DIABETES MELITUS TYPE I

dr. H. Hakimi, Sp.AK dr. H. Charles Darwin Siregar, Sp.A dr. Melda Deliana, Sp.AK dr. Siska Mayasari Lubis, Sp.A

PEDIATRIC ENDOCRINOLOGY MEDICAL SCHOOL USU/H. Adam Malik HOSPITAL Medan

Introduction
Chronic disease Difficult to cure Major DM group in children.

DM Classification based on etiology (ADA,1998)

1. DM type I ( B cell destruction) : a. immune mediated b. idiopathic 2. DM type II (insulin resistant) 3. DM other type a. genetic defect of B cell function b. genetic defect of insulin function c. pancreas exocrine disease d. endocrinopathy e. drug and chemical substance induction f. Infection g. uncommon immune mediated DM h. Genetic syndrome related to DM 4. DM gestasional

Definition
Systemic disorder because glucose metabolism disorder, characterised by chronic hyperglicemy Caused by autoimunne process which destroy pancreas B cell insulin production decrease or stopped

Patogenese
Addison disease
Tirodiditis hashimoto Anemia pernisiosa

Viral infection

Chemical exposure

HLA B8,DR3,BW15,DR4 activation autoantibody process

langerhans islets destruction

Pancreas B cell function failure Insulin secretion decrease or stop

DM type I

diagnostic criteria
Normal blood glucose : <126 mg/dl ( 7 mmol/L) Diagnose is determined if one of this criteria fulfilled :
Polyuria , polydipsy, polyphagy, decrease weight , blood glucose ad random >200mg/dl Asymptomatic : blood glucose ad random >200mg/dl

Glucose tolerance test (GTT)

GTT is not nesecary if distinguished symptoms are found Indication : GTT in doubtful case glucose dose : 1,75 gr/W in 200-250 cc water in 5 minutes GTT result intepretation :
DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200 mg /dl Impaired Glucose tolerance : fasting blood glucose <140 mg/dl or at 2nd hour : 140 199 mg/dl Normal : fasting blood glucose < 110 mg/dl or at 2nd hour : < 140 mg/dl

Epidemology
Incidence is higher in Caucasian Highest in Finland 43/100.000 , lowest in Japan 2/ 100.000 foo age < 5 yrs old Peak incidence :
Age 5 6 yrs old 11 yrs old

New cases >50% : >20 yrs old Genetic and environment factors : HLA pattern, virus, toxin, etc

Clinical appearance
Acute Polyuria, polydypsy, rapid weight decrease, hyperglycemy Delayed diagnose : ketoacidosis with all the consequences

DM type I management
Good metabolic control with normal blood glucose level Unified team
Spesific objective 1. optimal growth 2. normal emosional development 3. Good metabolic control without causing hypoglycemy 4. Few school absence days and active in school 5. Patient doesnt manipulate disease

Objective 1. 2. 3. Free from symptoms Enjoy social life Prevent complications

6. Able to manage disease independently

Insulin
Earlier : pig/cow pancreatic gland purification Recombinant technology : human insulin Usage based on age , social economic, culture, and drug distribution Important to know :
somogyi effect dawn effect Morning hyperglycemy

Insulin
Ultra short acting insulin ( lispro )
Give 15 min before meal Useful in sick day management and before meal injection

Short acting insulin

For acute stage : ketoacidosis, new patient, injection before meal, and in surgery or combination with medium acting insulin For toddler : prevent hypoglycemy

Insulin
Medium acting Insulin
Used twice daily for patient with same daily routine pattern Widely used in children

Mix Insulin
Standard mixture ( short+medium acting insulin) Good metabolic control For young age child with low education parent

Insulin
Insulin pen Mixing insulin Storage : temp 4 8 oC not in freezer
Type onset (hour) peak(hour) duration(hour)

Ultra short acting short acting

0,25 0,5 1

1 2-4

4 5-8

Medium acting
Long acting

1-2
2

4-12
6-20

8-24
18-36

Insulin Regiment
Insulin usage principal Depend on Indonesia situation and condition Use glucometer and routine daily home testing Objective parameter : Serum HbA1c / 3 months Insulin dose adjustment :
For metabolic control Honeymoon period, adolescent, sick days, surgery

