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Type 1 Diabetes

Type 1 Diabetes

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Type 1 Diabetes

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  1. Type 1 Diabetes Karen S. Penko, MD Fellow, Pediatric Endocrinology September 2005

  2. PREP Content Specifications • Recognize signs/symptoms • Know how to treat type 1 diabetes • Know the value of hemoglobin A1c • Know the natural history • Counsel patients on self-management • Differentiate Somogyi & dawn phenomena

  3. PREP Content Specifications • Know how to manage sick days • Know the long-term complications • Know importance of blood glucose control in preventing long-term complications • Recognize the association with other autoimmune disorders

  4. Gary Hall Jr. Olympic swimming medalist Type 1 diabetes

  5. Case 1 • 18 y/o white male, father pages on-call peds endo: • Polyuria, polydipsia x 1 week • 16 y/o brother has type 1 diabetes • Using brother’s supplies, BG “high”, large urine ketones • What should we do? • Leaving for college next week

  6. Serum glucose Venous pH Bicarb UA Serum acetone Electrolytes 497 mg/dl 7.396 27 mmol/l 150 mg/dl ketones, + glucose Negative Na 133, K 4.2, Cl 94, BUN 14, creat 0.8 At WRAMC ED

  7. Diagnostic Criteria • Symptoms of diabetes and a casual plasma glucose 200 mg/dl, OR • Fasting plasma glucose 126 mg/dl, OR • 2-hour plasma glucose 200 mg/dl during an oral glucose tolerance test. • In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day.

  8. Presenting Signs/Symptoms • Polyuria, Polydipsia • Nocternal enuresis • Polyphagia • Weight loss • Fatigue, weakness • Blurry vision • Ketoacidosis: abdominal pain, nausea, vomiting, mental status changes

  9. Epidemiology • Prevalence 1:300 • Peak age of diagnosis: 11-13 y/o • Risk for sibling: 6% • Risk for monozygotic twin: 50% • Risk for offspring: 2-10%, higher side if father has diabetes • Highest incidence: Finland, Sardinia

  10. Pathophysiology • Autoimmune destruction of pancreatic -cell • Antibodies: • Islet cell • Insulin • Anti-glutamic acid decarboxylase 65 • T-cell mediated • Lymphocytic infiltration

  11. Pathophysiology • Genetic susceptibility • Association with HLA DR3/4, DQ 2/8 alleles • Environmental triggers • Viruses: congenital rubella, coxsackievirus, enterovirus, mumps • Early exposure to cow’s milk

  12. Progression to Type 1 DM Autoimmune markers (ICA, IAA, GAD) Autoimmune destruction Islet Cell Mass Honeymoon 100% Islet loss “Diabetes threshold”

  13. Associated Autoimmune Disorders • Thyroid (Hashimoto’s, Graves’): 5-10% • Celiac Disease: 6% • Addison’s disease: <1%

  14. Nicole Johnson Miss America 1999 Type 1 diabetes

  15. Management • Diabetes team • Insulin • Diet • Exercise • Psychological support

  16. Banting and Best 1923 Nobel Prize for discovery and use of insulin in the treatment of IDDM

  17. The Miracle of Insulin February 15, 1923 Patient J.L., December 15, 1922

  18. Novo Nordisk NovoLog (aspart) NovoLog Mix 70/30 Novolin R Novolin N Novolin 70/30 Sanofi-Aventis Lantus (glargine) Lilly Humalog (lispro) Humalog Mix 75/25 Humulin R Humulin N Humulin 70/30 Humulin 50/50 Lente, Ultralente have been discontinued Insulin Preparations - US

  19. Treatment with Insulin • Total daily requirement: • 0.5-1 unit/kg/day • 1.5 units/kg/day during puberty • Typical Regimens • NPH and Regular • Basal/Bolus: glargine and Novolog/Humalog

  20. Insulin Delivery • Vials and syringes • Pens • Insulin pump

  21. Physiological Serum Insulin Secretion Profile 75 Breakfast Lunch Dinner 50 Plasma insulin (µU/ml) Dawn phenomenon 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  22. NPH and Regular 75 Breakfast Lunch Dinner 50 R R Plasma insulin (µU/ml) N N 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  23. NPH and Regular 2/3 NPH 1/3 Regular AM 2/3 ½ NPH (2/3) ½ Regular (1/3) PM 1/3

  24. NPH and Regular • Regular insulin given 30 min prior to a meal • NPH dose often given at bedtime • Prescribed amount of carbs at meals/snacks

