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Questions and Answers
What is a potential mechanism of action related to vitamin D deficiency in type 1 diabetes?
At what age is the peak incidence of type 1 diabetes reported?
Which country has the highest reported incidence of type 1 diabetes in children?
What are common symptoms associated with type 1 diabetes as showcased in the clinical scenario?
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What misconception did the mother have about her son's condition in the clinical scenario?
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What is the recommended goal for fasting plasma glucose (FPG) during pregnancy to prevent complications?
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What should be done if the glomerular filtration rate (GFR) is below 30?
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Which test is NOT recommended for screening distal symmetric polyneuropathy (DPN) in patients with diabetes?
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Which medication can be used to help improve sensation in patients with neuropathy?
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What complication is associated with neuropathy plus poor perfusion due to atherosclerosis?
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What is the half-life of Icodec, a new insulin studied for Type 2 diabetes?
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Which FDA-approved treatment is designed to delay the onset of Type 1 diabetes?
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Which type of medications are being studied for their effects on Type 1 diabetes?
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What essential medical alert is required for every person with Type 1 diabetes?
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Which supply is essential for managing lows for a person with Type 1 diabetes?
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How often should patients with type 1 diabetes (T1D) typically be seen for check-ups?
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Which of the following is considered a 'quick' carbohydrate to raise blood glucose levels quickly?
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What is a common mistake when administering quick carbohydrates for hypoglycemia?
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In the case of hyperglycemia, what is the meaningful number indicating high blood glucose?
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What is the 'correction factor' (CF) formula for treating hyperglycemia?
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What is a potential cause of hyperglycemia in patients with T1D?
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In the example of a 15-year-old female with T1D, what injection is her friend likely to have received for quick relief of symptoms?
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When checking blood glucose levels greater than 250 mg/dL, what is a recommended practice?
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What is the threshold for a fasting plasma glucose (FPG) test to be considered positive for diabetes?
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Which A1C level indicates a positive result for diabetes?
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What is the main reason for performing self-monitoring of blood glucose (SMBG)?
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What is the target blood glucose range for most patients when using SMBG?
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What is a potential disadvantage of Continuous Glucose Monitoring (CGM)?
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What is indicated by a C-Peptide level of less than 0.2 nmol/L?
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How often should Continuous Glucose Monitoring devices typically be changed?
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What is the goal for A1C levels in relation to microvascular complications?
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What is the primary cause of Type 1 Diabetes (T1D) related to pancreatic function?
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What environmental trigger is associated with the onset of Type 1 Diabetes?
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What diagnostic marker can indicate the presence of autoimmune activity in T1D?
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What percentage of diabetes cases in the United States are attributed to Type 1 Diabetes?
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What is the gold standard treatment for managing Type 1 Diabetes?
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What anatomical change is associated with the progression of Type 1 Diabetes?
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Which of the following lab diagnostics is NOT typically used for the diagnosis of Type 1 Diabetes?
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What percentage increase in the incidence of Type 1 Diabetes was reported between 2001 and 2009?
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What does a C-Peptide level of less than 0.2 nmol/L indicate?
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What is the recommended target range for blood glucose in self-monitoring?
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What is a valid indicator of hyperglycemia in a random plasma glucose test?
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What is the main advantage of Continuous Glucose Monitoring (CGM) over Self-Monitoring Blood Glucose (SMBG)?
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Which A1C level indicates a positive result for diabetes?
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How frequently should blood glucose ideally be checked with SMBG?
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Which autoimmune marker is NOT mentioned in the diagnostic criteria for T1D?
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What is the significance of measuring A1C levels below 7%?
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What is the main risk of giving too much quick carbohydrate too quickly during hypoglycemia treatment?
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Which option correctly describes the recommended method for calculating insulin doses when blood glucose is high?
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Which of the following symptoms is NOT associated with hyperglycemia?
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When addressing a patient's high blood glucose levels greater than 250 mg/dL, what is a key practice?
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What is the appropriate response for the clinic when a patient has elevated blood glucose due to illness?
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What is a 'quick' carbohydrate option that can be used for treating hypoglycemia?
