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Type 1 Diabetes Mellitus


Type 1 Diabetes Mellitus insulins Key s Type 1 vs. type 2 diabetes Lambert P, et al. Medicine 2006; 34(2): 47-51 Nolan JJ. Medicine 2006; 34(2): 52-56 ... – PowerPoint PPT presentation

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Title: Type 1 Diabetes Mellitus

Type 1 Diabetes Mellitus insulinsKey slides
Type 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

Goals of management
  • Manage symptoms
  • Prevent acute and late complications
  • Improve quality of life
  • Avoid premature diabetes-associated death
  • An individualised approach

Glycaemic control
Lifestyle (e.g. diet exercise)
Patient education
Eye care
Microalbuminuria kidneys
Foot care
Approximate 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
Which 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
  • 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

Tight control with intensive insulin reduces
development and progression of microvascular
complicationsDCCT. N Engl J Med 1993 329
  • 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

Are 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

What 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
  • 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

What 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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