Diabetes Mellitus Type 1 Presentation

EPIDEMIOLOGY ▪1.25 million Americans have T1D ▪Most common in people younger than 20 years ▪Most common metabolic disease in children ▪Represents 1 in 400-600 children  ▪Genetic Susceptibility: (presence of HLA haplotypes on chromosome 6: DR4-DQ8or DR...

EPIDEMIOLOGY ▪1.25 million Americans have T1D ▪Most common in people younger than 20 years ▪Most common metabolic disease in children ▪Represents 1 in 400-600 children  ▪Genetic Susceptibility: (presence of HLA haplotypes on chromosome 6: DR4-DQ8or DR3-DQ2) ▪T1DM or T2DM in a first degree relative ▪Viral Infections RISK ▪Immunization FACTORS ▪Diet ▪Higher Socioeconomic Status ▪Obesity ▪Vitamin D deficiency ▪Perinatal factors such as maternal age, and Low Birth weight  ▪Classic new onset of chronic polydipsia, polyuria, polyphagia weight loss with hyperglycemia and ketonemia (or ketonuria) ▪Diabetic Ketoacidosis CLINICAL ▪Dehydration MANIFESTATI ▪Decreased Energy level ON ▪Confusion ▪Fruity odor to breath ▪In young children or infants, failure to grow and gain weight PHYSICAL EXAMINATIONS AND SCREENINGS ▪ Vital signs and BMI ▪ Fundoscopic and visual examination to screen for diabetic retinopathy look for neovascularization, microaneurysms. ▪ Auscultate heart for rate, rhythm, murmur, clicks or extra heart sound ▪ Palpation of thyroid to rule out thyroid disorders ▪ Skin examination for signs for dehydration ▪ Neurological examination for neuropathy ▪ Feet examination for pulses, swelling, nail thickness, gangrene ▪ Psychosocial screening for depression DIAGNOSTIC CRITERIA To distinguish T1DM from T2DM ▪ C-peptide insulin level (normal 0.5 to 2 ng/mm) - Below normal in T1DM and normal or above normal in T2DM. ▪ Insulin level: little or no insulin T1DM ▪ Presence of Autoantibodies ▪ Anti-glutamic acid decarboxylase, insulin autoantibodies, and islet-cell antibodies TREATMENT: PHARMACOLOGIC Treated with intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion ▪Insulin therapy: ▪ Rapid acting: Lispro, Aspart (15 mins before meal) ▪ Short acting: Regular(HumilinR/Novolin R) (30 mins before meal) ▪ Intermediate acting: NPH (HumilinN/Novolin N) (works for about 16 hrs) taking between meals and at bed time. ▪ Long acting: Gargline (Lantus, Levemir}, Toujeo works (20- 24 hrs) CALCULATIONS OF DAILY INSULIN REQUIREMENTS ▪ Initial Total Daily Dose (TDD) : 0.4 to 0.5 u/kg/day. ▪ Usual Total Daily Dose (TDD) : 0.4 to 1 u/kg/day in divided doses Dosing is broken down to 50% basal and 50% prandial ▪ Basal insulin: intermediate (NPH)- or long-acting (eg, glargine, degludec, detemir) in 1 to 2 daily injections. Bolus or prandial insulin: administered before or at mealtimes (depending on the formulation) as a rapid-acting CALCULATIONS OF DAILY INSULIN REQUIREMENTS Example: For a person who weighs 60 kg. If starting with 0.4u/kg/day TDD= 60 kg x 0.4u/day= 24 units/day 50% basal insulin= 12 units 50% prandial insulin= 12 units in divided doses to be given before or at mealtimes or 4 units with each meal CALCULATIONS OF DAILY INSULIN REQUIREMENTS Dose adjustment Basal or/ and prandial insulin must be titrated to achieve glucose control and avoid hypoglycemia Prandial insulin correction factor for elevated blood sugar>150: Subtract 100 from the blood sugar and divide by 50. Administer the number of units of insulin ▪ Example: Blood sugar is 200 mg/dL 1. 200-100 = 100. 2. Divide 100/50 = 2 units insulin to correct elevated blood sugar. TREATMENT: NON-PHARMACOLOGICAL ▪ Diabetes self-management: self-monitoring of glucose level multiple times daily. ▪ Nutrition management: Individualized and culturally sensitive ▪ Exercise is recommended for all adults with the goal of 150 min of moderate-to-vigorous intensity aerobic activity daily activities at least 3 days per week. ▪ Diabetes education should be periodic, culturally sensitive and developmentally appropriate. Stress on maintaining ideal body weight, daily exercise, smoking avoidance or cessation , taking COMPLICATIONS ▪ Hypoglycemia ▪ Hyperglycemia ▪ Diabetic ketoacidosis ▪ Diabetic retinopathy ▪ Diabetic nephropathy (microalbuminuria or macroalbuminuria, impaired GFR, or both) ▪ Diabetic Neuropathy ▪ Skin ulcerations, gangrene of lower extremities ▪ Chronic or acute infections secondary to hyperglycemia ▪ Increases risk for Cardiovascular Disease and Dyslipidemia HYPOGLYCEMIA Defined as abnormally low plasma glucose concentration with or without symptoms. No specific glucose level to define hypoglycemia as glycemia threshold vary within and between person; usually occur at glucose level less than 65 mg/dl or 3.6 mmol/lit Neurogenic symptoms: tremors, palpitation, anxiety, sweating, hunger and paresthesia Neuroglycopenic symptoms: dizziness, weakness, drowsiness, delirium, confusion and seizures /coma HYPOGLYCEMIA Management Asymptomatic Hypoglycemia: if glucose level ≤70 mg/dL (3.9 mmol/L). Repeat test in15 to 60 minutes. Symptomatic hypoglycemia: Take 15 to 20 grams of fast acting carbohydrate ( such as 3 to 4 glucose tablets, ½ cup (4 ounces) of orange juice , 1 tablespoon of sugar or 6 to 8 hard candies). Retest in 15 mins. If glucose remains < 70 mg/dl, repeat treatment as necessary. This can be followed by long-acting carbohydrate such as a meal or a snack. Severe Hypoglycemia: Requires assistance of another person to administer carbohydrate, glucagon or resuscitative actions GlucaGen HypoKit or Glucagon Emergency: IM, IV, SubQ: 1 mg; may repeat in 15 minutes as needed. FOLLOW-UP § Physical examinations every 3 months focused on growth and development §Assess for psychological issues and family stress that could impact DM management on every visit §Check for additional autoimmune disease soon after diagnosis and every 2-3 years (thyroid dysfunction and celiac disease) §HTN screening at every visits §Dyslipidemia screening annually §Screen for micro and macrovascular complications such as nephropathy annually, retinopathy every 2-5 years §Neuropathy screening: comprehensive foot exam annually REFERRAL Endocrinologist Diabetes educator Dietitian Mental health professional for newly diagnosed and or initiation of insulin pump Obstetrician during pregnancy (Holier, 2018)