TYPE I DM NEWLY DIAGNOSED What is diabetes?

Diabetes is a condition where the amount of glucose in your blood is too high because the body cannot use it properly. This is because your pancreas does not produce any insulin, or not enough, to help glucose enter your bodys cells or the insulin that is produced does not work properly (known as insulin resistance). Insulin is the hormone produced by the pancreas that allows glucose to enter the bodys cells, where it is used as fuel for energy so we can work, play and generally live our lives. It is vital for life. Glucose comes from digesting carbohydrate and is also produced by the liver If you have diabetes, your body cannot make proper use of this glucose so it builds up in the blood and isnt able to be used as fuel. What is Type 1 diabetes? Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin. Insulin is the key that unlocks the door to the bodys cells. Once the door is unlocked glucose can enter the cells where it is used as fuel. In Type 1 diabetes the body is unable to produce any insulin so there is no key to unlock the door and the glucose builds up in the blood. Nobody knows for sure why these insulin-producing cells have been destroyed but the most likely cause is the body having an abnormal reaction to the cells. This may be triggered by a virus or other infection. Diabetes symptoms Symptoms occur because some or all of the glucose stays in the blood and it isnt being used as fuel for energy. The body tries to reduce blood glucose levels by flushing the excess glucose out of the body in the urine. (Go through symptoms) Diabetes management

People with Type 1 diabetes will require insulin. Insulin cannot be taken in a tablet form because, being a protein, it would be digested in the stomach before it had any effect. Insulin can be given in different ways via an injection, using a syringe, pen device or via an insulin pump. The needle is small, as it only needs to be injected under the skin (subcutaneously), either in the stomach, buttocks, thighs or upper arms. The insulin is then absorbed into small blood vessels and arrives in the bloodstream. Manufactured insulin can be either synthetic (human) or animal in origin, and falls into five main categories: rapid-acting short-acting intermediate acting (also called isophane insulin) fixed mixtures (of rapid - or short-acting and intermediate-acting insulin) long-acting

Benefits Intensive insulin treatment can improve blood sugar control, which can improve how you feel on a daily basis as well as reduce your risk of health complications later in life Drawbacks There are a few drawbacks to intensive insulin treatment: You will need to coordinate your daily activities, what you eat, how much and when you exercise, and you will need to check your blood sugar frequently (4 or more times per day). There is an increased risk of low blood sugar episodes (hypos) Some people gain weight initially, although exercise can counteract this effect.

Injection technique The following is a description of subcutaneous insulin injection. Choose the site to inject. It is not necessary to clean the skin with alcohol unless the skin is dirty. Pinch up a fold of skin and quickly insert the needle at a 90 angle (or other angle, as described above). Keep the skin pinched to avoid injecting insulin into the muscle. Push the plunger down completely to inject the insulin. Hold the syringe and needle in place for 5 seconds. Release the skin fold. Remove the needle from the skin. Monitoring Glucose levels Knowing the level of glucose in your blood is useful for when you are trying to control your diabetes. It can help to maintain day-to-day control, detect hypoglycaemia, assess control during any illness, and helps to provide information that can be used in the prevention of long term complications. People with diabetes will also have tests to check longer term blood glucose levels called HbA1c Blood glucose targets Children with Type 1 diabetes (NICE 2004) Before meals: 4-8mmol/l Two hours after meals: less than 10mmol/l Adults with Type 1 diabetes (NICE 2004) Before meals: 4- 7mmol/l 2 hours after meals: less than 9mmol/l HbA1c targets For most people with diabetes, the HbA1c target is below 6.5%, since evidence shows that this can reduce the risk of developing diabetic complications, such as nerve damage, eye disease, kidney disease and heart disease.

You will also want to keep an eye on your blood fat (lipid) levels, blood pressure, feet and eyes. Diabetic Ketoacidosis In the short term, consistent high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA).

Why does this happen? This happens because of a lack of glucose entering the cells where it can be used as energy. The body begins to use stores of fat as an alternative source of energy, and this in turn produces an acidic by-product known as ketones. How ketones affect the body
Ketones are very harmful and the body will immediately try to get rid of them by excreting them in urine. Consequently, when ketones are present and blood glucose levels are rising, people often become increasingly thirsty as the body tries to flush them out. If the level of ketones in the body continues to rise, ketoacidosis develops (ketoacidosis means acidity of the blood, due to an excess of ketones in the body). Their harmful effect becomes more apparent, and nausea or vomiting may start. In addition, the skin may become dry, eyesight blurred and breathing deep and rapid. Unfortunately, because of vomiting, the body becomes even more dehydrated and less efficient at flushing out the ketones, allowing levels to rise even faster. As the level of ketones rise, it may be possible to smell them on the breath - often described as smelling like pear drops or nail varnish. Eventually, if untreated, the level of ketones will continue to rise and, combined with high blood glucose levels, a coma will develop which can be fatal. However, at any of these intermediate stages, ketoacidosis can be treated and damage usually limited. Obviously, the sooner, the better.

