Practical Management of Diabetes not DKA

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Practical Management of Diabetes (not DKA)

• Dr Susanna Hart
• February2006

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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

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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

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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

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Insulin needed by GLUT4 transporter to move
glucose into cells

• CHO
• FAT
• PROTEIN
• Counter-regulatory hormone stimulation

• Hyperglyceamia
• Dehydration
• Electrolyte disturbance
• Ketosis
• Metabolic acidosis

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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BUT..

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

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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

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Pen or Syringe?

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

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Why are we fussed about glycaemic control and
HbA1C ?

• Retinopathy
• Nephropathy
• Cardiovascular Disease
• Neuropathy
• Fetal and Maternal Morbidity
• Hypercholesterolaemia and hypertryglyceridaemia

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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

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Coeliac disease in 4.5
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Eye problems
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Diabetic retinopathy after 5y of diabetes
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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

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Diabetic complications

• Social Services
• CAMHS
• DLA
• Diabetes UK

• Depression
• Eating disorder
• Risk taking
• Rebellion
• Excess responsibility
• Smoking
• Alcohol
• Driving

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OPD Discussion points

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

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Rotate sites at same meal each dayFastest
absorption from abdomen, slowest thighsBeware
lipohypertrophy
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Hypoglycemia

• Great parental concern
• Asymptomatic at night
• Deaths X 2 normal child (DKA and CO)
• Dawn phenomena
• Hypoglycemia unawareness
• Alcohol
• Sports
• Illness
• Xs insulin

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Sick Day Rules
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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

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Exercise
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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

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Future developments

• Pumps
• Nasal Insulin with Lantus
• Pancreatic transplants

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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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