What’s New in Paediatric T1DM

What’s New in Paediatric T1DM

TCH Paediatric Multidisciplinary Diabetes Team10 July 2013

Learning objectives• Recognise clinical signs and symptoms to allow for

the earliest possible diagnosis and referral of children with new-onset T1DM.

• Describe current insulins and regimen options available in 2013.

• Develop an understanding of the various technologies available for the management of T1DM at home.

• Understand strategies for and review sick-day management plans for children with T1DM in your practice.

Case study1• 4 yr old boy• GP presentation: 3 week history of

weight loss, polyuria and polydipsia. • 2 day history of sore throat• Woke up in the morning with ‘heavy

breathing’• Past medical and family history were

unremarkable.

Case study2Physical examination• Alert• GCS score 15/15• Kussmaul breathing present• PR 136 bpm, RR 44, BP 92/58• >5% dehydration• Dry cracked lips• Weight 16kg (~3kg weight loss in 4 weeks)• Pharyngitis

Case study3• At GP surgery: BGL 25mmol/L – referred to

ED In ED:• Capillary blood gas: pH 7.18, bicarbonate

(HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected = 142) , K 4.9 mmol/L

Corrected Na = measured Na + 0.3 (glucose – 5.5)

Case study4Management:• 10ml/kg bolus Normal saline• Re-assessed: PR 118, RR 36, BP 96/58• IV insulin infusion: 0.1U/kg/hr• Fluids: N/S + 40mmol/L KCL at maintenance

+ 5% replacement over 48 hrs• Transferred to HDU – further management

as per DKA protocol

Case study5At resolution of ketoacidosis:• Initiated on MDI: Levemir at bedtime;

Novorapid with meals using an insulin dosing card.

• DNE / Dietician / Social work involvement

• Discharged home on day 5 with nightly contact with on-call Paediatric Endocrinologist for dose adjustments

• Type 1 diabetes

– β-cell destruction• Type 2 diabetes

– Progressive insulin secretory defect• Other specific types of diabetes

– Genetic defects in β-cell function, insulin action

– Diseases of the exocrine pancreas– Drug- or chemical-induced

• Gestational diabetes mellitus (GDM)

Diabetes Care 2013;36(suppl 1):S11.

Classification of Diabetes

A1C ≥6.5%OR

Fasting plasma glucose≥7.0 mmol/L

OR2-h plasma glucose ≥11.1 mmol/L during

an OGTTOR

A random plasma glucose ≥11.1 mmol/L

Diabetes Care 2013;36(suppl 1):S13; Table 2.

Criteria for diagnosis of Diabetes

Categories of increased risk for diabetes (prediabetes)

IFG: 5.6–6.9 mmol/LOR

IGT: 2-h plasma glucose in the 75-g OGTT7.8–11.0 mmol/L

ORA1C 5.7–6.4%

*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.

Diabetes Care 2013;36(suppl 1):S13; Table 3.

Criteria for Prediabetes

• Autoimmune destruction of the pancreatic islet cell

• Hallmark = lymphocytic infiltration of islets

• Progresses over years• Leads to insulin deficiency• Glucagon production is

preserved but impaired action

Pathogenesis of T1DM

Diabetic Medicine 2009; 26(6): 596-601

Australian incidence (NDR) in children 0-14 years between 2000-2006

Incidence of T1DM in Australia

Genetics of T1DM 1

• Susceptibility to T1DM is an inheritable trait BUT >85% cases occur in the absence of first-degree relative

• Lifetime risk: first-degree relative (5%) vs general population (0.3%)

Genetics of T1DM 2

• Twin concordance: monozygotic (30-50%) vs dizygotic (6-10%)

• Risk increases with early age at diagnosis: 3-5 fold increase risk if first degree relative diagnosed <5 years age

Genetics of T1DM 3Susceptibility loci: HLA-DR3 and HLA-DR4• At least one locus: 95% T1DM vs 3%

general population

Protective loci: HLA-DR2, HLA-DR5, and HLA-DQB1*0602• 1 in 15,000 people with HLA-DQB1*0602

develop T1DM

Environmental factors in T1DM

• Cow’s milk protein exposure (bovine serum albumin and β-lactoglobulin)

• Vitamin D deficiency• Viruses: coxsackie A or B, enterovirus, rubella,

cytomegalovirus, ECHO virus, EBV, mumps, retrovirus• Drugs & toxins: eg alloxan-like or streptozotocin- like

agents that induce oxidant beta-cell damage• Stress

The Environmental Determinants of Diabetes in the Young (TEDDY) study

Islet-specific autoantibodies1• Islet cell autoantibodies (ICA)• Glutamic acid decarboxylase autoantibodies

(GADA)• Insulinoma-associated 2 autoantibodies (IA-2A)• Insulin autoantibodies (IAA)• Zinc transporter autoantibodies (ZnT8A).

