type 1 diabetes karen s. penko, md fellow, pediatric endocrinology september 2005

Type 1 DiabetesType 1 Diabetes

Karen S. Penko, MDKaren S. Penko, MD

Fellow, Pediatric EndocrinologyFellow, Pediatric Endocrinology

September 2005September 2005

PREP Content SpecificationsPREP Content Specifications

• Recognize signs/symptomsRecognize signs/symptoms

• Know how to treat type 1 diabetesKnow how to treat type 1 diabetes

• Know the value of hemoglobin A1cKnow the value of hemoglobin A1c

• Know the natural historyKnow the natural history

• Counsel patients on self-managementCounsel patients on self-management

• Differentiate Somogyi & dawn Differentiate Somogyi & dawn phenomenaphenomena

PREP Content SpecificationsPREP Content Specifications

• Know how to manage sick daysKnow how to manage sick days

• Know the long-term complicationsKnow the long-term complications

• Know importance of blood glucose Know importance of blood glucose control in preventing long-term control in preventing long-term complicationscomplications

• Recognize the association with other Recognize the association with other autoimmune disordersautoimmune disorders

Gary Hall Jr.Gary Hall Jr.

Olympic swimming Olympic swimming medalistmedalist

Type 1 diabetesType 1 diabetes

Case 1Case 1

• 18 y/o white male, father pages on-call 18 y/o white male, father pages on-call peds endo:peds endo:– Polyuria, polydipsia x 1 weekPolyuria, polydipsia x 1 week– 16 y/o brother has type 1 diabetes16 y/o brother has type 1 diabetes– Using brother’s supplies, BG “high”, large Using brother’s supplies, BG “high”, large

urine ketonesurine ketones– What should we do?What should we do?

• Leaving for college next weekLeaving for college next week

At WRAMC EDAt WRAMC ED

Serum glucoseSerum glucose

Venous pHVenous pH

BicarbBicarb

UAUA

Serum acetone Serum acetone

ElectrolytesElectrolytes

497 mg/dl497 mg/dl

7.3967.396

27 mmol/l27 mmol/l

150 mg/dl ketones, + glucose150 mg/dl ketones, + glucose

NegativeNegative

Na 133, K 4.2, Cl 94, BUN 14, Na 133, K 4.2, Cl 94, BUN 14, creat 0.8creat 0.8

Diagnostic CriteriaDiagnostic Criteria

• Symptoms of diabetes and a casual plasma Symptoms of diabetes and a casual plasma glucose glucose 200 mg/dl, OR200 mg/dl, OR

• Fasting plasma glucose Fasting plasma glucose 126 mg/dl, OR126 mg/dl, OR

• 2-hour plasma glucose 2-hour plasma glucose 200 mg/dl during an 200 mg/dl during an oral glucose tolerance test.oral glucose tolerance test.

• In the absence of unequivocal hyperglycemia, In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat these criteria should be confirmed by repeat testing on a different day.testing on a different day.

Presenting Signs/SymptomsPresenting Signs/Symptoms

• Polyuria, PolydipsiaPolyuria, Polydipsia• Nocternal enuresisNocternal enuresis• PolyphagiaPolyphagia• Weight lossWeight loss• Fatigue, weaknessFatigue, weakness• Blurry visionBlurry vision• Ketoacidosis: abdominal pain, nausea, Ketoacidosis: abdominal pain, nausea,

vomiting, mental status changesvomiting, mental status changes

EpidemiologyEpidemiology

• Prevalence 1:300Prevalence 1:300

• Peak age of diagnosis: 11-13 y/oPeak age of diagnosis: 11-13 y/o

• Risk for sibling: 6%Risk for sibling: 6%

• Risk for monozygotic twin: 50%Risk for monozygotic twin: 50%

• Risk for offspring: 2-10%, higher side if Risk for offspring: 2-10%, higher side if father has diabetesfather has diabetes

