Type I DM

Question 1

T1DM pathophysiology

Answer 1

B-cell destruction -> absolute insulin deficiency

Mostly in children and young adults

Immune mediated and Idiopathic
Corner stone in managemetn: euglycemic control
Can result to spontaneous ketoacidosis

Question 2

ADA crieteria for dianosing DM:
1. A1C
2. Fasting plasma glucose
3. Casual plasma glucose
4. 2-h plasma glucose

Answer 2

1. A1C > or = 6.5%
2. Fasting plasma glucose: >126mg/dl
3. Casual plasma glucose: >200mg/dl AND symptoms of hyperglycemia/crisis
4. 2h plasma glucose OGTT: >200mg/dl

1. NGSP certified; DCCT standardized 2. 8hr fasting 3. polydipsia and polyuria 4. WHO guidelines

Question 3

Prediabetes crieteria:
1. A1C
2. FBS
3. 2H plasma glucose

Answer 3

1. A1C 5.7-6.4%
2. FBS 100-125mg/dl
3. OGTT 140-199mg/dl

Question 4

Treatment options in T1DM (3)

Answer 4

1. Insulin
2. B-cell transplant
3. Pancreas transplant

Question 5

Synthetic form of B-cell induced amylin

Answer 5

Pramlintide

Promotes staiety, slows gastric emptying, aids in suppressing post prandial glucagon secretion, reduced A1C

Given in patietns unable to achieve glucose control with insulin alone

AE: Nausea, severe hypoglycemia

Question 6

Most common concentration of insulin

Answer 6

100units/ml / U100

others: U200, U300, U500

Question 7

NPH 20U BID is equivalent to

Answer 7

Insulin glargine 40u OD

1 unit of insulin can be substituted for a longer or shorter acting as long as total daily dose is equivalent

Question 8

Physiologic regimen of insulin

Answer 8

1/2 daily requirement given as BASAL INSULIN (BID intermediate acting or OD Long acting

1/2 daily requirement as prandial doses of RAPID INSULIN 5-30 mins before each meal

prandial: 1 unit per 15g CHO or fixed amount

Question 9

Total insulin daily dose

Answer 9

0.4 to 1 u/kg/d

Half Prandial

Half basal

Methods of delivery: SQ, IV, Inhalation, Continuous SQ infusion using pump

IV takes effect in 10-15 mins

Question 10

Most common method of insulin administration

Answer 10

SQ injection

Complications: Fibrosis or lipodystrophy
Limit injections to 1 site and rotate within the region

Question 11

How is conservative supplemental dose of rapid acting insulin calculated?

Answer 11

T1DM: 1 unit per 50mg/dl above desired glucose level

T2DM: 1 unit per 30mg/dl above desired glucose level

to achieve a goal blood glucose of 100 milligrams/dL (5.5 mmol/L) in a patient with T1DM who has a glucose level of 350 milligrams/dL (19.5 mmol/L), administer 5 units of rapid-acting insulin.

Question 12

Gross finding on NPH vial that suggests its ineffectiveness

Answer 12

Frosting

Question 13

Major adverse effect of tight glycemic control

Answer 13

Hypoglycemia

<70mg/dl

Other factors aside from insulin: Surge of glucagon is absent and Epinephrine secrtion is blunted (neuropathy, age autonomic dysfunction. these two along with beta blocker use result to hypoglycemic unawareness or hypoglycemia assocaited autonomic failure

Question 14

Treatment of Hypoglycemia

Answer 14

15 to 20grams PO, IV, or IO repeated after 15 mins

Fructose does not cross BBB

Question 15

SL glucose

Answer 15

40% dextrose gel, 1 teaspoon

Question 16

Glucagon emergecy kit contains

Answer 16

1mg of IM glucacon

Results to glycogenolysis in 10 to 15 mins
Once able to swallow, give oral
Not effective if glycogen depleted
causes N/V = difficult to feed

Question 17

Disposition in insulin overdose resulting to hypoglycemia

Answer 17

Short acting: if OD, observed for hours

Long acting: Admitted, may be discharged if caretaker can monitor blood glucose

Question 18

Fruit juice

Answer 18

Dose: 1cup PO
Content: mostly fructose
8oz motts apple juice: 28g sugar

Question 19

Honey

Answer 19

Dose: 1 TBSP PO

17g sugar glucose and fructose

Question 20

Sugar containing soda

Answer 20

Dose: 12oz PO (one can)
pepsi: 41g sugar
sprite: 38g sugar
coke: 39g sugar

all mostlty fructose

Question 21

Glucose tablet

Answer 21

Dose: 4 tabs PO
16g glucose

Question 22

Glucose gel

Answer 22

Dose: 1 tube PO/SL
15g glucose

Question 23

Insulin pump remarks (5)

Answer 23

1. Basal rate 0.5 to 1.5u/hr
2. May add daily long acting insulin for HR patietns
3. Onset of ketoacidosis is rapid after pump failure or discontinuation
4. interstitial monitoring is not reliable in the ED for diagnostic purposes
5. Never disable the pump unless w DKA and to start insulin therapy

Question 24

Treatment of undiagnosed diabetic with hyperglycemia without ketoacidosis

Answer 24

Low dose regular or rapid acting insulin: 1 unit per 30-50mg above 250-300mg/dl

or long acting 0.1-0,2u/kg

Question 25

Treatment of undiagnosed diabetic with severe and symptomatic hyperglycemia

Answer 25

Regular or rapid acting insulin to reduce BG to 250 then discharge w metformin then ff up w endo in 24 hours

Question 26

Transplant options in T1DM (4)

Answer 26

1. Simultaneous pancreas and kidney
2. Kidney then pancreas
3. Pancreas alone
4. Islet cell transpalntation (Edmonton protocol; insulin independence is short lived, many require exogenous insulin after 2 years)

Life long immunosuppresion is required