1 paediatric and adolescent diabetes care dr noman ahmad 3 rd february 2011 cork university hospital
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Presentation Outline Definition Classification Pathophysiology Clinical Presentation Insulin types and regimens Insulin dose in different age groups Follow-up/Monitoring
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Learning Objectives
Understanding of insulin pharmacokinetics Right insulin regimen Aims of glycaemic control Complexity of management in different age
groups
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Definition
Diabetes mellitus is group of metabolic diseases
characterised by chronic hyperglycaemia resulting
from defects in insulin secretion, action or both
International society of paediatric and adolescent diabetes
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Classification
Type 1 diabetes (IDDM) Type 2 diabetes (NIDDM) Monogenic diabetes (MODY) Neonatal diabetes (Transient first 3 months) Mitochondrial diabetes Cystic fibrosis related diabetes (CFRD) Drug induced hyperglycaemia
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Pathophysiology T1DM
Autoimmune destruction (T1A DM) Non autoimmune destruction (T1B DM) Multiple genes
HLA genes (DR, DQ alpha, DQ beta) Autoantigen (Islet cells, Insulin, glutamic acid
decarboxylase GAD 65, Isulinoma associated protien 2 IA-2, Zinc transporte ZnT8
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Pathophysiology T1DM
Environmental factors
Viruses (Entero, Coxsackie, EBV) Cow’s milk Perinatal factors Vitamin D
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Pathophysiology T1DM
Association with other autoimmune diseases
Thyroid 20% Adrenal 1.7% Coeliac disease 10% Polyglandular autoimmune disease
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Pathophysiology T1DM
Genetic predispositionHLA associations
EnvironmentViruses, toxins, cow’s milk
Immune dysregulationGAD 65, IA-2,Insulin, ZnT8,Islet cells
Beta islet cell destructionInsulin deficiency
Type 1 diabetes
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Presentation of T1DM
Classic (most common) Polyuria, polydipsia and weight loss
Diabetic ketoacidosis Hyperglycaemia, metabolic acidosis and ketonuria
Silent Usually siblings of known cases
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Presentation of T2DM Girls 1.7 times more common Obesity, signs of insulin resistance (acanthosis
nigricans) Strong family history, LBW, gestational diabetes Insulin resistant states (puberty, PCOS) Impaired OGTT Elevated A1C DKA Hyperosmolar coma with no ketunuria
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INSULIN TYPES Short acting
Regular Analogs (Novorapid,Humolog,Apidra)
Intermediate acting NPH
Long acting Detemir (Levemir) Glargine (Lantus)
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Insulin Regimens
Conventional Premixed (Mixtard 30, Novomix 30) Short acting(Novorapid) and intermediate acting (NPH)
Intensive MDI (Lantus or Levemir and Novorapid) Insulin pump (CSII)
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Insulin Regimens
Conventional Positives
Twice a day No carbohydrate counting Good for new patients and school going kids Less chance of DKA
Negatives Non physiological Less flexible More risk of hypoglycaemia Loose glycaemic control
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Insulin Regimen (MDI)
Intensive Positive
Physiological Flexible Less risk of hypoglycaemia Good for teenagers Less long term side effects Better glyceamic control
Negatives More injections Carbohydrate counting More risk of DKA
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Insulin Pump
Continuous basal infusion Bolus with every meal or snack Correction bolus Regular or rapid insulin
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Insulin Pump
Advantages Flexible Precise Better glycaemic control Less variability Less Hypoglycemia Less long term complication
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Insulin Pump
Disadvantage Tethered with device Cost Infection Equipment failure Carbohydrate counting DKA Hinder in some activities
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Injection Sites
Fast absorption in abdomen Slow in legs Intermediate in arms Subcutaneous fat Skin very slow absorption Muscles too fast
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High Insulin Doses
Growth Puberty Sickness Stress Active/competitive sports Steroid therapy No physical activity
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Target Blood Glucose
Preprandial CDA 2008
0-6 years 6-12 6-12 years 4-10 >12 years 4-7
ISPAD 2009 5-8 for all kids
2 hours postprandial 5-10 for all kids
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Clinic Visit
History Glucose diary Hypoglycaemia Intercurrent illness Thyroid, adrenal, coeliac Exercise Hypoglycaemia supplies
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Clinic Visit
Examination Growth, weight, BP Thyroid Injection sites Finger poke sites Pubertal exam Retinal exam Prayer signs
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Clinic Visit
Investigations HbA1C every 3 months TSH annually Coeliac screen Lipid profile Albumin creatinine ratio Eye exam
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Infants And Toddlers
Brain is very sensitive to hypoglycaemia Sensitive to Regular/rapid insulin Picky eater May need to give insulin after meals
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Adolescents
Insulin resistance Non compliance Fabrication Denial Eating out and snacking Family conflicts Alcohol Eating disorders
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