• Highest incidence: Finland, SardiniaHighest incidence: Finland, Sardinia

PathophysiologyPathophysiology

• Autoimmune destruction of pancreatic Autoimmune destruction of pancreatic --cellcell

• Antibodies: Antibodies: – Islet cellIslet cell– InsulinInsulin– Anti-glutamic acid decarboxylase 65Anti-glutamic acid decarboxylase 65

• T-cell mediated T-cell mediated • Lymphocytic infiltrationLymphocytic infiltration

PathophysiologyPathophysiology

• Genetic susceptibilityGenetic susceptibility– Association with HLA DR3/4, DQ 2/8 allelesAssociation with HLA DR3/4, DQ 2/8 alleles

• Environmental triggersEnvironmental triggers– Viruses: congenital rubella, coxsackievirus, Viruses: congenital rubella, coxsackievirus,

enterovirus, mumpsenterovirus, mumps– Early exposure to cow’s milkEarly exposure to cow’s milk

Progression to Type 1 DMProgression to Type 1 DM

Autoimmune destruction

“Diabetes threshold”

Honeymoon

100% Islet loss

Autoimmune markers (ICA, IAA, GAD)

Islet Cell Mass

Associated Autoimmune Associated Autoimmune DisordersDisorders

• Thyroid (Hashimoto’s, Graves’): 5-10%Thyroid (Hashimoto’s, Graves’): 5-10%

• Celiac Disease: 6%Celiac Disease: 6%

• Addison’s disease: <1%Addison’s disease: <1%

Nicole JohnsonNicole Johnson

Miss America 1999Miss America 1999


ManagementManagement

• Diabetes teamDiabetes team

• InsulinInsulin

• DietDiet

• ExerciseExercise

• Psychological supportPsychological support

Banting and BestBanting and Best

1923 Nobel Prize for 1923 Nobel Prize for discovery and use of discovery and use of insulin in the insulin in the treatment of IDDMtreatment of IDDM

Patient J.L., December 15, 1922

February 15, 1923

The Miracle of InsulinThe Miracle of Insulin

Insulin Preparations - USInsulin Preparations - US

• Novo NordiskNovo Nordisk– NovoLog (aspart)NovoLog (aspart)

– NovoLog Mix 70/30NovoLog Mix 70/30

– NovolinNovolin R R

– NovolinNovolin N N

– NovolinNovolin 70/30 70/30

• Sanofi-AventisSanofi-Aventis– LantusLantus (glargine) (glargine)

• LillyLilly– Humalog (lispro)Humalog (lispro)

– Humalog Mix 75/25Humalog Mix 75/25

– HumulinHumulin R R

– HumulinHumulin N N

– HumulinHumulin 70/30 70/30

– HumulinHumulin 50/50 50/50

• Lente, Ultralente have Lente, Ultralente have been discontinuedbeen discontinued

Treatment with InsulinTreatment with Insulin

• Total daily requirement:Total daily requirement:– 0.5-1 unit/kg/day0.5-1 unit/kg/day– 1.5 units/kg/day during puberty1.5 units/kg/day during puberty

• Typical RegimensTypical Regimens– NPH and RegularNPH and Regular– Basal/Bolus: glargine and Novolog/HumalogBasal/Bolus: glargine and Novolog/Humalog

Insulin DeliveryInsulin Delivery

• Vials and syringesVials and syringes

• PensPens

• Insulin pumpInsulin pump

4:004:00

2525

5050

7575

8:008:00 12:0012:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch DinnerDinner

Pla

sma

insu

lin

(P

lasm

a in

suli

n (µ U

/ml)

U

/ml)

TimeTime

8:008:00

Physiological Serum Insulin Physiological Serum Insulin Secretion ProfileSecretion Profile

Dawn Dawn phenomenonphenomenon

4:004:00

2525

5050

7575

8:008:00 12:0012:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch DinnerDinner

Pla

sma

insu

lin

(P

lasm

a in

suli

n (µ U

/ml)

