Type I DM Flashcards
T1DM pathophysiology
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
ADA crieteria for dianosing DM:
1. A1C
2. Fasting plasma glucose
3. Casual plasma glucose
4. 2-h plasma glucose
- A1C > or = 6.5%
- Fasting plasma glucose: >126mg/dl
- Casual plasma glucose: >200mg/dl AND symptoms of hyperglycemia/crisis
- 2h plasma glucose OGTT: >200mg/dl
- NGSP certified; DCCT standardized 2. 8hr fasting 3. polydipsia and polyuria 4. WHO guidelines
Prediabetes crieteria:
1. A1C
2. FBS
3. 2H plasma glucose
- A1C 5.7-6.4%
- FBS 100-125mg/dl
- OGTT 140-199mg/dl
Treatment options in T1DM (3)
- Insulin
- B-cell transplant
- Pancreas transplant
Synthetic form of B-cell induced amylin
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
Most common concentration of insulin
100units/ml / U100
others: U200, U300, U500
NPH 20U BID is equivalent to
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
Physiologic regimen of insulin
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
Total insulin daily dose
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
Most common method of insulin administration
SQ injection
Complications: Fibrosis or lipodystrophy
Limit injections to 1 site and rotate within the region
How is conservative supplemental dose of rapid acting insulin calculated?
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.
Gross finding on NPH vial that suggests its ineffectiveness
Frosting
Major adverse effect of tight glycemic control
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
Treatment of Hypoglycemia
15 to 20grams PO, IV, or IO repeated after 15 mins
Fructose does not cross BBB
SL glucose
40% dextrose gel, 1 teaspoon
Glucagon emergecy kit contains
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
Disposition in insulin overdose resulting to hypoglycemia
Short acting: if OD, observed for hours
Long acting: Admitted, may be discharged if caretaker can monitor blood glucose
Fruit juice
Dose: 1cup PO
Content: mostly fructose
8oz motts apple juice: 28g sugar
Honey
Dose: 1 TBSP PO
17g sugar glucose and fructose
Sugar containing soda
Dose: 12oz PO (one can)
pepsi: 41g sugar
sprite: 38g sugar
coke: 39g sugar
all mostlty fructose
Glucose tablet
Dose: 4 tabs PO
16g glucose
Glucose gel
Dose: 1 tube PO/SL
15g glucose
Insulin pump remarks (5)
- Basal rate 0.5 to 1.5u/hr
- May add daily long acting insulin for HR patietns
- Onset of ketoacidosis is rapid after pump failure or discontinuation
- interstitial monitoring is not reliable in the ED for diagnostic purposes
- Never disable the pump unless w DKA and to start insulin therapy
Treatment of undiagnosed diabetic with hyperglycemia without ketoacidosis
Low dose regular or rapid acting insulin: 1 unit per 30-50mg above 250-300mg/dl
or long acting 0.1-0,2u/kg
Treatment of undiagnosed diabetic with severe and symptomatic hyperglycemia
Regular or rapid acting insulin to reduce BG to 250 then discharge w metformin then ff up w endo in 24 hours
Transplant options in T1DM (4)
- Simultaneous pancreas and kidney
- Kidney then pancreas
- Pancreas alone
- Islet cell transpalntation (Edmonton protocol; insulin independence is short lived, many require exogenous insulin after 2 years)
Life long immunosuppresion is required
