1 Paediatric And Adolescent Diabetes Care Dr Noman Ahmad 3 rd February 2011 Cork University Hospital.

1

Paediatric And Adolescent Diabetes

Care

Dr Noman Ahmad

3rd February 2011

Cork University Hospital

2

Presentation Outline Definition Classification Pathophysiology Clinical Presentation Insulin types and regimens Insulin dose in different age groups Follow-up/Monitoring

3

Learning Objectives

Understanding of insulin pharmacokinetics Right insulin regimen Aims of glycaemic control Complexity of management in different age

groups

4

Definition

Diabetes mellitus is group of metabolic diseases

characterised by chronic hyperglycaemia resulting

from defects in insulin secretion, action or both

International society of paediatric and adolescent diabetes

5

Insulin Physiology

6

Classification

Type 1 diabetes (IDDM) Type 2 diabetes (NIDDM) Monogenic diabetes (MODY) Neonatal diabetes (Transient first 3 months) Mitochondrial diabetes Cystic fibrosis related diabetes (CFRD) Drug induced hyperglycaemia

7

Pathophysiology T1DM

Autoimmune destruction (T1A DM) Non autoimmune destruction (T1B DM) Multiple genes

HLA genes (DR, DQ alpha, DQ beta) Autoantigen (Islet cells, Insulin, glutamic acid

decarboxylase GAD 65, Isulinoma associated protien 2 IA-2, Zinc transporte ZnT8

8

Pathophysiology T1DM

Environmental factors

Viruses (Entero, Coxsackie, EBV) Cow’s milk Perinatal factors Vitamin D

9

Pathophysiology T1DM

Association with other autoimmune diseases

Thyroid 20% Adrenal 1.7% Coeliac disease 10% Polyglandular autoimmune disease

10

Pathophysiology T1DM

Genetic predispositionHLA associations

EnvironmentViruses, toxins, cow’s milk

Immune dysregulationGAD 65, IA-2,Insulin, ZnT8,Islet cells

Beta islet cell destructionInsulin deficiency

Type 1 diabetes

11

Pathophysiology of T2DM

12

Presentation of T1DM

Classic (most common) Polyuria, polydipsia and weight loss

Diabetic ketoacidosis Hyperglycaemia, metabolic acidosis and ketonuria

Silent Usually siblings of known cases

13

Presentation of T2DM Girls 1.7 times more common Obesity, signs of insulin resistance (acanthosis

nigricans) Strong family history, LBW, gestational diabetes Insulin resistant states (puberty, PCOS) Impaired OGTT Elevated A1C DKA Hyperosmolar coma with no ketunuria

14

Acanthosis Nigricans

15

INSULIN TYPES Short acting

Regular Analogs (Novorapid,Humolog,Apidra)

Intermediate acting NPH

Long acting Detemir (Levemir) Glargine (Lantus)

16

Pharmacokinetics

17

Pharmacokinetics

18

Insulin Regimens

Conventional Premixed (Mixtard 30, Novomix 30) Short acting(Novorapid) and intermediate acting (NPH)

Intensive MDI (Lantus or Levemir and Novorapid) Insulin pump (CSII)

19

Insulin Regimens

Conventional Positives

Twice a day No carbohydrate counting Good for new patients and school going kids Less chance of DKA

Negatives Non physiological Less flexible More risk of hypoglycaemia Loose glycaemic control

20

Conventional Regimen

NovorapidInsultard(NPH)

0 30 4 6 12 16 18

21

Insulin Regimen (MDI)

22

Insulin Regimen (MDI)

Intensive Positive

Physiological Flexible Less risk of hypoglycaemia Good for teenagers Less long term side effects Better glyceamic control

Negatives More injections Carbohydrate counting More risk of DKA

23

Insulin Pump

Continuous basal infusion Bolus with every meal or snack Correction bolus Regular or rapid insulin

24

Insulin Pump

25

Insulin Pump

26

Insulin Pump

Advantages Flexible Precise Better glycaemic control Less variability Less Hypoglycemia Less long term complication

27

Insulin Pump

Disadvantage Tethered with device Cost Infection Equipment failure Carbohydrate counting DKA Hinder in some activities

28

Injection Sites

Fast absorption in abdomen Slow in legs Intermediate in arms Subcutaneous fat Skin very slow absorption Muscles too fast

29

High Insulin Doses

Growth Puberty Sickness Stress Active/competitive sports Steroid therapy No physical activity

30

Target Blood Glucose

Preprandial CDA 2008

0-6 years 6-12 6-12 years 4-10 >12 years 4-7

ISPAD 2009 5-8 for all kids

2 hours postprandial 5-10 for all kids

31

Target HbA1C

CDA 2008 <6 years 8.5% 6-12 < 8% >12 years ≤ 7%

ISPAD 2009 < 7.5% for all kids

32

Clinic Visit

History Glucose diary Hypoglycaemia Intercurrent illness Thyroid, adrenal, coeliac Exercise Hypoglycaemia supplies

33

Clinic Visit

Examination Growth, weight, BP Thyroid Injection sites Finger poke sites Pubertal exam Retinal exam Prayer signs

34

Clinic Visit

Investigations HbA1C every 3 months TSH annually Coeliac screen Lipid profile Albumin creatinine ratio Eye exam

35

Infants And Toddlers

Brain is very sensitive to hypoglycaemia Sensitive to Regular/rapid insulin Picky eater May need to give insulin after meals

36

Adolescents

Insulin resistance Non compliance Fabrication Denial Eating out and snacking Family conflicts Alcohol Eating disorders

37

QUESTIONS