RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2014
Insulin-dependent diabetes mellitus (E10)
Pediatrics, Pediatric Endocrinology
general information
Short description
Approved on
Expert commission on health development issues
Ministry of Health of the Republic of Kazakhstan
Diabetes mellitus (DM) is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of impaired insulin secretion, insulin action, or both.
Chronic hyperglycemia in diabetes is accompanied by damage, dysfunction and failure various organs, especially the eyes, kidneys, nerves, heart and blood vessels(WHO, 1999, 2006 with additions).
I. INTRODUCTORY PART
Protocol name: Type 1 diabetes mellitus
Protocol code:
ICD-10 code(s):
E10 insulin-dependent diabetes mellitus;
Abbreviations used in the protocol:
ADA - American Diabetes Association
GAD65 - antibodies to glutamic acid decarboxylase
HbAlc - glycosylated (glycated) hemoglobin
IA-2, IA-2 β - antibodies to tyrosine phosphatase
IAA - insulin antibodies
ICA - islet cell antibodies
BP - blood pressure
ACE - angiotensin-converting enzyme
APTT - activated partial thromboplastin time
ARBs - angiotensin receptor blockers
IV - intravenous
DKA - diabetic ketoacidosis
I/U - insulin/carbohydrates
IIT - intensive insulin therapy
BMI - body mass index
IR - insulin resistance
IRI - immunoreactive insulin
HDL - lipoproteins high density
LDL - low density lipoproteins
MAU - microalbuminuria
INR - international normalized ratio
LMWH - continuous glucose monitoring
CSII - continuous subcutaneous infusion of insulin
UAC - general analysis blood
OAM - general urine analysis
Life expectancy - life expectancy
PC - prothrombin complex
RAE - Russian Association Endocrinologists
RKF - soluble fibrinomonomer complexes
ROO AVEK - Association of Endocrinologists of Kazakhstan
DM - diabetes mellitus
Type 1 diabetes - type 1 diabetes mellitus
Type 2 diabetes - type 2 diabetes mellitus
GFR - speed glomerular filtration
ABPM - daily monitoring blood pressure
SMG - daily glucose monitoring
SST - hypoglycemic therapy
TG - thyroglobulin
TPO - thyropyroxidase
TSH - thyroid stimulating globulin
Ultrasound Dopplerography
Ultrasound - ultrasonography
FA - physical activity
XE - grain units
CS - cholesterol
ECG - electrocardiogram
ENG - electroneuromyography
EchoCG - echocardiography
Date of protocol development: year 2014.
Protocol users: endocrinologists, therapists, pediatricians, doctors general practice, emergency doctors.
Classification
Table 1 Clinical classification of diabetes
| Type 1 diabetes | Destruction of pancreatic β-cells, usually leading to absolute insulin deficiency |
| Type 2 diabetes | Progressive impairment of insulin secretion secondary to insulin resistance |
| Other specific types of diabetes |
- genetic defectsβ-cell functions; - genetic defects in insulin action; - diseases of the exocrine pancreas; - induced medicines or chemicals(during the treatment of HIV/AIDS or after organ transplantation); - endocrinopathies; - infections; - other genetic syndromes associated with diabetes |
| Gestational diabetes | occurs during pregnancy |
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic diagnostic measures at the outpatient level:
Definition ketone bodies in urine
SMG or LMWH (in accordance with Appendix 1);
Determination of glycosylated hemoglobin (HbAlc).
Additional diagnostic measures at the outpatient stage:
ELISA determination of ICA - antibodies to islet cells, GAD65 - antibodies to glutamic acid decarboxylase, IA-2, IA-2 β - antibodies to tyrosine phosphatase, IAA - antibodies to insulin;
Determination of C-peptide in blood serum by immunochemiluminescence;
ELISA - determination of TSH, free T4, antibodies to TPO and TG;
Ultrasound of organs abdominal cavity, thyroid gland;
Fluorography of organs chest(according to indications - R-graphy).
The minimum list of examinations that must be carried out when referring to planned hospitalization:
Determination of glycemia on an empty stomach and 2 hours after meals (with a glucometer);
Determination of ketone bodies in urine;
Basic (required) diagnostic examinations held at stationary level
Glycemic profile: on an empty stomach and 2 hours after breakfast, before lunch and 2 hours after lunch, before dinner and 2 hours after dinner, at 10 pm and 3 am
Biochemical analysis blood: determination of total protein, bilirubin, AST, ALT, creatinine, urea, total cholesterol and its fractions, triglycerides, potassium, sodium, calcium), calculation of GFR;
UAC with leukoformula;
Determination of protein in urine;
Determination of ketone bodies in urine;
Determination of UIA in urine;
Determination of creatinine in urine, calculation of albumin-creatinine ratio;
Determination of glycosylated hemoglobin (HbAlc)
SMG (NMG) (in accordance with Appendix 1);
Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations not carried out at the outpatient level are carried out):
Ultrasound of the abdominal organs;
Determination of aPTT in blood plasma;
Determination of MNOPC in blood plasma;
Determination of RKF in blood plasma;
Determination of TV in blood plasma;
Determination of fibrinogen in blood plasma;
Determination of sensitivity to antimicrobials isolated crops;
Bacteriological research biological material for anaerobes;
Determination of blood gases and blood electrolytes with additional tests (lactate, glucose, carboxyhemoglobin);
Determination of insulin and antibodies to insulin;
Doppler ultrasound of blood vessels lower limbs;
Holter ECG monitoring (24 hours);
ABPM (24 hours);
X-ray of the feet;
ECG (12 leads);
Consultation with specialized specialists (gastroenterologist, vascular surgeon, general practitioner, cardiologist, nephrologist, ophthalmologist, neurologist, anesthesiologist-resuscitator);
Diagnostic measures carried out at the emergency stage emergency care:
Determination of glycemic level;
Determination of ketone bodies in urine.
Diagnostic criteria
Complaints and anamnesis
Complaints: thirst, frequent urination, weight loss, weakness, itchy skin, severe general and muscle weakness, decreased performance, drowsiness.
History: Type 1 diabetes, especially in children and young adults, begins acutely and develops over several months or even weeks. The manifestation of type 1 diabetes can be triggered by infectious and other concomitant diseases. The peak incidence occurs in the autumn-winter period.
Physical examination
The clinical picture is caused by symptoms of insulin deficiency: dry skin and mucous membranes, decreased skin turgor, “diabetic” blush, enlarged liver, smell of acetone (or fruity smell) in the exhaled air, shortness of breath, noisy breathing.
Up to 20% of patients with type 1 diabetes have ketoacidosis or ketoacidotic coma at the onset of the disease.
Diabetic ketoacidosis (DKA) and ketoacidotic coma DKA- acute diabetic decompensation of metabolism, manifested by a sharp increase in glucose levels and the concentration of ketone bodies in the blood, their appearance in the urine and development metabolic acidosis, with varying degrees of impairment of consciousness or without it, requiring emergency hospitalization of the patient.
Stages of ketoacidosis :
Stage I ketoacidosis characterized by the appearance general weakness, increased thirst and polyuria, increased appetite and, despite this, weight loss,
The appearance of the smell of acetone in the exhaled air. Consciousness is preserved. Characterized by hyperglycemia, hyperketonemia, ketonuria +, pH 7.25-7.3.
At Stage II(precoma): an increase in these symptoms, shortness of breath appears, appetite decreases, nausea, vomiting, and abdominal pain are possible. Drowsiness appears with the subsequent development of a somnolent-soporous state. Characteristic: hyperglycemia, hyperketonemia, ketonuria + / ++, pH 7.0-7.3.
At Stage III (coma itself): there is a loss of consciousness, with a decrease or loss of reflexes, collapse, oligoanuria, severe symptoms dehydration: (dry skin and mucous membranes (tongue “dry as a grater”, dry lips, congestion in the corners of the mouth), Kussmaul breathing, signs of disseminated intravascular coagulation (cold and bluish extremities, tip of the nose, ears). Laboratory indicators worsen: hyperglycemia, hyperketonemia, ketonuria +++, pH ˂ 7.0.
During insulin therapy for type 1 diabetes, physical activity If patients with type 1 diabetes do not take enough carbohydrates, hypoglycemic conditions may occur.
Hypoglycemic conditions
The clinical picture of hypoglycemic conditions is associated with energy hunger of the central nervous system.
Neuroglycopenic symptoms:
. weakness, dizziness
. decreased concentration and attention
. headache
. drowsiness
. confusion
. unclear speech
. unsteady gait
. convulsions
. tremor
. cold sweat
. pallor skin
. tachycardia
. increased blood pressure
. feeling of anxiety and fear
Severity of hypoglycemic conditions:
Mild: sweating, trembling, palpitations, restlessness, blurred vision, hunger, fatigue, headache, incoordination, slurred speech, drowsiness, lethargy, aggression.
Severe: convulsions, coma. Hypoglycemic coma occurs if measures are not taken in time to relieve a severe hypoglycemic state.
Laboratory research
Table 2. Diagnostic criteria diabetes mellitus and other glycemic disorders (WHO, 1999, 2006, with additions)
* Diagnosis is based on laboratory determinations glucose levels.
