Type 1 Diabetes Guidelines ?

Prof. M. Hesham El HefnawyHead of National Institute of Diabetes & Endocrinology

E mail: drhefnawy@yahoo.com

Prof. Dr. Mohamed Hesham El-Hefnawy

| Confidential2

Preferred language: English

Who is Prof. El-Hefnawy?

-Dean of Egypt National Institute for Diabetes & Endocrinology-Certified Medical Diabetes Education Instructor (ADA, Verginia)

-Professor degree of Diabetes & Endocrinology in National Institute of Diabetes & Endocrinology (NIDE), Cairo, Egypt.

-Head of research unit in National Institute of diabetes & Endocrinology (NIDE).-Member of Research Ethics Committee of General Organization of Teaching

Hospitals & Institutes, (GOTHI).-Reviewer in the African Research Academy for evaluation of the researches to be

published in the International Journals of the Academy.-Member of ISPAD, (International Society of Pediatric & Adolescence Diabetes).-Sharing in writing a chapter of international Text-Book of Diabetes in Croatia in

2011.-International published researches in field of Diabetes management, epidemiology,

educational programs,….etc. -Contact details: drhefnawy@yahoo.com

Diabetes Cases in Middle Eastern and African Countries 1*

1. IDF. Diabetes Atlas. 5th edition. 2012 Update. http://www.idf.org/sites/default/files/IDFAtlas5E_Detailed_Estimates_0.xls. Accessed on April 18, 2013.

*All cases of diabetes, including type 1 and type 2 diabetes in patients aged 20-79 years

In 2012, Egypt had the highest number of people with diabetes

Egypt is one of the 20 countries of the IDF MENA region; 382 million people have diabetes in the world and more than 34.6 million

people in the MENA Region, by 2035 this will rise to 67.9 million in MENA region, There were 7.5 million cases of diabetes in Egypt in 2013.

Diabetes In Egypt .. 2013

IDF Diabetes Atlas sixth edition.Source; IDF Diabetes Atlas 2013.

http://www.idf.org/membership/mena/egypt

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1 Fong DS, et al. Diabetes Care. 2003; 26 [Suppl. 1]:S99–S102.2 Molitch ME, et al. Diabetes Care. 2003; 26 [Suppl.1]:S94–S98.

3 Kannel WB, et al. Am Heart J. 1990; 120:672–676.4 Gray RP & Yudkin JS. In Textbook of Diabetes. 1997.

5 Mayfield JA, et al. Diabetes Care. 2003;26 [Suppl. 1]:S78–S79.

DiabeticretinopathyLeading causeof blindness in working-age adults1

Diabeticnephropathy

Leading cause of end-stage renal disease2

Cardiovasculardisease

Stroke2- to 4-fold increase in cardiovascular mortality and stroke3

DiabeticneuropathyLeading cause of non-traumatic lower extremity amputations5

8/10 diabetic patients die from CV events4

Diabetes is a Serious Chronic Disease

Legacy effect: Early glycaemic control is key to long-term reduction in complications

Bad legacy effectAchieving glycaemic control late in the disease, after a prolonged period

of poor control, does not improve long-term risk of macrovascular

complications2

Long-standing, preceding hyperglycaemia accounted for the high rate of complications at baseline in VADT3

UKPDS=UK Prospective Diabetes Study; VADT=Veterans Affairs Diabetes Trial.1Holman RR, et al. N Engl J Med. 2008; 359: 1577–1589.

2Duckworth W, et al. N Engl J Med. 2009; 360: 129–139;3Del Prato S. Diabetologia. 2009; 52: 1219–1226.

Good legacy effectEarly, strict glycaemic control brings benefits,

reducing the long-term risk of microvascular and macrovascular complications (UKPDS1)

Is There Is Type 1 Guidelines ?

Management Of Type 1 DM•(1) Insulin.

•(2) Nutritional & Educational therapy.

•(3) Monitored Exercises.

•(4) Psycho-socio-economic Care.

•(5) Treatment of Complications :

•acute & chronic.

•(6) New Approaches for Treatment

•(7) Prevention trials of Type 1 D.M.

•(8) Prevention of complications.*Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1999; 26:5–20.

IndividualizedIndividualized

Individualized

Individualized

INSULIN•* Insulin is essential for life in type 1 D.M.

•* We have to reach to a strict control of D.M.(Glycated HbA1c < 7.5%).

•* Strict control is not to give multiple injections, but it is better to achieve excellent control ,to avoid most of the diabetic complications, by the least number of injections to avoid the lipodystrophy and for psychological reasons also.

Initial insulin dose:

• 0.4 - 0.8 U/kg/Day• Q: Why this wide range of the initial insulin

dose?– Family history of type 2 diabetes.– Lifestyle (sedentary vs. active). – Adiposity.– Gender (males usually require more than females). – Any remaining endogenous insulin secretion.– Concomitant illness.

•

Q: How to classify the initial insulin dose?

Basal: 40-50% of total dose.

•Bolus: 50-60% of total dose

Basal Insulin:

–NPH or Detimir twice daily.

–Galargin can be administered once daily. If it is decided to start with once daily basal insulin, it is usually administered at bedtime.

– Titration of basal insulin

• By observing glucose trends during periods of fasting.

• The median glucose level before breakfast

• Any information on glucose levels during the night when glycemia is not contaminated by food or prandial insulin.

•

Bolus (Prandial) Insulin

– Typical doses: 1 unit per 10 to 15 grams of carbohydrate.– But in obese patients: 1 unit per 5 grams of carbohydrate.– While thin patients: 1 unit per 20 grams of carbohydrate– Titration of bolus insulin dose

• Insulin Sensitivity Factor: The drop in blood glucose level (mg/dl), caused by each unit of insulin taken.

• For patients who use Regular (short-acting) insulin: Use

1500 rule. Divide 1500 by the total daily dose of Regular insulin, in units.

• For patients who use the Rapidly-acting Insulin Analogues: Use 1800 rule. Divide 1800 by the total daily dose of rapidly acting insulin analogues, in units.

Q: When higher doses (basal and bolus) of insulin may be needed?

– If your patient have an infection.

– If your patient reduce his level of activity.

– If you are prescribed a medicine that changes insulin sensitivity (such as Prednisone).

– If your patient are under emotional stress.

– During adolescence.

– During pregnancy.

Q: When lower doses (basal and bolus) of insulin may be needed?

– If your patient become more active.

– If your patient have problems with kidney function.

Methods of insulin injection

• Insulin syringes; – Insulin syringes must have a measuring scale

consistent with the insulin concentration (e.g. U 100 syringes for insulin concentration 100 U/ml).

– Injections by syringe are usually given into the deep SC tissue through a two-finger pinch of skin at a 45angle. A 90 angle can be used if the SC fat is thick enough.

• Pen injector devices:– Requires careful wait of 15 seconds after pushing in

the plunger helps to ensure complete expulsion of insulin through the needle.

Why These Slides are in White color??

Because ..

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