Modifications of metabolic control in type 1 diabetic children and adolescents: experience over the last 20 years

A review of 25 years' experience with the NovoPen family of insulin pens in the management of diabetes mellitus

NovoPen, the first insulin pen, was introduced in 1985. This review article is an update of a review paper published in 2006 on 20 years' use of the NovoPen family of insulin pens in the management of diabetes mellitus. The literature searches conducted in the earlier review article were updated with search results for new articles published since April 2005. This was followed by an iterative search of references cited in identified publications and by searches of abstracts from proceedings of major international diabetes conferences since 2005. Most of the original studies identified in the 2006 review showed that insulin regimens using the NovoPen family of insulin pens were at least as effective (and in some cases superior) in maintaining glycaemic control and were as safe (in terms of hypoglycaemia) as conventional insulin regimens employing vials and syringes. Most patients preferred the various NovoPen insulin pens over vials and syringes, with some evidence suggesting that the use of discreet devices, such as those of the NovoPen family, facilitates intensive insulin therapy regimens, thereby helping to improve lifestyle flexibility. The new search results showed that the current generation of the device for the adult population, NovoPen 4, retains these benefits and further meets patients' needs by improving ease of use, convenience and discretion, which may be particularly important for those with manual dexterity, visual or auditory impairments. There was also evidence that healthcare professionals would be more likely to recommend NovoPen 4 to their patients than other devices. The recently introduced NovoPen Echo, designed specifically for the paediatric population, combines half-increment dosing with a memory function that can be used to retrieve information about the time and amount of the last dose, potentially reducing the fear of double dosing or missing a dose. Evidence obtained from the new searches suggested that paediatric patients, their parents and healthcare professionals were highly satisfied with NovoPen Echo overall, with most paediatric patients rating it their favourite pen compared with other insulin pens. In conclusion, new data published over the last 5 years on the use of NovoPen devices add to the large body of published evidence supporting the patient-related benefits of durable insulin injection pens in the treatment of diabetes since the first such pen was introduced in 1985. Together, the benefits of NovoPen are considered likely to improve both patients' quality of life and their compliance with therapy.

A Review of 20??Years??? Experience with the Novopen?? Family of Insulin Injection Devices

NovoPen, the first insulin pen injector, was introduced in 1985. This article reviews the published evidence over two decades of use of the NovoPen family of injection devices in diabetes management. A search for NovoPen publications from 1985 onwards was conducted in the following databases: MEDLINE/PubMed, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, Database of Abstract Reviews and Effects, and Cochrane Controlled Trials Register. Publications were examined and underwent a selection process to identify studies of NovoPen devices (NovoPen [1], NovoPen 2, NovoPen 1.5 and NovoPen 3) in the diabetes/insulin therapy area that contained evidence of the effects of NovoPen in a variety of categories. Of the studies identified, most showed that insulin regimens using the NovoPen family of devices are at least as effective (and in some cases superior) in maintaining glycaemic control and are as safe (in terms of hypoglycaemia) as conventional insulin regimens employing syringes. The published evidence identified also showed that insulin administration via NovoPen devices was for most patients easier, more convenient and quicker than with conventional syringes and that most patients preferred the various NovoPen devices over syringes. There was also some evidence that the use of discreet devices, like those of the NovoPen family, facilitates adherence to intensive insulin therapy regimens, helps to improve lifestyle flexibility and reduces injection pain compared with conventional syringe-based regimens. Together these benefits of NovoPen devices are considered likely to improve both patients' quality of life and compliance with therapy. In conclusion, a large body of published evidence accumulated over the past two decades testifies to the patient-related benefits of the NovoPen family of insulin injection devices in the treatment of diabetes.

Lung function in children with diabetes mellitus

A cross-sectional study design was undertaken to assess pulmonary function in children with insulin-dependent diabetes mellitus (IDDM), and to establish if there is any relationship with diabetic factors and complications. Thirty-eight children (10 +/- 1.8 years) with IDDM and without clinical or radiological evidence of lung involvement, and 41 healthy age-matched reference subjects, underwent a pulmonary function study. Thirteen (34%) of 38 subjects with IDDM were studied at the onset of their disease. Adjusted values expressed as SD score of forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV(1)), and the transfer factor for carbon monoxide (TLCO) were found to be significantly lower than in controls (-0.54 +/- 0.87 vs. 0.40 +/- 1.10, P = 0.0008; -0.11 +/- 0.96 vs. 0.52 +/- 1.07, P = 0.01; -1.60 +/- 1.07 vs. -0.57 +/- 1.28, P = 0.001, respectively). These differences also existed in the group investigated at onset of diabetes. Residual volume (RV) and RV/total lung capacity ratio (RV/TLC) were significantly higher in the whole group of patients with IDDM than in controls (-0.20 +/- 0.83 vs. -0.80 +/- 0.88, P = 0.003; and 26 +/- 6.2 vs. 21 +/- 5.0, P = 0.0002, respectively). Seventeen patients (45%) had abnormal pulmonary function (SD score, less than -1.64): 16 subjects had reduced TLCO, 4 had reduced FVC, and in 3 of the 17, both functional indices were abnormal. There was no significant relationship between pulmonary function indices and diabetic factors or complications. The only significant association was between abnormal TLCO and females (P = 0.03), suggesting that sex may be a predisposing factor for the development of pulmonary complications. This study supports the view that the lung is functionally involved in children with IDDM early on in the course of the disease.

Diabetic retinopathy in childhood: long-term follow-up by fluorescein angiography beginning in the first months of disease

BACKGROUND

Little is known about minimal retinal lesions occurring in the first months of disease in children with type 1 diabetes mellitus (DM).

OBJECTIVE

To detect any early retinal change and to evaluate its progression in children diagnosed with type 1 DM.

PATIENTS

From 1979 to 1997 we examined by fluorescein angiography at diagnosis or within 15 months from the onset of DM 130 young patients with type 1 DM (mean age at diagnosis 10.08 +/- 2.62 yr). In 112 patients follow-up by fluorescein angiography was performed every 1.26 years with a mean of 5.41 fluorescein angiographies/patient.

METHODS

The stage of retinopathy was graded to detect minimal lesions. We also considered sex, pubertal stage, HLA, family history of DM, disease duration and HbA1c levels.

RESULTS

At first examination, 14 out of 127 (11%) readable angiographies showed minimal retinal changes. There was no statistically significant difference between the patients with or without lesions for all parameters considered. The 112 patients examined during follow-up were divided as follows: Group A: no retinopathy at first examination; Group A1: no retinopathy during follow-up; Group A2: retinal changes during follow-up; Group B: retinal changes at the first examination. Mean HbA1c value evaluated during the whole follow-up was lower in group A1 than in group A2. HbA1c levels at onset of the disease were significantly different in the three groups: in group A1 it was lower than in group A2 and in group B.

CONCLUSIONS

The presence of early lesions in the first year of disease in 11% of patients is probably due to the method of examination, which may detect even minimal retinal changes. This may be correlated to the acute metabolic failure present at the onset of disease. The prolonged follow-up seems to demonstrate that the early changes are not necessarily a negative prognostic factor in the evolution of diabetic retinopathy. We confirm that duration of DM and metabolic control are the main factors influencing the course of retinopathy in these young patients. Early fluorescein angiography is not particularly useful in the management of children with DM.