** The diagnosis of diabetes should always be confirmed by repeat blood glucose testing on subsequent days, unless there is definite hyperglycemia with acute metabolic decompensation or obvious symptoms. The diagnosis of gestational diabetes can be made based on a single blood glucose test.
*** In the presence of classic symptoms of hyperglycemia.
Determination of blood glucose:
- fasting - means the glucose level in the morning, after preliminary fasting for at least 8 hours.
- random - means the glucose level at any time of the day, regardless of the time of meal.
HbAlc - as a diagnostic criterion for diabetes :
As diagnostic criterion DM selected HbAlc level ≥ 6.5% (48 mmol/mol). An HbAlc level of up to 5.7% is considered normal, provided that it is determined by the National Glicohemoglobin Standardization Program (NGSP) method, according to the standardized Diabetes Control and Complications Trial (DCCT).
In the absence of symptoms of acute metabolic decompensation, the diagnosis should be made based on two numbers in the diabetic range, for example, twice HbAlc or one HbAlc + one glucose.
Table 3. Laboratory parameters diabetic ketoacidosis
|
Index |
Fine | With DKA | Note |
|
Glucose |
3.3-5.5 mmol/l | Usually above 16.6 | |
|
Potassium |
3.8-5.4 mmol/l | N or | With intracellular potassium deficiency, its level in plasma is initially normal or even increased due to acidosis. With the start of rehydration and insulin therapy, hypokalemia develops |
|
Amylase |
<120ЕД/л | Lipase levels remain within normal limits | |
|
Leukocytes |
4-9x109/l | Even in the absence of infection (stress leukocytosis) | |
| Blood gas composition: pCO2 | 36-44 mm Hg. | ↓↓ | Metabolic acidosis with partial respiratory compensation |
|
pH |
7,36-7,42 | With concomitant respiratory failure, pCO2 is less than 25 mm Hg. Art., in this case, pronounced vasoconstriction of cerebral vessels develops, and cerebral edema may develop. Decreases to 6.8 | |
|
Lactate |
<1,8 ммоль/л | N or | Lactic acidosis is caused by hyperperfusion, as well as active synthesis of lactate by the liver under conditions of decreased pH.<7,0 |
| KFK, AST | As a sign of proteolysis |
Note. - increased, ↓ - decreased, N - normal value, CPK - creatine phosphokinase, AST - aspartate aminotransferase.
Table 4. Classification of DKA by severity
| Indicators | DKA severity | ||
|
light |
moderate | heavy | |
| Plasma glucose (mmol/l) | > 13 | > 13 | > 13 |
| Arterial blood pH | 7.25 - 7.30 | 7.0 - 7.24 | < 7.0 |
| Serum bicarbonate (mmol/L) | 15 - 18 |
10 - 15 |
< 10 |
| Ketone bodies in urine | + | ++ | +++ |
| Ketone bodies in serum | |||
| Plasma osmolarity (mosmol/l)* | Varies | Varies | Varies |
|
Anion difference** |
> 10 | > 12 | > 14 |
| Impaired consciousness |
No |
No or drowsiness | Stupor/coma |
* For calculation, see section Hyperosmolar hyperglycemic state.
**Anion difference = (Na+) - (Cl- +HCO3-) (mmol/l).
Indications for consultation with specialists
Table 5. Indications for specialist consultations*
|
Specialist |
Goals of consultation |
| Consultation with an ophthalmologist | For diagnosis and treatment diabetic retinopathy: performing ophthalmoscopy with a wide pupil once a year, more often if indicated |
| Neurologist consultation | |
| Nephrologist consultation | For the diagnosis and treatment of diabetes complications - according to indications |
| Consultation with a cardiologist | For the diagnosis and treatment of diabetes complications - according to indications |
Differential diagnosis
Table 6 Differential diagnosis Type 1 diabetes and type 2 diabetes
| Type 1 diabetes | Type 2 diabetes |
| Young age acute onset(thirst, polyuria, weight loss, presence of acetone in urine) | Obesity, hypertension, sedentary lifestyle life, presence of diabetes in close relatives |
| Autoimmune destruction of β-cells of pancreatic islets | Insulin resistance in combination with secretory dysfunction of β-cells |
| In most cases - low level C-peptide, high titer of specific antibodies: GAD, IA-2, islet cells | Normal, increased or slightly decreased level of C-peptide in the blood, absence of specific antibodies: GAD, IA-2, islet cells |
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Treatment
Treatment Goals
The goal of treatment of type 1 diabetes is to achieve normoglycemia, normalize blood pressure, lipid metabolism and prevent complications of type 1 diabetes.
The choice of individual treatment goals depends on the patient's age, life expectancy, presence severe complications and the risk of severe hypoglycemia.
Table 7 Algorithm for individualized selection of treatment goals for HbAlc
*LE - life expectancy.
Table 8 These HbAlc target levels will correspond to the following pre/postprandial plasma glucose target values:
| HbAlc** | Plasma glucose on an empty stomach/before meals, mmol/l | Plasma glucose 2 hours after meals, mmol/l |
| < 6,5 | < 6,5 | < 8,0 |
| < 7,0 | < 7,0 | < 9,0 |
| < 7,5 | < 7,5 | < 10,0 |
| < 8,0 | < 8,0 | < 11,0 |
* These targets do not apply to children, adolescents and pregnant women. Target values glycemic control for these categories of patients are discussed in the relevant sections.
**Normal level according to DCCT standards: up to 6%.
Table 9 Indicators of lipid metabolism control
| Indicators | Target values, mmol/l* | |
| men | women | |
| General HS | < 4,5 | |
| LDL cholesterol | < 2,6** | |
| HDL cholesterol | > 1,0 | > 1,2 |
| triglycerides | <1,7 | |
*Conversion from mol/l to mg/dl: Total cholesterol, LDL cholesterol, HDL cholesterol: mmol/l×38.6=mg/dl Triglycerides: mmol/l×88.5=mg/dl
**< 1,8 - для лиц с сердечно-сосудистыми заболеваниями.
Table 10 Blood pressure control indicators
* Against the background of antihypertensive therapy
Blood pressure should be measured at every visit to the endocrinologist. Patients with systolic blood pressure (SBP) values ≥ 130 mmHg. Art. or diastolic blood pressure (DBP) ≥ 80 mm Hg. Art., blood pressure should be measured again on another day. If the mentioned blood pressure values are observed during repeated measurements, the diagnosis of hypertension is considered confirmed.
Treatment goals for children and adolescents with T1DM :
. achieving a level as close to normal as possible carbohydrate metabolism;
. normal physical and somatic development of the child;
. development of independence and motivation for self-control of glycemia;
. prevention of complications of type 1 diabetes.
Table 11
| Age groups | HbA1c level, % | Rational premises | ||
| Preschoolers (0-6 years old) | 5,5-10,0 | 6,1-11,1 | <8,5, но >7,5 | |
| Schoolchildren (6-12 years old) | 5,0-10,0 | 5,6-10,0 | <8,5 | |
| 5,0-7,2 | 5,0-8,3 | <7,5 | - risk of severe hypoglycemia - growing up and psychological aspects - lower target values (HbA1c<7,0%) приемлемы, если достигаются без большого риска гипогликемий |
Treatment tactics :
Insulin therapy.
Meal planning.
Self-control.
Non-drug treatment
Dietary recommendations
Calculation of meals for children: The energy requirement for a child under 1 year of age is 1000-1100 kcal. Daily caloric intake for girls from 1 to 15 years and boys from 1 to 10 years is calculated using the formula: Daily caloric intake = 1000 + 100 X n*
Daily caloric intake for boys from 11 to 15 years old is calculated using the formula: Daily caloric intake = 1000 + 100 X n* + 100 X (n* - 11) where *n is age in years.
The total daily energy intake should be distributed as follows: carbohydrates 50-55%; fats 30-35%; proteins 10-15%. Considering that the absorption of 1 gram of carbohydrates produces 4 kcal, the required grams of carbohydrates per day and the corresponding XE are calculated (Table 12).
Table 12 Estimated daily requirement for XE depending on age
Meal calculation for adults:
Daily caloric intake is determined depending on the intensity of physical activity.
Table 13 Daily caloric intake for adults
|
Labor intensity |
Categories | Amount of energy |
| Easy work |
Workers predominantly in mental labor (teachers, educators, except physical education teachers, workers in science, literature and the press); Light manual workers (automated process workers, salespeople, service workers) |
25-30 kcal/kg |
| Medium intensity work | drivers of various types of transport, public utility workers, railway workers and water workers | 30-35 kcal/kg |
| Hard physical labor |
The bulk of agricultural workers and machine operators, miners in surface work; Workers engaged in particularly heavy physical labor (masons, concrete workers, diggers, loaders, whose work is not mechanized) |
35-40 kcal/kg |
The total daily energy intake should be distributed as follows: carbohydrates - 50%; proteins - 20%; fats - 30%. Considering that the absorption of 1 gram of carbohydrates produces 4 kcal of energy, the required grams of carbohydrates per day and the corresponding XE are calculated (Table 14).
