The role of new technologies in treating children and adolescents with type 1 diabetes mellitus

Abstract:  Given the physiological and psychological impact of type 1 diabetes in children and adolescents, these patients present special challenges to pediatric health care providers. The goals of intensive management of diabetes have been clearly established since the publication of the Diabetes Control and Complication Trial (DCCT) in 1993 (1), which demonstrated that tight metabolic control achieved with intensive insulin therapy is superior to conventional treatment in reducing the risk of long-term microvascular complications. Thus, current recommendations mandate that youth with type 1 diabetes should aim to achieve metabolic control as close to normal as possible. However, strict glycemic control is hard to achieve requiring frequent blood glucose measurements and several insulin injections per day, and in addition is associated with an increased risk of severe hypoglycemia (1). Recurrent episodes of hypoglycemia, especially at young ages, may cause adverse effects on neurocognitive function, may lead to hypoglycemia unawareness, and may be associated with significant emotional morbidity for the child and parents. Since the discovery of insulin in 1921 there has been constant progress in the way patients with type 1 diabetes are treated. The introduction of recombinant insulin and insulin analogs as well as new insulin delivery systems and glucose monitoring devices enhanced the ability of both patients and medical teams to better define the therapeutic goals and to develop more effective therapeutic strategies. Recent advances in devices for insulin administration and glucose monitoring and the introduction of telemedicine are having a profound effect on the lives of youth with type 1 diabetes. This review focuses on the new technologies which have been developed for treating children and adolescents with type 1 diabetes.     

Use of a real‐time continuous glucose monitoring system in children and young adults on insulin pump therapy: patients' and caregivers' perception of benefit

Cemeroglu AP, Stone R, Kleis L, Racine MS, Postellon DC, Wood MA. Use of a real‐time continuous glucose monitoring system in children and young adults on insulin pump therapy: patients' and caregivers' perception of benefit. Background: Real‐time continuous glucose monitoring systems (RT‐CGMS) are a recently introduced technology for type 1 diabetes and experience in children is limited. Objective: To assess patient and caregiver's perception of benefits and disadvantages of RT‐CGMS in children or young adults with type 1 diabetes mellitus (DM) on insulin pump therapy. Subjects and Methods: Forty‐three subjects (3–25 yr) on insulin pump therapy were included in the study. Thirty‐four used RT‐CGMS for a short‐term trial (4 wk, ST group) and nine as a long‐term tool (2–18 months, LT group). Forty subjects or their caregivers completed a questionnaire. Results: On the basis of the questionnaire responses, hypoglycemia prevention was the most common perceived benefit (88%), followed by elimination of hypoglycemia‐related anxiety (83%), ease of pattern management (85%), improvement of diabetes control (80%), improvement of quality of life (78%), and ease of diabetes care (78%). Negative effects included irritation/annoyance from the sensor alarm (48%) and insertion site bruising, pain, or irritation (43%). A small percentage of patients who were interested in purchasing the device (12%) decided against using it LT after a 4‐wk trial on RT‐CGMS. Conclusions: The most common perceived benefits of RT‐CGMS are prevention of hypoglycemia and decrease in hypoglycemia‐related anxiety. Negative effects are uncommon and seem to be unlikely to affect the decision to use RT‐CGMS for a LT. A ST trial seems to be a valuable tool for the patient/caregiver in determining whether to purchase the device and in setting realistic expectations of its potential benefits.     

Effectiveness of sensor-augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study