TYPE 2 DM STARTING INSULIN Who can benefit from insulin treatment? Potentially, anyone with Type 2 diabetes stands to benefit from insulin treatment. Strong indications for insulin therapy include: symptoms of hyperglycaemia such as polyuria, thirst, recurrent fungal infections (especially genital thrush) or bacterial infections (especially urine infections) pregnancy or planning pregnancy oral hypoglycaemic treatments not tolerated/contra-indicated weight loss without dieting in someone of low or normal weight. Possible indications for insulin therapy include: unsatisfactory glycaemic control, even with the maximum tolerated dose of oral hypoglycaemic agents (OHAs) (HbA1c higher than 7 per cent, selfblood glucose monitoring results higher than 7mmols/litre before meals or 9 mmols/litre two hoursafter meals) personal preference painful neuropathy foot ulceration and infection. Which regimen? There is no one right choice, and one regimen is not necessarily forever. If it is unsuitable it should be changed There are many advantages to combining insulin with oral agents and this is now much more common. The advantages include: less risk of weight gain less risk of hypoglycaemia a simpler treatment regime Here are some examples of combination treatments and when they can be used: Once-daily intermediate-acting insulin at bedtime plus OHAs can be effective for people who are insulin resistant due to obesity. It is

particularly appropriate where the persons blood glucose is high overnight and in the morning, but comes down once they start their daily activities. Twice-daily pre-mixed insulin plus OHAs can be effective for people with significant hyperglycaemia after meals. Long-acting peakless insulin in the morning (or whenever is convenient, provided it is taken at the same time each day) plus OHAs can be used where the person has high blood glucose during the day and at night, and would otherwise need twice-daily basal insulin injections in combination with oral anti-diabetic drugs

Multiple injection therapy (basal/bolus) This regimen is closer to the way the body works naturally. The person uses basal insulin once a day, at the same time each day, with a bolus at mealtimes. This gives people much greater flexibility over when and what they can eat. Taking intermediate basal insulin with peaks, such as Insulatard or Humulin I at bedtime, in combination with a short-acting bolus such as Actrapid or Humulin S half-an-hour before meals, is usually effective in Type 2 diabetes.

Education issues Doses and timing - write it down! Injection technique, including rotating sites and disposing of sharps. Titration of doses, if appropriate at this stage. Some diabetes units use algorithms - ask at your local unit. Carbohydrates - regular intake of starchy carbohydrates will help stabilise blood glucose levels. People may need to be reminded which food groups these are. Hypoglycaemia - signs and symptoms, treatment and prevention (see below). Give the person an ID card showing that they are treated with insulin.

Driving - people having insulin treatment must tell DVLA and their insurance company. Explain the dangers of hypoglycaemia while driving, as well as the driving restrictions that apply. For more information, see the Diabetes UK website at www.diabetes.org.uk Blood glucose monitoring - timing and frequency of tests, and interpreting the results. Weight gain - many people put on weight when they start insulin. They may need to cut their food intake if they want to maintain their current weight. Follow up and contact numbers - arrange a further appointment, and provide both a routine contact and an emergency number, for example the NHS Direct number (0845 4647) or a helpline run by the insulin manufacture

Hypoglycaemia Early symptoms may include: pallor; sweating; fast heart rate; trembling; anxiety; irritability; hunger; and tingling lips. Late hypo symptoms include: headache; poor concentration; poor co-ordination; glazed eyes; slurred speech; confusion; aggressive behaviour; double vision; weak legs; drowsiness; loss of consciousness; and seizure Treat mild hypoglycaemia with 10-20g of fast-acting carbohydrate, for example three to six glucose tablets; 90 to 180 ml of a fizzy drink or squash (not the diet version); two teaspoons of sugar added to a cup of drink; or 50 to 100 ml of Lucozade. This should cause the blood glucose to rise rapidly.Wait ten minutes for this to happen and, if its a while before the next meal, this should be followed by some longeracting, starchy carbohydrate, for example, a sandwich or some biscuit In moderate hypoglycaemia, the patient may not be able to treat themselves, so their carer, partner, family and friends will need to know what to do. Hypostop dextrose gel, may be useful, but it must not be given to someone who is unconscious. Severe hypoglycaemia, with loss of consciousness, where the patient needs glucagon, is extremely unlikely in Type 2 diabetes, but can happen in cases of renal failure, or when people are trying to keep their glucose levels as close to normal as possible, for example, during pregnancy

Problems with insulin Insulin neuritis Insulin allergy Insulin oedema Needle phobia Lipohypertrophy Hypoglycaemia Weight gain