Table 14 Estimated need for carbohydrates (CA) per day
To assess digestible carbohydrates according to the XE system in order to adjust the insulin dose before meals for children and adults, use the table “Replacement of products according to the XE system” (Appendix 2).
It is recommended to limit protein intake to 0.8-1.0 g/kg body weight per day in patients with diabetes and early stages of chronic kidney disease and to 0.8 g/kg body weight per day in patients with late stages of chronic kidney disease. since such measures improve renal function (urinary albumin excretion, GFR).
Recommendations for physical activity
PA improves quality of life, but is not a method of glucose-lowering therapy for type 1 diabetes. PA is selected individually, taking into account the patient’s age, complications of diabetes, concomitant diseases as well as portability.
Physical activity increases the risk of hypoglycemia during and after exercise, so the main goal is to prevent hypoglycemia associated with physical activity. The risk of hypoglycemia is individual and depends on the initial glycemia, insulin dose, type, duration and intensity of physical activity, as well as the patient’s degree of training.
Prevention of hypoglycemia during short-term PA(no more than 2 hours) - additional intake of carbohydrates:
Measure glycemia before and after PA and decide whether you need to take an additional 1-2 XE (slowly digestible carbohydrates) before and after PA.
If the initial plasma glucose level is > 13 mmol/l or if PA occurs within 2 hours after a meal, additional XE intake before PA is not required.
In the absence of self-control, it is necessary to take 1-2 XE before and 1-2 XE after PA.
Prevention of hypoglycemia during long-term PA(more than 2 hours) - reduction in insulin dose, so long-term exercise should be planned:
Reduce the dose of short- and long-acting insulin preparations that will act during and after physical exercise by 20 - 50%.
For very long and/or intense PA: reduce the dose of insulin, which will act at night after PA, sometimes the next morning.
During and after long-term PA: additional self-monitoring of glycemia every 2-3 hours, if necessary, taking 1-2 XE of slowly digestible carbohydrates (at plasma glucose levels< 7 ммоль/л) или быстро усваиваемых углеводов (при уровне глюкозы плазмы < 5 ммоль/л).
Patients with type 1 diabetes who conduct self-monitoring and know how to prevent hypoglycemia can engage in any type of physical activity, including sports, taking into account the following contraindications and precautions:
Temporary contraindications to PA:
Plasma glucose level is above 13 mmol/l in combination with ketonuria or above 16 mmol/l, even without ketonuria (in conditions of insulin deficiency, PA will increase hyperglycemia);
Hemophthalmos, retinal detachment, the first six months after laser photocoagulation of the retina; uncontrolled arterial hypertension; IHD (in consultation with a cardiologist).
Glycemic monitoring
Self-control- regular monitoring of glycemia by trained patients or members of their families, analysis of the results obtained, taking into account diet and physical activity, the ability to independently adjust insulin therapy depending on the changing conditions of the day. Patients should independently measure their blood glucose levels before main meals, postprandially, before bedtime, before and after physical activity, if hypoglycemia is suspected and after its relief. It is optimal to determine glycemia 4-6 times a day.
When prescribing a method of self-monitoring of glucose levels to a patient, it is necessary to make sure that the patient understands the instructions for its use, can use it and, based on the results obtained, make treatment adjustments. The patient’s ability to use the self-monitoring method should also be assessed during observation.
Goals of self-monitoring of blood glucose levels:
. monitoring changes in emergency situations and assessing daily levels of control;
. interpretation of changes in estimating immediate and daily insulin requirements;
. selection of insulin dose to reduce fluctuations in glycemic levels;
. detection of hypoglycemia and its correction;
. correction of hyperglycemia.
SMG system used as a modern method for diagnosing changes in glycemia, identifying hypoglycemia, adjusting treatment and selecting glucose-lowering therapy; promotes patient education and participation in their care (Appendix 1).
Patient education
Education of patients with diabetes is an integrating component of the treatment process. It should provide patients with the knowledge and skills to achieve specific therapeutic goals. Educational activities should be carried out with all patients with diabetes from the moment the disease is diagnosed and throughout its duration.
The goals and objectives of training should be specified in accordance with the current condition of the patient. For training, specially developed structured programs are used, addressed to patients with type 1 diabetes and/or their parents (including training on insulin pump therapy). Training should include psychosocial aspects, since emotional health is closely associated with a favorable prognosis for diabetes.
Training can be carried out either individually or in groups of patients. The optimal number of patients in a group is 5-7. Group training requires a separate room that can be kept quiet and adequately lit.
Diabetes schools are created on the basis of clinics, hospitals and consultative and diagnostic centers on a territorial basis. One school is created in each endocrinology department of a hospital.
Patient education is carried out by specially trained medical workers: an endocrinologist (diabetologist), a nurse.
Drug therapy
Insulin therapy for type 1 diabetes
Insulin replacement therapy is the only treatment for type 1 diabetes.
Insulin administration regimens :
. Basal-bolus mode (intensified mode or multiple injection mode):
- basal (medium-duration insulin preparations and peak-free analogues, with pump therapy - ultra preparations short acting);
- bolus (short- and ultra-short-acting insulin preparations) for meals and/or corrections (to reduce elevated glycemic levels)
The regime of continuous subcutaneous infusion of insulin using an insulin pump allows you to bring the level of insulinemia as close as possible to the physiological level.
. During the period of partial remission, the insulin therapy regimen is determined by the blood glucose level. Correction of the insulin dose should be carried out daily, taking into account data from self-monitoring of glycemia during the day and the amount of carbohydrates in food, until the target levels of carbohydrate metabolism are achieved. Intensified insulin therapy, including multiple injection regimens and pump therapy, leads to a reduction in the incidence of vascular complications.
Table 15 Recommended insulin delivery devices
For children, adolescents, and patients with a high risk of vascular complications, the first-line drugs are ultra-short- and long-acting analogues of genetically engineered human insulin. The optimal means of administering insulin is an insulin pump.
| Insulin preparations by duration of action | Onset of action in, min | Peak action in, hour | Duration of action, hour |
| Ultra-short-acting (human insulin analogues)** | 15-35 | 1-3 | 3-5 |
| Short acting** | 30-60 | 2-4 | 5-8 |
| Long-term non-peak action (insulin analogue)** | 60-120 | Not expressed | Up to 24 |
| Average duration of action** | 120-240 | 4-12 | 12-24 |
*Mixed human insulins are not used in pediatric practice.
**The use of this type of insulin in pediatric practice is carried out taking into account the instructions.
Insulin dose
. Each patient's need for insulin and the ratio of insulins of different durations are individual.
. In the first 1-2 years of the disease, the need for insulin averages 0.5-0.6 U/kg body weight;
. After 5 years from the onset of diabetes, in most patients, the need for insulin increases to 1 U/kg of body weight, and during puberty it can reach 1.2-1.5 U/kg.
Continuous subcutaneous insulin infusion (CSII)
Insulin pumps- a means for continuous subcutaneous administration of insulin. It uses only one type of insulin, mainly a fast-acting analogue, which is supplied in two modes - basal and bolus. With CSII, you can achieve blood sugar levels as close to normal as possible while avoiding hypoglycemia. Today, CSII is successfully used in children and pregnant women with diabetes.
In children and adolescents, the method of choice is the use of CSII with the function continuous glucose monitoring due to the ability to achieve the best glycemic control with minimal risk of hypoglycemia. This method allows the patient with diabetes not only to see changes in glycemia on the display in real time, but also to receive warning signals about critical blood sugar levels and promptly change therapy, achieving good diabetes control with low glycemic variability in the shortest possible time.
Benefits of using insulin pumps:
Decline:
. Severe, moderate and mild forms of hypoglycemia
. Average HbA1c concentration
. Fluctuations in glucose concentrations throughout the day and between days
. Daily dose of insulin
. Risk of developing microvascular disease
Improvement:
. Patient satisfaction with treatment
. Quality of life and health status
Indications for the use of pump therapy:
. ineffectiveness or inapplicability of multiple daily insulin injections despite proper care;
Large variability of glycemia during the day, regardless of HbA1c level; labile course of diabetes mellitus;
. “dawn phenomenon”;
. decreased quality of life;
. frequent hypoglycemia;
. young children with low insulin requirements, especially infants and newborns; there are no age restrictions for using pumps; high sensitivity to insulin (insulin dose less than 0.4 IU/kg/day);
. children with needle phobia;
Initial complications of diabetes;
Chronic renal failure, kidney transplantation;
Diseases gastrointestinal tract accompanied by gastroparesis;
Regular exercise;
. pregnancy
Indications for CSII use in children and adolescents
Obvious indications
. Recurrent severe hypoglycemia
. Newborns, infants, young children and preschool children
. Suboptimal diabetes control (eg, HbA1c level above target for age)
. Marked fluctuations in blood glucose levels regardless of HbA1c values
. Pronounced morning phenomenon
. Microvascular complications and/or risk factors for their development
Tendency to ketosis
. Good metabolic control, but treatment regimen does not fit lifestyle
Other indications
. Adolescents with eating disorders
. Children with fear of needles
. Skipping insulin injections
The pump can be used for any duration of diabetes, including at the onset of the disease.