Slover RH, Welsh JB, Criego A, Weinzimer SA, Willi SM, Wood MA, Tamborlane WV. Effectiveness of sensor‐augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study. Objective: Maintenance of appropriate A1C values and minimization of hyperglycemic excursions are difficult for many pediatric patients with type 1 diabetes. Continuous glucose monitoring (CGM) sensor‐augmented pump (SAP) therapy is an alternative to multiple daily injection (MDI) therapy in this population. Research design and methods: Sensor‐augmented pump therapy for A1C reduction (STAR 3) was a 1‐yr trial that included 82 children (aged 7–12) and 74 adolescents (aged 13–18) with A1C values ranging from 7.4 to 9.5% who were randomized to either SAP or MDI therapy. Quarterly A1C values were obtained from all subjects. CGM studies were carried out at baseline, 6 months, and 12 months to quantify glycemic excursions [calculated as area under the glucose concentration‐time curve (AUC)] and variability. In the SAP group, sensor compliance was recorded. Results: Baseline A1C values were similar in subjects randomized to the SAP (8.26 ± 0.55%) and MDI groups (8.30 ± 0.53%). All subsequent A1C values showed significant (p < 0.05) treatment group differences favoring SAP therapy. Compared with the MDI group, subjects in the SAP group were more likely to meet age‐specific A1C targets and had lower AUC values for hyperglycemia with no increased risk of hypoglycemia. Glucose variability improved in the SAP group compared to the MDI group. Children wore CGM sensors more often and were more likely to reach age‐specific A1C targets than adolescents. Conclusions: SAP therapy allows both children and adolescents with marginally or inadequately controlled type 1 diabetes to reduce A1C values, hyperglycemic excursions, and glycemic variability in a rapid, sustainable, and safe manner.     

Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research

Patton SR, Williams LB, Eder SJ, Crawford MJ, Dolan L, Powers SW. Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research. Objective: This study presents data on the use of continuous glucose monitoring (CGM) in young children with type 1 diabetes mellitus (T1DM). CGM provides moment‐to‐moment tracking of glucose concentrations and measures of intra‐ and interday variability, which are particularly salient measures in young children with T1DM. Methods: Thirty‐one children (mean age = 5.0 yr ) with T1DM wore the Medtronic Minimed CGM for a mean of 66.8 h. The CGM was inserted in diabetes clinics, and parents were provided brief training. Results: Few difficulties were experienced and families cited the acceptability of CGM. Participants' CGM data are compared with self‐monitoring blood glucose (SMBG) data as well as data from older children with T1DM to illustrate differences in methodology and variability present in this population. CGM data are used to calculate glucose variability, which is found to be related to diabetes variables such as history of hypoglycemic seizures. Conclusions: CGM is an acceptable research tool for obtaining glucose data in young children with T1DM and has been used previously in older children and adults. CGM may be particularly useful in young children who often experience more glucose variability. Data obtained via CGM are richer and more detailed than traditional SMBG data and allow for analyses to link blood glucose with behavior.     

Insulin pump therapy

Intensive insulin therapy is the mainstay of diabetes care as it prevents or delays the long term complications of Type 1 diabetes mellitus. Insulin pump therapy can deliver improved diabetes control and at the same time reduce the number and serious nature of any hypoglycaemic episodes. The therapy is not associated with an increased risk of diabetic ketoacidosis. Pump therapy should follow National Institute for Health and Care Excellence Guidelines and be instigated and supported by teams experienced in insulin pump therapy, with skills and competences to ensure sustained positive outcomes. Continuous glucose monitoring further improves blood glucose control providing continuous feedback with warnings of rapid changes in glucose and/or attainment of high or low glucose concentrations. Continuous glucose monitoring is cost effective by reducing fear of hypoglycaemia, blood glucose finger prick testing and a marked reduction in hypoglycaemic episodes. The hybrid closed loop systems offering algorithm driven insulin adjustment based on sensor readings are now commercially available bringing into play more effective and safer insulin delivery with a further step change in diabetes control and well being.     

The effectiveness of Internet-based blood glucose monitoring system on improving diabetes control in adolescents with type 1 diabetes

