Home Health Diabetes: Unit – 5: Management of Type 1 Diabetes Mellitus

Diabetes: Unit – 5: Management of Type 1 Diabetes Mellitus

by Kedir Abdulatif

UNIT – 5
MANAGEMENT OF TYPE 1 DIABETES MELLITUS

Module Objectives
By the end of this module trainees will be able to:
• Describe Goals of Type 1 DM Management
• Describe comprehensive management of type 1 DM
• Understand the different types of insulin and their use
• List the different regimens of insulin therapy
• Explain the different complications of insulin
therapy
• Describe the basic use of insulin.

Outline of Presentation
• Introduction
• Management
• Goals of management
• Management Components
• Benefits of intensive treatment
• Glucose Homeostasis
• Insulin use
• Honeymoon Period
• Routine Care Recommendations
• Glycemic targets
• Complications
• Tips in the use of insulin

Introduction
Type 1 Diabetes:
• Affects children, adolescents, or young adults (usually < 30 yrs of age)
• Patients are usually not obese
• First diagnosis may be during an episode of diabetic ketoacidosis
• Characterized by absolute insulin deficiency due to destruction of beta cells
• Patients have lifetime dependence on exogenous insulin administration for survival
• Clinical diabetes occurs when 80-90% of islet cells are destroyed
• Constitutes 10% of all cases of diabetes

Goals of treatment
1. Decreasing plasma glucose levels and urine
glucose excretion to eliminate symptoms
2. Prevent diabetic ketoacidosis and severe
hypoglycemia
3. Inducing positive nitrogen balance to restore lean body mass and physical capability and to
maintain normal growth, development, and life
functioning
4. Preventing or greatly minimizing the late
complications of diabetes

Management Components
Refer to Algorithm 1
• Patient and family education
• Setting targets
• Diet
• Exercise
• Reduction of risk factors
• Daily monitoring of blood glucose
• Use of Insulin – human and analogs

Patient and Family Education
• Cornerstone of therapy
• Should be Lifelong
• Step by step
• Components
– Causes of diabetes
– Symptoms and signs of diabetes
– Components of its management: Insulin injections, etc
– Selfcare (with adequate emphasis on oral hygiene and foot care, SMBG )
– Acute complications: hypoglycemia, ketoacidosis, infections
– Chronic complications

Dietary Management
• Individualize
• Assess Dietary Habits
• There is no one diabetic diet for all
– Carbohydrate (45–65% of total caloric intake)
– Protein (10–35% of total caloric intake)
– Low Fat (35% of total caloric intake)
• Avoid Simple Sugars
• High Fibre
• Fruits and Vegetables

Physical Exercise
• Important component of diabetes care
• Helps maintain
– cardiovascular conditioning
– insulin sensitivity
– general well-being
• Patients need education on how to adjust their meals, their insulin doses and timing, or both to prevent hypoglycemia before, during, and after exercise
• High-impact sports are contraindicated for patients with
– advanced retinopathy who are at risk for vitreous hemorrhage
– peripheral neuropathy or vascular disease who are at risk for foot trauma
• Aerobic, Stretch, Strength Exercises
• > 5 times per week for 30-60 min each day

Benefits of intensive therapy
• Intensive treatment reduced the risks of retinopathy, nephropathy, and neuropathy by 35% to 90% compared with conventional treatment
• Absolute risks of retinopathy and nephropathy were proportional to the A1C
• Intensive treatment was most effective when begun early, before complications were detectable
• Risk reductions achieved at a median A1C 7.3% for intensive treatment (vs 9.1% for conventional)
• Benefits of 6.5 years of intensive treatment extended well beyond the period of most intensive implementation (“metabolic memory”)
Intensive treatment should be started as soon
as is safely possible after the onset of T1DM
and maintained thereafter

Insulin Therapy
Two types of insulin are currently in use
• Standard Human Insulin
• Insulin Analogues

Insulin Regimens
•Basal Regimen
•Twice daily NPH insulin alone
•Bi-Phasic Regimen (Mixed-Split)
•Premixed or Mixed Insulin
•Basal-Bolus Regimen (Intensive Insulin Therapy)
• Prandial insulin + Basal insulin

Ideal Insulin Replacement Therapy
Basal/Bolus Insulin Regimen Concept
Basal Insulin – intermediate/ long-acting insulins
– Nearly constant day-long insulin level
– Suppress hepatic glucose production
– Cover 50% of daily needs
• Bolus Insulin – short/ rapid acting insulins
(Prandial)
– Immediate rise and sharp peak at 1 hr
– Limit postprandial hyperglycemia
– Cover 10-20% of total daily insulin requirement at each meal

Methods of Insulin Administration
• Initial Regimen should be Simple
• Insulin dose at 0.2-0.4 U/kg/day
• Adjust dose by 2-4 U every 3-5 days
• First Target the FBS, then the Post Prandial glucose level
• Standard (Conventional) regimen
– Long or Intermediate Acting insulin
–With or Without Short-acting Insulin
–BID dosing even at a small doses
–Once daily dose is no more acceptable

Case Study 1
History
• M.T. is a 16 year old female from Adama town
presented with increasing thirst, polyuria and
weight loss over the past 3 weeks.
• She was treated for malaria 3 weeks back
• Has no family history of DM
• Has no heat or cold intolerance
• No similar symptoms in the past

Case Study…
Physical exam
• Wt : 35 kg Ht: 156cm
• BP 100/60mmHg PR= 96/min Temp=36.6 oC
• Dry tongue and buccal mucosa
• Lethargic
• Thyroid not palpable
• Liver is palpable 3cm BRCM, TVLS 12.5cm
• No other finding
What is your working diagnosis?
What tests do you like to order to confirm your diagnosis?

