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Paediatric And Adolescent Diabetes

Care

Dr Noman Ahmad

3rd 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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Insulin Physiology

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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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Pathophysiology of T2DM

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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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Acanthosis Nigricans

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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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Pharmacokinetics

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Pharmacokinetics

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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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Conventional Regimen

NovorapidInsultard(NPH)

0 30 4 6 12 16 18

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Insulin Regimen (MDI)

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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

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Insulin Pump

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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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Target HbA1C

CDA 2008 <6 years 8.5% 6-12 < 8% >12 years ≤ 7%

ISPAD 2009 < 7.5% 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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QUESTIONS