Landau Z, Mazor‐Aronovitch K, Boaz M, Blaychfeld‐Magnazi M, Graph‐Barel C, Levek‐Motola N, Pinhas‐Hamiel O. The effectiveness of Internet‐based blood glucose monitoring system on improving diabetes control in adolescents with type 1 diabetes. Objective: To determine whether the use of an Internet‐based blood glucose monitoring system could improve glycemic control in adolescents with type 1 diabetes mellitus (T1DM). Methods: In a randomized, controlled clinical trial, a total of 70 adolescent subjects with T1DM were recruited. Subjects randomized to the intervention group (n = 36) were instructed to submit their blood glucose levels weekly by Internet to the Diabetes Care Team during a period of 6 months. Subjects randomized to the control group (n = 34) did not submit results but were under routine follow‐up. Results: At baseline, patients were 15.1 ± 2.6 years of age with mean HbA1c of 8.3 ± 1.3%. At the 6‐month follow‐up period, no by‐group differences in change from baseline to end of treatment HbA1c levels were detected. In the intervention group, 12/36 did not submit blood glucose levels and were classified as non‐compliant. In a secondary exploratory analysis in which non‐compliant patients were omitted, HbA1c values in the compliant intervention group declined from 8.5 ± 1.7% at baseline to 8.2 ± 1.2% at 6 months, while in the control group HbA1c values increased from 8.2 ± 1.1 to 8.4 ± 1.1%, this difference did not reach statistical significance. Conclusions: An Internet‐based blood glucose monitoring system was not associated with improved glycemic control in adolescents with T1DM. Identification of a sub‐group of compliant subjects who may improve metabolic control by using this tool is needed.     

Sociodemographic and psychosocial factors associated with continuous subcutaneous insulin infusion in adolescents with type 1 diabetes

Cortina S, Repaske DR, Hood KK. Sociodemographic and psychosocial factors associated with continuous subcutaneous insulin infusion in adolescents with type 1 diabetes. Objective: To examine the role of sociodemographic factors and psychosocial adjustment in continuous subcutaneous insulin infusion (CSII) use among adolescents with type 1 diabetes. Methods: A total of 150 adolescents with type 1 diabetes and their caregivers completed measures of general psychological functioning, diabetes functioning, and stressful life events. Blood glucose monitoring (BGM) frequency and glycemic control were also assessed. Logistic regression was used to determine associations between CSII use and sociodemograpic and psychosocial factors. Results: All logistic regression models were significant, indicating a large proportion of the variance in CSII use was associated with sociodemographic, diabetes‐specific and psychosocial variables. Final models showed higher frequency of BGM and having private insurance as significant correlates of CSII use. CSII use was also associated with adolescent and caregiver reports of sharing of responsibilities around diabetes management and negative affect regarding BGM. Conclusions: Adolescents currently prescribed CSII therapy evidenced key differences from their counterparts using multiple daily injections (MDI) in insurance status, diabetes management behavior, and family functioning related to diabetes. Efforts to understand the role of family factors in the maintenance of CSII therapy with clinical indicators of CSII use may inform treatment effectiveness.     

Psychological aspects of continuous glucose monitoring in pediatric type 1 diabetes

Abstract:  Clinical use of near-continuous glucose monitors (CGMs) could have substantial impact on family management of pediatric type 1 diabetes and could generate both beneficial and adverse psychological reactions. In addition to glycemic benefits, CGM could possibly yield educational and motivational benefits. Conversely, CGM may also lead to information overload and increased treatment burden. Further, patients and families with certain affective, behavioral, and cognitive characteristics might derive greater benefit from CGM use. As information about these processes could facilitate optimal clinical use of CGM, the Diabetes Research in Children Network (DirecNet) included measurement of selected psychological variables in a recent randomized trial of the GlucoWatch G2^® Biographer (GW2B, Cyngus, Inc., Redwood City, CA, USA). A multicenter sample of 200 youths with type 1 diabetes was randomized to 6 months of either continued usual care (UC) using a conventional home glucose meter for diabetes or supplementation of standard care with use of the GW2B. Diabetes treatment adherence, diabetes-specific quality of life, and diabetes-related anxiety were measured at baseline and at the end of the study. Satisfaction with use of the GW2B was measured at the end of the study. The results indicated neither adverse nor beneficial psychological effects of CGM use. More frequent GW2B use over the 6-month study was found among youths whose parents reported higher scores for treatment adherence and diabetes-related quality of life at baseline. The study illustrates the empiric assessment of the psychological context of CGM use and establishes methods that are applicable to new CGM devices as they emerge.     

