Case Based Discussion

Management of Diabetes Mellitus

Dr. PMA.Ahamed

Registrar in Paediatrics

TH Kurunegala

Case History

Ama, a 10 year old schooling child was admitted with the

history of sudden onset of dizziness, fainting attack and

chest pain.

She was diagnosed with DM one year back. Had put on

MIXTARD insulin with diet control and attends regular

clinic follow-up.

Her main complaints were dizziness, abdominal pain and

vomiting. Also had severe headache.

No history of losing consciousness, had neither fever nor

urinary symptoms.

No history of recent weight loss.

Mother checks her early morning CBS REGULARLY

which usually remains above 200 mg/dl.

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Case History Cont’d…..

No history of hypoglycemic episodes.

Does not miss her breakfast.

Takes three main meals and 2 snacks with sugar and

carbohydrate restriction.

Child’s activities compromised due to the illness but she

attends to school regularly.

Her vision and renal function were checked initially and

were normal.

She has no asthma and was not on prolonged steroid.

No family history of DM or Hypothyroidism.

Development is normal

Vaccination is up to date.

13-Aug-14 3

Case History Cont’d…..

Father runs a coconut business that generates a reasonable

income.

Mother, a house wife has a fairly good understanding of the

disease. she is aware about hypoglycemic symptoms but her

knowledge on dietary modification for insulin dose

adjustment [carbohydrate count or glycemic index] seems to

be poor.

Insulin is injecting by mother using insulin pen. she is aware

of rotating injection sites, taking correct dose and

subcutaneous administration.

School teachers and class mates are informed about her

illness.

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Examination

Average built. Weight 30.5Kg just below 50th centile, height

140cm on 75th centile.

Looks ill, active and mildly dyspneic but no fruity odour.

Mild dehydration ++, she is not febrile.

No cataract and fundus normal.

No finger clubbing, no LJM (prayer sign)

No obvious goiter, no features of Thalassemia or Cushioned

No areas of lipodystrophy.

HR 96 and good volume, BP 100/70mmHg, No postural drop.

RR 36 lungs clear, no recession.

Abdomen soft non tender no hepatosplenomegaly,

no visible scars.

CNS GCS 15/15. peripheral sensation for touch normal.

5

Investigation

CBS 660 mg/dl

Urine

SE - Na 138, K 3.8 mmol/dL

Renal function - normal

Urine micro albumin 6mg/dL

Urine albumin/creatinin ratio - normal

UFR

U.CULTURE

FBC NAD

HbA1C 16%

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NORMAL

ketone bodies - positive

ward test - brick red

Diagnosis DM/DKA

Diagnosis is straight forward

RBS > 200mg/dl or 11.1mmol/L

With typical symptoms

+/- ketonuria

DIFFERENTIAL DIAGNOSIS

type 2 DM in obese child

Transient hyperglycemia due to physical stress (rare)

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DKA Management Goals

Correct dehydration and electrolyte imbalance

Correct hyperglycemia by insulin administration

Prevent of treatment complication

These goals are achieved by adhering to the evidence

base protocols.

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DKA Protocol / MILUWAUKEE Protocol

Has been used for more than 20yrs in a large clinical setting

with no death no neurological sequale

A standard water deficit 85ml/kg

Mild – moderate DKA - 10- 24hrs correction

Sever DKA 30-36 hrs

Transition to oral intake and SC insulin

when DKA resolved

pCO2 >15mEq/L and pH>7.30

Normal SE

A flow sheet is mandatory for close observation.

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Flow Sheet

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Approach Consideration 1st hour

10-20 mL/kg IV bolus(A) 0.9% N.Saline or LR (C) *

Insulin drip(A) IV at 0.05 to 0.10 U/kg/hr(A)

NBM(E)

Monitor -In/Out put, neurologic status(E)

Mannitol at bedside[1g/kg IV for cerebral edema](C)

2nd hour until DKA resolution

0.45%NS + continue insulin drip + added K 40mmoL/l(A)

IV rate =[ SWD + maintenance – bolus ]/23hours

5% glucose if blood sugar < 250 mg/dL(14 mmol/L) (B)

If K <3 mEq/L, give 0.5 to 1.0 mmol/kg as oral K

solution OR increase IV K to 80 mmol/L(E) .