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What might contribute to a patient's hyperglycemia during a stressor, such as an illness?
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How frequently are patients with Type 1 Diabetes typically seen for check-ups?
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What is the primary cause of diabetic ketoacidosis (DKA)?
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Which symptom is commonly associated with diabetic ketoacidosis?
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What is the primary mechanism of action of amylin analogs like Symlin (Pramlintide)?
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What is a known adverse effect of SGLT1/2 inhibitors?
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What is the starting dose of Symlin (Pramlintide) for patients with type 1 diabetes?
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Which of the following conditions may contribute to the development of diabetic ketoacidosis?
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What is the recommended initial treatment for diabetic ketoacidosis?
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What characterizes the presence of an increased anion gap in diabetic ketoacidosis?
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What is the half-life of Efsitora, one of the new insulins studied for Type 2 diabetes?
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What is a requirement for an individual to be eligible for Teplizumab treatment?
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What does Teplizumab treatment primarily aim to do?
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Which of the following is NOT essential for every person with Type 1 diabetes according to the information provided?
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Which of the following medications is being studied for its effects on Type 1 diabetes?
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What is a potential consequence of inadequate levels of vitamin D in relation to pancreatic cells?
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Which age group shows the peak incidence of type 1 diabetes?
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Which region has the highest documented incidence of type 1 diabetes in children younger than 20?
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What symptom was NOT mentioned in the clinical scenario of the 9-year-old boy?
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What is a common misconception held by the mother regarding her son's symptoms?
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What is the recommended general goal for fasting plasma glucose (FPG) levels during pregnancy to help prevent complications?
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What is considered a critical intervention for patients with a GFR lower than 30?
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Which of the following is not a recommended option for improving sensation in patients with neuropathy?
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What is the most common consequence of neuropathy combined with poor perfusion in diabetic patients?
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Which test is specifically recommended for screening distal symmetric polyneuropathy (DPN) in diabetic patients?
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What is the primary cause of Diabetic Ketoacidosis (DKA)?
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Which of the following symptoms is characteristic of Diabetic Ketoacidosis?
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What is the recommended initial fluid treatment for a patient with DKA?
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What is an adverse effect of Amylin (Pramlintide)?
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Which medication class inhibits the reabsorption of glucose in the kidneys?
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In patients requiring high doses of insulin, what type of insulin is recommended?
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What should be monitored for patients using SGLT1/2 inhibitors?
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An injection of Synthetic Amylin is primarily used for which purpose?
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What is a common mistake when administering quick carbohydrates for hypoglycemia?
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What does the correction factor (CF) formula for treating hyperglycemia help determine?
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What type of carbohydrate is recommended for immediate elevation of blood glucose during hypoglycemia?
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Which symptom is commonly associated with hyperglycemia?
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What is the recommended practice when blood glucose levels exceed 250 mg/dL?
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How often should patients with Type 1 Diabetes typically have follow-up appointments?
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What is indicated by blood glucose levels greater than 150 mg/dL?
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What immediate action should be taken for a patient experiencing severe hypoglycemia?
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What is the target blood glucose range for most patients utilizing Self-Monitoring of Blood Glucose (SMBG)?
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What A1C level is considered diagnostic for diabetes?
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How often should the Continuous Glucose Monitoring sensor typically be changed?
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What is indicated by a C-Peptide level of less than 0.2 nmol/L?
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What is the appropriate frequency for a patient with Type 1 Diabetes to check their blood glucose levels?
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What test indicates hyperglycemia in the presence of antibodies for Type 1 Diabetes diagnosis?
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What is a common advantage of Continuous Glucose Monitoring compared to Self-Monitoring Blood Glucose?
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What is the significance of maintaining A1C levels below 7% for patients with Type 1 Diabetes?
