Diabetes mellitus (Type 1): clinical approach
文摘
科学
2024-07-07 15:42
澳大利亚
If you would like to view past exciting content, please click on the following link.Diabetes mellitus represents a chronic condition characterized by the inability of tissue cells to properly absorb and utilize glucose, leading to its accumulation in the bloodstream. Normally, insulin produced by pancreatic islet beta cells facilitates the uptake and storage of glucose, amino acids, and triglycerides, as well as the stimulation of glycolysis, protein synthesis, and lipogenesis through its interaction with insulin receptors on tissue cells.There are two primary types of diabetes: type 1 and type 2. Type 1 diabetes involves the autoimmune destruction of pancreatic islet beta cells, resulting in a severe deficiency of insulin and subsequent hyperglycemia. In contrast, type 2 diabetes arises from pancreatic islet beta cells becoming less responsive to stimulation for insulin production, combined with insulin resistance, leading to inadequate response by tissue cells to the insulin produced.Both types of diabetes can manifest as hyperglycemia, which may range from prediabetes to severe conditions like diabetic ketoacidosis (DKA), typically seen in type 1 diabetes, or hyperosmolar hyperglycemic state (HHS), more common in type 2 diabetes.When suspecting type 1 diabetes, an ABCDE assessment should be conducted to determine the patient's stability. If unstable, priority should be given to stabilizing the airway, breathing, and circulation, possibly requiring intubation. Following stabilization, IV access should be established, and if the patient is hypotensive, IV fluids should be administered for volume resuscitation. Continuous monitoring of vital signs, including pulse oximetry, blood pressure, and heart rate, is essential.Subsequent steps involve assessing for DKA or HHS through a focused history, physical examination, and appropriate laboratory tests, including point-of-care blood glucose, serum osmolality, basic metabolic panel (BMP), urinalysis, hemoglobin A1c, and arterial or venous blood gas analysis (ABG or VBG).Typical symptoms include fatigue, headache, dry mouth, polyuria, polydipsia, and confusion. Physical examination may reveal tachypnea, tachycardia, hypotension, and dry mucous membranes. Laboratory findings aid in distinguishing between DKA and HHS, with DKA characterized by elevated random blood glucose levels exceeding 250 mg/dL, along with anion gap metabolic acidosis and ketones in the urine, whereas HHS typically presents with extremely elevated blood glucose levels often surpassing 600 mg/dL, along with hyponatremia, hypokalemia, and a high serum osmolality.Management of both conditions involves IV fluid resuscitation to correct dehydration and electrolyte imbalances, insulin therapy if necessary, and monitoring of potassium levels, in addition to addressing any underlying causes or precipitating factors.Diabetes mellitus, a chronic condition, arises when tissue cells fail to properly absorb and utilize glucose, resulting in its accumulation in the bloodstream. Typically, pancreatic islet beta cells produce insulin, facilitating glucose uptake, storage, and various metabolic processes in tissue cells.The two primary types of diabetes are type 1 and type 2. In type 1 diabetes, autoimmune destruction of pancreatic islet beta cells leads to severe insulin deficiency and subsequent hyperglycemia. In contrast, type 2 diabetes involves pancreatic islet beta cells becoming less responsive to insulin stimulation, accompanied by insulin resistance, causing inadequate tissue cell response to the available insulin.Both types of diabetes can result in hyperglycemia, ranging from prediabetes to severe conditions like diabetic ketoacidosis (DKA) in type 1 diabetes and hyperosmolar hyperglycemic state (HHS) in type 2 diabetes.For suspected type 1 diabetes mellitus, an ABCDE assessment is crucial to determine patient stability. Unstable patients require immediate stabilization of airway, breathing, and circulation, potentially including intubation, IV access, and fluid resuscitation. Continuous monitoring of vital signs is essential. Assessing for DKA or HHS involves obtaining a focused history, physical examination, and relevant laboratory tests.Symptoms such as fatigue, headache, dry mouth, polyuria, and polydipsia are common in diabetic patients. Physical examination may reveal tachypnea, tachycardia, hypotension, and dry mucous membranes. Laboratory results aid in distinguishing between DKA and HHS, guiding appropriate management including fluid resuscitation, electrolyte repletion, and insulin therapy, as well as addressing underlying causes.For stable patients, a focused history and physical examination are followed by laboratory tests such as hemoglobin A1c, fasting blood glucose, oral glucose tolerance test, or random blood glucose test to confirm the diagnosis. Further diagnostic steps involve assessing underlying mechanisms, including antibody testing and C-peptide levels, distinguishing between type 1 and type 2 diabetes.Insulin therapy is initiated for type 1 diabetes, involving basal and bolus dosing based on individualized factors. Blood glucose monitoring and diabetes self-management education are integral components of treatment, aiming to maintain blood sugar levels within a target range and prevent complications.Additionally, your patient should collaborate with a dietitian to learn carbohydrate counting, establish an insulin-to-carbohydrate ratio for pre-meal insulin dosing, and understand how to adjust insulin doses for variations in routine, such as illness or increased physical activity.Here's a noteworthy tip! Patients requiring frequent glucose monitoring may benefit from a continuous glucose monitor (CGM), which provides continuous blood glucose monitoring. Similarly, an insulin pump offers continuous insulin infusion, with some CGMs and insulin pumps capable of real-time communication.After prescribing an insulin regimen and completing self-management education, schedule a follow-up in 3 months to reassess hemoglobin A1c levels. If the patient responds adequately to treatment, with a hemoglobin A1c below 7%, maintain the current treatment plan, repeat hemoglobin A1c testing every 3 months, and conduct annual screenings for diabetic retinopathy, neuropathy, and nephropathy.Conversely, if the hemoglobin A1c remains at or above 7%, indicating an inadequate response to treatment, adjust the insulin regimen to achieve improved blood glucose control. Continue monitoring hemoglobin A1c every 3 months to track progress and conduct annual screenings for diabetic complications.To summarize, when suspecting type 1 diabetes mellitus, prioritizing patient stabilization is crucial, especially if they exhibit signs of instability such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). For unstable patients, prompt management with IV fluid resuscitation, electrolyte repletion, and possibly IV insulin therapy is necessary.In stable patients, diagnostic tests including hemoglobin A1c, fasting blood glucose, oral glucose tolerance test (OGTT), and random blood glucose are conducted to confirm the diagnosis of diabetes mellitus. Further tests involving GAD65 antibodies, ICA2 antibodies, and C-peptide levels aid in distinguishing type 1 diabetes from other forms.If diagnosed with type 1 diabetes, initiating a regimen of daily basal and bolus insulin therapy is essential. Regular monitoring of blood glucose levels and hemoglobin A1c is crucial to ensure an adequate response to treatment. Additionally, annual screenings for diabetic complications such as retinopathy, neuropathy, and nephropathy are recommended to prevent and manage long-term complications."American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan—2022 Update" Endocrine Practice (2022)"The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)" Diabetes Care (2021)"Type 1 diabetes" The Lancet (2018)"Harrison's: Principles of Internal Medicine." United States: McGraw-Hill Education. ((2018)) - - - - - - - END - - - - - - -
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