DIABETES MELITUS DIABETES MELITUS TYPE ITYPE I

Dr. H. Hakimi Sp.A.KDr. H Charles Darwin Siregar Sp.A

Dr. Melda Deliana Sp.A.KDr. Siska Mayasari Lubis, SpA

PEDIATRIC ENDOCRINOLOGY MEDICAL SCHOOL USU/H. Adam Malik

HOSPITALMedan

Introduction• Chronic disease • Difficult to cure • Major DM group in children.

DM Classification based on etiology (ADA,1998)

1. DM type I ( B cell destruction) :a. immune mediatedb. idiopathic

2. DM type II (insulin resistant) 3. DM other type a. genetic defect of B cell function

b. genetic defect of insulin functionc. pancreas exocrine diseased. endocrinopathye. drug and chemical substance inductionf. Infectiong. uncommon immune mediated DM h. Genetic syndrome related to DM

4. DM gestasional

Definition• Systemic disorder because glucose

metabolism disorder, characterised by chronic hyperglicemy

• Caused by autoimunne process which destroy pancreas B cell insulin production decrease or stopped

Patogenese

langerhans islets destruction

Addison disease Tirodiditis hashimoto Anemia pernisiosa Viral infection

HLA B8,DR3,BW15,DR4 activation

autoantibody process

Chemical exposure

Pancreas B cell function failure

Insulin secretion decrease or stop

DM type I

diagnostic criteria• Normal blood glucose : <126 mg/dl ( 7 mmol/L)• Diagnose is determined if one of this criteria

fulfilled :– Polyuria , polydipsy, polyphagy, decrease weight

, blood glucose ad random >200mg/dl– Asymptomatic : blood glucose ad random

>200mg/dl

Glucose tolerance test (GTT)

• GTT is not nesecary if distinguished symptoms are found• Indication : GTT in doubtful case • glucose dose : 1,75 gr/W in 200-250 cc water in 5

minutes• GTT result intepretation :

– DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200 mg /dl

– Impaired Glucose tolerance : fasting blood glucose <140 mg/dl or at 2nd hour : 140 – 199 mg/dl

– Normal : fasting blood glucose < 110 mg/dl or at 2nd hour : < 140 mg/dl

Epidemology• Incidence is higher in Caucasian• Highest in Finland 43/100.000 , lowest in Japan 2/

100.000 foo age < 5 yrs old• Peak incidence :

– Age 5 – 6 yrs old– 11 yrs old

• New cases >50% : >20 yrs old• Genetic and environment factors : HLA pattern,

virus, toxin, etc

Clinical appearance• Acute• Polyuria, polydypsy, rapid weight decrease,

hyperglycemy• Delayed diagnose : ketoacidosis with all the

consequences

DM type I management

• Good metabolic control with normal blood glucose level

• Unified team

Objective Spesific objective

1. Free from symptoms 1. optimal growth

2. Enjoy social life 2. normal emosional development

3. Prevent complications 3. Good metabolic control without causing hypoglycemy

4. Few school absence days and active in school

5. Patient doesn’t manipulate disease

6. Able to manage disease

independently

Insulin• Earlier : pig/cow pancreatic gland purification• Recombinant technology : human insulin• Usage based on age , social economic,

culture, and drug distribution • Important to know :

– somogyi effect– dawn effect – Morning hyperglycemy

Insulin

• Ultra short acting insulin ( lispro )– Give 15 min before meal– Useful in sick day management and before meal injection

• Short acting insulin– For acute stage : ketoacidosis, new patient, injection before

meal, and in surgery or combination with medium acting insulin

– For toddler : prevent hypoglycemy

Insulin• Medium acting Insulin

– Used twice daily for patient with same daily routine pattern

– Widely used in children

• Mix Insulin– Standard mixture ( short+medium acting insulin)– Good metabolic control – For young age child with low education parent

Insulin• Insulin pen• Mixing insulin• Storage : temp 4 – 8 oC not in freezer

Type onset (hour) peak(hour) duration(hour)

Ultra short acting 0,25 1 4

short acting 0,5 –1 2-4 5-8

Medium acting 1-2 4-12 8-24

Long acting 2 6-20 18-36

Insulin Regiment • Insulin usage principal• Depend on Indonesia situation and condition• Use glucometer and routine daily home testing • Objective parameter : Serum HbA1c / 3 months • Insulin dose adjustment :

