Type 1 diabetes

Question 1

What is LADA?

Answer 1

Latent autoimmune diabetes in adults - more older people are presenting with type 1 diabetes

Question 2

What can diabetes present alongside?

Answer 2

following pancreatic damage and endocrine diseases like Cushing’s

Question 3

What is monogenic diabetes?

Answer 3

caused by one gene e.g. MODY, mitochondrial diabetes (can features phenotypically as T2/T1 DM)

Question 4

Which diabetes do the majority of patients suffer from?

Answer 4

Type 2

Question 5

What causes type 1 diabetes?

Answer 5

An environmental influence + addition to genetic influences, can cause the destruction of beta cells. Usually autoimmune. Once this happens, the patient is insulin deficient, which leads to hyperglycaemia.

Question 6

What causes type 2 diabetes?

Answer 6

In type 2 diabetes, there is a stronger genetic influence. It is associated with obesity, and patients develop insulin resistance. Eventually, patients become hyperglycaemic. In these patients, the pancreas works hard to produce a lot of insulin, but the body can’t use it. Eventually, the beta cells fail.

Question 7

Which diabetes is ketoacidosis a feature of?

Answer 7

T1DM - caused by a lack of insulin in the body, which causes the body to break down fat for energy. Ketones are released into the body as the fat is broken down.

Question 8

Describe the process of type 1 diabetes development

Answer 8

• There are environmental and genetic influences, that occur over time
• The patient gets pre-diabetes, followed by overt diabetes, as the beta cells start to malfunction
• Slow process
• Patients admit, sick from diabetic ketoacidosis
• Diabetes type 1 is a relapsing remitting disease

Question 9

What is an important factor in type 1 diabetes?

Answer 9

Immune system - if you have one autoimmune condition you are more likely to get another. Risk of automimmunity in relatives

Question 10

What can be measured in T1DM to differentiate from T2DM?

Answer 10

auto antibodies

Question 11

In type 1 diabetes which cells are present?

Answer 11

lots of plasma cells and t cells (t cells involved in beta cell destruction)

Question 12

How does the environment affect T1DM?

Answer 12

Higher prevalence of T1DM in the winter months, compared with the summer - could be a virus targeting beta cells during this time

Certain places around the world have a higher prevalence too

Question 13

Give examples of antibodies that can be measured in T1DM?

Answer 13

• Islet cell antibodies (ICA)
• Insulin antibodies (IAA)
• Glutamic acid decarboxylase antibodies (GADA)
• Insulinoma-associated-2 autoantibodies (IA-2A)

(some people with T1DM don’t have antibodies)

Question 14

What are the signs of diabetes?

Answer 14

• Dehydration
• Cachexia
• Hyperventilation
• Smell of ketones
• Glycosuria
• Ketonuria

Question 15

What are the symptoms of diabetes?

Answer 15

• Polyuria
• Nocturia
• Polydipsia
• Blurring of vision
• Thrush
• Weight loss
• Fatigue

Question 16

What happens to adipose tissue if you lack insulin?

Answer 16

Fatty acids in adipose tissue are broken down. Therefore triglycerides start to release lots of fatty acids. They are taken up by the liver and ketone bodies are made. These can be detected in the urine and blood. Some ketones can go to kreb’s cycle.

Question 17

What happens to muscle during insulin deficiency?

Answer 17

proteins are released from muscle -> liver-> glucose production

Question 18

What happens to glucose during insulin deficiency?

Answer 18

Glucose is released from liver into circulation, not taken up by muscle and causes hyperglycaemia

Question 19

What are the aims of T1 diabetes treatment?

Answer 19

• Reduce early mortality
• Avoid acute metabolic decompensation
• Prevent long term complications (retinopathy, nephropathy, neuropathy, vascular disease)
• Type 1 diabetics need exogenous insulin to preserve life

Question 20

What should the diet be like in T1DM?

Answer 20

• Reduce calories as fat
• Reduce calories as refined carbohydrate
• Increase calories as complex carbohydrate
• Increase soluble fibre
• Balanced distribution of food over course of day with regular meals and snacks

Question 21

What are the two parts to insulin treatment?

Answer 21

with meals
background insulin (basal production)

Question 22

Is the insulin long or short acting with meals and background?

Answer 22

with meals - short

background - long

Question 23

Give examples of insulin analogues with meals

Answer 23

lispro, aspart, glulisine

Question 24

Is human insulin or an analogue given with meals?

Answer 24

both

Question 25

What should the insulin maintain in T1DM?

Answer 25

basal insulin level

Question 26

What are some background insulin analogue examples?

