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Care Suggestions

Medical science has made great strides in advancing diabetes care practice in recent years. This page summarizes my view of the best care practices as they apply to kids with type 1 diabetes. I am not a doctor -- I'm just a parent who has cared for a child with diabetes since September 1989. I've written this page because I am asked quite often for my opinion on diabetes care, and having all this in one place makes it easy for me to answer. Remember, the information on this page is the opinion of one non-medical person and does not reflect the opinions of anyone else associated with Children with Diabetes. Everything here though is well supported by peer reviewed studies, cited below.

If you're new to diabetes, these recommendations can help you understand what is possible. If you're using a different regimen than is described below and are reaching your diabetes care goals, then there is no reason to change.

Underlying everything on this page is the fact that the patient -- or for kids with diabetes, the parents -- are in charge of their diabetes care. As parents, we are the best advocates for our children. We see our kids everyday, we know how their bodies react to the stresses of school, sports, and everything else that is a part of their lives. Since we're in charge, the choices of which meter to use, whether to use pump therapy and -- if so -- which pump to use, when we'll eat, and everything else related to our care are ours to make. The members of the diabetes team provide guidance based on current medical science, advise us on therapy options, and help us learn how to live our lives as if we didn't have diabetes, to the extent that that is possible. The diabetes team is like the coaching staff of a sporting team, and we are like the players. The coaching staff helps us learn the game, but the game is ours to play and ours to win.

Since diabetes care is highly individualized, you should discuss any change in care with your diabetes team before you do anything.

For more information, see American Diabetes Association: Clinical Practice Recommendations and Standards of Medical Care in Diabetes - 2014.

-- Jeff Hitchcock
Founder, Children with Diabetes

1. Monitor Blood Sugar Often
 


The only data available to manage diabetes care is blood glucose values. As such, it simply makes sense that the more data we have, the better our decisions can be and the more opportunities we'll have to make adjustments in care to maximize the amount of time our kids spend with their blood glucose values in their target ranges.

Since we began asking our readers about blood glucose monitoring frequency in October 1998, we've seen an increase in daily checks from an average of 4.6 to 8.0 times per day. (See the most recent poll on the topic from November 2013.) The trend toward more frequent monitoring is evident in the number of people who report checking more than six times per day, which in November 2013 was 89%. And 40% of our readers report checking ten times a day or more.

One of the hotly debated topics among parents is nighttime blood glucose monitoring. In a poll we ran in March 2013, 34% of readers report checking nighttime blood glucose levels every night. 48% report checking at least once a week. The number of people checking at night is also increasing. Since diabetes doesn't go away during sleep, checking at night makes sense, especially for young kids whose brains are still developing. A growing body of evidence points to more nocturnal hypoglycemia than previously thought and to a greater number of problems associated with nocturnal hypoglycemia.

The bottom line is that blood glucose data is the cornerstone for all diabetes management. Monitor often, and thank your child whenever they check themselves, regardless of the blood glucose number. These numbers aren't "good" or "bad" -- they're just numbers. And they're the most important numbers you have to make a difference in your child's quality of care. Cherish each and every one.

 
  References:
  1. Hypoglycemia during sleep impairs consolidation of declarative memory in type 1 diabetic and healthy humans
  2. Benefits and Limitations of Self-Monitoring of Blood Glucose
  3. Nocturnal Hypoglycemia in Type 1 Diabetes: An Assessment of Preventive Bedtime Treatments. Free full text available in PDF format.
  4. Neurocognitive functioning in children with type-1 diabetes with and without episodes of severe hypoglycaemia [Dev Med Child Neurol. 2003 Apr;45(4):262-8].
  5. Blood glucose estimations in adolescents with type 1 diabetes: predictors of accuracy and error [J Pediatr Psychol. 2003 Apr-May;28(3):203-11].
  6. Decreased consciousness of hypoglycaemia and the incidence of severe hypoglycaemia in children and adolescents with diabetes type 1 [Endokrynol Diabetol Chor Przemiany Materii Wieku Rozw. 2002;8(2):77-82].
  7. Severe hypoglycemia and long-term spatial memory in children with type 1 diabetes mellitus: a retrospective study [J Int Neuropsychol Soc. 2003 Jul;9(5):740-50].
  8. Hypoglycemia in children with type 1 diabetes: current issues and controversies [Pediatr Diabetes. 2003 Sep;4(3):143-50].
  9. Nocturnal hypoglycemia detected with the Continuous Glucose Monitoring System in pediatric patients with type 1 diabetes [J Pediatr. 2002 Nov;141(5):625-30].
  10. Facilitating access to glucometer reagents increases blood glucose self-monitoring frequency and improves glycaemic control: a prospective study in insulin-treated diabetic patients. Diabet Med. 2004 Feb;21(2):129-35.
 
2. If You Use Regular and NPH Insulin, It's Time to Consider a Change
 


Our readers report that hypoglycemia and the fear of going low is the hardest part of diabetes (Poll from April 2014). Therefore it makes sense that anything that can be done to reduce the risk of hypoglycemia, without sacrificing blood glucose control, would be welcomed.

