Nelsons Hour DM in Children

8/19/2019 Nelsons Hour DM in Children

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NELSON’S HODIABETES MELLITU

CHILDREY KEVINPOST-GRADU


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OBJECTIVES

• Know th n!t"#!$ h%&to#' o( %n&"$%n-)*n)nt)%!+t& ,$$%t"& t'* /

• Know th *#%n0%*$& o( 10t%2 ,!n!3,nt: %n

)%t !n) 5#0%&• Know th 2!$" o( H3+ A0 !& !n %n)5 o( $on3 t

3$'0,%0 0ont#o$


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CLASSI6ICATION O6 DM

Type 1 Diabetes Mellitus(T1DM)

Type 2 Diabetes Mellit(T2DM)

Insulin-dependent DM/ Juvenile Diabetes

Non-insulin dependent D Adult-onset DM

R&"$t& (#o, th )70%n0' o(

%n&"$%n &0#t%on +0!"& o(*!n0#!t%0 0$$ )!,!3

A 0on&8"n0 o( %n&"$%n

#&%&t!n0 o00"##%n3 !t th $th &9$t!$ ,"&0$4 $%2# !n!)%*o& t%&&"4 w%th 2!#%o"&)3#& o( B-0$$ %,*!%#,n

On&t o00"#& *#)o,%n!nt$' %n0h%$)hoo) w%th ! ,)%!n !3 o( -; '!#&

Mo&t *#2!$nt %n !)"$t&< Ch!n) !)o$&0nt& w%th th%& t'"&"!$$' o+&


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IMPAIRED GLUCOSE TOLERANCE

• Mt!+o$%0 &t!3 th!t %& %nt#,)%!t +twn no3$"0o& ho,o&t!&%& !n) )%!+t&

• Euglycemic %n )!%$' $%2& w%th no#,!$ !n) n!#$'no#,!$ 3$'0!t) h,o3$o+%n $2$&

• M!n%(&t hyperglycemia on$' whn 0h!$$n3) o#!$ 3$"0o& $o!) "&) !(t# th &t!n)!#)%@) o#!3$"0o& to$#!n0 t&t


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TYPE 1 DIAETES MELLITUS


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TYPE DM: EPIDEMIOLO!Y

• A00o"nt& (o# o( !$$ 0!&& o( DM !10t%n3 ;,%$$%on *o*$ %n th wo#$)

• A00o"nt& (o# ,o&t 0!&& o( DM %n 0h%$)hoo)< ;%n)%2%)"!$& w%th TDM *#&nt !& !)"$t&

• G%#$& !n) +o'& !# equally afected

• P!9 *#&nt!t%on %n two !3 3#o"*&:

• ;- '!# o( !3

• T%, o( *"+#t'


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TYPE DM: EPIDEMIOLO!Y

Relati"eA#e$te%

Ris& 'Diabetes

S%+$%n3

6!th# ;-

Moth# -

Ch%$)

GnPo*"$!t%on

.

Type 'Ti*

+'*$

Mono@'3ot%0

D%@'3ot%0

!"# of newly diagnosed type 1 DM patients DONOT have a family member with T1DM


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TYPE DM: PATHO!ENESIS - NATURHISTORY

• Th n!t"#!$ h%&to#' o( t'* DM %n2o$2& th 1 &

In%t%!t%on o( !"to%,,"n%t'

P#0$%n%0!$ !"to%,,"n%t' w%th *#o3#&&%2 $o&& o( 0$$ ("n0t%on

On&t o( 0$%n%0!$ )%&!&

T#!n&%nt #,%&&%on hon',oon *#%o)/

E&t!+$%&h) D%&!&

D2$o*,nt o( Co,*$%0!t%on&


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• h!t t#%33#& th%& !"to%,,"n #&*on& #,!%n&"n0$!# +"t th (o$$ow%n3 !# %,*$%0!t)

V%#!$ %n(0t%on& R"+$$!4 nt#o2%#"&4 ,",*& 2%#"

D%t %n %n(!n0' !#$' %nt#o)"0t%on o( Cow?& ,%$9/L!09 o( 5*o&"# to 0#t!%n %n(0t%on& H'3%n

h'*oth&%&/

P&'0ho$o3%0 &t#&&


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• D2$o*,nt o( !"to%,,"n%t' %& !&&o0%!t) w%th th !**!#o( &2#!$ !"to!nt%+o)%&:

. I&$t 0$$ !"to!nt%+o)%& ICA&/

F. In&"$%n !"to!nt%+o)%& IAA&/

. G$"t!,%0 !0%) )0!#+o5'$!& ; 9D!

