Type 1 DM Training Module updated dt. 25.07.2025.pdf

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5. 1



A Ready Reckoner for Medical Officers on Type 1 Diabetes Mellitus


Table of Contents


Sl. No. Chapter Page No.
1. Definition and Classification 5
2. Glycemic Monitoring 7
3. Nutritional Management 11
4. Insulin Therapy 17
5. Hypoglycemia 26
6. Long-term Complications and Screening 28
7. Sick-Day Management 30

6. 2

Contributors:
1. Definition and Classification
Prof. Sridevi A Naaraayan
Professor of Pediatrics
Institute of child health
Madras Medical College, Chennai.
2. Glycemic Monitoring
Dr. J. Dhivyalakhmi
Associate Professor and Paediatric Endocrinologist
Dept. Of Pediatrics
Sri Ramachandra Medical College and hospital, Chennai.
3. Nutritional Management
Prof. Sridevi A Naaraayan
Professor of Pediatrics
Institute of child health
Madras Medical College, Chennai.
4. Insulin Therapy
Dr. Pushpa Saravanan,
Associate professor
Institute of Diabetology
Madras Medical College, Chennai.
Dr. Elambirai
Junior Resident
Institute of Diabetology
Madras Medical College, Chennai.
5. Hypoglycemia
Prof. G. Prakash
HOD, Department of Diabetology,
Govt Mohan Kumaramangalam Medical College & Hospital, Salem

7. 3

Dr. A. K. Porkodi
Senior Resident in Diabetology
Govt Mohan Kumaramangalam Medical College & Hospital, Salem
6. Long-term Complications and Screening
Prof. G. Prakash
Dr. A. K. Porkodi
7. Sick-Day Management
Prof. G. Prakash
Dr. A .K. Porkodi

8. 4

LIST OF ABBREVIATIONS

ISPAD - International Society for Paediatric and Adolescent Diabetes
DKA - Diabetic Ketoacidosis
MODY - Maturity Onset Diabetes of Young
NDM - Neonatal Diabetes Mellitus
NPH - Neutral Protamine Hagedorn
GDM - Gestational Diabetes Mellitus
LSM - Lifestyle Modification
HHS - Hyperosmolar Hyperglycemic State
GA - General Anaesthesia
FPG - Fasting plasma glucose
PPG - Post -Prandial glucose
NODAT - New Onset Diabetes After Transplant
CSII - Continuous Subcutaneous Insulin Infusion

TDI - Total Daily Insulin
LH – Lipohypertrophy
T1D - Type 1 Diabetes
BG - Blood Glucose
ICMR - Indian Council of Medical Research
ICR - Insulin Carbohydrate Ratio
TDD - Total Daily Dose
SMBG - Self monitoring of blood glucose
CGM - Continuous Glucose Monitoring
TIR - Time in Range
TBR - Time Below Range
TAR - Time above range
ORS - Oral Rehydration Solution

9. 5

1. DEFINITION AND CLASSIFICATION
DEFINITION:
As per International Society for Paediatric and Adolescent Diabetes (ISPAD) criteria,
• Classic symptoms or hyperglycemic crisis (DKA) with random blood sugar ≥ 200mg/dl
• Fasting blood glucose ≥ 126 mg/dl
• Postprandial blood glucose ≥ 200 mg/dl
• HbA1c ≥ 6.5%
point to diabetes in children.

PRESENTATION:
Childhood diabetes can present in 3 ways
1. Diabetic ketoacidosis characterized by the triad of hyperglycemia, ketonemia and high anion
gap metabolic acidosis.
2. Symptomatic with osmotic symptoms namely polyuria, polyphagia, polydipsia, easy
fatigability and weight loss.
3. Incidentally diagnosed.