Multiple and specific combinations of autoantibodies more predictive

Diabetes Care 2009;32:2269-74

Islet-specific autoantibodies2• Not causative • Present months to years before onset of

symptoms• Persist for varying duration after onset• 90-95% T1DM have at least one at

diagnosis

Cell Mol Life Sci 2007;64:865-72Ann Intern Med 2004;140:882-6J Clin Endocrinol Metab 2004;89:3896-902.Diabetes 1999;48:460-8

Atkinson MA & Eisenbarth GS. Lancet 2001; 358; 221-229

The Pathogenesis of T1DM

Meal

Normal glucose homeostasis

Insulin secretion

Fasting blood glucose is not an appropriate screen test for T1DM

Clinical Presentation• Polyuria – 95%• Weight loss – 61%• Fatigue – 52%

Polyuria is often missed on history

The EURODIAB studyDiabetologia 2001;44(Suppl 3):B75-80.

• Utilize intensive therapy aimed at near-normal BG and A1C levels

• Prevent diabetic ketoacidosis and severe hypoglycemia

• Achieve the highest quality of life compatible with the daily demands of diabetes management

• In children, achieve normal growth and physical development and psychological maturation

• Establish realistic goals adapted to each individual’s circumstances

Goals of T1DM Management

DCCT and EDIC Findings• Intensive treatment reduced the risks of retinopathy,

nephropathy, and neuropathy by 35% to 90% compared with conventional treatment

• Absolute risks of retinopathy and nephropathy were proportional to the A1C

• Intensive treatment was most effective when begun early, before complications were detectable

• Risk reductions achieved at a median A1C 7.3% for intensive treatment (vs 9.1% for conventional)

• Benefits of 6.5 years of intensive treatment extended well beyond the period of most intensive implementation(“metabolic memory”)

DCCT/EDIC Research Group. JAMA. 2002;15;287:2563-2569.

Intensive treatment should be started as soon as is safely possible after the onset of T1DM and maintained thereafter

Principles for Good Glycaemic Control

• Paedaitric Endocrinologist• Diabetes Nurse Educator / Nurse Practitioner• Dietician• Social Worker• Psychologist

• Age-appropriate clinics

ISPAD Clinical Practice Consensus Guidelines 2006–2007

The Multidisciplinary Team Approach

ISPAD Clinical Practice Consensus Guidelines 2006–2007

• Education for parents / child (age appropriate)

• Correct insulin regimen• Contact in between clinics for adjustments• Good relationship with GP

Contributors to good glycaemic control

Rapid (Humalog, Novorapid, Apidra)

Hours

Long (glargine)

Short (Humalin R, Actrapid)

Intermediate (NPH, Protaphane)

Long (detemir)

InsulinLevel

0 2 4 6 8 10 12 14 16 18 20 22 24

N Engl J Med. 2005;352:174-183.

Pharmacokinetics of insulin Products

Pre-mix

Twice-daily

MDI

IncreasedComplexity

Better control

Less Hypoglycaemia

CSII

INSULIN DOSING CARDEzy-BICC

SMART-METERAccu-Chek Aviva Expert

INSULIN DOSING APPInsulin Pro

Insulin dosing advice

DKA

Risk factors for DKA at diagnosis of T1DM

• Younger age• Ethnic minority• No first degree relative• Low SES/poor medical access/uninsured• Lack of community health screening• Lower weight SDS at diagnosis

Rates of DKA inversely related to prevalence of T1DM

Diabet Med 2013. doi: 10.1111/dme.12252Pediatr Clin N Am 2011; 58 : 1301–1315

• Hyperglycemia BG > 11 mmol/l (young or partially treated children, pregnant adolescents may

present with “euglycemic ketoacidosis”)

• Venous pH <7.3 and/or bicarbonate <15 mmol/L– mild DKA pH <7.3 bicarbonate <15 – moderate pH <7.2 bicarbonate <10– severe pH <7.1 bicarbonate < 5

• Glucosuria and ketonuria/ketonemia (β-HOB)