Recent studies have shown that an insulin regimen of either (a) multiple daily injections, using Lantus® (Insulin Glargine) as a basal and either NovoLog® (Insulin Aspart) or Humalog® (Insulin Lispro) to cover food, or (b) insulin pump therapy, results in a reduced risk of hypoglycemia, especially at night, while maintaining good control. This is great news for everyone who uses insulin. This quote sums up the data:

"Combination therapy with insulin glargine plus lispro reduced the incidence of nocturnal hypoglycemia and was at least as effective as R/NPH insulin therapy in maintaining glycemic control in adolescents on multiple injection regimens."1

Evidence of this data being put into practice was demonstrated clearly in a poll we ran in January 2014, asking readers which insulin(s) they used. Among users of rapid-acting insulin, the use of Regular has dropped to 7%, with NovoLog being used by 58%, Humalog by 20%, and Apidra by 9%. This is a dramatic decline from 2000, when 26% of people reported using Regular. Among users of long-acting insulin, the change is equally dramatic, with NPH use dropping to just over 9% compared with 73% in 2000. The use of Lantus has grown from zero in 2000 to 73% of people using long-acting insulin, with Levemir, new in 2005, at 18%. (See the Excel spreadsheet from the poll for specific details.)

For parents of toddlers, while not ideal, the fast-acting insulin analogs can be injected after a meal is eaten. For anyone who given a toddler an injection of Regular insulin and then watched them refuse to eat, the ability to inject after the meal is a major benefit.

