Diabetes_vogt - Type 1 Diabetes Type Karen S. Penko, MD...

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Unformatted text preview: Type 1 Diabetes Type Karen S. Penko, MD Fellow, Pediatric Endocrinology September 2005 PREP Content Specifications PREP • • • • • • 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 Differentiate phenomena phenomena PREP Content Specifications PREP • • • Know how to manage sick days Know the long-term complications Know importance of blood glucose Know control in preventing long-term complications complications • Recognize the association with other Recognize autoimmune disorders autoimmune Gary Hall Jr. Gary Olympic swimming Olympic medalist medalist Type 1 diabetes Case 1 Case • 18 y/o white male, father pages on-call 18 peds endo: peds – Polyuria, polydipsia x 1 week – 16 y/o brother has type 1 diabetes – Using brother’s supplies, BG “high”, large Using urine ketones urine – What should we do? • Leaving for college next week At WRAMC ED At Serum glucose Venous pH Bicarb UA Serum acetone Serum Electrolytes Electrolytes 497 mg/dl 7.396 27 mmol/l 150 mg/dl ketones, + glucose Negative Na 133, K 4.2, Cl 94, BUN 14, Na creat 0.8 creat Diagnostic Criteria Diagnostic • Symptoms of diabetes and a casual Symptoms plasma glucose ≥ 200 mg/dl, OR • Fasting plasma glucose ≥ 126 mg/dl, OR Fasting • 2-hour plasma glucose ≥ 200 mg/dl 2-hour 200 during an oral glucose tolerance test. during • In the absence of unequivocal In hyperglycemia, these criteria should be confirmed by repeat testing on a different day. day. Presenting Signs/Symptoms Presenting • • • • • • • Polyuria, Polydipsia Nocternal enuresis Polyphagia Weight loss Fatigue, weakness Blurry vision Ketoacidosis: abdominal pain, nausea, Ketoacidosis: vomiting, mental status changes vomiting, Epidemiology 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 Risk father has diabetes father • Highest incidence: Finland, Sardinia Pathophysiology Pathophysiology • Autoimmune destruction of pancreatic β Autoimmune cell • Antibodies: Antibodies: – – – Islet cell Insulin Anti-glutamic acid decarboxylase 65 • T-cell mediated T-cell • Lymphocytic infiltration Pathophysiology Pathophysiology • Genetic susceptibility – Association with HLA DR3/4, DQ 2/8 alleles • Environmental triggers – Viruses: congenital rubella, coxsackievirus, Viruses: enterovirus, mumps enterovirus, – Early exposure to cow’s milk Progression to Type 1 DM Progression Autoimmune markers (ICA, IAA, GAD) Autoimmune destruction Islet Cell Mass Honeymoon “Diabetes threshold” 100% Islet loss Associated Autoimmune Disorders Disorders • • • Thyroid (Hashimoto’s, Graves’): 5-10% Celiac Disease: 6% Addison’s disease: <1% Nicole Johnson Nicole Miss America 1999 Type 1 diabetes Management Management • • • • • Diabetes team Insulin Diet Exercise Psychological support Banting and Best Banting 1923 Nobel Prize for 1923 discovery and use of insulin in the treatment of IDDM treatment The Miracle of Insulin Patient J.L., December 15, 1922 February 15, 1923 c. 1923 c. Insulin Preparations - US Insulin • 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 Lente, have been discontinued discontinued Treatment with Insulin Treatment • 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 Insulin Delivery Insulin • • • Vials and syringes Pens Insulin pump Physiological Serum Insulin Physiological Secretion Profile Secretion Plasma insulin ( µU/ml) 75 Breakfast Lunch Dinner 50 Dawn Dawn phenomenon phenomenon 25 4:00 4:00 8:00 12:00 16:00 Time Time 20:00 20:00 24:00 24:00 4:00 8:00 NPH and Regular Plasma insulin ( µU/ml) 75 Breakfast 50 Lunch R R N N 25 4:00 4:00 Dinner 8:00 12:00 16:00 Time Time 20:00 20:00 24:00 24:00 4:00 8:00 NPH and Regular AM 2/3 AM PM 1/3 2/3 NPH 1/3 Regular ½ NPH (2/3) ½ Regular (1/3) NPH and Regular NPH • Regular insulin given 30 min prior to a Regular meal meal • NPH dose often given at bedtime • Prescribed amount of carbs at Prescribed meals/snacks meals/snacks NPH and Regular NPH • • • • AM blood glucoses → Evening NPH AM Evening Lunch → AM Regular Dinner → AM NPH Bedtime → PM Regular Basal/Bolus Breakfast Lunch Plasma insulin Aspart or Lispro Dinner Aspart or Lispro Aspart or Lispro Glargine 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00 Basal/Bolus Basal/Bolus • Basal: glargine, 50% total daily dose • Bolus: NovoLog or Humalog Bolus: – Insulin to carbohydrate ratio – Correction Correction BG – target BG Correction factor Basal/Bolus Basal/Bolus • I:CHO = 450/total daily insulin dose = I:CHO amount of carbs 1 units will cover amount • Correction Factor: “1700 rule” = Correction 1700/TDD 1700/TDD • Glargine can not be mixed with any other Glargine insulins insulins Basal/Bolus Basal/Bolus • Glargine dose limited by which blood Glargine sugar? – 2 AM and