Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Outpatient Management, co -morbidities & complications of Type 1 Diabetes Mellitus Prof. Abdulmoein Al-Agha, Consultant, Pediatric Endocrinologist, King Abdulaziz University Hospital, Jeddah, KSA Available at my website: aagha,kau.edu.sa Overview Education Immunization Glycemic targets Psychology Insulin therapy Comorbidities Glucose monitoring Complications Nutrition Hypoglycaemia Type 1 DM • Autoimmune destruction of the pancreatic islet cell • Hallmark = lymphocytic infiltration of islets • Progresses over months - years • Leads to insulin deficiency initially • Later may also be associated with glucagon deficiency Goals of T1DM Management • Utilize intensive therapy aimed at nearnormal BG and A1C levels • Prevent diabetic ketoacidosis and severe hypoglycemia • Achieve the highest quality of life compatible with the daily demands of diabetes management • Achieve normal growth and physical development and psychological maturation • Establish realistic goals adapted to each individual’s circumstances Education • Education, from diagnosis onwards, is complex, touching on a range of issues medical and social • It is best done by a multidisciplinary team trained in paediatric diabetes • Education topics should include: – – – – – – – Prevention, detection and treatment of hypoglycaemia Insulin action and administration Dosage adjustment Blood glucose (BG) and Ketone testing Sick-day management Prevention of DKA Nutrition and exercise Glucose Monitoring • Self-monitoring of blood glucose is an essential part of management of type 1 diabetes • Subcutaneous continuous glucose sensors allow detection of asymptomatic hypoglycemia and hyperglycemia • Subcutaneous continuous glucose sensors may have a beneficial role in children and adolescents but evidence is not as strong as in adults MONITORING STRATEGIES • Self Blood Glucose Monitoring – 4-6 / day – Affected by anemia, hemoglobinopathy • Urine Testing – Ketones - PRN • Glycosylated Hemoglobin - HbA1 C - quarterly • Blood lipids - annually • Thyroid function – annually • Urine micro albumin – annually • Dilated fundoscopic – annually Glycemic Targets Age (years) A1C (%) FPG / premeal PG (mmol/L) 2-hour pc PG (mmol/L) Considerations <6 <8.0% 6.0-10.0 N/A* Caution is required to minimize hypoglycemia because of the potential association between severe hypoglycemia and later cognitive impairment. Consider target of <8.5% if excessive hypoglycaemia occurs 6-12 ≤7.5% 4.0-10.0 N/A 13-18 ≤7.0% 4.0-7.0 5.0-10.0 Targets should be graduated to the child’s age. Consider target of <8.0% if excessive hypoglycaemia occurs Appropriate for most adolescents *Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available A1C = Glycated Haemoglobin; FPG = Fasting Plasma Glucose; PG = Plasma Glucose; N/A = Not Available Continuous Glucose Monitoring Interstitial Fluid Measurement Interstitial fluid glucose (G2) is almost always comparable with blood glucose (G1) Insulin Therapy 1921 Banting Best Insulin was the first discovered (late 1920's) which won the doctor and medical student who discovered it the Nobel Prize (Banting and Best) Banting & Best Types of Insulin for Use in T1DM Insulin Type (trade name) Onset Peak Duration 10 - 15 min 10 - 15 min 10 - 15 min 1 - 1.5 h 1 - 1.5 h 1-2h 3-5h 3-5h 3.5 - 4.75 h 30 min 2-3h 6.5 h 1-3h 5-8h Up to 18 h 90 min Not applicable Up to 24 h (glargine 24 h, detemir 16 - 24 h) Bolus (prandial) Insulins Rapid-acting insulin analogues (clear): • Insulin aspart (NovoRapid®) • Insulin glulisine (Apidra™) • Insulin lispro (Humalog®) Short-acting insulins (clear): • Insulin regular (Humulin®-R) • Insulin regular (Novolin®geToronto) Basal Insulins Intermediate-acting insulins (cloudy): • Insulin NPH (Humulin®-N) • Insulin NPH (Novolin®ge NPH) Long-acting basal insulin analogues (clear) • Insulin detemir (Levemir®) • Insulin glargine (Lantus®) Pharmacokinetics of Insulin Products Rapid (lispro, aspart, glulisine) Insulin Level Short (regular) Intermediate (NPH) Long (glargine) Long (detemir) 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours Adapted from Hirsch I. N Engl J Med. 2005;352:174-183. FDA approves Afrezza to treat diabetes • June 30, 2014 -Millions of people with type 1 or type 2 diabetes will have another treatment option now that the FDA has approved an inhaled insulin, called Afrezza, the rapid-acting insulin is taken before each meal Insulin Therapy • Insulin is the mainstay of medical management • The choice of insulin regimen depends on many factors: – Child’s age – Duration of diabetes – Family lifestyle – Socioeconomic factors – Family, patient, and physician preferences Everyone has different needs Insulin regimens Frequently used regimens • Two injections daily mixture of short and intermediate-acting insulin (before breakfast and before evening meal) • Three injections daily using a mixture of short and intermediate acting insulin