 
  References:
  1. Effect of insulin analogues on risk of severe hypoglycaemia in patients with type 1 diabetes prone to recurrent severe hypoglycaemia (HypoAna trial): a prospective, randomised, open-label, blinded-endpoint crossover trial.
  2. Effects of Insulin Detemir and NPH Insulin on Body Weight and Appetite-Regulating Brain Regions in Human Type 1 Diabetes: A Randomized Controlled Trial. Free full text available in HTML and PDF formats.
  3. A comparison of insulin detemir and neutral protamine Hagedorn (isophane) insulin in the treatment of diabetes: a systematic review.
  4. Contemporary rates of severe hypoglycaemia in youth with Type 1 diabetes: variability by insulin regimen.
  5. Long-acting insulin analogue detemir compared with NPH insulin in type 1 diabetes: a systematic review and meta-analysis.
  6. Comparison of human insulin and insulin analogues on hypoglycaemia and metabolic variability in type 1 diabetes using standardized measurements (HYPO score and Lability Index).
  7. Optimizing the Replacement of Basal Insulin in Type 1 Diabetes Mellitus: No Longer an Elusive Goal in the Post-NPH Era.
  8. Lower HbA1c after 1 year, in children with type 1 diabetes treated with insulin glargine vs. NPH insulin from diagnosis: a retrospective study.
  9. Clinical Experience with Insulin Glargine in Type 1 Diabetes.
  10. Evaluation of the long-term cost-effectiveness of insulin detemir compared with neutral protamine hagedorn insulin in patients with type 1 diabetes using a basal-bolus regimen in Sweden.
  11. Cost-effectiveness of insulin detemir compared to NPH insulin for type 1 and type 2 diabetes mellitus in the Canadian payer setting: modeling analysis.
  12. Insulin Analogs versus Human Insulin in the Treatment of Patients with Diabetic Ketoacidosis: a randomized controlled trial.
  13. Institution of Basal-Bolus Therapy at Diagnosis for Children With Type 1 Diabetes Mellitus. Free full text available in HTML and PDF formats.
  14. Improved glycaemic control by switching from insulin NPH to insulin glargine: a retrospective observational study. Free full text available in PDF format.
  15. A Comparison of Glycemic Variability Associated With Insulin Glargine and Intermediate-Acting Insulin When Used as the Basal Component of Multiple Daily Injections for Adolescents With Type 1 Diabetes.
  16. Long-term improvement of fasting glycaemia after switching basal insulin from NPH to detemir in children with type 1 diabetes: a 1-year multicentre study.
  17. Insulin Glargine Versus Intermediate-Acting Insulin as the Basal Component of Multiple Daily Injection Regimens for Adolescents with Type 1 Diabetes Mellitus.
  18. Cost of severe hypoglycaemia in patients with type 1 diabetes in Spain and the cost-effectiveness of insulin lispro compared with regular human insulin in preventing severe hypoglycaemia.
  19. Long-term efficacy and safety of insulin detemir compared to Neutral Protamine Hagedorn insulin in patients with Type 1 diabetes using a treat-to-target basal-bolus regimen with insulin aspart at meals: a 2-year, randomized, controlled trial.
  20. Improved glycemic control and lower frequency of severe hypoglycemia with insulin detemir; long-term experience in 105 children and adolescents with type 1 diabetes.
  21. Treatment satisfaction and quality of life with insulin glargine plus insulin lispro compared with NPH insulin plus unmodified human insulin in people with Type 1 diabetes.
  22. A Randomized, Controlled Trial Comparing Twice-a-Day Insulin Glargine Mixed With Rapid-Acting Insulin Analogs Versus Standard Neutral Protamine Hagedorn (NPH) Therapy in Newly Diagnosed Type 1 Diabetes. Free full text available in HTML and PDF formats.
  23. Survey of glargine use in 115 pregnant women with Type 1 diabetes.
  24. Clinical experience in treatment with the long-term insulin analogue glargine in a diabetes centre.
  25. Less hypoglycemia with insulin glargine in intensive insulin therapy for type 1 diabetes. U.S. Study Group of Insulin Glargine in Type 1 Diabetes [Diabetes Care, 23:639-643, 2000]. Full text available as PDF.
  26. Insulin Detemir Is Associated With More Predictable Glycemic Control and Reduced Risk of Hypoglycemia Than NPH Insulin in Patients With Type 1 Diabetes on a Basal-Bolus Regimen With Premeal Insulin Aspart [Diabetes Care 26:590-596, 2003]. Full text available as HTML or PDF.
  27. Hypoglycemia Prevalence in Prepubertal Children With Type 1 Diabetes on Standard Insulin Regimen: Use of Continuous Glucose Monitoring System [Diabetes Care 26:662-667, 2003]. Full text available as HTML or PDF.
  28. Randomized Cross-Over Trial of Insulin Glargine Plus Lispro or NPH Insulin Plus Regular Human Insulin in Adolescents With Type 1 Diabetes on Intensive Insulin Regimens [Diabetes Care 26:799-804, 2003]. Full text available as HTML or PDF.
  29. Intensive Replacement of Basal Insulin in Patients With Type 1 Diabetes Given Rapid-Acting Insulin Analog at Mealtime: A 3-month comparison between administration of NPH insulin four times daily and glargine insulin at dinner or bedtime [Diabetes Care 26:1490-1496, 2003]. Full text available as HTML or PDF.
  30. A Comparison of Postprandial and Preprandial Administration of Insulin Aspart in Children and Adolescents With Type 1 Diabetes [Diabetes Care 26:2359-2364, 2003]. Full text available as HTML or PDF.
  31. Outpatient Insulin Therapy in Type 1 and Type 2 Diabetes Mellitus [JAMA. 2003;289:2254-2264]
  32. Tight Control of Type 1 Diabetes: Recommendations for Patients from the American Academy of Family Physicians recommends Lantus over NPH (see page 5)
  33. Treatment with the insulin analogue lispro in children and adolescents with type 1 diabetes mellitus: evaluation over a 3-year period [Diabetes Nutr Metab. 2002 Feb;15(1):7-13].
  34. Comparison of insulin lispro with regular human insulin for the treatment of type 1 diabetes in adolescents [Clin Ther. 2002 Apr;24(4):629-38].
  35. Efficacy of Humalog injections before an afternoon meal and their acceptance by children and adolescents with type 1 diabetes [Diabet Med. 2002 Dec;19(12):1026-31].
  36. Intensive insulin treatment versus conventional regimen for adolescents with type 1 diabetes, benefits and risks [Saudi Med J. 2003 May;24(5):485-7].
  37. Insulin glargine: an updated review of its use in the management of diabetes mellitus [Drugs. 2003;63(16):1743-78].
  38. Effect of therapy with insulin glargine (lantus) on glycemic control in toddlers, children, and adolescents with diabetes [Diabetes Technol Ther. 2003;5(5):801-6].
  39. Nocturnal hypoglycemia: clinical manifestations and therapeutic strategies toward prevention [Endocr Pract. 2003 Nov-Dec;9(6):530-43].
  40. Reduced hypoglycemic episodes and improved glycemic control in children with type 1 diabetes using insulin glargine and neutral protamine Hagedorn insulin [J Pediatr. 2003 Dec;143(6):737-40].
  41. Prevalence of chronic diabetes complications in dependence on insulin therapy method in children and adolescents with type 1 diabetes.
  42. Is insulin detemir able to favor a lower variability in the action of injected insulin in diabetic subjects?
  43. Intensive insulin therapy today: 'basal-bolus' using multiple daily injections or CSII?
  44. Long-acting insulin analogues (insulin glargine or determir) and continuous subcutaneous insulin infusion in the treatment of type 1 diabetes mellitus in the paediatric population.
  45. A review of human and analogue insulin trials.
  46. Evaluation of the cost-effectiveness of insulin glargine versus NPH insulin for the treatment of type 1 diabetes in the UK.
  47. An economic assessment of analogue basal-bolus insulin versus human basal-bolus insulin in subjects with type 1 diabetes in the UK.
  48. Glargine versus NPH insulin: Efficacy in comparison with insulin aspart in a basal bolus regimen in type 1 diabetes-The glargine and aspart study (GLASS) A randomised cross-over study.
  49. Glycaemic control and hypoglycaemia in children, adolescents and young adults with unstable type 1 diabetes mellitus treated with insulin glargine or intermediate-acting insulin.
  50. Treatment with insulin glargine reduces asymptomatic hypoglycemia detected by continuous subcutaneous glucose monitoring in children and adolescents with type 1 diabetes.
  51. Comparison between basal insulin glargine and NPH insulin in patients with diabetes type 1 on conventional intensive insulin therapy.
  52. Glycemic variation and hypoglycemia in patients with well-controlled type 1 diabetes on a multiple daily insulin injection program with use of glargine and ultralente as basal insulin.
 
3. Consider Insulin Pump Therapy
 


In October 1998, 16% of CWD readers reported using an insulin pump. Thirteen years later, in September 2013, that number was 64%. Study after study report on the benefits of pump therapy, including a reduced risk of hypoglycemia compared with a regimen of Regular and NPH and better control as evidenced by HbA1c levels. Control is comparable when comparing pump use to a regimen of multiple daily injections of Lantus and NovoLog or Humalog18, but still people choose pump therapy. Why is that?

