Endo E1- T1DM

What type of insulin do patients with T1DM require to reverse the catabolic condition?

Exogenous

What is the pathophysiology of T1DM?

circulating insulin is very low or absent

plasma glucagon is elevated

pancreatic beta cells fail to respond to all insulin-secretory stimuli

What type of antibodies are found in the majority of Type 1A DM patients?

Islet cell Abs (& anti-insulin Abs)

What are most islet cell antibodies are directed against?

Glutamic acid decarboxylase (GAD)

What are some environmental agents that have been hypothesized to induce an attack on beta cell function?

Viruses, Toxic chemicals, Exposure to cow's milk in infancy, Cytotoxins

Prevalence of T1DM is inc it what pts?

pts with other AI disease (Graves, Hashimoto, Addison)

What is the most common metabolic disease of childhood?

T1DM

What region has the highest prevalence rates for T1DM?

Scandinavia

Is T1DM more common in men or women?

Men

What is the peak age of onset for T1DM?

11-13

T1DM usually starts during childhood, but what other age range has a relatively high incidence?

30s/early 40s

What are the MC sx of T1DM?

polyuria, polydipsia, polyphagia + fatigue, nausea, blurred vision

*all d/t hyperglycemia

Why does polyuria occur in T1DM?

Due to osmotic diuresis secondary to hyperglycemia

Why does thirst occur in T1DM?

Due to hyperosmolar state & dehydration

Why does polyphagia with weight loss occur in T1DM?

Dehydration and reduced glycogen, PTNs, & TRGs

T1DM may present with (hyper/hypokalemia)

Hypokalemia

Glucose and its metabolites cause (dilation/constriction) of the lens causing blurred vision

Dilation

What can cause RUQ pain in a T1DM patient?

Acute fatty liver

Persistent abdominal pain may indicate what other serious cause of DKA?

Pancreatitis

Chronic GI symptoms in later stages of T1DM are due to what?

Visceral autonomic neuropathy

What type of pattern does numbness and tingling commonly present in for T1DM patients?

bilateral, symmetric, ascending, stocking/glove pattern

What causes neuropathy in T1DM patients?

accumulation of Sorbitol in peripheral sensory nerves due to sustained hyperglycemia

Beta cell destruction may start how long before onset of clinical symptoms?

Months-years

T/F: In new cases of diabetes, physical exam findings are often normal

True

Do DKA patients present with hypotension or hypertension?

Hypotension

What symptoms are associated with DKA?

Kussmaul respirations, Dehydration, Hypotension, AMS

Criteria for diagnosis of T1DM:

A1C ≥ 6.5%

OR FPG ≥ 126 mg/dl

OR OGTT ≥ 200 mg/dl

OR in a pt with classic symptoms, random plasma glucose ≥ 200 mg/dl

Fasting is defined as no caloric intake for at least ___ hours

8

What lab test is the most reliable indicator of DKA?

Plasma acetone (beta-hydroxybutyrate)

Insulin level below ___ μU/mL is indicative of T1DM

5

A high + titer of what antibody suggests Type 1A DM?

glutamic acid decarboxylase

*islet cell or insulin abs also present

When treating T1DM, the insulin dose should be adjusted to maintain preprandial plasma glucose at what levels?

80-150 mg/dL

For insulin naive patients who are underweight, older age, or on hemodialysis, how many units/kg of insulin should be given total each day?

0.3 U/kg

For insulin naive patients who are normal weight, how many units/kg of insulin should be given total each day?

0.4 U/kg

For insulin naive patients who are over weight, how many units/kg of insulin should be given total each day?

0.5 U/kg

For insulin naive patients who are obese, insulin resistant, or taking glucocorticoids, how many units/kg of insulin should be given total each day?

0.6 U/kg

Pt weigh 200 lbs what is the # U they need per day?

36 U insulin/day (200lbs → 90kg; .04U x 90kg = 36 U)

*18 basal at night; other 18 split 6U/meal

Sliding scale:

BG < 150 --> give __U

0U

Sliding scale:

BG 150-199 --> give __U

2U

Sliding scale:

BG 200-249 --> give __U

4U

Sliding scale:

BG 250-299 --> give __U

6U

Sliding scale:

BG 300-349 --> give __U

8U

What is the insulin:carb ratio?

rule of 500

500/total daily insulin dose = 1U to cover x g of CHO

Ex: 36 U/day → 500/36 =14 → 1:14 G CHO (1U per 14 G CHO)

add this too the sliding scale dose

Pt pre-lunch BG is 230 (SS = 4U). Pt eating a sub w/ 40g CHO. ICR is 1:14. How much insulin should they receive?

7U

1:14 → 40/14 = 3U

3U + 4U (SS) = 7U

T/F: Hypoglycemia is common initially with pump therapy

True

Who should you consider an insulin pump for?

A1C >7% + frequent hypoglycemia

hypoglycemic events that require 3rd party assistance or interferes w/ life (work, school, etc)

frequent unpredictable BG fluctuations

pts who think diabetes management impedes on life

What is the first line therapy for treatment of T1DM?

Subcutaneous insulin injections

When should rapid & short-acting insulins be used?

Before meals or BG >250

What are rapid-acting insulins?

regular insulin, lispro, aspart insulin

What is Lispro insulin (humalog)?

form of regular insulin that is genetically engineered w/ the reversal of AA Lysine and proline in the B chain

What is aspart insulin (Novolog)?

has aspartic acid substituted for proline in position 28 of B chain

What are intermediate-acting insulins?

Neutral protamine Hagedorn & Lente insulin

What are long-acting insulins?

Ultralente insulin & insulin glargine (Lantus)

What is an extend insulin (lasting >32 hr)?

insulin zinc suspension (Ultralente)

What is Ultralente dosed at?

10 U and adjust according to pt response

Who should use insulin detemir (Levemir)?

indicated for QD or BID SC administration for pts requiring long-acting basal insulin

What type of insulin is contraindicated in patients who take Heparin?

Neutral protamine Hagedorn (NPH) insulin

What is Pramlintide acetate (Symlin)?

Synthetic analogue of human amylin that slows gastric emptying, suppresses postprandial glucagon secretion, and regulates food intake

Is Pramlintide acetate (Symlin) used as monotherapy or in combination for DM?

Combination w/ insulin

How can patients prevent hypoglycemia if they are planning to work out for more than 30 minutes?

Decrease insulin by 10-20% or have an extra snack

What is the Dawn phenomenon?

normal tendency of BG to rise in the early morning before breakfast

What causes the Dawn phenomenon?

nocturnal spikes in GH causing insulin resistance

What is the Somogyi phenomenon?

Nocturnal hypoglycemia that is followed by a marked increase in fasting plasma glucose with an increase in plasma ketones

What causes the Somogyi phenomenon?

rebound hyperglycemia from nocturnal hypoglycemia

How can you prevent the Dawn and Somogyi phenomena?

adminstering intermediated insulin at bedtime