DIAGNOSIS AND MANAGEMENT OF TYPE 1 DIABETES MELITUS

Epidemiology of type 1 diabetes

Age of onset peaks preschool

puberty
Autumn/winter peaks

Epidemiology of type 1 diabetes

Increasing in recent years Geographic variation Lack of treatment

Pathogenesis of type 1 diabetes Immunological activation

Progressive beta-cell destruction Insufficient beta-cell function Dependent on exogenous insulin Risk of ketoacidosis

Pathogenesis of type 1 diabetes

Genetic susceptibility Immune factors other autoimmune disease antigen-specific antibodies Environmental trigger viruses bovine serum albumin nitrosamines: cured meats chemicals: vacor (rat poison), streptozotin

Pathogenesis of type 1 diabetes

Trigger Immunological abnormalities

Genetic Beta-cell mass

Clinical diabetes
Pre-diabetes Honeymoon Chronic phase Time (months - years)

Idiopathic type 1 diabetes

Non-autoimmune type 1 diabetes

No autoimmune markers Permanent insulinopenia Ketoacidosis People of African and Asian origin

Insulin deficiency in type 1 diabetes

Glucose uptake Glycogenolysis Gluconeogenesis (amino acids) Ketone production (fatty acids)

Blood glucose

Glucose uptake Protein degradation amino acids

Triglyceride degradation fatty acids

Diagnosing diabetes

Normal

Impaired fasting glucose* Impaired glucose tolerance**

Diabetes

FPG

<6.1mmol/L <110mg/dL

6.1 to 6.9mmol/L* 110 to 126mg/dL 7.8 to 11mmol/L** 126 to 200mg/dL

7.0mmol/L 126mg/dL 11.1mmol/L 200mg/dL

2hr PG <7.8mmol/L <126mg/dL

Calculate Total Daily Insulin (TDI) = 0.5 unitsx weight (kg) OR (sum of current doses) eg: if weight is 60 kg, TDI = 30 units

Total Mealtime Insulin (lispro, aspart or regular) = 60% of TDI eg: 60% x 30 units = 18 units

Total Basal Insulin (NPH, glargin, ultralente) = 40% of TDI eg: 40% x 30 units = 12 units

Bedtime doses Lunch doses Breakfast doses Dinner doses = total basal insulin = 1/3 of mealtime = 1/3 of mealtime = 1/3 of mealtime eg: 40% x 30 unit Insulin Insulin Insulin = 12 units eg: 1/3 x 18 = 6 units eg: 1/3 x 18 = 6 units eg: 1/3 x 18 = 6 units

Fig. Initiation of multiple daily injection insulin therapy (four injection per day)
Adopted from Joslins Diabetes Mellitus, 2005

Summary

Type 1 diabetes
Results from progressive betacell destruction

People with type 1 diabetes need insulin therapy to live