First and foremost, pump therapy provides an enormous amount of freedom. You have essentially normal schedule freedom. You can eat when you want, not when some long-acting dose of insulin is peaking. (Lantus users experience the same freedom from the long-acting peaks of NPH.) You also have the freedom to eat more often, and in smaller amounts, than you would if you have to take an injection for each and every morsel that you ate. While MDI users could do the same, it could means an enormous number of injections per day. Pump users simply program their pump to deliver an insulin bolus whenever they eat. This has profound implications for quality of life*.

You also have the freedom from injections. Pump users replace their infusion set on average every three days (poll from February 2013), compared with someone who would need to take more than a dozen injections during that same period if on MDI with Lantus or Levemir.

The precision with which pumps can deliver small amounts of insulin cannot be matched by syringes or pens. This gives pump users the ability to cover smaller amounts of food more precisely, and to take tiny extra amounts of insulin to bring down blood sugars that are higher than desired. This flexibility cannot be matched by syringes or pens due to the limits of their dosing accuracy.

Pump users also always have their insulin with them. There's no "I forgot my insulin" moments when you're out or at school.

Pump use isn't for everyone. Some people don't like the idea of wearing a medical device all the time. Some people would prefer not to spend the extra money on the pump when the same level of glucose control can be achieved with MDI using Lantus (though the schedule and eating freedom is not the same). But for many people, an insulin pump represents the best that medicine and science has to offer today.

