childhood diabetes mellitus type 1 for students

Type 1 diabetes mellitus

1. Treatment of Type 1 diabetes
Dr. Amir Babiker
MBBS, FRCPCH (UK), CCT (UK)
Consultant Paediatric Endocrinologist, KKUH
and Assistant Professor, King Saud University

2. DM
A metabolic disorder of multiple
aetiologies characterized by:
•Chronic hyperglycemia
•Disturbances of CHO, fat and protein metabolism
•Defects of insulin secretion, insulin action or both.

3. Diagnostic Criteria
Condition 2 hour glucose Fasting glucoseHbA
1c
mmol/l(mg/dl) mmol/l(mg/dl) %
Normal <7.8 (<140) <6.1 (<110) <6.0
Impaired fasting
glycaemia
<7.8 (<140)
≥ 6.1(≥110) &
<7.0(<126)
6.0–6.4
Impaired glucose
tolerance
≥7.8 (≥140) <7.0 (<126) 6.0–6.4
DM ≥11.1 (≥200) ≥7.0 (≥126) ≥ 6.5
OR Symptoms of hyperglycaemia and casual plasma glucose ≥ 11.1 mmol/l
(200 mg/dl)
•A positive result, in the absence of unequivocal hyperglycemia, should be
confirmed by a repeat of any of the above methods on a different day.
Diabetes mellitus is characterized by recurrent or persistent hyperglycaemia,
and is diagnosed by demonstrating any one of the following:
[

4. Types of DM
•T1DM (IDDM, Juvenile DM): Autoimmune,
idiopathic
•T2DM (NIDDM, Adult onset):Obesity,
Acanthosis nigricans, FH.
•Gestational DM
•Other: Monogenic, congenital, neonatal,
2ry..etc

7. Map of published incidence rates (per 100 000) of type 1 diabetes in
children. Source: Solte´sz et al. (2).
Childhood type 1 diabetes
Pediatric Diabetes 2007: 8 (Suppl. 6): 6–14

11. Management Goals
•Prevent death & alleviate symptoms
•Achieve biochemical control
•Maintain growth & development
•Prevent acute complications
•Prevent or delay late-onset complications

12. Management Components
•Insulin:
•Regular and NPH (1/3 and 2/3)
•Analogues (Mixed, ultra short, Detemir & Glargine)
•Insulin pumps (CSII): Open and closed loops.
•Support:
•Education: CHO counting, I:CHO, Self care &
injections, hypos management, Sick day rules
•Psychological
•Annual review: Examination, Invx: Blood and urine,
Eye
•Life style:
•Diet (CHO = 50 - 60%, Fats: < 30%, Proteins 10 – 20%)
•Sensible exercise

13. Concepts
•Honeymoon phase or partial remission:
weeks to 2 years, due to B cell hyperplasia.
•Early morning hyperglycaemia: with NPH & Regular
(Somogyi & Dawn phenomena)
•Sick day rules:
•Check Blood sugar every 2-4 hrs
•Check ketones
•Drink plenty of fluids
•Need extra insulin to clear ketones
•Never omit insulin
•Hypoglycaemia may be a problem especially in
young children

14. DKA
Children with T1DM who have:
Hyperglycaemia (BG >11 mmol/l)
 pH < 7.3
 Bicarbonate < 15 mmol/l
 With ketonaemia and/ or ketonuria.
and who has:
Acidotic respiration, dehydration, drowsiness and/or
abdominal pain/vomiting

15. DKA
They can die from :
Cerebral oedema: This is unpredictable, occurs
more frequently in younger children and newly
diagnosed diabetes and has a mortality of around
25%.
Hypokalaemia: This is preventable with careful
monitoring and management
Aspiration pneumonia: NGT.