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Study Notes
T1D Epidemiology
- Prevalence of T1D is higher in areas with less sun exposure
- Vitamin D deficiency may play a role in T1D development due to increased gut permeability and faulty immune response
- Peak incidence of T1D is in children 5-7 years old and during puberty
- T1D affects males and females equally
- Finland has the highest incidence of T1D with 65 new cases per 100,000 children under 20 years old per year
T1D Presentation
- A 9 year old boy presents with polyuria, polydipsia, unintentional weight loss and increased appetite for 3-6 months
- Mother reports subtle changes in mood and energy, worsening over the past couple of weeks
T1D Diagnostics
- Diagnostic Criteria for T1D includes:
- A1c > 6.5%
- Fasting Plasma Glucose (FPG) > 126 mg/dL
- Random Plasma Glucose (RPG) > 200 mg/dL
- Presence of antibodies (IAA, GADA, ZnT8A, ICA)
- C-Peptide < 0.2 nmol/L
- Hyperglycemia in the presence of antibodies is an indicator of T1D
- C-peptide levels reflect the level of endogenous insulin and disease progression
T1D Monitoring
- Self-Monitoring of Blood Glucose (SMBG) involves finger pricks to test serum glucose levels
- SMBG is used to monitor insulin dosages and ensure targets are met
- Target blood glucose range for T1D is 80 - 120 mg/dL
- SMBG checks should be performed 3 to 4 times daily, requiring approximately 150 test strips per month
- Common SMBG brands include One Touch, Freestyle, Contour, and Accu-Check
- Continuous Glucose Monitoring (CGM) involves a sensor placed under the skin, providing glucose readings every 5 minutes
- CGM pros include more readings and trends, less finger pricks, and alarms for highs and lows
- CGM cons include expense and potential delay in real-time blood glucose readings
- CGM sensors are typically changed every 10 days
- Common CGM brands include Dexcom, Medtronic, and Freestyle
T1D Glycemic Goals
- A1c < 7% reduces microvascular complications and is linked to reduced macrovascular disease risk when implemented early after diagnosis
- General glycemic goals for patients with T1D are:
- A1c < 7%
- Fasting Blood Glucose < 90 mg/dL
- Postprandial Blood Glucose < 180 mg/dL
- Patients with T1D are typically seen every 3-6 months, depending on A1c and treatment changes
T1D "Quick" Carbs
- Simple carbs quickly raise blood glucose levels
- Examples of "quick" carbs include:
- 4 oz juice or regular soda
- 1 juice box
- 4 glucose tabs
- 1 gummy pack
- 1 glucose gel pack
- 1 tablespoon honey or sugar
T1D Hyperglycemia
- High Blood Glucose > 150 mg/dL
- Signs and Symptoms:
- Polyuria, polydipsia, polyphagia, blurry vision, fatigue
- Causes:
- Miscalculation of insulin dose, missed insulin dose, non-compliance, stress, illness, age, hormonal changes
- Treatment:
- Correction Factor (CF) = 1800/TDD
- Correction dose calculation: (BG - target)/CF
- Wait 1-2 hours before administering another correction dose and do not give the full dose
- Duration of action for rapid acting insulin is 4 hours
- Check for ketones when BG > 250 mg/dL
- Increase fluid intake to help lower blood glucose levels
T1D Inpatient Hyperglycemia
- Example of order set for inpatient hyperglycemia management focuses on caution to prevent hypoglycemia
- Fluids are crucial for management
- Use of insulin analogs (e.g., Humalin R U-500 vial, Tresiba U-200 pen) may be necessary
T1D Pregnancy
- Tighter glycemic control is essential during pregnancy to prevent pre- and postnatal complications
- Recommended blood glucose targets:
- Fasting Blood Glucose < 90 mg/dL
- Postprandial Blood Glucose < 120 mg/dL
- Monitor for diabetic complications like:
- Preeclampsia
- Polyhydramnios
- Macrosomia
- Hypoglycemia in the newborn
T1D and Kidney Disease
- Long-standing T1D can have an impact on kidney function
- Monitor for signs of kidney disease:
- Albuminuria
- Elevated creatinine
- Hypertension
- Initiate treatment for kidney disease if necessary
T1D Neuropathy
- Stocking-and-glove distribution of neuropathy is a common symptom
- Loss of sensation can lead to balance problems and injuries
- Screen for neuropathy in all T1D patients at diagnosis and 5 years after diagnosis
- Medications for neuropathy management:
- Pregabalin (Lyrica)
- Gabapentin (Neurontin)
- Tricyclic antidepressants (amitriptyline, nortriptyline, imipramine)
- Topical lidocaine or capsaicin
T1D Advances in Management
- New once-weekly insulins (Icodec and Efsitora) show promise in delaying T1D onset
- Teplizumab, FDA approved for delaying T1D onset, is the first of its kind
- Studying T2DM medications (metformin and GLP-1 agonists) for use in T1D
T1D Essentials
- Every T1D patient requires:
- T1D medical alert ID
- Insulin (basal and bolus)
- Needles for insulin delivery
- Blood glucose monitoring device
- Blood glucose testing strips (expensive)
- Lacets for meter
- Glucagon injection
- Supplies for low blood sugar
- Alcohol preps
T1D Management
- T1D patients should have quarterly visits with their healthcare provider for A1c, neurological and podiatric checks
- Yearly funduscopic examinations are necessary
- Attend school health plans to manage T1D
- Extra supplies should be available for pump site failures, insulin degradation, or hyperglycemia
Type 1 Diabetes Overview
- An autoimmune disease characterized by the destruction of beta cells in the pancreas.
