TCA Suppression and DM1

TAGUM, Rubyrose G.
CASE

A 32-year-old male with type 1 diabetes since the age of

14 years was taken to the emergency room because of
drowsiness, fever, cough, diffuse abdominal pain, and
vomiting. Fever and cough started 2 days ago and the
patient could not eat or drink water. He has been
treated with an intensive insulin regimen (insulin
glargine 24 IU at bedtime and a rapid-acting insulin
analog before each meal).
CASE

On examination he was
tachypneic
temperature was 39 C (102.2 F)
pulse rate 104 beats per minute
respiratory rate 24 breaths per minute
supine blood pressure 100/70 mmHg
dry mucous membranes
poor skin turgor, and rales in the right lower chest
slightly confused
CASE

Rapid hematology and biochemical tests showed

hematocrit 48%,
hemoglobin 14.3 g/dl (143 g/L)
white blood cell count 18,000/l, glucose 450mg/dl (25.0 mmol/L)
urea 60 mg/dl (10.2 mmol/L)
creatinine 1.4 mg/dl (123.7 mol/L)
Na+ 152 mEq/L, K+ 5.3 mEq/L
PO4 32.3 mEq/L (0.74 mmol/L)
Cl 110 mmol/L
CASE

Arterial pH was 6.9

PO 2 95 mmHg
PCO 2 28 mmHg
HCO 39 mEq/L
O2 sat 98%.
The result of the strip for ketone bodies in urine was strongly
positive and the concentration of -OHB in serum was 3.5 mmol/L.
Urinalysis showed glucose 800 mg/dl and specific gravity 1030.
BIOCHEMICAL
PATHWAY
DIABETES

a number of diseases that involve problems with the

hormone insulin. Normally, the pancreas releases insulin
to help your body store and use the sugar and fat from
the food you eat.
occurs when one of the following occurs:
When the pancreas does not produce any insulin
When the pancreas produces very little insulin
When the body does not respond appropriately to insulin
TYPES OF DIABETES
DM T1 vs DM T2
DIABETES MELLITUS Type 1

when the body loses the ability to make insulin or can

only make a very small amount of insulin
usually caused by an autoimmune process, and your
bodys immune system mistakenly destroys the insulin-
producing cells
about 10% of individuals with diabetes have type 1
diabetes.
 DM1

SIGNS AND SYMPTOMS

DIAGNOSIS DM1

Diagnostic criteria by the American Diabetes Association

(ADA) include the following [2] :
A fasting plasma glucose (FPG) level 126 mg/dL (7.0
mmol/L), or
A 2-hour plasma glucose level 200 mg/dL (11.1 mmol/L)
during a 75-g oral glucose tolerance test (OGTT), or
A random plasma glucose 200 mg/dL (11.1 mmol/L) in a
patient with classic symptoms of hyperglycemia or
hyperglycemic crisis
MANAGEMENT DM1

Glycemic control
The ADA recommends using patient age as one consideration in the
establishment of glycemic goals, with different targets for preprandial,
bedtime/overnight, and hemoglobin A1c (HbA1c) levels in patients aged 0-6,
6-12, and 13-19 years.
Self-monitoring
Optimal diabetic control requires frequent self-monitoring of blood glucose
levels, which allows rational adjustments in insulin doses.
Insulin therapy
Patients with type 1 diabetes require lifelong insulin therapy. Most require 2
or more injections of insulin daily, with doses adjusted on the basis of self-
monitoring of blood glucose levels.
Diet and activity
INHERITANCE DM1

The cause of the autoimmune destruction of pancreatic B-cells is

still being researched, but genetics, viruses, allergens, and
environmental exposures are all potential causes.
It has been shown that all people with type 1 diabetes have at
least one similar gene.
Individuals who have a primary family member with type 1
diabetes have a 5-6% chance of developing the disease, while
individuals with no family history of the disease only have a 0.4%
chance of developing type 1 diabetes.
PATHOGENESIS
BIOCHEMICAL
PATHWAY
Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis (DKA)

an acute, major, life-threatening complication of
diabetes
mainly occurs in patients with type 1 diabetes, but it
is not uncommon in some patients with type 2
diabetes
a complex disordered metabolic state characterized
by hyperglycemia, ketoacidosis, and ketonuria.
SIGNS AND SYMPTOMS DKA

The most common early symptoms of DKA are the insidious

increase in polydipsia and polyuria.
The following are other signs and symptoms of DKA:
Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse abdominal pain,
decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1 diabetes
History of failure to comply with insulin therapy or missed insulin injections
due to vomiting or psychological reasons or history of mechanical failure of
insulin infusion pump
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion); frank coma is
uncommon but may occur when the condition is neglected or with severe
dehydration/acidosis
SIGNS AND SYMPTOMS DKA

Signs and symptoms of DKA associated with possible

intercurrent infection are as follows:
Fever
Coughing
Chills
Chest pain
Dyspnea
Arthralgia
DIAGNOSIS DKA

Ill appearance
Dry skin
Labored respiration
Dry mucous membranes
Decreased skin turgor
Decreased reflexes
Characteristic acetone (ketotic) breath odor
Tachycardia
Hypotension
Tachypnea
MANAGEMENT DKA

Treatment of ketoacidosis should aim for the following:

Fluid resuscitation
Reversal of the acidosis and ketosis
Reduction in the plasma glucose concentration to normal
Replenishment of electrolyte and volume losses
Identification the underlying cause
THANK YOU!!!