N Datz

Current practice of insulin pump therapy in children and adolescents - the Hannover recipe.

Abstract:  Increasing evidence points to the importance of achieving low blood glucose variability and also a low hemoglobin A1c (HbA1c) to prevent diabetic late complications. Continuous subcutaneous insulin infusion (CSII) is associated with lower blood glucose variability in children. Frequent indications for starting CSII in youth are recurrent hypoglycemia, need for increased flexibility, poor glycemic control, dawn phenomenon, or needle phobia. At our center, about one‐third of all patients across all age groups are currently on CSII. Although the average glycemic control is not very different from those on multiple daily injections, fewer patients are seen in the segment of very high and very low HbA1c with CSII. Across centers, the ‘recipes’ tailoring CSII treatment to individual patients and cultures are based more on experience than on evidence. However, several typical pediatric features have been identified. Patterns of the hourly basal rate and prandial insulin requirements vary with age. While many adolescents have increased requirements at dawn and dusk, young children show increasing needs in the second half of the day. Low insulin requirements, particularly in neonates, may need insulin dilution. The selection of catheters and needles has to be appropriate for the age. The opportunity to have an electronic memory read‐out of all entries and alarms offers new possibilities of therapeutic monitoring, particularly in those youth not keeping good logbooks. This feature can be helpful, if a trustful relationship between the diabetes team and the family is established.

Insulin detemir is characterized by a more reproducible pharmacokinetic profile than insulin glargine in children and adolescents with type 1 diabetes: results from a randomized, double‐blind, controlled trial*

Abstract:  Insulin detemir (detemir) has previously been shown to be associated with lower within‐subject variability compared with other basal insulin preparations in adults with type 1 diabetes mellitus (T1DM). This randomized, double‐blind, crossover trial compared the within‐subject variability of detemir and insulin glargine (glargine) in pharmacokinetic properties in children and adolescents with T1DM. The trial enrolled 32 children and adolescents (19 girls and 13 boys; mean ± SD: age 13 ± 2.5 yr and T1DM duration 6.3 ± 3.0 yr) with a hemoglobin A1c (HbA1c) of 7.9 ± 1.0%. Participants were randomized to a specific treatment sequence in which a dose of 0.4 U/kg of detemir and glargine was injected subcutaneously 24 h apart at each of two dosing visits. Insulin concentrations were measured at frequent intervals for a period of 16‐h post‐dosing. Detemir showed statistically significantly less within‐subject variability compared with glargine with a 3.1‐fold and 2.9‐fold lower coefficient of variation (CV, %) for the area under the concentration–time curve [AUC(0–16 h)] and the maximum concentration (Cmax), respectively. Separate analyses demonstrated a 2.5‐fold and 2.9‐fold lower CV (%) with detemir in children (8–12 yr) and a 4‐fold and 3.8‐fold lower CV (%) with detemir in adolescents (13–17 yr). No safety concerns were raised during the trial. In conclusion, within‐subject variability in pharmacokinetic properties was significantly lower for detemir than for glargine in children and adolescents with T1DM. This indicates a less variable absorption with detemir, which is expected to be associated with a more predictable therapeutic effect also in this population.

Current use of metformin in addition to insulin in pediatric patients with type 1 diabetes mellitus: an analysis based on a large diabetes registry in Germany and Austria

With increasing obesity in childhood and adolescence, weight gain, and insulin resistance become also more frequent in patients with type 1 diabetes mellitus (T1DM). Especially during puberty, insulin therapy often has to be intensified and higher insulin doses are necessary. Some studies point to a beneficial effect of metformin in addition to insulin in these patients. In order to describe current practice and possible benefits, we compared pediatric T1DM patients with insulin plus metformin (n = 525) to patients with insulin therapy only (n = 57 487) in a prospective multicenter analysis.