Answer 26

glargine, determir, degludec

Question 27

What is the structure of backrgound insulin?

Answer 27

non c bound to zinc or protamine

Question 28

What do patients inject themselves with when they eat and why?

Answer 28

long acting insulin - lasts patient till next meal short acting insulin

Question 29

Why are insulin analogues genetically modified?

Answer 29

to alter absorption, distribution. metabolism and excretion

Question 30

What is an insulin pump?

Answer 30

A device that administers continuous insulin. The pump has pre-programmed basal rates and bolus for meals. The pump does not measure glucose – so there is no completion of the feedback loop. Used in patients with severe diabetes.

Question 31

What is islet cell transplantation?

Answer 31

Some of the beta cells from the donor pancreas are taken, cells are isolated, and then injected into the liver. Through hepatic veins, these beta cells migrate around the body, and can then produce insulin..

Question 32

How do we measure the success of diabetes treatment?

Answer 32

- Measure capillary glucose levels - Monitor glucose levels in by taking a blood sample - Measuring glucose is using a glucose monitor – measures glucose in real time - A continuous glucose monitor can help with glucose control long term

Question 33

How can HBA1c be used to measure glucose levels?

Answer 33

HbA1c is a blood sample that relies on red cells attaching to the glucose monitor - HbA1c red cells react with glucose –> this is irreversible and non-covalent - The lifespan of red cells is around 120 days, so this test gives us an idea of glucose levels over 3 months - The rate of glycation is faster in some individuals

Question 34

What does a high HBA1c mean?

Answer 34

more glucose

Question 35

What happens to HBA1c accuracy in patients with thalasseamia, renal failure etc?

Answer 35

The red cell half life will be changed

Question 36

What is ketoacidosis?

Answer 36

Patients are hyperglycaemic- Reduced tissue glucose utilisation and increased hepatic glucose production. A a result, patient has a metabolic acidosis - circulating ketone bodies

Question 37

What is hypoglycaemia's definition? What happens if BG ,=<3? What happens if BG <2?

Answer 37

<3.6 mmol/l If blood glucose < 3 mmol/l: most mental processes will be impaired If blood glucose < 2 mmol/l: consciousness is impaired

Question 38

Why does hypoglycaemia occur in diabetes?

Answer 38

- Occasional hypoglycaemic episodes are inevitable as a result of treating diabetes - Such episodes are a major cause of anxiety in patients & families

Question 39

What is severe hypoglycaemia?

Answer 39

Any hypoglycaemic episode that requires the help of another person to treat it

Question 40

What are the effects of hypoglycaemia on patients?

Answer 40

- Severe hypoglycaemia may contribute to arrhythmia and sudden death - Hypoglycaemia may have long-term effects on the brain (cognitive problems, irreversible damage) - Recurrent hypoglycaemic episodes result in a loss of warning – frightening

Question 41

Who is at risk of hypoglycaemia?

Answer 41

Those with a lower quality of glycaemic control. Hypoglycaemia is more frequent in patients with low HbA1c

Question 42

When and why doe hypoglycaemic episodes occur?

Answer 42

They can occur at any time, but often there is a clear pattern (e.g. pre-lunch episodes are common, nocturnal episodes are very common and often not recognised) Patients may start going to the gym while not changing their insulin dose, patients may miss meals or have inadequate snacks, patients may drink lots of alcohol and Inappropriate insulin regime

Question 43

Signs/symptoms of hypoglycaemia

Answer 43

Due to increased autonomic activation - Palpitations (tachycardia) - Tremor - Sweating - Pallor/cold extremities - Anxiety Due to impaired CNS function - Drowsiness - Confusion - Altered behaviour - Focal neurology - Coma

Question 44

How should hypoglyaemia be treated (oral)?

Answer 44

If the patient is conscious, feed the patient - Give quick acting glucogels – rapidly absorbed as a solution or as tablets - Complex CHO – to maintain blood glucose after initial treatment

Question 45

How could hypoglycaemia be treated (parenteral)?

Answer 45

If the patient has impaired consciousness - Intravenous dextrose (10%) glucose infusion - 1mg glucagon (intramuscular) - Avoid concentrated solutions (e.g. 50% glucose) – can cause severe skin reactions

Question 46

How are patients taught to deal with hypoglycaemia?

Answer 46

They can be taught how to inject themselves when they are having a hypoglycaemia episode. However if you have been fasting for days the glycogen stores in the liver are depleted.

Question 47

Importance of haplotypes in T1DM

Answer 47

Some HLA types have a higher genetic suscpetibility | HLA-DR3 and HLA-DR4 deletions pose a significant risk to chance of getting T1DM.