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PPC3 Exam 2 > Diabetes 1 > Flashcards

Diabetes 1 Flashcards

1
Q

Diabetes Incidence (6)

A
  1. Affects approximately 193,000 youth <20 years
  2. 2.2/1,000 American youth
  3. Incidence of type 1 and type 2 diabetes in youth increasing in US and world
  4. Highest prevalence of DM is among older children
  5. T1DM remains a disease of white children for the most part
  6. T2DM doesn’t affect many young children; usually occurs around the time of puberty and adolesence
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2
Q

SEARCH Findings: DM in Youths (4)

A
  1. Majority of all new DM cases <10yrs had type 1 DM regardless of race/ethnicity
  2. Youth ≥10 yrs –> Type 1 most common form of DM for non-Hispanic white and Hispanic youth
  3. Type 2 DM –> More common after age of 10 years
    * Higher rates among US minority populations
  4. Implications for youth entering adulthood with disease duration, increased risk for complications, diabetes during reproductive years
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3
Q

T1DM onset age, race, islet autoimmunity, insulin secretion, insulin sensitivity, DKA at onset, obesity, and % of diabetes

A

Onset Age: throughout childhood

Race: All (lowest in NA)

Onset: Acute/severe

Islet Autoimmunity: present

Insulin Secretion: very low

Insulin Sensitivity: Normal (with BG control)

DKA at Onset: 20-40%

Obesity: as in population

% of diabetes: 87%

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4
Q

T2DM onset age, race, islet autoimmunity, insulin secretion, insulin sensitivity, DKA at onset, obesity, and % of diabetes

A

Onset Age: Pubertal/teen

Race: Highest in NA and Black

Onset: subtle to severe

Islet Autoimmunity: unusual

Insulin Secretion: variable

Insulin Sensitivity: decreased

DKA at Onset: more unusual

Obesity: >90%

% of diabetes: 10.5%

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5
Q

T1DM mode of inheritance, gender and biochemistry at dx

A

Mode of Inheritance: generally sporadic

Gender: male = female

Biochemistry at dx: hyperglycemia, ketosis common, acidosis common

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6
Q

T1DM Markers (4)

A
  1. Elevated HbA1c
  2. Low Insulin
  3. Low C peptide
  4. Antibodies common (anti-ICA, anti-GAD)
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7
Q

T2DM mode of inheritance, gender and biochemistry at dx

A

Mode of Inheritance: strongly familial

Gender: females > male

Biochemistry at dx: hyperglycemia, ketosis common, acidosis uncommon

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8
Q

T2DM Markers (4)

A
  1. Elevated HbA1c
  2. Normal Insulin
  3. High C-peptide
  4. Antibodies are uncommon
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9
Q

Genetic Syndromes associated with Type 1 Diabetes (10)

A
  1. Down syndrome
  2. Klinefelter syndrome*
  3. Turner syndrome
  4. Wolfram syndrome
  5. Friedreich’s ataxia
  6. Huntington’s chorea
  7. Lawrence-Moon Beidel syndrome
  8. Myotonic dystrophy
  9. Porphyria
  10. Prader-Willi syndrome
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10
Q

Type 1 Diabetes: Pathophysiology (6)

A
  1. Idiopathic; may have no family history
  2. Immune-mediated; Progressive autoimmune destruction of the β cells of the pancreas
    * 75% of individuals with type 1 diabetes will test positive for the presence of autoantibodies at the time of diagnosis
  3. Permanent loss of the body’s ability to produce insulin
  4. Insidious process of unknown duration
  5. Abrupt clinical onset and generally occurs over a two to three week period
    * May begin to present with increased urination, thirst, etc, and then start to have the other manifestations
  6. 20 to 40% of new cases of type 1 diabetes present in diabetic ketoacidosis
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11
Q

T1DM Inheritance Susceptibility (5)

A
  1. Most (85%) cases occur sporadically
  2. Increased risk if family member has type 1 diabetes
  3. Mother 10 fold risk
  4. Father 35 fold risk
  5. Siblings - 40 fold risk
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12
Q

Diabetes: Classic Symptoms (7)

A
  1. Polyuria; Getting rid of glucose in urine
  2. Nocturia; Parents may not understand why child is wetting the bed
  3. Polydipsia
  4. Polyphagia
  5. Blurred vision
  6. Weight loss or failure to gain weight
  7. Fatigue/Lethargy
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13
Q