16. Hypoglycaemia
•Target blood glucose: 4 – 8 mmol/l.
•Treat all blood glucose below 4 mmol/l to
avoid hypo unawareness.
•Symptoms:
–Sympathetic: pallor, tachycardia, sweating,
tremors
–Neuroglycopoenic: irritability, headache,
nausea, seizure, stupor, coma

17. Hypoglycaemia
•Causes:
–Missed or delayed meal
–Exercise
–Alcohol
–Overdose of insulin
–Impaired food absorption (CD)
–Addison’s disease
•Treatment:
–Oral CHO: glucose tabs, gel and fluids
–I/M glucagon
–10% Dx 2 ml/kg bolus

18. Modern Management
“Optimized” or “Intensive” therapy.
•Physiological insulin replacement
•Assessment of glycaemic control (SMBG)
•Hospital tests (HbA1c, …etc)
•Insulin dosage adjustment
•Healthy diet
•Diabetes education

19. *Not statistically significant due to small number of events.
†
Showed statistical significance in subsequent epidemiologic analysis.
DCCT Research Group. N Engl J Med. 1993;329:977-986; Ohkubo Y, et al. Diabetes Res Clin Pract.
1995;28:103-117; UKPDS 33: Lancet. 1998;352: 837-853; Stratton IM, et al. Brit Med J.
2000;321:405-412.
Intensive Therapy for Diabetes:
Reduction in Incidence of Complications
T1DM
DCCT
T2DM
Kumamoto
T2DM
UKPDS
A1C 9% → 7% 9% → 7% 8% → 7%
Retinopathy 63% 69% 17%–21%
Nephropathy 54% 70% 24%–33%
Neuropathy 60% 58% –
Cardiovascular
disease
41%* 52* 16%*
✝
T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.

20. Elements of Intensive therapy
•Multiple-component insulin regimen
•Careful balance of food intake, activity, and insulin dosage
•Daily self-monitoring of blood glucose (SMBG)
•Patient adjustments of food intake and insulin dosage and
use of insulin supplements according to predetermined plan
•Defined target blood glucose levels (individualized)
•Frequent contact between patient and staff
•Patient education and motivation
•Psychological support
•Assessment (HbA1c and annual review)

21. Representative target blood glucose levels suitable for
young otherwise healthy patient
Ideal
mg/dl (mM)
Acceptable
mg/dl (mM)
Preprandial 70-105 (3.9-5.8 )70-130 (3.9-7.2)
1-h postprandial 100-160 (5.6-8.9)100-180 (5.6-10.0)
2-h postprandial 80-120 (4.4-6.7)80-150 (4.4-8.3)
2-4 h postprandial 70-100 (3.9-5.6 )70-120 (3.9-6.7)

22. Insulin
Since the discovery of insulin less
than 100 years ago, diabetes
treatment and technology have
come a long way in helping
people with diabetes manage
their disease.

25. Types of Insulin
JAMA 2003;289:2254-64 - Clin Pharmacology Online, 2009
Type Product Brand
Rapid-Acting Lispro
Aspart
Glulisine
Humalog
Novolog
Apidra
Short-Acting Regular “R” Humulin, Novolin, ReliOn
Intermediate-Acting NPH “N” Humulin, Novolin, ReliOn
Basal Glargine
Detemir
Lantus
Levemir
Premixed 70/30 regular
75/25 lispro
70/30 aspart
50/50
Humulin, Novolin, ReliOn
Humalog 75/25
Novolog Mix 70/30
Humulin, Humalog

26. Comparison of Human Insulin and
Analogues
JAMA 2003;289:2254-64. Clin Pharmacology Online, 2009
Insulin
Preparations
Onset of
Action
Peak Duration
of Action
Lispro, Aspart,
Glulisine*
5-15 min 30-90 min 4-6 h
(*6-8 h)
Regular 30-60 min 2-4 h 6-10 h
NPH 1-2 h 4-8 h 10-20 h
Glargine 1-2 h None 24 h
Detemir 1-2 h 6-8 h 12-24 h

30. Principles of Management
Relationship with the patients/families:
Communication: Education – Motivation –Support
Dose or treatment changes
Basic concepts:
Insulin analogues - basal bolus regimen
CHO Counting
I:CHO ratio
IS (CF)

31. Insulin regimens
•Once daily insulin (NPH or basal)- partial
remission
•Twice daily
•Three times a day
•4 times a day
•Continuous subcutaneous insulin infusion (CSII)
•Closing the loop (Artificial pancreas)

