.75 units; 18.75 / 24 = 0.78 U/hr, rounded to 0.8 U/hr.
120
When should nighttime basal rate adjustments be made?
Before daytime basal rates are verified
## Footnote
Testing typically occurs during the first week of insulin pump therapy.
121
What factors may necessitate retesting of basal rates?
* Significant weight change
* Change in exercise routine
* Hormonal changes (e.g., puberty, menopause)
* As needed
## Footnote
These factors can affect insulin requirements.
122
What are the recommendations for verifying nighttime basal rates?
• Assess basal rate accuracy on three nights.
• Eat the evening meal early, preferably before 5 pm.
• Take the usual insulin bolus for dinner and correction, if needed.
• Choose a familiar meal or one with a known carbohydrate amount.
• Avoid meals with 15 to 20 g of fat, 10 g of fiber, and alcohol.
• Avoid any food or insulin bolus after the evening meal.
• Avoid exercise other than typical activity.
• Monitor BG at specified times.
• Stop the test if BG is < 70 mg/dL or > 250 mg/dL.
123
How are nighttime basal rate adjustments made?
• If BG levels change by 20 to 30 mg/dL, adjust the basal rate by 0.1 U/hr.
• Start adjustments 1 to 3 hours before the BG change.
• Continue until FBG is within the target range (80–130 mg/dL).
124
What is the procedure for making daytime basal rate adjustments?
• Skip breakfast and check BG every hour from 7 am to 12 noon.
• If BG changes by 20 to 30 mg/dL, adjust the basal rate by 0.1 U/hr.
• After setting the morning basal rate, skip other meals on separate days and repeat monitoring.
125
What is the role of Pramlintide in type 1 diabetes treatment?
Pramlintide delays gastric emptying, decreases inappropriate glucagon secretion, and increases satiety.
## Footnote
It is approved as an adjunct to insulin therapy for patients who have not achieved glycemic control despite optimal insulin therapy.
126
What is the recommended treatment for hypoglycemia?
• Take dextrose for a BG of < 70 mg/dL.
• Consume 15 g of a quick-acting carbohydrate.
• Wait 15 minutes and retest BG.
• If BG is still < 70 mg/dL, take additional dextrose.
• Eat a meal or snack once glucose normalizes.
127
Why does rebound hyperglycemia occur after hypoglycemia?
• Overtreatment with too much carbohydrate.
• No treatment may lead to hormone release and increased hepatic glycogenolysis.
• Foods with fat delay digestion, prolonging hypoglycemia.
128
What is the use of glucagon in treating severe hypoglycemia?
Glucagon raises BG when a person is unable to swallow due to a seizure or unconsciousness.
## Footnote
All patients using MDI or pump therapy should receive a glucagon emergency kit prescription.
129
What has studies demonstrated about optimal diabetes management?
It decreases chronic complications
## Footnote
This highlights the importance of effective diabetes management in preventing long-term health issues.
130
What is intensive insulin therapy also known as?
Basal-bolus therapy
## Footnote
This therapy is essential for mimicking normal pancreatic insulin secretion.
131
What type of insulin is required to manage blood glucose fluctuations due to hepatic glucose production?
Basal insulin
## Footnote
Basal insulin provides a steady level of insulin to maintain normal blood glucose levels.
132
How is bolus insulin matched to carbohydrate intake?
Using a carbohydrate-to-insulin ratio
## Footnote
This helps to manage blood glucose spikes after meals.
133
What is the purpose of correctional bolus insulin?
To reduce blood glucose to within normal limits
## Footnote
It is particularly effective when a high glucose correction factor is used.