 
  References:
  1. Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study.
  2. Glycaemic variability in paediatric patients with type 1 diabetes on continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI): a cross-sectional cohort study.
  3. Insulin Delivery and Glucose Monitoring Methods for Diabetes Mellitus: Comparative Effectiveness (PDF).
  4. Morning Hyperglycemia in Children and Adolescents with Type 1 Diabetes and Different Modes of Therapy: An Evaluation of the DPV Data Pool.
  5. Benefits of subcutaneous continuous insulin infusion in type 1 diabetic patients with high glycemic variability.
  6. Contemporary rates of severe hypoglycaemia in youth with Type 1 diabetes: variability by insulin regimen.
  7. Sensor-augmented pump therapy from the diagnosis of childhood type 1 diabetes: results of the Paediatric Onset Study (ONSET) after 12 months of treatment.
  8. Basal Insulin Substitution with Glargine or Continuous Subcutaneous Insulin Infusion in Adult Type 1 Diabetes Patients-A Randomized Controlled Trial.
  9. Sensor-Augmented Insulin-Pump Therapy.
  10. Pilot Study for Assessment of Optimal Frequency for Changing Catheters in Insulin Pump Therapy-Trouble Starts on Day 3.
  11. Consequences of delayed pump infusion line change in patients with type 1 diabetes mellitus treated with continuous subcutaneous insulin infusion.
  12. Improvements in cognition, mood and behaviour following commencement of continuous subcutaneous insulin infusion therapy in children with type 1 diabetes mellitus: a pilot study.
  13. Continuous subcutaneous insulin infusion leads to immediate, stable and long-term changes in metabolic control.
  14. In Type 1 diabetic patients with good glycaemic control, blood glucose variability is lower during continuous subcutaneous insulin infusion than during multiple daily injections with insulin glargine.
  15. Comparison of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) in paediatric Type 1 diabetes: a multicentre matched-pair cohort analysis over 3 years.
  16. Quality of life and treatment satisfaction in adults with Type 1 diabetes: a comparison between continuous subcutaneous insulin infusion and multiple daily injections.
  17. Continuous subcutaneous insulin infusion benefits quality of life in preschool-age children with type 1 diabetes mellitus.
  18. Continuous subcutaneous insulin infusion therapy: effects on quality of life. Free full text available in PDF format.
  19. Continuous subcutaneous insulin infusion attenuated glycemic instability in preschool children with type 1 diabetes mellitus. The influence of long-term therapy with the insulin pump (CSII) in patients with type 1 diabetes mellitus on metabolic compensation and on the incidence of hypoglycaemia. Comparison with intensified conventional insulin therapy (MDI).
  20. Durability of Insulin Pump Use in Pediatric Patients With Type 1 Diabetes.
  21. The impact of continuous subcutaneous insulin infusion on health-related quality of life in children and adolescents with type 1 diabetes.
  22. Long-term benefits of continuous subcutaneous insulin infusion in children with Type 1 diabetes: a 4-year follow-up.
  23. Insulin pump therapy in type 1 diabetes mellitus.
  24. Insulin Pump Therapy in Preschool Children with Type 1 Diabetes Mellitus Improves Glycemic Control and Decreases Glucose Excursions and the Risk of Hypoglycemia. Free full text available in PDF format.
  25. Comparison of the effects of continuous subcutaneous insulin infusion (CSII) and NPH-based multiple daily insulin injections (MDI) on glycaemic control and quality of life: results of the 5-nations trial.
  26. Insulin pump therapy in childhood diabetes-cost implications for Primary Care Trusts.
  27. Determinants of glycaemic control in type 1 diabetes during intensified therapy with multiple daily insulin injections or continuous subcutaneous insulin infusion: importance of blood glucose variability.
  28. Insulin pump therapy in preschool children with type 1 diabetes mellitus improves glycemic control and decreases glucose excursions and the risk of hypoglycemia.
  29. Continuous subcutaneous insulin infusion in toddlers and children with type 1 diabetes mellitus is safe and effective.
  30. Insulin pump use in young adolescents with type 1 diabetes: a descriptive study.
  31. A Two-Center Randomized Controlled Feasibility Trial of Insulin Pump Therapy in Young Children With Diabetes.
  32. Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life.
  33. Insulin Pump Helps Kids With Diabetes.
  34. Persistence of Benefits of Continuous Subcutaneous Insulin Infusion in Very Young Children With Type 1 Diabetes: A Follow-up Report.
  35. Continuous subcutaneous insulin infusion with short-acting insulin analogues or human regular insulin: efficacy, safety, quality of life, and cost-effectiveness
  36. Insulin Pump Therapy: A meta-analysis [Diabetes Care 26:1079-1087, 2003]. Full text available as HTML or PDF.
  37. Safety and Effectiveness of Insulin Pump Therapy in Children and Adolescents With Type 1 Diabetes [Diabetes Care 26:1142-1146, 2003]. Full text available as HTML or PDF.
  38. A Randomized, Controlled Study of Insulin Pump Therapy in Diabetic Toddlers
  39. The cost-effectiveness of continuous subcutaneous insulin infusion compared with multiple daily injections for the management of diabetes [Diabet Med. 2003 Jul;20(7):586-93].
  40. Metabolic control in young children with type 1 diabetes treated with continuous subcutaneous insulin infusion (insulin pump) [Endokrynol Diabetol Chor Przemiany Materii Wieku Rozw. 2003;9(1):11-5].
  41. Comparison of continuous subcutaneous insulin infusion and multiple daily injection regimens in children with type 1 diabetes: a randomized open crossover trial [Pediatrics. 2003 Sep;112(3 Pt 1):559-64].
  42. The Insulin Pump in Infants and Young Children
  43. Continuous subcutaneous insulin infusion in diabetes mellitus type 1 and 2: lower HbA1c-values and a high level of patient satisfaction [Ned Tijdschr Geneeskd. 2003 Oct 11;147(41):2021-5].
  44. Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes [J Pediatr. 2003 Dec;143(6):796-801].
  45. A Randomized Trial of Continuous Subcutaneous Insulin Infusion and Intensive Injection Therapy in Type 1 Diabetes for Patients With Long-Standing Poor Glycemic Control [Diabetes Care 25:2074-2080, 2002]. Full text available as HTML or PDF.
  46. Continuous Subcutaneous Insulin Infusion at 25 Years: Evidence base for the expanding use of insulin pump therapy in type 1 diabetes [Diabetes Care 25:593-598, 2002]. Full text available as HTML or PDF.
  47. Insulin pump therapy in toddlers and preschool children with type 1 diabetes mellitus [J Pediatr. 2002 Oct;141(4):490-5.]
  48. Less severe hypoglycaemia, better metabolic control, and improved quality of life in Type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy; an observational study of 100 consecutive patients followed for a mean of 2 years [Diabet Med. 2002 Sep;19(9):746-51].
  49. Beneficial effects of continuous subcutaneous insulin infusion in older patients with long-standing type 1 diabetes [Endocr Pract. 2001 Sep-Oct;7(5):364-9].
  50. Pilot Study Indicates Insulin Pump Therapy is Effective for Infants and Preschool Children with Type I Diabetes [Duke University press release from May 6, 2002]
  51. The Business of Insulin Pumps in Diabetes Care: Clinical and Economic Considerations [Clinical Diabetes 20:214-216, 2002].
  52. Glycemic parameters with multiple daily injections using insulin glargine versus insulin pump [Diabetes Technol Ther. 2004 Feb;6(1):9-15].
 
4. Continuous Sensing Makes Sense
 


Continuous glucose sensors have the potential to revolutionize diabetes care by offering, for the first time, a minute-by-minute window into glucose levels and to alarm when glucose levels exceed safe thresholds. Parents of kids with diabetes and adults with diabetes will be able to sleep through the night, knowing that an unexpected low blood sugar will be detected and an alarm will sound. (See citations below about nocturnal hypoglycemia.) Everyone will be able to see the immediate effects of food on their glucose levels, and will be able to make changes in their diets to improve glucose control.

Continuous sensing is not equivalent to blood glucose however. Continuous sensors measure glucose in the interstitial space, not the blood. While the two values correlate well when the blood glucose is stable, there is a difference during periods of rapid change, such as immediately after a meal. This does not mean that continuous sensors are not accurate, or even that they are less accurate. They just measure something different. Everyone involved in diabetes -- the patients, the diabetes team members, the scientific community, and industry -- are learning how to make the best sense of this new data. And along the way, the nature of treating diabetes is changing.