- The destruction of beta cells leads to an inability to produce insulin, which is required for glucose uptake by cells.
- T1D accounts for only 5-10% of all diabetes cases.
- T1D is diagnosed based on clinical presentation, blood glucose levels (fasting plasma glucose, random plasma glucose, HbA1c), C-peptide levels, and the presence of autoantibodies.
T1D Pathophysiology
- Both genetic factors (HLA-DQ, HLA-DR) and environmental triggers like viral infections (Coxsackie virus) or dietary factors (early introduction of cow's milk) contribute to the development of T1D.
- The immune system attacks and destroys beta cells in the pancreas, leading to a chronic inflammatory state.
T1D Signs and Symptoms
- Classic symptoms include polyuria (excessive urination), polydipsia (increased thirst), polyphagia (excessive hunger), weight loss, fatigue, and blurred vision.
- These symptoms often develop rapidly and can lead to diabetic ketoacidosis (DKA) if left untreated.
T1D Treatment
- Insulin is the cornerstone of T1D treatment.
- Insulin can be administered via multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) using an insulin pump.
- Self-monitoring of blood glucose (SMBG) and continuous glucose monitoring (CGM) are essential tools for managing T1D.
T1D Complications
- Acute: Hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), diabetic ketoacidosis (DKA).
- Chronic: Diabetic retinopathy (eye damage), diabetic neuropathy (nerve damage), diabetic nephropathy (kidney damage), cardiovascular disease.
T1D Management
- Glycemic goals for T1D patients are typically an A1c < 7%.
- Regular follow-up appointments with a healthcare provider are crucial for monitoring blood glucose levels and adjusting treatment plans.
- Patients with T1D often require a combination of insulin therapy, SMBG or CGM, and lifestyle modifications to manage their condition.
Hypoglycemia
- Hypoglycemia (low blood sugar) is a potentially dangerous complication of T1D.
- Symptoms include sweating, shakiness, confusion, weakness, and dizziness.
- Treatment for hypoglycemia depends on the severity of the episode and may involve administering a quick-acting carbohydrate source (e.g., juice, sugar, glucose tablets).
- Glucagon is a hormone that can be administered in cases of severe hypoglycemia.
Hyperglycemia
- Hyperglycemia (high blood sugar) is another common complication of T1D.
- Symptoms include increased thirst, frequent urination, fatigue, blurred vision, and increased hunger.
- Correction factors (CF) are used to calculate insulin doses based on blood glucose levels and target glucose range.
Diabetic Ketoacidosis (DKA)
- DKA is a serious complication of T1D characterized by dehydration, hyperglycemia, and the accumulation of ketones in the blood.
- Symptoms include fruity breath, Kussmaul respirations, weakness, nausea, vomiting, abdominal pain, and fatigue.
- Treatment involves immediate fluid administration, insulin therapy, and electrolyte correction (often with potassium).
Additional T1D Treatment Options
- Amylin: A synthetic hormone that mimics the action of amylin, a naturally occurring hormone produced by beta cells.
