Lecture 23 - Type 1 Diabetes Clinical Presentation & Rationale for Insulin Administration

what is the initial presentation for type 1 diabetes

usually developed before 20 years old

hyperglycemia but little glucose used for cellular energy

polyuria, polydipsia, polyphagia

weight loss (can be sudden), lean body composition

20-40% present with diabetic ketoacidosis

when can diabetic ketoacidosis present

initial presentation for type 1 diabetes

acute illness

when insulin doses are missed

what are s/s of diabetic ketoacidosis

high blood glucose (>14)

dehydration

metabolic acidosis (pH<7.4, low HCO3-, anion gap)

electrolyte imbalances (Na/K)

increased respiratory rate

acetone (fruity) odor to breath (from ketones)

abdominal pain

decreased consciousness

what are general emergency treatments for diabetic ketoacidosis 

fluid replacement, insulin therapy, electrolyte monitoring

what are the risk factors for type 1 diabetes

family history (immediate family), especially age of onset

genetic markers

autoantibodies

environmental factors

what is the rate of beta cell destruction dependent on

genetic predisposition

immunogenic abnormalities

what is the honeymoon period of type 1 diabetes

retain some beta cell function

this may cause hypoglycemia if there is still endogenous insulin release in patients taking insulin

what are environmental risk factors for type 1 diabetes 

recent stressful event 

irregular vaccination schedule

fetal infections

nitrosamine-containing products 

is screening recommended for type 1 diabetes

no

what are the long term goals of therapy for type 1 diabetes

prevent onset or delay progression of microvascular and macrovascular complications

what are the short term goals of therapy for type 1 diabetes

alleviate symptoms of hyperglycemias and minimize the risk of hypoglycemia

how are the goals of therapy for type 1 diabetes accomplished 

maintaining glycemic treatment targets

• A1c

• fasting pre-meal blood glucose

• 2-hour post-prandial blood glucose 

physiologic replacement of insulin

what is the target A1c for most people

<7.0%

what is the target A1c for children and adolescents

<7.5%

what is the target fasting pre-meal blood glucose for most people

4-7 mmol/L

what is the target fasting pre-meal blood glucose for children and adolescents 

4-8 mmol/L

what is the target 2-hour post-prandial blood glucose for most people

5-10 mmol/L

how does the hexamer formation of insulin affect its absorption

insulin in hexamer form is released slowly into the body

insulin in single subunits is absorbed rapidly

what kind of insulin is NPH

basal intermediate acting

cloudy

e.g. Humulin N, Novolin ge NPH

what kind of insulin is glaragine

basal long-acting

clear

e.g. Basaglar, Lantus, Toujeo, Semglee

what kind of insulin is detemir

basal long-acting

clear

e.g. Levemir

what kind of insulin is degludec

basal ultra-long-acting

clear

e.g. Tresiba

what kind of insulin is icodec

once-weekly basal 

clear

e.g. Awiqli

what kind of insulin is lispro

bolus rapid-acting

clear

e.g. Humalog (100 & 200), Admelog

what kind of insulin is aspart

bolus rapid-acting

clear

e.g. Fiasp, NovoRapid, Turapi, Kirsty

what kind of insulin is glulisine

bolus rapid-acting

clear

e.g. Apidra

what kind of insulin is regular 

bolus short-acting

clear

e.g. Humulin R, Novolin ge Toronto

what is the recommended insulin regimen for type 1 diabetes

basal-bolus (intensive glycemic control)

• basal = long-acting or intermediate acting

• bolus (meal related) = rapid acting or short acting

increased risk of hypoglycemia

what are other insulin regimens for type 1 diabetes that are not recommended 

split-mixed → combination of rapid/short acting plus intermediate acting administered before breakfast and supper

sliding-scale → AVOID

what is the important evidence from the DCCT and EDIC studies of type 1 diabetes

multidose intensive insulin regimen is recommended (basal-bolus)

statistically significant and clinically important reduction in microvascular complications and macrovascular complications

statistically significant and clinically important increase in risk of hypoglycemia