U

/ml)

TimeTime

8:008:00

NPH and RegularNPH and Regular

RR RR

N N

AM 2/3AM 2/3

PM 1/3PM 1/3

2/3 NPH2/3 NPH

1/3 Regular1/3 Regular

½ NPH (2/3)½ NPH (2/3)

½ Regular (1/3)½ Regular (1/3)



• Regular insulin given 30 min prior to a Regular insulin given 30 min prior to a mealmeal

• NPH dose often given at bedtimeNPH dose often given at bedtime

• Prescribed amount of carbs at Prescribed amount of carbs at meals/snacksmeals/snacks


• AM blood glucoses AM blood glucoses → Evening NPH→ Evening NPH

• Lunch → AM RegularLunch → AM Regular

• Dinner → AM NPHDinner → AM NPH

• Bedtime → PM RegularBedtime → PM Regular

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

8:0012:008:00

Time

Glargine

Lispro Lispro Lispro

Aspart Aspart Aspartor oror

Pla

sma

insu

lin

Basal/BolusBasal/Bolus


• Basal: glargine, 50% total daily doseBasal: glargine, 50% total daily dose

• Bolus: NovoLog or Humalog Bolus: NovoLog or Humalog – Insulin to carbohydrate ratioInsulin to carbohydrate ratio– Correction Correction

BG – targetBG – targetCorrection factorCorrection factor


• I:CHO = 450/total daily insulin dose = I:CHO = 450/total daily insulin dose = amount of carbs 1 units will coveramount of carbs 1 units will cover

• Correction Factor: “1700 rule” = Correction Factor: “1700 rule” = 1700/TDD1700/TDD

• Glargine can not be mixed with any other Glargine can not be mixed with any other insulinsinsulins


• Glargine dose limited by which blood Glargine dose limited by which blood sugar? sugar? – 2 AM and breakfast2 AM and breakfast

• Which blood sugar is affected by the Which blood sugar is affected by the I:CHO ratio?I:CHO ratio?– 2 hour post-prandial2 hour post-prandial


• AdvantagesAdvantages– 2-3 shots per day2-3 shots per day– ““Easier” – less carb counting and Easier” – less carb counting and

calculationscalculations

• DisadvantagesDisadvantages– Strict dietary planStrict dietary plan– Less flexibleLess flexible– Less physiologicLess physiologic


• AdvantagesAdvantages– More physiologicMore physiologic– More flexibleMore flexible– Less hypoglycemiaLess hypoglycemia

• DisadvantagesDisadvantages– More labor-intensive (CHO counting, insulin More labor-intensive (CHO counting, insulin

calculations)calculations)– At least 4 injections per dayAt least 4 injections per day

DietDiet

• Healthy, balanced dietHealthy, balanced diet– 50-60% total calories from carbohydrate50-60% total calories from carbohydrate– <30% fat<30% fat– 10-20% protein10-20% protein

• Carbohydrate countingCarbohydrate counting

• No forbidden foods - moderationNo forbidden foods - moderation

• Eating too much will not cause ketosisEating too much will not cause ketosis

ExerciseExercise

• Increases sensitivity to insulin Increases sensitivity to insulin

• Helps control blood sugarHelps control blood sugar

• Lowers cardiovascular riskLowers cardiovascular risk

• Blood sugar usually decreases but may Blood sugar usually decreases but may initially increaseinitially increase

• Hypoglycemia may occur during, Hypoglycemia may occur during, immediately after, or 8-24 hours laterimmediately after, or 8-24 hours later

ExerciseExercise

• Check blood sugar before, during, afterCheck blood sugar before, during, after

• Always have snacks availableAlways have snacks available

• May need extra snacks or decreased May need extra snacks or decreased insulin (learn from experience)insulin (learn from experience)– Usually 15 gm CHO for every 30 min Usually 15 gm CHO for every 30 min

vigorous exercisevigorous exercise

• Do not exercise if ketones are presentDo not exercise if ketones are present

Psychosocial SupportPsychosocial Support

• Every newly diagnosed family should Every newly diagnosed family should meet with a psychologistmeet with a psychologist