ETIOLOGICAL CLASSIFICATION OF DIABETES:
1. Type 1 diabetes – characterized by destruction of beta cells leading to insulin deficiency
2. Type 2 diabetes – predominantly due to insulin resistance
3. Gestational diabetes
4. Other specific types
A. Genetic defects of beta cell function
i.Neonatal diabetes
ii.Maturity Onset Diabetes of Young (MODY)
iii.Mitochondrial DNA mutations
iv.Wolfram syndrome
v.Thiamine Responsive Megaloblastic Anemia and Diabetes
B. Genetic defects of insulin action
C. Other genetic syndromes associated with diabetes
D. Other autoimmune syndromes associated with diabetes
E. Drug or chemical induced
F. Diseases of exocrine pancreas

10. 6

G. Infections
H. Endocrinopathies associated with diabetes.

INVESTIGATIONS TO BE DONE FOR A NEWLY DIAGNOSED CHILD WITH DIABETES
MELLITUS:
1. Ultrasonogram abdomen to visualize pancreas
2. Glycosylated hemoglobin (HbA1c) level
3. Fasting and postprandial C peptide levels (Fasting C Peptide levels < 0.6 ng/ml is suggestive
of type 1 diabetes)
4. Auto antibodies namely GAD antibody and IA-2 antibody (Positive in 80% of patients with
type 1 diabetes within 1 year of diagnosis)
5. Thyroid function tests as co morbid screening.
6. Fasting lipid profile as co morbid screening.
7. Genetic testing, only if indicated.

INDICATIONS FOR GENETIC TESTING IN CHILDHOOD DIABETES MELLITUS :
• Family history of diabetes in the 1st degree relative [MODY]
• Age less than 12 months and especially in first 6 months of life [NDM]
• Mild-fasting hyperglycemia (100–150 mg/dl), especially if young, non-obese, and
asymptomatic (MODY)
• A prolonged honeymoon period lasting more than 1 year or an unusually low requirement for
insulin of ≤0.5 U/kg/day after 1 year of diabetes (MODY)
• Associated conditions such as deafness, optic atrophy, or syndromic features (mitochondrial
disease)

11. 7

2. GLYCEMIC MONITORING

Optimizing blood glucose level reduces short and long-term complications in Type 1 diabetes. Adequate
blood glucose control helps in preventing negative impact of prolonged hyperglycemia with cognition and brain
structure in a developing brain in children. The International Society for Pediatric and Adolescent Diabetes
(ISPAD) provides comprehensive guidance for the management of Type 1 Diabetes Mellitus (T1DM),
particularly in children, adolescents, and young adults. It is emphasized to provide individualized care plans
using effective educational strategies in order to achieve glucose targets that are person centered and empower
young people and caregivers. This section will focus on glycemic monitoring adapted from ISPAD guidelines
• SMBG (Self monitoring of blood glucose) – using a glucometer
o Essential tool in a resource limited setting
o Ideal will be to monitor a 7 point testing in a day (Pre and post meal with a nocturnal BG
check). However, glucometer strips are expensive and has to be rationed in a limited resourse
setting. Hence, monitoring BG during fasting, pre lunch, pre dinner and 2 am (nocturnal) will
work out effective.
o Targets
▪ Premeal Glucose: 70–180 mg/dL
▪ Fasting glucose: 70-144 mg/dL
▪ Explanation – The above ranges aligns with the CGM time in range target of >70%
between 70 and 180 mg/dl and has a strong correlation with other CGM metrics and
HbA1c.
o Limitations:
▪ Multiple needle pricks (pain) – can lead to poor compliance
▪ Glucose trends are not available
• HbA1c:
o To be monitored every 3 monthly
o Target: ≤7.0% for most children and adolescents. During Honeymoon phase target can be
lowered ≤6.5%
o Practical considerations:

12. 8

▪ The maximum lifespan of erythrocytes is 100–120 days with an average of 40-60 days.
Hence, HbA1c reflects average blood glucose concentration in the preceding 8-12
weeks. More recent blood glucose concentrations contribute more to the HbA1c (50%
contribution from the previous 30 days, with 40% contributions from the previous 31–
90 days and 10% contribution from 91–120 days)
o Limitations:
▪ Clinical states associated with altered rates of hemoglobin turnover or erythrocyte
survival will affect HbA1c measurements
▪ Increased erythrocyte turnover resulting in lower HbA1c – recovery from Iron
deficiency anemia and folate and B12 deficiency, Chronic kidney disease (post
dialysis), Acute blood loss Hemolysis (e.g., Sickle cell trait/ disease,
thalassemia, G6PD) Cystic fibrosis, Chemotherapy
▪ Reduced erythrocyte turnover resulting in higher HbA1c - Iron, vitamin B12,
and folate deficiency, Chronic kidney disease.
▪ In the above clinical states, use of CGM is arguably the best to provide a better
reflection of overall glycemia compared to SMBG. If CGM data are not available,
evaluation of fructosamine or 1,5-anhydroglucitol (1,5-AG) may be the only
alternative to monitor glycemia compared to HbA1C.
• Continuous glucose monitoring (CGM) (Figure 1)
o Recommended for all children and adolescents with diabetes. For non‐adjunctive use (that is,
diabetes‐related decisions and insulin dosing are made based on CGM values alone without
cross checking with SMBG), currently available CGMs has to be used in children above 4
years for Abbot Libre Flash glucose monitors and 7 years and above for Medtronic Guardian
Sensor 4.
o Provides real-time glucose readings, trends, and alerts for hypo- and hyperglycemia.
o Facilitates improved glycemic control and quality of life.
o Targets:
▪ Time in Range (TIR): 70% within 70–180 mg/dL.
▪ Time Below Range (TBR): <4% below 70 mg/dL, and <1% below 54 mg/dL.

13. 9

▪ Time above range (TAR): <25% above 180 mg/dl and <5% above 250 mg/dl
Note: Targets should be individualized based on age, duration of diabetes, comorbidities, and risk of
hypoglycemia.
Special Considerations
• Young Children (<6 years):
o Higher risk of hypoglycemia; targets may be adjusted to balance safety and glycemic control.
• Adolescents:
o Puberty-related insulin resistance and psychosocial factors may affect glycemic control;
tailored support is crucial.

Figure 1:















16 hrs day

14. 10

Conclusions
• In a nutshell – ISPAD 2022 guidelines on glycemic targets

• Implement individualized glycemic targets considering patient-specific factors.
• Educate patients and families on interpreting glucose data and adjusting therapy accordingly.

15. 11

3. NUTRITIONAL MANAGEMENT

GENERAL GUIDELINES:
The mainstay of treatment of type 1 Diabetes (T1D) is insulin, but optimal glycaemic control
can be achieved only with a combination of diet and exercise along with insulin therapy. Dietary
management for Type 1 Diabetes focuses on consistent carbohydrate intake, portion control, regular
meal-timings with snacks in-between and choosing nutrient-rich foods while restricting processed,
sugary, and high-fat options. Individuals need to learn about carbohydrate counting and its impact on
blood glucose levels.
COMPONENTS OF A MEAL :
The basic ingredients of food are macro and micro-nutrients. Macronutrients include
carbohydrates, proteins, fats and fiber; micronutrients include vitamins and minerals. Carbohydrates
have by far the greatest short-term impact on blood glucose (BG) levels. They get converted to glucose
within the first two hours of eating and have a direct influence on post-meal BG levels. Proteins and
Fats take up to 3-4 hours to increase BG. When consumed in small to moderate amounts (most home
cooked meals), their role in BG control is lesser.
BALANCED DIET:
ICMR (Indian Council of Medical Research) specifically, recommend a balanced diet with 50-
55% of total calories from carbohydrates, up to 20-30% from fats, and 15-20% from protein,
respectively with fiber intake recommended at 20-30 g/day. The guidelines also suggest reduce salt
intake to 2.5gm per day for children aged 1-3, 3gm for 4-8, 3.8gm for 9+ children and adolescents,
and 6gm for adults. Limit or eliminate added sugar from the diet, as it offers no nutritional value
beyond calories.
CARBOHYDRATES :
Carbohydrates are required for energy and each gram of carbohydrate yields 4 calories.
Healthy carbs are those which are slowly digested, leading to sustained BG levels with good satiety.
Unhealthy carbs are those which are quickly digested and absorbed and cause BG spikes. Foods with
low glycemic index and glycemic load are preferred, to reduce post-meal BG spikes. Carbohydrate
content should be mainly in major meals which will be preceded by insulin. Low carb and carb-free

