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Diabetes Resident Lecture

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Talk for residents on service. This is not medical advice!

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Diabetes Resident Lecture

  1. 1. Diabetes: A survival guide Joyce Lee, MD, MPH Robert Kelch Professor of Pediatrics University of Michigan http://www.doctorasdesigner.com/ Twitter: @joyclee
  2. 2. This is not medical advice for patients with diabetes. These are rules of thumb shared with residents who are usually taking care of new onset patients who have the right to call the endocrinology service anytime!
  3. 3. Lilly Novo Nordisk Start Peak End Humalog Novolog 10 min 1.5 hr 3 hr Humulin N (NPH) Novolin N (NPH) 1.5 hr 4-6 hr 12 hr Humulin R (Regular) Novolin R (Regular) 20 min 3-4 hr 6 hr Humalog Mix 70/30 Novolog Mix 70/30 70% NPH +30% Novolog Humulin Mix 70/30 Novolin Mix 70/30 70% NPH +30% Regular Lantus, Levemir, Toujeo 1 hr - 24 hr The suffix hints at the onset and duration of action
  4. 4. Basal Insulin (Lantus/Levemir/Basaglar/Tresiba) Controls blood sugar between meals and overnight Beginning Dose: 50% of Total Daily Dose of insulin Must be given at a consistent time each day and cannot be mixed with other insulins Bolus Insulin (Humalog/Novolog/Apidra) Covers food at meals & large snacks Lowers a high blood sugar Type of insulin used in pump
  5. 5. Start with a total daily dose of 0.5 U/kg/day and bump it down or up based on clinical presentation 0.5 U/kg/d0.3 0.7 Younger, No ketones Older, DKA Insulin doses for a New Onset Patient 30 kg x 0.5 u/kg/day=15 units/day
  6. 6. Basal Insulin (Lantus/Levemir/Basaglar/Tresiba) 50% of the total daily dose (TDD) TDD 15 units Lantus 7.5 units Bolus Insulin (Humalog/Novolog/Apidra) Carb ratio “500 rule” (500/TDD) Correction factor “1800 rule” (1800/TDD) Carb ratio 500/15=33 → 1 unit insulin: 30 gm Correction 1800/15=120 → 1 unit insulin to drop BS by 120 pts (correct to target blood glucose) Target BG 120
  7. 7. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 BS was 240 pre lunch Child plans to eat 60 gm carb You are on call, how much insulin do you give to your patient?
  8. 8. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 BS was 240 pre lunch Child plans to eat 60 gm carb You are on call, how much insulin do you give to your patient?
  9. 9. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 BS was 240 pre lunch Child plans to eat 60 gm carb You are on call, how much insulin do you give to your patient? 2 for Carbs, 1 for correction=3
  10. 10. Patients must always get their Lantus! Avoid dextrose in IVF for diabetics. Exception: Aggressive insulin tx with hypo/normoglycemia (SQ, Insulin Drip) Mod/large ketones=insulin deficiency Mod/large ketones-give extra insulin Small/trace ketones-drink more water In the hospital hypoglycemia is worse than hyperglycemia as long as there are no ketones Pearls
  11. 11. Regimen? Ketones? Last dose of insulin? Last meal? Things to think about when dosing insulin:
  12. 12. Regimen? 7.5 L, 1:30, 1:120 Ketones? Large Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?
  13. 13. Regimen? 7.5 L, 1:30, 1:120 Ketones? Large Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD 6 units Novolog + Lantus
  14. 14. Regimen? 7.5 L, 1:30, 1:120 Ketones? Trace-small Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime?
  15. 15. Regimen? 7.5 L, 1:30, 1:120 Ketones? Trace-small Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime? Full, half, or no insulin correction dose at bedtime; No correction at 2 AM Give Lantus!
  16. 16. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Novolog 4U 1hr ago Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime?
  17. 17. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Novolog 4U 1hr ago Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime? Reassess for ketones 3 hours after last insulin dose No Novolog yet (just got some 1 hr ago!) Give Lantus
  18. 18. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Novolog 4U 1hr ago Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime?
  19. 19. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Novolog 4U 1hr ago Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime? Reassess for ketones 3 hours after last insulin dose No Novolog yet (just got some 1 hr ago!) Give Lantus
  20. 20. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Lantus qhs Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime?
  21. 21. Regimen? 7.5 L, 1:30, 1:120 Ketones? Moderate Last dose of insulin? Lantus qhs Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 480 at bedtime? Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD Try 4.5 units Novolog. Check for ketones q3 hrs.
  22. 22. Regimen? 7.5 L, 1:30, 1:120 Ketones? Trace-small Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 120 at bedtime?
