Type 1 Diabetes

Question 1

What type of condition is T1 diabetes? What happens?

Answer 1

An autoimmune condition in which insulin-producing beta-cells in the pancreas are attacked and destroyed by the immune system

Question 2

What cells are involved with T1 diabetes?

Answer 2

Insulin-producing beta-cells in the pancreas

Question 3

What happens to insulin levels and glucose levels in T1 diabetes?

Answer 3

The result is a partial or complete deficiency of insulin production, which results in hyperglycaemia that requires life long insulin treatment

Question 4

What are treatment options for T1 diabetes?

Answer 4

Multiple daily insulin injections
Insulin pump
Islet cell transplant
Artificial pancreas (pump + real-time glucose monitoring)

Question 5

At what ages does T1 diabetes present?

Answer 5

Usually in childhood but can be later

Question 6

At what ages does T2 diabetes present?

Answer 6

Usually in adulthood but can be in children

Question 7

Is diabetic ketoacidosis a feature of T1 or T2 diabetes?

Answer 7

Mainly T1 but can present in T2

Question 8

How does T1 diabetes develop?

Answer 8

In stages:
Starts w genetic predisposition
Precipitating event (eg virus)
Autoimmune events are triggered

Question 9

What is long standing T1 diabetes?

Answer 9

Immune cells are not near the islets and you are left with peri islet fibrosis

Question 10

Describe the immunology of T1 diabetes

Answer 10

Primary step is the presentation of auto-antigen to auto-reactive CD4+ T lymphocytes
CD4+ cells activate CD8+ T lymphocytes
CD8+ cells travel to islets and lyse beta-cells expressing auto-antigen
Exacerbated by release of pro-inflammatory cytokines
Underpinned also, by defects in regulatory T-cells that fail to suppress autoimmunity

Question 11

Are all beta cells destroyed in T1 diabetes?

Answer 11

No, a small amount of insulin may still be produced

Question 12

Why is it useful to produce a small amount of insulin in T1 diabetes?

Answer 12

Less risk of complications occouring

Question 13

What genes increase susceptibility of developing T1 diabetes most?

Answer 13

HLA genes

Question 14

What are some environmental factors that can trigger T1 diabetes

Answer 14

There are loads but some include:
Enteroviral infections
Cow’s milk protein exposure
Seasonal variation
Changes in microbiota

Question 15

What antibodies are present in T1 diabetes?

Answer 15

Pancreatic auto-antibodies

Question 16

What are symptoms of T1 diabetes?

Answer 16

Excessive urination (polyuria) 
Nocturia
Excessive thirst (polydipsia) 
Blurring of vision
Recurrent infections eg thrush
Weight loss
Fatigue

Question 17

What are signs of T1 diabetes?

Answer 17

dehydration 
cachexia (ongoing muscle wastage that can't be reversed by nutritional supplements)
hyperventilation
smell of ketones
glycosuria 
ketonuria

Question 18

What does lack of insulin do in muscles?

Answer 18

Increase proteinolysis

Question 19

What does lack of insulin do in the liver?

Answer 19

Inhibit hepatic glucose output

Increase output of ketone bodies

Question 20

What does lack of insulin do in adipose tissue?

Answer 20

Increase lipolysis

Question 21

What are the aims for treatment in T1 diabetes?

Answer 21

Maintain glucose levels without excessive hypoglycaemia
Restore a close to physiological insulin profile
Prevent acute metabolic decompensation
Prevent microvascular and macro vascular complications

Question 22

What are the main acute complication of T1 diabetes?

Answer 22

Diabetic ketoacidosis
Uncontrolled hyperglycaemia
Hypoglycaemia

Question 23

Is human insulin ever zero?

Answer 23

No, we have a basal insulin level (it is relatively flat)

Question 24

What are the 2 types of insulin given to diabetics?

Answer 24

Short acting insulin

Basal (long lasting) insulin

Question 25

What is insulin pump therapy?

Answer 25

Continuous delivery of short-acting insulin analogue e.g. novorapid via pump into subcutaneous space

Question 26

What do you have to do with an insulin pump?

Answer 26

Actively bolus for meals

Question 27

What dietary advice are T1 diabetics given?

Answer 27

They should receive training for carbohydrate counting | Swap refined carbs for complex carbs

Question 28

How does a closed loop/artificial pancreas work?

Answer 28

Have a real time glucose sensor that detects changes in glucose Use an algorithm to calculate insulin requirement Insulin pump delivers calculates insulin

Question 29

What are choices for transplantation?

Answer 29

Islet cell transplant | Whole pancreas and kidney transplant

Question 30

What do we need to transplant with the pancreas? When is pancreas transplant given

Answer 30

Transplant kidneys too | For those with end stage renal failure

Question 31

What does transplantation require life long?

Answer 31

Immunosupression

Question 32

What is the best blood test to monitor diabetes control?

Answer 32

Hba1c (glycated haemoglobin)

Question 33

How are glucose levels mainly monitored?

Answer 33

Capillary (finger prick) blood glucose monitoring

Question 34

What does Hba1c show? Give one disadvantage of it

Answer 34

Reflect last 3 months (red blood cell lifespan) of glycaemia | Biased to the 30 days preceding measurement

Question 35

What is used to guide insulin dose?

Answer 35

Self monitoring and hba1c

Question 36

How urgent is diabetic ketoacidosis?

Answer 36

Extremely, its a medical emergency

Question 37

How is diabetic ketoacidosis diagnosed?

Answer 37

pH <7.3 Ketones increased (urine of capillary blood) HCO3- <15 mmol/L Glucose >11 mmol/L

Question 38

How is hypoglycaemia diagnosed?

Answer 38

<3.6 mmol/L

Question 39

What are symptoms of hypoglycaemia?

Answer 39

Adrenergic- tremor, palpitation, sweating, hunger | Neuroglycopaenic- somnolence, confusion, in cooridination, seizures/coma

Question 40

When does hypoglycaemia become problematic?

Answer 40

Excessive frequency Impaired awareness (unable to detect low blood glucose) Nocturnal hypoglycaemia Recurrent severe hypoglycaemia

Question 41

What are risks of hypoglycaemia?

Answer 41

``` Seizure / coma/ death (dead in bed) Impacts on emotional well-being Impacts on driving Impacts on day to day function Impacts on cognition ```

Question 42

What are risk factors for developing hypoglycaemia?

Answer 42

``` Exercise Missed meals Inappropriate insulin regime Alcohol intake- can blunt symptoms Lower HbA1c Lack of training around dose-adjustment for meals ```

Question 43

How can we help those with hypoglycaemia?

Answer 43

Indication for insulin-pump therapy (CSII) May try different insulin analogues Revisit carbohydrate counting / structured education Behavioral psychology support Transplantation