Contraindications for transfer to insulin pump therapy:
. lack of compliance of the patient and/or family members: insufficient training or unwillingness or inability to apply this knowledge in practice;
. psychological and social problems in the family (alcoholism, antisocial families, behavioral characteristics of the child, etc.); mental disorders;
Severe visual and (or) hearing impairment in the patient;
Conditions for transferring to pump therapy:
. sufficient level of knowledge of the patient and/or family members;
. transfer in inpatient and outpatient settings by a physician who has undergone special training in pump therapy;
Conditions for stopping pump therapy:
. the child or parents (guardians) wish to return to traditional therapy;
. medical indications: - frequent episodes of ketoacidosis or hypoglycemia due to improper pump management;
- ineffectiveness of pump therapy due to the patient’s fault (frequent missed boluses, inadequate frequency of self-monitoring, lack of insulin dose adjustments);
- frequent infection at catheter insertion sites.
Application of CSII:
Rapid insulin analogues (lispro, aspart or glulisine) are currently considered the insulin of choice for pump therapy, and dosages are estimated in the following way:
. Basal rate: A common initial approach is to reduce the total daily insulin dose for syringe therapy by 20% (some clinics reduce the dose by 25-30%). 50% of the total daily dose for pump therapy is given as a basal rate, divided by 24 to get the hourly dose. The number of basal levels is adjusted by monitoring blood glucose levels.
. Bolus insulin. Bolus doses are adjusted according to measured postprandial blood glucose levels (1.5 to 2 hours after each meal). Carbohydrate counting is now considered the preferred method, in which the insulin bolus dose size is estimated according to the carbohydrate content of the meal, the insulin/carbohydrate (I/C) ratio depending on the individual patient and food, and the insulin adjustment dose, the size of which is based on pre-meal blood glucose levels and how significantly they deviate from target blood glucose levels. The I/U ratio can be calculated as 500/total daily insulin dose. This formula is often called the “rule of 500.” The correction dose used to correct the meal bolus for pre-meal blood glucose levels and to correct unexpected hyperglycemia between meals is estimated using the insulin sensitivity factor (ISF), which in mmol/L is calculated by the formula 100/total daily dose insulin (“rule of 100”).
Treatment of DKA
Treatment of diabetes with severe DKA should be carried out in centers where it is possible to assess and monitor clinical symptoms, neurological status and laboratory parameters. Pulse, respiratory rate, blood pressure, neurological status, and ECG monitoring are recorded hourly. An observation protocol is maintained (results of all measurements of blood or plasma glucose, ketone bodies, electrolytes, serum creatinine, pH and gas composition of arterial blood, glucose and ketone bodies in urine, volume of fluid administered, type of infusion solution, method and duration of infusion, fluid loss (diuresis) and insulin dose). At the beginning of treatment, laboratory parameters are determined every 1-3 hours, then less frequently.
Treatment of DKA includes: rehydration, insulin administration, restoration of electrolyte disturbances; general measures, treatment of conditions that caused DKA.
Rehydration carried out with a 0.9% NaCl solution to restore peripheral circulation. Rehydration in children with DKA should be done more slowly and carefully than in other cases of dehydration.
Insulin therapy for DKA should be administered continuously by infusion using a low-dose regimen. To do this, it is better to use a dispenser (infusion pump, perfuser). Small doses of intravenous short-acting insulin are used. The initial dose is 0.1 IU/kg body weight per hour (you can dilute 50 IU of insulin in 50 ml of saline, then 1 IU = 1 ml). 50 ml of the mixture is pumped through the intravenous infusion system to absorb insulin on the walls of the system. The insulin dose is maintained at 0.1 U/kg per hour at least until the patient recovers from DKA (pH greater than 7.3, bicarbonates greater than 15 mmol/L, or normalization of the anion gap). With a rapid decrease in glycemia and metabolic acidosis, the insulin dose can be reduced to 0.05 U/kg per hour or lower. In young children, the initial dose can be 0.05 U/kg, and in case of severe concomitant purulent infection, it can be increased to 0.2 U/kg per hour. In the absence of ketosis on days 2-3 - intensive insulin therapy.
Potassium reduction. Replacement therapy is necessary regardless of the concentration of potassium in the blood serum. Potassium replacement therapy is based on serum determinations and continues throughout the entire period of intravenous fluid administration.
Fighting acidosis. Bicarbonates are used only in cases of severe acidosis (blood pH below 7.0), which threatens to suppress external respiration (at a pH below 6.8), when carrying out a complex of resuscitation measures.
Monitoring the patient's condition. The glucose content in capillary blood is determined every hour. Every 2-4 hours, the level of glucose, electrolytes, urea, and blood gas composition in the venous blood is determined.
Complications of DC therapy: cerebral edema, inadequate rehydration, hypoglycemia, hypokalemia, hyperchloremic acidosis.
Treatment of hypoglycemic conditions
Patients who develop hypoglycemia without symptoms, as well as patients who have had one or more episodes of severe hypoglycemia, should be advised to aim higher glucose levels to avoid the development of hypoglycemia, at least for several weeks, and with with the goal of partially eliminating the problem of developing asymptomatic hypoglycemia and reducing the risk of hypoglycemia episodes in the future.
Mild hypoglycemia(not requiring assistance from another person)
Glucose (15-20 g) is the preferred treatment for conscious patients with hypoglycemia, although any form of carbohydrate containing glucose can be used.
Take 1 XE of quickly digestible carbohydrates: sugar (3-5 pieces of 5 g each, better dissolved), or honey or jam (1 tablespoon), or 100 ml of fruit juice, or 100 ml of lemonade with sugar, or 4-5 large tablets glucose (3-4 g each), or 1 tube of carbohydrate syrup (13 g each). If symptoms persist, repeat taking the products after 15 minutes.
If hypoglycemia is caused by short-acting insulin, especially at night, then additionally eat 1-2 XE of slowly digestible carbohydrates (bread, porridge, etc.).
Severe hypoglycemia(requiring assistance from another person, with or without loss of consciousness)
. Place the patient on his side, free the oral cavity from food debris. If you lose consciousness, do not pour sweet solutions into the oral cavity (danger of asphyxia!).
. Inject 40 - 100 ml of 40% dextrose (glucose) solution intravenously until consciousness is completely restored. In severe cases, glucocorticoids are used intravenously or intramuscularly.
. An alternative is 1 mg (0.5 mg for small children) of glucagon subcutaneously or intramuscularly (administered by a relative of the patient).
. If consciousness is not restored after intravenous administration of 100 ml of 40% dextrose (glucose) solution, this indicates cerebral edema. Hospitalization of patients and intravenous administration of colloidal solutions at the rate of 10 ml/kg/day are required: mannitol, mannitol, hydroxyethyl starch (pentastarch).
. If the cause is an overdose of oral hypoglycemic drugs with a long duration of action, intravenous drip administration of a 5-10% dextrose (glucose) solution is continued until glycemia normalizes and the drug is completely eliminated from the body.
Rules for the management of patients with diabetes during intercurrent diseases
. Never stop insulin therapy!
. More frequent and careful monitoring of blood glucose and blood/urine ketone levels.
. Treatment of intercurrent disease is carried out in the same way as in patients without diabetes.
. Diseases with vomiting and diarrhea are accompanied by a decrease in blood glucose levels. To prevent hypoglycemia - reduce the dose of short-acting and long-acting insulin by 20-50%, light carbohydrate foods, juices.
. With the development of hyperglycemia and ketosis, correction of insulin therapy is necessary:
Table 17 Treatment of ketoacidosis
|
Blood glucose |
Ketones in the blood | Correction of insulin therapy |
| More than 14 mmol/l | 0-1mmol/l | Increasing the dose of short/ultra-short insulin by 5-10% of the total daily dose |
| More than 14 mmol/l | 1-3mmol/l | |
| More than 14 mmol/l | More than 3mmol/l | Increasing the dose of short/ultra-short insulin by 10-20% of the total daily dose |
Table 18 Treatment of painful DPN
| Pharmacological group | ATX code | International name | Dosage, frequency, duration of administration | Level of evidence |
| Anticonvulsants | N03AX16 | Pregabalin | 150 mg orally 2 times / day (if necessary, up to 600 / day) duration of administration - individually depending on the effect and tolerability | A |
| N03AX12 | Gabapentin | 1800-2400 mg/day in 3 divided doses (start with 300 mg, gradually increasing to a therapeutic dose) | A | |
| Antidepressants | N06AX | Duloxetine | 60 mg/day (if necessary 120/day in 2 divided doses) for 2 months | A |
| N06AA | Amitriptyline | 25 mg 1-3 times a day (individually) duration of administration - individually depending on the effect and tolerability | IN |
Table 19 Treatment of treatment-resistant painful DPN
List of main medicines
(100% chance of use):
ACE inhibitors, ARBs.
List of additional medicines(less than 100% chance of use)
Nifedipine;
Amlodipine;
Carvedilol;
Furosemide;
Epoetin alfa;
Darbepoetin;
Sevelamer carbonate;
Tsinacaltset; Albumen.
