Treatment of Type 1 Diabetes

Question 1

Why is insulin life-saving in type 1 DM?

Answer 1

Prevents Diabetic ketoacidosis (DKA)

Question 2

What is the long-term goal of insulin treatment?

Answer 2

Prevent chronic complications of poor glycaemic control

Question 3

What do the current guidelines recommend for HbA1c?

Answer 3

< 18 years: < 59mmol/mol

>18 years: < 53mmol/mol

Question 4

What are the current guidelines regarding exercise in T1DM?

Answer 4

150 minutes of moderate-intense execise weekly

Spread over 3 days, no more than 2 consecutive days without

Question 5

A carbohydrate snack should be given before exercise if blood glucose levels are below which point?

Answer 5

< 5.6 mmol/l

Question 6

After diagnosis, when should insulin therapy be started?

Answer 6

ASAP

Question 7

How does insulin administration aim to mimic physiological insulin release?

Answer 7

Combining a basal insulin with bolus dosing at mealtimes

Question 8

Give 3 examples of long acting insulins

Answer 8

1. Glargine
2. Detemir
3. Degludec

Question 9

Which intermediate-acting insulin is often used for basal dosing?

Answer 9

NPH

(isophane insulin)

Question 10

Give 3 examples of rapid acting insulins

Answer 10

1. Lispro
2. Aspart
3. Glulisine

Question 11

What is a frequent cause of nocturnal hypoglycaemia?

Answer 11

Dinnertime NPH (or other intermediate-long acting insulin)

Question 12

Which other coexistant conditions contribute to more unstable diabetes?

Answer 12

1. Coeliac disease
2. Thyroid disease
3. Addison’s disease
4. Psychosocial stress

Question 13

If there is a concern for noctural hypoglycaemia, what should a patient do?

Answer 13

Take a 3am blood glucose test

Question 14

Why are both alcohol and exercise potentially dangerous in T1DM?

Answer 14

They can cause delayed hypoglycaemia

(by up to 24 hours)

Question 15

In patients with uncontrolled postprandial hyperglycaemia, which adjunctive treatment can be used?

Answer 15

Pramlintide

Question 16

What is pramlintide?

Answer 16

Amylin analogue

Question 17

What is amylin and what is its physiological function?

Answer 17

A hormone secreted with insulin normally (not at all in T1DM) which promotes the acute 1st phase of the insulin response by:

1. Slowing gastric emptying
2. Promoting satiety
3. Inhibiting inappropriate glucagon secretion

Question 18

What is the recommened HbA1c level before conception?

Answer 18

< 48 mmol/mol

The target during pregancy is 43 mmol/mol

Question 19

Why should women be evaluated before pregancy?

Answer 19

1. Poor glycaemic control may damage foetus
2. Retinopathy, nephropathy, neuropathy and CVD in the mother may worsen in pregnancy if it is present

Question 20

Which condition is more common in pregnant women with diabetes?

Answer 20

Pre-eclampsia

Question 21

Women with diabetes are at increased risk of having a baby with which type of defect?

Answer 21

Neural tube defects

(spina bifida, anencephaly etc.)

Question 22

Which treatment is given to diabetic women to reduce the liklihood of their baby developing neural tube defects during pregancy?

Answer 22

Folic acid

(prior to (0.4mg) and during pregancy (5mg))

Question 23

What is the first line treatment for T1DM in non-pregnant adults?

Answer 23

Basal-Bolus Insulin

Basal insulin (glargine, NPH, detemir or degludec)

AND

Bolus insulin (regular, lispro, aspart or glulisine) OR pump

Question 24

What are the potential adjunct therapies for the first line T1DM treatment?

Answer 24

1. Pre-meal insulin correction dose
2. Amylin analogue (e.g. pramlintide)

Question 25

What is the second line treatment for T1DM?

Answer 25

**Fixed Insulin Dose** Insulin isophane biphasic OR Insulin aspart biphasic OR Insulin lispro biphasic OR Insulin degludec/insulin aspart

Question 26

When would a fixed-dose insulin regimen be used?