Impaired β‐cell sensitivity to glucose and maximal insulin secretory capacity in adolescents with type 2 diabetes

Elder DA, Woo JG, D’Alessio DA. Impaired β‐cell sensitivity to glucose and maximal insulin secretory capacity in adolescents with type 2 diabetes. Background: Adults with type 2 diabetes mellitus (T2DM) have broad impairments in β‐cell function, including severe attenuation of the first‐phase insulin response to glucose, and reduced β‐cell mass. In adolescents with T2DM, there is some evidence that β‐cell dysfunction may be less severe. Our objective was to determine β‐cell sensitivity to glucose and maximal insulin secretory capacity (AIR_max) in teenagers with T2DM. Methods: Fifteen adolescents with T2DM [11 F/4 M, age 18.4 ± 0.3 yr, body mass index (BMI) 39.8 ± 2.2 kg/m²] and 10 non‐diabetic control subjects (7 F/3 M, age 17.4 ± 0.5 yr, BMI 41.5 ± 2.2 kg/m²) were studied. T2DM subjects had a mean duration of diabetes of 48.8 ± 6.4 months, were treated with conventional therapies, and had good metabolic control [hemoglobin A1c (HbA1c) 6.7 ± 1.2%]. Insulin and C‐peptide were determined before and after a graded glucose infusion and after intravenous arginine at a whole blood glucose level of ≥22 mM. Results: The insulin response to increasing plasma glucose concentrations was blunted in the diabetic compared with control subjects (34.8 ± 11.9 vs. 280.5 ± 57.8 pmol/mmol; p < 0.0001), and AIR_max was also significantly reduced in the diabetic group (1868 ± 330 vs. 4445 ± 606; p = 0.0005). Conclusion: Even adolescents with well‐controlled T2DM have severe impairments of insulin secretion. These data support β‐cell dysfunction as central in the pathogenesis of T2DM in young people, and indicate that these abnormalities can develop over a period of just several years.     

Screening for type 2 diabetes and prediabetes in obese youth: evaluating alternate markers of glycemia – 1,5‐anhydroglucitol,fructosamine, and glycated albumin

Hemoglobin A1c (HbA1c) is increasingly performed over the oral glucose tolerance test (OGTT) as the initial screening test for type 2 diabetes in youth. However, the optimal strategy for identifying type 2 diabetes in youth remains controversial. Alternate glycemic markers have been proposed as potentially useful tools for diabetes screening. We examined the relationships among fructosamine (FA), glycated albumin (GA), and 1,5‐anhydroglucitol (1,5‐AG) with traditional screening tests, HbA1c and OGTT. Youth 10–18 yrs, BMI ≥85th‰, and HbA1c <7.5% had a single visit with measurement of HbA1c, 1,5‐AG, FA, GA, and a standard OGTT. Distributions of FA, GA, and 1,5‐AG by HbA1c and 2‐hour glucose (2hG) categories were compared. Receiver operating characteristic (ROC)‐curves were generated to determine the cut points at which alternate markers maximized sensitivity and specificity for predicting prediabetes and diabetes. One hundred and seventeen, 62% female, 59% Hispanic, 22% White, 17% black, median 14.1 yr, and body mass index (BMI) z‐score 2.3 participated. Median values of each alternate marker differed significantly between prediabetes and diabetes HbA1c and 2hG categories (p < 0.017). Only GA medians differed (p = 0.006) between normal and prediabetes HbA1c. Area under the receiver operating characteristic curves (ROC‐AUCs) for alternate markers as predictors of prediabetes (0.5–0.66) were low; however, alternate marker ROC‐AUCs for identifying diabetes (0.82–0.98) were excellent. Although the alternate markers were poor predictors of prediabetes, they all performed well predicting diabetes by 2hG and HbA1c. Whereas the usefulness of these markers for identifying prediabetes is limited, they may be useful in certain scenarios as second line screening tools for diabetes in overweight/obese youth.     