Treatment of diabetic retinopathy
Patients with macular edema, severe nonproliferative diabetic retinopathy, or proliferative diabetic retinopathy of any severity should be promptly referred to a diabetic retinopathy specialist.
. Laser photocoagulation therapy to reduce the risk of vision loss is indicated for patients with a high risk of proliferative diabetic retinopathy, clinically significant macular edema, and in some cases with severe nonproliferative diabetic retinopathy.
. The presence of retinopathy is not a contraindication to the use of aspirin for the purpose of cardioprotection, since the use of this drug does not increase the risk of retinal hemorrhages.
Treatment of arterial hypertension
Non-drug methods of blood pressure correction
. Limiting table salt consumption to 3 g/day (do not salt food!)
. Loss of body weight (BMI<25 кг/м2) . снижение потребления алкоголя < 30 г/сут для мужчин и 15 г/сут для женщин (в пересчете на спирт)
. To give up smoking
. Aerobic physical activity for 30 - 40 minutes at least 4 times a week
Drug therapy for arterial hypertension
Table 20 Main groups of antihypertensive drugs (can be used as monotherapy)
|
Group name |
Name of drugs |
| ACE inhibitors |
Enalapril 5 mg, 10 mg, 20 mg, Lisinopril 10 mg, 20 mg Perindopril 5 mg, 10 mg, Fosinopril 10 mg, 20 mg |
| BRA |
Losartan 50 mg, 100 mg, Irbesartan 150 mg |
|
Diuretics: .Thiazide and thiazide-like .Loop .Potassium-sparing (aldosterone antagonists) |
Hydrochlorothiazide 25 mg, Furosemide 40 mg, |
|
Calcium channel blockers (CCBs) .Dihydropyridine (BCP-DHP) .Non-dihydropyridine (BCP-NDHP) |
Nifedipine 10 mg, 20 mg, 40 mg Amlodipine 2.5 mg, 5 mg, 10 mg B erapamil, verapamil SR, diltiazem |
|
β-blockers (BB) .Non-selective (β1, β2) .Cardioselective (β1) .Combined (β1, β2 and α1) |
Propranolol Bisoprolol 2.5 mg, 5 mg, 10 mg, Nebivolol 5 mg Carvedilol |
Table 21 Additional groups of antihypertensive drugs (use as part of combination therapy)
Optimal combinations of antihypertensive drugs
. ACEI + thiazide,
. ACEI + thiazide-like diuretic,
. ACEI+ BCC,
. ARB + thiazide,
. ARB + BKK,
. CCB + thiazide,
. BKK-DGP + BB
Table 22 Preferred indications for prescribing various groups of antihypertensive drugs
|
ACEI - CHF - LV dysfunction - IHD - Diabetic or non-diabetic nephropathy - LVH - Proteinuria/MAU - Atrial fibrillation |
BRA - CHF - Post-MI - Diabetic nephropathy - Proteinuria/MAU - LVH - Atrial fibrillation - ACEI intolerance |
BB - IHD - Post-MI - CHF - Tachyarrhythmias - Glaucoma - Pregnancy |
BKK -DGP - ISAG (elderly) - IHD - LVH - Atherosclerosis of the carotid and coronary arteries - Pregnancy |
|
BKK-NGDP - IHD - Atherosclerosis of the carotid arteries - Supraventricular tachyarrhythmias |
Thiazide diuretics - ISAG (elderly) - CHF |
Diuretics (aldosterone antagonists) - CHF - Post-MI |
Loop diuretics - Terminal stage of chronic renal failure |
Treatment of hypertension in children and adolescents:
Pharmacotherapy for high BP (SBP or DBP persistently above the 95th percentile for age, sex, or height, or persistently >130/80 mmHg in adolescents), in addition to lifestyle measures, should be initiated as soon as possible after diagnosis is confirmed. .
The advisability of prescribing an ACE inhibitor as a starting drug for the treatment of hypertension should be considered.
. The target is constant blood pressure< 130/80 или ниже 90 перцентиля для данного возраста, пола или роста (из этих двух показателей выбирается более низкий).
Correction of dyslipidemia
Achieving compensation for carbohydrate metabolism helps to reduce the severity of dyslipidemia in patients with type 1 diabetes, which developed as a result of decompensation (mainly hypertriglyceridemia)
Methods for correcting dyslipidemia
. Non-drug correction: lifestyle modification with increased physical activity, weight loss (according to indications) and nutritional correction with reduced consumption of saturated fats, trans-forms of fats and cholesterol.
. Medication correction.
Statins- first-line drugs to reduce LDL cholesterol levels. Indications for prescribing statins (always in addition to lifestyle changes):
When LDL cholesterol levels exceed target values;
Regardless of the initial level of LDL cholesterol in patients with diabetes with diagnosed coronary artery disease.
If the goals are not achieved despite the use of the maximum tolerated dose of statins, then a reduction in LDL cholesterol concentration by 30-40% of the initial level is considered a satisfactory result of therapy. If lipid targets are not achieved during treatment with adequate doses of statins, combination therapy with the addition of fibrates, ezetimibe, niacin, or bile acid sequestrants may be prescribed.
Dyslipidemia in children and adolescents:
. In children over 2 years of age with a strong family history (hypercholesterolemia [total cholesterol concentration > 240 mg/dL] or development of cardiovascular events before age 55 years) or unknown, a fasting lipid profile should be examined immediately after the diagnosis of diabetes (after reaching glycemic control). If there is no family history, the first measurement of lipid concentrations should be performed in adolescence (10 years or older). In all children diagnosed with diabetes at or after puberty, fasting lipid profile testing should be performed immediately after diagnosis of diabetes (once glycemic control has been achieved).
. In case of deviations in indicators, it is recommended to determine the lipid profile annually. If LDL cholesterol concentrations correspond to the acceptable risk level (< 100 мг/дл ), измерение концентрации липидов можно проводить каждые 5 лет.
Initial therapy consists of optimizing glucose control and nutritional therapy that limits saturated fat intake.
. Prescription of statins is indicated for patients over 10 years of age who, despite diet and an adequate lifestyle, have LDL cholesterol levels > 160 mg/dL (4.1 mmol/L) or > 130 mg/dL (3.4 mmol/L) in the presence of one or more risk factors for cardiovascular diseases.
. The target level is LDL cholesterol< 100 мг/дл (2,6 ммоль/л).
Antiplatelet therapy
. Aspirin (75-162 mg/day) should be used as a remedy primary prevention in patients with T1DM and increased cardiovascular risk, including patients over 40 years of age, as well as persons with additional risk factors ( cardiovascular family history of diseases, hypertension, smoking, dyslipidemia, albuminuria).
. Aspirin (75-162 mg/day) should be used as a remedy secondary prevention in patients with diabetes and a history of cardiovascular diseases.
. In patients with cardiovascular disease and intolerance to aspirin, clopidogrel should be used.
. Combination therapy with acetylsalicylic acid (75-162 mg/day) and clopidogrel (75 mg/day) is advisable for a period of up to one year in patients after acute coronary syndrome.
. Aspirin is not recommended for people under 30 years of age due to the lack of convincing evidence of the benefits of such treatment. Aspirin is contraindicated in patients under 21 years of age due to the risk of Reye's syndrome.
Celiac disease
. Patients with type 1 diabetes should undergo testing to identify celiac disease, including determination of antibodies to tissue transglutaminase or endomysin (this requires confirmation normal concentrations serum IgA) as early as possible after diagnosis of diabetes.
. If there is growth retardation, lack of weight gain, weight loss, or gastrointestinal symptoms, repeat tests should be performed.
. In children without symptoms of celiac disease, the advisability of periodic re-examination should be considered.
. Children with positive antibody test results should be referred to a gastroenterologist for further evaluation.
. Children with confirmed celiac disease need to consult a nutritionist and be prescribed a gluten-free diet.
Hypothyroidism
. Children with type 1 diabetes immediately after diagnosis need to have antibodies to thyroid peroxidase and thyroglobulin determined.
Determination of concentration thyroid-stimulating hormone should be carried out after optimizing metabolic control. At normal values Repeated tests must be carried out every 1-2 years. In addition, the patient should be prescribed the mentioned study if symptoms of thyroid dysfunction, thyromegaly or abnormalities in growth occur. If thyroid-stimulating hormone levels are outside the normal range, free thyroxine (T4) levels should be measured.
Drug treatment provided on an outpatient basis
Short-acting insulins
Ultra-short-acting insulins (analogs of human insulin)
Intermediate-acting insulins
Long-acting non-peak insulin
List of additional medications (less than 100% probability of use):
Antihypertensive therapy:
Antilipidemic drugs
:
Treatment diabetic neuropathy
:
Antianginal agents
NSAIDs
Medicines affecting coagulation
(Acetylsalicylic acid 75mg);
Drug treatment provided at the inpatient level
List of essential medicines (100% probability of use):
Insulin therapy:
Short-acting insulin in vials (for ketoacidosis) and cartridges;
Ultra-short-acting insulins (analogues of human insulin: aspart, lispro, glulisine);
Medium-acting insulins in vials and cartridges;
Long-acting non-peak insulin (detemir, glargine);
Sodium chloride 0.9% - 100ml, 200ml, 400ml, 500ml;
Dextrose 5% - 400ml;
Potassium chloride 40 mg/ml - 10 ml;
Hydroxyethyl starch 10% - 500ml (pentastarch);
In hypoglycemic coma:
Glucagon - 1 mg;
Dextrose 40% - 20ml;
Osmotic diuretic (Mannitol 15% - 200ml).
