Management of Type 1 Diabetes

in Children & Adolescents

-update-
Diego Botero, MD
2023
UdeA
 Diabetes in Pediatrics
• Treatment
-basal bolus therapy
-CSII
• Monitoring
-CGMS
-ketones
-future technology
• Management of sick days
 Options in Insulin Therapy
• Current
– Multiple injections
– Insulin pump (CSII)
• Future
– Implant (artificial pancreas)
– Transplant (pancreas; islet cells)
 Available insulins
Type Onset (Hrs) Peak (Hrs) Duration(Hrs) Comments
Rapid-acting 0.25 1 2-3 Ideal for
Lispro basal/bolus
Aspart therapy
Glulisine
Short-acting 0.5-1 2-4 4-6 Longer action
Regular if larger dose

Intermediate- 0.5-1 4-6 8-16 Peak and

acting duration
NPH variable
Long-acting 0.5-1 None 23-26
Glargine Cannot be
Detemir mixed with
Ultra Long-ac 0.3-1.5 None 40 other insulins
Degludec
 Insulin Glargine
• Clinical benefits:

– Once-daily dosing because of its prolonged

duration of action and smooth, peakless time-action
profile

– Comparable or better glycemic control (FBG)

– Lower risk of nocturnal hypoglycemic events

– Doesn’t cover meals, snacks!

 Changes in Approach

• Intensify control
-DCCT results and impact upon long term
complications
• Increase monitoring
-More frequent testing
-Lunch time testing
-Testing at different times
• Increase insulin injections
 DCCT: Glycemic Control
According to Treatment Group
 Relative Risk of Progression of
Diabetic Complications

15
13
11 Retinop
RELATIVE RISK

9
Neph
7
5 Neurop

3
1
6 7 8 9 10 11 12
Mean A1C
DCCT Research Group, N Engl J Med 1993, 329:977-986.
The Basal/Bolus Insulin Concept
• Basal insulin
– Suppresses glucose production between meals
and overnight
– 40% to 50% of daily needs
• Bolus insulin (mealtime)
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirement at
each meal
* Correction factor for hyperglycemia
 Basal/Bolus Therapy
Insulin to Cover the Meal
Breakfast Lunch Dinner Snack

Humalog Humalog Humalog Humalog

Lantus
Alternative Approaches to Insulin Delivery

Int J Pharm Investig 2016 Jan-Mar; 6(1): 1–9

Alternative Approaches to Insulin Delivery
• Inhaled insulin
-Approved by the FDA in 2006 (Exubera) for use in
adults
-Does not replace basal insulin
-May replace fasting-acting insulin
-Efficacy similar to other insulin formulations
-Incidence of hypoglycemia similar to SC insulin
-Small decrease in FEV1
-Withdrawn from the market in 2007
• Afrezza (insulin Human, inhalation powder), FDA
approved in 2014.
 INHALED INSULIN
(short acting insulin)
 SMART PENS
• In-built calculator that recommends insulin dose (short acting insulin)
• Memory to remember the amount & time of insulin dosage
• Automatic transmission of insulin dose to the mobile logbook through
Bluetooth technologies.
• Calculates real acting insulin on board.

2020: https://www.healthline.com/diabetesmine/smart-insulin-pens-what-to-know
 CSII or Insulin Pump
• More intensive management
• More flexibility
• Similar to basal-bolus regimen
• Continuous sc infusion of short acting insulin
• Requires calculation of both, a carbohydrate
dose of food and correction dose
• In the event of pump malfunction, have only 3-4
hours of insulin coverage
 Variable Basal Rate:
CSII Program
Breakfast Lunch Dinner
Plasma insulin

Bolus Bolus Bolus

Basal infusion

4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00

Time
History of Pumps
• Automatic correction boluses and an adjustable glucose target down to 100 mg/dl.

• Medtronic is targeting >80% time in range goal for 780G users.

• Bluetooth connectivity to the pump. Users will be able to view pump data on their
phones, upload pump data wirelessly, and update their pump wirelessly.

• It uses the Guardian CGM, which requires two fingersticks per day and has a seven-day
wear time.
Metabolic Advantages with CSII
• Improved glycemic control
• Better pharmacokinetic delivery of insulin
– Less hypoglycemia
– Less insulin required
• Improved quality of life
 New Approaches to BG
Monitoring
• New blood glucose monitoring technology:
– Less blood, less pain, less time
– Alternative sites
– Easy-to-use, automated
– Blood glucose and blood ketone monitoring
– Meter memory with computer interface
– Continuous or frequent monitoring
 Bolus Wizard Calculator : meter-
entered

• Monitor sends BG value to pump via radio

waves : No transcribing error
• Enter carbohydrate intake into pump
• “Bolus Wizard” calculates suggested dose
 BG Monitoring Improves
HbA1c

P<0.02 Anderson: J Peds, 1997

Levine: J Peds, 2001
Laffel: J Peds, 2003
 Continuous Glucose Monitoring
Systems (CGMS)
• Potential to improve daily fluctuations in blood glucose
while decreasing the incidence of hypoglycemia .
• Efficacy compared with SMBG is not certain.
• CGMS is expensive.
• Does not eliminate the need for fingersticks.
• Currently available meters are most inaccurate in the
low range of glucose.
 CGM System
-Basic components-

•Sensor: Inserted subcutaneously on the stomach or back of the arm. It is responsible for
measuring the blood glucose levels every minute or five minutes

•Transmitter: Wireless component of the sensor. It sends the blood glucose levels to
the receiver, reader, or a smart phone app.

