type i diabetes mellitus mr 8/14/09 j.chen. management insulin monitoring nutrition exercise...
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Type I Diabetes Mellitus
MR 8/14/09J.Chen
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Management
• Insulin• Monitoring• Nutrition• Exercise• Education
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Insulin
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Insulin Requirements
• Preadolescent-0.5-1 unit/kg/day• Adolescents-0.8-1.2 units/kg/day• During honeymoon period-<0.5 units/kg/day
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Starting an Insulin Regimen
• Split mixed Regimen vs. Basal/Bolus Regimen
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Split/Mixed Regimen
• 2-3 injections based on NPH• 2/3 in AM, 1/3 in PM• 2/3 NPH, 1/3 Regular/Rapid• More rapid/regular may be required in AM
because of dawn phenomenon (nocturnal release of counter regulatory hormones-less insulin sensitivity in AM)
• May require less during Honeymoon period
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Split/Mixed Regimen
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Monitoring• Traditionally before meals, at bedtime, overnight• More often when ill or active• Acceptable range– Fasting/preprandial:
• preschool: 100-180mg/dL• School age: 90-180mg/dL• Teenagers: 90-130mg/dL
– Bedtime/overnight• Preschool: 110-200mg/dL• School age:100-180mg/dL• Teenagers: 90-150mg/dL
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Basal Bolus Regimen
• Aims to achieve more physiologic insulin concentrations
• Basal provides baseline or fasting insulin• Bolus provides coverage for food and correct
for hyperglycemia• Basal rate given either through injection or via
insulin pump
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Basal/Bolus Regimen
• Basal requirement ~50% daily insulin need– Either long acting insulin or– Rapid acting insulin via pump
• Bolus dose has 2 parts:– 1. coverage for carbohydrates in meal– 2. correction for blood glucose concentration
outside of target range.
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Monitoring
• HbA1c– <6yr: 7.5-8.5%– 6-12yr:<8%– 13-19yr: <7.5%
• Urine or blood ketones should be monitored:– Blood glucose elevated– Nausea– Vomiting– Feeling ill
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Nutritional Management
• Balanced Diet with adequate calories and nutrients for normal growth
• 50-55% carbohydrate calories, 20% protein calories, 30% fat calories– Most carb calories should be complex
carbohydrates– Fat portion should be low in cholesterol and
saturated fats
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Nutritional Management
• Split/Mixed-– timing important– Snacks– Treats should be allowed
• Basal/Bolus– Flexibility in timing, amount, and content– Accurate carb counting and insulin dose
calculation
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NEXT TIME: DKA