Lipoatrophy in Children With Type 1 Diabetes An Increasing Incidence

Objectives: The objectives were to evaluate the current prevalence of lipoatrophy at insulin injection sites in young patients with type 1 diabetes. Methods: Standardized examination of insulin injection sites in all 678 patients with type 1 diabetes treated in 2013 in our outpatient clinic were conducted. In case of lipoatrophy photo documentation and standardized interview with parents and patients were performed. Methods: We identified a total of 16 patients (43.8% male) with lipoatrophy (overall prevalence 2.4%). The current mean age (±SD) of the affected patients was 14.4 ± 3.9 years, age and diabetes duration at onset of lipoatrophy were 11.5 ± 3.8 years and 5.4 ± 3.6 years, respectively. All patients were using analogs at the onset of lipoatrophy. In all, 14 of 16 patients (87.5%) were on insulin pump compared with 52% without lipoatrophy (P = .0018). The use of steel needle and Teflon catheter was equal between the pump patients. Concomitant autoimmune diseases were present in 37.5% of the patients (thyroiditis: n = 3, thyroiditis and celiac disease: n = 2, celiac disease: n = 1) compared with 15.0% in those without lipoatrophy (P = .0128). Conclusions: Lipoatrophy was present in young patients treated with modern insulins and pumps; however, the prevalence was relatively low as expected with the use of modern insulins. Our data may support the hypothesis that a constant mechanical element such as a subcutaneous catheter may trigger the development of lipoatrophy, particularly in those patients with more than 1 autoimmune disease.

Highlights of the 34th annual ISPAD meeting, 13–16 August 2008, Durban, South Africa

Datz N, Rachmiel M. Highlights of the 34th annual ISPAD meeting, 13–16 August 2008, Durban, South Africa. Pediatric Diabetes 2009: 10: 82–87. Nicolin Datz and Marianna Rachmiel Centre of Pediatric Endocrinology and Diabetes, Kinderkrankenhaus auf der Bult, Hannover, Germany; and Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Therapie mit Insulinpumpen

ZusammenfassungDie Insulinpumpentherapie (CSII) wird zur Behandlung des Typ-1-Diabetes besonders in der Pädiatrie in den letzten Jahren zunehmend eingesetzt. Obwohl randomisierte Studien nicht durchgängig eine Verbesserung des HbA1c und eine Senkung der Hypoglykämierate zeigen, sind bei richtiger Patientenauswahl die Erfahrungen überwiegend positiv. Die Behandlung mit den modernen programmierbaren Pumpen ist im Prinzip nicht schwieriger als eine intensivierte konventionelle Insulintherapie (ICT). Wegen der noch deutlicheren Trennung von Basal- und Prandialinsulinbedarf ist bei der CSII das Prinzip der differenzierten Prandial- und Basalinsulinsubstitution noch klarer erkennbar und darum auch einfacher umsetzbar. Ohne Zweifel können mit ihr gleichmäßigere Insulinspiegel erreicht werden als mit der ICT. ICT und CSII haben sich bei Kindern, Jugendlichen und Erwachsenen als 2 gleichwertige Varianten der intensivierten Insulintherapie erwiesen, die heute unstrittig als die Therapie der Wahl bei Typ-1-Diabetes gilt.AbstractInsulin pump therapy (CSII) is used with increasing frequency in type 1 diabetes, especially in paediatric patients. While not all randomized studies have shown better glycaemic control or a lower rate of hypoglycaemia, clinical experience of CSII is generally positive when patients are carefully selected. In principle, treatment with modern programmable pumps (CSII) is no more difficult than a conventional intensified multiple injection therapy (ICT). Owing to the clear differentiation made between prandial and basal insulin requirements, insulin substitution is more clearly recognizable and therefore easier to achieve.CSII definitely leads to more nearly constant insulin levels. Therefore, ICT and CSII have become established as equally valuable forms of intensified insulin therapy, which is now recognized as the therapy of choice in type 1 diabetes.

Die Hyposensibilisierung bleibt nur selten als Therapieoption übrig

ZusammenfassungAllergische Reaktionen auf Insulin sind seit der Einführung der Humaninsuline und der rekombinanten Insuline zwar selten, aber ein ernstzunehmendes Phänomen im diabetologischen Alltag. Neben der häufigeren lokalen Reaktion in Form von Urtikaria ist auch eine systemische Reaktion möglich. Die ärztliche Herausforderung besteht in der Fortführung der Insulintherapie. Nötig ist eine schnelle Diagnostik und das rasche Finden einer Therapiealternative. Anhand von zwei Kasuistiken wollen wir ein mögliches strategisches Vorgehen beschreiben, das auch zur Beruhigung der Patienten führen kann.