Bedtime insulin injections: an alternative regimen

Seasonal variation of haemoglobin A1 in children with insulin-dependent diabetes mellitus

The results of three controlled trials performed on children with insulin-dependent diabetes mellitus were examined for evidence of seasonal variation in concentrations of glycosylated haemoglobin (HbA1). All three studies showed lower levels during the summer months. Multiple regression analysis showed that the month of sampling accounted for a significant proportion of the total variance in HbA1 levels (P less than 0.001 in all three studies). We suggest that exercise, dietary changes and the frequency of minor illnesses may all contribute to this fluctuation which has important implications for the design of clinical trials in childhood diabetes.

Modern management of insulin-dependent diabetes mellitus

Currently available treatment methods, albeit improved, remain less than totally satisfactory. New developments such as improved viability of whole organ pancreatic transplants, islet cell transplantation, immunosuppression in the treatment of new-onset diabetes, development of reliable glucose sensors to provide continuous feedback for insulin delivery devices, and alternate routes for insulin administration may drastically change diabetes treatment in the future. For now, physicians must carefully consider the risks and benefits associated with available treatments when discussing therapeutic options with patients and their families. The wide range of therapies available provides the opportunity for patient and physician to select the most appropriate treatment regimen.

Two or three insulin injections in adolescence?

Morning hyperglycaemia remains a challenge to conventional insulin regimens. Eighteen adolescents participated in a one year crossover study to examine the effect of delaying the evening intermediate acting insulin from before the evening meal to bedtime. This three injection regimen caused slightly higher blood glucose concentrations in the early part of the night, and lower concentrations in the morning, but no overall change in glycosylated haemoglobin concentrations (HbA1c). Seasonal change accounted for substantially more of the variance in HbA1c concentrations than did the regimen change. The three injection regimen did not alter the frequency of hypoglycaemic episodes. Metabolic control on both regimens might have been improved by more intensive monitoring and medical attention. This study suggests that factors beyond medical control, such as seasonal variation, may contribute more to the control of diabetes in adolescents than changes in conventional insulin regimens, particularly when unaccompanied by intensive monitoring.