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Problems and challenges Problems and challenges in patients with type 1 in patients with type 1
diabetes.diabetes.
Larry A Distiller
Centre for Diabetes and Endocrinology
Johannesburg
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Type 1 Diabetes
Type 1 DM is, in essence, a simple hormone deficiency state……
Beta cell destruction results in Insulinopenia.
Exogenous Insulin is freely available. Replace this missing hormone
In concept, no different from hypothyroidism, HRT etc.!
So what’s the problem?
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Redefining the “problem” of diabetes
Diabetes the “Illness”:Patient has symptoms of hyperglycemia
Symptoms treated
Patient no longer ill!
Able to continue “normal” lifestyle with minimum disruptions.
Achieved with blood glucose <15mmol/l
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Redefining the “problem” of diabetes
Diabetes the “Risk Factor”:
The need to achieve as good glycaemic control as possible (HbA1c <7%) to avoid microvascular (and possibly macrovascular) complications.
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Targets for glycaemic control are set.
HbA1c <7%
FPG 4.4-6.7 mmol/l
PPG <10mmol/l But are seldom achieved
WHY?
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THEORETICAL BARRIERS TO CONTROL
Patient BarriersAgeGenderEducational levelPast experience with diabetesRace EthnicitySocioeconomic statusAttitudesPersonalityEnergy LevelPhysical HealthMental HealthReligionEmotional StatePast Experience with diabetes educationStress
Education BarriersVisionProfessionValuesKnowledgeSkillsAttitudePersonalityGenderEnergy LevelExperienceFlexibilityEthnicityReligion
Environmental BarriersStressEducational MethodReimbursement Physical SettingPart of countryWeatherFamilyFriendsWorkCultureProblems re:•Nutrition•Exercise•Medication•Foot Care•Emergencies
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The Treatment of the Patient with type 1 diabetes changed forever following the DCCT.
This change was preceded by and made possible by
the advent of three things:
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The foundation of modern diabetes management
SHGMPen
Devices/CSII
Diabetes Nurse
Educator
Intensive management of type 1 diabetes
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Allows for
Patient self-empowerment
Better acceptance of diabetes & its treatment through better patient counseling, education and understanding
Self-adjustment of insulin doses
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Goals of Insulin Therapy
• To achieve blood glucose profiles as close to the euglycaemic range as possible.
Target : HbA1c <7%
• To provide as much flexibility as possible.
• To ensure the best quality of life.
And at the same time to minimize hypoglycaemia
This is best done by mimicking normal insulin secretion as closely as possible
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Know & Understand your Insulins
• Types
• Onset of Action
• Onset & Duration of
Peak Action
• Total Duration of
Action
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Know Your Patient !
Each person is as unique as a fingerprint
• Age / self care ability
• Coexisting conditions
• Type & duration of diabetes
• Exercise
• Meal plan
• Medications / alcohol
• Complications etc…
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Your Client Must Also Understand the Insulin
• First: Listen
• Counsel – it is not a normal human activity to stab oneself repeatedly
• Educate
• Regular review & follow-up
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Decide
Which Insulin Regimen?Which Insulins?What expectations?
The patient cannot be dictated to, but must be a partner in the decision process.
The more frequently one injects, the more flexibility in life-style.
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Helping Your Patient Choose a Regimen
You get what you pay for!
• “Pay” 4 -5 injections “Buy” flexibility, quality of life, improved
control
• “Pay” 2 injections “Buy” control only with regimented
lifestyle and strict dietary habits
But in the end the PATIENT must make the choice. It is he/she, not you, who
has to live with it!
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And how low to go?
• The lower the HbA1c, the tighter the control, the higher the risk of hypoglycaemia.
• In most patients, the fear of hypoglycaemia in the short term exceeds the fear of long-term complications
So how low should we go?
Is a target HbA1c of <7% acceptable for everyone?
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Should the Risk of Hypoglycaemia modify our
Treatment?Yes
Age (<8yrs: >60yrs
CVD
Advanced Complications
Hypo Unawareness
Job-Risk
Sleeping alone
Etc.
No
Young
Healthy
Aware
Fit
Compliant
Most patients in the middle !
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And what about SHGM
FAQ
• How often?• When?• What does it mean?
“The answer, my friends, is blowing in the wind”
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There are four kinds of ‘testers”
1. Those who won’t
2. Those who don’t
3. Those who do – by “rote”.
4. Those who do with purpose.
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Those who won’t
• These patients refuse to test
or• Test 2-3 times a month – a pointless exercise
or• Prefabricate test results
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Those who don’t
• Test only when they “feel bad”, to confirm low or high blood glucose levels.
• Seldom test when they “feel alright”.
Not a cost-effective exercise and largely a waste of time
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Those who do – by “rote”
• These patients test 4 times a day, often obsessively, but do nothing whatsoever about the results.
• They seem to believe that either:
• Testing regularly makes them “good diabetics”
• Regular home glucose monitoring is therapeutic
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Those who do with purpose
Two groups:
• Fixed dose insulin therapy
• Functional Insulin therapy
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Fixed dose insulin therapy
• May be on twice daily or multiple injection regimen
• Insulin dose is fixed – no attempt to anticipate, no adjustment with meals.
In these patients “pattern testing” is recommended.Test 2-3 times a day at different times.Adjust insulin every 2-3 days.
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Functional Insulin therapy
• Carbohydrate-counting
• Regular before meal adjustments
• Corrective doses
The ideal situationTest 4+ times a day meaningfully
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Rules of Testing
No amount of sophistication is going to allay the fact that all your knowledge is about the past and all your decisions are about the future.
-Ian E Wilson
• Set Targets: the patient must know what glucose levels are satisfactory, which are too high and which are too low.
• Avoid hypoglycaemia. Lowest level recommended should be ≥4 mmol/l.
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Rules of Testing
And above all:
Always ask “why?”
• Why am I too high
• Why am I low?
• Why is my blood glucose normal?
And learn from past mistakes
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Don’t Try to Change History !
• Do not adjust insulin retrospectively
• History cannot be changed
• Pre meal / pre-bed results help to indicate adequacy of previous dose