  23. 23. Regimen? 7.5 L, 1:30, 1:120 Ketones? Trace-small Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with T1D with BS 120 at bedtime? Give Lantus
  24. 24. Regimen? 7.5 L, 1:30, 1:120 Ketones? Large Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with BS 120 at bedtime?
  25. 25. Regimen? 7.5 L, 1:30, 1:120 Ketones? Large Last dose of insulin? 3U Novolog at dinner Last meal? Dinner (5 PM) You are on call, how much insulin do you give to your patient with BS 120 at bedtime? Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD 6U Novolog. Give glucose through IV or make pt eat something. Check BS q 2 O/N. Give Lantus!
  26. 26. Regimen? 7.5 L, 1:30, 1:120 Ketones? none Last dose of insulin? 3 at dinnertime Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. What should you do about the Insulin and should you start IVF?
  27. 27. Regimen? 7.5 L, 1:30, 1:120 Ketones? none Last dose of insulin? 3 at dinnertime Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. What should you do about the Insulin and should you start IVF? Pts always need their Lantus, even if NPO! Give Lantus, no dextrose in IVF
  28. 28. Patients must always get their Lantus! Avoid dextrose in IVF for diabetics. Exception: Aggressive insulin tx with hypo/normoglycemia (SQ, Insulin Drip) Mod/large ketones=insulin deficiency Mod/large ketones-give extra insulin Small/trace ketones-drink more water In the hospital hypoglycemia is worse than hyperglycemia as long as there are no ketones Pearls
  29. 29. Diabetes in Children and Adolescents Joyce Lee, MD, MPH Robert Kelch Professor of Pediatrics University of Michigan http://www.doctorasdesigner.com/ Twitter: @joyclee
  30. 30. 15 year old male CC: “polyuria” HPI: Over the last month pt has been complaining of: Drinking lots of water and urinating 20-30 x a day Fatigue Weight loss of 15 lb No excess hunger No abdominal pain, vomiting, diarrhea Social History: 10th grade Family History: Mom had gestational diabetes which became type 2 diabetes; 3 generations of type 2 diabetes in the family
  31. 31. Physical Exam T 37.2, HR 77, RR 18, BP 141/70 Weight 90.4 kg, Ht 167 cm, BMI 32.2 (99%) HEENT: PERRL, EOMI, sclera anicteric, MMM Neck: Supple, no LNpathy, no goiter, +AN Heart: RRR, no murmurs Lungs: CTA bilat Abdomen + BS, Soft, NT, no HSM or masses Extremities are warm and dry, normal
  32. 32. Labs Na 130 K 4.4 Cl 96 CO2 22 BUN 18 Cr 1.1 Glu 603 Ca 9.8 Mg 2.2 Phos 4.8 pH 7.37 pCO2 39 pO2 60 UA: 1 g/dl glucose, 30 mg/dl ketones Hemoglobin A1c: 13.0% (3.8-6.4) AST 28 (8-30) ALT 46 (7-35) C-peptide: 1.3 ng/ml GAD65 Antibody: 0
  33. 33. Management NS bolus IVF ½ NS with KPhos and KCl 30 units Lantus insulin (basal) and 10 units of Novolog insulin (short-acting) with each meal What type of diabetes does this child have? How does this affect his management?
