#7: Become #1 in the Diagnosis and Management of T1DM

September 2, 2020 | By Justin Berk

A guide to the diagnosis, workup, and management of type 1 diabetes with Dr. Hussein Abdullatif

Summary

Type 1 Diabetes – this episode is definitely a sweet one! Join us for a conversation with our guest Dr. Hussein Abdullatif (UAB), covering the diagnosis, workup, and management of Type 1 Diabetes Mellitus. We discuss the initial lab work-up, approach to treatment, atypical presentation, and how it’s okay to eat donuts around the time of an insulin shot!

Credits

• Written and Produced by: Shannon Snellgrove
• Infographic: Shannon Snellgrove
• Cover Art: Christopher Chiu MD (Cribsiders); Shannon Snellgrove (Curbsiders)
• Hosts: Justin Berk MD and Christopher Chiu MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Hussein Abdullatif MD

Time Stamps

• Diagnosis of T1DM 6:10
• Presentation of T1DM 9:30
• Explaining T1DM to a parent 11:20
• Genetic Predisposition to Diabetes 14:40
• T1DM Antibodies 16:30
• Initial workup for concomitant autoimmune disease 20:30
• Atypical Presentation of T1DM 22:14
• Treatment of T1DM 28:30
• Dietary Modifications in T1DM 32:30
• Checking blood sugars 39:10
• Honeymoon Period 41:45
• Hypoglycemia 43:20
• Sports, Sickness, Alcohol and Glucose levels 47:45
• Periop glucose management 50:30
• Long-term complications of T1DM 52:10
• Closed-Loop System and Future Treatments 55:30

Type 1 Diabetes Pearls

1. A Hemoglobin A1c ≤ 6.5% does not exclude T1DM
2. A person with normal glucose metabolism should never have blood sugars over 200, even if they just ate a big slice of cake! 
3. Begin conversations with families at the time of diagnosis by emphasizing that the family did nothing wrong to make their child have diabetes, nor could they have done anything to prevent their child from getting the disease.
4. Having a close family member with T1DM increases the risk of developing T1DM to 1 in 50. 
5. Negative antibodies do not exclude a diagnosis of T1DM, but it should trigger a thought process of thinking this could be another or new form of the disease that acts like T1DM but may not necessarily be T1DM. 
6. Screening for other autoimmune conditions such as thyroid disease and Celiac disease should be included as part of the diagnostic workup for T1DM. 
7. Insulin pumps can fail, so it is important that a patient knows how to manage their diabetes through injections in the case of pump failure. 
8. It is important to continually remind patients during the “Honeymoon phase” that it is indeed just a phase. Patients and families need to be prepped and educated to not panic when their diabetes control suddenly worsens. 

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Approach to Diagnosis 

Expert opinion: 

• • • One should have at least two separate lab draws in order to minimize the risk of lab/machine error, especially if the first value is a point-of-care test. 
    • It is not imperative to space out when you draw labs in order to diagnose diabetes.  

• A person with normal glucose metabolism should never have blood sugars over 200, even if they just ate a big slice of cake. 

Common presentations

• Typical presentation in ages 2 and up: fatigue, hunger, polyuria, polydipsia, and weight loss. 
• Can present in Diabetic Ketoacidosis (DKA) with signs and symptoms such as nausea/vomiting, abdominal pain, fatigue, and changes in the level of consciousness. The goal is to catch Type 1 Diabetes before DKA. 

Explaining the diagnosis

• In Type 1 Diabetes, the body doesn’t make insulin, which leads to a build up of glucose.
• There is a strong genetic component linked to Type 1 DM.
• Expert opinion: Dr. Latif describes how he often likes to begin the conversation with families at the time of diagnosis by emphasizing that the family did nothing wrong to make their child have diabetes, nor could they have done anything to prevent their child getting the disease. Families can often feel guilty and blame themselves for the diagnosis.  It is important to educate and empower families at the time of a diagnosis of T1DM.

Initial Workup for T1DM

Antibodies commonly ordered (Mayer-Davis et al. Ipsad Clinical Practice Guidelines. 2018.):

• Anti-glutamic acid decarboxylase 65 (anti-GAD)
• Some form of islet cell antibody (ica512, Ia2, etc.)
• Anti-zinc transporter 8
  • The presence of zinc transporter 8 antibodies make us lose the remaining islet cells faster (Williams, C.L., Long, A.E. Diabetologia. 2019.)
• •  

Expert opinion: The more antibodies you order, the more likelihood you will have at least one positive in someone with T1DM. If you order all three categories of antibodies, you will have a 90% chance of catching someone with T1DM. There are types of T1DM that will have negative antibodies.  Negative antibodies do not exclude a diagnosis of T1DM, but it should trigger a thought process of thinking this could be another or new form of disease that acts like T1DM but may not necessarily be T1DM. 

• Screening for other autoimmune conditions such as Celiac disease, thyroid disease, Addison’s disease, and inflammatory bowel disease should be included as part of the diagnostic workup for T1DM. 

Atypical presentations

Approach to Treatment

• Basal-bolus insulin is the mainstay treatment for T1DM
  • Basal insulin being long-acting and given once or twice daily. Bolus insulin is short-acting and given with meals or snacks and should be calculated from the number of carbohydrates consumed.
  • Expert opinion: Insulin pumps can fail, so it is important that a patient knows how to manage their diabetes through injections in case their pump fails. 
• Expert opinion: A patient’s social history should be taken into account when choosing a treatment regimen for T1DM. A diagnosis of diabetes can be shocking and stressful to a patient and their family at first.  It is easy for them to feel overwhelmed and defeated. It may be wise to start off slow with set doses of insulin or a sliding scale before introducing any formulas for counting carbohydrates to calculate insulin doses. 

