Comparison of breakfast and bedtime administration of insulin glargine in children and adolescents with Type 1 diabetes

Insulin regimens for newly diagnosed children with type 1 diabetes mellitus in Australia and New Zealand: A survey of current practice

AIM

There is no consensus on the optimal insulin treatment for children newly diagnosed with type 1 diabetes mellitus (T1DM). The aims of this study were (i) to describe the insulin regimens used at diagnosis by patient age and geographical region and (ii) to explore differences between and within Australia (AU) and New Zealand (NZ) with regards to other aspects of patient management and education.

METHODS

An online survey of medical professionals caring for children with T1DM in AU and NZ was undertaken. Questions included clinic demographics, insulin regimen/dosing choices and patient education.

RESULTS

Of 110 clinicians identified, 100 responded (91%). The majority of those in AU (69%, P < 0.0001) favour multiple daily injections (MDI) for all ages. In NZ, for patients < 10 years old, (twice daily (BD)) BD therapy was favoured (75%, P < 0.0001), with MDI dominant for ages ≥ 10 years (82%, P < 0.0001). Insulin pump therapy was never considered at diagnosis in NZ, but 38% of clinicians in AU considered using pumps at diagnosis in patients <2 years, but rarely in patients aged 2 and over (16%). Differences in clinician choices were also seen in relation to starting insulin dose.

CONCLUSION

This is the first study to examine current clinical practice with regards to children newly diagnosed with T1DM. Practice varies across Australasia by clinician and region. This lack of consensus is likely driven by ongoing debates in the current paediatric diabetes evidence base as well as by differences in clinician/centre preference, variations in resourcing and their interpretations of the influence of various patient factors.

A randomized clinical trial comparing breakfast and bedtime administration of insulin glargine in children and adolescents with type 1 diabetes

BACKGROUND

Insulin glargine provides effective glycemic control when administered at bedtime in adults.

OBJECTIVE

This study aims to investigate whether insulin glargine is equally effective if administered in the morning or at bedtime in combination with preprandial anologue insulin.

METHODS

Twenty-eight patients that have been treated with an intensified insulin regimen for at least one year were randomized to insulin glargine injection at breakfast (06:00-09:00) (12 patients) or bedtime (21:00-24:00) (16 patients), plus meal-time anologue insulin in the two groups. Glucose data from each day were analyzed at four different times: between 9:00 and 21:00 (t1), between 21:00 and 24:00 (t2), between 24:00 and 04:00 (t3),04:00 and 09:00 (t4) by the Minimed continuous glucose monitoring system.

RESULTS

Baseline characteristics were similar in the two groups. The sensor values were lower before breakfast in the bedtime group (180.5 ± 49.0 vs 223.8 ± 47.3 mg/dl, p=0.03). There were 13.7 events.patient (-1).day(-1) in the bedtime group and 6.9 events.patient (-1).day(-1) in the breakfast group in which glucose levels fell below 60 mg/dl (p=0.3). There were 121.6 events.patient (-1).day(-1) in the bedtime group and 162.4 events.patient (-1).day(-1) in the breakfast group in which glucose levels exceeded 180 mg/dl (p=0.05). Nighttime hypoglycemia only reached to a statistical significance between the two groups between 24:00 and 04:00. There were no significant correlations between the duration of nocturnal hypoglycemia, age, duration of diabetes, gender and HbA1c levels.

CONCLUSION

Breakfast group is hyperglycemic during the day and hyperglycemia starts in the morning at 04:00. There is no significant difference in the frequency or duration of hypo/hyper glycemia during the day and night irrespective of the timing of glargine injection except pre-breakfast levels are significantly better in the bedtime group and hypoglycemia occurs between midnight and 04:00 in the bedtime group.

The Transition from Insulin Infusions to Long-Term Diabetes Therapy: The Argument for Insulin Analogs

After cardiac surgery, it is medical mismanagement to place an order for sliding scale insulin at the time of transitioning from intravenous insulin. Use of basal-prandial-correction therapy with insulin analogs constitutes a suitable transitioning regimen for inpatient management of hyperglycemia after heart surgery, to be ordered before interruption of intravenous insulin infusion, in conjunction with a program of blood glucose monitoring before meals, at bedtime, and midsleep. In the ambulatory setting, in comparison to neutral protamine Hagedorn, long-acting insulin analogs reduce hypoglycemia. In comparison to regular insulin, rapid-acting insulin analogs reduce hypoglycemia and improve postprandial control. A standardized approach to order entry for basal-prandial-correction therapy enhances safety and staff familiarity while preserving individualization of patient care. Proposed predictors of successful transition are described. Dose requirements during intravenous insulin infusion can be used to guide initial dose assignments of basal insulin therapy. As the patient approaches discharge, the total daily doses of subcutaneous insulin and basal insulin dose are decreased, and the proportion of prandial insulin approaches or exceeds 50% of the total daily dose as the absolute amount of prandial insulin increases. Before discharge, hyperglycemic patients not known to have diabetes should be advised of the need for outpatient reassessment, and those known to have diabetes but requiring intensification of therapy should participate in decision-making concerning their options for intensified treatment.