. T'#o&%n *ho&*h!t!& %n&"$%no,!-!&&o0%!t) F

;. %n0 t#!n&*o#t# !nt%+o)%&

• On&t o( !"to%,,"n%t': * years old


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2. PRE+LINI+AL AUTOIMMUNITY 7PRO!RESSI8E LOSS O/ ETA3+ELL /UN+T

• Antibodies !# ! ,!#9# (o# th *#&n0 o(!"to%,,"n%t' +"t th !0t"!$ )!,!3 to +t! 0$*#%,!#%$' +-cell mediated,

•

H%&to$o3%0 !n!$'&%& o( th *!n0#!& (#o, *t& w%th#0nt-on&t TID #2!$& insulitis4 w%th !n %n7$t#o( th %&$t& o( L!n3#h!n& +' ,onon"0$!# 0$$&4%n0$")%n3 T !n) B $',*ho0't&4,ono0't&=,!0#o*h!3& !n) NK 0$$&


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ROLE O/ AUTOANTIODIES

• Th #%&9 o( 0$%n%0!$ )%&!& %n0#!&& )#!,!t%0!$$' w%th !n%n0#!& %n th n",+# o( !"to!nt%+o)%&:

• o( 0h%$)#n w%th !nt%+o)' *#o3#&& to DM

• whn F !nt%+o)%& !# *#&nt

•

whn !nt%+o)%& !# *#&nt• Th h%3h# !nt%+o)' t%t#& !# ,o# $%9$' to *#o3#&& to 0

)%&!&

• Ch%$)#n %n who, IAA& !**!#) w%th%n th &t F '# o( $%(#!*%)$' )2$o*) !nt%-%&$t 0$$ !nt%+o)%& !n) *#o3#&&))%!+t& ,o# (#8"nt$'


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ROLE O/ !ENETI+S IN DISEASEPRO!RESSION

• $igh-ris $%A alleles (e.g. HLA DR=-DQF= 3no!# ,o# $%9$' to )2$o* ,"$t%*$ !nt%+o)%& !n)*#o3#&& to )%&!&

• A**!#!n0 o( !nt%+o)%& %& ,o# $%9$' to *#)%0t

)%!+t& %n tho& w%th ! .amily history o. diabetetho& w%th no (!,%$' h%&to#' o( TDM

• Environmental .actors %n)"0 t#!n&%nt !"to%,,"%n ,!n' 0h%$)#n4 +"t tho& w%th genetic susceptib!# ,o# $%9$' to & *#o3#&&%on o( !"to%,,"n%t' !

2nt"!$ )2$o*,nt o( )%!+t&.


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0. ONSET O/ +LINI+AL DISEASE

• P#o3#&&%2 +t! 0$$ )&t#"0t%on w%$$ 2nt"!$$'*#&nt w%th 0$%n%0!$ TDM

• It w!& tho"3ht th!t o( th tot!$ +t! 0$$ ,!)&t#o') +' th t%, 0$%n%0!$ )%&!& )2$o*&

• D&t#"0t%on %& ,o# #!*%) !n) ,o# 0o,*$t %nyounger children

• In older children !n) adults4 th *#o*o#t%on o(&"#2%2%n3 +t! 0$$& %& 3#!t# -F/ !n) &o,+t! 0$$& &"#2%2 "* to '# !(t# on&t o( )%!+


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. TRANSIENT REMISSION

• A.9.!. Hon',oon P#%o)

•

At th t%, o( )%!3no&%&4 &o, 2%!+$ +t! 0$$& !&t%$$ *#&nt !n) th& ,!' *#o)"0 no"3h %n&"$!) to *!#t%!$ #,%&&%on o( th )%&!&


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9. ESTALISHED DISEASE

• O2# t%,4 !$,o&t !$$ +t! 0$$& !# )&t#o')

• P!t%nt +0o,& tot!$$' )*n)nt on e(ogenouinsulin (o# &"#2%2!$.


