DIABETES MELITUS DIABETES MELITUS TYPE ITYPE I

dr. H. Hakimi, Sp.AKdr. H. Charles Darwin Siregar, Sp.Ag p

dr. Melda Deliana, Sp.AKdr. Siska Mayasari Lubis, Sp.A

PEDIATRIC ENDOCRINOLOGYMEDICAL SCHOOL USU/H Adam MalikMEDICAL SCHOOL USU/H. Adam Malik

HOSPITALMedan

IntroductionIntroduction• Chronic disease • Difficult to cure• Difficult to cure • Major DM group in children.

DM Classification based on etiology (ADA,1998)

1 DM type I ( B cell destruction) :1. DM type I ( B cell destruction) :a. immune mediatedb. idiopathic

2. DM type II (insulin resistant)2. DM type II (insulin resistant) 3. DM other type

a. genetic defect of B cell functionb. genetic defect of insulin functiongc. pancreas exocrine diseased. endocrinopathye. drug and chemical substance inductionf. Infectiong. uncommon immune mediated DM h. Genetic syndrome related to DM

4 DM gestasional4. DM gestasional

DefinitionDefinition• Systemic disorder because glucose

metabolism disorder, characterised bymetabolism disorder, characterised by chronic hyperglicemy

• Caused by autoimunne process which y pdestroy pancreas B cell insulin production decrease or stopped

Patogenese

Addison disease Tirodiditis hashimoto Anemia pernisiosa Viral infection Chemical exposure

HLA B8 DR3 BW15 DR4 acti ationHLA B8,DR3,BW15,DR4 activation

autoantibody process

langerhans islets destruction

Pancreas B cell function failure

Insulin secretion decrease or stop

DM type I

diagnostic criteriadiagnostic criteria• Normal blood glucose : <126 mg/dl ( 7 mmol/L)• Diagnose is determined if one of this criteria• Diagnose is determined if one of this criteria

fulfilled :– Polyuria , polydipsy, polyphagy, decrease weight o yu a , po yd psy, po yp agy, dec ease e g t

, blood glucose ad random >200mg/dl– Asymptomatic : blood glucose ad random

>200 /dl>200mg/dl

Glucose tolerance test (GTT)Glucose tolerance test (GTT)

• GTT is not nesecary if distinguished symptoms are foundI di ti GTT i d btf l• 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 /dlI i d Gl t l f ti bl d l <140– 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/dlg

EpidemologyEpidemology• 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 oldAge 5 6 yrs old– 11 yrs old

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

Clinical appearanceClinical appearance• Acute• Polyuria polydypsy rapid weight decrease• Polyuria, polydypsy, rapid weight decrease,

hyperglycemy• Delayed diagnose : ketoacidosis with all theDelayed diagnose : ketoacidosis with all the

consequences

DM type I management

• Good metabolic control with normal blood glucose level • Unified teamUnified team

Objective Spesific objective

1 Free from symptoms 1 optimal growth1. Free from symptoms 1. optimal growth

2. Enjoy social life 2. normal emosional development

3. Prevent complications 3. Good metabolic control without causing hypoglycemycausing hypoglycemy

4. Few school absence days and active in school

5. Patient doesn’t manipulate disease5. Patient doesn t manipulate disease

6. Able to manage disease independently

Insulin• Earlier : pig/cow pancreatic gland purification• Recombinant technology : human insulinRecombinant technology : human insulin• Usage based on age , social economic,

culture, and drug distribution • Important to know :

– somogyi effectd ff t– dawn effect

– Morning hyperglycemy

Insulin• Ultra short acting insulin ( lispro )

– Give 15 min before meal– Useful in sick day management and before meal injection y g j

• Short acting insulinF k id i i i j i b f– For acute stage : ketoacidosis, new patient, injection before meal, and in surgery or combination with medium acting insulinF t ddl t h l– For toddler : prevent hypoglycemy

Insulin• Medium acting Insulin

– Used twice daily for patient with same daily ti ttroutine pattern

– Widely used in children

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

InsulinInsulin• Insulin pen• Mixing insulin• Storage : temp 4 – 8 oC not in freezer

Type onset (hour) peak(hour) duration(hour)