 
  References:
  1. Effect of Sensor-Augmented Insulin Pump Therapy and Automated Insulin Suspension vs Standard Insulin Pump Therapy on Hypoglycemia in Patients With Type 1 Diabetes. See also Low-Glucose-Suspension Feature Cuts Severe Hypoglycemia (Free Medscape membership required).
  2. Hypoglycemia in Patients with Type 1 Diabetes: Epidemiology, Pathogenesis, and Prevention.
  3. Detection and treatment efficacy of hypoglycemic events in the everyday life of children younger than 7 yr.
  4. Hypoglycaemia, fear of hypoglycaemia and quality of life in children with Type 1 diabetes and their parents.
  5. Review: Continuous glucose monitoring reduces HbA1c more than self-monitoring in type 1 diabetes.
  6. The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial.
  7. Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes.
  8. How continuous monitoring changes the interaction of patients with a mobile telemedicine system.
  9. Use of Continuous Glucose Monitoring in Subjects With Type 1 Diabetes on Multiple Daily Injections Versus Continuous Subcutaneous Insulin Infusion Therapy.
  10. Continuous glucose monitoring reduces both hypoglycaemia and HbA(1c) in hypoglycaemia-prone type 1 diabetic patients treated with a portable pump.
  11. Sensor-augmented pump therapy from the diagnosis of childhood type 1 diabetes: results of the Paediatric Onset Study (ONSET) after 12 months of treatment.
  12. Quality of Life Measures in Children and Adults with Type 1 Diabetes: The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Randomized Trial.
  13. Use of a real-time continuous glucose monitoring system in children and young adults on insulin pump therapy: patients' and caregivers' perception of benefit.
  14. Effectiveness of Continuous Glucose Monitoring in a Clinical Care Environment: Evidence from the JDRF-CGM Trial.
  15. Use of continuous glucose monitoring system in the management of severe hypoglycemia.
  16. Reducing glycaemic variability in type 1 diabetes self-management with a continuous glucose monitoring system based on wired enzyme technology.
  17. Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes - The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group
  18. Sensor-Augmented Insulin Pump Therapy: Results of the First Randomized Treat-to-Target Study.
  19. The Accuracy and Efficacy of Real-Time Continuous Glucose Monitoring Sensor in Patients with Type 1 Diabetes.
  20. Sensor-augmented pump therapy in type 1 diabetes.
  21. Oscillating glucose is more deleterious on endothelial function and oxidative stress than mean glucose in normals and type 2 diabetic patients.
  22. Accuracy of the 5-Day FreeStyle Navigator Continuous Glucose Monitoring System. Free full text available in HTML and PDF formats.
  23. Hypoglycemia during sleep impairs consolidation of declarative memory in type 1 diabetic and healthy humans.
  24. Evaluating the Clinical Accuracy of Two Continuous Glucose Sensors Using Continuous Glucose Error Grid Analysis (Diabetes Care 28:2412-2417, 2005)
  25. Improvement in Glycemic Excursions With a Transcutaneous, Real-Time Continuous Glucose Sensor (Diabetes Care 29:44-50, 2006)
  26. Awakening and Counterregulatory Response to Hypoglycemia During Early and Late Sleep.
  27. Defective Awakening Response to Nocturnal Hypoglycemia in Patients with Type 1 Diabetes Mellitus. Free full text available in PDF format.
  28. Awakening from Sleep and Hypoglycemia in Type 1 Diabetes Mellitus. Free full text available in PDF format.
  29. Impaired overnight counterregulatory hormone responses to spontaneous hypoglycemia in children with type 1 diabetes.
  30. Nocturnal hypoglycaemia in Type 1 diabetic patients, assessed with continuous glucose monitoring: frequency, duration and associations.
  31. Use of Continuous Glucose Monitoring in the Detection and Prevention of Hypoglycemia.
  32. Impact of Real-Time Continuous Glucose Monitoring on Children and Their Families.
  33. Extended use of a new continuous glucose monitoring system with wireless data transmission in children with type 1 diabetes mellitus (Diabetes Technol Ther. 2006 Apr;8(2):139-45)
  34. Evaluation of CGMS® During Rapid Blood Glucose Changes in Patients with Type 1 Diabetes (Diabetes Technol Ther. 2006 Apr;8(2):146-55)
  35. Continuous subcutaneous glucose monitoring in children with type 1 diabetes mellitus: a single-blind, randomized, controlled trial (Pediatr Diabetes. 2006 Jun;7(3):159-64)
  36. Subcutaneous glucose sensor values closely parallel blood glucose during insulin-induced hypoglycaemia.
  37. Unrecognised hypoglycaemia in children and adolescents with type 1 diabetes using the continuous glucose monitoring system: Prevalence and contributors. (J Paediatr Child Health. 2006 Dec;42(12):758-63)
  38. Nocturnal hypoglycaemia in Type 1 diabetic patients, assessed with continuous glucose monitoring: frequency, duration and associations.
  39. Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus.
  40. The role of continuous glucose monitoring in clinical decision-making in diabetes in pregnancy.
  41. The Medtronic MiniMed Gold Continuous Glucose Monitoring System: An Effective Means to Discover Hypo- and Hyperglycemia in Children Under 7 Years of Age.
  42. Continuous Subcutaneous Glucose Monitoring System in diabetic mothers during labour and postnatal glucose adaptation of their infants.
 
5. Insist on Immediate HbA1c Feedback at Clinic Visits
 


Two studies published in Diabetes Care (citations below) have shown that when patients can discuss their HbA1c reading with their diabetes team during a clinic visit, their blood glucose control improved significantly. This makes sense intuitively. Given how busy families are, and how overbooked most clinics are, if you don't discuss your HbA1c at the time of the clinic visit, you're unlikely to discuss it all and therefore you won't have a chance to make adjustments in care.