16. 12

list should also be provided for those on rapid acting insulin, for in between snacking. Sources of
various forms of carbohydrates are listed below.
GOOD CARBOHYDRATE BAD CARBOHYDRATE
Complex carbohydrates Simple carbohydrates Refined carbohydrates
Whole grain cereals –
unpolished rice, wheat
Fruits Polished rice, white bread
Oats, barley, millets Some vegetables Maida, aerated drinks
Root vegetables Milk Junk food, candy

PROTEIN:
Proteins are needed for growth and each gram provides 4 calories. Sources include milk and
milk products, dhals, sprouted and unsprouted pulses, soya bean, nuts, egg, fish, chicken and meat.
FAT:
Fat is a source of energy and each gram provides 9 calories. Mono and polyunsaturated fat is preferred
over saturated and trans-fat. Dietary cholesterol intake is essential component and has to be limited to
less than 300mg/day. Sources of various forms of fat are listed below.
MUFA PUFA Saturated fat Trans fat Dietary cholesterol
Groundnut oil Safflower oil Butter Vanaspati Milk products
Rice bran oil Sunflower oil Cheese Processed food Meat
Nuts Salmon Egg yolk Deep fried foods Poultry
Olives Grean leafy veg Processed meat Bakery items

FRUITS:
Whole fruits are preferred over fruit juices. While fruits like apple, guava, orange, grapes,
pears and papaya are to be consumed in moderate quantities, fruits to be avoided include banana,
mango, jack fruit, sapotta and pine apple.

17. 13

Foods to be included in diet:
• Fruits: Whole fruits are preferable to juices due to their higher fiber content resulting in
lower glycemic index.
• Vegetables: A wide variety of non-starchy vegetables, like spinach and gourd varieties.
• Whole Grains: Brown rice, quinoa, oats, and whole wheat bread.
• Lean Protein: Fish, chicken, turkey, lean beef, and eggs.
• Low-Fat Dairy: Milk, yogurt, and cheese.
Foods to consumed in limited quantities or avoided:
• Sugary Drinks and Foods: Sodas, juices, candy, and baked goods.
• Processed Foods: Fast food, packaged snacks, and highly refined grains.
• Red Meat: Limit intake and choose leaner protein sources.
• Saturated and Trans Fats: Found in fatty meats, full-fat dairy, and many processed foods.
Debunking food myths:
• No particular cereal or pulse is superior to one another.
• Prefer more solid chewable form over semisolid form, as gruels will cause sudden rise in blood
glucose level.
• Artificial sweeteners should be avoided as they found harmful in long term use.
• Biscuits to be avoided even the one so called sugar free, dietary biscuits as they contain
artificial sweeteners and added salts.
• Avoid ready to eat foods and preserved food.
CARBOHYDRATE COUNTING :
Carbohydrate serving in a meal determines the rise in blood glucose and is the factor
determining the insulin requirement. Carbohydrate counting followed by calculation and
administration of appropriate insulin dose leads to better glycemic control as well as offers flexibility
in eating pattern in children with diabetes.

18. 14

Food exchanges:
Food exchanges helps to introduce variety in the diet and to suit better the patient need. Foods
containing the same carbohydrate contents are grouped together so that any item in that group can be
selected for preparing the daily menu. For example, 1 slice of bread, 1 medium sized apple, 1 medium
sized idly each have the same amount of carbohydrates (15 gms)
Cereal exchange:

Each of the following items contain 15gms of carbohydrate, 60 Kcal, 3 gms of proteins and negligible fat.
. ITEM Grams Common measurement
Rice (Uncooked) 25 2 Table spoon
Rice (Cooked) 80 1/3 Cup
Rice flakes 20 2 Table spoon
Rice, Puffed 20 3/4 Cup
Rava/ sooji (Uncooked) 25 3 Table spoon
Rava/Sooji (Cooked) - UPPUMA 1/3 cup
Oats (Uncooked) 25 3 Table spoon
Vermicelli 25 3 Table spoon
Wheat flour 25 3 Table spoon
Ragi flour 25 3 Table spoon
Rice flour 25 3 Table spoon
Arrow root flour 25 3 Table spoon
Idli 45 1 Medium size
Dosa 55 1 Medium size
Chappathi 40 1 Medium size
Bread 30 1 slice
Noodles (cooked) 75 1/3 cup

