Metabolic control by insulin detemir in basal-bolus therapy: treat-to-target study in children and adolescents with type 1 diabetes

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Insulin and Adjunctive Treatments in Children and Adolescents with Diabetes

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and updates recommendations on the principles of intensive insulin regimens, including more intensive forms of multiple daily injections with new-generation faster-acting and ultra-long-acting insulins; a summary of adjunctive medications used alongside insulin treatment that includes details on pramlintide, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RA) and sodium-glucose cotransporter inhibitors; and key considerations with regard to access to insulin and affordability to ensure that all persons with diabetes who need insulin can obtain it without financial hardship.

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Comparison of Once-daily Versus Twice-daily Injection of Insulin Detemir in Children with Type 1 Diabetes Mellitus

Background: The purpose of this study was to compare the effectiveness of once-daily versus twice-daily insulin detemir injection in children with type 1 diabetes mellitus (T1DM). Methods: In this randomized 4-month clinical trial, 60 children aged 33 - 156 months with T1DM were randomly assigned into two groups, once-daily (group 1) and twice-daily (group 2) detemir insulin injection with pre-meal insulin Aspart. The first month of the study was devoted to educating the patients and insulin dose titration. Hemoglobin A1C (HbA1C) measured at the end of the first month and again after the fourth month. Hypoglycemia as one of the major complications was defined as blood glucose lower than 70 mg/dL with clinical symptoms or blood glucose lower than 50 mg/dL in the absence of clinical symptoms. Results: Mean HbA1C in the fourth month was 8.5% ± 1% in group 1 and 8.5% ± 1.1% in group 2 (P = 0.98). Mean changes in the fourth month compared to baseline were -0.09% (95% CI: -0.47 - 0.3) in group 1, and -0.42% (95% CI: -0.94 - 0.09) in group 2 (P = 0.273). The treatment modification rate was 39% and 15% in groups 1 and 2, respectively (P = 0.02). However, there were no statistically significant differences between the two groups in terms of insulin dose, hypoglycemia, and other complications. Conclusions: Twice-daily injections did not change HbA1c in comparison with once-daily injections. However, the lower treatment modification rate in the twice-daily group in the age group of our study was considerable.

Good glycemic control without exceeding the BMI trajectory during the first 5 years of treatment in children and adolescents with type 1 diabetes

OBJECTIVE

To study BMI changes and glycemic control in children and adolescents during the first 5 years following diagnosis of type 1 diabetes.

RESEARCH DESIGN AND METHODS

The 295 children and adolescents (<18 years) diagnosed with type 1 diabetes started on multiple injection treatment and were followed during the first 5 years of treatment with respect to glycemic control and weight change. Growth curves preceding the onset of diabetes were obtained from the school health services and child care centers. BMI was recalculated into BMI SD scores (BMISDS).

RESULTS

Prior to the onset of diabetes, the BMISDS was 0.46 ± 1.24 (mean ± SD), which decreased to -0.61 ± 1.36 (p < 0.001) at presentation. At 1 year, BMISDS was 0.59 ± 0.99 (p > 0.05) and increased to 0.80 ± 1.03 at 5 years; 0.97 ± 0.93 in females versus 0.68 ± 1.08 in males (p < 0.001). BMISDS at 1 year and 5 years were directly proportional to and highly predicted by BMISDS prior to the onset of type 1 diabetes, (r = 0.76; p < 0.001) vs. (r = 0.58; p < 0.001). HbA1c at 1 year was 50 ± 10 mmol/mol, which increased to 58 ± 12 mmol/mol (p < 0.001) at 5 years; females had HbA1c 60 ± 14 mmol/mol versus males 56 ± 11 mmol/mol (r = 0.35, p < 0.001). There was a correlation, irrespective of gender, between HbA1c and BMISDS at 1 year (r = 0.18, p < 0.003), but not at 5 years (r = 0.036, (p > 0.5).

CONCLUSION

During the first 5 years of treatment of type 1 diabetes in children and adolescents it is possible to achieve good glycemic control without excess weight gain.

Recovery of premorbid BMI trajectory without overshoot during the first year of treatment of children with type 1 diabetes

OBJECTIVE

To study body mass index (BMI) changes and metabolic control in children and adolescents during the first year following the diagnosis of type 1 diabetes.

RESEARCH DESIGN AND METHODS

200 children and adolescents (<18 years) diagnosed with type 1 diabetes, started on multiple injection treatment and followed up for 1 year were studied with respect to metabolic control and weight change. Growth curves preceding the onset of diabetes were procured from the school health services. BMI was recalculated into BMI SD scores (BMISDS).

RESULTS

Glycated hemoglobin (HbA1c) at 1 year was 6.7±1.3% (50±10 mmol/mol). HbA1c was positively correlated with daily insulin dose (R(2)=0.13; p<0.001), negatively correlated with age (R(2)=0.03; p<0.05) but not related to gender, BMISDS at 1 year, HbA1c at presentation, or ketoacidosis at presentation. Prior to the onset of diabetes, BMISDS was 0.41±1.20 and decreased to -0.63±1.25 at presentation. BMISDS at 1 year was 0.54±0.97 and not different from the premorbid value (p>0.05). In a multiple regression analysis, BMISDS at 1 year was directly proportional to and highly predicted by BMISDS prior to onset of diabetes (R(2)=0.57; p<0.001). BMISDS at 1 year was also inversely correlated with age (R(2)=0.03; p<0.001) but could not be predicted by gender, daily insulin dose, HbA1c at 1 year, HbA1c at presentation, or by ketoacidosis at presentation.

CONCLUSIONS

During the first year of treatment of type 1 diabetes in children and adolescents, it is possible to achieve good metabolic control without excess weight gain.

Type 1 Diabetes in the Young: Organization of Two National Centers in Israel and Slovenia

Type 1 diabetes is a chronic autoimmune disease that affects mainly young people. In the last 50 years, a steady increase of the T1D incidence in the young is reported worldwide, with an average 4 % increase annually. In addition, the mean age at the diagnosis is decreasing. Studies show that good metabolic control is important not only for delaying the chronic complications of diabetes but also for improving the quality of life of patients and their families. Continuous education, together with modern technology, is crucial in achieving these goals. Longitudinal data on glycated hemoglobin (HbA1c), along with the data on severe hypoglycemia and severe diabetic ketoacidosis, can describe the quality of care in a defined population. Two national reference diabetes centres taking care of children, adolescents and young adults with diabetes in Israel and Slovenia are described.

Influence of the Type of Basal Insulin and Other Variables on Clinical Outcomes in Children with Newly Diagnosed Type 1 Diabetes

Background. Basal insulin detemir and glargine each have characteristics that may make them a superior choice in children and adolescents with type 1 diabetes, but there is a paucity of data on glycemic results in this population. Objective. Examination of variables associated with achievement of HbA1c goal in children and adolescents with newly diagnosed type 1 diabetes. Methods. The primary outcome, factors associated with achievement of HbA1c goal, was examined in a retrospective chart review. Variables, including type of basal insulin, were collected during the first year of diagnosis of patients in a pediatric diabetes clinic. Secondary outcomes included change in HbA1c, severe hypoglycemic events, and episodes of DKA. Results. 94 patients were included in the study. HbA1c at diagnosis was found to be a significant predictor of achievement of goal at 3 months (P=0.002) and of change in HbA1c at 3 and 12 months (P<0.001 for each). Severe hypoglycemia and episodes of DKA were uncommon. Conclusions. Choice of basal insulin was not found to be a predictor of achieving HbA1c goal or of change in HbA1c over the course of the first year of diagnosis with type 1 diabetes.