  34. 34. Random Fasting Plasma Glucose Oral Glucose Tolerance Test (2 hr value) Hemoglobin A1c Normal <200 <100 <140 <5.7% Prediabetes - 100-125 140-199 5.7-6.0% Diabetes* ≥200 ≥126 ≥200 6.5% Diabetes Definition *Tests must be abnormal on two separate days
  35. 35. Risk of Retinopathy
  36. 36. In 1998, the fasting glucose threshold was changed from ≥ 140 mg/dl to ≥126 mg/dl & HbA1c was adopted for diagnosis in 2010
  37. 37. CDC 3 10.7 9.9 1.6 3.6 2.1 0 2 4 6 8 10 12 Diagnosed Undiagnosed Age Group (yrs) %withdiabetes 18-44 45-64 ≥65 % of diagnosed and undiagnosed diabetes among US adults aged ≥18 years in 2015
  38. 38. Insulin-Dependent Non-Insulin Dependent Age Child Adult Body Habitus Thin Obese Signs of Insulin Resistance No AN,PCOS, HTN, dyslipidemia Onset Acute Indolent Sx Polys, wt loss Asx Ketoacidosis Yes No Insulin? Yes No
  39. 39. Spectrum of Diabetes Autoantibodies Insulin Secretion (C-peptide) Type 2 DM Insulin resistance Usually with obesity Insulin secretory defect Negative autoantibodies High insulin secretion (C-pep ≥ 0.8) Type 1 DM B-cell destruction Prone to ketoacidosis Autoimmune Positive autoantibodies Low insulin secretion (C-pep < 0.8) Libman I, Becker D 2006 Diabetes Classification
  40. 40. “2 Hit Disease” Insulin Resistance + Beta-cell Failure
  41. 41. “2 Hit Disease” Insulin Resistance + Beta-cell Failure
  42. 42. Children with T2D have lower insulin sensitivity, lower insulin secretion, and a lower glucose disposition index
  43. 43. 9.8% (n=118) 90.2 % (n=1088) Klingensmith, Diabetes Care, 2010 Prescreening for the TODAY study Treatment options for youth with new onset type 2 diabetes GAD65/IA-2 Ab Assays T2D Phenotype Autoantibody Positive Autoantibody Negative Obese T1D T2D
  44. 44. SEARCH 5 centers supported by CDC and NIDDK – California (Kaiser Permanente Southern California, excluding San Diego [7 counties]) – Colorado [14 counties, including Denver] – Ohio [8 counties, including Cincinnati] – South Carolina [4 counties, including Columbia] – Washington state [5 counties, including Seattle] Type 1a (Ab+, low c-pep(<0.6)); Type 1b (Ab-, low c-pep); type 2 The study population included youth younger than 20 years residing in the geographic study areas or who were members of participating health plans in 2001 and 2009. Dabelea, JAMA 2014
  45. 45. Over the 8-year period, the adjusted prevalence of type 1 diabetes increased 21.1% (95% CI, 15.6%–27.0%) among US youth. Increases were observed in: -Both sexes -White, black, Hispanic, and -Asian Pacific Islander youth -Age 5 years or older
  46. 46. The overall prevalence of type 2 diabetes between 2001 and 2009 increased by 30.5% Highest prevalence of T2D was in: -American Indians, followed by black, Hispanic, and Asian Pacific Islander youth -Lowest prevalence in white youth
  47. 47. Mayer Davis NEJM 2017 Adjusted relative annual increase in T1D=1.8% (p<0.001) Adjusted relative annual increase in T2D=4.8% (p<0.001)
  48. 48. TODAY Inclusion Criteria 10–17 years old with T2D for less than two years BMI ≥ 85% Fasting c peptide > 0.6 ng/mL and no autoantibodies Exclusion criteria: Renal insufficiency, uncontrolled hypertension, liver disease, uncontrolled hyperlipidemia 699 subjects were randomized to Metformin monotherapy Metformin plus rosiglitazone Metformin plus an intensive lifestyle intervention Primary outcome: Length of time to glycemic failure, defined as a hemoglobin A1c (HbA1c) ≥ 8% for at least six months or the inability to wean from insulin injections for at least three months after acute metabolic decompensation
  49. 49. Nearly half (45.6%) of all TODAY participants reached glycemic failure over an average time of 3.86 years The difference between the metformin monotherapy and metformin plus rosiglitazone arms was statistically significant, suggesting that adding a second oral medication early in the disease process of youth-onset T2D may help to promote durable glycemic control
  50. 50. Metformin plus rosiglitazone was more effective at preventing glycemic failure in girls (65% of the cohort) than in boys Among girls, those in the metformin plus rosiglitazone group did better than girls in the other two treatment arms There were no treatment group differences in the boys.
  51. 51. Non-Hispanic blacks had the highest rates of glycemic failure (52.8%), followed by Hispanics (45%) and whites (36.6%) Metformin monotherapy was least effective in non-Hispanic blacks compared to other racial/ethnic groups No significant differences were found in other treatment arms
  52. 52. Tx of T2D Lifestyle Management to achieve 7–10% decrease in excess weight & 60 min of moderate to vigorous physical activity per day Metabolically stable patients (A1C <8.5% and asymptomatic), use metformin. Youth with marked hyperglycemia (blood glucose ≥250 mg/dL, A1C ≥8.5% without ketoacidosis at diagnosis who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss should be treated initially with NPH or basal insulin (0.25 – 0.5 units/kg starting dose) is while metformin is initiated and titrated When the A1C target (6.5%) is no longer met with metformin monotherapy, or if contraindications or intolerable side effects of metformin develop, basal insulin therapy should be initiated. No other T2D meds approved by the FDA for kids
  53. 53. Screening of Children with T2D for complications Retinopathy Urine microalbumin BP Cholesterol Goal LDL-C <100 mg/dL); HDL > 35 mg/dL; Triglycerides <150 mg/dL NAFLD PCOS

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