In a poll we ran in July 2013, the overwhelming majority of our readers report finger stick HbA1c testing in the clinic. 70% report finger stick HbA1c testing in the clinic, compared with 49% in March 2003. Yet 25% report still getting a venous blood draw, compared with 37% in March 2003. Both show a trend toward greater use of HbA1c tests that can be performed immediately in the clinic and which allow patients to discuss the results immediately with their diabetes team.

If your diabetes team does not use a device that measures HbA1c immediately, you have a couple options:

  1. Arrange to have the blood drawn a week or so before your regular clinic visit so that the results are available to discuss with your diabetes team.
  2. Purchase a home HbA1c test kit and perform the measurement yourself. Discuss the results with your diabetes team during your clinic visit.
  3. Find another diabetes team.

 
  References:
  1. Effect of Point-of-Care on Maintenance of Glycemic Control as Measured by A1C [Diabetes Care 30:713-715, 2007]
  2. HbA1c Measurement, which includes descriptions of the home HbA1c kits on the market today.
  3. Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients [Diabetes Care 22:1785-1789, 1999]. Full text available as PDF.
  4. Rapid A1c Availability Improves Clinical Decision-Making in an Urban Primary Care Clinic [Diabetes Care 26:1158-1163, 2003]. Full text available as HTML and PDF.
 
6. Check Blood Ketones, Not Urine Ketones
 


Ketones in the blood can be detected well before ketones in the urine be detected, offering you the opportunity to treat sooner than you would if you waited for urine testing. (Have you ever tried to make a three year old pee on command?) Also, being able to test with a finger stick eliminates the need to find a bathroom to test if you're away from home. (How many of you carry urine ketone strips when you're out shopping or at an amusement park? And if you do, do you like the thought of peeing on a strip in a filthy public bathroom?)

Two studies from February 2006 demonstrate clear medical benefit from blood ketone testing. The first study (Diabetic Medicine 23 (3), 278-284) showed a significant reduction in hospitalizations during sick days (38 vs. 75 per 100 patient days) for people who used blood ketone testing compared with urine ketones testing. Staying out of the hospital is a very powerful argument for using blood ketone testing. The second study (Diabetes Technol Ther. 2006 Feb;8(1):67-75) showed that, for patients using insulin pumps, blood ketone testing could identify interruptions in insulin flow faster and more accurately than even blood glucose monitoring and could thus help pumpers prevent DKA better than if they didn't use blood ketone testing.

While some argue that the cost of blood ketone testing is much higher than urine ketone testing (about $4 per blood ketone strip versus as low as $0.10 per urine ketone strip), annual testing costs will likely be about the same if you check for ketones about 10 times per year, which is about what our readers reported in a recent poll. Urine test strips have a 90-day lifetime, after which they must be replaced. Priced at about $10 per 100 strips, the annual cost of urine testing is about $40. At $4 per test for blood ketone testing, if you test 10 times a year, the annual cost is also about $40 per year. If you check for ketones more often, then urine testing might be more economical, but the clinical benefits described in recent studies still argue for using blood ketone testing.

Of course, the benefits of feedback on what's happening in your body at that instant, not having to force toddlers to pee on demand, not having to drag a sick teenager out of bed to the bathroom, and not having to go into a public bathroom when you're out and not feeling well are -- as the advertisement says -- priceless.

 
  References:
  1. Blood beta-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review.
  2. Sick day management using blood 3-hydroxybutyrate (3-OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial.
  3. Early detection of insulin deprivation in continuous subcutaneous insulin infusion-treated patients with type 1 diabetes.
  4. Impaired endothelial antithrombotic activity following short-term interruption of continuous subcutaneous insulin infusion in type 1 diabetic patients.
  5. Review of the Precision Xtra blood glucose meter, which can also also measure blood ketones.
  6. Sick day management using blood 3-hydroxybutyrate (3-OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial. (Diabetic Medicine 23 (3), 278-284)
  7. Early detection of insulin deprivation in continuous subcutaneous insulin infusion-treated patients with type 1 diabetes. (Diabetes Technol Ther. 2006 Feb;8(1):67-75)
  8. Accuracy of an Electrochemical Sensor for Measuring Capillary Blood Ketones by Fingerstick Samples During Metabolic Deterioration After Continuous Subcutaneous Insulin Infusion Interruption in Type 1 Diabetic Patients [Diabetes Care 26:1137-1141, 2003]. Full text available as HTML or PDF.
  9. The direct measurement of 3-beta-hydroxy butyrate enhances the management of diabetic ketoacidosis in children and reduces time and costs of treatment. [Diabetes Nutr Metab. 2003 Oct-Dec;16(5-6):312-6].
  10. The hospital and home use of a 30-second hand-held blood ketone meter: guidelines for clinical practice [Diabet Med. 2001 Aug;18(8):640-5].
 
7. Get Tested for Celiac
 


Celiac disease, also called celiac sprue, is an autoimmune disorder that occurs when the body reacts to foods containing grains such as wheat, barley, and rye. The body is reacting to a protein called gluten, which is present in grains. Celiac is relatively common in people who have type 1 diabetes or a relative with type 1 or another autoimmune disorder. If you have type 1 diabetes, a relative with type 1 diabetes, or you have other autoimmune disorders in your family, you should ask your doctor about being tested for celiac.