- SGLT1/2 Inhibitors: A class of medications that block the reabsorption of glucose in the kidneys, lowering blood glucose levels.
- GLP-1 Agonists: A class of medications that stimulate insulin release and slow gastric emptying, potentially reducing insulin requirements and improving glycemic control.
New Developments in T1D Treatment and Prevention
- New Once-Weekly Insulins: New long-acting insulin formulations (e.g., Icodec and Efsitora) are being investigated for their potential to improve glycemic control and reduce hypoglycemia risk.
- Teplizumab: The first FDA-approved medication for delaying the onset of T1D in individuals with detectable autoantibodies.
- Metformin and GLP-1 Agonists: Studies are investigating the use of these medications traditionally used for type 2 diabetes for the treatment of T1D.
Vitamin D and T1D
- Vitamin D deficiency may increase gut permeability due to gut flora modification and early introduction of complex proteins.
- Inadequate vitamin D levels may make pancreatic β cells more susceptible to autoimmune attack.
T1D Epidemiology
- Type 1 diabetes can be diagnosed at any age and in people of every race, shape, and size.
- Peak incidence is in 5-7 year olds and during puberty
- T1D is equal among males and females.
- The highest incidence is in Finland with 65 new cases per 100,000 children under 20 years old per year, followed by Sweden at 30 per 100,000.
T1D Presentation and Clinical Scenario
- A 9 year old boy presents with polyuria, polydipsia, and unintentional weight loss despite increased appetite for 3-6 months.
- The patient's mother notes subtle changes in mood and energy, worsening over the past few weeks.
- The patient tests negative for the flu.
- Random plasma glucose (RPG) is 450 mg/dL, A1C is 9%.
- Anti-bodies for GAD, IAA, and IA-2A are pending
T1D Diagnostics and Criteria
- Diagnostic tests include A1c, fasting plasma glucose (FPG), random plasma glucose (RPG), antibodies, and C- peptide.
- A1c greater than 6.5% is diagnostic.
- FPG greater than 126 mg/dL is diagnostic.
- RPG greater than 200 mg/dL is diagnostic.
- Positive for >1 antibody is diagnostic.
- C-peptide levels less than 0.2 nmol/L are also diagnostic.
- C-peptide levels determine endogenous insulin production/activity, allowing monitoring of disease progression.
T1D Monitoring
Self Monitoring of Blood Glucose (SMBG)
- Test glucose levels using a small blood sample from a finger prick.
- Used to see if insulin doses are keeping patients in target range.
- The target range is 80-120 mg/dL.
- Check 3-4 times daily.
- Common brands include One Touch, Freestyle, Contour, Accu-Check.
Continuous Glucose Monitoring (CGM)
- A sensor with an electrode placed subcutaneously measures glucose in interstitial fluid every 5 minutes.
- Pros include more frequent readings, less finger sticks, and alarms for low/high glucose levels.
- Cons include expense and a delay in real-time blood glucose readings.
- Change the sensor every 10 days, depending on the brand.
- Common brands include Dexcom, Medtronic, and Freestyle.
Glycemic Goals
- A1c less than 7% decreases microvascular complications and reducing macrovascular disease if implemented soon after diagnosis.
- A1c of 8% or greater warrants glucagon injection for severe hypoglycemia.
T1D “Quick” Carbs
- “Quick” carbs provide rapidly available glucose to the bloodstream.
- Examples include 4 oz juice or soda, 1 juice box, 4 glucose tablets, 1 gummy pack, 1 glucose gel pack, and 1 tablespoon of honey or sugar.
- Administer promptly when needed.
- Avoid too much too quickly, as this can lead to rebound hyperglycemia.
- Avoid "slow" carbs before "quick" carbs, as the quick carb will not be absorbed easily and will take longer for blood glucose to rise.
T1D Treatment
Hyperglycemia
- A high blood glucose level greater than 150 mg/dL.
- Symptoms include polyuria, polydipsia, polyphagia, blurry vision, and fatigue.
- Causes include miscalculation of insulin dose, missed dose, non-compliance, stress, illness, and age-related hormonal changes.
