Management of DM1 Lec.2 By Dr. Athal Humo 2015- 2016

Aims of treatment: To maintain a balance between tight glucose control and avoiding hypoglycemia. To eliminate polyuria and nocturia. To prevent ketoacidosis. To permit normal growth and development with minimal effect on lifestyle. Minimize the risk of long-term microvascular & macrovascular complications.

Constituents of Treatment: Basic education Insulin therapy Nutritional management Exercise Monitoring

Basic Education: Education is fundamental to diabetes management & metabolic control. Teaching about diabetes is best handled by a diabetes management team, including a physician, nurse, educator, dietitian, & mental health professional. The family of diabetic patient must be taught the following basic of treatment: monitoring the child's blood glucose and urine ketones. preparing and injecting the correct insulin dose subcutaneously at the proper time. recognizing and treating low blood glucose reactions. having a basic meal plan.

Insulin Therapy The dose of insulin needed over 24 hours varies according to the pubertal development of the patient: Prepubertal 0.7U/kg/day Mid puberty 1 U /kg/day Late puberty 1.2U/kg/day At time of the diagnosis of diabetes, patient have some residual B- cells, thus, there is often a temporary decrease in insulin requirements 1-3 months after diagnosis (the honey moon period) & this period may last in some cases up to 12 months or more. In this period, is needed about 60-70% of the full replacement dose based on pubertal status. The optimal insulin dose can only be determined empirically, with frequent self-monitored blood glucose levels & insulin adjustment by the diabetes team.

Types of insulin: Recombinant DNA technology is used to manufacture all currently available types of insulin and based on the amino acid sequence of human insulin. Rapid acting insulin: e.g. lispro, aspart. Short acting insulin: e.g. regular Intermediate acting insulin: e.g. NPH, detemir, lente Long acting insulin: detemir, glargine Several different mixes are available which combine different percent of short or rapid acting insulin with intermediate acting insulin e.g. mixtard. *Detemir can be cosidered either intermediate or long acting, its time of action is dose related.

Insulin Regimens: NPH-based regimen: two doses of NPH are given, per day: one in the morning shortly before breakfast & 2nd in the evening, either at dinner or at bed time. Then either regular or rapid acting insulin is given at breakfast and dinner. This regimen may use NPH and regular together at breakfast and again at dinner. The total daily dose is split into two shots and each shot is a mix of NPH and regular which may be given in the same syringe. With one variation, the evening dose is divided so regular insulin is given at dinner & NPH at bedtime. This allows the NPH to last until morning. The use of rapid acting insulin decrease the problem of between- meal insulin peaks when regular is used.

AM 2/3 PM 1/3 2/3 NPH 1/3 Regular 2/3 NPH 1/3 Regular The Intermediate acting 70% of the dose & the short or rapid acting 30%. 2/3 NPH 1/3 Regular AM 2/3 2/3 NPH 1/3 Regular PM 1/3

A/ the quick decline of L/A effect is blunted by the rising NPH/Lente effect, producing a broad tail, which slowly declines to baseline at supper B/ L or A pre-meal; NPH or Lente at breakfast and bedtime. Moving the evening long-acting insulin helps to cover the pre-breakfast hours C/ Regular and NPH or Lente at breakfast and supper. This produces the least physiologic profile, with large excesses before lunch and during the early night, combined with poor coverage before supper and breakfast.

Basal/bolus regimens: The basal insulin component provides baseline, between meals, or fasting insulin needs. The bolus component provides insulin to cover food requirements & to correct hyperglycemia. The basal component may be provided by either rapid acting insulin given by the basal rate using an insulin pump, or with once or twice daily injection of detemir or glargine. detemir or glargine cannot be mixed with any other insulin. Usual basal requirments are about 50% of the total daily insulin requirements.

Lispro or aspart pre-meal; glargine or detemir at bedtime

Inhaled insulin regimen: Premeal inhaled insulin combined with once daily long acting insulin at bed time giving a promising result.

How inject insulin Insulin may be injected into the subcutaneous tissue of the upper arm, the anterior and lateral aspects of the thigh, the buttocks and the abdomen. Rotation of the injection sites is essential to prevent lipohypertrophy or, more rarely, lipoatrophy. The skin should be pinched up and the insulin injected better at a 45° angle in young child to avoid injection of insulin in muscle. Using a long needle or an injection technique that is 'too vertical' causes a painful, bruised intramuscular injection. Shallow intra- dermal injections can also cause scarring and should be avoided

Nutritional Management It is important for children and adolescents with type 1 diabetes to have a nutritionally balanced diet with adequate calories and nutrients for normal growth. The caloric mixture should comprise approximately: 55% carbohydrate. 30% fat. 15% protein. The total daily caloric intake is divided to provide: 20% at breakfast. 20% at lunch. 30% at dinner. 10% for each of the midmorning, midafternoon, and evening snacks, if they are desired. In older children, the midmorning snack may be omitted and its caloric equivalent added to lunch.