There are many other tests that should be part of your diabetes care regimen, including micoalbuminuria, thyroid, lipids, and an annual eye exam including a retinal photograph. Discuss these with your diabetes team.

  References:
  1. Update on coeliac disease and type 1 diabetes mellitus in childhood.
  2. Increasing prevalence of coeliac disease over time.
  3. Newly identified genetic risk variants for celiac disease related to the immune response. See also Major Breakthrough in the Treatment of Coeliac Disease by TCD Researchers; Coeliac Disease linked to Diabetes in new TCD Research, Coeliac link to diabetes and TCD scientists in coeliac breakthrough.
  4. Incidence of Autoimmune Diseases in Celiac Disease: Protective Effect of the Gluten-Free Diet.
  5. Screening for coeliac disease in type 1 diabetes [Arch Dis Child. 2002 Dec;87(6):495-8]. Full text available as HTML or PDF.
 
8. Consider Type 2 Medications in Type 1 Diabetes
 


Everyone with type 1 diabetes requires injected insulin. Sometimes, however, insulin may not be enough. During puberty, for example, teens with type 1 can become resistant to the effects of insulin. This is thought to be caused by the effects of growth hormone. A study published in Diabetes Care in January 2003 showed that teens with type 1 who were having difficulty with control could benefit from the addition of metformin, an oral agent typically used in type 2 diabetes. The results were positive. Recent research also shows benefits, especially for reducing insulin needs.

So, if your teen is struggling with blood sugar control, you may wish to ask your diabetes team about adding metformin to your diabetes care regimen. It's not for everyone, but in the right kids, it can make a difference. Although metformin use is off-label in the US for type 1 diabetes (as of 2014), health professionals sometimes prescribe metformin for type 1 diabetes patients in appropriate circumstances. If your teen is struggling with blood sugar control, you may wish to discuss metformin with your diabetes health care team.

More recently, studies are reporting significant benefits from using GLP-1 agonists in type 1 diabetes. These drugs, injected like insulin, are approved in the US only for adults with type 2 diabetes, but their use among adults with type 1 is growing, along with more scientific trials of their use in adults with type 1 diabetes. Examples of these drugs are Victoza and Byetta.

Another new class of drugs for adults with type 2 diabetes is called SGLT-2 inhibitors, where "SGLT" stands for sodium glucose cotransporter. These drugs cause the kidney to excrete glucose at a lower level in the blood, rather than reabsorbing it, resulting in lower blood glucose levels and weight loss. The first drug of this class is called Invokana, but many others are nearing approval and the marketplace.

 
  References:
  1. Effects of low dose metformin in adolescents with type I diabetes mellitus: a randomized, double-blinded placebo-controlled study.
  2. Renal glucose handling in diabetes and sodium glucose cotransporter 2 inhibition. Free full text available in HTML format.
  3. Four weeks of treatment with liraglutide reduces insulin dose without loss of glycemic control in type 1 diabetic patients with and without residual beta-cell function. Free full text available in HTML and PDF formats.
  4. Liraglutide as additional treatment for type 1 diabetes. Free full text available in HTML and PDF formats.
  5. Sodium-Glucose Cotransporter 2 Inhibition and Glycemic Control in Type 1 Diabetes: Results of an 8-Week Open-Label Proof-of-Concept Trial.
  6. Effect of sitagliptin on glucose control in adult patients with Type 1 diabetes: a pilot, double-blind, randomized, crossover trial.
  7. The use of metformin in type 1 diabetes: a systematic review of efficacy.
  8. Metformin added to insulin therapy for type 1 diabetes mellitus in adolescents.
  9. Used of oral antidiabetic agents in pediatric patients - own observations.
  10. Effect of adjunct metformin treatment in patients with type-1 diabetes and persistent inadequate glycaemic control. A randomized study. Free full text available in HTML and PDF formats.
  11. The addition of metformin in type 1 diabetes improves insulin sensitivity, diabetic control, body composition and patient well-being.
  12. The effect of metformin on blood glucose control in overweight patients with Type 1 diabetes.
  13. Usefulness of the addition of metformin to insulin in pediatric patients with type 1 diabetes mellitus [Pediatr Int. 2005 Aug;47(4):430-3]
  14. Metformin as additional therapy in adolescents with poorly controlled type 1 diabetes: randomised placebo-controlled trial with aspects on insulin sensitivity [Eur J Endocrinol. 2003 Oct;149(4):323-9].
  15. Metformin as an adjunct therapy in adolescents with type 1 diabetes and insulin resistance: a randomized controlled trial [Diabetes Care. 2003 Jan;26(1):138-43]. Full text available as HTML or PDF.
  16. The Benefits of Metformin Therapy During Continuous Subcutaneous Insulin Infusion Treatment of Type 1 Diabetic Patients [Diabetes Care 25:2153-2158, 2002]. Full text available as HTML or PDF.
  17. Contraindications to the use of metformin [BMJ 2003;326:4-5 (4 January)]. Full text in PDF format.
 


                 
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Last Updated: Wednesday December 31, 2014 20:55:34
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