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA criteria

ISPAD Clinical Practice Consensus Guidelines 2006–2007

Pathophysiology of DKA

• Feeling unwell for a short period, often less than 24 hours

• Polyuria, polydipsia and increased thirst, nocturia• Polyphagia • Weight loss • Nausea and vomiting, vomitus can have coffee-

ground colour due to haemorrhagic gastritis• Abdominal pain, due to dehydration and acidosis• Weakness

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 1

• Neurologic signs: restlessness, agitation,lethargy and drowsiness, coma. Increased

• Osmolality is the main factor that contributes to altered mental status

• Visual disturbances due to hyperglycaemia • Deep and rapid breathing, known as Kussmaul

breathing, may have acetone odour on breath.

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 2

• Signs of dehydration due to fluid loss through polyuria, vomiting and breathing: reduced skin turgor, dry mucous membranes

• Signs of hypovolaemia: tachycardia, hypotension, postural hypotension

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 3

• Mild hypothermia due to acidosis-induced peripheral vasodilation, warm dry skin.

• Fevers are rare despite infection. Severe hypothermia is a poor prognostic sign

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 4

Measurement of Ketone bodies

Hypoglycaemia

Hypoglycaemia 1

• Diaphoresis• Tachycardia/

Palpitations• Shakiness• Tingling• Pallor

Adrenergic

• Confusion• Irritability• Behavoural changes• Difficulties concentrating• Headache• Visual disturbance• Slurred speech• Altered consciousness• Seizures

Neuroglycopenic

Hypoglycaemia 2• Check BGL if symptoms: <4.0mmol/L• To increase BGL by 3-4mmol/L:

<30kg child use 10g≥30kg child use 15g

• Re-check BGL every 10-15 mins and repeat treatment if necessary

ISPAD GuidelinesPediatric Diabetes 2009: 10(Suppl. 12): 134–145

Hypoglycaemia 3• Check 20-30 mins after resolution to

ensure BGL maintained• Solid food should be avoided until BGL ≥

4mmol/L (impairs absorption of fast-acting CHO)

• Severe hypoglycaemia: IM Glucagon – 0.5mg in <12 years; 1.0mg in ≥ 12 years

ISPAD GuidelinesPediatric Diabetes 2009: 10(Suppl. 12): 134–145

Cognitive Effects of Hypoglycemia in Children

• Repeated and early exposure to severe hypoglycemia has been reported to reduce long-term spatial memory in children with type 1 diabetes

• Early exposure to hypoglycemia may be more damaging to cognitive function than later exposure

Diabetes Care. 2005;28:2372-2377.

Incidence of Severe Hypoglycemia: T1DM Exchange

Garg S, et al. Presented at 5th International Conference on Advanced Technologies & Treatment for Diabetes, Barcelona, 2012.

J Pediatr. 2002;141:490-495.

Causes of Hypoglycemia in Toddlers and Preschoolers

• Unpredictable food intake and physical activity

• Imprecise administration of low doses of insulin

• Frequent viral infections• Inability to convey the symptoms of low

blood sugar

Glucose Variability and Health Outcomes: Direct and Indirect

Pathways

Health Psychol. 1992;11:135-138Diabetes Care. 1996;19:876-879;

Diabetes Technol Ther. 2008;10:69-80.

Glucose variability

Reluctance to intensify therapy

High A1C

ComplicationsMorbidity Mortality

Quality of life

Fear of hypoglycemia

Severe hypoglycemia

Controversial

DEXCOM MEDTRONIC

HYPOMON

Sick Day Management

STRESS

COUNTER-REGULATORY

HORMONE

INSULINRESISTANCE KETOSISHYPERGLYCAEMIA

Also hypoglycaemia with ketosis eg gastroenteritis

Sick Day Management 1

Sick day management 2• Regular BGL and ketone monitoring• Additional insulin: 10-20% of total daily

insulin as regular corrections• Encourage oral fluids

IV fluids necessary if unable to maintain BGL to sustain additional required insulin

Paediatric Diabetes 2009; 10 (Suppl. 12): 134-145

Sick day management 3

Insulin pump:• Check pump / line / site• Subcutaneous injection may be

appropriate• Increase basal rate: 150-200% • Regular correction boluses

Paediatric Diabetes 2009; 10 (Suppl. 12): 134-145

Who and when to call

• Concerns regarding early presentation of T1DM

• New diagnosis• Existing patients – issues while reviewing

at GP surgery

0466 655 068