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3232
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Diabetes Mellitus: Commonest chronic endocrinal
metabolic disease in children.
Due to insulin deficiency (type 1)
and or insulin resistance (type 2).
Disturbed Carboh drate Fat &
Protein metabolism.
HYPERGLYCEMIA.
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100 < 126 mg%
a e es 126 mg%
2h plasma glucose during OGTT
Less than 140 mg%
140 - 199 mg % 200 mg%
> 140 < 200 mg%
ADA. Position statement. Diagnosis and classification of diabetes Diabetes Care 2006,
29:S43-S48
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SYMPTOMS & BLOOD GLUCOSE LEVELS DO NOTDIFFERENTIATE TYPE 1 FROM TYPE 2
Diagnosis of type 2
.
Family history of type 2diabetes.
Signs of insulin resistance
Normal or high fasting.
Absent auto antibodies.
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Screening for Type 2 Diabetes
1
puberty
Over weight Plus any two of the
following risk factors: Family history of type 2 diabetes. Maternal history of diabetes or
gestational diabetes mellitus (GDM)
Signs of insulin resistance orconditions associated with insulinresistance
es : pre erre
Frequency: every 2 years
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a e es om p ca on s
Acute:
Insulin reaction ( hypoglycemia)
Microvascular
.
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ypog ycem a
Most common complication of diabeteso 100% of Type 1 patients affected
o 10% year develop severe attack (requiring
assistance)o
Multiple causes:
o Increased insulin dose
o reduced food intake
o delayed or omitted meal
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ymp oms o ypog ycem a
A renergic Neurog ycopenic
Palpitations Dizziness
Tachycardia
Pallor
Confusion
Agitation wea ng
Tremors
oma
Seizure
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50% after 15 yearsLong-term
10%diabetes
Prevention of long termi 20-40 % after 20 ears
complications.,
A new focus forpediatric diabetes care
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Diabetes Control & Complication TrialDiabetes Control & Complication Trial
1441 pt
10yrsTDM1
Intensive Insulin Therapy
Tight glycemic control
7 6 % Retinopathy
Ne hro ath
6 9 % Neuropathy
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children & adolescents
Insulin/medication
Exercise
BGBG BGBG
Food intake
BGBG
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Ke oints in Diabetes carein Children
Soothe, Educate, Empower &Support patient & care-giver.
Provide choices & involve
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a
Insulin injection.
Testing for urine ketones.
ecogn t on an treatment ohypoglycemia
Healthy Diet and life style. Sick day management
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Practical steps in Insulintherapy
maturity level
Imitate nature as much as
Adjust dose according to
. Use additional doses for
unexpec e g va ues or ex ra
carb.
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NOPre-meal Bed-time Hb A1C
mg/dl
mg/dl
. - - .>7.5
6-12 r. 90-180 100-180 < 8
13-19 yr. 90-130 90-150 < 7.5#
Diabetes Care- ADA Suppl. 1 / 2010
# < 7 if achievable without hypoglycemia
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Physiologic INSULIN strategy
Think like a Pancreas !
ADJUST for
Meal size, content, exercise &
BG
BOLUSES
to control hepatic glucose outputduring fasting
to cover meals & snacks ingested
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Physiologic Insulin SecretionRapidly generated, Short-lived,
prandial insulin peaks
Breakfast Lunch DinnerPrandial Insulin
un mL50
Low stead basal
Inu
(Um
25
Basal Insulin Fasting
insulin profile
g5-10 (U/mL
Skyler JS. In: DeFronzo RA, ed. Current Therapy of Diabetes Mellitus. St. Louis: Mosby- Year Book;
1998:108-116; Galloway JA, Chance RE. Horm Metab Res. 1994;26:591
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Total insulin dose : 0.5 to 1.2
Basal insulin: 40% to 50% of daily needs
Bolus insulin (prandial/mealtime) 10% to 20% of total dail insulinbefore meals.
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Key points for successfulinsulin therapy
Know the feeding and activity style of the.
Discuss insulin choices with the family. Explain time activity profile of chosen
Provide simple troubleshootingns ruc ons.
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Soluble or Regular insulin: Actrapid 100U/ml Humulin R 100U/ml
Insulins
In gyLong-acting insulin analogsGLARGINE (Lantus)DETEMIR Leve ir
Insulatard.Hmulin N
Rapid-acting insulin analogs:
INSULIN LISPRO (Humalog)
INSULIN GLULISINE (Apidra)
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Glargine/Detemir NPH
Basal insulin
Glargine / Detemir
Given once daily.
No need for snacks to revent h o l cemia.
Less nocturnal hypoglycemia.
No need for shaking.
No difference in the absorption rate from leg, arm
or abdomen.
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Regular
Human Insulin
Actrapid
onset: 30-60 mint.
Peak: 3 (2-4) hours
Duration: 6- 8 hours
Ra id InsulinAnalogs
onse : - m n . Peak: 1 hr.
Duration: 3- 4 hours
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Normal pattern of insulin
nLev
els 3 meal related insulin boluses
maInsuli
Plas
Basal Insulin
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours
Adapted from Rosenstock J, Wyne K. In: Goldstein BJ, Muller-Wieland D, eds. Textbook of Type 2 Diabetes. London, England:Martin Dunitz; 2003:131-154.