Sporadic pseudohypoparathyroidism type‐1b with asymptomatic hypocalcemia

Pseudohypoparathyroidism type 1b (PHP‐1b) is usually diagnosed on various symptoms of hypocalcemia. Previous studies reported a few cases of autosomal dominant pattern PHP‐1b identified on familial analysis with asymptomatic hypocalcemia. Herein we report the case of a 6‐year‐old male patient with sporadic PHP‐1b incidentally detected on preoperative examination. He had neither characteristic findings of Albright hereditary osteodystrophy nor evidence of tetany. Sporadic PHP‐1b was diagnosed on the basis of clinical observation and laboratory examination. In addition, genetic testing using methylation‐specific multiplex ligation‐dependent probe amplification indicated broad methylation abnormalities and confirmed the sporadic form of PHP‐1b. Sporadic PHP‐1b might often be overlooked when diagnosis is done simply on definitive clinical features. To avoid this, DNA sequencing and methylation analysis should be performed even in the absence of definitive clinical features.     

Factors associated with increased risk of insulin pump discontinuation in pediatric patients with type 1 diabetes

de Vries L, Grushka Y, Lebenthal Y, Shalitin S, Phillip M. Factors associated with increased risk of insulin pump discontinuation in pediatric patients with type 1 diabetes. Background: There are few reports on rates and predictors for pump discontinuation in the pediatric population. Objective: To study the rate of and predictors for insulin pump discontinuation among pediatric patients with type 1 diabetes. Methods: Medical chart review of 530 patients with type 1 diabetes who had started pump therapy between 2000 and 2008 in our center revealed that 11.3% had discontinued pump use after 3 d to 5 yr; of these, 9.1% discontinued pump use at least 3 months after initiation. Relevant data were retrieved from the files of these patients and from those of 100 randomly assigned pump‐treated patients. Results: The pump discontinuation group had a significantly higher proportion of female patients (75 vs. 46%, p = 0.001) and patients above 10 yr of age (93.8 vs. 80%, p = 0.03) than the reference group. Comparable findings were noted for age at diagnosis, pubertal stage, anthropometric data and duration of diabetes at pump initiation, rate of severe hypoglycemic and diabetic ketoacidosis episodes. There were no between‐group differences in number of daily insulin injections and blood glucose measurements before pump treatment. At pump initiation, HbA_1c was significantly higher in patients discontinuing pump therapy than in the controls (8.6 ± 1.4 vs. 8.1 ± 1.0, p = 0.02). This difference was maintained at the last follow‐up visit recorded. Conclusions: Almost 90% of our cohort maintained pump therapy. Female gender, age older than 10 years in girls and poor metabolic control at pump initiation were associated with higher risk for pump discontinuation – for such patients intensified individual and family support may serve to maximize persistent pump therapy.     

Use of the DirecNet Applied Treatment Algorithm (DATA) for diabetes management with a real-time continuous glucose monitor (the FreeStyle Navigator)

Background:  There are no published guidelines for use of real-time continuous glucose monitoring data by a patient; we therefore developed the DirecNet Applied Treatment Algorithm (DATA). The DATA provides algorithms for making diabetes management decisions using glucose values: (i) in real time which include the direction and rate of change of glucose levels, and (ii) retrospectively based on downloaded sensor data.
Objective:  To evaluate the use and effectiveness of the DATA in children with diabetes using a real-time continuous glucose sensor (the FreeStyle Navigator).
Subjects:  Thirty children and adolescents (mean ± standard deviation age = 11.2 ± 4.1 yr) receiving insulin pump therapy.
Methods:  Subjects were instructed on use of the DATA and were asked to download their Navigator weekly to review glucose patterns. An Algorithm Satisfaction Questionnaire was completed at 3, 7, and 13 wk.
Results:  At 13 wk, all of the subjects and all but one parent thought that the DATA gave good, clear directions for insulin dosing, and thought the guidelines improved their postprandial glucose levels. In responding to alarms, 86% of patients used the DATA at least 50% of the time at 3 wk, and 59% reported doing so at 13 wk. Similar results were seen in using the DATA to adjust premeal bolus doses of insulin.
Conclusions:  These results show the feasibility of implementing the DATA when real-time continuous glucose monitoring is initiated and support its use in future clinical trials of real-time continuous glucose monitoring.     