After DKA resolution

Oral intake with subcutaneous insulin(C)

12

Sample Calculation for a 30kg Child

IV rate =[SWD+ Maintenance – Bolus ]/23hours

Standard Water Deficit (SWD)

85ml/kg = 2550ml

Maintenance (24 hr)

1st 10 kg 100 mL/kg

2nd 10 kg 50 mL/kg

for all remaining kg 25 mL/kg =1750ml

1st hr = 10ml/kg IV bolus N.Saline =300mL

Then 2550+1750-300/23hrs = 175ml/hr

13-Aug-14 13

Discussion

Long Term Management - Goals Of Treatment

Control BSL [ Insulin therapy, Diet and activity]

Prevent of acute complication [hypoglycemia, DKA]

Ensuring optimum growth and development

Maintaining normal life style

Adequate education for the patient and parents

Early detection and Rx of associated disease

Reducing long term complication by maintaining good

metabolic control

Regular screening and early intervention

Provide psychological support

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Control BSL

Insulin Therapy

Type of insulin

Dosage schedule

Monitoring

Education

Any thing new ?

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Insulin Therapy Cont’d……

Insulin has 4 basic formulations:

Ultra ̶ short-acting ( lispro, aspart, glulisine)

Traditional short-acting ( regular, soluble)

Medium or intermediate-acting ( isophane, lente, detemir),

Long-acting ( ultralente, glargine)

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Diagrammatic Representation of Insulin Activity

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Meals vs BSL vs Insulin level

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Exogenous Insulin effect with time

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Injection Regimens

Twice daily combinations of short and intermediate acting

insulin.

Multiple injection regimens using once-daily or twice-daily

injections of long-acting or intermediate-acting insulin and

short-acting insulin given at each meal

A combination of the above 2 regimens, with a morning

injection of mixed insulin, an afternoon premeal injection of

short-acting insulin and an evening injection of intermediate-

or long-acting insulin

Continuous subcutaneous insulin infusion (CSII) using an

insulin pump

CSII with close loop monitoring (external pancreas)

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Dose Depending on the pubertal stage;

0.7 u/kg/day in pre pubertal

1.0 u/kg/day at mid puberty

1.2 u/kg/day by the end of puberty

Newly diagnosed; 60-70% of above values due to residual β

cell function (honey moon period)

1/3 long acting of total insulin

2/3 short acting ( 3 divided dose for each meals)

Insulin schedule should be adjusted to optimal BS control

Frequent self monitoring of BS and dose adjustment

paramount

Storage and supply of insulin should be discuss properly

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Continuous subcutaneous insulin infusion (CSII) –

Rapid-acting insulin infused continuously 24 hours a day

through an insulin pump at 1 or more basal rates, with

additional boluses given before each meal and correction

doses administered if blood glucose levels exceed target

levels

Bionic pancreas or CSII with close loop monitoring

Pancreas and islet cell transplantation

Technically demanding and rejection are limiting factors

Regeneration of islet cells

1.In vitro by using embryonic stem cells

2.Ex vivo by using bone marrow stem cells differentiate to β cell

in vitro

3.In vivo regeneration therapy

23

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CSII

BIONIC

PANCREAS

Injection Phobia

Alternatives to injecting insulin have been constantly

sought

Oral insulin research: expensive but promising

Many major pharmaceutical companies are at the

research and development stage of following

Pre meal oral insulin (oralin)

Delayed-absorption capsules

Oral sprays

Inhaled form of insulin (Exubera)

Sublingual lozenges

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Diet

Dietary management is an essential component.

Aim of dietary management

No strict diet restriction.

Dietary recommendations should take into account the

patient’s eating habits and lifestyle.

A daily caloric intake prescription should balance the

child's food intake with insulin dose and activity.

Keep blood glucose concentrations as close as possible

Avoiding extremes of hyperglycemia and hypoglycemia

Recommendations for amounts of dietary carbohydrate,

fat, and protein.

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Diet Cont’d……

Carbohydrates - 50-55% of daily energy intake; no more

than 10% of carbohydrates should be from sucrose or other

refined carbohydrates

Fat - Should provide 30-35% of daily energy intake

Protein - Should provide 10-15% of daily energy intake

Instructions on how to divide calories between meals and

snacks

20% for breakfast

35% for lunch

30% for dinner

15% for snack

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Dietary Freedom

Carbohydrate counting

The ability to estimate the carbohydrate content of food

The dietitian should develop a diet plan for each child to suit

individual needs and circumstances.