Milk Exchange: (Each milk exchange has 10-12 gms carbohydrate, 6 gms protein, 156 Kcal)
ITEM QUANTITY Carbohydrate content
Cow milk (whole) 1 cup 240 ml
Soy milk 1 cup 240 ml
Curds 3/4 cup 160 ml

Fruit Exchange: (Each fruit exchange has 15 gms of carbohydrate, 60 Kcal, No protein or Fat)
ITEM Weight in grams Common measurement
Apple 112 1 medium size
Banana 75 1 medium size
Chikoo 75 1 medium size
Dates 44 3 medium size
Grapes 50 17 Nos.
Guava 100 1 medium size

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Jack fruit 75 4-5 medium pieces
Mango 75 1/2 medium size
Mosambi (edible portion) 137 1 large size
Orange (edible portion) 100 1 large size
Papaya 154 3/4 cup
Pineapple 154 3/4 cup
Pomegranate 100 1/2 cup
Watermelon 364 1/4 cup
Musk melon 45 1/2 cup
Kiwi 70 1 medium size
Amla 109 6-7 nos
Strawberries 153 1 ¼ cup

PREPARATION OF A MODEL DIET CHART :
AGE – 6 Years
RDA – 1350 calories
Step 1 – 50% of calories have to be provided by carbohydrate. Hence 675 calories are to be obtained
from carbohydrates.
Step 2 – Since each gram of carbohydrate provides 4 calories, 675 calories will be provided by 675/4
= 168 gm of carbohydrates.
Step 3 – Since 15 gm of carbohydrate constitutes 1 exchange, 168 gm constitutes 168/15 = 11
exchanges.
Step 4 – These 11 exchanges to be planned as 3 exchanges for breakfast +1 exchange for mid-morning
snack + 3 exchanges for lunch +1 exchange for mid evening snack + 3 exchanges for dinner.
Step 5 – Appropriate food items can be chosen for each meal from the exchanges table.
INSULIN CARBOHYDRATE RATIO:
Determine the amount of carbohydrates (grams) covered by one unit of insulin
ICR = 500 ÷ by total daily dose (TDD)
For Example, in a child who receives 40 units of insulin per day:
500 ÷ 40 = 12.5 grams
1unit covers ~ 12.5 grams of carbohydrate

20. 16

Whenever the child is consuming food in excess of allowed exchanges, extra unit of insulin can be
given according to extra grams of carbohydrate consumed. This offers flexibility in meal planning and
ensures optimal glycemic control even with irregular meal pattern.

21. 17

4. INSULIN THERAPY

Insulin is the backbone of Diabetes management and is the only available treatment for Type 1
Diabetes Mellitus at present. It has very high efficacy for glucose lowering.
CLASSIFICATION OF INSULIN
• Basal Insulin
o Neutral protamine Hagedorn (NPH)
o Ultralente (extended Insulin Zinc suspension)
o Long acting Insulin analogs: Detemir, Glargine, Degludec

• Prandial Insulin
o Regular Insulin
o Analogue forms: Aspart, Lispro and Glulisine

