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Routine Care

Routine Care. Principles of care. 1. 2. Insulin therapy. 3. Blood glucose testing. 4. Dietary advice. 5. Use of HbA1c. 6. Quality of care indicators. Programme. Monitoring growth in childhood. 7. Principles of Care. Goals of care include: Eradicate symptoms.

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Routine Care

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  1. Routine Care Presentation title

  2. Principles of care 1 2 Insulin therapy 3 Blood glucose testing 4 Dietary advice 5 Use of HbA1c 6 Quality of care indicators Programme Monitoring growth in childhood 7

  3. Principles of Care • Goals of care include: • Eradicate symptoms. • Prevention of acute complications • Hypoglycaemia • Diabetic ketoacidosis • Optimum growth and pubertal development • Ensure good psycho-social adaptation and function • Prevention of long term complications

  4. Components of care Education Insulin Diet Monitoring Support of the child and family INSULIN FOOD

  5. Management - who? Multi-disciplinary team Medical personnel Diabetes educator Dietician Social worker Psychologist

  6. Insulin therapy Presentation title

  7. Insulin Human insulin Produced by recombinant DNA technology Usually U-100 concentration Beware of older U-40 insulins Different types classified by their duration of action

  8. Short acting regular insulin Onset=30-60 minutes Peak=2-4 hours Duration=4-8 hours Given 30 minutes before meal Actrapid, Humulin R

  9. Rapid acting analogues • Onset: 15 minutes • Peak: 30 min-3 hours • Duration: 3-5 hours • Given 15 minutes before food 1320 Insulin profile 1200 1080 NovoRapid®, adolescents aged 13–17 years 960 NovoRapid®, children aged 6–12 years 840 720 HI, adolescents aged 13–17 years 600 HI, children aged 6–12 years 480 Serum insulin (pmol/L) 360 240 120 0 -30 0 30 60 90 120 180 210 240 270 300 330 150 Time (min) NovoRapid, Humalog, Apidra

  10. Intermediate-acting insulin Onset: 2-4 hours Peak: variable Duration: 10-18 hours Not related to meals Usually twice daily Sometimes 3-4 times/day NPH, Insulatard, Monotard, Protaphane, Humulin N

  11. Insulin profiles Slide no 11 Aspart, lispro, glulisine Regular NPH Detemir Plasma Insulin Levels 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours

  12. Mixing insulin • Fixed ratio combination insulin • Combination of short and long acting insulin • Most commonly 30% and 70% combination • E.g. Actraphane, Mixtard 30 • Two peaks of action • Often used in twice daily regimens • Self-mixed combinations • Mixed regular/rapid insulin with NPH in syringes • Create own mix to suit patient

  13. Insulin therapy No perfect insulin preparation Choice of insulin individualised to give as physiological insulin profile as possible Be careful of the concentration of insulin (U-100, U-40) Need proper storage of insulin Compliance with treatment regimen is key to success

  14. Insulin regimens • Twice daily regimen • Mix of short acting and long acting before breakfast and supper • Multiple daily injections • Intermediate or long acting insulin twice daily • Short acting insulin with each meal

  15. Insulin regimens Slide no 15 MDI with Lantus-Levemir CSII

  16. Blood glucose testing Presentation title

  17. Blood glucose testing • Treating diabetes dependent on blood glucose changes during the day • Identify times when at risk for hyper- or hypoglycaemia • Blood levels related to • Insulin regimen and doses • Pattern of eating • Activity / illness • Blood glucose information is used to help patient and family learn – not done for staff!

  18. Interpretation Needs records of insulin, food, activity, etc.

  19. Patterns of testing (1) • Pre- and post-meals, bedtime (7 tests/day) • Pre-meals, bedtime (4 tests/day) • Pre-breakfast, pre- and post-selected meal for 1 week (3 tests/day) • Change selected meal weekly • When symptoms of hypoglycaemia occur • When a top-up dose of insulin is needed for extra food or during illness

  20. Patterns of testing (2) • Strips are expensive • Patterns determined by • Availability of strips • Insulin regimen • Level of control • Patient factors • Pattern changed to get useful information • Needs patient records of food and insulin for readings to be valuable!

  21. Dietary advice Presentation title

  22. Principles Need to have a healthy diet Amount and proportions appropriate for age and growth Carbohydrate content of food matched with insulin regimen Understanding of how to match insulin with food is key Best done with the assistance of a dietician

  23. Dietary review Taken at diagnosis Review regularly (annually) Correct food, correct amount and correct times Review food patterns, activities and insulin regimen Growth and stage of puberty influence diet

  24. Use of HbA1c Presentation title

  25. What is HbA1c Red blood cells contain Haemoglobin (Hb) Glucose sticks onto Hb  HbA1c Slow and irreversible HbA1c reflects average blood glucose over 2-3 months High glucose = increased HbA1c Non diabetics: 4-6% (normal range)

  26. What does it tell us Measure of the average blood glucose Correlates with risk of long-term complications Rising HbA1c requires action Ideal HbA1c <6.5% fix slide pix Add EAG table vs A1c???

  27. A1c vs estimated average glucoses

  28. 28

  29. Quality of care indicators Presentation title

  30. Patient indicators

  31. Clinic indicators

  32. Remember Vital to measure regularly the progress of diabetes Basic patient indicators measured at every visit (e.g. once a month) Measurement of growth a very good indicator of the quality of care Each visit an opportunity for repeated information and education

  33. Monitoring growth in childhood Presentation title

  34. Growth Growth follows a predictable pattern over time Growth can be affected by diabetes, i.e. insufficient insulin dosing can cause stunted growth even if blood glucose levels seem fine Type 2 diabetes, overweight contributes to the diabetes Normal growth indicator of adequate diabetes care

  35. Growth charts Can use population specific charts Center for Disease Control (CDC) charts Charts specific for boys and girls and for different age ranges Height, weight, BMI

  36. Measurements Measure height and weight at each clinic visit, once every three months, at least twice a year Record in medical chart and plot on growth chart  Standing height without shoes For young children under 2.5 years, total body length should be measured Measure weight to nearest 0.1 kg if possible

  37. Measuring equipment

  38. Questions

  39. Changing Diabetes® and the Apis bull logo are registered trademarks of Novo Nordisk A/S

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