32. Twice daily regimens

33. 3 times/day regimen

34. 4 times/day regimen

36. Basal bolus regimen
•This is the most intensive regime with three pre-prandial doses of
short /rapid acting insulin and a bedtime dose of intermediate or
long acting insulin. While this regime offers no improvement in
metabolic control compared to any other insulin regime, this may be
the most suitable regimen for people who do not have a stable daily
routine as the time and dose of insulin can be varied according to
when the meal is taken and its carbohydrate content.
•Generally 30 - 50% of the total daily insulin requirements should be
given as intermediate or long acting insulin at bedtime with the
remaining insulin being given as short / rapid acting before
breakfast, lunch and evening meal depending on the needs of the
individual.

37. Dose adjustment
Premixed/Biphasic insulin (2/day)
Blood Testing
Times
Blood Glucose
<4mmol/l
Or Hypo
Blood
Glucose
4-7 mmol/l
Blood
Glucose
8 – 14 mmol/l
Blood
Glucose
>15mmol/l
Before Bed
and Before
Breakfast
Reduce
Evening meal
insulin
by 4 units
Optimal Increase
Evening meal
insulin
by 2 units
Increase
Evening meal
insulin
by 4 units
Before Lunch
and Before
Evening Meal
Reduce
morning insulin
by 4 units
Optimal Increase
morning insulin
by 2 units
Increase
morning insulin
by 4 units

38. Dose adjustment - MDI
Blood Testing
Times
Blood Glucose
<4mmol/l
Or Hypo
Blood
Glucose
4-7 mmol/l
Blood
Glucose
8 – 14 mmol/l
Blood
Glucose
>15mmol/l
Before
Breakfast
Reduce bedtime
intermediate insulin
by 4 units
OPTIMAL
Increase bedtime
intermediate /long
insulin by 2 units
Increase bedtime
intermediate /long
insulin by 4 units
Before
Lunch
Reduce morning
short acting insulin
by 2-4 units
OPTIMAL
Increase morning
short acting insulin
by 2 units
Increase
morning short acting
insulin by 4 units
Before
Evening
Meal
Reduce lunchtime
short acting insulin
by 2-4 units
OPTIMAL
Increase lunchtime
short acting insulin
by 2 units
Increase lunchtime
short acting insulin
by 4 units
Before
Supper/
Bedtime
Reduce Evening meal
short acting insulin
by 2-4 units
OPTIMAL
Increase evening
meal short acting
insulin by 2 units
Increase evening
meal short acting
insulin by 2 units

39. General Advice on Insulin Dose Adjustment
•Insulin may need adjusting for exercise, meal composition, patterns in
blood sugar levels, during illness and weight loss or gain episodes.
•Do not adjust dose on a “single” raised blood glucose.
•Adjust according to the chart above and monitor for at least 48 hours to
judge the effect before further adjustment
•Blood glucose target range should be set Individually for each patient.
•Dose adjustment is individualized and needs to be monitored closely.
•Patients should be educated to adjust their own insulin
•Document change of insulin dose in the nursing notes.
•If problems persist in controlling the blood glucose level seek advice from
the Diabetologist.

40. Insulin Pumps (CSII)

43. Type 1 diabetes – children/adolescents
Current technologies
–Insulin analogues
•Fast acting: lispro, aspart, glulisuline
•long acting (basal): glargine, detemir, Degludec
–Insulin pump therapy (CSII)
–Continuous Glucose Monitoring systems (CGMS)
Insulin dose delivery & adjustment strategies
•Patient education/empowerment tools
•SMBG + basal/bolus therapy
•CHO counting techniques (DAFNE: Dose Adjustment for Normal
Eating)
•Insulin sensitivity

44. New approaches to the management of
Type 1 diabetes
• Limitations of current treatment
approaches
• Future therapy options:
Immune manipulation/modulation
Optimizing Sc insulin delivery
Optimizing Sc insulin action

45. Challenges
•Non-availability of insulin in poor countries
•injection sites & technique
•Insulin storage & transfer
•Mixing insulin preparations
•Insulin & school hours
•Adjusting insulin dose at home
•Sick-day management
•Recognition & Rx of hypo at home

47. Thank You