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Chronic diabetes: Case A

Chronic diabetes: Case A. 42 yr male, Type 1 for past 22 yrs FBG significantly elevated (HbA1c = 8%) CBGM initiated to determine why px has elevated levels Results: ave BG 7.3mmol/L normal to low BG till 3am followed by sig. Morning to 13.9mmol.L. Principles CBGM.

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Chronic diabetes: Case A

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  1. Chronic diabetes: Case A • 42 yr male, Type 1 for past 22 yrs • FBG significantly elevated (HbA1c = 8%) • CBGM initiated to determine why px has elevated levels • Results: ave BG 7.3mmol/L normal to low BG till 3am followed by sig. Morning to 13.9mmol.L

  2. Principles CBGM • BSL tightly regulated under hormonal influence • 4-8mmol/L • for optimal physiological fn • CBGM allows assessment of BSL in 24hr day rather than • ‘Traditional’ intermittent BSL testing = snapshot at certain times of the day • HbA1c = average BSL 3/12 • CBGM = Informative + Appropriate info on BSL

  3. APPLICATIONS CBGM • Helps identify hypo- & hyper- glycaemia • WHEN they happen? • WHY they happen? • Helps OPTIMISE diabetic treatment of px • Helps PREVENT complications of hypo- & hyper- glycaemia • Eg macro/micro vascular disease • retinopathy

  4. Mr MJ’s current insulin regimen • Breakfast • 6 units of regular insulin • Lunch • 3 units of regular insulin • 1 unit of lispro insulin • Dinner • 7 units of regular insulin • Bedtime • 8 units of isophane insulin

  5. Blood sugar levels • Overnight – normal • Progressively fall until 3 am • After isophane insulin action peaks, levels steadily rise to 13.9 mmol/L • Dawn Phenomenon • Day – BGLs decline from morning peak

  6. Dawn Phenomenon • Occurs in type 1 diabetes • Due to • previous evenings sustained-action insulin wearing off • Increased resistance to insulin developed by body in response to nocturnal surges of growth hormone • Can be avoided by • giving insulin immediately before bed • using a longer acting insulin

  7. Insulin Time to inset (hrs) Peak action (hrs) Duration of action (hrs) Generic name Very short-acting 0-0.25 1 3.5-4.5 Lispro Aspart Short-acting 0.5 1-4 4-6 Neutral Intermediate-acting 1-2 4-12 12-18 Isophane Lente Long-acting 4 8-12 18-28 Ultralente Combination Biphasic Insulin

  8. The problem… • Mr MJ has already tried lente and ultralente insulin suspensions but these caused erratic blood glucose levels and did not counteract the dawn phenomenon • Mr MJ needs a continuous release of insulin rather than the large bolus he is receiving at present • Options • Increased number of insulin injections with smaller dose • Insulin pump

  9. INSULIN INFUSION PUMPS

  10. INSULIN PUMP THERAPY • Uses a portable electromechanical pump to help mimic nondiabetic insulin delivery. • Infusing short-acting insulin into the subcutaneous tissue at pre selected rates. • Also infuses a bolus dose to cover mealtime or snack time insulin requirements.

  11. ...INSULIN INFUSION PUMPS

  12. A typical profile of basal insulin infusion rates with CSII:

  13. MISCONCEPTIONS • The pump is NOT an artificial pancreas. • Patients cannot ignore their calorie and carbohydrate restricted diets. • Self monitoring of BGLs is still required as in patients who rely on MDIs • Will NOT eliminate episodes of severe hypoglycaemia or hyperglycaemia.

  14. ADVANTAGES • Better glycaemic control than conventional and intensive management • Management of the ‘Dawn Phenomenon’. • Severe hypoglycaemia reduced.

  15. …ADVANTAGES • Improves or slows progression of nephropathy, peripheral and autonomic neuropathy, and retinopathy. • IMPROVEMENT IN LIFESTYLE!

  16. DISADVANTAGES • Diabetic ketoacidosis risk • Hypoglycaemia • Cost • Catheter Site Infection and Contact Dermatitis

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