Clinical Pearls & Morning Reports
Newer formulations of insulins and technologic advances have been developed that increase the likelihood that a patient will achieve better glycemic control. Read the NEJM Clinical Practice Article here.
Q: What preparations of basal insulin are used most often to treat children and adolescents with type 1 diabetes mellitus?
A: Glargine, detemir, and degludec are the most common preparations of basal insulin used in the treatment of children and adolescents with type 1 diabetes mellitus. Neutral protamine Hagedorn (NPH) insulin is a less expensive and readily obtainable intermediate-acting insulin; however, the use of NPH usually requires two daily injections, whereas one daily injection is usually sufficient when glargine, detemir, or degludec are used.
Q: Are there new treatments for severe hypoglycemia in children?
A: When a patient is unresponsive and unable to ingest oral glucose, treatment has traditionally required intramuscular or subcutaneous injections of glucagon, which needs reconstitution immediately before use. To surmount this problem, a new liquid, ready-to-use glucagon analogue has proved to be effective and is available for use in children 6 to 17 years of age. A stable glucagon preparation is available in either prefilled syringes or an autoinjector and is approved for use in children as young as 2 years of age. An intranasally administered powder form of glucagon has also been approved for children 4 years of age or older; it is safe, effective, easy to use, and does not require reconstitution before use.
A: Randomized trials of the use of continuous glucose monitors in children, with or without pump use, have shown substantial benefits for glycemic control. As compared with self-monitoring of glucose, continuous glucose monitoring significantly, although modestly, improved glycated hemoglobin levels (adjusted difference, −0.37%) in persons 14 to 25 years of age; among younger children 2 to 7 years of age, continuous glucose monitoring considerably reduced the time that glucose levels were less than 70 mg per deciliter (by about 40 minutes daily) and reduced parental fears of this outcome, although the use of continuous glucose monitors did not improve glucose time in range. A metaanalysis of randomized trials that compared continuous glucose monitors with self-monitoring of blood glucose, some of which included children, showed significant reductions in glycated hemoglobin and severe hypoglycemia in the group that used continuous glucose monitors; benefits among children appeared similar to those among adults. Similarly, lower glycated hemoglobin levels and lower incidence of diabetic ketoacidosis were observed with the use of continuous glucose monitors and insulin pumps in a large international pediatric cohort. Studies of continuous glucose monitoring together with pump use report improved psychosocial outcomes and quality of life.
A: Insulin pumps, first introduced more than four decades ago, are increasingly used in children. Improved communication between continuous glucose monitors and insulin pumps has yielded the next generation of advanced insulin delivery with automation. Such artificial-pancreas systems incorporate an algorithm that uses data from a continuous glucose monitor to direct insulin delivery. The most recent advances provide for automated increases in insulin delivery for elevated glucose levels above 180 mg per deciliter or for rising glucose levels that predict impending hyperglycemia. The automated insulin-delivery systems, known as hybrid closed-loop systems, assess the rate of change in glucose to guide increases and decreases in, or suspension of, insulin delivery. Several hybrid closed-loop systems that have been approved by the Food and Drug Administration are currently in use, and others are in development.