• Insulin Mixtures
o Premixed insulins: Preparations of short and intermediate acting Insulins are
available in a wide range of ratios. The most commonly used premixed Insulin is
30/70 which contains 30% short acting and 70% intermediate acting Insulin and
50/50 combination contains 50% short acting and 50% intermediate acting Insulin.
o Insulin Co-formulation: It is a combination of 30% insulin aspart with 70% insulin
Degludec.
Types of Insulin preparations and Insulin analogues
Type Onset of action Peak action (hr) Duration of
action (hr)
Rapid acting
Insulin Lispro 10-20 mins 1-1.5 3-5
Insulin Aspart 10-20 mins 1-1.5 3-5
Insulin Glulisine 10-30 mins 1-2 3-5
Fast acting Insulin Aspart 3 -5 mins 1 -3 2 -4
Short acting
Regular(soluble) Insulin 30-60 mins 2-3 6-8
Intermediate acting
Insulin Zinc suspension or
lente*
1-2 hrs 8-10 12-16
Neutral protamine hagedom
(NPH) or Isophane Insulin
1-2 hrs 8-10 12-16
Premixed
Human insulin mix 30% + 70%
Mix 25%+ 75%
Mix 50%+ 50%
30-60 mins 2-10 12-16
Insulin Aspart mix 30% +70% 10 – 20 mins 1-4 12 - 16
Insulin Lispro mix 25% + 75% 15 mins 0.5 – 2.5 hrs 12-16

22. 18

Long acting
Insuling glargine 2-4 hrs - 24
Insulin detemir 1-4 hrs - 16 - 20
Insulin Degludec 0.5 –1.5 hrs - 36- 40
Coformulation
Insulin Aspart 30% +
Degludec 70%
15 mins 0.5 – 2.5 hrs 36-40

Goals of Insulin therapy
• To eliminate symptoms of hyperglycemia
• To prevent diabetic ketoacidosis.
• To arrest severe catabolic state and regain lean body mass.
• To reduce frequent infections.
• To decrease fetal and maternal morbidity in pregnancy
• To prevent and delay microvasucular and macrovasucular complications
Indications for insulin initiation
• All type 1 DM from the time of diagnosis
• All GDM not responding to LSM
• Catabolic symptoms, glucolipotoxicity
• Severely decompensated patients with DKA, HHS, Acute infections
• Hospitalized patients with moderate to severe illness not suitable for oral glucose lowering
agents
• Patients undergoing major surgeries or procedures under GA
• High glycemic parameters: HbA1c >9.0% , FPG >200, PPG >300 mg/dl
• Post pancreatectomy, chronic calcific pancreatitis,
• New Onset Diabetes After Transplant (NODAT).
• Drug induced diabetes

23. 19

Insulin regimens

CSII – Continous Subcutaneous Insulin Infusion

Type 1 diabetes is best managed with basal bolus regimen or CSII. Split mix regimen or pre mixed
insulin make dose titration difficult and should be avoided in type 1 diabetes.

Bolus Insulins
1)Regular human insulin
Advantages:
• Control post-prandial glucose (PPG)
• Can be mixed with intermediate acting insulin in a syringe device
• Cost effective
Limitation:
• Lack of meal-time flexibility
• Opportunity to improve PPG control
2) Rapid acting analogues (Aspart, lispro, Glulisine)

Diabetes
Type1
Intensive
Insulin
therapy
Basal Bolus CSII
Type 2
Add basal only
Basal Plus Basal Bolus
Insulin
Mixtures

24. 20

Advantages:
• Better control of PPG
• Mealtime flexibility
• Lower risk of nocturnal hypoglycemia vs Regular Human Insulin
Limitation:
• Expensive
• Cannot be mixed with intermediate or long acting insulins in the same syringe.
3) Fast-acting insulin aspart
Advantages:
• Closely mimics physiological mealtime insulin secretion
• Better control of both 1 hour and 2 hour PPG control
• Lower risk of hypoglycemia vs aspart
• Post-meal dosing flexibility up to 20 min after start of meal

Limitations
• Expensive
• Cannot be mixed with long acting insulins
Basal Insulins
1) Intermediate acting
Advantages
• Stabilize blood glucose levels during fasting and in post absorptive phase
• Cost effective in resource poor settings
• Can be mixed with regular insulin to reduce the number of pricks per day.
Limitations
• As this insulin has a peak level, risk of hypoglycemia is more.
• Maybe associated with more glycemic variability.