Insulin Injection
Injection technique : subcutaneous with pinchet Self injection Local reaction : rare

Meal adjustment
Objective : achieve good metabolic control without ignoring calory requirement Total calory : 1000 + (age(year)x100) calory per day Carbohydrate 60 65% , protein 25%, lipid <30%

Metabolic Control
Metabolic Target(mg/dl) Excellent good moderate poor Preprandial <120 <140 <180 >180

Postprandial
Urine reduction HbA1c

<140
<7%

<200
7-7,9%

<240
+-+ 8-9%

>240
>+ >10%

Management
Management when diagnosed
Insulin : start 0,5 U/kg/day, gradually adjust education

ketoacidosis management
Insulin Fluid elektrolite balance Acid base balance

Management while surgery Management while Ramadhan fasting Complication

Complication
Short term complication : hypoglicemy, ketoacidosis Hypoglycemy : blood glucose < 50 mg/dL
neurogenic symptoms Cholinergic Sweating,hungry,numb Adrenergic Tremor, tachycardy, pale, Palpitation, neuroglycopeny weak, headache, visual disturbance dizziness, tired, sleepy, affective disorder l (depression,angry), coma, convulsion

anxious

Long term complication

Retinopathy Nefropathy Growth & development disorder

Hypoglycemy
Prevention
Regular insulin management Regular food intake Parent supervision and education

Therapy
Mild/moderate hypoglycemy Give 10 20 gr of carbohydrate followed by snack Lemonade honey glucose tablet can be used Severe hypoglycemy Unconscious / convulsion Oral medication is rarely used shile unconscious Parent education inject glucagon 0,5 mg or 1 mg for child > 5 yrs old

Education
Objective
Understand the disease Motivation Type 1 DM management skill Positive attitude Good metabolic control Logic decision of daily management

First education --> at hospital Continous education :

Camp School

Advice on :
Long journey Alkoholic and smoker

Growth and diabetes

Monitor:
Body height/3 months Body weight Physical and mental development

Psychosocial aspects
Family education Parent training on DM care Advice parent not to give excessive protection

Ketoacidosis Protocol
1.Body weight measurement (kg) 2.Dehidration therapy decision 3.Calculation of free water deficit 4.Administration of normal saline (0,9NS), bolus if orthostatic or shock occurs 5.Calculate excess of water deficit after the third bolus 6.Calculate maintainance fluid requiremmnt for the next 48 hours 7.Calculate total fluid given within 48 hours

Ketoacidosis Protocol
8. Calculate the value of fluid exchange per hour divided by the value on number 7 per 48 hour 9. Make and start regular insulin drip at 0,1 unit/BW/hour 10.Perform fluid exchange at insulin drip at substract of number 9 from 8 11.Determine fluid type which is used as substitute : - Sodium -patient with Na>145mmol/L: 0,9NS -patient with Na<145mmol/L:0,45NS

Ketoacidosis Protocol
-Potassium -Urine (-) : dont give K+ -Urine (+) : add KCL20-40mmol/L -Give K+ as half Chloride/half phophate at first 8 hour -Dextrose - Patient with BG>15mmol/L: dont give dextrose - Patient with BG<15mmol/L: give 5-12,5% dextrose - Try to maintain BG 10-15mmol/l without adding isulin dose.

Ketoacidosis Protocol
-Bicarbonate : NaHCO3 is not advised 12. Start fluid replacement therapy as mention on umber 11 with the value in number 10 13.Observe neurological signs to see whether cerebral oedem exists. Severe headache, consciousness or blood pressure changes, dilated pupil, bradicardy, postural signs and incontinence Perform rapid intervention (intubate, mildly hyperventilate, give mannitol 1 gr/kgBB/iv bolus)

Ketoacidosis Protocol
14. Follow laboratorium value: -Follow BG/ 30-60 mnt, whether the child response ? -Follow Na,K,Cl,HCO3, capillary pH value/ 2 4 hrs -Follow Ca and P value if phosphate is given -Re- check urine glucose and ketone 15. Re- evaluate every fluid change , antisipate the change of K, dextrose, etc value