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Practical Management of Diabetes not DKA

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Type 1 Diabetes in Children. T1DM 99% childhood diabetes but only 5 10 ... Coeliac disease in 4.5% Eye problems. Diabetic retinopathy after 5y of diabetes ... – PowerPoint PPT presentation

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Title: Practical Management of Diabetes not DKA


1
Practical Management of Diabetes (not DKA)
  • Dr Susanna Hart
  • February2006

2
Type 1 Diabetes in Children
  • T1DM 99 childhood diabetes but only 5 10 all
    diabetes.
  • T2DM Increasingly common
  • Obesity
  • Sedentary lifestyle
  • Increasing insulin resistance
  • FH
  • MODY
  • rare single gene defect with
  • faulty insulin secretion
  • low insulin requirement
  • no ketosis.
  • Autosomal dominant

3
Why did I develop T1DM?
  • Genetic predisposition
  • HLA types allele DQB10302 and DQA10301 increase
    risk of diabetes
  • HLA types allele DQB10602 decrease risk of
    diabetes
  • Autoimmune destruction of pancreas by
  • GAD (Glutamic acid decarboxylase) antibodies
  • IA-2 (Islet Cell ) antibodies (Tyrosine
    phosphatase like protein)
  • IAA (Insulin ) antibodies destroy B cells
    especially under 5y age
  • Also used to predict risk of diabetes developing
  • GAD 28 GAD IAA 41 GAD IAA IA2 49
  • PLUS viral infections ? Cocksackie ? Parvovirus

4
What are we trying to do in managing T1DM?
  • Eliminate hyperglycaemic symptoms
  • Prevent DKA and hyperosmolar coma
  • Restore lean body mass, Height velocity and
    Weight gain
  • Improve physical exercise capacity
  • Reduce infection frequency

5
Insulin needed by GLUT4 transporter to move
glucose into cells
  • CHO
  • FAT
  • PROTEIN
  • Counter-regulatory hormone stimulation
  • Hyperglyceamia
  • Dehydration
  • Electrolyte disturbance
  • Ketosis
  • Metabolic acidosis

6
Counter-regulatory hormones
  • Epinephrine (Adrenal)
  • Growth Hormone (Pituitary)
  • Cortisol (Pituitary)
  • Glucagon (Pancreas)
  • Impair insulin secretion (E)
  • Antagonise action of insulin (E/C/GH)
  • Promote glycogenolysis and gluconeogenesis
    (E/C/GH)
  • Makes hyperglycemia worse and metabolic
    decompensation
  • Lipolysis increases, causing hypercholesterolaemia
    , increased triglycerides and ffa

7
INSULINS
  • Rapid acting (Insulin Aspartate Novorapid)
  • Onset 10-15m Peak 60m Lasts 4-5h
  • Used in 2,3 and 4 injection day regimes
  • Flexible
  • Use at or after meals
  • Reduces nocturnal hypoglycemia
  • Improves post prandial BG

8
Intermediate INSULIN
  • Isophane NPH Insulatard
  • May be replaced by insulin detemir in the future
    Levemir
  • Used with rapid acting insulin in 2 or 3
    injection regimes

9
Long acting Insulin
  • Glargine Lantus
  • 2 additional arginine molecules added to NH2
    terminal of the B chain and glycine substituted
    for asparagine at position 21 of A chain
  • Soluble at pH4, precipitates at neutral pH
  • Slow even action over 24h with no peaks
  • Cannot be mixed

10
How do you start giving insulin?
  • Usually need 0.5 1 unit / kg / day total
    insulin
  • May need 1.5 units / kg/day in some teenagers
  • Work out daily dose
  • Decide if giving 2 or 3 or 4 injections a day

11
Most children under 10 years cannot adequately be
in charge of insulin dose at school
  • Twice daily
  • When do they eat most?
  • Give 2/3 pre breakfast and 1/3 pre supper
  • At each dose give 1/3 RA and 2/3 IA
  • Advantages
  • Less injections
  • School manages
  • Disadvantages
  • Less easy to control
  • Rigid mealtimes and CHO content
  • Exercise difficult
  • Less good control
  • Hypos with unscheduled activity

12
3 or 4 times daily injection is more flexible,
less nocturnal hypos ?? Better control 4 blood
tests
  • 3 injections
  • Total daily dose divided as
  • 2/3 pre breakfast (1/3 RA 2/3 IA)
  • 1/3 left divided again into 1/3 RA given pre
    supper and 2/3 IA given pre bed
  • Weight 30kg
  • Total insulin is 30 units/day (20 and 10)
  • Pre breakfast give 7 units Novorapid with 13
    units Insulatard
  • Pre supper give 3 units Novorapid
  • Pre bed give 7 units Insulatard

