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mcatmemoranda · 2 years

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Diagnosis of DM: HgbA1c greater than or equal to 6.5%, fasting blood glucose level above 126 mg/dL, random blood glucose of 200 mg/dL or higher with symptoms . You have to repeat the number to make the diagnosis. I learned that if blood glucose is 200 mg/dL and you have symptoms, that's enough to make the diagnosis then and there.

Two hour oral glucose tolerance test - blood glucose above 200 mg/dL at 2 hours is diabetes; blood glucose 150 to 200 mg/dL is pre-diabetes.

Fatigue, weight loss, polyuria, polyphagia are common presenting symptoms.

Risk of type 1 diabetes is 1 in 500. But if you have a family member who has type 1 diabetes, it's increased to 1 in 50. It's 50% if you have an identical twin who has it.

You can also test the pt for thyroid disease, celiac disease. Antibodies for diabetes: glutamic acid decarboxylase 65 (GAD65) antibody and some form of islet cell antibody like ICA512 or IA2 anti-insulin antibody. Another antibody you could order is anti zinc transporter 8 antibody. Not having the antibodies doesn't exclude the diagnosis. If you have the zinc transporter 8 antibody, you lose islet cells 20% faster.

You can check C-peptide level. Pro-insulin has C-peptide on it. C-peptide gets cut off of pro-insulin, which then becomes active insulin. C-peptide is a marker of innate insulin production. If you have C-peptide, it means your body is producing insulin. If you have insulin in your body, but no C-peptide, it means you injected insulin and your body didn't make that insulin.

Screen for pts with DM1 for other autoimmune diseases such as celiac disease, thyroid disease, Addison disease, rheumatoid arthritis. They are also at risk for IBD. Thyroid disease + diabetes + Addison's disease = autoimmune polyglandular syndrome.

A baby less than 1 years old who has diabetes can present like she has sepsis. It could be DKA.

Pts can have neonatal diabetes. Pts who present at less than 6 months old should have genetic testing for autoimmune diseases.

Hemolytic uremic syndrome or other storage diseases (like hemochromatosis or cystinosis) can cause pancreatitis-induced insulin dependent diabetes.

Maturity-onset diabetes of the young (MODY) is a group of several conditions characterized by abnormally high blood sugar levels. It's genetic and mild. Pts with MODY have none of the antibodies associated with DM1 and don't need insulin.

Pts can present at any age with diabetes type 1. If it develops in older age, it takes longer to progress to the point where they need insulin. Sometimes they are misdiagnosed as having type 2 diabetes.

Type 1 DM tx: basal bolus insulin regimen = daily basal insulin bolus + meal time insulin injections. Most pts are not started on insulin pumps because insulin pumps can fail. Pts should start with insulin they inject themselves so that they know how to do this in case an insulin pump were to fail. Glargine, detemir, tresiba are long acting basal insulins.

You teach pts how to carb count and use pre-meal insulin. Can also give sliding scale insulin.

Avoid sugary beverages. Learn to count carbs. Do insulin to carb ratio. Low carb diet can help. But in pediatric pts, you can limit to 50 to 100 grams of carbs daily.

Pts should check blood glucose before meals abd at bedtime. They should check it at 2:00 a.m. in the beginning of treatment to ensure they don't become hypoglycemic in the middle of the night. Can also check blood sugar 2 hours after a meal to ensure that the meal time bolus is appropriate. Aim for blood glucose level between 80 and 150 mg/dL (but it ranges depending on the kid's age) and how recently they were diagnosed. You want 50% of blood glucose readings to be in that goal range. If less than 50% of blood sugars are in that goal range, then you have to adjust treatment regimen.

Use fasting blood glucose to titrate basal insulin. You can skip a meal and check blood glucose every 2 hours. If blood glucose rises 30 mg/dL or drops 30 mg/dL every 2 hours, then your basal insulin needs adjustment.

Type 1 DM - loss of 80% of pancreatic islet cells. When the pt starts receiving insulin, the remaining 20% of islet cells can start producing insulin. That may make it easier to control the diabetes initially. This is called "Honeymoon phase."

I googled it and found this:

In the period after a diagnosis of type 1 diabetes, some people experience a ‘honeymoon’ phase. During the honeymoon the pancreas is still able to produce a significant amount of its own insulin. This helps to lower blood sugar levels and can reduce the amount of insulin you need to inject or pump.

