T1D @ School Managing Type 1 Diabetes in the School Setting

1. T1D @ School Managing Type 1 Diabetes in the School Setting Edward Bellfield, MD, MPH, FAAP Associate Physician, Pediatric Endocrinology Southern California Permanente Medical Group Kaiser Permanente Medical Center Los Angeles | Panorama City

2. Learning Objectives • Understand the significance of appropriate diabetes control. • Know how to manage type 1 diabetes to achieve adequate blood sugars during school hours. • Recognize how to utilize monitoring devices to assist with diabetes management during school hours. https://www.dailytelegraph.com.au/

3. Criteria for Diagnosis of Diabetes 1) 2) 3) 4) Hemoglobin A1c ≥ 6.5% OR Fasting plasma glucose ≥ 126 mg/dL OR 2 hour plasma glucose ≥ 200 mg/dL during an OGTT OR Random plasma glucose ≥ 200 mg/dL ADA. II. Classification and Diagnosis of Diabetes. Diabetes Care 2015; 38(suppl 1):S9. Table 2.1.

4. Types of Diabetes • Type 1 • Type 2 • Gestational • Genetic defects of β-cell function (MODY, mitochondrial, neonatal) • Genetic defects of insulin action • Genetic defects of insulin receptor (Donahue, Rabson-Mendenhall, type A insulin resistance) • Defects of exocrine pancreas (CFRD, pancreatitis, hemochromatosis) • Endocrinopathies(Cushings, acromegaly, pheochromocytoma, etc) • Drug induced (glucocorticoids, β-agonists, pentamidine) • Infections (rubella, CMV) ADA. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2014; 37(suppl 1). Table 1.

5. Type 1 Diabetes • Autoimmune destruction of pancreatic -cell • Can occur at any age https://www.niddk.nih.gov/

6. Type 1 Diabetes • Pancreas unable to produce insulin • Insulin is necessary for normoglycemia Presenting signs/symptoms: • Polyuria, Polydipsia, Polyphagia • Nocturnal enuresis • Weight loss • Fatigue, weakness • Blurry vision • Ketoacidosis: abdominal pain, nausea, vomiting, mental status changes

7. Symptoms of DKA www.aboutkidshealth.ca

8. Causes of Type 1 Diabetes Honeymoon Phase Time

9. Epidemiology • 200,000 people under the age of 20 years old have Type 1 diabetes. • Between 2011-2012, 17,900 children/adolescents under the age of 20 were diagnosed with Type 1 diabetes. • There was a 21% increase in people diagnosed with Type 1 diabetes between 2001 and 2009 under the age of 20. • Among people under the age of 20, non-Hispanic whites had the highest rates of new diagnosis of Type 1 diabetes. SEARCH for Diabetes in Youth Study, 2017

10. Type 1 Diabetes at Schools Antelope Valley • Acton-Agua Dulce Unified School District • Antelope Valley Union High School District • Eastside Union School District • Palmdale School District • Westside Union School District Santa Clarita Valley • Castaic Union School District • Newhall School District • Saugus Union School District • William S Hart Union High School District San Fernando Valley/Metro LA • Burbank Unified School District • Los Angeles Unified School District San Gabriel Valley • Alhambra Unified School District • Pomona Unified School District Kern County • Southern Kern Unified School District

11. Treatment Replace what is missing blog.joslin.org

12. Types of Insulin Insulin Onset Duration Peak Humalog/Novolog/Apidra (short acting) 5 minutes 4 hours 1-2 hrs Lantus/Levemir/Basaglar (long acting)4-6 hours 24 hrs peakless Humulin, Novolin (intermediate)60-120 min 18-24 hrs 6-12 hrs www.bd.com

13. Humalog Humalog Humalog Lantus B L D Insulin Regimens - MDI HS Regular Regular NPH NPH B L D HS

14. Insulin Pumps

15. Insulin Pumps

16. Insulin Regimens - Pump Bolus Bolus Bolus Basal B L D

17. Insulin Dosing • Insulin Sensitivity Factor (ISF) or Correction Factor (CF): # of points 1 unit of insulin will drop BG • Insulin-to-Carb Ratio or Carb Ratio (ICR): # of grams of carbohydrates 1 unit of insulin will cover • Goal Range or Target Blood Glucose (BG): All corrections should aim for a BG in this range.

18. Terminology Correction Dose – Bolus of insulin that is meant to correct an elevated BG down to the target amount. Coverage Dose – Bolus of insulin that is meant to stabilize a BG for the amount of carbohydrates eaten

19. Physician Orders • Correction Dose – 1:50 starting at 150 mg/dL • Correction Dose – 1:50 above 150 mg/dL Correction Factor Threshold for Insulin Threshold for insulin is at 200 NOT 150 Correction Factor BG Target

20. Physician Orders • BG Target: Either stated directly OR (Threshold for Dosing) – (ISF) • If BG Target is presented as a range, ok to use the midpoint as your ‘target number’

21. Correction Formula Measured Glc – BG Target ISF units of short-acting insulin = Correction Dose = 1:50 starting at 150 mg/dL • Measured BG 336 • 336 – 100 • 50 • = 4.4 = 4 units

22. Adding in Carb Coverage Insulin to Carb Ratio = 1:15 60 g this meal 60/15 = 4 units

23. Total Pre-Meal Insulin Dose Correction Dose + Carb Coverage Dose 4 units + 4 units = 8 units

24. Total Pre-Meal Insulin Dose

25. Rounding When in doubt, round down

26. Exercise Guidelines

27. Troubleshooting - Highs Insulin Dosing Insufficient quantity Insufficient carb intake Calculation error Insulin Rx Expired/spoiled insulin Injection technique Supplies Expired/spoiled strips Student Physical activity Anxiety Illness/Infection/Injury

28. Troubleshooting - Highs www.diabetes.org

29. Troubleshooting - Lows Insulin Dosing Insufficient carb intake Calculation error Activity Post-physical activity diabetesforecast.org

31. diatribe.org

32. Continuous Glucose Monitors

33. Continuous Glucose Monitors No fingersticks required Accurate within 30% of fingerstick values Verify lows with fingersticks

34. Continuous Glucose Monitors

35. Continuous Glucose Monitors Fingerstick calibration required 2-4x per day Verify lows with fingersticks Receiver is a smartphone

36. Other CGMs

37. Other CGMs

38. Smart Pens

39. Research for a Cure

40. Take Home Points • Type 1 diabetes is a lifelong chronic condition • Insulin is the main treatment • When in doubt, ask for help