breakfast • Which blood sugar is affected by the Which I:CHO ratio? I:CHO – 2 hour post-prandial NPH and Regular NPH • Advantages – 2-3 shots per day – “Easier” – less carb counting and Easier” calculations calculations • Disadvantages – – – Strict dietary plan Less flexible Less physiologic Basal/Bolus Basal/Bolus • Advantages – More physiologic – More flexible – Less hypoglycemia • Disadvantages – More labor-intensive (CHO counting, insulin More calculations) calculations) – At least 4 injections per day Diet 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 Exercise Exercise • • • • Increases sensitivity to insulin Increases Helps control blood sugar Lowers cardiovascular risk Blood sugar usually decreases but may Blood initially increase initially • Hypoglycemia may occur during, Hypoglycemia immediately after, or 8-24 hours later immediately Exercise Exercise • • • Check blood sugar before, during, after Always have snacks available May need extra snacks or decreased May insulin (learn from experience) insulin – Usually 15 gm CHO for every 30 min Usually vigorous exercise vigorous • Do not exercise if ketones are present Psychosocial Support Psychosocial • Every newly diagnosed family should Every meet with a psychologist meet • Guilt • Anger • Fear • Denial • Depression Case 1: Special Concerns for College Students College • • • • • Independence Dining hall food Alcohol – lowers blood sugar Roommate aware of diabetes, glucagon Airline travel – prescription labels Case 1 Case • Discharged after teaching complete on – Glargine and Humalog – 0.7 units/kg/day • 3 weeks after diagnosis blood sugars weeks begin going low begin • What is going on? Honeymoon Phase Honeymoon • • • • • • 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 Resolution residual β-cell function Case 1 Case • Blood glucoses continue to be so low that Blood pt takes himself off all insulin pt • Normal blood glucoses for 5 months off Normal insulin insulin • Blood glucoses begin to rise • Homesickness • Depression Long Term Complications Long • • • • Retinopathy Nephropathy Neuropathy Cardiovascular disease • Prevention by optimal glucose control Diabetes Control and Complications Trial Complications Conventional Therapy • 1-2 injections/day • Mean A1c 9% Intensive Therapy • ≥3 injections/day • Mean A1c 7% • 1983-1993, early termination given results 1983-1993, • Intensive therapy delays onset and progression Intensive of long-term complications in type 1 diabetes of Diabetes Control and Complications Trial Complications • Intensive therapy reduced risk by: – – – – 76% for retinopathy 54% for nephropathy 69% for neuropathy 41% for macrovascular disease • Adverse events – Hypoglycemia – Weight gain Case 1 – Follow-up visit Case • • • • Home from college on break Insulin requirement 0.5 units/kg/day Physical exam Monitoring for complications Physical Exam Physical • • • • • • • Height, weight, BP Pubertal progression Thyroid Abdomen Shot sites - lipohypertrophy Feet Medical alert tag Necrobiosis Lipodica Necrobiosis Prayer Sign Prayer Limited joint Limited mobility mobility Associated with: Associated poor control, increased risk of retinopathy, nephropathy nephropathy Monitoring Monitoring • • • Hemoglobin A1c – every 3 months Celiac screen – at diagnosis and if ssx Annually – – – – TSH Ophthalmology exam - after 10 and 3-5 yrs disease Ophthalmology Urine microalbumin - after 10 and 5 yrs disease Lipid panel - puberty, unless fam hx, q5 years if Lipid normal normal – Influenza vaccine Influenza Case 1 Case • • • • • Hemoglobin A1c - 6.0% Ophthalmology exam – no retinopathy TSH, FT4 – normal Lipids – cholesterol 143 Urine microalbumin - negative Hemoglobin A1c Hemoglobin A1C • Reflects blood Reflects glucose over the past 3 months months • Goal <7 for adults <7.5% for teens <7.5% <8% for 6-12 y/o <8% 7.5-8.5% for <6 y/o 7.5-8.5% BG 6 135 7 170 8 205 9 240 10 275 11 310 12 345 Case 1 Case • 1 year after diagnosis, remains diligent year about sending blood sugars about • Insulin requirements 0.5 units/kg/day • A1c 5.9% • Interested in the insulin pump )))) ))))) )))) Insulin Pump Candidates Insulin • Highly motivated • Willing to perform frequent blood Willing glucose monitoring glucose • Good control on basal/bolus regimen • Proficient at carbohydrate counting • Proficient at adjusting insulin doses with Proficient I:CHO and correction factor I:CHO Insulin Pump Insulin • • Only NovoLog or Humalog insulin Hourly basal rate: Hourly 1. 1. 2. 