Signs and symptoms As ketoacids accumulate…(6)

A

breaking down proteins that the body needs b/c can’t metabolize carbohydrates → ketones accumulate → following manifestations occurs:

  1. Abdominal pain
  2. Nausea/vomit
  3. Fruity smelling breath
  4. Weakness (caused by dehydration)
  5. Mental confusion
  6. Diabetic ketoacidosis
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14
Q

DKA: General (4)

A
  1. Type 1 Diabetes onset
  2. 20-40% hospital admissions
  3. More common in
    a. Children <4 yrs of age
    b. No family history of T1DM
    c. Families of lower socioeconomic status (SES) or poorer access to care
  4. More unusual in type 2 diabetes, but not impossible
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15
Q

DKA In Children with Known Diabetes (6)

A
  1. More common in children with poor metabolic control or previous episodes of DKA
  2. Adolescent girls
    * Not taking insulin → won’t gain weight
  3. Psychiatric comorbidity (including eating disorders)
  4. Lower SES, lack of or interrupted health insurance
  5. Inappropriate interruption of insulin pump therapy
    * Occlusion alarms aren’t sensitive; can have poor infusion leading to DKA
    * Need to change site
  6. 75% episodes associated with insulin omission or treatment error; remainder inadequate insulin therapy during intercurrent illness
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16
Q

Diagnostic Studies at Diagnosis (4)

A
  1. Urine for glucose and ketones
  2. Metabolic screen for acid-base status to exclude DKA
  3. HemoglobinA1c
  4. Screen for presence of pancreatic auto-antibodies
    a. Confirm diagnosis of type 1 diabetes in cases where there may be uncertainty regarding type of diabetes
17
Q

Diabetes Diagnostic Criteria (4)

A

A1C >/= 6.5%

OR

FPG >/= 126 mg/dl (no caloric intake for at least 8 hours)

OR

2-h plasma glucose >/= 200 mg/dl during an OGTT (using 75g anhydrous glucose dissolved in water)

OR

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose of >/= 200mg/dl

18
Q

Diabetes Differential Dx (4)

A

Distinguish from
1. Stress-induced hyperglycemia **Can occur in as many as 4% of normal children during serious illness

  1. Maturity-onset diabetes of the young (MODY)

Identify co-occurrence of

  1. Thyroiditis
  2. Celiac disease
    * Many centers will now screen for these two with diabetes because of the increased co-occurrence
19
Q

Type 1 Diabetes: Long term Goals of Therapy (5)

A
  1. Normal growth, weight gain, sexual maturation
  2. Optimize glycemic control
  3. Maintain uniform glycemic level of HbA1c <7.5% for all youth
  4. Positive psychosocial adjustment to diabetes
  5. Minimize acute or chronic complications
20
Q

A1 Goals for <6 years old, 6-12 years old and 13-19 years old

A

SHOULD BE <7.5% IN ALL AGES

21
Q

Management of New Onset Type 1 Diabetes (5)

A
  1. Determining insulin regimen and dose
  2. Target range for blood glucose levels
  3. Managing child’s diet
  4. Education regarding insulin injection, blood glucose monitoring, carbohydrate counting, hypoglycemia prevention, managing diabetes during illness, adjusting insulin or carbohydrate intake for exercise
  5. Diabetes education tailored based on
    a. Child’s age, family management priorities, health literacy
    b. Child included in education – age 6 years
22
Q

Management of New Onset Type 1 Diabetes: With ketoacidosis (4)

A

Hospitalized

i. IV insulin treatment
ii. Fluid replacement
iii. Monitoring to prevent cerebral edema
iv. Want to counteract acidosis prior to worrying about bringing down the blood glucose levels

23
Q

Management of New Onset Type 1 Diabetes: With no ketoacidosis (2)

A

i. Insulin initiated

ii. Diabetes education initiated

24
Q

Screening with New Onset T1DM (2)

A
  1. Hypothyroidism – 25% of youth with T1DM have + thyroid autoantibodies at time of diagnosis but may have normal thyroid function
  2. Celiac disease – tissue transglutaminase or anti-endomysial antibodies – occurs more frequently in children with diabetes (1%-16%) compared to those without diabetes (0.3% - 1%)
    * Screen if suspicious → not growing well, belly pain, etc.
25
Q

Intensive insulin regimens: Basal/Bolus (3)