• GuiltGuilt

• AngerAnger

• FearFear

• DenialDenial

• DepressionDepression

Case 1: Special Concerns for Case 1: Special Concerns for College StudentsCollege Students

• IndependenceIndependence

• Dining hall foodDining hall food

• Alcohol – lowers blood sugarAlcohol – lowers blood sugar

• Roommate aware of diabetes, glucagonRoommate aware of diabetes, glucagon

• Airline travel – prescription labelsAirline travel – prescription labels

Case 1Case 1

• Discharged after teaching complete onDischarged after teaching complete on– Glargine and HumalogGlargine and Humalog– 0.7 units/kg/day0.7 units/kg/day

• 3 weeks after diagnosis blood sugars 3 weeks after diagnosis blood sugars begin going lowbegin going low

• What is going on?What is going on?

Honeymoon PhaseHoneymoon Phase

• Educate that it may happenEducate that it may happen

• Diabetes is not cured!Diabetes is not cured!

• Occurs within first 3 months of diagnosisOccurs within first 3 months of diagnosis

• Insulin requirements <0.5 units/kg/dayInsulin requirements <0.5 units/kg/day

• Lasts weeks to up to 2 yearsLasts weeks to up to 2 years

• Resolution of glucotoxicity, recovery of Resolution of glucotoxicity, recovery of residual residual ββ-cell function-cell function

Case 1Case 1

• Blood glucoses continue to be so low that Blood glucoses continue to be so low that pt takes himself off all insulinpt takes himself off all insulin

• Normal blood glucoses for 5 months off Normal blood glucoses for 5 months off insulininsulin

• Blood glucoses begin to riseBlood glucoses begin to rise

• HomesicknessHomesickness

• DepressionDepression

Long Term ComplicationsLong Term Complications

• RetinopathyRetinopathy

• NephropathyNephropathy

• NeuropathyNeuropathy

• Cardiovascular diseaseCardiovascular disease

• Prevention by optimal glucose controlPrevention by optimal glucose control

Diabetes Control and Diabetes Control and Complications TrialComplications Trial

Conventional TherapyConventional Therapy• 1-2 injections/day1-2 injections/day• Mean A1c 9%Mean A1c 9%

Intensive TherapyIntensive Therapy• ≥≥3 injections/day3 injections/day• Mean A1c 7%Mean A1c 7%

• 1983-1993, early termination given results1983-1993, early termination given results• Intensive therapy delays onset and progressionIntensive therapy delays onset and progression of long-term complications in type 1 diabetesof long-term complications in type 1 diabetes

Diabetes Control and Diabetes Control and Complications TrialComplications Trial

• Intensive therapy reduced risk by:Intensive therapy reduced risk by:– 76% for retinopathy76% for retinopathy– 54% for nephropathy54% for nephropathy– 69% for neuropathy69% for neuropathy– 41% for macrovascular disease41% for macrovascular disease

• Adverse eventsAdverse events– HypoglycemiaHypoglycemia– Weight gainWeight gain

Case 1 – Follow-up visitCase 1 – Follow-up visit

• Home from college on breakHome from college on break

• Insulin requirement 0.5 units/kg/dayInsulin requirement 0.5 units/kg/day

• Physical examPhysical exam

• Monitoring for complicationsMonitoring for complications

Physical ExamPhysical Exam

• Height, weight, BPHeight, weight, BP

• Pubertal progressionPubertal progression

• ThyroidThyroid

• AbdomenAbdomen

• Shot sites - lipohypertrophyShot sites - lipohypertrophy

• FeetFeet

• Medical alert tagMedical alert tag

Necrobiosis LipodicaNecrobiosis Lipodica

Prayer SignPrayer Sign

Limited joint Limited joint mobilitymobility

Associated with: Associated with: poor control, poor control, increased risk of increased risk of retinopathy, retinopathy, nephropathynephropathy