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:. +OMPLI+ATIONS

• So, *!t%nt& )2$o* &0on)!#' 0o,*$%0!t%on& o( )%!+tth!t !**!# to + #$!t) to how w$$-0ont#o$$) th )%!+h!& +n

Mi$,'"as$ula, +';pli$ati'*s Ma$,'"as$ula, +';p

D%!+t%0 #t%no*!th' Co#on!#' !#t#' )%&

D%!+t%0 n"#o*!th' P#%*h#!$ !#t#%!$ )

D%!+t%0 n*h#o*!th' St#o9


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+LINI+AL MANI/ESTATIONS

• D0#!&%n3 B-0$$ ,!&& w%th wo#&n%n3 %n&"$%no*n%!4

*#o3#&&%2 h'*#3'$0,%! !n) 2nt"!$ 9to!0%)o&%& !%,*$' th!t symptoms steadily increase4 (#o, !#$'%nt#,%ttnt *o$'"#%! to DKA !n) 0o,!4 o2# w9& "&"#!th# th!n ,onth&

• In%t%!$$'4 intermittent polyuria or nocturia

• Ch#on%0 h'*#3$'0,%! t#%33#& ,o# *#&%&tnt diuresnocturnal enuresis !n) polydipsia

• 6,!$& ,!' )2$o* monilial vaginitis (#o, th 0h#3$'0o&"#%!


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• C!$o#%& !# $o&t %n th "#%n 3$'0o&"#%!/4 t#%33#%n3 !0o,*n&!to#' hyperphagia

• I( h'*#*h!3%! )o& not 9* *!0 w%th 3$'0o&"#%!4 $o&& o( +on&"&4 w%th clinical eight loss !n) )%,%n%&h) subcutan.at ensues

•

hn 5t#,$' $ow $2$& o( %n&"$%n !# #!0h)4 9to!0%)&!00","$!t !n) *#o)"0 abdominal discom.ort0 nausea emesis< )h')#!t%on !00$#!t& 0!"&%n3 eaness ororthostasis +"t *o$'"#%! *#&%&t&

• Kto!0%)o&%& 5!0#+!t& &',*to,& !n) $!)& to 1ussmaulrespirations0 .ruity breath odor0 prolonged corrected 2

interval0 diminished neurocognitive .unction !n)

coma


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• Y'u*6e, +


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TREATMENT

• E50$$nt )%!+t& 0ont#o$ %n2o$2& ,!n' 3o!$&:

To ,!%nt!%n ! +!$!n0 +twn t%3ht 3$"0o&0ont#o$ !n) !2o%) h'*o3$'0,%!

To $%,%n!t *o$'"#%! !n) no0t"#%! To *#2nt 9to!0%)o&%&

To *#,%t no#,!$ 3#owth !n) )2$o*,nt w%t,%n%,!$ 10t& on $%(&t'$


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INSULIN THERAPY

• In%t%!$ )!%$' )o& %& "&"!$$' h%3h# %n / *#*"+#t!$ 0

!n) tho& F/ w%th DKA !t th t%, *#&nt!t%on• O*t%,!$ %n&"$%n )o& 0!n on$' + )t#,%n) ,*%#%0

(#8"nt &$(-,on%to#) +$oo) 3$"0o& $2$& !n) %n&"!)>"&t,nt +' th )%!+t& t!,.


