Diabetes Update and DKA Queensland Paediatric Society of QLD Dr. Jason Yates Paediatric Endocrinologist

Transcription

1 Diabetes Update and DKA Queensland Paediatric Society of QLD 2018 Dr. Jason Yates Paediatric Endocrinologist

2 Type 1 Diabetes - Paediatrics Most common Paediatric endocrine presentation >90% of all Paediatric diabetes 24/ in Australia (0-14yo) 45% present with Diabetic Keto-acidosis (DKA) Queensland Peer Review Stats 2017 Male and female equal Peak age 5-7yo and then at puberty

3 Incidence AIHW.gov.au Slide 3

4 Definitions (Take home slide) Finger prick BGL is all that is required to diagnose T1DM Fasting BGL >7mmol/L Diabetes transfer to nearest hospital Random BGL >11mmol/L Diabetes transfer to nearest hospital Random BGL 7-11mmol/L Discuss with local diabetes clinic (Paed Endo/Paediatrician) Blood ketones useful Treat all paediatric Diabetes as T1DM until proven otherwise. Slide 4

5 Symptom recognition Commonly there is a history of polyuria and polydipsia for up-to 8 weeks Other symptoms include; Weight loss Fatigue Blurred vision Vomiting 20-50% present in diabetic keto-acidosis More likely in younger age group <5yo Slide 5

6 Insulin Options Short acting (Bolus) Novorapid Humalog Apidra Long acting (Basal) Levemir Lantas CSII (Pump) Other options not a recommended starting point Protophane Novomix 30 Mixtard 30/70, 50/50 Actrapid Slide 6

7 Insulin Action Time Slide 7

8 Insulin Pump - CSII Basal able to be adjusted more accurately Bolus more convenient Studies show better control and better QOL Cons Always attached, constant reminder, formal dress Slide 8

9 Medtronic Slide 9

10 MyLife Ypsopump The Bluetooth word mark and logos are registered trademarks owned by Bluetooth SIG, Inc., and any use of such marks by Ypsomed AG is under license. The third-party trademarks used herein are trademarks of their respective owners. Slide 10

11 Slide 11

12 Tslim X2 Insulin pump Slide 12

13 Accu-chek Solo Micropump Slide 13

14 Accu-chek Solo Micropump Slide 14

15 CGMS Real time BGL (15min delay) Alarms for hypo and hyper Tracking algorhythms Interaction with pump for auto suspend Close the Loop! Con false alarms, another attachment, expensive Slide 15

16 Slide 16

17 Downloads Slide 17

18 Dexcom Clarity Slide 18

19 Downloads Slide 19

20 The Future Closing the loop Smart insulin Less invasive BGL monitoring Cheaper access to technology Immune therapy! Slide 20

21 The Problem Slide 21

22 Incidence of DKA Slide 22

23 Incidence of DKA Global problem Increasing despite stability in incidence rates Large burden on patients, families and health care setting Why? Slide 23

24 Survey of New Patients Mater Children s Hospital 2013 Polyuria 76% Polydipsia 82% Weight loss 82% Lethargy 41% Abdo pain 23% Blurred vision 11% No Statistical significance between DKA and non DKA group 75% had symptoms of one month or less Slide 24

25 Survey of New Patients Mater Children s Hospital % had diagnosis of diabetes at first presentation 30% of these were in the DKA group 66% of those in DKA had no clear diagnosis after the first visit to the doctor Other Dx included UTI and Gastro 57% of the DKA group had no known relative with Diabetes Slide 25

26 Survey GP information night 32 GPs at a Mater information night All had but two had working glucometers in their practice 60% (19)had never diagnosed a child with T1DM in their career Of the 40% (13) that had 30% (4)only once 15% (2) more than twice 3 didn t specify Slide 26

27 Prevention studies DKA incidence Parma Italy was able to reduce its rate of DKA from >80% to <15% using a poster campaign targeting GPs and schools King Et.al in Newcastle got similar results reducing from 35% to <15% over a two year period Both of these studies focused on symptom recognition and point of care testing Slide 27

28 International Society of Paediatric and Adolescent Diabetes Slide 28

29 Health Economics A large majority of DKA presentations are preventable DKA is leading cause of mortality in T1DM Health economics Average cost of a ward bed for the MCH is $780 per night Average PICU bed for 24 hours - $4700 DKA requires a minimum of hours in PICU to stabilise This also extends their inpatient stay due to delayed education This doesn t account for morbidity related cost Slide 29

30 Medium to Long term Morbidity One episode of DKA at presentation can have a medium term impact on cognition (Cameron et.al Diabetes Care June 2014) Slide 30

31 Honeymoon Honeymoon (Partial remission) is defined as a period of time post diagnosis where residual beta cell function improves glycaemic control Definition HbA1c <7.5%, Total daily insulin <0.5units/kg/day Onset 2-4 weeks post diagnosis Slide 31

32 Importance of Honeymoon? Improved control in early stages of diagnosis shown to improve long term outcomes via metabolic memory (EDIC) Positive predictors of prolonged honeymoon from diagnosis (>12months) Older age Lower HbA1c at diagnosis Non DKA Intensive Insulin Therapy DKA at diagnosis is shown to decrease the chance of a prolonged honeymoon period in newly diagnosed T1DM Slide 32

33 Diabetes Control and Complications Trial (DCCT) Slide 33

34 Epidemiology of Diabetes Interventions and Complications Study at 30 years (EDIC) Slide 34

35 Summary DKA is a severe presentation of T1DM Increasing incidence of DKA at first presentation nationally and internationally Largely preventable with early recognition Has short/medium and long term consequences Early recognition and diagnosis of T1DM essential Primary Care, community awareness and educational facilities have a large role to play Slide 35

36 In case you missed it! Finger prick BGL is all that is required to diagnose T1DM Fasting BGL >7mmol/L Diabetes transfer to nearest hospital Random BGL >11mmol/L Diabetes transfer to nearest hospital Random BGL 7-11mmol/L Discuss with local diabetes clinic (Paed Endo/Paediatrician) Blood ketones useful Treat all paediatric Diabetes as T1DM until proven otherwise. Slide 36

37 Questions? Slide 37

38 Slide 38