Title: Type 1 Diabetes Mellitus
1Type 1 Diabetes Mellitus insulinsKey slides
2Type 1 vs. type 2 diabetesLambert P, et al.
Medicine 2006 34(2) 47-51Nolan JJ. Medicine
2006 34(2) 52-56
- Features of type 2 diabetes
- Usually presents in over-30s (but also seen
increasingly in younger people) - Associated with overweight/obesity
- Onset is gradual and diagnosis often missed (up
to 50 of cases) - Not associated with ketoacidosis, though ketosis
can occur - Immune markers in only 10
- Family history is often positive with almost 100
concordance in identical twins
- Features of type 1 diabetes
- Onset in childhood/adolescence
- Lean body habitus
- Acute onset of osmotic symptoms
- Ketosis-prone
- High levels of islet autoantibodies
- High prevalence of genetic susceptibility
3Goals of management
- Manage symptoms
- Prevent acute and late complications
- Improve quality of life
- Avoid premature diabetes-associated death
- An individualised approach
Glycaemic control
BP
Lipids
Lifestyle (e.g. diet exercise)
Patient education
Management
Eye care
Microalbuminuria kidneys
Foot care
4Approximate pharmacokinetic profiles of human
insulin and insulin analoguesHirsch IB. N Engl J
Med 2005 352 174-83
N.B. Duration of action will vary widely between
and within people NPH neutal protamine
hagedorn/isophane insulin
5Which insulin regimens are used?
- Regimen individualised depending on various
factors e.g. patient choice and cognitive
abilities, age, mealtimes, diet, exercise,
shiftwork, target HbA1C, risk or experience of
hypoglycaemia, previous control if already on
insulin. - Three basic regimens NICE. Type 1 diabetes
Clinical Guideline 15, 2004 - One, two or three insulin injections/day
- Multiple daily injection
- Continuous subcutaneous insulin infusion
OR
6Tight control with intensive insulin reduces
development and progression of microvascular
complicationsDCCT. N Engl J Med 1993 329
977-86
- Multicentre RCT (no of patients 1441)
- Insulin treatment intensive vs. conventional
- Mean 6.5 years
- Primary outcome
- development and progression of retinopathy
- (Change gt3 steps on fundus photography sustained
over 6 months DOO) - Secondary outcomes nephropathy, neuropathy,
cardiovascular events, adverse events - Observational follow up of DCCT cohort EDIC
study (no patients1375). All patients advised
intensive treatment - Diabetes Control and Complications Trial (DCCT)
- Epidemiology of Diabetes Interventions and
Complications (EDIC) - Disease oriented outcome, often used as proxy
measure for patient outcomes, which may be loss
of vision or reduced visual acuity
7Are insulin analogues better?
- Rapid-acting analogues
- Rapid-acting insulin analogues have only a minor
benefit over short-acting soluble insulin in most
type 1 diabetes patients (Ô 0.1 HbA1C). - Overall hypoglycaemia comparable effects with
soluble insulin. - Cautious approach until long-term efficacy and
safety data. - Expensive, but see NICE.
- Siebenhofer A, et al. Cochrane 2006, Issue 2
- Long-acting analogues
- In most studies, glycaemic control (HbA1C) with
insulin glargine and detemir appears to be
comparable to that achieved with daily or twice
daily isophane (NPH) insulin. - The incidence of hypoglycaemia is similar to or
slightly less than that of NPH. - Several studies suggest insulin glargine and
detemir reduce the incidence of nocturnal
hypoglycaemia compared with NPH, but it is
unclear whether this is due to the pharmacology
or frequency of admin of the basal insulin. - Cautious approach until long-term efficacy and
safety data. - Expensive, but see NICE.
- Warren E, at al Health Technology Assessment
2004 8(45) 1-72
8What is the optimum HbA1C threshold?NICE. Type 1
diabetes Clinical Guideline 15, 2004
- NICE
- Advise adults that HbA1Clt7.5 is likely to
minimise risk of developing diabetic eye, kidney
or nerve damage in long term. - Adults who want to achieve HbA1C down to, or
towards, 7.5 should be given all appropriate
support in their efforts to do so. - Advise patients with increased arterial risk
that approaching lower HbA1C levels (e.g. 6.5 or
lower) may be of benefit to them (and support
them). - Dont pursue tight control without discussing
pros and cons if risk/experience of hypoglycaemia
or effort to achieve target curtails QoL. - For children and young people, target HbA1Clt7.5
without frequent disabling hypoglycaemia. - Identified by albumin excretion rate,
features of metabolic syndrome, or other arterial
risk factors
9What is a NICE regimen?NICE 2004 Clinical
Guideline 15
- Multiple insulin injections regimens, in adults
who prefer them, should be used as part of an
integrated package of which education, food and
skills training should be integral parts DCCT. N
Engl J Med 1993 329 977-86 - Twice-daily insulin regimens should be used by
those adults who consider number of daily
injections an important issue in QoL - Biphasic insulin preparations are often the
preparation of choice in this circumstance - Biphasic rapid-acting insulin analogue premixes
may give an advantage to those prone to
hypoglycaemia at night - Such twice daily regimens may also help
- 1. those who find adherence to their agreed
lunch- time injection difficult - 2. adults with learning difficulties who may
require assistance from others
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