List of additional medicines (less than 100% probability of use):
Antibacterial therapy:
Penicillin series(amoxicillin + clavulanic acid 600 mg);
Nitroimidazole derivatives (metronidazole 0.5% - 100ml);
Cephalosporins (cefazolin 1g; ceftriaxone 1000 mg; cefepime 1000 mg).
Antihypertensive therapy
:
. ACE inhibitors(Enalapril 10 mg; Lisinopril 20 mg; Perindopril 10 mg; Fosinopril 20 mg; Captopril 25 mg);
. combination drugs(Ramipril + Amlodipine 10 mg/5 mg; Fosinopril + Hydrochlorothiazide 20 mg/12.5 mg);
. ARBs (Losartan 50 mg; Irbesartan 150 mg);
. diuretics (Hydrochlorothiazide 25 mg; Furosemide 40 mg, Spironolactone 50 mg);
. Ca channel blockers (Nifedipine 20 mg; Amlodipine 5 mg, 10 mg; Verapamil 80 mg);
. imidazonin receptor agonists (Moxonidine 0.4 mg);
. beta blockers (Bisoprolol 5 mg; Nebivolol 5 mg; Carvedilol 25 mg);
Antilipidemic drugs
:
. statins (Simvastatin 40 mg; Rosuvastatin 20 mg; Atorvastatin 10 mg);
Treatment of painful diabetic neuropathy:
. anticonvulsants (Pregabalin 75 mg);
. antidepressants (Duloxetine 60 mg; Amitriptyline 25 mg);
. neurotropic B vitamins (Milgamma);
. opioid analgesics (Tramadol 50 mg);
Treatment of diabetic neuropathy:
. derivatives of alpha-lipoic acid (thioctic acid fl 300 mg/12 ml, tablet 600 mg;);
Treatment diabetic nephropathy
:
. Epopoetin beta 2000IU/0.3ml;
. Darbepoietin alfa 30 µg;
. Sevelamer 800 mg;
. Cinacalcet 30 mg;
. Albumin 20%;
Antianginal agents
(Isosorbide mononitrate 40 mg);
NSAIDs
(Ketamine 500mg/10ml; Diclofenac 75mg/3ml or 75mg/2ml);
*If symptoms appear chronic complications Diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the issue of the frequency of examinations is decided individually.
Table 24 List of instrumental examinations necessary for dynamic monitoring in patients with type 1 diabetes *
| Methods instrumental examination | Frequency of examination | |||||||||||||||||||
| SMG | Once a quarter, more often if indicated | |||||||||||||||||||
| Blood pressure control | At every doctor visit | |||||||||||||||||||
| Examination of the legs and assessment of foot sensitivity | At every doctor visit | |||||||||||||||||||
| ENG of lower extremities | 1 time per year | |||||||||||||||||||
| ECG | 1 time per year | |||||||||||||||||||
| Checking equipment and inspecting injection sites | At every doctor visit | |||||||||||||||||||
|
X-ray of the chest organs
* Goals should be individualized depending on the duration of diabetes; age/life expectancy; concomitant diseases; the presence of concomitant cardiovascular diseases or progressive microvascular complications; the presence of hidden hypoglycemia; individual discussions with the patient. Table 26 Age-individualized target levels of carbohydrate metabolism in children and adolescents (ADA, 2009)
|
Diagnosing type 1 diabetes (insulin-dependent) is not difficult in most cases. The clinical picture, compiled only on the basis of a patient interview, already allows us to talk about the presence of pathology. In most cases, laboratory tests only confirm the primary diagnosis.
Glucose circulation in a healthy body.
The pathology occurs as a result of the inability of the pancreas to produce insulin in sufficient quantities. Typical symptoms of the disease are weight loss and at the same time increased appetite, constant thirst, frequent and excessive urination, weakness, and sleep disturbances. Patients experience pale skin coloring and a tendency to colds and infections. Pustular rashes often appear on the skin, and wounds do not heal well.
The listed symptoms are usually characteristic of type 1 disease. In this case, the pathology develops rapidly, often patients can even name the exact date of the onset of the first symptoms. The disease can manifest itself after severe stress or viral infections. Insulin-dependent diabetes mainly affects young people.
Laboratory research
Diagnosing type 1 diabetes contains several important points. This is a questioning and examination of the patient, as well as conducting tests to determine the amount of sugar in the blood and urine. Normally, the amount of glucose varies up to 6.5 mmol/l. Under normal conditions, there should be no sugar in urine.
The endocrinologist examines the skin (whether there are scratches or areas of inflammation) and the subcutaneous fat layer (it is thinning). To make the most accurate diagnosis, it is necessary to do several laboratory tests at intervals of several days. If the disease is suspected, additional diagnosis of type 1 diabetes is carried out.
Basic methods:
- a blood test for sugar, done several times: on an empty stomach, and also after meals, sometimes done before bedtime;
- measurement of glycosylated hemoglobin is carried out to determine the degree of the disease, normal values are 4.5-6.5% of total hemoglobin, an increase in glycosylated hemoglobin indicates the presence of diabetes, but may signal iron deficiency;
- test for glucose tolerance - the patient is given a glucose solution (75 g of glucose is diluted in 200 g of water), the analysis is carried out after 120 minutes, using the test you can separate prediabetes from real diabetes;
- urine test for the presence of sugar - the presence of glucose in the urine is caused by a significant concentration of sugar in the blood (over 10 units);
- in some cases, studies are prescribed to determine the insulin fraction; the disease is characterized by a low content of the free insulin fraction in the blood;
- measuring the level of acetone in the urine - often the disease causes metabolic disorders and ketoacidosis (concentration of organic acids in the blood), this analysis determines the presence of ketone bodies in the secretions.
To identify complications and make a prognosis of the disease, additional studies are prescribed: retinotherapy (examination of the fundus of the eye), excretory urography (determines the presence of nephropathy and renal failure), electrocardiogram (checks the condition of the heart).
A glucometer is the main tool for self-monitoring of a diabetic patient.
Self-control during illness
Diabetes requires 24/7 monitoring of glucose levels. Over the course of 24 hours, sugar readings can change significantly. Changes have a negative impact on health. It is necessary to somehow constantly monitor glucose levels and respond accordingly to changes.
What causes changes in indicators:
- emotional stress, not only stress, but also excessive joy;
- the amount of carbohydrates in food consumed.
To track your sugar levels, you don't need to go to the hospital and have your blood tested every hour. The necessary research can be done at home. For this purpose, there are glucometers and rapid tests in the form of strips made of paper and plastic.
Rapid tests are designed to determine sugar in the blood and urine. This type of research is considered approximate. The package with express tests includes lancets for pricking the finger and scarifiers (for drawing blood). A drop of blood is transferred to the reagent strip, after which its color changes. The standard scale determines the approximate sugar level. The presence of sugar in the urine is determined in a similar way.
A glucometer gives more accurate readings. A drop of blood is placed on the plate of the device, and the sugar level is displayed on its display. In addition to the listed home tests, you can use tests for the presence of acetone in urine. The presence of acetone in the discharge indicates serious disorders of the internal organs caused by insufficient sugar correction.
It is worth noting that the readings of glucometers from different manufacturers may differ from each other. Therefore, doctors recommend comparing the readings from your device with the results obtained in the laboratory.
Allowing not only to distinguish diabetes from other diseases, but also to determine its type and prescribe correct and effective treatment.
Diagnosis criteria
The World Health Organization has established the following:
- the blood glucose level exceeds 11.1 mmol/l with a random measurement (that is, the measurement is carried out at any time of the day without taking into account);
- (that is, no less than 8 hours after the last meal) exceeds 7.0 mmol/l;
- the blood glucose concentration exceeds 11.1 mmol/l 2 hours after a single dose of 75 g of glucose ().
In addition, the classic signs of diabetes are:
- – the patient not only frequently “runs” to the toilet, but also produces much more urine;
- polydipsia– the patient is constantly thirsty (and drinks a lot);
- – is not observed in all types of pathology.
Differential diagnosis of diabetes mellitus type 1 and type 2
At some point, there is too little insulin to break down glucose, and then...
This is why type 1 diabetes appears suddenly; often precedes the initial diagnosis. The disease is mainly diagnosed in children or adults under 25 years of age, more often in boys.
Differential signs of type 1 diabetes are:
- almost complete absence of insulin;
- presence of antibodies in the blood;
- low C-peptide levels;
- patient weight loss.
Type 2 diabetes
A distinctive feature of type 2 diabetes is insulin resistance: the body becomes insensitive to insulin.
As a result, the breakdown of glucose does not occur, and the pancreas tries to produce more insulin, the body spends energy, and.