– For metabolic control– Honeymoon period, adolescent, sick days, surgery

Insulin Injection• Injection technique : subcutaneous with

pinchet• Self injection• Local reaction : rare

Meal adjustment• Objective : achieve good metabolic control

without ignoring calory requirement • Total calory : 1000 + (age(year)x100) calory

per day• Carbohydrate 60 – 65% , protein 25%, lipid

<30%

Metabolic ControlMetabolic Target(mg/dl) Excellent good moderate poor

Preprandial <120 <140 <180 >180

Postprandial <140 <200 <240 >240

Urine reduction - - + - + >+

HbA1c <7% 7-7,9% 8-9% >10%

Management• Management when diagnosed

– Insulin : start 0,5 U/kg/day, gradually adjust– education

• ketoacidosis management– Insulin– Fluid– elektrolite balance– Acid base balance

• Management while surgery• Management while Ramadhan fasting• Complication

Complication• Short term complication : hypoglicemy, ketoacidosis• Hypoglycemy : blood glucose < 50 mg/dL

neurogenic symptoms neuroglycopeny

Cholinergic weak, headache, visual disturbance

Sweating,hungry,numb dizziness, tired, sleepy, affective disorder l

Adrenergic (depression,angry), coma, convulsion

Tremor, tachycardy, pale, Palpitation,

anxious

Long term complication• Retinopathy• Nefropathy• Growth & development disorder

Hypoglycemy• Prevention

– Regular insulin management– Regular food intake– Parent supervision and education

• Therapy– Mild/moderate hypoglycemy

• Give 10 – 20 gr of carbohydrate followed by snack • Lemonade honey glucose tablet can be used

– Severe hypoglycemy• Unconscious / convulsion• Oral medication is rarely used shile unconscious• Parent education inject glucagon 0,5 mg or 1 mg for child >

5 yrs old

Education• Objective

– Understand the disease– Motivation– Type 1 DM management skill– Positive attitude– Good metabolic control– Logic decision of daily management

• First education --> at hospital• Continous education :

– Camp– School

• Advice on :– Long journey– Alkoholic and smoker

Growth and diabetes

• Monitor:– Body height/3 months– Body weight– Physical and mental development

Psychosocial aspects• Family education• Parent training on DM care• Advice parent not to give excessive

protection

Ketoacidosis Protocol1.Body weight measurement (kg)

2.Dehidration therapy decision

3.Calculation of free water deficit

4.Administration of normal saline (0,9NS), bolus if orthostatic or shock occurs

5.Calculate excess of water deficit after the third bolus

6.Calculate maintainance fluid requiremmnt for the next 48 hours

7.Calculate total fluid given within 48 hours

Ketoacidosis Protocol8. Calculate the value of fluid exchange per hour divided by the

value on number 7 per 48 hour 9. Make and start regular insulin drip at 0,1 unit/BW/hour 10.Perform fluid exchange at insulin drip at substract of

number 9 from 8 11.Determine fluid type which is used as substitute :

- Sodium-patient with Na>145mmol/L: 0,9NS-patient with Na<145mmol/L:0,45NS

Ketoacidosis Protocol-Potassium

-Urine (-) : don’t give K+

-Urine (+) : add KCL20-40mmol/L

-Give K+ as half Chloride/half phophate at first 8 hour

-Dextrose

- Patient with BG>15mmol/L: don’t give dextrose

- Patient with BG<15mmol/L: give 5-12,5% dextrose

- Try to maintain BG 10-15mmol/l without adding isulin dose.

Ketoacidosis Protocol

-Bicarbonate : NaHCO3 is not advised 12. Start fluid replacement therapy as mention on umber 11 with

the value in number 10 13.Observe neurological signs to see whether cerebral oedem

exists. Severe headache, consciousness or blood pressure changes, dilated pupil, bradicardy, postural signs and incontinence Perform rapid intervention (intubate, mildly hyperventilate, give mannitol 1 gr/kgBB/iv bolus)

Ketoacidosis Protocol14. Follow laboratorium value:

-Follow BG/ 30-60 mnt, whether the child response ?

-Follow Na,K,Cl,HCO3, capillary pH value/ 2 – 4 hrs-Follow Ca and P value if phosphate is given-Re- check urine glucose and ketone

15. Re- evaluate every fluid change , antisipate the change of K, dextrose, etc value