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Two doses of pre-mixed Conv.
els
PrePre- -mixed Conv Insmixed Conv Ins PrePre--mixed Conv Insmixed Conv Ins
sulinLe
PlasmaI
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours
Adapted from Rosenstock J, Wyne K. In: Goldstein BJ, Muller-Wieland D, eds. Textbook of Type 2 Diabetes. London, England:Martin Dunitz; 2003:131-154.
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Two doses of pre-mixed insulin
els
PrePre--mixed analogmixed analog PrePre--mixed analogmixed analog
sulinLe
PlasmaI
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours
Adapted from Rosenstock J, Wyne K. In: Goldstein BJ, Muller-Wieland D, eds. Textbook of Type 2 Diabetes. London, England:Martin Dunitz; 2003:131-154.
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What are the shortcomings
?
lsPrePre--mixedmixed
PrePre--mixedmixed
B-B ins can not be adjusted separately.
No prandial coverage for lunch.R
ma
InsulinLev
overlaps & or mismatching
0 2 4 6 8 10 12 14 16 18 20 22 24
Plas
HoursIs there a compromise ?
Additional Reg or Rapid insulin analog for the
lunchNow it is 3 !
Fix time and content of meals & snacks.
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Pre-meal Rapid-acting Analogues & Bed
linLevels
m
aInsu
Pla
0 2 4 6 8 10 12 14 16 18 20 22 24
HoursIt is 4 !
INSULIN REGIMENS
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INSULIN REGIMENS
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Insulin correction & Supplement doses
prevent hyperglycemia
--
This insulin can only be regular,This insulin can only be regular, lisprolispro,,
aspartaspart oror g u s neg u s ne umu numu n ,, ActrapActrap ,,HumalogHumalog,, NovorapidNovorapid, or, or ApidraApidra))
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Age Insulin units added / Insulin units
mg a ove
target.
a e
carbohydrate atmeal.
10 years of ageIf Family history is negative
Fasting lipid profile
YEARS with Positive Family history of highcholesterol premature cardiovascular event
3 Bp in 3 sep days Target > 90th centile for
age, sex & Ht
M t f T 2 Di b t
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Management of Type 2 Diabetes
< 250mg/dl OR DKA
Metformin 500 mg qdincrease gradually Insulin
ntinuei
gradua
Dis
c
Target not reached
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1.
Hyperglycemia: Blood glucose > 200 mg /dl.
2. Ketonemia: Total serum ketone >3
nitroprusside test on undiluted urine.A
3. Acidosis: Blood pH < 7.3 & reducedserum bicarbonate to < 15 mEq/L.
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Diabetic KetoacidosisCommon Precipitating Causes
Infection
Psychic stress
Trauma
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Insulin deficienc + Counter re ulator
hormones
Increased Glycogenolysis.
Increased Gluconeogenesis.
Decreased entry of glucose tothe cells.
H l i > 200 /dl
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Hyperglycemia > 200 mg/dl
Hyperglycemia
plasma osmolality
Osmotic diuresisIntracellular dehydration
Dehydration ECF volume Electrolyte loss
(Na+, K+, PO4, MG++)
Shock GFR
glucose acidosis azotemia ( BUN)
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Major Ketoacids
Beta-hydroxybutyric acid
Acetoacetic acid Acetone
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1.Accumulation of Ketoacids
Diminished ketone body utilization
2. Lactic Acidosis.
. .
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Diabetic KetoacidosisSymptoms & Signs
Polyuria, polydipsia . Deh dration
Low blood pressure, rapid pulse
Kussmaul respirations Deep, rapid respiratory pattern
Anorexia, nausea, vomiting
Abdominal pain Altered mental status
Correlates with the degree of hyperosmolality
Di b ti K t id i
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Diabetic KetoacidosisLaboratory abnormalities due to hyperglycemia
Elevated blood glucose
Hyponatremia
ucosur a
Di b i K id i
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Diabetic KetoacidosisLaboratory abnormalities due to metabolic acidosis
Decreased pH ecrease p
Low serum bicarbonate
Increased anion gap
(= Na - [(Cl + HCO3)
Ketonemia Ketonuria
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Treatment of DiabeticKetoacidosis
1. Replace fluid and electrolyte losses
2. Insulin to Correct acidosis and
.
3. Look for and treat precipitating causes
an comp ca ons
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1. ap correc on o
shock andypovo em a s
hour):
Normal saline or Ringers,
the 1st hour.
Repeat if necessary.
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2. Slow correction of Deficit +
a ntenance over -
hours): ow muc e c
according to degree of dehydration
50 100 ml/Kg How muchmaintenance
Calculation of maintenance fluidsCalculation of maintenance fluids::
100 ml/kg for the first 10 kilograms of100 ml/kg for the first 10 kilograms ofbody weight +body weight +50 ml/kg for the next 10 kilograms of50 ml/kg for the next 10 kilograms of
20 ml/kg for the remaining body weight20 ml/kg for the remaining body weight
above 20 kilogramsabove 20 kilograms
Slow correction of Deficit +
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Slow correction of Deficit +
a ntenance over 4- ours :
normal saline.
Shift to Glucose 5% in half strengthsaline when blood glucose drops to
Potassium (30-40 mEq/liter of IVfluid).
Slow correction of Deficit +
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Slow correction of Deficit +
a ntenance over 4- ours :
ar n a y w a s reng normal saline.
Shift to Glucose 5% in halfstren th saline when blood
glucose drops to
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Saline or Ringer's Lactate for shock &hypovolaemia
Later on strength saline