Dietary Modifications

• While inpatient, a patient with diabetes can be given a regular diet since their blood sugars will be monitored regularly and given insulin based on a sliding scale.
• Patients should be educated on how to count carbohydrates in their diet to calculate the appropriate insulin bolus doses. Traditionally, 1 “carb” = 15 g of carbohydrates. 
  • Helping Your Child Count Carbohydrates
• Expert opinion: Dr. Latif explained that the only dietary modification that he advises at the time of diagnosis to his patients is to avoid sugary drinks.   A patient should be able to eat normally as long as they are able to accurately calculate the insulin dose needed based on the carbohydrates consumed. However, it has been shown that a low carb diet (30-50 g of carbs/day) can be beneficial for controlling their blood sugars (Lennerz et al. Pediatrics. 2018).  This is still an area of controversy due to the risk of hypoglycemia (O’Connor. The New York Times. 2018.). Dr. Latif counsels his patients who are interested in a low carb diet that they should start with a less extreme low carb option such as 50-70 g of carbs/day. 

Blood sugar goals

• Patients should check their blood sugars before each meal and before going to sleep
  • Following a new diagnosis, patients should check their blood sugar at 2 am to monitor overnight glucose levels.
  • Patients may also need to check their sugars after meals to confirm that their insulin boluses are appropriate. 
• There is a range of blood sugars that patients with diabetes should aim for depending on their age group. It is important to monitor the overall blood sugar pattern, not just individual measurements, with the goal of at least half of readings within the desired range.

“The Honeymoon phase”

• In T1DM, at least 80% of the insulin-producing islet cells are lost and the remaining ~20% that are present and capable of producing some insulin. After initiating treatment for T1DM, the islet cells remaining may start producing insulin. This may make it easier to control their diabetes shortly after initiating treatment, hence, “the honeymoon phase” (Abdul-Rasoul et. al Pediatric Diabetes. 2006).

Expert opinion: When the “Honeymoon Phase” ends, there is often panic from the family/child where they believe they are doing something wrong because the control of their diabetes is worsening. It is important to continually remind patients during the “Honeymoon phase” that it is indeed just a phase. Patients and families need to be prepped and educated to not panic when their diabetes control suddenly worsens. 

Hypoglycemia

A blood sugar <80 mg/dL should be considered low in a patient with diabetes. While physiologically, it is normal to have a blood sugar in the 60s or 70s, a patient with diabetes should aim for >80 in order to provide a buffer to prevent dangerously low blood sugars (<60).

Expert opinion: Dr. Laitf educates his patients to avoid blood sugars below 70 or 80 and to have no more than two blood sugars below 50 in one week. If they are having blood sugars below 50 often, then adjustments should be made in their treatment regimen to avoid the risk of hypoglycemia. 

The major risk of hypoglycemia is the development of neuroglycopenia (low glucose in the brain), which can lead to altered levels of consciousness and seizures (Driscoll et al. Current Diabetes Reports. 2016.).

Signs and symptoms of hypoglycemia include sweating, palpitations, tremors (SNS activation)

Expert opinion: Dr. Latif advises patients to  use the rule of 15:15:15 to treat hypoglycemia. 

• • If sugar is low, give 15 grams of carbohydrates and wait 15 minutes. If it is still low after 15 minutes, give another 15 grams of carbohydrates.  

Acute stressors and T1DM

• Sports can increase sympathetic tone, which raises blood sugar.  Additionally, sports increase aerobic metabolism which leads to the consumption of more glucose. However, muscles will not consume additional glucose if there is no insulin. Patients should not participate in exercise if they have high sugars (>350) or if ketones are present due to the potential to progress towards DKA. 
• During an acute illness, blood sugars can vary from high (due to increased stress hormones) to low (due to lack of dietary intake). Patients should take their basal insulin while sick, but check their blood sugars more often than normal and tailor their boluses accordingly. 

A1C goals/chronic complications

Complications depend on both how high the A1C’s are and for what length of time they were high.

• A1C’s should be measured every 3 months to assess overall glycemic control (Chiang et al. Diabetes Care. 2018.)
• Advise patients to aim for as low of an A1C as possible (<7.5%) while avoiding low sugars. Additionally, educate patients that the trend of A1C’s over time is more important than one specific value. (Chiang et al. Diabetes Care. 2018.)
• It is important for patients to receive preventative screenings for the complications of diabetes (eye exams, lipid profile, kidney function, urinalysis, peripheral neuropathy etc.) (Chiang et al. Diabetes Care. 2018. and AAP guidelines for retinopathy screening in T1DM).

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Goal

Listeners will feel confident in the presentation, diagnostic workup, and management of Type 1 Diabetes.

Learning objectives

After listening to this episode listeners will…  

1. Identify the signs and symptoms of type 1 diabetes 
2. Practice appropriate work-up in the diagnosis of type 1 diabetes
3. Manage type 1 diabetes with evidence-based therapies
4. Identify the appropriate insulin analogues in daily diabetes management using basal/bolus concepts
5. Educate patients and have meaningful discussions about effective self-management of type 1 diabetes (including diet and lifestyle changes)

Disclosures

Dr. Abdul-Latif reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.

Citation

Abdullatif H, Snellgrove S, Chiu C, Berk J. “Type 1 Diabetes”. The Cribsiders Pediatrics Podcast. https:/www.thecribsiders.com/ September 2, 2020