The exact causes of the incidence of type 2 pathology are unknown, but it has been established that in approximately 40% of cases the disease.
It also most often affects people with an unhealthy lifestyle. – mature people over 45 years old, especially women.
Differential signs of type 2 diabetes are:
- elevated insulin levels (may be normal);
- elevated or normal levels of C-peptide;
- noticeably .
Often, type 2 diabetes is asymptomatic, manifesting itself already in the later stages when various complications appear: the functions of internal organs begin to be disrupted.
Table of differences between insulin-dependent and non-insulin-dependent forms of the disease
Since type 1 diabetes is caused by insulin deficiency, it is called diabetes. Type 2 diabetes is called non-insulin dependent because the tissues simply do not respond to insulin.
Video on the topic
About the differential diagnosis of diabetes mellitus type 1 and 2 in the video:
Modern methods of diagnosing and treating diabetes make it possible, and if certain rules are followed, it may be no different from the life of people who do not suffer from the disease. But to achieve this, correct and timely diagnosis of the disease is necessary.
Diabetes mellitus is one of the most common chronic diseases in Russia. Today it ranks third in mortality among the population, second only to cardiovascular diseases and cancer.
The main danger of diabetes is that this disease can affect both adults and elderly people, as well as very young children. At the same time, the most important condition for successful treatment of diabetes mellitus is timely diagnosis of the disease.
Modern medicine has wide possibilities for diagnosing diabetes mellitus. Differential diagnosis is of great importance for making the correct diagnosis of a patient, which helps to identify the type of diabetes and develop the correct treatment method.
Types of diabetes
All types of diabetes have similar symptoms, namely: high blood sugar, extreme thirst, excessive urination and weakness. But despite this, there is a significant difference between them, which cannot be ignored when diagnosing and subsequent treatment of this disease.
Important factors such as the speed of development of the disease, the severity of its course and the likelihood of complications depend on the type of diabetes. In addition, only by establishing the type of diabetes can one identify the true cause of its occurrence, and therefore choose the most effective methods of combating it.
Today in medicine there are five main types of diabetes. Other forms of this disease are rare and, as a rule, develop as complications of other diseases, for example, pancreatitis, tumors or injuries of the pancreas, viral infections, congenital genetic syndromes and much more.
Types of diabetes:
- Diabetes mellitus type 1;
- Diabetes mellitus type 2;
- Gestational diabetes mellitus;
- Steroid diabetes;
- Diabetes insipidus.
Most often, patients are diagnosed with type 2 diabetes. It accounts for over 90% of all cases of this disease. The second most common type is diabetes mellitus type 1. It is detected in almost 9% of patients. The remaining types of diabetes account for no more than 1.5% of patients.
Differential diagnosis of diabetes mellitus helps to accurately determine what type of disease the patient suffers from.
It is especially important that this diagnostic method makes it possible to distinguish the two most common types of diabetes, which, although they have a similar clinical picture, differ significantly in many respects.
Diabetes mellitus type 1
Sugar level
Type 1 diabetes is characterized by a partial or complete cessation of the production of the hormone insulin. Most often, this disease develops due to a serious disturbance in the functioning of the immune system, as a result of which antibodies appear in the human body that attack the cells of the own pancreas.
As a result, the cells secreting insulin are completely destroyed, which causes a sharp increase in blood sugar levels. Type 1 diabetes mellitus most often affects children in the age group from 7 to 14 years. Moreover, boys suffer from this disease much more often than girls.
Type 1 diabetes is diagnosed in people over 30 years of age only in exceptional cases. Typically, the risk of developing this type of diabetes decreases markedly after age 25.
Type 1 diabetes mellitus is characterized by the following differential features:
- Chronically elevated blood sugar levels;
- Low C-peptide levels;
- Low insulin concentration;
- Presence of antibodies in the body.
Diabetes mellitus type 2
Type 2 diabetes mellitus develops as a result of insulin resistance, which manifests itself in the insensitivity of internal tissues to insulin. Sometimes it is also accompanied by a partial reduction in the secretion of this hormone in the body.
In type 2 diabetes mellitus, the disturbance of carbohydrate metabolism is less pronounced. Therefore, in patients with the second form of diabetes, an increase in the level of acetone in the blood is extremely rare and there is a lower risk of developing ketosis and ketoacidosis.
The diagnosis of type 2 diabetes is much more common in women than in men. At the same time, women over 45 years of age constitute a special risk group. This type of diabetes is generally more common in mature and elderly people.
However, recently there has been a trend toward “younger” type 2 diabetes. Today, this disease is increasingly diagnosed in patients under 30 years of age.
Type 2 diabetes is characterized by a longer development, which can be practically asymptomatic. For this reason, this disease is often diagnosed in the later stages, when the patient begins to experience various complications, namely decreased vision, the appearance of non-healing ulcers, disruption of the heart, stomach, kidneys and much more.
Differential signs of type 2 diabetes mellitus:
- Blood glucose is significantly increased;
- noticeably increased;
- C-peptide is increased or normal;
- Insulin is elevated or normal;
- Absence of antibodies to pancreatic β-cells.
Almost 90% of patients with type 2 diabetes are overweight or severely obese.
Most often, this disease affects people prone to abdominal obesity, in which fat deposits are mainly formed in the abdominal area.
Sign Diabetes mellitus type 1 Diabetes mellitus type 2 Hereditary predisposition Rarely seen Occurs frequently Patient's weight Below normal Overweight and obesity Onset of the disease Acute development Slow development Patient's age at onset of illness Most often children from 7 to 14 years old, young people from 15 to 25 years old Mature people 40 years and older Symptoms Acute onset of symptoms Subtle manifestation of symptoms Insulin level Very low or absent Elevated C-peptide level Absent or greatly reduced High Antibodies to β-cells Are revealed None Tendency to ketoacidosis High Very low Insulin resistance Not visible There is always The effectiveness of glucose-lowering drugs Ineffective Very effective Need for insulin injections Lifetime Absent at the onset of the disease, develops later Course of diabetes With periodic exacerbations Stable Seasonality of the disease Exacerbation in autumn and winter Not visible Analysis of urine Glucose and acetone Glucose When diagnosing diabetes mellitus, differential diagnosis helps to identify other types of this disease.
The most common among them are gestational diabetes, steroid diabetes and diabetes insipidus.
Steroid diabetes
Develops as a result of long-term continuous use of hormonal drugs glucocorticosteroids. Another cause of this disease is Itsenko-Cushing syndrome, which affects the adrenal glands and provokes increased production of corticosteroid hormones.
Steroid diabetes develops like type 1 diabetes. This means that with this disease, the patient’s body partially or completely stops producing insulin and there is a need for daily injections of insulin drugs.
The main condition for the treatment of steroid diabetes is the complete cessation of taking hormonal drugs. Often this is enough to completely normalize carbohydrate metabolism and relieve all symptoms of diabetes.
Differential signs of steroid diabetes:
- Slow development of the disease;
- Gradual increase in symptoms.
- No sudden spikes in blood sugar levels.
- Rare development of hyperglycemia;
- Extremely low risk of developing hyperglycemic coma.
Gestational diabetes
Gestational diabetes develops only in women during pregnancy. The first symptoms of this disease, as a rule, begin to appear at 6 months of gestation. Gestational diabetes often affects absolutely healthy women who did not have any problems with high blood sugar before pregnancy.
The cause of the development of this disease is considered to be hormones secreted by the placenta. They are necessary for the normal development of the child, but sometimes block the action of insulin and interfere with the normal absorption of sugar. As a result, a woman’s internal tissues become insensitive to insulin, which provokes the development of insulin resistance.
Gestational diabetes often goes away completely after childbirth, but it significantly increases a woman's risk of developing type 2 diabetes. If a woman had gestational diabetes during her first pregnancy, there is a 30% chance that she will develop it during subsequent ones. This type of diabetes often affects women during late pregnancy - from 30 years of age and older.
The risk of developing gestational diabetes increases significantly if the expectant mother is overweight, especially highly obese.
In addition, the development of this disease may be affected by the presence of polycystic ovary syndrome.
Diabetes insipidus
Diabetes insipidus develops due to an acute lack of the hormone vasopressin, which prevents excessive fluid secretion from the body. As a result, patients with this type of diabetes experience excessive urination and extreme thirst.
The hormone vasopressin is produced by one of the main glands of the body, the hypothalamus. From there it passes into the pituitary gland, and then penetrates the blood and, along with its flow, enters the kidneys. By acting on kidney tissue, quasopressin promotes the reabsorption of fluid and the preservation of moisture in the body.
There are two types of diabetes insipidus – central and renal (nephrogenic). Central diabetes develops due to the formation of a benign or malignant tumor in the hypothalamus, which leads to a sharp decrease in the production of vasopressin.
In renal diabetes insipidus, the level of vasopressin in the blood remains normal, but the kidney tissues lose sensitivity to it. As a result, the kidney tubule cells are unable to absorb water, which leads to the development of severe dehydration.
