Contemporary management of adolescents with diabetes mellitus

Posted on October 29, 2009

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Treatment for Type 1 Diabetes Insulin Therapy Insulin is the only medication that is effective in lowering blood glucose levels in type 1 diabetes. The use of insulin requires daily management of those factors that affect the insulin dose (food, physical activity, illness, stress). See Table 5 for common insulin preparations. Rapid-acting insulin may be given before, during, or immediately after a meal. Administration after a meal may help reduce the postprandial hyperglycemia associated with high fat meals. The number of insulin injections/day will vary; insulin may be delivered with insulin syringes, insulin pens or external insulin pumps.

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• Conventional therapy– 2 daily injections of mixed insulin (rapid- or short-acting and intermediate-acting) before breakfast and the evening meal.

• Conventional therapy with a split night-time dose– 1 injection of mixed insulin (rapid- or shortacting and intermediate-acting) before breakfast, 1 injection of rapid- or short-acting insulin before the evening meal and 1 injection of intermediate-acting insulin before the bedtime snack. This regimen is used to help reduce fasting hyperglycemia associated with the long interval between the evening meal and breakfast and the duration of action of the intermediate-acting insulin and to facilitate management of the dawn phenomenon.

• Multiple daily injections (MDI) of rapid- or short-acting insulin before every meal (and sometimes large snacks) with intermediate- or long-acting insulin once or twice a day. The addition of rapid- or short-acting insulin before lunch helps reduce pre-supper hyperglycemia with less risk of hypoglycemia associated with very large pre-breakfast doses of intermediateacting insulin. With the exception of a bedtime snack to prevent hypoglycemia during the night, snacks usually are not required with MDI– an advantage for busy teens and those who wish to maintain a target weight. This may be called intensive therapy depending on the level of glycemic control that is targeted.

• Intensive therapy with a continuous subcutaneous insulin infusion (CSII or insulin pump)– Rapid-acting insulin is delivered constantly to meet the body’s basal need to suppress hepatic glucose production. A bolus dose of insulin is given before meals and snacks based on the amount of carbohydrate eaten and the measured level of blood glucose. This regimen is for motivated teens who are willing to test frequently (>4 times/day), monitor carbohydrate intake accurately, adjust insulin doses and commit to frequent contact with the diabetes team.

http://www.epi.umn.edu/let/pubs/img/adol_ch14.pdf