The number of carbohydrates in a food can be determined

by reading the nutrition label, consulting a reference book

or website, carrying a database on a personal digital

assistant (PDA)

Exchange planning

All foods are categorized as either a carbohydrate, meat or

meat substitute, or fat.

In this system, one serving of a carbohydrate (eg, one small

apple can be exchanged for any other carbohydrate

(eg, 1/3 cup cooked pasta) 28

Activity

No restrictions on activity

Exercise has real benefits

Educate the patients about the effects of exercise on the

blood glucose level.

Should check blood sugar level before and after exercising

Adjusting insulin dose for exercise

Make sure to maintain their hydration status during

exercise

Avoiding excessive weight gain or weight loss

Early detection of hypoglycemic symptoms

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Monitoring

self-monitoring of blood glucose levels(SMBG)

A minimum of 4 daily BS should be measured for Optimal

diabetic control

requires frequent Monitoring when hypoglycemia

inter current illness, dietary changes and unusual

physical activity

Availability of glucometer /strips and cost are limiting

factors

Continuous glucose monitors (CGMs) /RT-CGM

contain subcutaneous sensors that measure interstitial

glucose levels every 1-5 minutes, providing alarms when

glucose levels are too high or too low or are rapidly rising

or falling.

HbA1c level

30

Target BSL and HbA1C

Age (year)

Pre meal BSL

( mg/dL)

HbA1C(%)

<5

100 -200

7.5 - 9

5 - 11

80 - 150

6.5 - 8

12 - 15

80 - 130

6 - 7.5

18 <

70 - 120

5.5 - 7

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Somagi Phenomenon

Rebound hyperglycemia in early morning after an incident

of hypoglycemia this rebound is secondary to the release

of counter regulatory hormones

Commonly reported more frequently at night due to

unrecognized and untreated hypoglycemia when as sleep

So evening dose of insulin should be reduced

Dawn phenomenon Rise in blood sugar in the early morning hours due to low

insulin level

So the dose of insulin should be increased or change to

long acting

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Parent and Patient Education

About disease and importance of follow-up

Recognition of hypoglycemia and initial management

Blood glucose monitoring

Insulin therapy

Healthy eating habits

Physical activity

Dealing with ups and downs of illness

Keeping communication and getting information

Coping styles and support groups 33

Where to find reliable health information?

National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Diabetes & Digestive & Kidney Diseases

(www.niddk.nih.gov)

American Diabetes Association (ADA)

(www.diabetes.org)

The Endocrine Society

(www.endo-society.org)

Hormone Health Network

(www.hormone.org/diseases-and-conditions/diabetes)

Local Diabetic Clinics

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Long Term Monitoring and Follow-up

Growth assessment

Injection site examination

Evaluation for signs of associated autoimmune disease

Blood pressure

Retinal screening, Retinoscopy or Fundal photography

Urine examination for microalbuminuria and nephropathy

Neuropathy screening and foot care

Macro vascular complication

35

Screening Guidelines

When Frequency Preferred Screening Method

Retinopathy After 5yr PPC

After 2yr PC 1-2 yearly Fundal photography

Nephropathy After 5yr PPC

After 2yr PC annually Overnight timed urine albumin

Neuropathy - - Physical exam

Macrovasc. After 2yr Every 5 yr lipids

Thyroid At diagnosis Every 2-3yr TSH

Celiac At diagnosis Every2-3yr Tissu transglutaminase, endomysial ab

Can We Prevent Type I Diabetes ???

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Viral Infection

CRS

?mumps

Early exposure to gluten

Cows milk/formula

Hygienic hypothesis

Breast feeding

Psychological stress

Omega3, Vit C/D/E, Zn

(TEDDY study)

MHC/HLA Types

CTLA 4

Interleukin receptor

Summary

Pathophysiolgy of type 1 DM

Treatment of DKA

Long term management of DM

Advances in the management

Monitoring and follow-up

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35 01-05-02

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Series 1

Series 2

Any ?

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