DM type 1

DM (short notes book)

Recall basic blood sugar regulation by endocrine pancreas

3 methods of diagnosing DM

Ø Fasting

> 120 mg/dl on 2 separate occasions = DM

100-120 = Prediabetes

< 100 = normal

ØAfter ingestion of 75 g glucose - at 2 hours >200mg/dl = DM

ØGlycosylated Hb > 6.3 = DM

When to diagnose impaired glucose tolerance?

After ingestion of 75 g glucose at 2 hours

venous plasma glucose – between 140 – 200

Classifcation of Diabetes Mellitus?

Primary - Insulin dependent diabetes mellitus (IDDM,type I) and Non insulin dependent diabetes ( NIDDM, Type II) (non obese and obese)

(Insulin dependency referes to development of ketoaciodosis in the in the absence of insulin therapy.)

Secondary

Pancreatic disease

Homornal abnormalities

Drug or chemical induced

Genetic syndromes

others

Classifcation of Diabetes Mellitus?

Primary - Insulin dependent diabetes mellitus (IDDM,type I) and Non insulin dependent diabetes ( NIDDM, Type II) (non obese and obese)

(Insulin dependency referes to development of ketoaciodosis in the in the absence of insulin therapy.)

Secondary

Pancreatic disease

Homornal abnormalities

Drug or chemical induced

Genetic syndromes

others

Type 1 Diabetes

Clinical Characteristics

Body habitus –

not obese

often have a recent history of weight loss,

Age

T1DM often present at an age close to puberty or earlier age.

Family history –

Up to 10 percent of patients with T1DM 10 %

Clinical Presentation

1) Classic presentation

new onset

Polyuria, polydipsia, weight loss

2) Diabetic ketoacidosis

3) Silent (asymptomatic) incidental discovery

Laboratory testing for DM type 1

Antibodies –

islet-specific pancreatic autoantibodies

glutamic acid decarboxylase (GAD)

40K fragment of tyrosine phosphatase (IA2)

insulin,

zinc transporter 8 (ZnT8)

Up to 30 percent of individuals with the classic presentation of T2DM have positive autoantibodies

Insulin and C-peptide levels – reduced

Prevalence of DM

Total 1 -2 percent

IDDM 25%

NIDDM 75%

Why treat diabetes?

It is a life long illness

Good control will delay the onset of complications and lengthen productive life

A wide ranging therapeutic armamentarium is available

Principles of management

Basic understanding of the disease

Training in Insulin administration

Blood glucose testing and testing for

Symptoms of hypoglycemia

Age based management targets

Infants

Toddlers

Preschool and early school-aged children

School-aged children

Adolescents

Adults

Complications of DM?

Macrovascular complications

cardiovascular (IHD, MI)

cerebrovascular (stroke)

peripheral vascular

Microvascular complications

Diabetic nephropathy

diabetic neuropathy

diabetic retinopathy

Associated autoimmune diseases in children and adolescents with type 1 diabetes mellitus

Autoimmune thyroiditis — Up to 20 percent of patients with type 1 diabetes have positive anti-thyroid antibodies (anti-thyroid peroxidase and/or anti-thyroglobulin), and 2 to 5 percent of patients with type 1 diabetes develop autoimmune hypothyroidism

Celiac disease — About 5 percent of patients with type 1 diabetes will develop celiac disease

Addison's disease — Less than 1 percent of children with type 1 diabetes have autoimmune adrenalitis.

Polyglandular autoimmune syndrome type 2 - Autoimune adrenal diseses + Autoimmune Hypothyroidism

5 historic types of insulin

1. Beef

2. Pork

Highly purified animal insulin ( Mono-component )

short acting (1-1.5 hrs onset

(Hypurin® Bovine Neutral and Hypurin Porcine Neutral)

4.Human insulin ( Human sequence insulin ) - see below

5. Insulin analogues - short acting and long acting (basal insulin)

>> What is C peptide?

>> Two ways of creating human sequence insulin?

Enzyme modification of pork or beef insulin

Recombinant gene technology

(Actrapid Novo Nordisk)

(Humulin Lilly)

I(nsuman rapid Aventis)

You know regular insulin story, what about insulin analogue story?

>> short acting insulin analogues? (RAPID ACTING)

Very rapid onset of action due to rapid dissociation to monomers (preprandial insulins )

Duration of action short

Insulin aspart ( Novo rapid- Novo )

Insulin lispro ( Humolog - Lilly )

Insulin Glulisine ( Apidra-Aventis )

>> intermemediate acting?

Isophane insulin - also known as neutral protamine Hagedorn NPH Short acting insulin ( Human or analogues ) mixed with protamine ( Novolin, Humalin )

Onset 2-4 hours

Peak 6-7 hours

>> biphasic insulin?

Human sequence mixd with protamine

Mixtard 30 (Novo Nordisk)

Insulin analogues mixed with protamine

Novomix ( Novo Nordisk)

Lente mixed with zinc? - used as cost effective in basal regimens

>> basal insulin (long-acting)?

INSULIN DETEMIR

(Recombinant human insulin analogue—long acting)

INSULIN GLARGINE

(Recombinant human insulin analogue— long acting)

( Lantus® (Aventis Pharma

Insulin Degludec

Hyperglycaemia in pregnancy - possibilities (3)?