  25. NPH and Regular • AM blood glucoses → Evening NPH • Lunch → AM Regular • Dinner → AM NPH • Bedtime → PM Regular

  26. Basal/Bolus Breakfast Lunch Dinner Aspart Aspart Aspart or or or Lispro Lispro Lispro Plasma insulin Glargine 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  27. Basal/Bolus • Basal: glargine, 50% total daily dose • Bolus: NovoLog or Humalog • Insulin to carbohydrate ratio • Correction BG – target Correction factor

  28. Basal/Bolus • I:CHO = 450/total daily insulin dose = amount of carbs 1 units will cover • Correction Factor: “1700 rule” = 1700/TDD • Glargine can not be mixed with any other insulins

  29. Basal/Bolus • Glargine dose limited by which blood sugar? • 2 AM and breakfast • Which blood sugar is affected by the I:CHO ratio? • 2 hour post-prandial

  30. NPH and Regular • Advantages • 2-3 shots per day • “Easier” – less carb counting and calculations • Disadvantages • Strict dietary plan • Less flexible • Less physiologic

  31. Basal/Bolus • Advantages • More physiologic • More flexible • Less hypoglycemia • Disadvantages • More labor-intensive (CHO counting, insulin calculations) • At least 4 injections per day

  32. Diet • Healthy, balanced diet • 50-60% total calories from carbohydrate • <30% fat • 10-20% protein • Carbohydrate counting • No forbidden foods - moderation • Eating too much will not cause ketosis

  33. Exercise • Increases sensitivity to insulin • Helps control blood sugar • Lowers cardiovascular risk • Blood sugar usually decreases but may initially increase • Hypoglycemia may occur during, immediately after, or 8-24 hours later

  34. Exercise • Check blood sugar before, during, after • Always have snacks available • May need extra snacks or decreased insulin (learn from experience) • Usually 15 gm CHO for every 30 min vigorous exercise • Do not exercise if ketones are present

  35. Psychosocial Support • Every newly diagnosed family should meet with a psychologist • Guilt • Anger • Fear • Denial • Depression

  36. Case 1: Special Concerns for College Students • Independence • Dining hall food • Alcohol – lowers blood sugar • Roommate aware of diabetes, glucagon • Airline travel – prescription labels

  37. Case 1 • Discharged after teaching complete on • Glargine and Humalog • 0.7 units/kg/day • 3 weeks after diagnosis blood sugars begin going low • What is going on?

  38. Honeymoon Phase • Educate that it may happen • Diabetes is not cured! • Occurs within first 3 months of diagnosis • Insulin requirements <0.5 units/kg/day • Lasts weeks to up to 2 years • Resolution of glucotoxicity, recovery of residual β-cell function

  39. Case 1 • Blood glucoses continue to be so low that pt takes himself off all insulin • Normal blood glucoses for 5 months off insulin • Blood glucoses begin to rise • Homesickness • Depression

  40. Long Term Complications • Retinopathy • Nephropathy • Neuropathy • Cardiovascular disease • Prevention by optimal glucose control

  41. Conventional Therapy 1-2 injections/day Mean A1c 9% Intensive Therapy ≥3 injections/day Mean A1c 7% Diabetes Control and Complications Trial • 1983-1993, early termination given results • Intensive therapy delays onset and progression • of long-term complications in type 1 diabetes

  42. Diabetes Control and Complications Trial • Intensive therapy reduced risk by: • 76% for retinopathy • 54% for nephropathy • 69% for neuropathy • 41% for macrovascular disease • Adverse events • Hypoglycemia • Weight gain

  43. Case 1 – Follow-up visit • Home from college on break • Insulin requirement 0.5 units/kg/day • Physical exam • Monitoring for complications

  44. Physical Exam • Height, weight, BP • Pubertal progression • Thyroid • Abdomen • Shot sites - lipohypertrophy • Feet • Medical alert tag

  45. Necrobiosis Lipodica

  46. Prayer Sign Limited joint mobility Associated with: poor control, increased risk of retinopathy, nephropathy

  47. Monitoring • Hemoglobin A1c – every 3 months • Celiac screen – at diagnosis and if ssx • Annually • TSH • Ophthalmology exam - after 10 and 3-5 yrs disease • Urine microalbumin - after 10 and 5 yrs disease • Lipid panel - puberty, unless fam hx, q5 years if normal • Influenza vaccine

  48. Case 1 • Hemoglobin A1c - 6.0% • Ophthalmology exam – no retinopathy • TSH, FT4 – normal • Lipids – cholesterol 143 • Urine microalbumin - negative

  49. Hemoglobin A1c • Reflects blood glucose over the past 3 months • Goal <7 for adults <7.5% for teens <8% for 6-12 y/o 7.5-8.5% for <6 y/o

  50. Case 1 • 1 year after diagnosis, remains diligent about sending blood sugars • Insulin requirements 0.5 units/kg/day • A1c 5.9% • Interested in the insulin pump