13
4 injections a day Basal Bolus
  • Weight
  • Total dose/day at say 1 unit /kg/day
  • 40 60 as Long acting Insulin
  • 60 40 left divided into 3 as RA pre meals
  • Weight 40kg
  • TDD is 40 units insulin
  • Lantus
  • 20 units pre bed
  • Novorapid
  • 8 units pre breakfast
  • 9 units pre lunch and
  • 9 units pre supper

14
How do we know dosage is correct and how do we
change it?
  • Aim is pre meal BG 4 7
  • 3 monthly HbA1C lt 7.4 (8.4 in young children)
  • If pre breakfast BG high/low increase/decrease
    evening IA or LA until in normal range.
  • Check 3am BG to look for nocturnal hypoglycemia

15
How do we know dosage is correct and how do we
change it?
  • Pre lunch BG high/low
  • Increase/decrease RA pre breakfast insulin
  • Pre supper BG high/low
  • Increase/decrease pre breakfast IA insulin if 2X
    regime
  • Increase /decrease pre lunch RA insulin if 4 X
    regime
  • Pre bed BG high/low
  • Increase/decrease pre supper RA insulin

16
BUT..
  • More/Less food/CHO/complex or not
  • Too much / too little insulin
  • Injection site
  • Exercise or not
  • Infection
  • Emotion

17
How much and how often do we change insulin
dosage?
  • Most children by 1 unit and see what happens for
    1 or 2 days and then change again. Adolescents
    maybe 2 units
  • Lantus (LA) change every 4 days or more

18
Pen or Syringe?
  • Pens
  • Easy to use
  • Painful?
  • Discreet
  • Correct dosage
  • Expensive
  • 5 8mm needles at 45

19
Why are we fussed about glycaemic control and
HbA1C ?
  • Retinopathy
  • Nephropathy
  • Cardiovascular Disease
  • Neuropathy
  • Fetal and Maternal Morbidity
  • Hypercholesterolaemia and hypertryglyceridaemia

20
Outpatient Screening
  • 3 monthly
  • HbA1C
  • AIM 7.4
  • Ht Wt BMI
  • BP
  • Annually
  • Retinal screen
  • Lipids
  • Early am albumin/creatinine urine ratio
  • TSH
  • Endomyesial ab
  • Flu vaccine Pneumovax
  • Psychological
  • Dietician

21
Coeliac disease in 4.5
22
Eye problems
23
Diabetic retinopathy after 5y of diabetes
24
Diabetic complications
  • Autoimmune thyroid disease
  • Thyroid antibodies
  • TSH
  • Hypercholesterolaemia
  • FH Lipids LDL lt 2.6 and cholesterol
  • Diet Statins
  • Nephropathy
  • Microalbuminuria is a marker for proliferative
    retinopathy and macrovascular complications
  • ACE inhibitors help by lowering renal vascular
    resistance
  • Rare before puberty

25
Diabetic complications
  • Social Services
  • CAMHS
  • DLA
  • Diabetes UK
  • Depression
  • Eating disorder
  • Risk taking
  • Rebellion
  • Excess responsibility
  • Smoking
  • Alcohol
  • Driving

26
OPD Discussion points
  • Glucose testing !! 4 X day several times a week
  • BG results
  • School
  • Travelling
  • Sick Day Rules
  • Hypoglycemia
  • Feet
  • Injection sites

27
Rotate sites at same meal each dayFastest
absorption from abdomen, slowest thighsBeware
lipohypertrophy
28
Hypoglycemia
  • Great parental concern
  • Asymptomatic at night
  • Deaths X 2 normal child (DKA and CO)
  • Dawn phenomena
  • Hypoglycemia unawareness
  • Alcohol
  • Sports
  • Illness
  • Xs insulin

29
Sick Day Rules
30
Travelling
  • Medical insurance
  • Facilities
  • Letter for syringes/info
  • 2 supplies of insulin etc in different cases
  • Cool bag
  • Snacks Glucose
  • Novarapid
  • Hypoglycemia
  • EAST
  • Each zone loses 1 hour
  • 6h loss reduce last insulin by 20 25 depending
    on flight times
  • WEST
  • Gain an hour each zone so extra dose required
  • 3hours or less, no chnge

31
Exercise
32
The Team MOST important
  • Senior Paediatric ward nurses
  • Paediatric dietician
  • Specialist Diabetic Nurse (1 / 100 children)
  • Specialist HV
  • Retinal Screening
  • Psychological support
  • Podiatry
  • Lead / Special interest Paediatrician

33
Future developments
  • Pumps
  • Nasal Insulin with Lantus
  • Pancreatic transplants

34
FAQs
  • I have run out of insulin
  • My insulin is green
  • Ive given the wrong dose too much extra CHO and
    regular checks, too little observe Bg and ketones
  • Not sure injected all insulin reassure check BG
    and ketones
  • Just had a seizure check BG, give glucagon
  • Child out drinking or taken drugs Check BG ensure
    food eaten wake at normal time in am for food and
    insulin

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