insulin diabetic ketoacidosis discharge.pptx

Insulin diabetes mellitus type 1

1. INSULIN JAYARAMAN SEETHARAMAN

2. TYPE 1 DM Absence of Insulin Peripheral utilisation of Glucose is halted & Post prandial hyperglycemia results Low plasma insulin Catabolic activity in liver by Glycogenolysis & Gluconeogenesis Endogenous glucose production Fasting hyperglycemia Counter-regulatory hormones induces glycogenolysis & gluconeogenesis, lipolysis & ketogenesis Epinephrin , cortisol & growth hormones oppose the action of insulin & Decrease the peripheral tissue utilization of glucose & glucose clearance Elevated blood glucose level

3. PREPARATION PROPERTIES ONSET PEAK EFFECTIVE DURATION RAPID – ACTING : LISPRO , ASPART GLULISINE FASTER ONSET; SHORTER DURATION 15 mins 0.5 – 1.5 hr 3 – 4 hr SHORT – ACTING : REGULAR 30 mins 2 hr 3 – 6 hr INTERMEDIATE : NPH INSULIN (protamine) SLOWER ONSET; LONGER DURATION 2-4 hr 6 – 10 hr 10 - 16 hr LENTE (no longer used) SLOWER ONSET; LONGER DURATION 3-4 hr 6 – 12 hr 12 - 18 hr LONG – ACTING : ULTRA LENTE (no longer used) SLOWER ONSET; LONGER DURATION 6 – 10 hr 10 – 16 hr 18– 20 hr GLARGINE (LANTUS) SLOWER ONSET; LONGER DURATION 4 hr NO PEAK 24 hr LEVEMIR 3-4 hr Relatively peakless 12 – 24 hr

4. INSULIN RE Q UIREMENT CURRENT INSULIN - generated using recombinant DNA technology DOSAGE : During DKA : 0.1U/kg/hr of Short acting insulin During Recovery : 2-3 U/kg/day Honey moon phase : 0.5U/kg/day or Less or Virtually no insulin Intensification phase : Infection – 0.7 to 1 U /kg/day Puberty - 1 – 1.5 U/kg/day INSULIN RQUIREMENT IS HIGHER IN PUBERTAL CHILDREN Insulin sensitivity reduces during puberty – Insulin dose is increased upto 1.5 units/kg/day Insulin sensitivity normalises at the End of puberty - Insulin dose reverted to 1unit/kg/day

5. SUBCUTANEOUS INSULIN DOSING AGE (yr) TARGET GLUCOSE (mg/dl) TOTAL DAILY INSULIN (U/kg/Day) BASAL INSULIN % OF TOTAL DAILY DOSE BOLUS INSULIN UNITS ADDED PER 100 mg/dl above Target UNITS ADDED PER 15 g AT MEAL 0-5 100 - 200 0.6 – 0.7 25 - 30 0.50 0.50 5-12 80 - 150 0.7 – 1.0 40 - 50 0.75 0.75 12-18 80 – 130 1.0 – 1.2 40 – 50 1.0 - 2.0 1.0 - 2.0

6. INSULIN REGIMEN 2 DOSE SPLIT - MIX Regime (NPH) Intermediate acting + Short Acting (Regular) BASAL - BOLUS INSULIN Regime Long-acting insulin typically insulin Glargine (Lantus) + Rapid Acting

7. 2 DOSE SPLIT - MIX Regime COMMOMLY USED CONVENTIONAL INSULIN PLAN (NPH) Intermediate acting + Short Acting (Regular) 2 Injections are given daily DAILY CALCULATED DOSE OF INSULIN IS DIVIDED 2 / 3 rd 1 / 3 rd MORNING PRIOR TO BREAKFAST & EVENING PRIOR TO DINNER 2/3 NPH + 1/3 Short acting 1/3 - 1/2 Short acting 1 / 2 - 2 / 3 NPH + (At Dinner or Bedtime)

8. Insulin injection is given 20 – 30 mins before meal as the onset of action of Regular Insulin is 30 minutes after Injection as the hexamers must dissociate into monomers subcutaneously before being absorbed into the circulation Delaying the meal 30-60 min after the injection for optimal effect a delay rarely attained in a busy child’s life

9. BASAL - BOLUS INSULIN Regime Long-acting insulin typically Glargine (Lantus) + Short / Rapid Acting insulin Long-acting analog glargine (G) with rapid bolus (L or A) on top of the basal insulin More physiologic pattern of insulin effect Insulin Glargine is steadily absorbed & acts over 24 hours provides a constant background level of insulin without definite peak of action - FLATTER 24-HR PROFILE Given once daily before bedtime ADVANTAGES : Postprandial glucose elevations are better controlled Between-meal hypoglycemia and nighttime hypoglycemia are reduced

10. SOMOGYI PHENOMENON Rebound hyperglycemia - rare Excess Exogenous insulin [evening dose of intermediate – acting ] SILENT HYPOGLYCEMIA DURING THE NIGHT Release of counter-regulatory hormones in the night [Glucagon , cortisol , growth hormone & adrenaline] Early morning hyperglycemia Appropriate reduction in the evening dose of intermediate - acting insulin

11. DAWN PHENOMENON Nocturnal secretion of growth hormones Early morning hyperglycemia (usually recurrent) shifting the timing of evening dose of intermediate acting insulin from pre- dinner to 2 hours after dinner or at B edtime evening short- acting insulin dose is given at pre-dinner

12. INSULIN ADJUSTMENTS IN SPLIT- MIX REGIMEN SMBG INSULIN TO BE ALTERED Fasting Night NPH (SOMOGYI PHENOMENON) Pre- Lunch Morning regular Pre-Dinner Morning NPH Bed Time Night regular SMBG INSULIN TO BE ALTERED Fasting & Pre-meals Long acting analog Post meal Rapid or Regular before that meal INSULIN ADJUSTMENTS IN BASAL BOLUS REGIMEN