Differential diagnosis of diabetes mellitus and diabetes insipidus table:
Sign Diabetes insipidus Diabetes Feeling thirsty Very strongly expressed expressed Volume of urine excreted in 24 hours From 3 to 15 liters No more than 3 liters Onset of the disease Very spicy Gradual Enuresis Often present Absent High blood sugar No Yes Presence of glucose in urine No Yes Relative density of urine Low High Patient's condition during analysis with dry eating Noticeably worsening Doesn't change The amount of urine excreted during analysis with dry eating Does not change or decreases slightly Doesn't change Blood uric acid concentration Over 5 mmol/l Increases only in severe stages of the disease As you can see, all types of diabetes are similar in many ways and a differential diagnosis helps distinguish one diabetic type from another. This is extremely important for developing the correct treatment strategy and successfully combating the disease. The video in this article will tell you how diabetes is diagnosed.
Type 1 diabetes mellitus refers to a classic autoimmune organ-specific disease, which results in the destruction of insulin-producing β-cells of the pancreas with the development of absolute insulin deficiency.
People who suffer from this disease require insulin therapy for type 1 diabetes, which means they need daily insulin injections.
Also very important for treatment are diet, regular exercise and constant monitoring of blood glucose levels.
What it is?
Why does this disease occur and what is it? Type 1 diabetes mellitus is an autoimmune disease of the endocrine system, the main diagnostic feature of which is:
- Chronic hyperglycemia- increased blood sugar levels.
- Polyuria, as a consequence of this - thirst; weight loss; excessive or decreased appetite; severe general fatigue of the body; stomach ache.
The disease most often affects young people (children, adolescents, adults under 30 years of age), and may be congenital.
Diabetes develops when it occurs:
- Insufficient production of insulin by endocrine cells of the pancreas.
- Violation of the interaction of insulin with the cells of the body's tissues (insulin resistance) as a result of a change in the structure or decrease in the number of specific receptors for insulin, a change in the structure of insulin itself, or a violation of the intracellular mechanisms of signal transmission from receptors to cell organelles.
Insulin is produced in the pancreas, an organ located behind the stomach. The pancreas is made up of a collection of endocrine cells called islets. Beta cells in the islets produce insulin and release it into the blood.
If the beta cells do not produce enough insulin or the body does not respond to the insulin that is present in the body, glucose begins to accumulate in the body rather than being absorbed by the cells, leading to prediabetes or diabetes.
Causes
Despite the fact that diabetes mellitus is one of the most common chronic diseases on the planet, medical science still does not have clear data on the causes of the development of this disease.
Often, for the possibility of developing diabetes, the following prerequisites must be present.
- Genetic predisposition.
- The process of destruction of β-cells that make up the pancreas.
- This can occur both under external adverse influences and under autoimmune influences.
- The presence of constant psycho-emotional stress.
The term “diabetes” was first introduced by the Roman physician Aretius, who lived in the second century AD. He described the disease as follows: “Diabetes is a terrible suffering, not very common among men, dissolving flesh and limbs into urine.
Patients continuously release water in a continuous stream, as if through open water pipes. Life is short, unpleasant and painful, thirst is insatiable, fluid intake is excessive and not commensurate with the huge amount of urine due to even greater diabetes. Nothing can stop them from drinking fluids and passing urine. If they refuse to drink fluids for a short time, their mouth becomes dry, their skin and mucous membranes become dry. Patients become nauseated, agitated, and die within a short period of time.”
What will happen if left untreated?
Diabetes mellitus is terrible for its destructive effect on human blood vessels, both small and large. Doctors give a disappointing prognosis to patients who do not treat type 1 diabetes: the development of all heart diseases, damage to the kidneys and eyes, gangrene of the extremities.
Therefore, all doctors advocate that at the first symptoms you need to go to a medical facility and have sugar tests done.
Consequences
The consequences of the first type are dangerous. Among the pathological conditions the following can be distinguished:
- Angiopathy is vascular damage due to capillary energy deficiency.
- Nephropathy is damage to the renal glomeruli due to impaired blood supply.
- Retinopathy is damage to the retina.
- Neuropathy – damage to the sheaths of nerve fibers
- Diabetic foot– characterized by multiple lesions of the extremities with cell death and the appearance of trophic ulcers.
Without insulin replacement therapy, a patient with type 1 diabetes will not be able to live. With inadequate insulin therapy, against the background of which the criteria for compensation of diabetes are not achieved and the patient is in a state of chronic hyperglycemia, late complications begin to quickly develop and progress.
Symptoms
The hereditary disease type 1 diabetes can be detected by the following symptoms:
- constant thirst and, consequently, frequent urination, leading to dehydration;
- rapid loss of body weight;
- constant feeling of hunger;
- general weakness, rapid deterioration of health;
- The onset of type 1 diabetes is always acute.
If you notice any symptoms of diabetes, you should immediately undergo a medical examination. If such a diagnosis occurs, the patient requires regular medical supervision and constant monitoring of blood glucose levels.
Diagnostics
Diagnosis of type 1 diabetes in the vast majority of cases is based on the detection of significant hyperglycemia on an empty stomach and during the day (postprandial) in patients with severe clinical manifestations of absolute insulin deficiency.
Results that indicate a person has diabetes:
- Fasting plasma glucose 7.0 mmol/L or higher.
- When conducting a two-hour glucose tolerance test, the result was 11.1 mmol/L or higher.
- A random blood sugar reading is 11.1 mmol/L or higher and there are symptoms of diabetes.
- Glycated hemoglobin HbA1C - 6.5% or higher.
If you have a home glucometer, just measure your sugar with it, without having to go to the laboratory. If the result is above 11.0 mmol/l, this is most likely diabetes.
Type 1 diabetes treatment methods
It must be said right away that diabetes of the first degree cannot be cured. No medicine can revive cells that are dying in the body.
Treatment goals for type 1 diabetes:
- Keep your blood sugar as close to normal as possible.
- Monitor blood pressure and other cardiovascular risk factors. In particular, have normal blood test results for “bad” and “good” cholesterol, C-reactive protein, homocysteine, fibrinogen.
- If diabetes complications do occur, detect them as early as possible.
- The closer a diabetic’s sugar is to normal levels, the lower the risk of complications on the cardiovascular system, kidneys, vision, and legs.
The main direction in the treatment of type 1 diabetes is constant monitoring of blood sugar, insulin injections, diet and regular exercise. The goal is to keep blood glucose within normal limits. Tighter control of blood sugar levels may reduce the risk of diabetes-related heart attack and stroke by more than 50 percent.
Insulin therapy
The only possible option to help a patient with type 1 diabetes is to prescribe insulin therapy.
And the sooner treatment is prescribed, the better the general condition of the body will be, since the initial stage of type 1 diabetes mellitus is characterized by insufficient production of insulin by the pancreas, and later it stops producing it altogether. And there is a need to introduce it from the outside.
Dosages of drugs are selected individually, while trying to imitate fluctuations in insulin in a healthy person (maintaining the background level of secretion (not associated with food intake) and postprandial secretion - after eating). For this purpose, ultra-short, short-acting, medium-acting and long-acting insulins are used in various combinations.
Typically, long-acting insulin is administered 1-2 times a day (morning/evening, morning or evening). Short-term insulin is administered before each meal - 3-4 times a day and as needed.
Diet
To manage your type 1 diabetes well, you need to learn a lot of different things. First of all, find out which foods raise your sugar and which do not. A diabetic diet can be used by all people who follow a healthy lifestyle and want to maintain youth and a strong body for many years.
First of all this:
- Exclusion of simple (refined) carbohydrates (sugar, honey, confectionery, jam, sweet drinks, etc.); consume mainly complex carbohydrates (bread, cereals, potatoes, fruits, etc.).
- Maintaining regular meals (5-6 times a day in small portions);
Limiting animal fats (lard, fatty meat, etc.).Sufficient inclusion of vegetables, fruits and berries in the diet is beneficial, as they contain vitamins and microelements, are rich in dietary fiber and ensure normal metabolism in the body. But you should keep in mind that some fruits and berries (prunes, strawberries, etc.) contain a lot of carbohydrates, so they can only be consumed taking into account the daily amount of carbohydrates in the diet.
To control glucose, an indicator such as a bread unit is used. It was introduced to control the sugar content in food products. One unit of bread equals 12 grams of carbohydrates. To utilize 1 unit of bread, an average of 1.4 units of insulin is required. Thus, it is possible to calculate the average need of the patient’s body for sugars.
Diet No. 9 for diabetes involves the consumption of fats (25%), carbohydrates (55%) and proteins. Stronger restriction of sugars is required in patients with renal failure.
Physical exercise
In addition to diet therapy, insulin therapy and careful self-monitoring, patients must maintain their physical fitness by applying those physical activities that are determined by the attending physician. Such combined methods will help you lose excess weight, prevent the risk of cardiovascular diseases and chronically high blood pressure.
- When exercising, the sensitivity of body tissues to insulin and the rate of its absorption increases.
- Glucose consumption increases without additional insulin.
- With regular training, normoglycemia stabilizes much faster.
Physical exercise greatly affects carbohydrate metabolism, so it is important to remember that during training the body actively uses glycogen reserves, so hypoglycemia may occur after exercise.
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