A 5‐yr follow‐up nerve conduction study for the detection of subclinical diabetic neuropathy in children with newly diagnosed insulin‐dependent diabetes mellitus

Lee S‐S, Han H‐H, Kim H. A 5‐yr follow‐up nerve conduction study for the detection of subclinical diabetic neuropathy in children with newly diagnosed insulin‐dependent diabetes mellitus. Pediatric Diabetes 20XX: 00: 000–000 Objective: To investigate the changes of peripheral nerve conduction in children with insulin‐dependent diabetes mellitus (IDDM) prospectively from diagnosis and to know how those results were related to clinical risk factors. Methods: A total of 37 patients (14 males and 23 females) aged 3–19 yr (mean 12.0 ± 3.7) with newly diagnosed IDDM underwent bilateral nerve conduction studies (NCS) of median, ulnar, posterior tibial, peroneal, and sural nerves annually for 5 yr. Results: In all, 12 patients (32.4%) showed electrophysiological evidence of polyneuropathy in at least two different nerves including the sural nerve at the diagnosis of IDDM; 20 patients (54%) had multiple (≥2) abnormalities in parameters of NCS. The most common abnormal parameters at the diagnosis were conduction velocities of peroneal motor and sural nerves. In sequential NCS over 5 yr, the percentage of abnormal nerve conduction velocities rose except within the sural nerve. Poor metabolic control, height, duration of diabetes, and older age of onset were related to the changes of parameters of NCS over 5 yr. Among those risk factors, the duration of diabetes and sustained hyperglycemia affected the parameters of NCS more frequently than others. Conclusions: Children with IDDM frequently have nerve conduction abnormalities without clinical neuropathy at initial diagnosis. The frequency of abnormalities of any attribute of nerve conduction increased over the 5 yr follow‐up. The duration of diabetes and poor glycemic control proved to be more important risk factors over 5 yr as related to the development of subclinical neuropathy.     

Controlling the blood glucose of type 1 diabetes mice by co‐culturing MIN‐6 β cells on 3D scaffold

T1D is an autoimmune disease, which may be caused by lack of insulin‐secreting β cells due to damage of autoimmune system. Living with T1D is a challenge for the child and the family; cell transplantation is a treatment option for diabetes in children. To establish a microenvironment suitable for cell growth and proliferation as well as for sustained cellular function, we used MIN‐6 β cells as seed cells and SF‐IV collagen as a 3D composite scaffold to construct artificial pancreas in this experiment. The cell viabilities were determined by MTT assay, and the response of cells to different glucose concentrations was observed by glucose stimulation test. Artificial pancreas was transplanted into the abdominal cavity of T1D mice, and the changes of blood glucose were monitored. After 10 days, insulin expression was detected by immunohistochemical method, and the claybank stained area showed effectiveness of insulin secretion. A series of experiments showed that implantation of 3D cell scaffold into the abdominal cavity can effectively control the blood glucose level of T1D mice. It also had longer‐lasting hypoglycemic effects than simple cell transplantation, which was expected to become a new method for the treatment of T1D.     

Continuous subcutaneous insulin infusion versus multiple daily injections for type 1 diabetes

To review the literature on continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) to help the family of a 13‐year‐old girl with type 1 diabetes mellitus on MDI choose the best insulin delivery method for her to improve her glycaemic control. A literature search was performed to assess available evidence regarding CSII use versus MDI use for glycaemic control. We identified 15 relevant articles and present these, with a detailed analysis of a multicentre randomised controlled trial by Mueller‐Godeffroy et al. Although CSII use demonstrated a reduction in HbA_1c (?0.18 to ?0.7%) in some studies compared to MDI, this finding was not consistent across all studies. Mueller‐Godeffroy et al. did not find a statistically significant different in HbA_1c between CSII and MDI patients; however, additional benefits of insulin pump therapy, including improved diabetes‐related quality of life and reduced care giver burden, were reported. Further high‐quality randomised controlled trials and long‐term data are required to assess the benefits of CSII over MDI and the longevity of these methods.     