25. 21

2) Long acting analogues
Advantages
• Owing to their peakless action profile, these insulins cause less hypoglycemia
• Glycemic variability is low
• Usually once daily dose is sufficient.
Limitations
• Cannot be mixed with long acting analogues in syringe device, hence more number of
injections per day
• Expensive

Calculation of Insulin dose
Phase Dose requirement
Initiation <0.5 IU/kg/day
Prepubertal children 0.7 - 1.0 IU/kg/day
During puberty 1.2 IU/kg/day up to 2 IU/kg/day

26. 22

Target Glycaemic control
Self monitoring of blood glucose and continuous glucose monitoring are helpful in insulin
dose titration to achieve the targets. 1 to 2 units of insulin increments or reduction should be adviced
based on blood glucose monitoring.

Glucose level (mg/dl)
Measurement Normal Goal Additional action suggested
Whole Blood (Capillary blood glucose)
Average Preprandial glucose <100 80-120 <80 or >140
Average bedtime glucose <110 100-140 <100 or >160
Plasma
Preprandial Glucose <110 90-130 <90 or >150
Postprandial Glucose (2 h after
beginning of meal)
<120 <180 <110 or > 180
HbA1c <5.6% <7% >8%


Insulin Injection technique & Rotation of insulin injection sites

27. 23

Injecting Through Insulin Syringe

Injecting Through Pen


If a needle is left attached to the pen, there is a possiblity of entry of air and contaminants into the
cartridge. Temperature and pressure changes may cause air bubbles to form in the cartridge when
cold and insulin to leak out when hot. Leakage of premixed insulin can alter the mixture ratio and
can compromise the correct dosage.

Improper use or reuse of injection devices can cause
• Pain
• Bleeding and bruising
• Contamination and infection
• Dosage inaccuracy causing poor glycaemic control
• Breaking and lodging of needles uder the skin

28. 24

• Lipodystrophy – can be lipoatrophy or lipohypertrophy (LH)


Lipohypertrophy is a thick soft to firm swelling
with rubbery consistency, seen or palpated on
the skin at the site of insulin injections. It is due
to repeated reuse of needles at the same
injection site. Patients who have LH, either do
not rotate sites or rotate incorrectly. They
develop unexplained hypoglycemia and have
glycemic variability



Note: The first insulin injection ever given to a human being was followed by severe reaction, hence
injection technique is critical from the word “GO”
Insulin storage & Transport
The effectiveness of Insulin is compromised if exposed to heat or freezing temperatures. Hence, for
adequate blood sugar regulation, insulin storage and transportation within the recommended
temperature range is imperative.
Unopened vials and cartridges should be stored in a refrigerator between 2 to 8 degree centigrade,
until the expiry date. Once a vial or pen is opened, it can be stored at room temperature (15 to 30
degree centigrade) for about a month. Exposure to temperature above 30 degrees should be avoided.
While travelling, insulin can be carried in insulated bags or coolers with ice packs to maintain the
temperature. Insulin vial or cartridge should never come in direct contact with ice.
Adverse effects of Insulin
1.Hypoglycemia
2.Weight gain
3.Lipohypertrophy & Lipoatrophy
4. Local reactions: allergy, abscess, infection.
5. Insulin edema

29. 25

Patient education
It will include imparting knowledge to help patients
• Choose and manage devices
• Choose injection regimen
• Use correct injection technique
• Proper rotation, care and self examination of injection sites
• Understanding injection complications and management
• Safe disposal of sharps and clinical waste

Conclusion
• At present Insulin is the only solution for type 1 diabetes management
• Insulin regimen should be individualised, no one size fits all. None of the regimen is perfect.
• When in doubt about the type of diabetes, use Insulin
• Always take time to educate the patients and care-givers to dispel the myths about insulin.
• Proper storage of insulin and insulin injection site rotation are important for adequate blood
glucose control.
• A timely and selective introduction of insulin replacement therapy will help achieve and
maintain euglycemia and thus reduce/ prevent disease associated complications

30. 26

5. HYPOGLYCEMIA
The Whipple’s triad mentioned below is used as criteria for the diagnosis of hypoglycemia:
1) Symptoms, signs or both consistent with hypoglycaemia.
2) A low, reliably measured plasma glucose concentration.
3) Resolution of symptoms and signs of hypoglycemia after the plasma glucose is raised.
Classification of Hypoglycemia:
Level 1 Hypoglycemia Level 2 Hypoglycemia Level 3 Hypoglycemia
Blood Glucose levels
>=54mg/d & <70mg/dl.
Blood Glucose levels
<54mg/dL.
a severe event characterized by altered
mental and/or physical functioning that
requires assistance from another person
for recovery, irrespective of glucose level.

