Our 10 year old son was diagnosed with type 1 diabetes four and a half years ago, and four weeks ago, our 13 year old had a routine urine test which showed ketones and glucose. His A1Cc was 11.4%, and he had a high level of antibodies. The doctors say this an indication of diabetes, but there is some question as to whether or not to start him on insulin yet. He has none of the symptoms of diabetes our younger son had when he was diagnosed, but his fasting blood sugars are between 8 and 11 mmol/L [144 and 198 mg/dl] most mornings with a little glucose but no ketones in his urine. Through the day his levels tend to stay at around 11 mmol/L [198 mg/dl]. Our paediatrician feels we should leave him alone until he shows some obvious symptoms, but clinical researchers I have spoken to in feel he is better off starting on a small dose of insulin now. How do we know the best way of dealing with this?

In the light of the positive antibody test, the high hemoglobin A1c level and the unequivocally abnormal fasting blood sugars, there can be no doubt that your older son also has type 1A (autoimmune) diabetes. Personally, I come down on the side of the clinical researchers in thinking that he should start insulin right away. There are two good reasons for not delaying, the first is that it should help to begin the business of education and getting used to the routine of diabetes in a calmer climate, and more importantly, at this stage any acute infection might precipitate DKA [diabetic ketoacidosis] which has significant risks.

Of course by doing this, you forego any chance of joining a research project in Melbourne to delay insulin dependence with nicotinamide or perhaps some of the new immunomodulatory agents like MMF and sirolemus. To set against this though, he will sooner reach a point in which he may be able to consider the great flexibility of being on an insulin pump or of one of the newer intensive regimens like using Lantus (insulin glargine) once a day in combination with a variable dose of Humalog or Novolog just before or just after meals. These are regimens that can both give excellent control and fit in with a teen age lifestyle.

DOB