Ultra short acting 0,25 1 4

short acting 0,5 –1 2-4 5-8g

Medium acting 1-2 4-12 8-24

Long acting 2 6-20 18-36

Insulin RegimentInsulin Regiment • Insulin usage principal• Depend on Indonesia situation and conditionp• Use glucometer and routine daily home testing • Objective parameter : Serum HbA1c / 3 months • Insulin dose adjustment :

– For metabolic controlHoneymoon period adolescent sick days surgery– Honeymoon period, adolescent, sick days, surgery

Insulin InjectionInsulin Injection• Injection technique : subcutaneous with

pinchetpinchet• Self injection• Local reaction : rareLocal reaction : rare

Meal adjustmentMeal adjustment• Objective : achieve good metabolic control

without ignoring calory requirementwithout ignoring calory requirement • Total calory : 1000 + (age(year)x100) calory

per dayp y• Carbohydrate 60 – 65% , protein 25%, lipid

<30%

Metabolic ControlMetabolic ControlMetabolic Target(mg/dl) Excellent good moderate poor

Preprandial <120 <140 <180 >180

Postprandial <140 <200 <240 >240

Urine reduction - - + - + >+

HbA1c <7% 7-7,9% 8-9% >10%

ManagementManagement• 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

C li ti• Complication

Complication• Short term complication : hypoglicemy, ketoacidosis• Hypoglycemy : blood glucose < 50 mg/dL

neurogenic symptoms neuroglycopeny

Cholinergic weak, headache, visual disturbance

Sweating,hungry,numb dizziness, tired, sleepy, affective disorder l

Adrenergic (depression,angry), coma, convulsion

Tremor tachycardy pale PalpitationTremor, tachycardy, pale, Palpitation,

anxious

Long term complicationLong term complication• Retinopathy• Nefropathy• Nefropathy• Growth & development disorder

HypoglycemyP ti• Prevention– Regular insulin management– Regular food intake– Parent supervision and education

• Therapypy– Mild/moderate hypoglycemy

• Give 10 – 20 gr of carbohydrate followed by snack • Lemonade honey glucose tablet can be used e o ade o ey g ucose tab et ca be used

– Severe hypoglycemy• Unconscious / convulsion• Oral medication is rarely used shile unconsciousOral medication is rarely used shile unconscious• Parent education inject glucagon 0,5 mg or 1 mg for child

> 5 yrs old

EducationObj i• Objective – Understand the disease– Motivation

T 1 DM t kill– Type 1 DM management skill– Positive attitude– Good metabolic control

Logic decision of daily management– Logic decision of daily management• First education --> at hospital• Continous education :

C– Camp– School

• Advice on :L j– Long journey

– Alkoholic and smoker

Growth and diabetes• Monitor:

B d h i ht/3 th– Body height/3 months– Body weight– Physical and mental development– Physical and mental development

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

protectionprotection

Ketoacidosis ProtocolKetoacidosis Protocol1.Body weight measurement (kg)2.Dehidration therapy decisionpy3.Calculation of free water deficit4.Administration of normal saline (0,9NS), bolus if

orthostatic or shock occurs5.Calculate excess of water deficit after the third bolus 6 Calculate maintainance fluid requiremmnt for the6.Calculate maintainance fluid requiremmnt for the

next 48 hours7.Calculate total fluid given within 48 hoursg

Ketoacidosis Protocol8. 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/hour9. 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 9NSpatient with Na>145mmol/L: 0,9NS-patient with Na<145mmol/L:0,45NS

Ketoacidosis Protocol-Potassium

-Urine (-) : don’t give K+

-Urine (+) : add KCL20-40mmol/L-Give K+ as half Chloride/half phophate at first 8 hour

-Dextrose- Patient with BG>15mmol/L: don’t give dextrose

Patient with BG<15mmol/L: give 5 12 5% dextrose- Patient with BG<15mmol/L: give 5-12,5% dextrose- Try to maintain BG 10-15mmol/l without adding isulin

dose.

Ketoacidosis ProtocolKetoacidosis 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 oedem13.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 mildlyincontinence Perform rapid intervention (intubate, mildly hyperventilate, give mannitol 1 gr/kgBB/iv bolus)

Ketoacidosis Protocol14. 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 givenRe check urine glucose and ketone-Re- check urine glucose and ketone

15. Re- evaluate every fluid change , antisipate the change of K, dextrose, etc value