Causes of hypoglycemia:
Poor oral intake, Excessive physical activity, Excess insulin dose.
Symptoms and Signs of Hypoglycemia:
Autonomic symptoms Neuroglycopenic symptoms
palpitations,
tremulousness,
anxiety,
sweating,
Hunger,
Paraesthesia,
pallor and diaphoresis.
cognitive impairment,
loss of concentration,
confusion,
behavioural changes,
psychomotor abnormalities,
seizures and coma.
Behavioural changes like irritability, agitation, quietness,
stubbornness and tantrums especially in preschool
children.

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Normally autonomic symptoms precede neuroglycopenic symptoms, but in children with type
1 diabetes due to repeated episodes of hypoglycemia, Hypoglycemia unawareness may occur where
the child directly develops neuroglycopenic symptoms without autonomic symptoms.
Management:
Level 1 and Level 2 Hypoglycemia should be treated with 15- 20 g of carbohydrates in adults and
0.3g/kg of carbohydrates in children. Pure glucose like glucose tablets or jelly is the preferred initial
treatment but any form of carbohydrate like glucose-containing drinks such as 150 to 200 mL of fresh
fruit juice can be used.
Chocolate is best avoided because the fat content tends to retard glucose absorption. Dietary
protein intake may increase insulin secretion and should not be used to treat hypoglycemia.
Level 3 Hypoglycemia has to be treated with intravenous fluids like 75 to 100 mL of a 20%
dextrose solution or even 150 to 200 mL of a 10% dextrose in adults and 5ml/kg of 10% dextrose in
children.
Intramuscular glucagon of 1 mg can also be administered.
A complex carbohydrate food should be followed after resolution of hypoglycemia to prevent
recurrence.

32. 28

6. LONG TERM COMPLICATIONS AND SCREENING
NEPHROPATHY:
Initial screening Follow-up frequency Goal
Diabetes duration of 5
years.

Method:
Urine Albumin-to-
creatinine
ratio
If normal - annually
If abnormal - repeat with
confirmation in two of three samples
over 6 months (first morning void is
recommended).
Urine Albumin-to-
creatinine ratio <30 mg/g

Retinopathy:
Initial screening Follow-up frequency Goal
Diabetes duration of
5 years.
Method:
Dilated fundoscopy or
Retinal photography.
If normal, annually. No retinopathy

Neuropathy:
Initial screening Follow-up frequency Goal
Diabetes duration of
5 years.
Method:
Foot exam with pinprick, 10-g
monofilament sensation
vibration test and ankle reflexes.
If normal, annually No neuropathy

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CO MORBIDITY SCREENING
Thyroid disease:
Initial screening Follow-up frequency Goal
Soon after diagnosis Every 1–2 years if thyroid
antibodies negative,
more often if symptoms
develop or presence of
thyroid antibodies.
Appropriate treatment of
underlying thyroid
disorder.

Lipid profile:
Initial screening Follow-up frequency Goal
Soon after diagnosis Every 3 years Maintenance of appropriate level

Blood pressure:
Initial screening Follow-up frequency Goal
Soon after diagnosis Annually Maintenance of appropriate level

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7. SICK-DAY MANAGEMENT

Sick-day management management includes adequate hydration and adjustments of the insulin
dose based on frequent monitoring of blood glucose and ketones.
The goal is to maintain blood glucose levels between 70 and 180 mg/dl during illness.
DO’s:
Hyperglycemic crisis:
Monitor blood glucose more frequently (every 2-3 hours)
Monitor ketones frequently.
Maintain adequate hydration.
Insulin dose adjustment as per measured blood glucose levels.
Hypoglycemia episodes:
Individuals who are unable to eat and has persistent vomiting, consider emergency hospital
admission for further management.
DON’ts:
Avoid skipping insulin dose.
Avoid dehydration.
Avoid ORS.

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