Case Study…
Laboratory test
• BMI:14.4 Kg/m²
• CBC-Normal
• Random Blood Sugar was 320mg/dl
• Urinalysis and Microscopy
✓ No protein,
✓ Ketone 2+ ,
✓ glucose 3+,
✓ negative microscopy

Discussion Points
• Does she have diabetes?
• If so, which type? Discuss your reasons
• Will you start her on treatment?
• If so, what drug will you start her with?
• At what dose
• How frequently would you like to adjust her medicine
• What else will you include in her management?
• What is the risk of chronic complication at time of diagnosis in this patient?
• She was admitted and treated and improved and was discharged.
• She was appointed to come after 1 week

Case Study ….
• 4 days later she was brought back by her relatives
as they noticed that she was talking irrelevant
things and was very weak and was sweating
profusely early in the morning.
• What could be the reason?
• What would you do?
• How would you like to treat?
• On follow up what will you do to avoid further
episodes?

Honeymoon period
• Occurs after several weeks of exogenous insulin
treatment & excellent metabolic control has been
established.
• Dependency on exogenous insulin decreases or
ceases entirely for weeks to months to 2 years
• Temporary remission (honeymoon phase) is marked by an increase in serum C-peptide levels which indicates an increase in endogenous insulin secretion
• Within 5 years after diagnosis of childhood type 1 diabetes mellitus, C-peptide virtually disappears
from the serum.

Considerations for glycemic goals
Residual life expectancy
• Duration of DM
• Presence or absence of micro- and
macrovascular complications
• CVD risk factors
• Comorbid conditions
• Risk for severe hypoglycemia
• Patient’s psychological, social, and economic status

Complications of Insulin Therapy
1. hypoglycemia
• potentially life threatening
• Preventable
• Treatable
Carefully educate about recognition of
hypoglycemic symptoms and Management

2. Weight Gain
Possible causes:
• Improvement in glycemic control
• increased food intake to treat or prevent
hypoglycemia .
• Insulin itself may stimulate appetite.
• combination of all these effects
Management:
• Pre-inform patients
• Identify cause and try to correct

3. Worsening retinopathy
• in severe background or proliferative
retinopathy
– regimens to achieve tight glucose
control has been shown to exacerbate the
underlying retinopathy.
• treat the retinopathy before instituting tight glucose control

4. Insulin Allergy
• less common with human insulin
• Local reactions at the injection site.
• Can be to the insulin itself or other components such as the protamine in NPH
• generalized allergic reactions & anaphylactic shock are rare
Rx: mild local allergic reactions – antihistamines severe reactions require desensitization.

5. Morning Hyperglycemia
Dawn Phenomenon: Morning Hyperglycemia
mainly caused by overnight growth hormone
secretion and increased insulin clearance.
Somogyi phenomenon: rebound hyperglycemia from late-night or earlymorning hypoglycemia, thought to be from an exaggerated counter-regulatory response.
To differentiate Somogyi effect from Dawn
phenomenon
 check BG @ 2-3 am for a couple of days

6. Lipodystrophy
(hypertrophy /atrophy)
• repeated single site injection
• easily accessible sites commonly affected
• forms lump at injection site
• less painful- patient tends to choose it for
injection
• insulin absorption from this site is not
reliable
(Injection in to the skin may cause skin
necrosis)

Exercise
• Role play on:
– DSME
– Insulin
– How to use Glucometer

Practical tips about insulin therapy
1. Insulin storage:
• preferably @ 4-8 0c, in a fridge ( do not
freeze)
• in separate container
• not In a fridge door
• check expiry date
• if fridge not available, can be kept in a cool,
dark, well ventilated place
Note: a vial in use is stable @ 25oc for 6
wks, @ 37oc for 4 wks

Practical tips about insulin therapy..
2. To mix cloudy insulin, roll between hands
3. Transporting insulin – advise pts to:
– carry adequate supply
– valid prescription
– carry insulin in a hand bag
– avoid keeping insulin in direct contact with
ice pack

Practical tips about insulin therapy…
4. Mixing Insulins:
• inject air in to the vials before drawing
insulin
• draw soluble insulin first, then the intermediate
• avoid contaminating short acting insulin with the intermediate acting one
• should be injected with in 5 minutes of mixing
• if there is difficulty mixing, better inject
separately

Practical tips about insulin therapy…
5. Injection sites:
Abdomen, thighs, buttock, arms
• fast absorption from abdomen , slow from thigh
• preferred sites for soluble insulin – abdomen
• for longer acting insulin – the thighs
• caution! injecting on exercising muscle
• use one area for a particular time of the day
• rotate injection areas
• avoid injecting in to lipodystrophy site

6. Injection techniques:
• no need of cleaning with alcohol
• if need be, clean with water
• make a skin fold – inject @ 90o
in most; with long needles or very thin pt.–@ 45o
• slight bleeding is ok
• never give intermidiate insulin IV

Note that insulin absorption is
increased by – exercising
– a hot bath/sauna
– rubbing the injection site
– IM injection
decreased by – inactivity
– extreme cold
– injection in to hypertrophic area

7. Before changing insulin dosages
check
– insulin storage
– patient compliance
– injection techniques ( resuspension, dosages,
mixing procedures, & injecting)
– injection sites
– eating plans, exercise, BG monitoring compliance
– other factors e.g. stress, infection, other illnesses
N.B. if food is not readily available, be cautious in dose escalation

END OF UNIT – 5

 

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