MonitoringMonitoring

• Hemoglobin A1c – every 3 monthsHemoglobin A1c – every 3 months• Celiac screen – at diagnosis and if ssxCeliac screen – at diagnosis and if ssx• AnnuallyAnnually

– TSHTSH

– Ophthalmology exam - after 10 and 3-5 yrs disease Ophthalmology exam - after 10 and 3-5 yrs disease

– Urine microalbumin - after 10 and 5 yrs diseaseUrine microalbumin - after 10 and 5 yrs disease

– Lipid panel - puberty, unless fam hx, q5 years if Lipid panel - puberty, unless fam hx, q5 years if normalnormal

– Influenza vaccine Influenza vaccine

Case 1Case 1

• Hemoglobin A1c - 6.0%Hemoglobin A1c - 6.0%

• Ophthalmology exam – no retinopathyOphthalmology exam – no retinopathy

• TSH, FT4 – normalTSH, FT4 – normal

• Lipids – cholesterol 143Lipids – cholesterol 143

• Urine microalbumin - negativeUrine microalbumin - negative

Hemoglobin A1cHemoglobin A1c

• Reflects blood Reflects blood glucose over the past glucose over the past 3 months3 months

• Goal <7 for adultsGoal <7 for adults

<7.5% for teens<7.5% for teens

<8% for 6-12 y/o<8% for 6-12 y/o

7.5-8.5% for <6 y/o7.5-8.5% for <6 y/o

A1CA1C BGBG

66 135135

77 170170

88 205205

99 240240

1010 275275

1111 310310

1212 345345

Case 1Case 1

• 1 year after diagnosis, remains diligent 1 year after diagnosis, remains diligent about sending blood sugarsabout sending blood sugars

• Insulin requirements 0.5 units/kg/dayInsulin requirements 0.5 units/kg/day

• A1c 5.9%A1c 5.9%

• Interested in the insulin pumpInterested in the insulin pump

) ) ) ) ) ) ) ) ) )

) ) )

Insulin Pump CandidatesInsulin Pump Candidates

• Highly motivatedHighly motivated

• Willing to perform frequent blood Willing to perform frequent blood glucose monitoringglucose monitoring

• Good control on basal/bolus regimenGood control on basal/bolus regimen

• Proficient at carbohydrate countingProficient at carbohydrate counting

• Proficient at adjusting insulin doses with Proficient at adjusting insulin doses with I:CHO and correction factorI:CHO and correction factor

Insulin PumpInsulin Pump

• Only NovoLog or Humalog insulinOnly NovoLog or Humalog insulin

• Hourly basal rate: Hourly basal rate: 1.1. 80% of total daily insulin dose80% of total daily insulin dose

2.2. Divided by 2Divided by 2

3.3. Divide by 24Divide by 24

• Same I:CHO and correction factorSame I:CHO and correction factor

Insulin PumpInsulin Pump

• AdvantagesAdvantages– Mimics physiologic pancreatic secretionMimics physiologic pancreatic secretion– LifestyleLifestyle– Accurate dosingAccurate dosing– Less hypoglycemiaLess hypoglycemia

• DisadvantagesDisadvantages– No depot to protect from DKANo depot to protect from DKA– Labor intensiveLabor intensive– ExpensiveExpensive

Jason JohnsonJason Johnson

Detroit Tigers Detroit Tigers PitcherPitcher

Type 1 diabetes Type 1 diabetes diagnosed age 11diagnosed age 11

Wears insulin pump Wears insulin pump on fieldon field

Case 2Case 2

• 9 y/o male with type 1 diabetes for 4 9 y/o male with type 1 diabetes for 4 yearsyears

• NPH and Regular insulin 2 shots per dayNPH and Regular insulin 2 shots per day

• Total insulin dose = 0.8 units/kg/dayTotal insulin dose = 0.8 units/kg/day

• Relatively high AM numbersRelatively high AM numbers

Case 2Case 2

BB LL DD HSHS

200200 110110 106106 120120

220220 9797 102102 115115

198198 105105 132132 110110

241241 9999 9696 122122

Case 2Case 2

• What is going on?What is going on?

