DIABETES MELITUS TYPE I

DIABETES MELITUS TYPE I dr. H. Hakimi, Sp.AK dr. H. Charles Darwin Siregar, g Sp.A p dr. Melda Deliana, Sp.AK dr. Siska Mayasari Lubis, Sp.A

PEDIATRIC ENDOCRINOLOGY MEDICAL SCHOOL USU/H. USU/H Adam Malik HOSPITAL Medan

Introduction • Chronic disease • Difficult to cure • Major DM group in children.

DM Classification based on etiology (ADA,1998) 1 DM type I ( B cell destruction) : 1. a. immune mediated b. idiopathic 2. DM type II (insulin resistant) 3. DM other type a. genetic defect of B cell function b. g genetic defect of insulin function c. pancreas exocrine disease d. endocrinopathy e. drug and chemical substance induction f. Infection g. uncommon immune mediated DM h. Genetic syndrome related to DM 4 DM gestasional 4.

Definition • Systemic disorder because glucose metabolism disorder, characterised by chronic hyperglicemy • Caused byy autoimunne p process which destroy pancreas B cell Æinsulin production decrease or stopped

Patogenese Addison disease

Tirodiditis hashimoto

Anemia pernisiosa

Viral infection

HLA B8 B8,DR3,BW15,DR4 DR3 BW15 DR4 acti activation ation autoantibody process langerhans islets destruction

Pancreas B cell function failure Insulin secretion decrease or stop DM type I

Chemical exposure

diagnostic criteria • Normal blood glucose : 200mg/dl – Asymptomatic : blood glucose ad random >200 /dl >200mg/dl

Glucose tolerance test (GTT) • GTT is not nesecary if distinguished symptoms are found • Indication I di ti : GTT in i doubtful d btf l case • glucose dose : 1,75 gr/W in 200-250 cc water in 5 minutes • GTT result intepretation : – DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200 mg /dl – Impaired I i d Glucose Gl tolerance t l : fasting f ti blood bl d glucose l 50% : >20 yrs old • Genetic and environment factors : HLA pattern pattern, virus, toxin, etc

Clinical appearance • Acute • Polyuria, Polyuria polydypsy, polydypsy rapid weight decrease decrease, hyperglycemy • Delayed diagnose : ketoacidosis with all the consequences

DM type I management • •

Good metabolic control with normal blood glucose level Unified team

Objective

Spesific objective

1 1.

Free from symptoms

1 optimal growth 1.

2.

Enjoy social life

2. normal emosional development

3.

Prevent complications

3. Good metabolic control without causing hypoglycemy 4. Few school absence days and active in school 5. Patient doesn’t doesn t manipulate disease 6. Able to manage disease independently

Insulin • Earlier : pig/cow pancreatic gland purification • Recombinant technology : human insulin • Usage based on age , social economic, culture, and drug distribution • Important to know : – somogyi effect – dawn d effect ff t – Morning hyperglycemy

Insulin • Ultra short acting insulin ( lispro ) – Give 15 min before meal – Useful in sick day y management g and before meal injection j

• Short acting insulin – F For acute stage : ketoacidosis, k id i new patient, i injection i j i before b f meal, and in surgery or combination with medium acting insulin – For F toddler t ddl : preventt hypoglycemy h l

Insulin • Medium acting Insulin – Used twice daily for patient with same daily routine ti pattern tt – Widely used in children

• Mix Insulin – Standard mixture ( short+medium acting insulin) – Good metabolic control – For young age child with low education parent

Insulin • Insulin pen • Mixing insulin • Storage : temp 4 – 8 oC not in freezer Type

onset (hour)

peak(hour)

duration(hour)

Ultra short acting

0,25

1

4

short acting g

0,5 –1

2-4

5-8

Medium acting

1-2

4-12

8-24

Long acting

2

6-20

18-36

Insulin Regiment • • • • •

Insulin usage principal Depend p on Indonesia situation and condition Use glucometer and routine daily home testing Objective parameter : Serum HbA1c / 3 months Insulin dose adjustment : – For metabolic control – Honeymoon period period, adolescent adolescent, sick days days, surgery

Insulin Injection • Injection technique : subcutaneous with pinchet • Self injection • Local reaction : rare

Meal adjustment • Objective : achieve good metabolic control without ignoring calory requirement • Total calory : 1000 + (age(year)x100) calory per day p y • Carbohydrate 60 – 65% , protein 25%, lipid