Week 11 - Diabetes Flashcards
What is BORN and what is its mission?
Better Outcomes Registry and Network in Ontario
–> Improves care for individuals, children and youth by taking formation from population to optimize the HC system
–> Advocates for health promotion
What is type I DM?
Autoimmune destruction of beta cells
–> aka Insulin dependent
What causes t1DM?
Combination of genetics + environment
–> Autoimmune, HLA-6p21
What is DM type II?
Insulin resistance puts stress on the pancreas. Initially treated with diet and exercise.
Do most people with DM type 2 also have obesity?
Yes. Only 10% with DM2 do not.
What causes DM type 2? What comorbidities is it associated with?
Combination of genetics, ethnicity, environment, and comorbid conditions such as:
–> Obesity, dyslipidemia, PCOS, HTN, nonalcoholic fatty liver disease, obstructive sleep apnea
What are the new onset symptoms for DM type 1?
Polyuria, polydipsia, polyphagia (or anorexia)
N/V
Decreased energy, weight loss, dehydration, pale, irritability, UTI, DKA.
What are the new onset symptoms of DM type 2?
Can look like type one.
DKA and HHS in 25% of cases
Who should be routinely screened for DM type 2?
Those with a BMI > 85th percentile with one or more risk factors
What are some family hx risk factors for t2DM?
history in a first or second degree relative
What are some signs of insulin resistance?
Acanthosis nigricans
HTN
Dyslipidemia
PCOS
What is the relationship between LBW and diabetes?
Those with low birth weight are at higher risk of experiencing insulin resistance
How does maternal t2DM or GDM affect a child’s insulin response?
Child is more likely to experience insulin resistance later in life
What blood sugar readings (fasting, 2 hour post prandial) indicate DM?
Postprandial (or ever): >11 mmol/L
Fasting > 7 mmol/L
What HcA1C indicates poorly maintained blood sugars or DM diagnosis?
> /= 6.5%
What is an important factor in diagnosing t1DM?
Anti-GAD autoantibody positive
Why would a child living with DM be admitted to CHEO?
DKA
Non diabetes related surgery, illness, or infection
Eating disorders and other mental health challenges
Social issues
What diet is helpful for t1DM?
There is no diet for youth/children with t1DM - nutrition requirement are the same age matched peers
Beneficial to limit foods high in sugar like juice, syrup, candy (just like all of us!)
What are the rapid insulins? When are they given before meal?
Lispro, aspart, glulisine
–> Given 10-15 minutes before meal
What are the short acting insulins? When are they given?
Regular, Toronto
–> given 30 minutes before meal
What are the long acting insulins? How long can they last?
Lantus (glargine), detemir, Tresiba (degludec)
–> Can last 24-42 hours
Diabetes management is based on which three pillars?
Insulin, nutrition, activity.
What is BID insulin?
Mix of rapid and intermediate insulin twice a day.
BGL testing 4 times a day: Ac, HS
What two insulin regimens do not offer great control?
BID & TID
What is TID insulin?
Rapid and intermediate - intermediate at bedtime. Three injections daily.
Can use a long acting instead of intermediate at bedtime.
How are insulin regimes chosen?
Based on pt age, abilities, finances, and family support.
What are the advantages of BID/TID?
Simple and straightforward - less injections.
Good for structured lifestyles
Can work well during the honeymoon phase
Why does the honeymoon phase occur in t1DM?
Initial support does not need to be as high when 20% of beta cells are still functional. This can last weeks or months
What are the disadvantages of BID/TID insulin therapy?
Fixed timing of meals and carbs at each meal
Must eat snacks to prevent lows
Increased risk for hypoglycemia
Intermediate insulin is outdated and difficult to titrate to meet insulin needs
This routine is not recommended and should be changes to an MDI or pump
What is the routine for multiple times daily insulin?
Basal insulin (24 hour) given once daily
Meals and corrections done with rapid insulin with a insulin-to-carbohydrate ratio via sliding scale.
BGL testing 4+ times daily.
What insulin does an insulin pump deliver at what rate?
Uses only fast/rapid acting insulin to deliver an automatic basal rate to cover background requirements and keep levels stable through day.
–> pump user can deliver extra bolus to cover carbs in meals and snacks. The pump can also deliver a correction bolus for occasional high blood sugars.
Still need to test BGL minimum 4 times daily.
What are some advantages of MDI therapy?
Flexibility and opportunities to adjust with activity, more choice to initiate insulin
Less variability in BGLs
Resembles physiological management and improves HbA1C. Less hypoglycemia.
What are some benefits of Pump insulin therapy?
Same as MDI plus…
Different types of boluses, temporary basal rates, less injections, and option for automation.
What are some disadvantages of MDI therapy?
Increased BGL monitoring + carb counting
Intense regime requiring commitment and memory, heavy parental involvement. Supervision for lunch and afternoon snack injection.
Needs more needles
May also need BID long-acting
What are some disadvantages of pump insulin therapy?
Risk for DKA d/t only rapid insulin.
More trouble shooting.
Parental involvement
Increased BGL monitoring
Carb counting
Cloudy insulin needs to be mixed, rolled, dipped how many times?
12
In which order should we teach families to draw up clear/cloudy insulin?
Clear –> Cloudy
To see bubbled
What temperature should families be instructed to to store insulin at?
Room temperature
How long should we avoid an injection site that has developed lipohypertrophy?
3 months.
What length needle do we inject insulin for children?
4 mm
Move up 5-6mm for adults or teens if needed.
What does flash/continuous glucose monitoring tell us? What are its advantages and disadvantages?
It reads interstitial fluid’s sugar levels
–> Useful for big picture trends, esp while sick, exercising, or overnight.
–> Downside is that is can lag behind the true BGL, it can fall off, and that is needs a warm up time when a new sensor it applied.
What kinds of continuous glucose monitoring be integrated with a pump? Which cannot?
Dexcom G6 CGM + Medtronic Guardian
–> Can be integrated
Freestyle Libre GCM
–> Cannot integrate
How often does CGM of FGM need to be changed?
7-15 days
How long does a glucose pump last?
Needs to be changed every 3 days.
How can we prevent hypoglycemia?
- Decrease insulin or eat extra food for exercise/activity
- Eat all carbs that insulin was given for
- Be accurate with counting and dosing
What dose of fast acting glucose should be given for hypoglycemia?
0.3g/kg
How can we prevent hyperglycemia in diabetes?
- Illness management - may need more insulin
- Accurate carb counting, timing of meals, accurate dosing
When should ketones be assessed in a diagnosed diabetic?
If BGL 14 mmol/L with illness OR
> 17 mmol/L twice 2-4 hours apart while well.
How can ketones be assessed?
with urine or blood, although blood is more reliable
DKA can look like the stomach flu. What symptoms make it resemble this?
Cramping, N/V, tiredness.
What are symptoms of DKA?
Abd cramps, N/V, tiredness, fast shallow breathing, fruity breath, decreased consciousness
How can we treat DKA?
Correct acidosis first, then BGL
Mild-moderate can be corrected in the ER, admit if not
What is covered in the sessions for teaching with new diagnosis of DM?
1a - survival tips (glucometer, injections, when to call in)
1b - what is dm, sliding scale, full food diary, school, medical alert and prescriptions
2 - Diet with dietician
3 - Dietitian and rn: ketones, honeymoon, trends, CGM/FGM, emergencies
4 - Dietician and rn: hypoglycemia, illness management, screening for late effects, age based like drinking , driving, drugs.
Why is good sugar control so important in DM?
With poor glycemic control, complications can appear 2.5-3 years following diagnosis
With good control, they can be postponed 20+ years