Answer 26

1. Already doing well on a fixed dose 2. Cannot manage 3-4 daily injections 3. Has trouble mixing insulin

Question 27

What is the first line treatment for someone who is pregnant and has T1DM?

Answer 27

**Basal-Bolus Insulin** Basal insulin (NPH or detemir) AND Bolus insulin (regular, lispro or aspart)

Question 28

What is the second line treatment for someone who is pregant and has type 1 diabetes?

Answer 28

**Basal-Bolus Insulin** Basal insulin (glarcine) AND Bolus insulin (regular, lispro or aspart) OR pump

Question 29

# This is different in different situations How often should patients have their HbA1c checked?

Answer 29

1. Meeting treatment goal (\< 59 mmol/mol (\< 18 years) or \< 53mmol/mol (\> 18 years) - Every 6 months 2. Therapy is being modified or not meeting goal - Every 3 months 3. Pregnant - Every month

Question 30

If patients with T1DM also have atherosclerotic CVD, which treatment should they also be on as well as standard insulin and adjunctive treatments?

Answer 30

High-intensity statin

Question 31

If patients have T1DM and are aged 40-75, without any atherosclerotic CVD or risk factors, what other treatment should they be on as well as standard insulin and adjunctive treatment?

Answer 31

Moderate-intensity statin

Question 32

In all patients who have had type 1 diabetes for 5 years or more, yearly screening must take place for what?

Answer 32

1. Increased urinary albumin secretion 2. Serum creatinine (estimated kidney glomerular filtration)

Question 33

What characterises diabetic ketoacidosis?

Answer 33

1. Hyperglycaemia 2. Metabolic acidosis

Question 34

What are the most common triggers or causes for DKA?

Answer 34

1. Missed insulin 2. Physiological stress such as infection or MI

Question 35

In insulin deficiency (within a T1DM patient), what happens?

Answer 35

Stress hormones (glucagon, cortisol and catecholamines) raise blood sugars by stimulating ketogenesis

Question 36

What follows from stress hormone release in a T1DM patient?

Answer 36

1. Hyperglycaemia 2. Ketosis

Question 37

Why is DKA associated with dehydration?

Answer 37

Hyperglycaemia and ketosis cause **osmotic diuresis** which leads to dehydration

Question 38

What are the symptoms of diabetic ketoacidosis?

Answer 38

1. Dehydration (dry mouth) 2. Metabolic acidosis 3. SOB 4. Abdominal pain 5. Nausea 6. Vomiting 7. Altered snesorium

Question 39

What does the treatment of DKA involve?

Answer 39

1. Rapid rehydration 2. Insulin infusion 3. Correction of electrolyte imbalance and potassium repletion 4. Treatment with bicarbonate (pH \< 6.9 only)

Question 40

What is the main complication of insulin treatment?

Answer 40

Hypoglycaemia

Question 41

What is the definition of: a) glucose alert value b) significant hypoglycaemia

Answer 41

a) \< 3.9 mmol/l b) \< 3.0 mmol/l

Question 42

How can hypoglycaemia be treated assuming the patient can take oral treatment?

Answer 42

118ml (4 fl/oz) of fruit juice or sweetened fluids or Glucose tablets (15-20g CHO) Blood sugar should be tested and the treatment effect should be apparent in 15 minutes

Question 43

What is the treatment for hypoglycaemia if oral intake is not possible?

Answer 43

Injection of glucagon or IV dextrose

Question 44

What is dextrose?

Answer 44

Form of glucose (5% in water is used as a treatment for hypoglycaemia)

Question 45

What is given to patients with T1DM, should they ever have a severe hypoglycaemic episode?

Answer 45

Glucagon kit (this is useful when a patient cannot eat or drink)

Question 46

Clinically significant hypoglycaemia is defined as what?

Answer 46

\< 3mmol/l