1	Type 1 Diabetes in Adults Francine Ratner Kaufman, M.D. Distinguished Professor of Pediatrics The Keck School of Medicine of USC Head, Center for Diabetes and Endocrinology Childrens Hospital Los Angele
2	Prevalence of Diabetes in the United States
3	Incidence of Type 1 Diabetes Incidence increasing by 3.4% per year 50% of patients diagnosed before age 20 years 50% of patients diagnosed after age 20 years Often mistaken for type 2 diabetes—may make up 10% to 30% of individuals diagnosed with type 2 diabetes Oral agents ineffective; insulin therapy required Autoimmune process slower and possibly different Can usually be confirmed by beta cell antibodies Loss of c-peptide
4	Making the Diagnosis of Type 1 Diabetes Symptoms of diabetes Polyuria, polydipsia, polyphagia, diabetic plus ketoacidosis (DKA) Random plasma glucose ³200 mg/dL* Fasting plasma glucose (FPG) ³126 mg/dL* Oral glucose tolerance test (OGTT) with 2-hour value ³200 mg/dL* Loss of c-peptide c-peptide<0.8 ng/dL Presence of islet autoantibodies GADA, ICA, IA-2A, IAA
5	Natural History of “Pre”–Type 1 Diabetes
6	Rationale for Intensive Therapy of Type 1 Diabetes Glucose Control Is Critical
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8	Risk of Progression of Microvascular Complications vs A1C DCCT
9	Intensive Therapy for Diabetes: Reduction in Incidence of Complications
10	Long-term Microvascular Risk Reduction in Type 1 Diabetes Combined DCCT-EDIC
11	Cost-Effectiveness of Intensive Therapy in Type 1 Diabetes DCCT Modeling Study
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13	Current Targets for Glycemic Control
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15	Action Profiles of Insulins
16	Normal Daily Plasma Insulin Profile Nondiabetic Obese Individuals
17	Basal/Bolus Treatment Program with Rapid-acting and Basal Analogs
18	Physiologic Multiple Injection Regimens The Basal-Bolus Insulin Concept Basal insulin Controls glucose production between meals and overnight Near-constant levels Usually ~50% of daily needs Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals Immediate rise and sharp peak at 1 hour postmeal 10% to 20% of total daily insulin requirement at each meal For ideal insulin replacement therapy, each component should come from a different insulin with a specific profile or via an insulin pump (with one insulin)
19	Basal-bolus Therapy: More frequent decision making, testing, and insulin dosing Allows for variable food consumption based on hunger level Ability to skip meal or snack if desired (bedtime) Reduced variability of insulin absorption Easy to adapt to acute changes in schedule (exercise, sleeping in on weekends)
20	Insulin Injection Devices Insulin pens Faster and easier than syringes Improve patient attitude and adherence Have accurate dosing mechanisms, but inadequate resuspension of NPH may be a problem
21	Mealtime Insulin and Severe Hypoglycemia Aspart vs Regular Insulin
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23	Insulin Pumps Continuous Subcutaneous Insulin Infusion (CSII) For motivated patients Expensive External, programmable pump connected to an indwelling subcutaneous catheter Only rapid-acting insulin Programmable basal rates Bolus dose without extra injection New pumps with dose calculator function Bolus history Requires support system of qualified providers
24	CSII vs Multiple Injections of Insulin Meta-analyses
25	Balancing Risk of Severe Hypoglycemia Against the Risk of Complications DCCT
26	Hypoglycemia Risk Factors
27	Weight Gain
28	Elderly Treatment Considerations
29	Special Considerations in the Elderly With Type 1 Diabetes Intensive therapy/tight control for otherwise healthy elderly patients Less strict glycemic goals for elderly patients with severe complications or comorbidities or with cognitive impairment FPG <140 mg/dL PPG <220 mg/dL
30	Risk of Hypoglycemia in the Elderly Erratic eating (quantities) Erratic timing of meals Renal impairment
31	Treatment Challenges in the Elderly With Type 1 Diabetes Lack of thirst perception predisposes to hyperosmolar state Confusion of polyuria with urinary incontinence or bladder dysfunction Increased risk of and from hypoglycemia Altered perception of hypoglycemic symptoms Susceptibility to serious injury from falls or accidents Compounding of diabetic complications by effects of aging Frequent concurrent illnesses and/or medications More frequent and severe foot problems
32	Monitoring Outcomes and Managing Risk Factors
33	Follow-up Visits Monitoring of Target Values: Cardiovascular Risk Factors
34	Follow-up Visits Quarterly Evaluations
35	Follow-up Visits Annual Evaluations
36	Diabetes as a Risk Equivalent of CAD
37	ABCs of CVD Risk Management
38	ABCs of CVD Risk Management (cont.)
39	ABCs of CVD Risk Management (cont.)
40	Management of Cardiovascular Risk in Diabetes Blood Pressure Control
41	Management of Cardiovascular Risk in Diabetes LDL Control
42	The Future of Type 1 Diabetes Care
43	Emerging Type 1 Diabetes Therapies
44	Inhaled Insulin in Type 1 Diabetes
45	New Class of Agents for Diabetes Pramlintide
46	Glucose Flux in Healthy Subjects
47	Multihormonal Regulation of Glucose Appearance and Disappearance
48	Pramlintide Improves Postprandial Glucose TYPE 1 DIABETES
49	Pramlintide Clinical Effects TYPE 1 DIABETES COMBINED PIVOTALS
50	Adverse Events* ³5% PRAMLINTIDE TYPE 1 DIABETES STUDIES
51	Continuous Glucose Monitoring Benefits of continuous glucose monitoring More complete glucose profile than with traditional SMBG Tracking of meal-related glycemic trends Detection of nocturnal hypoglycemia Facilitation of changes in insulin regimens Alarm for highs and lows (GlucoWatch) Remaining challenges Daily SMBG still required Not suited to many patients Limited accuracy, especially for hypoglycemia Glycemic pattern results confusing, subject to interpretation
52	Future Glucose Monitors Minimally invasive continuous glucose monitors Implanted glucose sensors Implanted insulin pumps “Closed-loop” systems
53	Can Type 1 Diabetes Be “Cured?” Islet Cell Transplantation 7 Type 1 Patients, Aged 29 to 54 Years, With History of Severe Hypoglycemia and Metabolic Instability
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