• What additional information do you What additional information do you want?want?

• 2AM blood sugar is 1222AM blood sugar is 122

• Dawn phenomenonDawn phenomenon

• To correct: Move evening NPH to To correct: Move evening NPH to bedtimebedtime

Case 2Case 2

• What if 2AM blood sugar was 59?What if 2AM blood sugar was 59?

• Somogyi phenomenon – rebound Somogyi phenomenon – rebound hyperglycemia after hypoglycemiahyperglycemia after hypoglycemia

• Treatment: decrease evening NPHTreatment: decrease evening NPH

Mary Tyler MooreMary Tyler Moore


Case 3Case 3

• 13 y/o black female, 2 week h/o polyuria, 13 y/o black female, 2 week h/o polyuria, polydipsia, 16 lb weight losspolydipsia, 16 lb weight loss

• Overweight, BMI 97%Overweight, BMI 97%

• Acanthosis nigricans on neckAcanthosis nigricans on neck

• 2 grandparents have type 2 diabetes2 grandparents have type 2 diabetes

Case 3Case 3

• Initial glucose – 634 mg/dlInitial glucose – 634 mg/dl

• Bicarb – 18 mmol/lBicarb – 18 mmol/l

• UA >80 mg/dl ketonesUA >80 mg/dl ketones

• Serum ketones – negativeSerum ketones – negative

• Type 1 or type 2?Type 1 or type 2?

Risk Factors for Type 2Risk Factors for Type 2

• ObesityObesity

• Acanthosis nigricansAcanthosis nigricans

• Family historyFamily history

• Maternal gestational diabetesMaternal gestational diabetes

Case 3Case 3

• Islet cell antibodies – positiveIslet cell antibodies – positive

• Anti-GAD 65 – positiveAnti-GAD 65 – positive

• Insulin antibodies – negativeInsulin antibodies – negative

• C-peptide - <0.5C-peptide - <0.5

• Type 1Type 1

Sick Day ManagementSick Day Management

• Never omit insulinNever omit insulin

• Insulin requirements are often greater Insulin requirements are often greater with illnesswith illness

• Hypoglycemia may be a problem, Hypoglycemia may be a problem, especially in younger childrenespecially in younger children

• Test blood sugars every 2-4 hoursTest blood sugars every 2-4 hours

• Check urine ketonesCheck urine ketones

Sick Day ManagementSick Day Management

• Drink plenty of fluids (1 cup per hour)Drink plenty of fluids (1 cup per hour)– Sugar-containing liquids for hypoglycemiaSugar-containing liquids for hypoglycemia

• Need extra insulin to clear ketonesNeed extra insulin to clear ketones– NPH/R: extra 20% of total dose as R q4 NPH/R: extra 20% of total dose as R q4

hourshours– Basal/bolus: correction dose q3 hours + Basal/bolus: correction dose q3 hours +

additional 20% of calculated correctionadditional 20% of calculated correction

• ED for persistent vomitingED for persistent vomiting

Halle BerryHalle Berry

ActressActress


New Directions: Inhaled InsulinNew Directions: Inhaled Insulin

PREP QuestionsPREP Questions

QuestionQuestionWhich of the following statements regarding the development Which of the following statements regarding the development

of type 1 diabetes is true?of type 1 diabetes is true?

A. Administration of parenteral insulin to those at risk has A. Administration of parenteral insulin to those at risk has been proven to decrease the likelihood of developing been proven to decrease the likelihood of developing diabetesdiabetes

B. HLA typing has not been shown to be useful in determining B. HLA typing has not been shown to be useful in determining the risk of developing diabetesthe risk of developing diabetes

C. Most patients have complete destruction of the beta cells, C. Most patients have complete destruction of the beta cells, with no residual function at the time of diagnosis.with no residual function at the time of diagnosis.