Treatment for Childhood Type 2 Diabetes

Urine glucose screening at school implemented in Japan is useful for detecting childhood type 2 diabetes at the early stage of the disease. Most patients detected by the screening can improve hyperglycemia and reduce overweight within one to three months by changing lifestyle with diet and exercise. For patients who are unable to alter their lifestyle and for those who have hyperglycemia despite maintaining these changes, a variety of oral hypoglycemic agents, including α-glucosidase inhibitors, sulfonylureas, glitinides, metformin, thiazolidenediones, and insulin are available. Metformin is considered to be the most effective oral agent as monotherapy for Japanese young persons with type 2 diabetes, because most of them are obese with insulin resistance. The approach to insulin therapy in patients with type 2 diabetes often differs from that most frequently used in patients with type 1 diabetes. Adjustment of the dose of insulin at each injection using sliding scales or algorithms is not required in most cases. In some cases, combination therapy with metformin and sulfonylureas or use of insulin is more effective for stabilization of blood glucose values. Therapeutic means for childhood type 2 diabetes should be variable depending on each patient’s characteristics.     

Continuous glucose monitoring in children with type 1 diabetes: before and after insulin pump therapy

Abstract: Objective: The aim of continuous subcutaneous insulin infusion (CSII) therapy in patients with type 1 diabetes mellitus (T1DM) is to mimic as closely as possible the normal physiologic pattern seen in individuals without diabetes. This study was undertaken to determine the specific areas of improved glycemic control in subjects after initiation of insulin pump therapy and times where further improvement is needed. Research design and methods: Eight patients with T1DM (age 7.5–17 yr) wore the Continuous Glucose Monitoring System (CGMS) (Medtronic MiniMed, Northridge, CA, USA) for 3 d before and 3 months after initiation of insulin pump therapy. The CGMS, which measures inter‐ stitial glucose concentrations every 5 min for a 72‐h period, was used to evaluate glucose profiles. Patients entered 4–5 fingerstick blood glucose measurements daily into the sensor for calibration. Detailed logs of food intake, exercise, and hypoglycemic symptoms were also recorded. Results: Hemoglobin A1c (HbA1C) was reduced (p < 0.007) following 3 months of insulin pump therapy. Post‐CSII continuous glucose profiles demonstrated an overall improvement in hourly mean glucose over a 24‐h period (p < 0.001) as well as a reduction in the area under the curve for glucose (27 ± 4 prepump vs. 8.6 ± 1.4 mg/dL/d postpump, p < 0.004). This improvement was a result of an attenuation of the maximal postprandial glycemic excursions. Postbreakfast 349 ± 24 vs. 267 ± 16 mg/dL, p < 0.003; lunch 340 ± 16 vs. 217 ± 20 mg/dL, p < 0.003. Postdinner average similarly decreased after 3 months of CSII by 22%, p < 0.04. Conclusions: Pump therapy specifically improved the postprandial glucose excursions in children.     

Does continuous glucose monitoring have clinical utility in contemporary management of diabetes?

Continuous, automated and non-invasive blood glucose monitoring systems have long been a goal to assist management of diabetes mellitus. The first continuous, albeit invasive, device available in Australia is the Medtronic MiniMed Continuous Glucose Monitoring System (CGMS), which is available for physician-supervised use to give a continuous blood glucose profile (5-minutely readings, viewable only after download by the physician) for periods of 72 h. With the availability of this technology, there is a need to assess the accuracy, reproducibility and ability to detect significant clinical events (particularly hypoglycaemia) and blood glucose patterns. The question of whether this technique allows long-term improvement of metabolic control also arises. We present four case studies to illustrate the use of CGMS in clinical practice and have reviewed the rapidly emerging literature. We conclude that CGMS is a useful clinical tool in the management of diabetes mellitus, provided that it is appropriately applied and the limitations are understood.