- Use the correction factor (CF) to calculate insulin doses based on blood glucose and target levels.
- Avoid giving full dose and wait 1-2 hours before administering another dose.
- Rapid acting insulin has a duration of action of 4 hours.
- Monitor blood glucose levels closely, particularly when they exceed 250 mg/dL.
- Staying hydrated can help lower blood glucose.
Inpatient Hyperglycemia
- An order set for inpatient hyperglycemia treatment should prioritize caution to prevent hypoglycemia.
- Time and fluids are key interventions.
Diabetic Ketoacidosis (DKA)
- Caused by dehydration, high blood glucose, and insulin deficiency.
- Free fatty acids accumulate, leading to decreased bicarbonate and increased anion gap.
- Symptoms include fruity breath, Kussmaul’s respirations, weakness, nausea, vomiting, abdominal pain, weakness/fatigue, and extreme dehydration.
- Causes include pump malfunction, non-compliance, comorbidities, sickness, and undiagnosed T1D.
- Treat with fluids, insulin drip, and potassium supplementation.
- Bicarbonate replacement may be considered.
Other T1D Medications
Amylin
- Symlin© (Pramlintide).
- Synthetic amylin produced by pancreatic β-cells.
- Used adjunctively to insulin for post-prandial glucose control.
- Administered subcutaneously via an injectable pen device, starting at 15 mcg with each meal containing at least 30g carbs or 250 calories.
- More common in Europe than the US.
- Adverse effects include severe hypoglycemia, nausea, vomiting, and stomach upset.
SGLT1/2 Inhibitors
- Farxiga© (Dapagliflozin), Jardiance© (Empagliflozin), Zynquista© (Sotagliflozin).
- Inhibit glucose reabsorption in the kidneys.
- Used adjunctively to insulin for A1C and FPG/RPG reduction.
- Administered orally once daily in different dosage forms.
- Not yet approved for Type 1 diabetes but used off-label.
- Adverse effects include hypotension, acute kidney injury, DKA in Type 1 diabetes, yeast infections, acute pharyngitis, and changes in urinary habits.
Insulin for Special Populations
Insulin Resistant Patients
- Require high insulin doses, often exceeding 200 units daily or 100 units per dose.
- Utilize insulin with higher potency/concentration, such as Humalin R U-500 vial or Tresiba U-200 pen.
Pregnant Patients
- Require tighter blood glucose control to prevent pre/postnatal complications.
- Targets include FPGs less than 90 mg/dL and PPGs less than 140 mg/dL.
Diabetic Nephropathy
- Defined by albuminuria (urinary albumin excretion rate of >30 mg/d or >200 μg/min) confirmed on at least 2 occasions 3-6 months apart.
- Progressive decline in GFR.
- Increase in arterial blood pressure.
- Treatment includes annual measurement of creatinine, urinary albumin excretion, and potassium.
- Consider ACE/ARB.
- Adjust insulin dose based on GFR and consult with a nephrologist if GFR is less than 30.
Diabetic Neuropathy
- Characterized by stocking-and-glove distribution of sensory loss in distal extremities.
- Loss of balance, especially with eyes closed, and painless injuries due to loss of sensation.
- Test with pinprick, vibration tuning fork, 10-g monofilament, and ankle reflexes.
- Screen all patients with T2D at diagnosis and all patients with T1D 5 years after diagnosis and at least yearly thereafter.
- Preventive care and regular foot exams are essential.
- Medications that may help sensation include pregabalin (Lyrica), gabapentin (Neurontin), tricyclic antidepressants (amitriptyline, nortriptyline, imipramine), and topical lidocaine or capsaicin.
- Diabetic neuropathy and poor perfusion can lead to non-healing foot ulcers and amputations.
- Refer to wound care or podiatry.
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Description
This quiz covers the epidemiology, presentation, and diagnostic criteria for Type 1 Diabetes (T1D). It highlights key factors such as prevalence rates, age of onset, and critical diagnostic markers. Test your knowledge on the incidence and symptoms associated with T1D, as well as the implications of vitamin D deficiency.