D. The presence of antibodies against islet cells and insulin can D. The presence of antibodies against islet cells and insulin can be predictive of the risk of developing diabetes.be predictive of the risk of developing diabetes.

AnswerAnswer

• D. The presence of antibodies against D. The presence of antibodies against islet cells and insulin can be predictive of islet cells and insulin can be predictive of the risk of developing diabetes.the risk of developing diabetes.

QuestionQuestion

Which of the following statements regarding insulin therapy Which of the following statements regarding insulin therapy is true?is true?

A. Inhaled insulin is not effective in children.A. Inhaled insulin is not effective in children.

B. Insulin pump therapy should be reserved for noncompliant B. Insulin pump therapy should be reserved for noncompliant adolescent patients.adolescent patients.

C. Insulin therapy should be discontinued temporarily during C. Insulin therapy should be discontinued temporarily during the “honeymoon” period.the “honeymoon” period.

D. Rapid-acting insulin is beneficial because it decreases D. Rapid-acting insulin is beneficial because it decreases glycosylated hemoglobin levels over time.glycosylated hemoglobin levels over time.

E. Use of rapid-acting insulin can decrease postprandial E. Use of rapid-acting insulin can decrease postprandial hyperglycemia and night-time hypoglycemia.hyperglycemia and night-time hypoglycemia.

AnswerAnswer

• E. Use of rapid-acting insulin can E. Use of rapid-acting insulin can decrease postprandial hyperglycemia and decrease postprandial hyperglycemia and night-time hypoglycemia.night-time hypoglycemia.

QuestionQuestion• You are seeing a 9 y/o boy who was diagnosed You are seeing a 9 y/o boy who was diagnosed

with type 1 diabetes 2 years ago. He with type 1 diabetes 2 years ago. He currently receives 2 daily injections of short- currently receives 2 daily injections of short- and intermediate-acting insulin. As part of and intermediate-acting insulin. As part of your evaluation, you ask to see his blood your evaluation, you ask to see his blood glucose diary. You note that most of his glucose diary. You note that most of his readings over the last month have been readings over the last month have been around 200 mg/dL. His mother is unwilling to around 200 mg/dL. His mother is unwilling to try a pump at this point.try a pump at this point.

QuestionQuestion

Which of the following management options is best?Which of the following management options is best?

A. Increase the evening dose of short-acting insulin.A. Increase the evening dose of short-acting insulin.

B. Increase the morning dose of intermediate-acting B. Increase the morning dose of intermediate-acting insulin.insulin.

C. Increase the morning dose of short-acting insulin.C. Increase the morning dose of short-acting insulin.

D. Obtain a hemoglobin A1c level, and if it is normal, D. Obtain a hemoglobin A1c level, and if it is normal, continue the current insulin regimen.continue the current insulin regimen.

E. Split the evening dose to administer intermediate-E. Split the evening dose to administer intermediate-acting insulin at bedtime.acting insulin at bedtime.

AnswerAnswer

• E. Split the evening dose to administer E. Split the evening dose to administer intermediate-acting insulin at bedtime.intermediate-acting insulin at bedtime.

SSG Mark ThompsonSSG Mark Thompson

Deployed to Iraq with Type 1 DiabetesDeployed to Iraq with Type 1 Diabetes

ResourcesResources

• www.childrenwithdiabetes.comwww.childrenwithdiabetes.com

• Clinical Practice Recommendations: Clinical Practice Recommendations: January Diabetes Care, ADA websiteJanuary Diabetes Care, ADA website

• American Diabetes AssociationAmerican Diabetes Association

• Juvenile Diabetes Research FoundationJuvenile Diabetes Research Foundation

type 1 diabetes karen s. penko, md fellow, pediatric endocrinology september 2005

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