Type 1 Diabetes

• Type 1 diabetes


  A condition where the pancreas stops being able to produce adequate insulin
• Insulin


  A hormone produced by the beta cells in the Islets of Langerhans in the pancreas. It is an anabolic hormone that reduces blood sugar levels by causing cells to absorb glucose from the blood and use it as fuel
• Glucagon


  A hormone produced by the alpha cells in the Islets of Langerhans in the pancreas. It is a catabolic hormone released in response to low blood sugar levels and stress
• Hyperglycaemia


  A condition where the glucose level in the blood keeps rising
• Glucose Metabolism


  Eating carbohydrates causes a rise in blood glucose levels, which are absorbed from the small intestine into the blood. The body uses these carbohydrates for energy, leading to a fall in blood glucose levels
• The underlying cause of type 1 diabetes is unclear. It may have a genetic component, but it is not inherited in any clear pattern. Certain viruses like Coxsackie B and enterovirus may trigger it
• Classic triad of symptoms of hyperglycaemia

  • Polyuria (excessive urine)
  • Polydipsia (excessive thirst)
  • Weight loss (mainly through dehydration)
• Type 1 diabetes may also present with diabetic ketoacidosis
• The body ideally wants to keep blood glucose concentration between 4.4 – 6.1 mmol/L
• Insulin is essential in enabling cells to take glucose out of the blood and use it as fuel. Without insulin, cells cannot take up and use glucose
• Insulin causes cells in the body to absorb glucose from the blood and use it as fuel. It also causes muscle and liver cells to absorb glucose from the blood and store it as glycogen in a process called glycogenesis
• Glucagon is released in response to low blood sugar levels and stress
• Glucagon


  A hormone produced by the alpha cells in the Islets of Langerhans in the pancreas. It is a catabolic hormone released in response to low blood sugar levels and stress to increase blood sugar levels
• Glucagon function


  Tells the liver to break down stored glycogen and release it into the blood as glucose (glycogenolysis). Also tells the liver to convert proteins and fats into glucose (gluconeogenesis)
• Ketones


  Water-soluble fatty acids produced in ketogenesis when there is insufficient glucose supply and glycogen stores are exhausted, such as in prolonged fasting
• Ketogenesis


  The production of ketones occurs when fatty acids are converted to ketones by the liver. Ketones can be used as fuel and cross the blood-brain barrier
• Producing ketones is normal and not harmful in healthy patients under fasting conditions or on very low carbohydrate, high-fat diets
• Ketone levels can be measured in the urine with a dipstick test and in the blood using a ketone meter
• People in ketosis have a characteristic acetone smell to their breath
• The kidneys buffer ketone acids in healthy people to prevent blood acidosis
• Type 1 diabetes causes extreme hyperglycaemic ketosis


  Results in life-threatening metabolic acidosis known as diabetic ketoacidosis
• Pathophysiology of Diabetic Ketoacidosis

  Occurs due to inadequate insulin. Common scenarios include the initial presentation of type 1 diabetes, an existing type 1 diabetic who is unwell, or not adhering to their insulin regime. Key features are ketoacidosis, dehydration, and potassium imbalance
• Without insulin, the body's cells cannot recognise glucose, leading to the production of ketones by the liver for fuel
• High blood glucose levels overwhelm the kidneys, causing dehydration through osmotic diuresis
• Insulin drives potassium into cells, without insulin potassium is not stored in cells leading to total body potassium being low
• Patients with diabetic ketoacidosis present with symptoms such as polyuria, polydipsia, nausea, vomiting, acetone smell to breath, dehydration, weight loss, hypotension, altered consciousness
• Diabetic ketoacidosis may be triggered by an underlying condition such as an infection
• It is important to look for signs of infections and other underlying pathology in patients with DKA
• Diagnosing Diabetic Ketoacidosis


  1. Check the

  2. Complete the diagnosis with appropriate tests and investigations
• Diabetic ketoacidosis may be triggered by an underlying condition, such as an infection
• In any patient with DKA, it is important to look for signs of infections and other underlying pathology that may need treatment
• Diagnosing Diabetic Ketoacidosis


  1. Check the local DKA diagnostic criteria for your hospital

  2. A diagnosis requires all three of: Hyperglycaemia (e.g., blood glucose above 11 mmol/L), Ketosis (e.g., blood ketones above 3 mmol/L), Acidosis (e.g., pH below 7.3)
• Treatment of Diabetic Ketoacidosis

  The most dangerous aspects of DKA are dehydration, potassium imbalance, and acidosis. Priority is fluid resuscitation to correct dehydration, electrolyte disturbance, and acidosis. This is followed by an insulin infusion to get the cells to start taking up and using glucose and stop producing ketones
• Diabetic ketoacidosis is a life-threatening medical emergency. Get experienced senior support and follow local protocols when treating patients. Local policies will dictate precisely what fluids and insulin to prescribe
• Principles of management for Diabetic Ketoacidosis

  • Fluids, Insulin, Glucose, Potassium, Infection, Chart fluid balance, Ketones
• TOM TIP: 'Remember, under normal circumstances, the rate of potassium infusion should not exceed 10 mmol/hour, as there is a risk of inducing an arrhythmia or cardiac arrest. In DKA, rates up to 20 mmol/hour may be used. Higher rates are only used in specific scenarios under expert supervision with cardiac monitoring and through a central line (rather than a peripheral cannula)'
• Checking for autoantibodies and serum C-peptide is not routinely recommended. They can be helpful when there is doubt about whether a patient has type 1 or type 2 diabetes
• Autoantibodies in type 1 diabetes

  • Anti-islet cell antibodies, Anti-GAD antibodies, Anti-insulin antibodies
• Serum C-peptide


  A measure of insulin production. It is low with low insulin production and high with high insulin production
• Long-Term Management of Type 1 Diabetes

  Monitoring and treatment are relatively complex, therefore patient education is essential. It involves components such as subcutaneous insulin, monitoring dietary carbohydrate intake, monitoring blood sugar levels, monitoring and managing complications, both short and long term