Approximately 70% of the carbohydrate content should be derived from complex carbohydrates such as starch; intake of sucrose and highly refined sugars should be limited. Diets with high fiber content are useful in improving control of blood glucose. High-protein intakes may contribute to diabetic nephropathy.

Exercise Physical fitness and regular exercise are to be encouraged in all children with type 1 diabetes. Regular exercise improves glycemic control through increased utilization of glucose by muscles. increased rate of absorption of insulin from its injection site. increasing insulin receptor number. In patients who are in poor metabolic control, vigorous exercise may precipitate ketoacidosis because of the exercise-induced increase in the counter-regulatory hormones.

No form of exercise, including competitive sports, should be forbidden to the diabetic child. But in order to avoid hypoglycemia that may develop during or after exercise, an additional carbohydrate exchange should be taken before exercise & a source of glucose like juice, sweets or candy should be available during & after the exercise. An appropriate regimen for regularly planned exercise that is frequently associated with hypoglycemia as follow: The total dose of insulin may be reduced by about 10-15% on the day of the scheduled exercise. Prolonged exercise, such as long-distance running, may require reduction of as much as 50% or more of the usual insulin dose.

Monitoring More frequent monitoring of blood glucose has been shown to correlate with improved glycemic control. Blood glucose traditionally is monitored before meals, at bedtime, and overnight. Ideally, the blood glucose concentration should range from approximately 80 mg/dL in the fasting state to 140 mg/dL after meals. Any significant elevation of blood glucose level above the upper limit of the range or bellow the lower limit mandates changing the corresponding dose of insulin by 10-15% accordingly.

In the NPH based regimen: Fasting blood glucose--- corresponds to the NPH insulin of the night dose. Noon blood glucose --- corresponds to the regular insulin of the morning. Presupper blood glucose --- corresponds to the NPH of the morning. Prebed time glucose --- corresponds to the regular insulin of the night.

A continuous glucose monitoring system (CGMS) records data obtained from a subcutaneous sensor every 5 min for up to 72 hr and provides the clinician with a continuous profile of tissue glucose levels. The interstitial glucose levels lag 13 min behind the blood glucose values at any given level. Glucowatch Biographer also measure interstitial glucose through a patch of membrane applied on the forearm. It provides real time interstitial fluid glucose values

Measurement of Glycated hemoglobin (HbA1c): HbA1c measurement reflects the average blood glucose concentration from the preceding 2-3 mo. It is recommended that HbA1c measurements be obtained 3-4 times per yr to obtain a profile of long-term glycemic control. The HbA1c fraction is usually less than 6%; in diabetics, Values of 6-7.9% represent good metabolic control. Values of 8.0-9.9%, fair control. Values of 10% or higher, poor control.

Urine or blood ketones also should be monitored when: The blood glucose levels are elevated (eg, above250 mg/dL). Children have a fever. They feel nauseous or are vomiting. When they are not feeling well. This monitoring is important in achieving the goal of aborting DKA episodes by treating early ketosis.

Complications of dm1 Acute complication: Hypoglycemia DKA Long term complication: Diabetic retinopathy Diabetic nephropathy Diabetic neuropathy

Hypoglycemia Hypoglycemia is a major proplem of diabetic children on insulin therapy. It has serious neurocognitive backdraws especially in the young children. Most children with T1DM can expect: mild hypoglycemia each week. moderate hypoglycemia a few times each year. severe hypoglycemia every few years.

Clinical Features Manifestation due to surge in catecholamines: pallor, sweating, apprehension or fussiness, irritability, hunger, tremor, and tachycardia. Manifestation due to cerebral glucopenia: moderate hypoglycemia: drowsiness, personality changes, mental confusion, and impaired judgment . severe hypoglycemia: inability to seek help and seizures or coma. Prolonged severe hypoglycemia can result in a depressed sensorium or stroke like focal motor deficits that persist after the hypoglycemia has resolved.

Treatment The child & the family members should aware about the manifestations of hypoglycemia & how to confirm it by measuring blood glucose level. A source of emergency glucose should be available at all times and places, including at school and during visits to friends. 5-10 g should be given as juice or a sugar-containing carbonated beverage or candy, and the blood glucose checked 15-20 minutes later. Patients, parents, and teachers should also be instructed in the administration of glucagon when the child cannot take glucose orally. An injection kit should be kept at home and school. The intramuscular dose is 0.5 mg if the child weighs ˂20 kg and 1 mg if ˃20 kg. The patient is then taken to hospital if necessary to be given IV glucose.

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