Type I Diabetes Mellitus

MR 8/14/09J.Chen

Management

• Insulin• Monitoring• Nutrition• Exercise• Education

Insulin

Insulin Requirements

• Preadolescent-0.5-1 unit/kg/day• Adolescents-0.8-1.2 units/kg/day• During honeymoon period-<0.5 units/kg/day

Starting an Insulin Regimen

• Split mixed Regimen vs. Basal/Bolus Regimen

Split/Mixed Regimen

• 2-3 injections based on NPH• 2/3 in AM, 1/3 in PM• 2/3 NPH, 1/3 Regular/Rapid• More rapid/regular may be required in AM

because of dawn phenomenon (nocturnal release of counter regulatory hormones-less insulin sensitivity in AM)

• May require less during Honeymoon period

Split/Mixed Regimen

Monitoring• Traditionally before meals, at bedtime, overnight• More often when ill or active• Acceptable range– Fasting/preprandial:

• preschool: 100-180mg/dL• School age: 90-180mg/dL• Teenagers: 90-130mg/dL

– Bedtime/overnight• Preschool: 110-200mg/dL• School age:100-180mg/dL• Teenagers: 90-150mg/dL

Basal Bolus Regimen

• Aims to achieve more physiologic insulin concentrations

• Basal provides baseline or fasting insulin• Bolus provides coverage for food and correct

for hyperglycemia• Basal rate given either through injection or via

insulin pump

Basal/Bolus Regimen

• Basal requirement ~50% daily insulin need– Either long acting insulin or– Rapid acting insulin via pump

• Bolus dose has 2 parts:– 1. coverage for carbohydrates in meal– 2. correction for blood glucose concentration

outside of target range.

Monitoring

• HbA1c– <6yr: 7.5-8.5%– 6-12yr:<8%– 13-19yr: <7.5%

• Urine or blood ketones should be monitored:– Blood glucose elevated– Nausea– Vomiting– Feeling ill

Nutritional Management

• Balanced Diet with adequate calories and nutrients for normal growth

• 50-55% carbohydrate calories, 20% protein calories, 30% fat calories– Most carb calories should be complex

carbohydrates– Fat portion should be low in cholesterol and

saturated fats

Nutritional Management

• Split/Mixed-– timing important– Snacks– Treats should be allowed

• Basal/Bolus– Flexibility in timing, amount, and content– Accurate carb counting and insulin dose

calculation

NEXT TIME: DKA