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2. NPH - LENTE

• Inh#nt $%,%t& +0!"& th' )o not 0#!t ! *!%n&"$%n $2$

• P#o)"0& ! &%3n%70!nt hypoglycemic efect )"#th ,%)#!n3 o( th%# )"#!t%on

• D%0"$t to *#)%0t th%# %nt#!0t%on w%th (!&t-!0t%n%n&"$%n&

• hn #3"$!# %n&"$%n %& 0o,+%n) w%th NPH o# Lth 0o,*o&%t %n&"$%n *oo#$' ,%,%0& no#,!$n)o3no"& %n&"$%n &0#t%on


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0. LISPRO - ASPART

• In&"$%n !n!$o3&

• A+&o#+) ,"0h 8"%09# +0!"& th' )o not (o#,h5!,#&

• P#o2%) )%&0#t *"$&& w%h $%tt$ %( !n' o2#$!* !n&ho#t t!%$ 10t

• A$$ow& +tt# 0ont#o$ o( *o&t,!$ 3$"0o& %n0#!&!n) #)"0& +twn-,!$ o# n%3htt%,h'*o3$'0,%!


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. !LAR!INE

• Lon3-!0t%n3 !n!$o3

• M"0h !tt# F h# *#o7$< !&%# to *#)%0t th 0o,+%n10t o( #!*%) +o$"& $%&*#o o# !&*!#t/ on to* o( th +!&%n&"$%n

• Po&t*#!n)%!$ 3$"0o& $2!t%on& !# +tt# 0ont#o$$) !n+twn-,!$ !n) n%3htt%, h'*o3$'0,%! !# #)"0

• B!&!$ %n&"$%n 3$!#3%n &ho"$) + *"-34# o( th tot!$ )oto))$#& !n) 64-"4# %n o$)# 0h%$)#n

• 7emaining portion o. the total daily dose %& *#o2%)+o$"& %n&"$%n )o&) +' +oth th 0!#+oh')#!t 0ontnt o,!$ !n) th *#*#!n)%!$ 3$"0o& 2!$"


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. !LAR!INE

• Lon3-!0t%n3 !n!$o3

• M"0h !tt# F h# *#o7$< !&%# to *#)%0t th 0o,+%n10t o( #!*%) +o$"& $%&*#o o# !&*!#t/ on to* o( th +!&%n&"$%n

• Po&t*#!n)%!$ 3$"0o& $2!t%on& !# +tt# 0ont#o$$) !n+twn-,!$ !n) n%3htt%, h'*o3$'0,%! !# #)"0

• B!&!$ %n&"$%n 3$!#3%n &ho"$) + *"-34# o( th tot!$ )oto))$#& !n) 64-"4# %n o$)# 0h%$)#n

• 7emaining portion o. the total daily dose %& *#o2%)+o$"& %n&"$%n )o&) +' +oth th 0!#+oh')#!t 0ontnt o,!$ !n) th *#*#!n)%!$ 3$"0o& 2!$"


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INSULIN THERAPY

• 6#8"nt +$oo) 3$"0o& ,on%to#%n3 !n) %n&"$%n!)>"&t,nt !# n0&&!#' %n th &t w9& !& 0h#t"#n& to #o"t%n !0t%2%t%& !n) !)!*t& to ! nw

n"t#%t%on!$ &0h)"$• Th ,!>o# *h'&%o$o3%0 $%,%t to t%3ht 3$"0o& 0ont#

hypoglycemia


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NUTRITIONAL MANA!EMENT

• N"t#%t%on %& o( 0#%t%0!$%,*o#t!n0 )"#%n3 0h%$)hoo)!n) adolescence4 whn!**#o*#%!t n#3' %nt!9 %&

#8"%#) to ,t th n)& (o#n#3' 5*n)%t"#4 3#owth!n) *"+#t!$ )2$o*,nt


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Nut,ie*t = '+al',ies

Re$';;e*%e% Daily I*ta&e

C!#+oh')#!t& ;; &ho"$) + )#%2) (#o, 0o,*$0!#+oh')#!t&

6!t &ho"$) + (#o, &!t"#!t) (!U* to (#o, *o$'"n&!t"#!t) (!R,!%n%n3 &ho"$) + (#o,

,ono"n&!t"#!t) (!t&P#ot%n ; ----

Cho$&t#o$ ,3

So)%", A2o%) 50&&%2 &o)%",< $%,%t to 44 %( h'*#tn&%2

6%+# F 3=)!'