A
  1. Continuous subcutaneous insulin infusion (CSII)via subcutaneous catheter –
    a. 60% children in national TID exchange registry report using insulin pump
    b. Basal (low dose, slow, continuous) rates and bolus (rapid release) insulin delivery at mealtime
    c. Individualized to child
    d. More physiologic pattern of insulin delivery
    e. Continuous amount of basal insulin over 24 hours; gets regulated to try and mimic physiological insulin (runs as a program)***
    * When the child goes to eat they initiate a bolus of insulin
  2. Multiple daily injections (basal/bolus) ≥4 injections/day
    a. Long acting insulin analog 1x day
    b. Rapid acting insulin at meal and snack times
  3. Total basal insulin
26
Q

Insulin Requirement Changes During Childhood (partial remission, pre-pubertal, pubertal, and post pubertal): Total daily insulin

A

Partial Remission (Honeymoon)- any age: = 0.5 u/kg/day

Pre-pubertal: 0.7-1.0 u/kg/day

Pubertal: 1.0-2.0 u/kg/day

Post pubertal: 1.0 u/kg/day

27
Q

Insulin Adjustments during Childhood (2)

A
  1. Insulin adjustments are EXPECTED during childhood
    a. Determine whether basal or bolus needs adjustment by average blood glucose levels
    b. Adjustment can be made in 10% increments
    c. Youth, parents can be taught to safely adjust insulin
  2. Hormonal changes during puberty can make you more insulin resistant
    * Need increased insulin
28
Q

Technological features of insulin pumps: insulin delivery (8)

A
  1. Low basal rates (0.025-0.05 units/hour)
  2. Multiple different basal rates
  3. Temporary basal rates and basal suspension
  4. Small bolus increments (0.025-0.10 units)
  5. Extended boluses for delayed digestion
  6. Bolus calculator based on BG level and carbohydrate quantity
  7. Multiple insulin:carbohydrate ratios, sensitivity factors, BG targets
  8. Missed meal bolus reminder
29
Q

Technological features of insulin pumps: safety features (4)

A
  1. Alarms for occlusion and low insulin reservoir
  2. Active insulin calculation (prevents insulin stacking)
  3. Keypad lock (useful for toddlers)
  4. Waterproof or watertight
30
Q

Technological features of insulin pumps: interface with BG monitoring (4)

A
  1. Electronic logbook software
  2. Reminder alarms for BG checks, bolus doses
  3. Wireless communication with remote BG meter
  4. Integration with continuous glucose monitoring technology
31
Q

Potential advantages of Insulin pumps compared to multiple daily injections (8)

A
  1. Better blood glucose control as reflected by hemoglobin A1c
  2. Reduced glycemic variability
  3. Ability to combat dawn phenomenon
  4. Ability to decrease or suspend insulin infusion for physical exercise
  5. Reduced hypoglycemia
  6. Improved QOL
    - Reduced fear of hypoglycemia
    - Greater lifestyle flexibility
  7. Benefits for parents
  8. Lower total daily insulin dose
32
Q

Blood Glucose Monitoring (7)

A
  1. Very small blood samples required
  2. Results available in 5 to 10 seconds
  3. Can fit in a pocket
  4. Store glucose value
  5. Display/trend results
  6. Real time continuous glucose monitoring (CGM)
  7. Approved for children
33
Q

Blood Glucose Monitoring Measurements

A

Measures intersitial glucose using sensor, wireless transmitter and receiver

34
Q

Blood Glucose Monitor Advantages (7)

A
  1. Require 2 calibrations with finger stick blood glucose readings/day
  2. Can give you information that you can’t get solely with finger stick monitoring
  3. More recent systems display real-time interstitial glucose levels and trend graphs on mobile phones
  4. Glucose data can be shared through the cloud in real time allowing family members to monitor from afar
  5. Alarms for preset low and high blood glucose readings
  6. 12/2016 FDA approved use of DexCom G5CGM for insulin dose calculations
  7. Use of CGM are effective in lowering A1c in adolescents
35
Q

CGM Integration with Insulin Pumps (2)

A
  1. Sensor augmented pump therapy
    a. Adjust insulin doses based on CGM readings
    b. Pause insulin when blood glucose is low
  2. 2017-first hybrid closed loop system became available in US
    a. Lower or increase basal rates based on blood glucose readings
    b. Require very attentive user

PPC3 Exam 2 (11 decks)

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