•Receiver: Called reader. It is a separate device that displays the data from the sensor

FreeStyle Dexcom Guardian Eversense

2021: https://www.healthline.com/health/diabetes/best-glucose-monitors
 Fingerstick blood glucoses (Type 1)
400
Glucose
Glucose (mg/dL)

measurement
300
Insulin
bolus
200

Target
100 Range

0
12:00 am 6:00 am 12:00 6:00 pm 12:00 am
Continuous glucose monitoring (CGMS) provides
a more comprehensive picture of the patterns

400
Glucose
Glucose (mg/dL)

measurement
300
Insulin
bolus
200

Target
100 Range

0
12:00 am 6:00 am 12:00 6:00 pm 12:00 am
 Monitoring for Ketosis
• Acetoacetate
– measured by nitroprusside reaction

• Acetone
– excreted primarily through the lungs and detected
as a fruity odor
– small amounts may be detected in urine

• -Hydroxybutyrate
– undetected by nitroprusside reaction
– major ketone body in acidosis
– new technology enables self/family blood
-OHB measurement
Urine Ketone Testing
 Diabetes Technology Timeline:
Convergence of insulin pumps & continuous glucose
monitoring (CGM) to a feedback loop
1922
Insulin CLOSED LOOP:
1936 Smart
Insulin • Artificial beta cell
PZI 1948 pump
Delivery NPH • Mechanical system
1978
• Stem cell
Insulin pump

Glucose 1970
Monitoring Ames meter
Blood test

1912 Retrospective Real-time

CGM CGM
Benedict
Urine test
TODAY
Banting & Best, Canada 1922
Practical issues in the management of
T1DM
including sick days
 Insulin dosing
• Insulin dose ~ Pubertal status, DKA?

No DKA DKA
Infant 0.25 0.5
Prepubertal 0.5 0.75
Pubertal 0.75 1

(expressed as units/kg/day)
Insulin dosing: basal bolus therapy
Step 1
• Calculating initial insulin regimen
– Prepubertal, no DKA
– 30 kg x 0.5 units/kg/day = 15 units/day

1/2 7.5 units Lantus

15
1/2
7.5 units Humalog
 Insulin dosing
I: CHO ratio

• Infant: 1 U : 30 gms

• Child : 1 U : 20 gms

• Adolescent: 1 U :10 gms

 Insulin dosing: basal bolus therapy

– Correction Factor for hyperglycemia (q3h)

• Sensitivity factor = 1800/total daily dose*
= 1800/15
= 120
• Target BS: 120 mg/dL
• Humalog 1 unit for every 120 mg/dL>120 mg/dL

Actual BS – Target BS
CF =
Sensitivity Factor
* 1500/TDD for regular insulin
http://perinatology.com/calculators/Insulin%20Correction%20Dose.htm
 Sick Day Management
• Fundamental Principles
1. Never omit insulin injections
2. Prevent dehydration
3. Frequent monitoring of BS, ketones
4. Supplemental insulin PRN
5. Treat underlying illness
6. Monitor for Sxs requiring attention
 Sick Day Management
• Never omit insulin injections
BS <80 80-200 201-300 301-400 >400
Rapid- Omit Usual Usual Usual dose Usual
acting dose dose dose

Booster None None K+ 5% K+ 10% 20%

(%TDD) K++ 10% K++ 15%
Int/long- 50-75% Usual Usual Usual Usual
acting usual dose dose* dose* dose* dose*

Recheck 1/2 hour 3 hours 3 hours 3 hours 3 hours

BS

* Reduce to 2/3 usual dose if ability to tolerate PO in doubt

 Sick Day Management
• Prevent dehydration
– 1-2 mL/kg of body weight/hour
– Increase in context of fever
– Fluids: Glucose, salt and potassium
• Unless hyperglycemic (BS > 200 mg/dL) and able
to tolerate PO
• Options if poor PO: soda, ginger ale, juice
– Example: 30-kg patient ~ 90 cc (3 oz)/hr
 Sick Day Management
• Frequent monitoring of BS, ketones
– Check BS q3-4h (q1/2h if BS < 90 mg/dL)
– Check urine for ketones until illness over
• Diapers? 2 cotton balls in diaper, squeeze
• Precision Xtra®: serum ketone meter
 Sick Day Management
• Supplemental insulin PRN
– Rapid-acting insulin PRN (per table)
• Humalog given q3h
• Regular given q4h
– Goals
• Normoglycemia
• Negative to trace ketones
• Remember: vomiting illness = exception for
reducing or omitting short acting insulin
 Sick Day Management
• Monitor for Sxs requiring attention
– Dehydration
– Unable to tolerate recommended PO
– Recurrent/persistent vomiting x 4 hours
– Possible DKA: abdominal pain,
hyperventilation, drowsiness
– Hyperglycemia/ketonuria (-emia)>12 hrs
– Cannot maintain BS>80 mg/dL
Medical Alert
Glucagon Kit
 Lecturas recomendadas:

Diabetes tipo 1

https://www.uptodate.com/contents/epidemiology-presentation-and-diagnosis-of-type-1-
diabetes-mellitus-in-children-and-adolescents

https://www.uptodate.com/contents/overview-of-the-management-of-type-1-diabetes-
mellitus-in-children-and-adolescents
Any Final Questions?