before breakfast & dinner short-acting insulin alone before Lunch • Basal-bolus regimen short-acting insulin 20-30 min before main meals intermediate or long-acting insulin at bedtime • Insulin pump 2 Vs 3 Daily insulin injections profiles Short acting insulin injection Breakfast Lunch Evening meal Long Acting insulin injection 2 x daily 3 x daily 8 10 12 14 16 18 20 22 24 2 4 Time 6 8 Basal/Bolus Treatment Program With RapidActing and Long-Acting Analogs Plasma insulin Rapid (lispro, aspart, glulisine) 4:00 Rapid (lispro, aspart, glulisine) Rapid (lispro, aspart, glulisine) Glargine or detemir 8:00 Breakfast 12:00 Lunch 16:00 20:00 Dinner Bed 24:00 4:00 8:00 Intensive insulin therapy • What was considered "intensive therapy" in the DCCT is now considered to be standard therapy for management of type 1 diabetes • Intensive insulin therapy (three or more injections per day or continuous subcutaneous insulin infusion with an insulin pump) is successful only if the patient is: – fully committed to it – has good understanding of the regimen – is supported by a health care team with sufficient expertise to educate the patient and to continuously monitor his or her progress Physiologic Multiple Injection Regimens: The Basal-Bolus Insulin Concept • Basal insulin – Controls glucose production between meals and overnight – Usually ~50% of daily needs • Bolus insulin (mealtime or prandial) – Limits hyperglycemia after meals – Immediate rise and sharp peak at 1 hour post-meal – 10% to 20% of total daily insulin requirement at each meal Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. Relative Risk of Progression of Diabetes Complications by Mean HbA1c: based on DCCT Data 15 13 Retinopaty 11 9 Nephropaty 7 Neuropathy 5 3 Microalbuminuria 1 6 7 8 9 10 11 Level of Diabetes Control = HbA1c 12 Advantages of intensive insulin therapy • Gain of 15.3 years of complication free living compared to conventional therapy Disadvantages of intensive insulin therapy • Hypoglycemia Peaked profiles result in uncontrolled glycaemic excursions • Injection issues Variability of absorption from different sites of injection Patients’ fear of multiple injections • Weight gain Hyperglycemia Microangiopathic complications Hypoglycemia Neuronal loss Poor school performance seizures Nutrition • All children with type 1 diabetes should receive counselling from a registered dietitian experienced in pediatric diabetes • Children with diabetes should follow a healthy diet as recommended for children without diabetes • There is no evidence that one form of nutrition therapy is superior to another in attaining ageappropriate glycaemic targets Nutrition • Use of insulin to carbohydrate ratios may be beneficial but is not required • The effect of protein and fat on glucose absorption must also be considered • Nutrition therapy should be individualized (based on the child’s nutritional needs, eating habits, lifestyle, ability, and interest) and must ensure normal growth and development without compromising glycaemic control Hypoglycaemia • Hypoglycaemia is a major obstacle for children with type 1 diabetes and can affect their ability to achieve glycemic targets • All families should understand the importance of hypoglycemia (severity and frequency) along with treatment and follow up strategies • Frequent use of continuous glucose monitoring in a clinical care setting may reduce episodes of hypoglycaemia Hypoglycaemia • There is no evidence in children that one insulin regimen or mode of administration is superior to another for reducing non-severe hypoglycaemia • In children, the use of mini-doses of glucagon has been shown to be useful in the home management of mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate • Dose = 10 mcg x (years of age) • Dose range 20 – 150 mcg Psychological Issues • For children, and particularly adolescents, there is a need to identify psychological disorders associated with diabetes and to intervene early to minimize the impact over the course of development • The risks increase exponentially during adolescence • Children and adolescents with diabetes have significant risks for psychological problems: – Depression – Anxiety – Eating disorders – Externalizing disorders Children with persistently poor glycemic control (e.g. A1C >10%) should be assessed by a specialized pediatric diabetes team for a comprehensive interdisciplinary assessment and referred for psychosocial support as indicated [Grade D, Consensus]. Intensive family and individualized psychological interventions aimed at improving glycemic control should be considered to improve chronically poor metabolic control [Grade A, Level 1A]. Autoimmune Thyroid Disease • Occurs in 15 to 30% of individuals with type 1 diabetes • Risk for AITD during the first decade of diabetes is directly related to the presence or absence of thyroid antibodies • Hypothyroidism is most likely to develop in girls at puberty • Hyperthyroidism also may occur more frequently in association with type 1 diabetes than in the general population Addison’s Disease • Is rare, even in those with type 1 diabetes • Targeted screening is required in those with unexplained recurrent hypoglycaemia and decreasing insulin requirements Celiac Disease • Celiac disease can be identified in 4 - 9% of children with type 1 diabetes • 60 to 70% of these children, the disease is asymptomatic • There is good evidence that treatment of classic or atypical celiac disease with a gluten-free diet improves: – Intestinal and extra-intestinal symptoms – Prevents the long-term squeal of untreated disease • Universal screening for and treatment of asymptomatic celiac disease remains controversial Screening for Comorbid Conditions Condition Indications for screening Screening test Autoimmune thyroid All children with type 1 diabetes Serum TSH level + thyroperoxidase disease antibodies Frequency At diagnosis and every 2 years thereafter Positive thyroid antibodies, thyroid symptoms or goiter Serum TSH level + thyroperoxidase antibodies Ever y 6–12 months Addison’s disease Unexplained recurrent hypoglycemia and decreasing insulin requirements 8 AM serum cortisol + serum sodium and potassium As clinically indicated Celiac disease Recurrent gastrointestinal Tissue transglutaminase As clinically indicated symptoms, poor linear growth, + immunoglobulin A levels poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic control COMPLICATIONS Acute Chronic • Hypoglycemia Neuropathy • Hyperglycemia Retinopathy • Ketoacidosis Nephropathy Diabetes Complications • Nephropathy, retinopathy, neuropathy and hypertension are relatively rare in paediatric diabetes • Screening efforts should focus most attention on post-pubertal patients with longer duration and poorer control of their diabetes Nephropathy • Screening for microalbuminuria (MAU) should be performed annually, commencing at 12 years of age in children with type 1 diabetes >5 years` duration [Grade D, Consensus]. • A first morning urine albumin to creatinine ratio (ACR) has high sensitivity and specificity for the detection of microalbuminuria (MAU) • Treatment is indicated only for those adolescents with persistent microalbuminuria Retinopathy • Retinopathy is rare in prepubertal children with type 1 diabetes and in post pubertal adolescents with good metabolic control Age ≥15 yrs + DM of 5 years If…. DM 5-10 yrs + normal eye exam + good glycemic control Begin annual screening Screen every 2 years Microangiopathic complications from DM can occur by the time of diagnosis but typically 10 – 15 yr Neuropathy • Neuropathy is mostly subclinical in children • Prospective nerve conduction studies and autonomic neuropathy assessment studies have demonstrated increased prevalence of abnormalities overtime • Vibration and monofilament testing have suboptimal sensitivity and specificity in adolescents Dyslipidemia • Children with type 1 diabetes who are <12 years of age should be screened for dyslipidemia if they have other risk factors, such as obesity (BMI >95th percentile for age and gender) and/or a family history of dyslipidemia or premature CVD Hypertension • Up to 16% of adolescents with type 1 diabetes have hypertension • Screen blood pressure at least twice / year • Treat according to the guidelines for children without diabetes Complication Indications & intervals for screening Screening method Nephropathy • Yearly screening commencing at 12 years of age in those with duration of type 1 diabetes ≥ 5 years • First morning (preferred) or random ACR • Abnormal ACR requires confirmation at least 1 month later with a first morning ACR, and if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate • Repeated sampling should be done ever y 3–4 months over a 12-month period to demonstrate persistence Retinopathy • Yearly screening commencing at 15 yrs of age with duration of DM ≥ 5 yrs • Screening interval can increase to 2 yrs if good glycemic control, duration of diabetes < 10 yrs, and no retinopathy at initial assessment • 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard); or • Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil; or • Digital fundus photography Neuropathy • Postpubertal adolescents with poor metabolic control should be screened yearly after 5 years’ duration of DM • Question and examine for symptoms of numbness, pain, cramps and paresthesia, as well as sensation, vibration sense, light touch & ankle reflexes Dyslipidemia • Delay screening post-diabetes diagnosis until metabolic control has stabilized • Screen at ≥12 years of age or <12 years of age with BMI > 95th percentile, family history of hyperlipidemia or premature CVD • Screen all children with type 1 diabetes at least twice a year • Fasting total cholesterol, high-density lipoprotein cholesterol, triglycerides, calculated low-density lipoprotein cholesterol Hyper tension • Use appropriate cuff size