Honeymoon phase can last up to 2 years or 3 years. This phase disappears. Blood glucose below 70 is low. Blood sugar should not be below 50 more than 2 times a week. If it occurs more often than that, you have to adjust their regimen. You want to avoid neuroglycopenia (low blood glucose in the brain). It can cause AMS and seizures. Sweating, palpitations, tremors are other symptoms of low blood glucose. Treat it by eating or drinking 15 grams of carbs, waiting 15 minutes, then rechecking blood glucose. If blood glucose is still low, give another 15 grams of carbs and check it again in 15 minutes. Glucose gel can be used or glucagon injection. Mini-dosing: 1 unit per year of age subcutaneous glucagon can be given.

Aerobic activity makes you absorb insulin. But if you don't have enough insulin, cells can't take it in. Kids with blood glucose above 350 mg/dL should not play sports. Increased activity increases sympathetic tone, which can increase blood glucose level.

If you've been very active during the day, your blood glucose can go low hours later, so for kids who play sports, they should check their blood glucose more frequently at end of day.

Illness can raise or lower glucose levels--stress can raise glucose and not eating can decrease it. Pts should still always take basal insulin when sick and should check blood sugars more frequently. You may need to avoid insulin boluses if your sugar is low.

NPO after midnight for pts who are going for surgery doesn't include cleat liquids. Diabetics can drink clear liquids up to 2 hours prior to surgery to treat low blood sugars. You can decrease these pts' basal insulin if necessary.

Vision, neurological, kidney problems, cardiovascular problems can occur as complications. If HgbA1c is persistently high over time, this can lead to the complications of diabetes. Check eyes yearly, check lipids yearly, check kidney function, urine albumin yearly. Glycosylation of cell proteins causes damage.

For toddlers, tolerate Hgba1c up to 8.5%. As they get older, aim for Hgba1c of 6.5%. It's hard to achieve that in type 1 DM. So 7.5% is not bad in a pt with type 1 DM.

Continuous glucose monitor checks blood glucose every 5 minutes or so. It's connected to the insulin pump, telling it to give more or less insulin based on the blood glucose trend. Pts still need to bolus themselves before meals.

There are diabetes camps where you can volunteer to learn more about diabetes.

From the post test:

Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17–30% of patients with type 1 diabetes.

Key Point: It is important to check other autoimmune studies when first diagnosing Type 1 Diabetes. Screening for thyroid dysfunction and for celiac disease should be considered. Other conditions such as primary adrenal insufficiency, autoimmune hepatitis, autoimmune gastritis, dermatomyositis, and myasthenia gravis, occur more commonly in the population with T1DM than in the general pediatric population and should be assessed and monitored as clinically indicated.

Citation:

American Diabetes Association. Diabetes Care 2020 Jan; 43(Supplement 1): S163-S182

International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines recommend a target HbA1c of <7.5% for all pediatric patients with strong emphasis placed on individualizing glucose targets to promote normoglycemia while preventing severe or frequent hypoglycemia.

Key Point: Advise patients to aim for as low of an A1C as possible (<7.5%) while avoiding low sugars. Additionally, educate patients that the trend of A1C’s over time is more important than one specific value.

Citation:

Chiang, J. L., Maahs, D. M., Garvey, K. C., Hood, K. K., Laffel, L. M., Weinzimer, S. A., Wolfsdorf, J. I., & Schatz, D. (2018). Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes care, 41(9), 2026–2044. https://doi.org/10.2337/dci18-0023

Differentiating the specific type of Diabetes is important due to the differences in treatment and education for the patient. The presence of one or more of these antibodies confirms the diagnosis of Type 1 Diabetes.

Key Point: It is helpful to order antibody studies to aid in the diagnosis of Type 1 Diabetes, especially if it is difficult to distinguish from Type 2, MODY, etc. However, negative antibodies do not exclude a diagnosis of T1DM, but it should trigger a thought process of thinking this could be another or new form of disease that acts like T1DM but may not necessarily be T1DM.

Citation:

Mayer-Davis et al. (2018) IPSAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology and classification of diabetes in children and adolescents. Pediatric Diabetes. 2018, 19(S27), 7-19.

#DKA #diabetes #peds #GAD65 #MODY #insulin dosing #honeymoon phase #podcasts #cribsiders

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