3. • 80% of total daily insulin dose Divided by 2 Divide by 24 Same I:CHO and correction factor Insulin Pump Insulin • Advantages – Mimics physiologic pancreatic secretion – Lifestyle – Accurate dosing – Less hypoglycemia • Disadvantages – No depot to protect from DKA – Labor intensive – Expensive Jason Johnson Jason Detroit Tigers Detroit Pitcher Pitcher Type 1 diabetes Type diagnosed age 11 diagnosed Wears insulin pump Wears on field on Case 2 Case • 9 y/o male with type 1 diabetes for 4 y/o years years • NPH and Regular insulin 2 shots per day • Total insulin dose = 0.8 units/kg/day • Relatively high AM numbers Case 2 Case B L D HS 200 110 106 120 220 97 102 115 198 105 132 110 241 99 96 122 Case 2 Case • What is going on? • What additional information do you What want? want? • 2AM blood sugar is 122 • Dawn phenomenon • To correct: Move evening NPH to To bedtime bedtime Case 2 Case • What if 2AM blood sugar was 59? • Somogyi phenomenon – rebound Somogyi hyperglycemia after hypoglycemia hyperglycemia • Treatment: decrease evening NPH Mary Tyler Moore Mary Type 1 diabetes Case 3 Case • 13 y/o black female, 2 week h/o polyuria, 13 polydipsia, 16 lb weight loss polydipsia, • Overweight, BMI 97% • Acanthosis nigricans on neck • 2 grandparents have type 2 diabetes Case 3 Case • • • • Initial glucose – 634 mg/dl Bicarb – 18 mmol/l UA >80 mg/dl ketones Serum ketones – negative • Type 1 or type 2? Risk Factors for Type 2 Risk • • • Obesity Acanthosis nigricans Family history • Maternal gestational diabetes Case 3 Case • • • • Islet cell antibodies – positive Anti-GAD 65 – positive Insulin antibodies – negative C-peptide - <0.5 • Type 1 Sick Day Management Sick • Never omit insulin • Insulin requirements are often greater Insulin with illness with • Hypoglycemia may be a problem, Hypoglycemia especially in younger children especially • Test blood sugars every 2-4 hours • Check urine ketones Sick Day Management Sick • Drink plenty of fluids (1 cup per hour) – Sugar-containing liquids for hypoglycemia • Need extra insulin to clear ketones – NPH/R: extra 20% of total dose as R q4 NPH/R: hours hours – Basal/bolus: correction dose q3 hours + Basal/bolus: additional 20% of calculated correction additional • ED for persistent vomiting Halle Berry Halle Actress Type 1 diabetes CGMS New Directions: Inhaled Insulin New PREP Questions PREP Question Question Which of the following statements regarding the Which development of type 1 diabetes is true? development A. Administration of parenteral insulin to those at risk has A. been proven to decrease the likelihood of developing diabetes diabetes B. HLA typing has not been shown to be useful in B. determining the risk of developing diabetes determining C. Most patients have complete destruction of the beta C. cells, with no residual function at the time of diagnosis. cells, D. The presence of antibodies against islet cells and insulin D. can be predictive of the risk of developing diabetes. can Answer Answer • D. The presence of antibodies against D. islet cells and insulin can be predictive of the risk of developing diabetes. the Question Question Which of the following statements regarding insulin Which therapy is true? therapy A. Inhaled insulin is not effective in children. B. Insulin pump therapy should be reserved for B. noncompliant adolescent patients. noncompliant C. Insulin therapy should be discontinued temporarily C. during the “honeymoon” period. during D. Rapid-acting insulin is beneficial because it decreases D. glycosylated hemoglobin levels over time. glycosylated E. Use of rapid-acting insulin can decrease postprandial E. hyperglycemia and night-time hypoglycemia. hyperglycemia Answer Answer • E. Use of rapid-acting insulin can E. decrease postprandial hyperglycemia and night-time hypoglycemia. night-time Question Question • You are seeing a 9 y/o boy who was You diagnosed with type 1 diabetes 2 years ago. He currently receives 2 daily injections of short- and intermediateinjections acting insulin. As part of your acting evaluation, you ask to see his blood glucose diary. You note that most of his readings over the last month have been around 200 mg/dL. His mother is unwilling to try a pump at this point. unwilling Question Question Which of the following management options is best? A. Increase the evening dose of short-acting insulin. B. Increase the morning dose of intermediate-acting B. insulin. insulin. C. Increase the morning dose of short-acting insulin. D. Obtain a hemoglobin A1c level, and if it is normal, D. continue the current insulin regimen. continue E. Split the evening dose to administer intermediateacting insulin at bedtime. Answer Answer • E. Split the evening dose to administer E. intermediate-acting insulin at bedtime. intermediate-acting SSG Mark Thompson SSG Deployed to Iraq with Type 1 Diabetes Resources Resources • www.childrenwithdiabetes.com • Clinical Practice Recommendations: Clinical January Diabetes Care, ADA website January • American Diabetes Association • Juvenile Diabetes Research Foundation ...
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