Diabetes 1

Question 1

Diabetes Incidence (6)

Answer 1

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

Question 2

SEARCH Findings: DM in Youths (4)

Answer 2

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

Question 3

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

Answer 3

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%

Question 4

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

Answer 4

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%

Question 5

T1DM mode of inheritance, gender and biochemistry at dx

Answer 5

Mode of Inheritance: generally sporadic

Gender: male = female

Biochemistry at dx: hyperglycemia, ketosis common, acidosis common

Question 6

T1DM Markers (4)

Answer 6

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

Question 7

T2DM mode of inheritance, gender and biochemistry at dx

Answer 7

Mode of Inheritance: strongly familial

Gender: females > male

Biochemistry at dx: hyperglycemia, ketosis common, acidosis uncommon

Question 8

T2DM Markers (4)

Answer 8

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

Question 9

Genetic Syndromes associated with Type 1 Diabetes (10)

Answer 9

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

Question 10

Type 1 Diabetes: Pathophysiology (6)

Answer 10

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

Question 11

T1DM Inheritance Susceptibility (5)

Answer 11

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

Question 12

Diabetes: Classic Symptoms (7)

Answer 12

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

Question 13

Signs and symptoms As ketoacids accumulate…(6)

Answer 13

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

Question 14

DKA: General (4)

Answer 14

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

Question 15

DKA In Children with Known Diabetes (6)

Answer 15

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

Question 16

Diagnostic Studies at Diagnosis (4)

Answer 16

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

Question 17

Diabetes Diagnostic Criteria (4)

Answer 17

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

Question 18

Diabetes Differential Dx (4)

Answer 18

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

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

Identify co-occurrence of

3. Thyroiditis
4. Celiac disease
   * Many centers will now screen for these two with diabetes because of the increased co-occurrence

Question 19

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

Answer 19

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

Question 20

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

Answer 20

SHOULD BE <7.5% IN ALL AGES

Question 21

Management of New Onset Type 1 Diabetes (5)

Answer 21

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

Question 22

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

Answer 22

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

Question 23

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

Answer 23

i. Insulin initiated

ii. Diabetes education initiated

Question 24

Screening with New Onset T1DM (2)

Answer 24

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.

Question 25

Intensive insulin regimens: Basal/Bolus (3)

Answer 25

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

Question 26

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

Answer 26

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

Question 27

Insulin Adjustments during Childhood (2)

Answer 27

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

Question 28

Technological features of insulin pumps: insulin delivery (8)

Answer 28

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

Question 29

Technological features of insulin pumps: safety features (4)

Answer 29

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

Question 30

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

Answer 30

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

Question 31

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

Answer 31

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

Question 32

Blood Glucose Monitoring (7)

Answer 32

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

Question 33

Blood Glucose Monitoring Measurements

Answer 33

Measures intersitial glucose using sensor, wireless transmitter and receiver

Question 34

Blood Glucose Monitor Advantages (7)

Answer 34

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

Question 35

CGM Integration with Insulin Pumps (2)

Answer 35

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