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• D%t!#' (!t& (#o, !n%,!$ &o"#0& !# #)"0) !n)#*$!0) +' *o$'"n&!t"#!t) (!t& (#o, 23t!+$S"+&t%t"t:

• M!#3!#%n (o# +"tt#

•

V3t!+$ o%$ (o# !n%,!$ o%$& %n 0oo9%n3• L!n 0"t& o( ,!t4 *o"$t#' !n) 7&h (o# (!tt' ,!t&

• Th %nt!9 o( 0ho$&t#o$ %& #)"0) +' $%,%t%n3 thn",+# o( 33 'o$9& 0on&",)


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• O0!&&%on!$ 50&&& t#!t&/ (o# +%#th)!'& !n) *!#t%& !# *#,%&&%+$ !n) to$#!t) to not (o&t#+$$%on !n) &t!$th %n o+t!%n%n3 )&%#) (oo)

• C!9& !n) 2n 0!n)%& !# *#,%&&%+$ on &*0%o00!&%on& !& $on3 !& th (oo) 0!#+oh')#!t 0ont!)>"&t) to ,!$ *$!n


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E>ER+ISE

• No (o#, o( 5#0%&4 %n0$")%n3 0o,*t%t%2 &*o#t&4 &

(o#+%))n (#o, ! 0h%$) w%th )%!+t&

• Th ,!>o# 0o,*$%0!t%on o( 5#0%& %& th *#&n0 hypoglycemic reaction )"#%n3 o# w%th%n ho"#& !(t5#0%&

• 7egular e(ercise %,*#o2& 3$"0o#3"$!t%on +' %n0%n&"$%n #0*to# n",+#

• In *!t%nt& who !# %n *oo# ,t!+o$%0 0ont#o$4 vigore(ercise ,!' *#0%*%t!t 9to!0%)o&%& +0!"& o( t5#0%&-%n)"0) %n0#!& %n th 0o"nt##3"$!to#'ho#,on&


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!LY+OSYLATED HEMO!LOIN

•

A #$%!+$ %n)5 o( $on3-t#, 3$'0,%0 0ont#o$• H+A0 #*#&nt& th (#!0t%on o( h,o3$o+%n to wh%0

h!& +n nonn@',!t%0!$$' !tt!0h) %n th +$oo) &t#

• Th (o#,!t%on o( H+A0 0ont%n"& %##2#&%+$' th#o"3#) +$oo) 0$$?& $%( &*!n o( !**#o5%,!t$' F )!'&.

• Th h%3h# th +$oo) 3$"0o& 0on0nt#!t%on !n) th th #) +$oo) 0$$?& 5*o&"# to %t4 th h%3h# %& th (o(H+A0

• H+A0 ,!&"#,nt #0t& th !2#!3 +$oo) 3$"00on0nt#!t%on (#o, th preceding *-3 mo.


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!LY+OSYLATED HEMO!LOIN

•R0o,,n)) th!t H+A0 ,!&"#,nt& + o+t t%,& ! '!#

• Th $ow# th H+A0 $2$4 th ,o# $%9$' th!t,%0#o2!&0"$!# 0o,*$%0!t%on& w%$$ + $&& &2#4 %n !**!#!n0 o# 2n !2o%)) !$to3th#

• 8puriously elevated %n th!$!&&,%! o# oth# 0w%th $2!t) h,o3$o+%n 6/

• 8puriously loer %n &%09$ 0$$ )%&!& o# oth0on)%t%on& w%th h%3h #) +$oo) 0$$ t"#no2#/

+ate6',y =


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6 y

In)%2%)"!$& w%tho"t )%!+t&

In)%2%)"!$& w= )%!+t&4 3oo) ,t!+o$%0 0ont#o$ -

In)%2%)"!$& w= )%!+t&4 (!%# ,t!+o$%0 0ont#o$

In)%2%)"!$& w= )%!+t&4 *oo# ,t!+o$%0 0ont#o$

A6e !,'up Ta,6et Hba1$ (=)

; .;-.;- .;-.

F-; .-.;

- ;.;-.


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RE/EREN+ES

• N$&on?& T5t+oo9 o( P)%!t#%0&4 F)%t%on

Documents

Nelsons Hour DM in Children