Glycaemic goals in pregnancy?

Fasting < 100

2 hour post prandial < 140

Tailored diet in pregnancy?

Carbohydrates 50%

Proteins 20%

Fats 30 % of energy requirement calculated as follows

Underweight 40 K Cal / Kg present weight

Normal weight 30

Over weight 24

Obese 12

Pharmacotherapy in pregnancy?

Metformin

Insulin

Aspirin if risk factor for eclampsia

Most sulfonylurea Contraindicated in pregnancy

Post partum prolonged fetal hyperinsulaemic hypoglycemia

Fetal hyperisuinaemia

Fetal macrosomia

Using Insulin

1.How do I store insulin vials?

●Insulin vials should be stored in the middle compartment of a fridge (at 2-8°C) preferably in a plastic box, with the syringe and the needle in use

●Don't place it in the freezer compartment

●If you are using an insulin pen you need not keep it in the fridge

middle compartment of fridge and not door!

2. I don't have a fridge at home. Is there any other method of storing insulin vials?

●If you don't have a fridge, you could keep the vial in a cool shady place

●Place the insulin vial in an small clay pot, and play the mug in a clay pot of water in a cool shady place, away from heat

●Don't keep it in the kitchen, near a cooker, on electrical equipment or the front compartment of a vehicle

●Don't allow sunlight to fall on the insulin vials

●If you are living in a cold climate as in Nuwara Eliya, you may keep insulin vials at room temperature

3. If I have to travel away from home, what is the best way to carry insulin?

●Carry the insulin vial with a sealed pack of ice cubes in a box

●It could also be carried tied in a plastic bag, and kept hanging in a small flask containing ice cubes, not touching the ice

●Don't dip the insulin vial in water or ice

4. How do I select the insulin syringe and needle?

●You can use any sterile syringe of 1ml marked U-100

●Needle size should be 29-31G (Higher G needles are fine and therefore cause less pain)

●The length of the needle should be less than 8mm. For adults. For children 4-6mm length is recommended. Longer needles are not suitable as they can pierce the muscle

●Although this is a plastic disposable syringe meant for single use, it may be used 2-4 times without boiling.

5. What are the important steps to follow before injecting insulin?

●10-15 minutes before injection, take the box containing the insulin out of the fridge to reduce the coldness. Cold insulin causes more pain

●Wash your hands with soap and water and wipe before handling the insulin vial. It is very important to prevent infection at the injection site

●Cleaning the site of injection : Take the injection after a bath or body wash; or else wash the area with soap and water and air dry or wipe

●Identify the correct type of insulin to be injected

●Wipe the top of the insulin vial with a spirit swab

●If you are using both clear (short acting) and cloudy (long acting) insulin from the clear vial into syringe before drawing cloudy insulin

6. Where do I inject insulin?

●You need to change the area of injection every 2-3 months

●Within the same area, change the spot of injection daily. Don't use the same spot to inject insulin every time. This will make the skin at that spot very hard, and the insulin will not be absorbed into blood properly

7. How do I draw insulin from the vial?

●If you are using a cloudy form of insulin, roll the vial gently between your palms 20 times to evenly distribute the particles

●If you are using a pen containing cloudy insulin, tilt it 20 times to mix the cloudy insulin

●Drawing in some air to the syringe equal to your insulin dose and pushing it into the insulin vial makes it easier to draw insulin 8. How do I inject insulin correctly?

●Approach the skin gently

●Push in the needle at 90°to the skin quickly, (45° at the thigh) preferably use a skin fold

●Inject the insulin smoothly but don't withdraw the needle immediately. This may result in a drop or two of insulin coming out. Wait for 10s, then withdraw the needle quickly

●After injection, don't wipe needle with cotton wool. If the tip is bent, or contains blood, discard it. If not, recap the used needle, put it back in the plastic wrapper and place it in the box. The syringe and needle can be re-used 2-4 times (ideally should be used only once)

basal bolus or mixed biphasic....nowdays biphasic come already mixed and no need to mix but if mix then take short acting first and then long acting

insulin pen expensive but can beused temporarily if going out and embarassed

continuous insulin pumps can also be used but expensive 14 laks...but used mainly for type 1 which flucturates

ask whether have fridge, if not used someone elses..otherwise other methods..can be stored at room temp for one month.. *normally people come to diabetic clinic once every 2 months

At clinic must examine site of injection and palpate and see whether atrophy or lipohypertrophy

if still fluctating, then must see whether complinace and diet and life style and whether injecting well and whether stony hypertrophy which means it wont be absorbed properly. can be atrophy leading to hypoglycemia *must to inpect the site *insulin dose usually 0.3/kg/day..may go up to 0.5 *50% with meal as bolus

rest half given at night *regimens? - basal bolus..basal...biphasic...

Can check sugar at morning and after meals and then adjust *what given at night is the intermediate or long acting and what with meals is short acting. This is the ideal. In sri lnaka 60% with meals,,basal... at night Basal at night..bous before meals.. Or then biphasic twice daily. Mixtard insulin. 2/3rd morning. 1/3rd evening.